CANCER TREATMENT REVIEWS 2001; 27: 275282

doi: 10.1053/ctrv.2001.0234, available online at http://www.idealibrary.com on

TUMOUR REVIEW

Nipple discharge: current diagnostic

and therapeutic approaches
G. H. Sakorafas
Department of Surgery, 251 Hellenic Air Force Hospital, Athens
Nipple discharge is a complex diagnostic challenge for the clinician. A variety of diseases (such as intraductal papillomas,
mammary duct ectasia, breast cancer, pituitary adenomas, breast abscesses/infections, etc.) can manifest as nipple discharge.
The importance of nipple discharge for both the patient and the physician is the possible association of this condition with an
underlying carcinoma. With heightened public awareness of breast cancer, an increasing number of women are asking their
health care providers about nipple discharge. A detailed clinical evaluation is invaluable to determine the pathophysiology,
assess the risk of malignancy, and plan treatment of the patient with nipple discharge. A combination of diagnostic tests,
including mammography, breast ultrasonography, and possibly galactography can help the clinician to establish the diagnosis
and plan proper management. Depending on the underlying breast pathology, a central or single lactiferous duct excision is the
procedure of choice. Breast carcinoma associated with nipple discharge should be treated by either a modified radical
mastectomy of breast-conservation therapy (i.e. duct-lobular segmentectomy with adequate, free margins [ideally >1 cm],
levels I and II axillary lymph node dissection, followed by breast irradiation). & 2001 Harcourt Publishers Ltd
Key words: Breast cancer; mastectomy; duct excision; nipple discharge; galactorrhea.

INTRODUCTION
Nipple discharge is a not-infrequent complaint
among women and is often the first indication of an
underlying breast pathology. It is the presenting
symptom in 310% of all women with breast- related
complaints and occurs in 1050% of women with
benign breast disease (1,2). Nipple discharge causes
patient anxiety and physician concern. Cancer must
be ruled out as a cause. Approximately 215% of
women and up to 20% of men who undergo surgery
for significant nipple discharge will be found to have
an underlying breast carcinoma as the cause of the
nipple discharge (35). Until the 1950s, mastectomies
were performed unnecessarily without obtaining a
histopathologic diagnosis since nipple discharge was
considered as a definite indicator of carcinoma of the
Correspondence to: George H. Sakorafas MD, Arkadias 1921,
GR-11526Athens,Greece,Tel:0013017487318;Fax:0013017487192;
E-mail: georgesakorafas@yahoo.com
0305-7372/01/027275 08 $35.00/0

breast (6,7). Recent advances in the diagnostic evaluation of patients with breast diseases allow a more
rational approach in the treatment of nipple discharge. The underlying, causative condition should
be recognized following a careful diagnostic investigation and appropriately treated. The aim of this
review is to summarize the currently available diagnostic approach and the therapeutic options in the
management of patients with nipple discharge.

DEFINITION CLASSIFICATION
A nipple discharge is a true, direct drainage from the
mammary duct or ducts, which appears on the surface of the nipple. Nipple discharge is considered as
clinically significant when it is spontaneous, persistent, and non-lactational discharge (8). This is an
important consideration, since approximately 2050%
of women will produce nipple secretions following
breast manipulations (such as breast massage or
nipple aspiration by using a specific device (9,10)).
& 2001 HARCOURT PUBLISHERS LTD

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G. H. SAKOR AFA S

Macroscopically, there are many types of nipple

discharge. Milky, multicoloured and purulent secretions are treated medically, except for an abscess
concomitant with a purulent discharge. Other types
include clear or watery, yellow or serous, pink or
serosanguineous, and bloody or sanguineous. These
four types may indicate an underlying cancer and,
therefore, often require surgery to obtain tissue and
achieve a histopathological diagnosis. Nipple discharge in breast cancer usually implies tumour
infiltration into the ductal system (11).
Pathogenetically, nipple discharge may be divided
into two categories:



Non-neoplastic
Neoplastic.

