The first question is, “Does the discharge come out spontaneously, or only when you squeeze your nipples?” For reasons unclear to me, many women are under the impression that squeezing the breast and nipples is part of the normal process of breast self-exam.
When a woman tells me she notes the discharge only when squeezing the breast, I tell her the first thing to do is stop squeezing. As it turns out, most women, whether previously pregnant or not, are able to get a drop or more of fluid with vigorous squeezing. But this type of discharge is normal. In most instances the discharge stops when the forceful pressure stops.
The second question is, “What does the discharge look like?” In most cases she will say the discharge is white, green, or other light colors, and I respond that this is of no concern.
If a woman says that it is dark in color, like old blood, or clear, like water, it could be associated with an underlying malignancy.
The clinical exam is just as important as the history. One of the major indicators that we could be dealing with a more serious breast condition is when the discharge is obvious with gentle squeezing of the breast. When it’s difficult to reproduce the discharge on clinical exam, the odds of it being related to cancer are markedly reduced.
Another clue that suggests a more serious underlying condition is when the discharge is limited to one spot in the nipple. Each breast has ten to fifteen major ducts, the tubes that transport milk to the nipple. When I compress the nipple I look carefully to determine the source of the discharge. If it comes from several ducts, I can be almost certain it is not associated with a malignancy.
Conversely, if the discharge comes from a single duct, a biopsy will likely be required. Nipple discharges associated with a hidden malignancy nearly always come from a single milk duct. In such cases a more detailed evaluation is mandatory.
We make certain that every patient seen in our center with a new nipple discharge has an updated mammogram. If there is even the slightest concern that a discharge may be associated with an underlying breast problem, we do a diagnostic mammogram and ultrasound to look for calcifications or other breast changes. Of course if an area of concern is noted, we perform a biopsy.
The second test that helps us determine the significance of discharge is the breast ultrasound. Often, the ultrasound will visualize an enlarged duct that contains a small mass. An ultrasound-guided core needle biopsy (see chapter seven) would almost always provide a specific diagnosis.
When the mammogram and ultrasound are negative but the discharge persists, an open surgical procedure is usually the next step. The challenge for the surgeon is to make certain the proper duct is removed—and this can be a problem, especially if the discharge is intermittent.
In cases of suspicious discharge, doctors commonly order a special X-ray study of the breast. Called a ductogram, the procedure is simply a study that outlines the internal structure of the breast duct. The procedure involves the placement of a small tube into the discharging duct. A contrast material is gently injected into the opening. Afterward, we do a breast X-ray, and the duct typically lights up, looking much like a branching tree with no leaves.
Normal ducts are smooth and round. When an abnormal growth causes the discharge, it typically shows up as a round or irregular mass that fills or blocks the duct. If the ductogram is completely normal, the patient can be safely observed. However, in some cases, the duct system is not adequately visualized, which usually means surgical removal is the next step.
In our center we prefer to do the ductogram on the morning of surgery. This avoids the problem of not finding the duct on a second attempt. After injecting the contrast material the radiologist injects a drop or two of blue dye to make it more visible to the surgeon. The entire duct, which is often an inch or more in length, is removed and sent to the pathologist.
In the majority of cases, the cause of the discharge is not associated with a malignancy—and thus removal of the discharging duct is curative. The most common cause of spontaneous nipple discharge is a small growth within the duct that is referred to as a papilloma, which is almost always benign. There are other causes of discharge for nipple discharge that are non-cancerous in origin—and all are cured with the removal of the discharging duct.
In approximately 5 percent of cases the discharge is caused by cancer and additional surgery is required. When the discharge is not associated with a breast mass or suspicious changes on the mammogram, the malignancy is almost always detected when it is small and the prognosis is excellent.
Although most cases of nipple discharge are easy to sort out, there are some in which it is difficult to determine the cause. A typical example is a woman who notes what appears to be a spontaneous discharge that looks like old blood, which seems to be coming out of a single duct. Episodes of discharge may occur for a few days and then disappear for weeks. With these patients, the discharge is often gone by the time she sees the doctor. It is common for the woman to bring in her bra, which has spots that resulted from her episodes of spontaneous discharge.
Yet even with intermittent discharge it is common to have a completely normal physician exam and normal breast imaging. In the past we simply followed up with these patients at regular intervals and instructed them to return immediately when the discharge recurred.
Now we have a more effective approach for clarifying the problem of such discharge. If a patient’s history is suggestive of a possible malignancy and the workup is completely normal, I recommend an MRI of the breast. When the MRI is normal, I explain to the patient that for practical purposes we can assume she does not have cancer. We continue to keep a watchful eye, but I have yet to see or hear of a case in which the MRI missed cancer as a cause of nipple discharge.
WHAT I’D TELL MY DAUGHTER
• Be concerned about a discharge that occurs on its own without squeezing.
• Any nipple discharge that occurs without squeezing should be evaluated by a physician. (This includes spots on one’s bra, even if discharge is not visible.)
• Spontaneous discharge that is bloody or clear is of high concern. Discharge that is white, green, or other colors is rarely associated with a malignancy.
Uncommon but Perilous Breast Problems
Infiltrating Lobular Cancer: The Devil’s Cancer
WHILE EARLY DETECTION PROTOCOLS work for the majority of women, they, like most things in life, are not perfect. One of the most frustrating situations in my practice occurs when a woman who has consistently followed recommended guidelines is diagnosed with a large, advanced breast cancer.
Although this is a rare event, there’s one type of malignancy that can be almost impossible to detect before it reaches the size of a large lemon. The proper medical name is infiltrating lobular cancer, but we refer to it as the Devil’s Cancer.
The majority of breast cancers arise in the ducts, tubes that connect the milk-producing glands to the nipple. The malignancies that begin here are called infiltrating ductal cancers. They are typically easy to diagnose on screening mammograms long before they grow to the size