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Management of the Palpable
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OTHER MASS-FORMING LESIONS
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Hamartomas
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Borgen PI, Wong GY, Vlamis V, et al. Current management of male breast cancer. A review of 104 cases. Ann Surg 1992;215(5):451–457; discussion 457–459.
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Management of the Palpable
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OTHER MASS-FORMING LESIONS
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Hamartomas
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Ciatto S, Cariaggi P, Bulgaresi P. The value of routine cytologic examina- tion of breast cyst fluids. Acta Cytol 1987;31(3):301–304.
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Management of the Palpable
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OTHER MASS-FORMING LESIONS
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Hamartomas
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Sickles EA, Filly RA, Callen PW. Benign breast lesions: ultrasound detection and diagnosis. Radiology 1984;151(2):467–470.
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Management of the Palpable
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OTHER MASS-FORMING LESIONS
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Hamartomas
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Pisano ED, Gatsonis C, Hendrick E, et al. Diagnostic performance of digi- tal versus film mammography for breast-cancer screening. N Engl J Med 2005;353(17):1773–1783.
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Management of the Palpable
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OTHER MASS-FORMING LESIONS
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Hamartomas
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Dupont WD, Page DL, Parl FF, et al. Long-term risk of breast cancer in women with fibroadenoma. N Engl J Med 1994;331(1):10–15.
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Management of the Palpable
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OTHER MASS-FORMING LESIONS
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Hamartomas
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Frantz VK, Pickren JW, Melcher GW, et al. Indicence of chronic cystic disease in so-called “normal breasts”; a study based on 225 postmortem examinations. Cancer 1951;4(4):762–783.
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Management of the Palpable
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OTHER MASS-FORMING LESIONS
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Hamartomas
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Wilkinson S, Anderson TJ, Rifkind E, et al. Fibroadenoma of the breast: a follow-up of conservative management. Br J Surg 1989;76(4):390–391.
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Management of the Palpable
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OTHER MASS-FORMING LESIONS
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Hamartomas
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van Dam PA, Van Goethem ML, Kersschot E, et al. Palpable solid breast masses: retrospective single- and multimodality evaluation of 201 lesions. Radiology 1988;166(2):435–439.
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Management of the Palpable
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OTHER MASS-FORMING LESIONS
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Hamartomas
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Houssami N, Irwig L, Simpson JM, et al. Sydney Breast Imaging Accuracy Study: comparative sensitivity and specificity of mammography and sonog- raphy in young women with symptoms. AJR Am J Roentgenol 2003;180(4): 935–940.
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Management of the Palpable
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OTHER MASS-FORMING LESIONS
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Hamartomas
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Bode MK, Rissanen T, Apaja-Sarkkinen M. Ultrasonography and core nee- dle biopsy in the differential diagnosis of fibroadenoma and tumor phyl- lodes. Acta Radiol 2007;48(7):708–713.
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Management of the Palpable
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OTHER MASS-FORMING LESIONS
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Hamartomas
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Kriege M, Brekelmans CT, Boetes C, et al. Efficacy of MRI and mammogra- phy for breast-cancer screening in women with a familial or genetic pre- disposition. N Engl J Med 2004;351(5):427–437.
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Management of the Palpable
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OTHER MASS-FORMING LESIONS
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Hamartomas
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Steinberg JL, Trudeau ME, Ryder DE, et al. Combined fine-needle aspira- tion, physical examination and mammography in the diagnosis of pal- pable breast masses: their relation to outcome for women with primary breast cancer. Can J Surg 1996;39(4):302–311.
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Management of the Palpable
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OTHER MASS-FORMING LESIONS
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Hamartomas
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Vetto J, Pommier R, Schmidt W, et al. Use of the “triple test” for palpable breast lesions yields high diagnostic accuracy and cost savings. Am J Surg 1995;169(5):519–522.
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Management of the Palpable
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OTHER MASS-FORMING LESIONS
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Hamartomas
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Bicker T, Schondorf H, Naujoks H. Long-term follow-up in patients with mammary gland changes found unsuspicious by aspiration cytology. Cancer Detect Prev 1988;11(3–6):319–322.
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Management of the Palpable
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OTHER MASS-FORMING LESIONS
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Hamartomas
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Gordon PB, Gagnon FA, Lanzkowsky L. Solid breast masses diagnosed as fibroadenoma at fine-needle aspiration biopsy: acceptable rates of growth at long-term follow-up. Radiology 2003;229(1):233–238.
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Management of the Palpable
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OTHER MASS-FORMING LESIONS
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Hamartomas
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Giard RW, Hermans J. The value of aspiration cytologic examina- tion of the breast. A statistical review of the medical literature. Cancer 1992;69(8):2104–2110.
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Management of the Palpable
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OTHER MASS-FORMING LESIONS
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Hamartomas
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Westenend PJ, Sever AR, Beekman-De Volder HJ, et al. A comparison of aspi- ration cytology and core needle biopsy in the evaluation of breast lesions. Cancer 2001;93(2):146–150.
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Management of the Palpable
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OTHER MASS-FORMING LESIONS
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Hamartomas
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Parker SH, Burbank F, Jackman RJ, et al. Percutaneous large-core breast biopsy: a multi-institutional study. Radiology 1994;193(2):359–364.
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Management of the Palpable
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OTHER MASS-FORMING LESIONS
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Hamartomas
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Rosen PP. Pathological assessment of nonpalpable breast lesions. Semin Surg Oncol 1991;7(5):257–260.
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Management of the Palpable
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OTHER MASS-FORMING LESIONS
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Hamartomas
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Welch ST, Babcock DS, Ballard ET. Sonography of pediatric male breast masses: gynecomastia and beyond. Pediatr Radiol 2004;34(12):952–957.
