The investigation and management of unilateral nipple discharge.

INTRODUCTION: Between 16,000 and 48,000 women are estimated to present to UK breast clinics with nipple discharge each year. The incidence of malignancy in these women is 2.7-24.2%. Currently, there is no consensus on the best way to investigate and manage these women. The aim of this study was to assess the rate of malignancy in women presenting with unilateral nipple discharge, and to evaluate the role of examination, imaging and cytology in reliably predicting outcome. METHODS: Breast units were asked to prospectively collect data on all new patients with unilateral nipple discharge. Data collected included discharge colour, whether it was uniductal or multiductal, examination and imaging findings, cytology results and outcome. RESULTS: Complete datasets were submitted by 5 units on 228 patients. The incidence of malignancy was 4.4%. Clinical examination was valuable in detecting malignancy and multiductal discharge was not related to malignancy. The positive predictive value for detecting malignancy for an abnormality found on mammography was 53.5% and for ultrasonography, it was 65.2%. The role of cytology in detecting malignancy was inconclusive with positive predictive values of the presence of red blood cells and epithelial cells at 6.1% and 10.7% respectively. CONCLUSIONS: A large number of women are investigated for nipple discharge (with huge resource implications) but there is little reliable evidence on the best way to investigate and manage these patients. A larger study is needed to evaluate the role of investigations in nipple discharge to produce guidelines on optimal management.

Evaluation and management of pathological nipple discharges without using intraductal imaging methods.

BACKGROUND: The most common cause of pathological nipple discharge (PND) is single papilloma, which is a benign intraductal lesion (BIL). However, underlying malign (MIL) or high-risk intraductal lesions (HIL) should be considered during examination. AIM: To reveal the value of conventional imaging methods (CIM), discharge characteristics, and cytology in lack of intraductal imaging methods to detect intraductal lesions (IL) and MIL that cause PND. METHODS: We compared the pathological findings with the characteristics of discharge, CIM, and cytology findings of the patients who admitted to our clinic with nipple discharge and underwent duct excision (n = 111). RESULTS: IL were detected in 69 (62.2%) patients as BIL (n = 31), HIL (n = 23), and MIL (n = 15). Most of the IL was observed with bloody, serosanguineous, and serous discharges (83.3%, 76.2%, and 69.2%, respectively). The sensitivities of ultrasonography, MRI, and cytology in detecting IL were found to be 50.7%, 42.6%, and 74.1%, while their specificities were found to be 73.8%, 88.2%, and 48.6%, respectively. None of the CIM was sufficient to detect MIL in 5 (33.3%) patients. The appearance of red blood cells detailed in cytology was significantly related to IL (p < 0.01), whereas the presence of inflammatory cells was related to ductal ectasia and periductal mastitis (p < 0.001). CONCLUSIONS: Although patients' physical examinations, CIM, and cytology findings were normal, duct excision procedures should be applied to exclude MIL or HIL, which can be a cause of discharge in case of suspicious color. The details in cytology reports have a role in increasing the value of cytology.

Implications of nipple discharge in Hong Kong Chinese women.

INTRODUCTION: There are no recent data on nipple discharge and its association with malignancy in Hong Kong Chinese women. This study reported our 5-year experience in the management of patients with nipple discharge, and our experience of mammography, ultrasonography, ductography, and nipple discharge cytology in an attempt to determine their role in the management of nipple discharge. METHODS: Women who attended our Breast Clinic in a university-affiliated hospital in Hong Kong were identified by retrospective review of clinical data from January 2007 to December 2011. They were divided into benign and malignant subgroups. Background clinical variables and investigative results were compared between the two subgroups. We also reported the sensitivity, specificity, and positive and negative predictive values of the investigations that included mammography, ultrasonography, ductography, and cytology. RESULTS: We identified 71 and 31 patients in the benign and malignant subgroups, respectively. The median age at presentation for the benign subgroup was younger than that of the malignant subgroup (48 vs 59 years; P=0.003). A higher proportion of patients in the malignant subgroup than the benign subgroup presented with blood-stained nipple discharge (87.1% vs 47.9%; P=0.002). Mammography had a specificity of 98.4% and positive predictive value of 66.7%; ultrasonography had a specificity of 87.0% and negative predictive value of 75.0%. Cytology and ductography were sensitive but lacked specificity. Ductography had a negative predictive value of 100% but a low positive predictive value (14.0%). Clinical variables including age at presentation, duration of discharge, colour of discharge, presence of an associated breast mass, and abnormal sonographic findings were important in suggesting the underlying pathology of nipple discharge. Multiple logistic regression showed that blood-stained discharge and an associated breast mass were statistically significantly more common in the malignant subgroup. CONCLUSIONS: In patients with non-blood-stained nipple discharge, a negative clinical breast examination combined with negative imaging could reasonably infer a benign underlying pathology.

The impact of malignant nipple discharge cytology (NDc) in surgical management of breast cancer patients.

BACKGROUND: The role of nipple discharge cytology (NDc) in the surgical management of breast cancer patients is unclear. We aimed: (i) to evaluate the effect of malignant NDc on the surgical approach to the nipple-areola complex, and (ii) to verify the association between malignant NDc and nipple malignancy. METHODS: We retrospectively analyzed a case series of 139 patients with NDc who underwent breast surgery. The clinical and histological findings, types of surgery with emphasis on nipple-areola complex amputation, immunohistochemical phenotypes of the carcinomas and measurements of the tumor-nipple distance were recorded. Additionally, in patients who showed HER2-positive lesions on definitive surgery, we evaluated the HER2 immunocytochemistry of the NDc smears. RESULTS: Thirty-two malignant and 107 benign/borderline NDc diagnoses were identified. All 32 malignant-NDc cases were histologically confirmed as malignant. Thirty borderline/benign-NDc cases were histologically diagnosed as malignant (sensitivity 58%). The majority of the patients with malignant NDc were treated with nipple-areola complex amputations in both the mastectomy and conservative surgery groups (P<0.001, χ251.77). Nipple involvement was strongly associated with HER2-positive ductal carcinoma in-situ (P<0.001, χ211.98). HER2 immunocytochemistry on the NDc revealed a 100% correlation with the immunocytochemistry performed on the surgical tissues. CONCLUSIONS: Malignant NDc influenced surgical management. The association of malignant NDc with nipple involvement is highly related to ductal carcinoma in-situ with HER2 overexpression. In case of HER2 positive NDc, nipple-areola complex involvement is more likely than in HER2 negative cases.