Patient's question:
Main symptoms: Milk can be squeezed from the right nippleOnset time: About half a year
Laboratory test results: None
Doctor's answer:
Nipple discharge has two types of primary causes: physiological and pathological. Physiological discharge refers to lactation during breastfeeding, discharge caused by sedatives or contraceptives, as well as minor nipple discharge before and after menstruation. It is generally bilateral, multi-ductal, and non-hemorrhagic. Pathological nipple discharge refers to various types of discharge caused by certain diseases, with an incidence rate second only to breast lumps and breast pain. This group accounted for 7.27% of inpatient surgical cases during the same period. Most nipple discharge is benign, with breast cancer accounting for 4% to 10.7% of cases, papillary tumors for 32.17% [2], and intraductal papillary tumors accounting for 44.8% to 49.8% of hemorrhagic discharges [3]. Hemorrhagic discharge is particularly noteworthy. It is often associated with breast cancer, especially in cases of nipple hemorrhagic discharge in individuals over 50, where more than half are breast cancer [4]. It must be emphasized that elderly nipple bleeding accompanied by breast lumps is closely related to breast cancer. All 7 breast cancer patients in this group were over 50 and presented with nipple bleeding along with breast lumps. Common causes of nipple discharge include intraductal papillary tumors, duct ectasia, cystic hyperplasia, and breast cancer. Other less common causes include papillomatosis, breast inflammation, breast fibroadenomas, simple cysts, pituitary tumors, etc. [4].3.2 Diagnosis of Nipple Discharge
Current common diagnostic methods include exfoliative cytology, ultrasound, near-infrared imaging, mammography, selective breast ductography, and ductoscopy. Exfoliative cytology is simple, convenient, and well-tolerated by patients. Breast ductography is suitable for unilateral single-duct lesions and has a diagnostic accuracy rate of 90% to 100% for duct ectasia [5]. Ultrasound, especially color Doppler ultrasound, is simple, non-invasive, and can assess duct dilation and detect small intraluminal lesions. Its sensitivity for intraductal papillary tumors is 68% [6]. Ductoscopy is a novel diagnostic method for determining the nature of intraductal microlesions causing non-lump-associated nipple abnormal secretions and identifying the source of nipple discharge [3]. While these various tests can be used for diagnosis and differential diagnosis, they all have a certain rate of false positives. The final diagnosis must rely on pathological tissue examination.
3.3 Treatment of Nipple Discharge
Surgery is the preferred treatment for pathological nipple discharge. The challenge of surgery lies in the accurate localization of the lesion. During surgery, an epidural anesthesia catheter is inserted into the discharge duct orifice, and 0.3 to 0.5 ml of methylene blue is slowly injected. A radial incision is made, followed by the excision of the affected duct and surrounding blue-stained glandular tissue. When performing segmental excision, care must be taken to ensure the resection extends to the margins to prevent recurrence. If a lump is palpated preoperatively or suspected intraoperatively, routine intraoperative rapid frozen section examination should be performed. Malignant cases should be treated as breast cancer. For cases with atypical hyperplasia indicated by intraoperative pathology, such as those over 50 years old, simple mastectomy may be considered. This group included 3 such cases. For patients with duct ectasia, cystic hyperplasia, and intraductal papillary tumors with atypical ductal epithelial hyperplasia, tamoxifen treatment for 3 months is recommended. Close follow-up is required after surgery.