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Management of the Palpable
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OTHER MASS-FORMING LESIONS
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Hamartomas
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Meijnen P, Oldenburg HS, Loo CE, et al. Risk of invasion and axillary lymph node metastasis in ductal carcinoma in situ diagnosed by core-needle biopsy. Br J Surg 2007;94(8):952–956.
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Management of the Palpable
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OTHER MASS-FORMING LESIONS
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Hamartomas
| null |
Tse GM, Law BK, Ma TK, et al. Hamartoma of the breast: a clinicopathological review. J Clin Pathol 2002;55(12):951–954.
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Management of the Palpable
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OTHER MASS-FORMING LESIONS
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Hamartomas
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C H A P T E R 5
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Management of Disorders of the Ductal System and Infections
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J. Michael Dixon and Nigel J. Bundred
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Management of Disorders of the Ductal System and Infections
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CHAPTER CONTENTS
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Nipple Discharge
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Management of Disorders of the Ductal System and Infections
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CHAPTER CONTENTS
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Investigations
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Management of Disorders of the Ductal System and Infections
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CHAPTER CONTENTS
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Differential Diagnosis of Nipple Discharge Periductal Mastitis and Duct Ectasia Etiology
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Management of Disorders of the Ductal System and Infections
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CHAPTER CONTENTS
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Nipple Inversion or Retraction
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Management of Disorders of the Ductal System and Infections
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CHAPTER CONTENTS
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Operations for Nipple Discharge or Retraction
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Management of Disorders of the Ductal System and Infections
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CHAPTER CONTENTS
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Microdochectomy
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Management of Disorders of the Ductal System and Infections
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CHAPTER CONTENTS
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Total Duct Excision or Division
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Management of Disorders of the Ductal System and Infections
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CHAPTER CONTENTS
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Breast Infection Mastitis Neonatorum Lactational Infection Nonlactational Infection
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Management of Disorders of the Ductal System and Infections
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CHAPTER CONTENTS
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Skin-Associated Infection Other Rare Infections
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Management of Disorders of the Ductal System and Infections
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CHAPTER CONTENTS
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Disorders of the ductal system can present as nipple discharge, nipple inversion, a breast mass, or periareolar infection.
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Management of Disorders of the Ductal System and Infections
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NIPPLE DISCHARGE
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Nipple discharge accounts for approximately 5% of refer- rals to breast clinics. It is a frightening symptom because of the fear of breast cancer. Approximately 95% of women pre- senting to the hospital with nipple discharge have a benign cause for the discharge. Discharge associated with a signifi- cant underlying pathologic process is spontaneous and more likely to be unilateral, arise from a single duct, be persistent (defined as more than twice per week), be troublesome, and be bloodstained or contain blood on testing. One study of 416 women with discharge identified bloody nipple discharge (odds ratio 3.7) and spontaneous discharge (odds ratio 3.2) as significant factors associated with a causative lesion (1).
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NIPPLE DISCHARGE
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For this reason, the physician must establish whether the discharge is spontaneous or induced, whether it arises from a single or from multiple ducts, and whether it is from one or both breasts. The characteristics of the discharge also need to be defined: whether it is serous, serosanguineous, bloody, clear, milky, green, or blue-black. The frequency of discharge and the amount of fluid also need to be assessed; this assessment is important for milky discharge, as galac- torrhea should be diagnosed only if the milky discharge is spontaneous, copious in amount, and arises from multiple ducts of both breasts.
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Management of Disorders of the Ductal System and Infections
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NIPPLE DISCHARGE
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Investigations
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Assessment should include the performance of a complete physical examination (Chapter 4) to identify the presence or absence of a breast mass. During the examination, firm
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Investigations
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pressure should be applied around the areola as pressure over a dilated duct will often produce the discharge; this is helpful in defining where an incision should be made for any subsequent surgery. The nipple is squeezed with firm digi- tal pressure and, if fluid is expressed, the site and charac- ter of the discharge are recorded. Testing the discharge for hemoglobin determines whether blood is present. Bloody discharge increases the risks of cancer being the cause for the discharge with an odds ratio (OR) 2.27, 95% confidence intervals (CI) 1.32–3.89, p < .001. In a recent meta-analysis, up to 20% of patients who had a bloodstained discharge or who had a discharge containing moderate or large amounts of blood had an underlying malignancy (2). The absence of blood in nipple discharge is not an absolute indication that the discharge is not related to an underlying malignancy; in one series of 108 patients the sensitivity of hemoccult testing was only 50% (3). If the discharge is serous or col- ored but spontaneous and persistent, then malignancy still needs to be excluded. Age is said to be an important pre- dictor of malignancy; in one series, 3% of patients younger than 40 years of age, 10% of patients between ages 40 and 60 years, and 32% of patients older than 60 years who pre- sented with nipple discharge as their only symptom were found to have cancer. Cytology of nipple discharge is of little value in determining whether duct excision should be per- formed. In a recent study of 618 patients who had nipple discharge cytology, the sensitivity and specificity of cytol- ogy were 16.7% and 66.1%, respectively. In comparison, the sensitivity for macroscopically bloodstained discharge was 60.6% with a specificity at 53.6% (4). Although some studies have reported better results with cytology, the variability of reported results is such that it cannot be relied on in the routine assessment of nipple discharge.
