nipple discharge
Introduction
Introduction to nipple discharge Nippledischarge is a common symptom of breast disease and can be divided into physiological discharge and pathological discharge. Physiological discharge refers to lactation during pregnancy and lactation, bilateral nipple discharge caused by oral contraceptives or sedatives, and unilateral or bilateral small discharges in postmenopausal women. Pathological discharge refers to non-physiological conditions. Under the condition that one or both sides of the catheter are unrelated to pregnancy or breastfeeding, the natural discharge from one or more catheters is intermittent and persistent from several months to several years. Nipple discharge mainly refers to pathological discharge. basic knowledge Probability ratio: Susceptible people: women. Mode of infection: non-infectious Complications: breast pain
Cause
Causes of nipple discharge
True spill (28%):
Refers to non-pregnancy, non-lactating nipple natural discharge, the cause of true nipple discharge can be caused by hemophilia, purpura, endocrine disorders, catheter lesions and intramammary lesions, such as intraductal papilloma, breast cystic Hyperplasia, mammary duct dilatation, ductal ductitis, intraductal carcinoma of the breast, etc., and account for more than 80% of all nipple discharge.
Multi-tube overflow (25%):
Unilateral multi-tube discharge is common in breast ductal dilatation, cystic hyperplasia of the breast. Bilateral multi-tube discharge is more common in endocrine disorders, drug reactions, amenorrhea - galactorrhea syndrome or some benign breast diseases.
False discharge (25%):
False discharge is caused by other diseases of the nipple causing nipple discharge, such as superficial erosion of the nipple or exudate of the chyle.
Single tube overflow (22%):
The nipple discharge is often unilateral, and can occur simultaneously on both sides. The overflow of the milk tube can be a single tube, or multiple tube discharge, unilateral single-tube nipple discharge, common in intraductal papilloma.
Pathogenesis
The nipple discharge is an abnormal secretion fluid of different nature and is discharged by the mammary duct. The lesions occur in or involve the mammary gland, which is a true nipple discharge, which causes the basic pathological changes of the nipple discharge to be invaded by different lesions of the large duct system of the breast. Inflammation, erosion, bleeding, etc., or malignant tumors invade large catheters to produce the above pathological changes.
1. Clinical classification, according to the pathogenesis, true nipple discharge is divided into 2 types:
(1) Intraductal type of breast: including new organisms originating from the ductal epithelium of the breast, ductal papilloma, ductal dilatation, cystic proliferative diseases, etc.
(2) Mammary duct appearance: including suppurative inflammation of the breast, tuberculosis, tumor and other diseases other than the catheter, involving or invading the catheter, causing the secretion to overflow from the nipple, and the incidence of the primary disease of the catheter system that produces the nipple discharge continues The damage is more, because the clinical appearance of the catheter type of the disease can cause more nipple discharge than the intraductal type, while the intraductal lesions are mostly benign, ductal lesions can cause nipple discharge, malignant benign The ratio is basically equal.
2. Properties of nipple discharge: The location and traits of nipple discharge are of great clinical significance for inferring the nature of the disease. According to the naked eye of nipple discharge, it can be divided into the following seven types.
(1) milk-like liquid: the color of the discharge is like fat-free milk, which is common in amenorrhea-galactorrhea syndrome (milk-overflow syndrome), anterior pituitary hyperfunction syndrome, or oral contraceptives, because the pituitary gland is inhibited by prolactin release. Due to many, some patients with mammary gland hyperplasia can also appear. At this time, there are often multiple tube overflows on both sides, which automatically flow out.
(2) Acne-like discharge: caused by breast duct dilatation, the patient has congenital nipple depression, and the nipple has lipid acne-like odorous secretion overflowing. This kind of spill is thick and mixed with various colors. Automatic spillover, usually double-sided multi-tube, patients often accompanied by burning, swelling, itching, can also be seen in menopausal or young and middle-aged women with hypogonadism.
(3) Water sample: The thin liquid is like water, which is caused by intraductal papilloma, cystic hyperplasia of the breast and breast cancer. Recently, some people think that about 50% of watery discharge may be cancer.
(4) purulent fluid: discharge like pus, common in postpartum acute mastitis, breast abscess.
(5) Serous liquid: It is pale yellow, and most cases are caused by intraductal papilloma in the lower part of the nipple. It can also be seen in cystic hyperplasia of the breast, ductal dilatation of the breast and breast cancer.
(6) bloody liquid or serous bloody liquid: bloody liquid is red, serous blood is pink, bloody discharge is more common in intraductal papilloma, if the patient is over 50 years old, unilateral nipple bloody discharge, often suggesting that Intraductal papillary carcinoma should be highly valued. Serous blood can be caused by intraductal papilloma, cystic hyperplasia of the breast, or by intraductal papillary carcinoma.
(7) Light green discharge: The secretion is a light-colored, pale green liquid, which is less common and is common in cystic hyperplasia of the breast.
Prevention
Nipple discharge prevention
1. Take the contraceptive pill and sedative medicine under the guidance of a doctor to prevent nipple discharge caused by improper use of the drug.
2. Non-physiological, pregnancy, breast nipple discharge other than breastfeeding should be promptly to the hospital for further examination, clear diagnosis, treatment.
Complication
Nipple discharge complications Complications breast pain
Can be complicated by breast pain.