NON-NEOPLASTIC
Galactorrhea
Galactorrhea is milky, from multiple ducts or both
breasts. It is most commonly observed after pregnancy and can last for 12 years (8). It may also occur
in young girls as they enter puberty and may last
for several months to a year without any underlying
pathology. Galactorrhea may be idiopathic or secondary to chest wall trauma, endocrine abnormalities
(most commonly prolactinomas, but also hypothyroidism and hyperthyroidism) or certain medications, including exogenous estrogen, tricyclic
antidepressants, cannabis, antihypertensives, phenothiazines, H2 antagonists, antipsychotic agents, oral
contraceptives etc. (12,13). These drugs cause galactorrhea by altering the endocrine pathway (hypothalamic-pituitary axis) for lactation. A common
mechanism is to suppress the inhibitory effect of
dopamine and thus increase the secretion of prolactin
from the anterior pituitary.

Physiologic
Physiologic nipple discharge is not spontaneous and
may be caused by breast or nipple manipulation
when checking for nipple discharge, by exogenous
estrogens, or by sexual stimulation. It is generally
bilateral, serous, and arises from multiple ducts.

Nipple discharge and pregnancy

Nipple discharge, unilateral or bilateral, even bloody
secretion, without significant underlying breast pathology, can be observed during pregnancy, usually in

the second trimester, and can continue as long as two

years after pregnancy and lactation (14). In this setting, nipple discharge is probably due to the epithelial development and to the projection of multiple
spurs of tissue, resembling minute papillomas, which
project into the ducts and alveoli; a delicate capillary
networks is then developed within the ducts. These
pseudo-papillomas are covered with only a single
layer of epithelial cells, and can easily be traumatized
and rupture or desquamate causing bloody nipple
discharge during pregnancy and lactation (15). The
presence of a mass should be excluded by a careful
physical examination, and these patients should be
followed at monthly intervals. This problem is
usually resolved following delivery and there are no
contraindications to breast-feeding.

Periductal mastitis
Non-puerperal periductal mastitis is another frequent
cause of a multicolored, sticky nipple discharge (16).
When infection is suspected, medical management
(which includes local care, improved nipple hygiene
techniques, avoidance of all nipple manipulation,
non-steroidal anti-inflammatory agents, bromocriptine, and anti-staphylococcal antibiotics) is indicated and is usually successful. In the case of a
lactating patient, the infant may need to be weaned
for the mastitis to resolve. However, if the inflammation results in the formation of an abscess, surgical
excision and drainage is necessary. It should be noted
that in the non-lactating woman, a necrotic breast
cancer albeit unusual can be misdiagnosed as a
breast abscess (13). Therefore, a biopsy of the abscess
wall should be performed during the incision and
drainage of the breast abscess. A non-healing eczematoid lesion of the nipple must be biopsied to
exclude Paget's disease of the breast (17).

Mammary duct ectasia

Mammary duct ectasia is the end result of increased
glandular secretions by the lactiferous ducts and
sinuses responding to the constant variation in estrogen and progesterone levels. Mammary duct ectasia
is often associated with chronic duct inflammation
(periductal mastitis). This results in a multicolored
nipple discharge (green, yellow, white, brown, gray,
or reddish brown). Usually the discharge originates
from multiple ducts and is often bilateral. Cytology
can show desquamated epithelium. An excisional
biopsy will show fibrosis and scarring of the lactiferous ducts and sinuses filled with a cellular material and desquamated epithelium (18).

