Changes in the nipple may be an important sign of breast cancer, and any new change should be assessed by a doctor immediately.
Nipple retraction and inversion
People can be born with inverted nipples, where the nipples indent inwards, although on stimulation they will generally face outwards. This is completely normal and does not require assessment by a doctor.
Nipple retraction or inversion that is new, occurring only in one breast, or where the nipple does not come out on stimulation can be a concerning sign of breast cancer. This should be discussed immediately with your doctor.
Skin changes of the nipple
The skin of the nipple can become red and scaly or crusted, or it may thicken. These can be important signs of a types of breast cancer, particularly Paget disease.
Paget disease of the nipple
Paget disease of the nipple is a very rare form of breast cancer, roughly 1-2% of all new breast cancers diagnosed. It presents as a scaly, raw or ulcerated lesion on the nipple, and can spread to the areola. A bloody discharge may be present, although often it may be clear or yellow.
Pain, a burning sensation and itching of the nipple can be present months before the emergence of the typical ulcerated lesion.
A palpable lump can be felt in roughly 50% of cases, and this will typically be behind or close to the nipple and areola but it can be anywhere in the breast.
Nipple discharge
Spontaneous nipple discharge is the third most common reason women present to a breast surgeon. Nipple discharge can be physiological or pathological. It can be associated with benign or malignant pathology. It can cause significant anxiety; however, fortunately it is the presenting symptom for breast cancer in less then 12% of all cases.
The most worrying discharge is a spontaneous single duct unilateral persistent discharge. The consistency and colour of the discharge does not decrease the suspicion for breast cancer.
Discharge due to breast cancer can be clear, sero-sanguineous or bloodstained.
Approximately half of the patients that present with nipple discharge will also have a breast lump and 20% of these patients will have a breast cancer.
Regarding nipple discharge, the questions that need to be answered are:
Is the nipple discharge spontaneous (fluids from the nipple without any squeezing of nipple or pressure on the breasts)? This is often best appreciated when discharge can be seen on the bra or clothing. Or is the discharge only with expression (fluid only is expelled from the nipple when the nipple is squeezed or stimulated or pressure is placed on the breast)?
It is important also to determine if the nipple discharge is unilateral or bilateral (one breast or both breasts)?
Is it coming from one duct or multiple ducts?
What colour is the nipple discharge?
Nipple discharge is common and will occur in up to 70% of all normal women when the breast is massaged or devices such as a breast pump are applied. Fluid discharge even in non-lactating women can be achieved (physiological discharge) with stimulation of the nipple. It is not spontaneous. It is not a cause for concern.
Milky nipple discharge is commonly seen in the normal stages of pregnancy and breastfeeding. Imaging of the breast will usually be undertaken when investigating any nipple discharge but multi duct non-spontaneous discharge will usually not require any surgery. Spontaneous nipple discharge not related to pregnancy or breastfeeding is considered abnormal. Spontaneous nipple discharge confirmed to a single duct which is unilateral is more likely to be associated with underlying pathology such as cancer or DCIS.
Nipple discharge associated with a breast lump ulceration of the nipple and areolar inversion/retraction of the nipple even if it is not spontaneous or blood stained requires urgent investigation.
Causes of Nipple Discharge
Duct ectasia- this is a common problem in which the milk ducts under the nipples enlarge and become inflamed. It is more common in smokers and more common post menopause Discharge from duct ectasia is usually bilateral green, yellow, or brown and usually comes for more than 1 duct. Surgical treatment is usually not required unless it is becoming problematic for the patient and it would normally be in the form of a total duct excision.
Intraductal papilloma- is a small growth (wart-like lesion) within the milk duct usually within 2 cm of the nipple. It can be asymptomatic or it can be associated with a nipple discharge. It usually comes from a single duct and is usually unilateral. In less than 10% of cases, a papilloma can be associated with cancer and surgical excision is necessary. It can occasionally be felt as a small lump near or just beside or beneath the nipple.
Types of Intraductal Papilloma-
Solitary intraductal papillomas: 1 lump usually near the nipple causing nipple discharge.
Multiple papillomas- groups of lumps usually do not cause nipple discharge and usually cannot be felt and usually greater than 2 cm from the nipple.
Papillomatosis, these are very tiny groups of cells within the ducts a type of hyperplasia (too many cells in the ducts scattered throughout the breast).
Intraductal papilloma can be removed with the procedure of microdochectomy. A small incision will be made at the edge of the areola after a probe has been placed in to a discharging duct while the patient is under a general anaesthetic. If a solitary intraductal papilloma is diagnosed at surgery. This will not increase the patient’s risk of breast cancer unless there are atypical cells found in the pathology specimen; however, multiple papillomas or papillomatosis may slightly increase the risk of developing breast cancer.
Dermatitis or eczema- may affect the skin of the nipple. This may cause weeping and crusting over the nipple with nipple discharge. Cortisone-based cream is the first line of treatment. It is, however, important that the problem is properly investigated (with a punch biopsy of the affected skin) if a trial of a cortisone-based cream does not resolve the problem in order to exclude Paget disease.
Paget disease of the breast -is a rare disease of the breast which presents with ulceration, erosion, crusting of the skin over the nipple, and may be associated with nipple discharge. It is important that if there are any changes to the skin over the nipple that this is investigated by a breast surgeon
Breast Cancer -approximately 5% of women with breast cancer will have nipple discharge and some of these will also have other symptoms such as a retracted nipple or a breast lump.
Galactorrhoea- a milky usually bilateral nipple discharge which is not related to pregnancy or breastfeeding. It can occur in men and babies. It occurs when the pituitary gland or the thyroid gland causes the abnormal production of prolactin. Prolactin is a hormone that stimulates milk production.
Some medications can also cause galactorrhoea such as antidepressants, antipsychotics, drugs used to treat high blood pressure, cocaine, opioids, herbal supplement, the oral contraceptive pill, and hormone replacement therapy. Tumours of the pituitary gland, hypothyroidism (under active thyroid), chronic renal disease, and excessive stimulation of the nipples can also cause galactorrhoea.
Management of Nipple Discharge
Dr Thornton will investigate the nipple discharge by performing an examination and reviewing the breast imaging ( mammogram and ultrasound) and also occasionally undertaking a nipple smear. The nipple discharge will be sent to the pathologist to examine under the microscope. Unfortunately, nipple discharge cytology has a low sensitivity for the detection of breast cancer and usually does not change the management for patients that have a single spontaneous duct discharge.
Microdochectomy (single duct excision) is the only procedure that will confirm a definitive histological diagnosis in a patient that presents with single duct discharge.
Multi duct discharge particularly that which is not spontaneous (eg- stimulation to the breast can produce a physiological discharge) is usually bilateral and surgery is usually not required. It is part of the normal function of the breast rather than being caused by a problem. Physiological discharge requires no treatment. The patient is advised to resist stimulating the nipples and the breasts as the problem will be self-perpetuating if stimulation is continuously applied. Discharge will usually cease when patient stop expressing from the nipple.
Spontaneous single duct or bloodstained discharge requires a full set of breast imaging in the form of ultrasound and mammogram (for patients over age of 35). A sample of the nipple discharge may be sent for cytological examination by the pathologist and any mass or lump beneath nipple or areola may be subjected to a biopsy (fine needle aspiration or core biopsy). If there is ongoing single duct spontaneous nipple discharge, a microdochectomy, or single duct excision is usually required. The offending duct will be removed in order to explore the duct under the microscope to rule out any significant abnormality/ pathology and to correct the problem.