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NIPPLE DISCHARGE
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Investigations
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Two related techniques have emerged: ductal lavage,
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Investigations
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in which fluid-yielding nipple ducts are cannulated at their
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38
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orifices and lavaged with saline while the breast is inter- mittently massaged (Chapter 20); and ductoscopy, in which discharging or fluid-yielding duct orifices are dilated and intubated with a microendoscope, and the lumen directly visualized. Both techniques have significant potential in terms of allowing repeated sampling of ductal epithelium over time and diagnosing the cause of nipple discharge (5). To learn ductoscopy takes longer than 6 months to over- come technical problems. Fiberoptic ductoscopy applied to 415 patients with nipple discharge was successful in identifying a lesion in 166 patients (40%) (6). Of these 166, 11 were subsequently shown to have ductal carcinoma in situ (DCIS); ductoscopy was suspicious in 8, a sensitivity of 73%, with a specificity of 99% and a positive predictive value of 80% (6). DCIS in this series tended to affect more peripheral ducts compared with papillomas. Numerous other small series have evaluated ductoscopy in nipple dis- charge (7,8). The sensitivity for malignancy in these other series varies from 81% to 100% (8). Ductoscopy appears of particular value for directing duct excision (7) and for detecting deeper lesions that can be missed by blind cen- tral duct excision (8). Surgical resection of lesions visual- ized on ductoscopy is facilitated by transillumination of the skin overlying the lesion. Lesions visualized by duc- toscopy can be sampled; in one report, 38 of 46 women with biopsy-proved papillomas were observed for 2 years with no case of missed cancer becoming evident (8). Newer biopsy devices using vacuum assistance are now available for diagnostic assessment and can be ductoscope or sono- graph guided.
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Management of Disorders of the Ductal System and Infections
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NIPPLE DISCHARGE
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Investigations
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Ductal lavage increases cell yield approximately 100
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times compared with analysis of discharge alone, aver- aging 5,000 cells per washed duct in one series (6). The sensitivity for cytology obtained by ductal lavage in this series was 64%, with a 100% positive predictive value. Other studies have reported lower sensitivities in the range of 50%, but a high specificity and a high overall accuracy rate (5). Both ductoscopy and ductal lavage remain investigative techniques, and the evidence that they are valuable in the detection of significant breast disease is limited.
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Management of Disorders of the Ductal System and Infections
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NIPPLE DISCHARGE
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Investigations
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Imaging of the ductal tree by ductography or galactog- raphy can identify intraductal lesions. Although this inves- tigation has only a 60% sensitivity for malignancy, a filling defect or duct cutoff has a high positive predictive value for the presence of either a papilloma or a carcinoma (9). In one report, ductography-directed excisions were significantly more likely than central duct excisions to identify a spe- cific underlying lesion (10). Ductography in one large study was, however, a poor predictor of underlying pathology and could not exclude malignancy (11). The value of ductogra- phy is that like ductoscopy, it can allow identification of the site of any lesion in younger women, allowing localization and excision of the causative lesion while retaining the abil- ity to lactate.
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Management of Disorders of the Ductal System and Infections
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Investigations
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Mammography has a high overall sensitivity for breast cancer, but not all malignant lesions that cause nipple dis- charge are visible mammographically and most patients with nipple discharge have negative mammograms (Chapter 12). In one series, the sensitivity of mammogra- phy for malignancy in patients with nipple discharge was only 57% with a positive predictive value of 16.7% and a negative predictive value of 91.4% (3). Nonetheless, mam- mography should be performed in women of appropriate age, because if a lesion is visualized it may help establish the cause of the discharge. Ultrasound has a low sensitiv- ity for malignancy in patients with nipple discharge but is a valuable method for localizing intraductal abnormalities,
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Management of Disorders of the Ductal System and Infections
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Investigations
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especially papillomatous lesions, in patients with no other clinical or radiologic findings (12). Any lesion visualized can be biopsied by core biopsy or excised using a vacuum- assisted large core biopsy device. (10,13) Patients with a visible lesion on ultrasonography appear significantly more likely to have malignancy than those women with a negative scan (10).
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Management of Disorders of the Ductal System and Infections
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NIPPLE DISCHARGE
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Investigations
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Controversy surrounds the need to excise lesions seen on breast imaging and diagnosed as papillomas on core biopsy. Although it has been traditional to recommend excision of core biopsy–proven papillary lesions, imaging follow-up rather than excision may be safe providing there is imaging–histopathologic correlation and that all atypical and discordant lesions are excised (14). The use of vacuum- assisted biopsy (VAB) to remove papillomas can avoid the need for surgical excision. In large papillomas, magnetic resonance imaging (MRI) may aid assessment of the pres- ence of malignancy, which is more likely if an enhancing rim is seen. The use of MRI to evaluate the ductal tree is gaining interest but should not be part of the standard investigation of nipple discharge. In one series, MRI was performed in 52 patients with nipple discharge and had a positive predictive value of 56% with a negative predictive value of 87% (11) (Chapter 14).
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Management of Disorders of the Ductal System and Infections
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NIPPLE DISCHARGE
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Investigations
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If clinical examination demonstrates a mass lesion or mammography or ultrasonography identifies an abnormal- ity suspicious of malignancy, then core biopsy of the lesion should be performed and the lesion managed appropriately (Section VII: Management of Primary Invasive Breast Cancer). If no abnormality is found on clinical or mammographic examination, patients are treated according to whether the discharge is from a single duct or multiple ducts (Fig. 5-1). Surgery is indicated in cases of spontaneous discharge from a single duct that is confirmed on clinical examination and has one or more of the following characteristics:
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Management of Disorders of the Ductal System and Infections
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Investigations
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Is bloodstained or contains moderate or large amounts of blood on testing
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Management of Disorders of the Ductal System and Infections
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Investigations
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Is persistent and stains clothes (occurs on at least two occasions per week)
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Management of Disorders of the Ductal System and Infections
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Investigations
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Is associated with a mass
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Management of Disorders of the Ductal System and Infections
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Investigations
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Is a new development in a woman older than 50 years of age, but is not thick or cheesy
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Management of Disorders of the Ductal System and Infections
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NIPPLE DISCHARGE
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Investigations
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Discharge from multiple ducts normally requires surgery only when it causes distressing symptoms, such as persis- tent staining of clothes. Some breast units adopt an age- related policy: Patients younger than age 30 years who have serous, serosanguineous, or watery discharge are observed, with microdochectomy reserved for cases in which dis- charge persists at review; patients older than 45 years of age are treated by a formal excision of the major duct sys- tem on the affected side; patients between 30 and 45 years of age are deemed suitable for either approach. The current evidence is that total duct excision is more effective than microdochectomy at establishing a specific diagnosis and has a lower chance of missing any underlying malignancy in women more than 40 years of age (15). Today, many units incorporate ductography and ductoscopy into their man- agement protocols, particularly in younger women (Fig. 5-1). The problem is how to treat a patient with nipple discharge in whom imaging, including ductography or ductoscopy and ductal lavage, fails to identify any serious lesion. Some argue that as discharge from malignant disease is more likely to be bloodstained, there is no place for conservative manage- ment of bloodstained discharge and that all patients with bloodstained discharge should undergo duct excision unless investigation has identified a specific benign cause (16). Others argue that in selected patients, who have no clinical
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Management of Disorders of the Ductal System and Infections
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Investigations
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FIGURE 5-1 Investigation of nipple discharge.