NIPPLE DISCHARGE

NEOPLASTIC
Neoplastic nipple discharge is usually unilateral,
localized to a single duct, spontaneous, intermittent
and persistent (3). The character of the fluid may be
bloody, serosanguinous, watery, cloudy, serous, or
green-gray. Neoplastic nipple discharge is usually
due to benign breast disorders, even when the fluid is
bloody. The commonest cause of neoplastic nipple
discharge is intraductal papilloma and papillomatosis, which account for about 45% of cases of nipple
discharge (19). Non-neoplastic causes of nipple discharge accounts for 40% of cases (25% and 15% are
secondary to mammary duct ectasia and fibrocystic
disease, respectively) (20). Only about 10% (range:
215%) of all of cases of pathologic nipple discharge
are secondary to carcinoma (21), and only one to five
per cent of all breast cancers are presented as nipple
discharge (20). Factors which are considered predictive of cancer include age above 55, bloody discharge, and the presence of a mass (2022). In one
study, 32% of the women older than 60 years of age
with spontaneous nipple discharge were found to
have an underlying carcinoma, whereas only 7% of
the women younger than 60 had a similar diagnosis
(23). Although a mass is usually present when the
discharge is due to cancer, there is no palpable mass
in 13% of cancers with nipple secretions (20).

277

discharge has stopped or is still present. In this

case the physician should reassure the patient that
malignancy is found in only a small percentage of
women with nipple discharge; the patient should be
encouraged to stop the manipulations of her breast.
Nipple discharge can be caused from a poorly fitting
brassiere, which firmly compresses the breast; this is
usually observed in young women (24). The physician should next determine whether the discharge is
unilateral or bilateral. Physiologic changes or a systemic disorder usually result in bilateral nipple discharges. A thorough breast examination should next
be performed. The physician should recognize any
pathological physical finding, such as retraction or
eczema of the nipple, dimpling of the skin, inflammatory changes, a breast mass (usually subareolar,
but also elsewhere in the breast), and axillary
lymphadenopathy. It is very important to recognize
during clinical examination the quadrant of the breast
from which the drainage emanates and to determine
if the discharge comes from one or several ducts of
the nipple. A magnifying glass may be very helpful
to determine this accurately. In a woman with an
intraductal lesion, a trigger point can commonly be
identified. Although not usually associated with a
palpable abnormality, compression of this trigger
point reliably produces the discharge.

Mammography

DIAGNOSTIC EVALUATION
The importance of nipple discharge for both the
patient and the physician is the possible association
of this condition with breast cancer. However, in
general, nipple discharge is more commonly associated with benign rather than malignant lesions. A
careful diagnostic evaluation should be performed to
recognize and appropriately treat the underlying
causative pathology.

Clinical evaluation
A detailed history should be obtained from any
patient with nipple discharge. At the time of the
initial visit, a careful history should be obtained to
determine whether the discharge is consistent with
galactorrhea, physiologic, or pathologic nipple discharge. It is important to determine whether the
discharge is noticed only with breast manipulation or
is spontaneous. When the discharge follows breast
manipulation, the surgeon should remember that the
influenced patient often manipulates the breast and
nipple even more, trying to discover whether the

Mammography is indicated in any patient with a

pathologic nipple discharge. Mammography can
reveal occult lesions, such as carcinoma, fibrocystic
changes, fat necrosis, and calcifications. Mammary
duct ectasia may be manifested as a dilated duct and
a carcinoma may be manifested by a mass, microcalcifications, or altered architecture of the breast
parenchyma. However, the physician should
remember that a negative mammogram does not
exclude breast carcinoma. In the study by Tabar et al.
(25) only half of the patients who presented with
nipple discharge and were diagnosed with breast
cancer had an abnormal mammogram.

Breast ultrasonography
Breast ultrasonography is a non-invasive diagnostic method, useful in the evaluation of patients
with nipple discharge; breast ultrasonography is
complementary to mammography. Due to recent
advances in ultrasound equipment, parts of the
ductal system measuring more than 0.5 mm in diameter can be clearly visualized. Breast ultrasonography may be useful in evaluating not only the

278

nature of an underlying lesion of the breast (i.e. cystic

vs solid tumours), but also its relationship with the
involved ductal system, and the transporting route
(single vs. multiple) to the nipple of the pathological
discharge caused by the mass (26). This is an advantage of ultrasonography over galactography, which
demonstrates only the lactiferous duct into which the
canulla is inserted. However, breast ultrasonography
is inferior to galactography in the detection of microcalcifications, and has a limited role in the detection
of peripheral small masses without ductal dilatation
and small lesions in excessively fatty breasts (27).

