Nipple discharge in reproductive age group women
-
Upload
dr-sujata-mittal -
Category
Healthcare
-
view
253 -
download
0
Transcript of Nipple discharge in reproductive age group women
![Page 1: Nipple discharge in reproductive age group women](https://reader035.fdocuments.net/reader035/viewer/2022062901/58f9b282760da3da068bcc1b/html5/thumbnails/1.jpg)
Nipple discharge in reproductive age group women
Dr. Sujata MittalSr. Consultant – Gynec. Oncology
PARAS HOSPITALS, GURGAON
![Page 2: Nipple discharge in reproductive age group women](https://reader035.fdocuments.net/reader035/viewer/2022062901/58f9b282760da3da068bcc1b/html5/thumbnails/2.jpg)
Breast and Nipple discharge
Hormone dependent sweat gland Responds to emotions
Hence secretions PhysiologicalPathological
situation
![Page 3: Nipple discharge in reproductive age group women](https://reader035.fdocuments.net/reader035/viewer/2022062901/58f9b282760da3da068bcc1b/html5/thumbnails/3.jpg)
Nipple Discharge: Anatomy & Physiology
Mammary ducts lined by actively dividing epithelial cells which slough
Orifice of non lactating women blocked by keratin plug
Ductal system responds to estrogen, progesterone and prolactin.(Pituitary Gland)
Hormones interplay in Pregnancy, lactation and in non lactating women
Pathological discharge is caused by growth or proliferation of mammary ductal epithelial liningMammary ducts are the seat of origin of Breast cancer and hence of significance. Stagnant pool
![Page 4: Nipple discharge in reproductive age group women](https://reader035.fdocuments.net/reader035/viewer/2022062901/58f9b282760da3da068bcc1b/html5/thumbnails/4.jpg)
Anatomy & Physiology (Contd.)
Breast cancer studies have shown that majority of lesions are
multifocal within the
confines of single duct
![Page 5: Nipple discharge in reproductive age group women](https://reader035.fdocuments.net/reader035/viewer/2022062901/58f9b282760da3da068bcc1b/html5/thumbnails/5.jpg)
Opportunity
Detect, Predict & TreatBC
Systematically via BLOOD At The WHOLE ORGAN The Individual ductal lobular structure
![Page 6: Nipple discharge in reproductive age group women](https://reader035.fdocuments.net/reader035/viewer/2022062901/58f9b282760da3da068bcc1b/html5/thumbnails/6.jpg)
Partial list of Nipple Aspirate Fluids
Proteins Immunoglobulins Fats Hormones Electrolytes Cells
Alpha 1 lipoprotein IgA Lauric Prolactin Sodium Epithelial
Alpha 1 acid glycoprotein IgM Myristic Estrone Potassium Myoepithelial
Alpha 2 macroglobulin IgG H chain Myristoleic Estradiol Chloride Macrophages
Alpha 2 HS glycoprotein IgG L chain Palmitic DHEAS Calcium Neutrophils
Alpha 1 antitrypsin IgE Palmitoleic Progesterone Phosphate Lymphocytes
Trypsin IgD Cholesterol Growth hormone Mast Cells
Beta liprotein Cholesterol epoxides Testosterone Erythrocytes
Beta glycoprotein III TGF-α
Ceruloplasmin EGF
![Page 7: Nipple discharge in reproductive age group women](https://reader035.fdocuments.net/reader035/viewer/2022062901/58f9b282760da3da068bcc1b/html5/thumbnails/7.jpg)
Definition of Discharge
When Secretions abundant/persistent enough to DISCHARGE SPONTANEOUSLY from DUCT ORIFICE DISCHARGE
![Page 8: Nipple discharge in reproductive age group women](https://reader035.fdocuments.net/reader035/viewer/2022062901/58f9b282760da3da068bcc1b/html5/thumbnails/8.jpg)
Definition of discharge
If Ductal system is Normal Physiological
If Ductal system affected Pathological
![Page 9: Nipple discharge in reproductive age group women](https://reader035.fdocuments.net/reader035/viewer/2022062901/58f9b282760da3da068bcc1b/html5/thumbnails/9.jpg)
Types of discharges associated with cancer
• Watery: 45%• Sanguineous: 25%• Serosanguinous: 12%• Serous: 6%