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Investigations
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or imaging abnormality, short-term observation with repeat evaluation is reasonable (17). A period of observation, par- ticularly in younger women (35 years of age), is appropri- ate if the history of discharge is short but if spontaneous discharge persists (2 per week) at review 4 to 6 weeks later and the discharge can be expressed from a single duct on examination, then surgical excision is indicated to establish the cause of the discharge.
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Management of Disorders of the Ductal System and Infections
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NIPPLE DISCHARGE
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Differential Diagnosis of Nipple Discharge
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Physiologic Causes
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In two-thirds of nonlactating women, a small quantity of fluid can be expressed from the ducts of the nipple if the nipple is cleaned, the breast massaged, and pressure applied. This fluid is physiologic secretion and varies in color from white to yellow to green to brown to blue-black; it is thought to represent apocrine secretion, as the breast is a modified apocrine gland. This physiologic secretion usually emanates from multiple ducts, and the discharge from each duct can vary in color. It is commonly found after pregnancy and is often noticed after a warm bath or after nipple manipulation. The discharge is not usually spontaneous or bloodstained and no specific treatment is required.
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Management of Disorders of the Ductal System and Infections
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NIPPLE DISCHARGE
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Differential Diagnosis of Nipple Discharge
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Intraductal Papilloma
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A true intraductal papilloma develops in one of the major subareolar ducts and is the most common lesion causing a serous or bloody nipple discharge. In approximately half of women with papillomas, the discharge is bloody; in the other half, it is serous (9). Papillomas should be differen- tiated from papillary hyperplasia, which affects the termi- nal duct lobular unit and can also cause nipple discharge. Central papillomas consist of epithelium covering arbores- cent fronds of fibrovascular stroma attached to the wall of the duct by a stalk (Fig. 5-2). The covering epithelium has a two-cell population, with a cuboidal or columnar cell lining covering an underlying layer of myoepithelial cells. A mass may be felt on examination in as many as one-third of cases.
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Management of Disorders of the Ductal System and Infections
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NIPPLE DISCHARGE
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Differential Diagnosis of Nipple Discharge
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Intraductal Papilloma
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Occasionally, the papilloma is so close to the nipple that it can be seen in the orifice of the duct at the nipple. The treat- ment of choice is microdochectomy. A solitary papilloma is not thought to be a premalignant lesion and is considered by some to be an aberration rather than a true disease pro- cess. Papillary lesions can be difficult to characterize on core biopsies.
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Management of Disorders of the Ductal System and Infections
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NIPPLE DISCHARGE
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Differential Diagnosis of Nipple Discharge
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Multiple Intraductal Papillomas
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In approximately 10% of patients with intraductal papil- lomas, multiple lesions are found; usually, two or three occur, often in the same duct. The term multiple intraductal papilloma syndrome is reserved for the rare and distinctive group of patients in whom one duct system contains five or more large and often palpable papillomas with a periph- eral distribution. Nipple discharge is less common than in
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Management of Disorders of the Ductal System and Infections
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NIPPLE DISCHARGE
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Differential Diagnosis of Nipple Discharge
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Multiple Intraductal Papillomas
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FIGURE 5-2 Histology of duct papilloma.
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Management of Disorders of the Ductal System and Infections
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NIPPLE DISCHARGE
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Differential Diagnosis of Nipple Discharge
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Multiple Intraductal Papillomas
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patients with a solitary intraductal papilloma. In one study, multiple papillomas were reported to be associated with an increased risk of breast cancer, but any increased risk is almost certainly associated with areas of atypical epithe- lial hyperplasia rather than with the papillomas themselves
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Management of Disorders of the Ductal System and Infections
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NIPPLE DISCHARGE
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Differential Diagnosis of Nipple Discharge
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Multiple Intraductal Papillomas
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(18). Repeated excision of papillomas in patients with mul- tiple intraductal papillomas can result in significant breast asymmetry. One option in such patients is to excise such lesions using ultrasound guidance by percutaneous vacuum- assisted biopsy (Fig. 5-3). This provides sufficient material for the pathologist to assess whether lesions are benign and whether atypia is present. Some patients have multiple recurrent peripheral papillomas involving a whole ductal system and in such patients surgery to excise the affected ductal tree should be considered. A segmental excision is often possible with subsequent breast reshaping.
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Management of Disorders of the Ductal System and Infections
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NIPPLE DISCHARGE
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Differential Diagnosis of Nipple Discharge
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Juvenile Papillomatosis
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A rare condition, juvenile papillomatosis, affects women between the ages of 10 and 44 years (19). The common pre- sentation is nipple discharge +/ a discrete mass lesion. In one series of 13 patients, 11 had peripheral and 2 central lesions (19). Three of the 13 presented with nipple discharge; 2 had a palpable peripheral mass lesion, and the remainder had nipple discharge alone. Treatment is by complete exci- sion. Patients with this condition may be at some increased risk of subsequent breast cancer, and close clinical and radiological surveillance of any woman with this condition is indicated.
