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Key Features

  • Common causes in the nonlactating breast

    • Duct ectasia

    • Intraductal papilloma

    • Carcinoma

  • Characteristics of nipple discharge and their clinical significance in nonpregnant, nonlactating women

    • Serous: Most likely benign fibrocystic condition, ie, duct ectasia

    • Bloody: More likely neoplastic–papilloma, carcinoma

    • Associated mass: More likely neoplastic

    • Unilateral: Either neoplastic or non-neoplastic

    • Bilateral: Most likely non-neoplastic

    • Single duct: More likely neoplastic

    • Multiple ducts: More likely fibrocystic condition

    • Milky: Endocrine disorders, medications

    • Spontaneous: Either neoplastic or non-neoplastic

    • Produced by pressure at single site: Either neoplastic or non-neoplastic

    • Persistent: Either neoplastic or non-neoplastic

    • Intermittent: Either neoplastic or non-neoplastic

    • Related to menses: More likely fibrocystic condition

    • Premenopausal: More likely fibrocystic condition

    • Taking hormones: More likely fibrocystic condition

Clinical Findings

  • Unilateral, spontaneous serous, or serosanguineous discharge from a single duct caused by

    • Ectatic duct

    • Intraductal papilloma (usually)

    • Intraductal cancer (rarely)

  • Bloody discharge suggests cancer but is more often due to benign papilloma in duct

  • Fibrocystic condition in premenopausal women characterized by spontaneous, brown or green discharge

    • From multiple ducts

    • Unilateral or bilateral

    • Most marked just before menstruation

  • Milky discharge from multiple ducts occurs from

    • Hyperprolactinemia

    • Certain drugs (antipsychotics)

  • A clear, serous, or milky discharge from single or multiple ducts

    • Can occur with oral contraceptives or estrogen replacement therapy

    • Disappears when patient stops taking drugs

    • More evident just before menstruation

  • Purulent discharge may originate in a subareolar abscess

Diagnosis

  • If unilateral discharge from single duct, involved duct can be identified by pressure at different sites around nipple at margin of areola

  • Check serum prolactin and thyroid-stimulating hormone levels if discharge is milky

  • Mammography and ultrasound may be helpful if localization of lesion is not possible

  • Differential diagnosis

    • Galactorrhea (eg, pregnancy, postpartum, hyperprolactinemia)

    • Mammary duct ectasia

    • Intraductal papilloma

    • Breast cancer

    • Oral contraceptives or estrogen replacement therapy

    • Fibrocystic condition

    • Subareolar abscess

Treatment

  • Any mass or, in the case of duct ectasia or intraductal papilloma, any involved duct should be excised

  • Abscesses require drainage or removal along with the related lactiferous sinus

  • When localization is not possible, no mass is palpable, and discharge is nonbloody, the patient should be reexamined every 3 or 4 mo for 1 yr, and mammography and ultrasound are performed

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