•Bloody: < 3%
![Page 10: Nipple discharge in reproductive age group women](https://reader035.fdocuments.net/reader035/viewer/2022062901/58f9b282760da3da068bcc1b/html5/thumbnails/10.jpg)
Types of Discharges with etiology
Lactation
Physiological
Pathological
• Milk• Colostrum (can last up to 2 years post partum)• Bloody/Guiac Postive in 30% women in 2nd/3rd trimester
• Hyperprolactnaemia: Neurogenic stimulation, medications, stress• Exogenous/Endogenous Hormones, Endocrine abnormalities• Medical & surgical conditions
• Papilloma• Duct Ectasia• Eczema of skin• DCIS/ Malignancy
![Page 11: Nipple discharge in reproductive age group women](https://reader035.fdocuments.net/reader035/viewer/2022062901/58f9b282760da3da068bcc1b/html5/thumbnails/11.jpg)
Etiology of Physiological Discharges
Neurogenic stimulation• Stress
• Sleep
• Exercise
• Excessive Stimulation
• High Midday Protein Meal
Medications• Hormones• Antidepressants• Antianxiolytics• H2Receptor Antagonists• Phenothiazines• Amphetamines• Antiemetics• Danazol• INH• Opiates• Antifungals
Medical & Surgical Conditions• Pituitary Adenoma• Hypothyroidism• CRF• Herpes Zoster• Thoractomy scar• Hypernephroma• Bronchogenic Carcinoma
![Page 12: Nipple discharge in reproductive age group women](https://reader035.fdocuments.net/reader035/viewer/2022062901/58f9b282760da3da068bcc1b/html5/thumbnails/12.jpg)
Evaluation
![Page 13: Nipple discharge in reproductive age group women](https://reader035.fdocuments.net/reader035/viewer/2022062901/58f9b282760da3da068bcc1b/html5/thumbnails/13.jpg)
![Page 14: Nipple discharge in reproductive age group women](https://reader035.fdocuments.net/reader035/viewer/2022062901/58f9b282760da3da068bcc1b/html5/thumbnails/14.jpg)
![Page 15: Nipple discharge in reproductive age group women](https://reader035.fdocuments.net/reader035/viewer/2022062901/58f9b282760da3da068bcc1b/html5/thumbnails/15.jpg)
![Page 16: Nipple discharge in reproductive age group women](https://reader035.fdocuments.net/reader035/viewer/2022062901/58f9b282760da3da068bcc1b/html5/thumbnails/16.jpg)
![Page 17: Nipple discharge in reproductive age group women](https://reader035.fdocuments.net/reader035/viewer/2022062901/58f9b282760da3da068bcc1b/html5/thumbnails/17.jpg)
Take Home Message
• Breast Manipulation• Normal Breast Secretions
Non spontaneous
•Unilateral Multiple Duct Benign F/U •Unilateral Single Duct Breast Path/BC USG+- Mammo If Normal Excise HPR
Spontaneous
•B/L Systemic Cause/ Galactorrhoea•Non Galactorrhoea Evaluate on principles of Unilateral
Spontaneous
![Page 18: Nipple discharge in reproductive age group women](https://reader035.fdocuments.net/reader035/viewer/2022062901/58f9b282760da3da068bcc1b/html5/thumbnails/18.jpg)
Mammography
• Standard Imaging Technique• Microcalcifications/Other signs of malignancy But Not useful for diagnosis of etiology of ND But High NPV and Specificity(94%)
![Page 19: Nipple discharge in reproductive age group women](https://reader035.fdocuments.net/reader035/viewer/2022062901/58f9b282760da3da068bcc1b/html5/thumbnails/19.jpg)
USG
• Non invasive• Limitations in small lesions without dialation &
with dense fatty tissue.• Duct Dilation, solid internal echoes, Duct wall
thickening in central or subareolar areas.• Important for FNAC
![Page 20: Nipple discharge in reproductive age group women](https://reader035.fdocuments.net/reader035/viewer/2022062901/58f9b282760da3da068bcc1b/html5/thumbnails/20.jpg)
ND CYTOLOGY
• Simple and useful• Controversial as aspirate is normally very less.• Recent Studied revealed Sensitivity of 85% and Specificity of 97%.• Should always be done