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Management of Disorders of the Ductal System and Infections
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NIPPLE DISCHARGE
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Differential Diagnosis of Nipple Discharge
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Carcinoma
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An invasive or noninvasive cancer can cause nipple dis- charge. Only rarely does an invasive cancer cause nipple discharge in the absence of a clinical mass. In most series,
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Management of Disorders of the Ductal System and Infections
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NIPPLE DISCHARGE
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Differential Diagnosis of Nipple Discharge
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Carcinoma
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FIGURE 5-3 Ultrasound of an intraduct papilloma char- acteristic of those seen in multiple papilloma syndrome— such lesions can be excised by mammotomy.
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Management of Disorders of the Ductal System and Infections
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NIPPLE DISCHARGE
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Differential Diagnosis of Nipple Discharge
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Carcinoma
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DCIS is responsible for up to 10% to 20% of unilateral spon- taneous nipple discharges (2). Nipple discharge alone or in association with a mass or Paget’s disease is the pre- senting feature in approximately one-third of symptomatic in situ cancers. With the advent of mammography, increas- ing numbers of noninvasive cancers are being detected and, overall, nipple discharge is the presenting symptom in 7% to 8% of cases of DCIS (Chapter 25). Scant data exist on the frequency with which in situ cancers that cause nipple dis- charge are visible on mammography, but it is recognized that a significant percentage of malignant lesions causing nipple discharge are not visible on mammography. A diag- nosis of invasive or noninvasive cancer is often established only by microdochectomy, but this operation is rarely, if ever, therapeutic. Despite a high rate of reported occult nipple–areolar complex involvement (20), a number of studies have demonstrated that breast-conserving surgery with nipple preservation is possible in patients presenting with DCIS or invasive carcinoma who have nipple discharge (21–23). Bauer et al. in 1998 reported that 11 of 43 patients with breast cancer with nipple discharge were success- fully treated by breast-conserving surgery. In the study by Cabioglu et al. (20), nipple preserving surgery was success- fully performed in one-half of all patients presenting with breast cancer and nipple discharge. There were no local recurrences in those patients who had radiotherapy post- operatively. Concerns about the safety of nipple-preserving breast-conserving surgery in patients with nipple discharge were raised by the retrospective review of Obedian and Haffty (21). Local disease recurrence was noted in 6 of 17 patients with nipple discharge. Patients in this series who underwent central excisions incorporating the nipple had a lower recurrence rate than those patients who had con- servation of the nipple–areolar complex. However, this dif- ference did not reach significance. The problem with such retrospective series is that margins were not adequately documented in most patients. It cannot, therefore, be deter- mined whether the high local recurrence rates reported by Obedian were attributable to residual tumor underneath the nipple. Although Cabioglu et al. (21) argue that long-term results obtained from larger series will be required before definitive conclusions can be drawn, they conclude that nipple-preserving breast-conserving surgery can be per- formed safely providing that negative margins are achieved and appropriate radiotherapy and systemic therapies are administered.
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Management of Disorders of the Ductal System and Infections
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NIPPLE DISCHARGE
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Differential Diagnosis of Nipple Discharge
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Bloody Nipple Discharge in Pregnancy
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Nipple discharge with blood present, either visibly or cyto- logically, during pregnancy or lactation is common. In 20% of women who experience nipple discharge during preg- nancy, blood is evident clinically. The likely cause is hyper- vascularity of developing breast tissue; it is benign, usually settles quickly, and requires no specific treatment. Only if it persists is investigation required.
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Management of Disorders of the Ductal System and Infections
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NIPPLE DISCHARGE
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Differential Diagnosis of Nipple Discharge
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Galactorrhea
|
Galactorrhea is characterized by copious bilateral milky discharge not associated with pregnancy or breast-feeding. Thick, creamy white discharge is not galactorrhea. A care- ful drug history should be taken because a number of drugs, particularly psychotropic agents, cause hyper- prolactinemia. Blood should be taken in patients with galactorrhea to measure prolactin, and if prolactin levels are significantly elevated (1,000 mU/L) in the absence of any drug cause, then a search for a pituitary tumor should be instituted. A diagnosis of hyperprolactinemia is suggested
|
Management of Disorders of the Ductal System and Infections
|
NIPPLE DISCHARGE
|
Differential Diagnosis of Nipple Discharge
|
Galactorrhea
|
by a history of galactorrhea, amenorrhea, and relative infertility. Galactorrhea disappears after appropriate drug therapy or surgical removal of any pituitary adenoma. Appropriate drug therapy includes administration of caber- goline. Bromocriptine is an alternative, but it is no longer used because it produces significant side effects in up to one-third of patients including, very rarely, strokes (24). For patients with troublesome galactorrhea who are intolerant of medication, bilateral total duct ligation is effective.
|
Management of Disorders of the Ductal System and Infections
|
NIPPLE DISCHARGE
|
Periductal Mastitis and Duct Ectasia
| null |
A variety of terms have been applied to the conditions now known as periductal mastitis and duct ectasia. Haagensen first introduced the term duct ectasia and considered the condition to be an age-related phenomenon; he believed that breast ducts dilated with age and that stagnant secretions in these dilated ducts leaked into surrounding tissues to cause periductal mastitis. This description of events ignores the findings that periductal inflammation predominates in young women, whereas duct dilatation increases in frequency with advancing age; the sequence of events described by Haagensen is therefore incorrect. If periductal mastitis and duct ectasia are related, then patients with duct ectasia would be expected to have a history of episodes of periduc- tal mastitis. In a study of 186 patients with the clinical syn- drome of duct ectasia, only 1 (0.5%) had a history of previous periductal mastitis; in contrast, 97 (70%) of 139 patients with the clinical syndrome of periductal mastitis reported a previ- ous clinical episode of periductal mastitis (25).