Fine needle aspiration (FNA)

FNA is a safe and effective first step in evaluating a
dominant breast mass and should be performed on
all palpable masses (28). However, false negative is a
limitation of this method and diagnosis may not be
possible due to inadequate sampling; in this case, an
excisional biopsy is necessary and remains the standard diagnostic approach of breast masses and in the
process of the decision-making (2830).

G. H. SAKOR AFA S

mainly due to its low sensitivity. However, cytology

may be a complementary examination during the
diagnostic evaluation of the patient with nipple discharge and has an acceptable specificity (up to 100%)
(33,36).

Tumour markers
Measurement of the carcinoembryonic antigen (CEA)
in nipple discharge has been proposed for the identification of patients with an underlying breast
cancer, since increased levels of CEA indicate the
presence of cancer (37). Levels of c-erbB-2 protein (38)
and of lactate dehydrogenase isoenzymes (39) have
also been proposed as useful parameters. Isoenzyme
levels in breast cancer nipple discharge tend to
increase in ascending order from LDH1 to LDH5 (39).
Measurement of c-erbB-2 protein levels in the nipple
discharge has been recently proposed as a useful
prognostic factor to estimate the aggressiveness of
the tumour (38). However, from a clinical point of
view, it should be noted that, at the present time, the
physician can not rely on tumour markers determinations to make therapeutic decisions, mainly due to
the low sensitivity of this diagnostic method.

Nipple discharge cytology

The first cytological diagnosis of breast carcinoma
from malignant cells in nipple discharge was made in
1914 (31). However, although the role of fine needle
aspiration cytology in the diagnosis of breast disease
is well established, exfoliative cylogical examination
of nipple discharge and scrape smears received considerably less attention. This is mainly due to its low
sensitivity (32). Exfoliative cytology of the breast is
inherently difficult because breast carcinoma cells are
generally smaller and less pleomorphic than those
arising from other organs and the cytological criteria
of malignancy are less evident in the often degenerated cells found in nipple discharge smears (33).
Nipple smears taken during the middle and third
trimester of pregnancy and in the postpartum patient
are very cellular and difficult to interpret (9). Moreover, spontaneous nipple discharge occurs in less
than 10% of patients with breast carcinoma; malignant cells are not always present in the nipple discharge and are found more frequently if a tumour lies
in a major duct and with smaller tumours more often
than large (34). The diagnostic rate may be improved
if multiple slides are prepared from more than one
examination since neoplastic cells are often detected
in the later smears since the discharge is often more
cellular in the last drops of secretions (35). It should
be emphasized that the clinician cannot rely on nipple
discharge cytology to make therapeutic decisions,

Galactography
Galactography was introduced more than 60 years
ago but was not widely used until the 1960s, when
this method was proposed to identify and to localize
intraductal pathology (25,40,41). Nowadays, its routine use in this clinical setting remains controversial.
The primary indication for ductography is spontaneous, ulilateral, single-duct nipple discharge
regardless of its appearance (41). The procedure
entails the identification and cannulation of the
secreting duct followed by injection of a sterile watersoluble contrast material. The `trigger point' should
be determined, as previously described. The most
difficult procedure in galactography is the gentle
insertion of a blunt needle or cannula into the lactiferous ducts (42,43). The use of good lighting (halogen lamp) and of magnifying glass greatly facilitates
the procedure. The specific discharging duct orifice is
identified; usually it is more patulous and slightly
erythematous compared with adjacent normal duct
openings (41).
If a trigger point has been found it can be used to
elicit a small droplet of fluid at the ductal opening.
A plastic catheter of a blunt sialography needle can be
used to cannulate the duct. The introduction of a
monofilament polypropylene guiding suture into
the secreting duct may facilitate the subsequent