![Page 21: Nipple discharge in reproductive age group women](https://reader035.fdocuments.net/reader035/viewer/2022062901/58f9b282760da3da068bcc1b/html5/thumbnails/21.jpg)
FNAC
Quite Sensitive
If Aspirate is less
Indicated
![Page 22: Nipple discharge in reproductive age group women](https://reader035.fdocuments.net/reader035/viewer/2022062901/58f9b282760da3da068bcc1b/html5/thumbnails/22.jpg)
DUCTOGRAPHY
• Secreting Duct is identified Canulated
Dye is Injected • More Sensitive than ND Cytology & MMG
But invasive, time consuming complications
• Can’t Differentiate between benign & Malignant
![Page 23: Nipple discharge in reproductive age group women](https://reader035.fdocuments.net/reader035/viewer/2022062901/58f9b282760da3da068bcc1b/html5/thumbnails/23.jpg)
CEMRI
• Increasingly being used.• Diagnostic Sensitivity is 86-100% for invasive
Ca.• Diagnostic Sensitivity is 46-100% for
intraductal Ca.• Useful for evaluation of ND with occult disease• Useful for differentiating Benign & Malignant.
![Page 24: Nipple discharge in reproductive age group women](https://reader035.fdocuments.net/reader035/viewer/2022062901/58f9b282760da3da068bcc1b/html5/thumbnails/24.jpg)
HPR
• Excision of duct• Reference To Onco surgeon
![Page 25: Nipple discharge in reproductive age group women](https://reader035.fdocuments.net/reader035/viewer/2022062901/58f9b282760da3da068bcc1b/html5/thumbnails/25.jpg)
Nipple Discharge
Q. Which of the following history questions is LEAST helpful in assessing woman with Breast discharge complaint?
1. Is the discharge spontaneous (comes out on its own) or only with expression of the nipple?
2. Is the discharge unilateral or bilateral?
3. What color is the discharge?
4. Is there pain associated with the discharge?
![Page 26: Nipple discharge in reproductive age group women](https://reader035.fdocuments.net/reader035/viewer/2022062901/58f9b282760da3da068bcc1b/html5/thumbnails/26.jpg)
Duct Ectasia (periductal mastitis)
Benign Disease in middle aged to elderly femalesCan mimic malignancyPathological feature: Dilated duct → engorged with breast secretion → infection →
retroareolar abscess → fibrosis → nipple retraction. Clinical features: Non Cyclical Mastalgia. Periareolar erythema. Nipple discharge: thick & creamy or greenish brown. Periareolar tender mass. -Nipple retraction (when healing occurs by fibrosis).
![Page 27: Nipple discharge in reproductive age group women](https://reader035.fdocuments.net/reader035/viewer/2022062901/58f9b282760da3da068bcc1b/html5/thumbnails/27.jpg)
Duct Ectasia (Contd.)
Etiology: Not known. Smoking is implicated in pathogenesis.Investigations: o Mammogram: opaque mass of dilated ducts & skin indentation. - Cytology: for discharge.
Management: - Infection: aspiration & antibiotic. - Abscess: drainage. - Severe discharge or recurrent sepsis: mammadochectomy (nipple
ducts excised through a circumareolar incision preserving the nipple).
![Page 28: Nipple discharge in reproductive age group women](https://reader035.fdocuments.net/reader035/viewer/2022062901/58f9b282760da3da068bcc1b/html5/thumbnails/28.jpg)
Intraduct papilloma
Benign. Occurring in middle-aged women. Clinical features: - Bloodstained discharge. - Bleeding from a single duct orifice - (pressure over a certain spot or the palpable mass). - Small mass: NOT usually. Investigation: - Mammogram (exclude carcinoma). - Cytology assessment. Management: - Duct orifice (bleeding) is identified: microdochectomy. - If not: excision of the major nipple ducts.
![Page 29: Nipple discharge in reproductive age group women](https://reader035.fdocuments.net/reader035/viewer/2022062901/58f9b282760da3da068bcc1b/html5/thumbnails/29.jpg)
Thank you