Nipple discharge

Question 1

A 44 year old woman presents with discharge from her right nipple. What are the differential diagnoses?

Answer 1

Impression
With a presentation of nipple discharge, I am largely concerned about ruling out Paget’s disease of the nipple/ malignancy as a potential cause (unilateral discharge), however would keep a broad differentials list in the approach to my assessment and management of this patient.

Question 2

Nipple discharge - Differentials

Answer 2

Differentials
- Normal physiological (menstrual cycle hormonal changes, excessive breast stimulation, duct ectasia (occurs in women approaching the menopause)
- Endocrine: hyperprolactinaemia (prolactinoma)
- Neoplasia
o Benign: fibrocystic change, fibroadenoma, phyllodes tumour, benign intraductal papilloma (can be watched or surgically removed)
o Malignant: DCIS/LCIS, invasive ductal/ invasive lobular (with specific sub-types and features including
- Infective: mastitis, breast abscess
- Galactorrhoea: irritative from rubbing
- Pregnancy (rule out in this woman)

Question 3

Nipple discharge - History

Answer 3

History

• Sx: consistency, colour, volume, timing, duration, changes across cycle, unilateral vs bilateral
• associated features: pain, swelling, erythema, breast mass, systemic features of malignancy, amenorrhoea, menstrual cycle changes, nipple retraction, paeu d’orange, lymphadenopathy
• RISKS: fam hx, BRCA1/2 mutations, smoking, recent trauma,
• DDx: prolactinoma (bitemporal hemianopia, amenorrhoea)

Question 4

Nipple discharge - Examination

Answer 4

Examination
- general observation + vital signs
- Breast examination: inspection (nipple retraction, discharge, erythema, other skin changes); palpation (masses, tethered vs mobile, pain/tenderness, identify location), contralateral breast assessment
- discharge inspection
o milky - likely physiological
o blood-stained - more concerning for malignancy
o purulent
- lymph nodes (Axillary, cervical, inguinal)
- Paget’s disease (looks like eczema of the nipple)

Question 5

Nipple discharge - Investigations

Answer 5

Investigations
Key/diagnostic
- triple assessment: exam, US/Mammogram, biopsy of any relevant masses
- cytology on breast discharge fluid (negative doesn’t rule out malignancy)

Bedside: urine ß-HCG,
Bloods: TFT, cultures, pituitary panel, quantitative ß-HCG
Imaging: MRI

Other: attempt microductectomy if diagnostic uncertainty, otherwise central duct excision (although can no longer breastfeed after that)

Question 6

Nipple discharge - Management

Answer 6

Management
Variety of options depending on the underlying cause
Principles
- MDT if cancer - tissue diagnosis for HR status and subsequent definitive treatment
- endocrinologist if physiological/endocrine cause
- breast endocrine surgeon