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Management of Disorders of the Ductal System and Infections
|
NIPPLE DISCHARGE
|
Periductal Mastitis and Duct Ectasia
|
Clinical Syndromes
|
Periductal mastitis is characterized clinically by episodes of periareolar inflammation with or without an associated mass, a periareolar abscess, or a mammary duct fistula. Nipple retraction can be seen early at the site of the affected duct and is often subtle. Nipple discharge can also occur and is often purulent.
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Management of Disorders of the Ductal System and Infections
|
NIPPLE DISCHARGE
|
Periductal Mastitis and Duct Ectasia
|
Clinical Syndromes
|
The clinical features of duct ectasia include nipple retrac- tion at the site of the shortened duct or ducts and creamy or cheesy, viscous, toothpaste-like nipple discharge. Patients with green discharge from multiple ducts are often diag- nosed as having duct ectasia, but most of these have leaking physiologic breast secretion. In one large series, periductal mastitis principally affected women between the ages of 18 and 48 years, whereas most patients who presented with duct ectasia were aged between 42 and 85 years.
|
Management of Disorders of the Ductal System and Infections
|
NIPPLE DISCHARGE
|
Etiology
| null |
Aging is an important factor in the cause of duct ectasia. The frequency of the condition increases with age and in one postmortem study, 48% of women aged 60 years or older had pathologic evidence of duct ectasia. Although early studies suggested that the lesions of both periductal mastitis and duct ectasia are sterile, when appropriate transport media are used, bacteria can be isolated from 83% of periareolar inflammatory masses and 100% of nonlactational abscesses and mammary duct fistulae. The organisms isolated are fre- quently anaerobic. In contrast, in a study of duct ectasia lesions bacteria were identified in only 1 of 11 patients, indi- cating that these lesions are usually sterile.
|
Management of Disorders of the Ductal System and Infections
|
NIPPLE DISCHARGE
|
Etiology
| null |
An association between smoking and periductal mastitis was first reported in 1988 (26). A subsequent study showed that heavy smokers are more likely to have recurrent infec- tions including abscesses and mammary duct fistulae than light smokers or nonsmokers. Studies with carefully matched cases and controls have shown a significant excess of smokers among patients with clinically diagnosed
|
Management of Disorders of the Ductal System and Infections
|
NIPPLE DISCHARGE
|
Etiology
| null |
periductal mastitis, but not in women with clinically diag- nosed duct ectasia. How cigarette smoking causes periduc- tal mastitis is unclear. Substances in cigarette smoke may either directly or indirectly damage the wall of subareolar ducts. Accumulation of toxic metabolites—such as lipid peroxidase, epoxides, nicotine, and cotinine—in the breast ducts has been demonstrated to occur in smokers within 15 minutes. Smoking has also been shown to inhibit growth of gram-positive bacteria in vivo and in vitro, leading to an overgrowth of gram-negative bacteria. This may affect the normal bacterial flora and allow overgrowth of pathogenic aerobic and anaerobic gram-negative bacteria, and would explain the presence of these organisms in the lesions of periductal mastitis. Microvascular changes have also been recorded in smokers and may result in local ischemia (27). The combination of damage caused by toxins, microvas- cular damage by lipid peroxidases, and altered bacterial flora appears to explain why smokers develop periductal mastitis.
|
Management of Disorders of the Ductal System and Infections
|
NIPPLE DISCHARGE
|
Etiology
| null |
Etiologic data thus suggest that periductal mastitis and duct ectasia are separate conditions with different causes. Duct ectasia appears to be an involutionary phenomenon, whereas periductal mastitis is a disease in which smoking and bacteria are important causal factors.
|
Management of Disorders of the Ductal System and Infections
|
NIPPLE DISCHARGE
|
Etiology
|
Other Causes of “Nipple” Discharge
|
Other diseases of the nipple–areolar complex can present with “nipple” discharge, including nipple adenoma, eczema, Paget’s disease, ulcerating carcinoma, and long-standing nipple inversion with maceration. Nipple adenoma is rare, but easy to diagnose (Fig. 5-4). It usually presents with a bloodstained discharge or change in contour or color of the nipple. Occasionally, an ulcer develops. Clinically, there is a nondiscrete mass in the substance of the superficial layer of the nipple. Definitive treatment is complete excision. Eczema or dermatitis can sometimes involve the nipple and is usually caused by irritation from chemicals on clothes or in cosmetics. Eczema can be differentiated from Paget’s dis- ease in that eczema affects primarily the areola and only rarely spreads onto the nipple. In contrast, Paget’s disease affects the nipple first and only secondarily affects the are- ola. Treatment for eczema is removal of any aggravating factor, such as perfumed soap or detergents, by the use of hypoallergenic washing materials for clothes and skin, and prescription of topical corticosteroids. Short courses of potent corticosteroids are often more effective at resolving nipple eczema than longer courses of dilute preparations.
|
Management of Disorders of the Ductal System and Infections
|
NIPPLE DISCHARGE
|
Etiology
|
Other Causes of “Nipple” Discharge
|
Long-standing nipple inversion with maceration is rare but is seen in some elderly people. The injured skin pro- duces a discharge, which can be purulent. Treatment is by careful cleaning of the affected area. Repeated nipple trauma caused by friction from rubbing of clothes on the nipple dur- ing jogging and cycling is sometimes sufficiently severe to cause nipple excoriation and bleeding.
|
Management of Disorders of the Ductal System and Infections
|
NIPPLE INVERSION OR RETRACTION
| null | null |
The terms inversion and retraction are often used inter- changeably, although some call the condition inversion only when the whole nipple is pulled in (Fig. 5-5), and use the term retraction when part of the nipple is drawn in at the site of a single duct to produce a slit-like appearance (Fig. 5-6). These changes can be congenital or acquired. The acquired causes, in order of frequency, are duct ectasia, periductal mastitis, carcinoma, and tuberculosis.