NIPPLE DISCHARGE

introduction of the catheter (43). Usually, the catheter

``falls'' painlessly into the duct all the way to the hub.
A small amount (0.20.4 ml) of undiluted watersoluble contrast material is gently injected. The injection is stopped if the patient has pain or burning. The
catheter is secured on the nipple with paper tape.
Subareolar magnification images in the craniocaudal
and 90 lateral positions are obtained. Leaving the
cannula in the duct minimizes the amount of contrast
material that leaks out during compression and preserves the ability to inject additional contrast agent
without the need for recannulation. Some have
advocated injecting the abnormal duct with a dilute
methylene blue solution just before the excision
so that it can be performed more precisely by the
surgeon and result in less breast tissue resection.
Galactography is more sensitive than either cytology or mammography in the detection of intraductal
lesions, but accurate differentiation of benign and
malignant ductal tumours by galactography alone is
impossible (26,40). Moreover, galactography cannot
identify multiple lesions or lesions in multiple ducts.
Ductographic findings suggestive of carcinoma
include irregular filling defects, ductal irregularities (distortion, displacement, complete obstruction
to flow of contrast, and contrast extravasation)
(25,41,44). Intraductal, smooth filling defects, complete ductal obstruction, ductal expansion with
apparent distortion and irregularity of the ductal
wall are the more common ductographic findings
seen with solitary papillomas; ductographic findings
in mammary duct ectasia include dilatation of the
ducts, with minimal branching and parenchymal
distribution (41). In general, most of the centrally
located, solitary intraductal tumours are benign
papillomas, while multiple or peripherally located
papillomas arising from the termilar ductal-lobular
unit have pre-malignant potential. Carcinomas tend
to be more irregular and deeper in position (41,45,46).
Galactography can improve the surgical localization of the underlying pathologic lesion and this
permits the performance of a more conservative
excision of breast parenchyma (47,48). The result is a
more acceptable cosmetic result. Accurate localization is also very important in women with large
breasts where a lesion may not be resected during a
routine duct excision or in a woman with a lesion
located in the peripheral ductal system (47). Without
accurate localization the surgeon should perform
either a mastectomy or a more extensive local
excision.
Galactography has the risk of causing mastitis
attributable to the contrast medium. There are not
absolute contraindications to ductography; relative
contraindications include the presence of a breast
abscess or diffuse mastitis as it may exacerbate the
inflammatory process (25,48). If too much contrast

279

material or pressure is used during injection, peripheral extravasation, lymphatic opacification and
even duct perforation (evidenced as a dense subareolar blush) may complicate the procedure. An
intense pain and severe burning during the contrast
injection should be viewed with a high index of
suspicion for these complications. Another potential
problem is the non-detection of small lesions if too
much contrast material is injected; to avoid this problem, it is advisable to begin with small amounts and
additional contrast material can be injected if initial
images show the duct is inadequately opacified (48).

Fiberoptic ductoscopy
Mammary duct (fiberoptic) ductoscopy has been
under investigation for more than a decade and has
recently received more attention as advances in technology provide smaller caliber scopes with improved
optics (4953). There is now available an extremely
small (d 0.9 mm) mammary ductoscope, with a
0.2 mm working channel. The improved technology
and smaller size of this instrument allow visualization and sampling from ducts with a suspected
pathology. The use of mammary ductoscopy may
improve the sometimes unsatisfying procedure of
duct excision for patients with pathologic nipple
discharge. There is evidence that in the future this
diagnostic method may have a place in the management of patients with breast cancer or even in screening of women who are at high risk (49). Moreover,
recent technological advances allow the performance
of therapeutic interventions through the working
channel of the instrument. Intraductal radiofrequency ablation and laser treatments and intraductal drug delivery via the mammary ductoscope
are just a few of the concepts already being
investigated (4953).

