Nipple discharge can be an early symptom of breast cancer, but most cases of nipple discharge are due to benign conditions. The following are guidelines to differentiate benign discharge from discharge that is associated with malignancy:
- Spontaneous Discharge: Discharge that comes out without squeezing is the only type of discharge of concern. If the discharge only occurs with squeezing, ignore it and stop squeezing your breast. Check your bra or night clothes for evidence of spontaneous discharge. If you see a spot, save it and show it to your doctor.
- Color: Worrisome discharge is typically either bloody or clear. Discharge that is green, milky, or other colors is almost always of no concern. Note: if you have large amounts of milky discharge and you are not breast feeding, it should be brought to the attention of your physician. Tests should be done to evaluate for the possibility of a pituitary tumor. Milky discharge with squeezing is not of concern.
- Single verses multiple ducts: If a woman squeezes her breast and notes discharge from multiple spots on the nipple, she can be reassured that the discharge is usually nothing to worry about. However, if the discharge is consistently coming from one spot on the nipple, it is of more concern. This observation should be confirmed by her physician (see link to picture).
How we approach the problem of nipple discharge.
First we do complete history and physical examination, and make sure we have an up-dated mammogram. If the examination and recent mammogram are negative, and the discharge is not-spontaneous, we reassure the patient. We suggest that she examine her bra and night clothes for spotting, and if this is observed, she should return for re-evaluation. Otherwise we suggest she be followed at routine intervals.
If the discharge is spontaneous, and is coming from a single duct, the next step is to do a ductogram. A ductogram is a procedure in which contrast material is placed into the duct (under local anesthesia) and an X-ray is taken (see link to picture). If an abnormality is seen in the duct the patient is taken directly to the operating room where the abnormal duct is removed.
If the ductogram is normal and it was done without technical problems, we advise the patient to observe the discharge. If the discharge persists we repeat the ductogram. In cases in which the ductogram does not clarify the cause of the discharge either because of technical problems or patient discomfort, we usually proceed to surgical exploration of duct.
We have used this approach in hundreds of patients with spontaneous single duct nipple discharge with consistently excellent results. In 90% of the cases the biopsy is benign and the discharge stops after the removal of the abnormal duct. These patients are returned to routing follow-up. The majority of cancers that are identified with this procedure are early cancers that have an excellent prognosis.
The ductoscope is a newer technology that allows the observer to look directly into the breast ducts. The procedure can be done in the office and seems to be fairly well tolerated. Its role is yet to be defined. However, since most breast cancers start in the ducts, it is exciting to have new technology that allows us to visualize the duct.
Ductal lavage is a relatively new technique that evaluates a relatively large sample of cells that are washed out (i.e. lavaged) from the ducts. We are concerned about the costs of this procedure. We have so far concluded the limited benefit is not justified by its cost.