|
Management of Disorders of the Ductal System and Infections
|
NIPPLE INVERSION OR RETRACTION
| null | null |
All patients with acquired nipple inversion or retraction should have a full clinical examination and, if the patient is
|
Management of Disorders of the Ductal System and Infections
|
NIPPLE INVERSION OR RETRACTION
| null | null |
FIGURE 5-4 Nipple adenomas.
|
Management of Disorders of the Ductal System and Infections
|
NIPPLE INVERSION OR RETRACTION
| null | null |
FIGURE 5-5 Nipple inversion from breast cancer. FIGURE 5-6 Slit-like nipple retraction from duct ectasia.
|
Management of Disorders of the Ductal System and Infections
|
NIPPLE INVERSION OR RETRACTION
| null | null |
FIGURE 5-7 Management of nipple retraction.
|
Management of Disorders of the Ductal System and Infections
|
NIPPLE INVERSION OR RETRACTION
| null | null |
older than 35 years, a mammogram. Management depends on the presence or absence of a clinical or mammographic abnormality (Fig. 5-7). Central, symmetric, transverse slit-like retraction is characteristic of benign disease; nipple inver- sion occurring in association with either breast cancer or inflammatory breast disease is more likely to involve the whole of the nipple and, in a breast cancer, to be associated with distortion of the areola, which may be evident only when the breast is examined in different positions (Figs. 5-5 and 5-6). Benign nipple retraction requires no specific treatment, but can be corrected surgically if the patient requests it and the surgeon considers the operation appropriate. Division or excision of the underlying breast ducts (total duct division or excision) may be required to evert the nipple; patients should be warned that they will not be able to breast-feed after this procedure and may lose some nipple sensation.
|
Management of Disorders of the Ductal System and Infections
|
OPERATIONS FOR NIPPLE DISCHARGE OR RETRACTION
|
Microdochectomy
| null |
Microdochectomy is indicated for spontaneous, persis- tent single-duct discharge and can be performed either through a radial incision across the areola or through a circumareolar incision centered over the discharging duct. A circumareolar incision leaves a better cosmetic scar. The discharging duct is cannulated either with a probe or a blunt-ended needle through which methylene blue can be injected. These various procedures allow the involved duct to be identified under the surface of the nipple. The dis- charging duct is dissected distally into the breast; a portion of duct over a distance of approximately 5 cm is removed because almost all significant disease affects the proximal 5 cm (9,28). If the remaining duct within the breast appears abnormal and dilated, then the distal duct can be excised or opened and any pathologic lesion in the remaining duct can be visualized and removed. This is an important maneu- ver because ductoscopy indicates that many significant lesions affect ducts some distance from the nipple. When performing a duct excision directed by ductoscopy, hav- ing visualized the abnormality in the duct, transmitted light immediately proximal or at the site of the lesion is used to direct the surgical excision. Once excision has been per- formed, the nipple should be squeezed gently to ensure that the discharging duct has been removed. Drains are not
|
Management of Disorders of the Ductal System and Infections
|
OPERATIONS FOR NIPPLE DISCHARGE OR RETRACTION
|
Microdochectomy
| null |
necessary after this procedure, any significant defect can be closed with mobilization of adjacent breast tissue, and the skin is closed in layers with absorbable sutures. Papillomas visible on ultrasonography can be removed by needle local- ization or percutaneous vacuum-assisted biopsy.
|
Management of Disorders of the Ductal System and Infections
|
OPERATIONS FOR NIPPLE DISCHARGE OR RETRACTION
|
Total Duct Excision or Division
| null |
Total duct excision can be a diagnostic procedure in older patients with nipple discharge and is indicated for multiple troublesome duct discharge or nipple eversion, and as treat- ment for periductal mastitis and its associated complica- tions. For nipple eversion duct division may be all that is required. Because the lesions of periductal mastitis usually contain organisms (Table 5-1), patients having operations for this condition should receive appropriate perioperative antibiotic treatment. Options for antibiotic therapy include amoxicillin–clavulanate or a combination of erythromycin and metronidazole hydrochloride. Some surgeons prefer total duct excision in older women with single-duct dis- charge who no longer wish to breast-feed. The reasoning is that is it is more likely than single-duct excision to obtain a specific diagnosis (15,16) and if there is a condition, such as duct ectasia, that affects all the ducts underneath the nipple, then any further discharge from the other affected ducts will be prevented. A circumareolar incision based at the six o’clock position is used unless a previous scar exists, in which case the same scar is reused. Dissection is per- formed under the areola down either side of the major ducts. Curved tissue forceps are passed around the ducts, and these are delivered into the wound. The ducts are secured and then divided from the undersurface of the nipple and, if a total duct excision is being performed, a 2- to 5-cm portion of ducts is excised depending on whether the operation is diagnostic or therapeutic.
|
Management of Disorders of the Ductal System and Infections
|
OPERATIONS FOR NIPPLE DISCHARGE OR RETRACTION
|
Total Duct Excision or Division
| null |
For patients having cosmetic nipple eversion, the pro-
|
Management of Disorders of the Ductal System and Infections
|
OPERATIONS FOR NIPPLE DISCHARGE OR RETRACTION
|
Total Duct Excision or Division
| null |
cedure can be performed through a small incision either at the areolar margin or at the base of the nipple and the ducts are divided sufficiently to ensure that the nipple everts. If the operation is being performed for periductal mastitis, the back of the nipple must be cleared of all ducts up to the nipple skin because recurrence can occur when residual dis- eased ductal tissue is left. In periductal mastitis only 2 to 3 cm of all the ducts need to be removed as the disease affects only the subareolar ducts. If the nipple was inverted before the operation, it is everted either by dividing the fibrous tis- sue which is keeping the nipple inverted or manually by firm
|
Management of Disorders of the Ductal System and Infections
|
OPERATIONS FOR NIPPLE DISCHARGE OR RETRACTION
|
Total Duct Excision or Division
| null |
digital pressure to stretch the tissue stopping the nipple from everting; only rarely are sutures required under the nipple to maintain nipple eversion. No drains are placed, and the wound is closed in layers with absorbable sutures. Patients should be warned before surgery that this opera- tion results in significantly reduced nipple sensitivity in up to 40% of women.