Investigation for extramammary causes of

galactorrhea
A careful drug history should be taken from a patient
presenting with galactorrhea. Prolactin levels and
thyroid function tests should then be performed.
Thyroid diseases should be evaluated and appropriately treated. If hyperprolactinemia is identified, a
pituitary adenoma should be suspected and the
patient referred for appropriate management. Large
pituitary tumours may cause visual field deficits. It
should be noted that transient and moderate elevation of prolactin levels has been associated with breast
stimulation, chest trauma, or thoracotomy. If the
investigation is without pathologic findings, the

280

G. H. SAKOR AFA S

patient should be assured that the galactorrhea is

rarely, if ever, associated with breast cancer. Ergot
derivatives and bromocriptine have been used in the
management of patients with severe idiopathic
galactorrhea and regular menses or amenorrhea,
respectively (12).

SURGICAL CONSIDERATIONS
The management of patients with `surgical' nipple
discharge involves a systemic approach. Systemic
causes of nipple discharge should be appropriately
managed, depending on the underlying cause
(Figure 1). During initial diagnostic evaluation, the
surgeon should determine if the discharge is spontaneous or caused by breast compression. Usually,
nipple discharge caused by `surgical diseases' of the
breast is produced from a single lactiferous duct and
is unilateral and spontaneous. The surgeon should
localize the specific `trigger point' on the breast, as
previously described (19). Frequently, the patients
have already localized this point before their examination. As previously noted, the etiology of `surgical'
nipple discharge is a pathologic abnormality of the
lactiferous ducts, such as intraductal papilloma,
fibrocystic change, breast abscess, and a malignant
neoplasm. If a palpable mass or a suspicious (on
mammography) lesion is present, an excisional biopsy should be performed, followed by the appropriate management, as indicated (2830). The
management of patients without a palpable or suspicious (on mammography) lesions is more challenging. Mammography is necessary to exclude
non-palpable breast lesions (i.e. micro-calcifications)
that may be associated with the nipple discharge.
Two therapeutic options are available in the surgical management of patients with surgical nipple

SYSTEMIC CAUSES

NIPPLE
DISCHARGE

MANAGEMENT

DIAGNOSTIC EVALUATION

SURGICAL NIPPLE DISCHARGE

Usually unilateral, spontaneous, from a
single or multiple lactiferous duct(s)

WITH A SUSPICIOUS LESION

(clinically and/or mammographically)

Excisional Biopsy
WITHOUT A SUSPICIOUS LESION
(clinically and/or mammographically)
Management as indicated

Central Duct
Excision

Single lactiferous
duct excision

(for pts with significant

nipple discharge from
multiple ducts)

(for pts with nipple

discharge from a single
duct) (localize the
trigger Point)

If Breast Cancer (*)

Modified
Radical
Mastectomy

Breast
Conservation
Therapy

Figure 1 Algorithm for the management of patients with nipple

discharge. (*) Axillary lymph node dissection is not indicated for
patients with ductal carcinoma in situ of the breast (DCIS).

discharge: the central duct excision and the single

lactiferous duct excision (Figure 1). Both procedures
can be performed under general or local anesthesia.
Complete central duct excision of the affected breast
(or excision of major mammary duct system) achieves removal of all the lactiferous ducts and sinuses
of the breast. This method, first described by Adair
and then in detail by Hadfield in 1960 (54) is indicated in patients with significant nipple discharge
from many ducts. In its classical form, the operation
can be performed through a circumareolar incision
for one-half of the areolar circumference over the
lower part of the areolar-cutaneous junction. The full
thickness of the areola is elevated sharply as a flap to
gain exposure to the terminal ducts by a subareolar
dissection. During dissection, meticulous hemostasis
should be obtained. If during the dissection a single,
dilated duct is identified it is then excised. If multiple
ducts are dilated or if none appears grossly abnormal,
all the lactiferous ducts and sinuses are excised. In
either case, the dissection should extent at a distance
of approximately 35 cm. To achieve complete
removal of the ductal system and excision of even
superficial lesions, the ducts should be transected at
the level of the dermis of the nipple. A better cosmetic
result can be achieved by leaving the residual cavity
to be filled with serum and by avoiding the use of
drains. A potential complication of the procedure is
the compromise of the neurovascular supply to the
nipple/areola complex; partial necrosis of nipple/
areola may result in some cases. Loss of nipple sensation is a much more common complication (55).
The main advantage of this method is that it prevents
further nipple discharge from missing multiple
intraductal papillomas, and decreases the incidence
of not removing all of the diseased lactiferous ducts
and sinuses (13). Disadvantages include the possibility of cosmetic deformity around the nipple/areola
complex. Moreover, in women of child-bearing age,
this procedure could limit their ability to breast
feed.
The other alternative surgical technique is the
removal of the diseased lactiferous duct, sinus, and
mammary gland tissue. This method is known as a
single duct excision and has the advantage of tissue
preservation, which may be important for women of
child-bearing age, who want to breast-feed. The
disadvantage is the possible failure to excise the
involved lactiferous duct, thereby resulting in a falsenegative biopsy or the inability of the method to
excise multiple lesions of the lactiferous ducts/sinuses. At the time of surgery, if preoperative galactography was not performed and methylene blue dye
was not injected into the duct, the secreting duct can
be cannulated with a lachrymal duct probe to aid in
the dissection and limit the resection of breast tissue.
This cannula should be left in place and will serve as

NIPPLE DISCHARGE

a guide to the surgeon and possibly to inject

methylene blue to facilitate visualization of the
abnormal duct (13). Alternatively, and after identifying the duct responsible for the nipple discharge
(for example, the duct containing the papilloma), the
duct should be clamped at the base of the nipple.
Using a hemostat, the duct is grasped and a coneshaped sector of mammary tissue surrounding the
disease is excised down to a depth of 35 cm. Again,
the residual cavity is left open and without drainage.
Single lactiferous duct excision can easily be performed through shorter circumareolar incisions (i.e.
for one-third or even one-fourth of the circumference
of the areola) exactly at the areolocutaneous junction
(56). This is important to prevent the complications
from the nipple/areola complex. The incision should
be placed to gain the greatest exposure, as the
quadrant of the breast from where the discharge
comes should be known (see `trigger point').
Duct ectasia generally does not require surgery
and should be managed conservatively (i.e. hygiene
measures). However, sometimes surgery may be
required, for example in the presence of a suspicious
mass, if the discharge is serosanguineous or sanguineous, etc. Infectious causes of nipple discharge
(evidenced by the presence of purulent discharge and
local inflammation) should be treated by the administration of antibiotics, but an abscess requires
incision and drainage (14).
As previously noted, factors associated with an
increased risk of an underlying breast cancer are age
above 55, bloody discharge, and the presence of a
mass (2022). Obviously, the patients who are diagnosed as having, or are strongly suspected of having
cancer (based on the results of clinical examination,
mammography and/or ultrasonography and fineneedle aspiration) need surgery, but it remains
debatable what the final surgery should be (Figure 1).
In the past, mastectomy was the preferred procedure,
because the concept of limited surgery had not been
established. Nowadays, the surgeon should consider
whether there is a possibility of a more limited surgery (i.e. breast-sparing procedures) for this type
of breast cancer. Although experience is limited
because of the small number of patients, duct-lobular
segmentectomy with an adequate free margin
(ideally > 1 cm) should be the procedure of choice for
patients with nipple discharge who are diagnosed or
are strongly suspected of having breast cancer (57).
Intraductal spreading of carcinoma is an unfavorable
pathologic factor in breast-conserving surgery for
patients with nipple discharge (58). Axillary lymph
node dissection (level I and II) and postoperative
breast irradiation should be performed as indicated
in breast-conservation therapy (2830, 59). Axillary
lymph node dissection is not indicated for ductal
cancer in situ (DCIS) (60).

281

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