|
Management of Disorders of the Ductal System and Infections
|
BREAST INFECTION
| null | null |
Breast infection presenting to surgeons is much less com- mon clinically now than it was previously because of early use of antibiotics in the community. It is occasionally seen in neonates, but most commonly affects women between the ages of 18 and 50 years. In the adult, breast infection can be considered lactational or nonlactational. Infection can also affect the skin overlying the breast, and occurs either as a primary event or secondary to a lesion in the skin, such as an epidermoid cyst, or a more generalized condition, such as hidradenitis suppurativa. The organisms responsible for different types of breast infection and the most appropriate antibiotics with activity against these organisms are sum- marized in Table 5-1 (29). The guiding principle in treating breast infection is to give antibiotics as early as possible to stop abscess formation; if the infection or inflammation fails to resolve after one course of antibiotics, then abscess formation or an underlying cancer should be suspected (30).
|
Management of Disorders of the Ductal System and Infections
|
BREAST INFECTION
|
Mastitis Neonatorum
| null |
Continued enlargement of the breast bud in the first week or two of life occurs in approximately 60% of newborns, and these enlarged buds can become infected, most often by Staphylococcus aureus, although the responsible organism is sometimes Escherichia coli. In the early stage, antibiotics (flucloxacillin) can control infection; however, if a localized collection is evident on ultrasound, incision and drainage, by aspiration or a small stab incision placed as peripherally as possible so as not to damage the breast bud, is effective at producing resolution.
|
Management of Disorders of the Ductal System and Infections
|
BREAST INFECTION
|
Lactational Infection
| null |
Lactational infection is now less common than it used to be. The infection is usually caused by S. aureus, but it can also be caused by S. epidermidis and Streptococcus species. The first stage is often development of a cracked nipple or a skin abra- sion due to nipple trauma from breast-feeding that results in both swelling, which compresses the subareolar breast ducts, and a break in the body’s defense mechanisms, which
|
Management of Disorders of the Ductal System and Infections
|
BREAST INFECTION
|
Lactational Infection
| null |
increases the number of bacteria on the skin of the breast. Bacteria then gain access to the breast ducts through the macerated nipple and infect the poorly draining segments. Infection is most common in a first pregnancy during the first 6 weeks of breast-feeding but is also seen during wean- ing. Symptoms include pain, erythema, swelling, tenderness, or systemic signs of infection. Clinically, the breast is swol- len, tender, and erythematous; if an abscess is present, a fluctuant mass with overlying shiny, red skin may be present (Fig. 5-8). Axillary lymphadenopathy is not usually a feature. Patients can be toxic with pyrexia, tachycardia, and leukocy- tosis. Antibiotics given at an early stage usually control the infection and stop abscess formation. Because more than 80% of staphylococci are resistant to penicillin, flucloxacil- lin or amoxicillin–clavulanate are given, except in patients with a penicillin sensitivity, for whom erythromycin or clar- ithromycin is usually effective. Tetracycline, ciprofloxacin, and chloramphenicol should not be used to treat infection in breast-feeding women because they enter breast milk and may harm the child. Patients whose condition does not improve rapidly on appropriate antibiotic therapy require hospital referral and assessment with ultrasonography to determine whether pus is present and to exclude an under- lying neoplasm (Fig. 5-9).
|
Management of Disorders of the Ductal System and Infections
|
BREAST INFECTION
|
Lactational Infection
| null |
Inflammatory cancers can be difficult to differentiate
|
Management of Disorders of the Ductal System and Infections
|
BREAST INFECTION
|
Lactational Infection
| null |
from abscesses. If an abscess is evident on ultrasonography and the overlying skin is not thinned or necrotic, the abscess can be aspirated to dryness following injection of local anes- thesia into the skin and the breast tissue and the cavity irri- gated with local anesthetic to minimize pain and to dilute thick pus. The abscess should be irrigated until all the pus is evacuated and the fluid aspirated is clear. A combination of repeated aspiration and oral antibiotics is usually effective at resolving local abscess formation and is the current treat- ment of choice for most breast abscesses (29,30). Aspiration should be repeated every 2 to 3 days until no further pus is obtained. Characteristically, the fluid aspirated changes over a few days from pus to serous fluid and then to milk. If the skin overlying the abscess is thinned and pus is visible superficially on ultrasonography, then after application of local anesthetic cream or infiltration of local anesthetic into the overlying skin, a small incision (mini-incision) is made over the point of maximal fluctuation, and the pus is drained
|
Management of Disorders of the Ductal System and Infections
|
BREAST INFECTION
|
Lactational Infection
| null |
(29). The cavity is then irrigated with local anesthetic solu- tion, which produces some pain relief. Irrigation is contin- ued every few days until the incision site closes. If the skin overlying the abscess is clearly necrotic, the necrotic skin can be excised to allow the pus to drain.
|
Management of Disorders of the Ductal System and Infections
|
BREAST INFECTION
|
Lactational Infection
| null |
Few lactational abscesses require drainage under gen- eral anesthesia. The placement of drains and packing of
|
Management of Disorders of the Ductal System and Infections
|
BREAST INFECTION
|
Lactational Infection
| null |
FIGURE 5-8 (A) Lactational breast infection: large abscess was present on ultrasound which was treated by aspiration with rapid resolution (B).
|
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