Symptom
Symptoms of nipple discharge Common symptoms Breast cystic hyperplasia Cystic mass Breast tingling nipple retraction nodular skin adhesion
1. Mammary duct dilatation: Mammary duct dilatation, also known as "plasma mastitis", often due to nipple retraction or mammary epithelial cell shedding, and a large number of lipid-containing secretions silted to block the catheter, resulting in poor secretion excretion The pressure in the tube is constantly increasing and causing the catheter to expand. The clinical features are as follows:
1 occurs in non-lactation or menopausal women aged 40 to 60 years old, with a history of breast-feeding disorders, the cause is common on one side.
2 nipple discharge is an early first symptom, often multiple catheter discharge, brown or grayish white thick.
3 often touch the areola area mass, the diameter is less than 3cm, the margin is regular, the early often adhere to the skin, the ipsilateral axillary lymph nodes are not swollen.
4 Selective mammography shows the location, extent and extent of the dilatation catheter.
5 nipple discharge and tumor aspiration cytology showed a large number of ductal epithelium, foam cells, plasma cells, lymphocytes, cell debris and necrosis.
2. Intraductal papilloma: more common in middle-aged people aged 40 to 50 years, the tumor is mostly located in the larger lactiferous duct under the areola, can be single or can involve several large catheters at the same time, the tumor is the majority of small branches It is composed of a new papillary organism, which looks like a small bayberry, has a pedicle and is connected to the affected dilated catheter wall. Its main clinical manifestations are:
1 The nipple intermittently discharges old blood, and a few are brown or yellow.
2 About 1/3 of the patients in the areola area can be licked and lumps, round, soft, smooth, active, less than 1cm in diameter.
3 Selective mammography showed a round or elliptical filling defect with a sand size in the 1-2 catheter, the proximal catheter was dilated, and the lumen was not completely interrupted.
4 cytology and tumor aspiration cytology can be seen in tumor cells.
3. Breast cystic hyperplasia: This disease is more common. According to the literature, the incidence rate is about 50% of women of childbearing age. Because some cases can develop into cancer, some people call it precancerous lesions. Catheters and glandular cells can also involve large and medium catheters. The clinical features are:
1 breast pain associated with the menstrual cycle, sometimes the breast has pain, stinging.
2 Two or more cystic masses or segmental granular nodules can be found in the two milks.
3 a small number of nipple discharge, serous, serous blood, blood.
4 mammography X-ray photography, showing a cotton-like or frosted glass in the milk, the density of the blurred border is increased, if the cyst is formed, the circle is visible, translucent shadow.
5 near-infrared breast scan, showing point, flaky gray shadow, blood vessels thickening, increase.
6B super shows hyperplasia: uneven hypoechoic area and no echogenic cyst.
4. Intraductal papillary carcinoma: more common in older women, is a special type of breast cancer, the average age of onset is 56 years old, its clinical features:
1 slow onset, long history, general course of more than 5 years.
2 The areola area is hard and often adheres to the skin.
3 About 1/4 of patients have bloody nipple discharge, often a single tube discharge.
4 Selective mammography showed that the proximal catheter was dilated, the tube wall had uneven filling defects, and the wall obstruction was completely interrupted.
5 overflow cytology examination showed cancer cells.
6 near-infrared mammography scan, visible gray shadow and abnormal blood vessels.
Examine
Nipple discharge check
1. Effusion cytology: Effusion cytology is simple, convenient, and can detect breast cancer at an early stage. It is an easy-to-accept diagnostic method for patients. Some scholars have suggested that all nipple discharge should be routinely performed for cytology.
2. Tumor aspiration cytology examination: nipple discharge accompanied by intramalignant mass, needle cytology examination of breast cancer diagnosis rate of up to 96%, the correct diagnosis rate of benign disease of nipple discharge is lower It is often considered in combination with clinical findings and other ancillary examinations.
3. Biopsy: It is the most reliable method for confirming the cause of nipple discharge, especially for early microscopic tumors, imaging, cytological diagnosis is negative and clinically suspicious, a reliable method for further diagnosis, if it can be used in imaging The positioning of the basic ascending biopsy can improve the diagnosis rate.
4. Near-infrared mammary gland scanning: The positive diagnosis rate of the discharge caused by catheter disease in the areola area can reach 80%-90%. The method is simple, non-invasive, and can be repeatedly checked. Some scholars have reported using near-infrared mammary gland. During the scan, a 2% Meilan catheter angiography was injected into the overflow tube to show the relationship between the discharge and the catheter, which could improve the etiological diagnosis rate of catheter disease in the areola area.
5. B-ultrasound: The coincidence rate of this method for the diagnosis of benign breast diseases can reach 80% to 90%. Ultrasound examination can reveal enlarged milk ducts, minimal cysts, and sometimes intraductal papilloma or filling defects. The diagnostic coincidence rate for malignant breast diseases can reach 71%-90%. It has been reported that the combination of general B-ultrasound and color Doppler ultrasonography can greatly improve the diagnostic coincidence rate of breast diseases. This method has no damage to patients. Painful, easy to use, with high resolution.
6. Selective mammography: It has a great diagnostic value for both benign and malignant breast diseases of nipple discharge, especially for those with nipple discharge without physical examination and other features, or other tests are negative, selective breast duct Contrast can clearly identify the location, nature and extent of the spill before surgery. The intraductal papilloma is mostly located in the main catheter and the 2nd and 3rd grade branch catheters. The angiographic features are single or multiple localized round or oval filling defects. The distal catheter is dilated, and the catheter obstruction is rare. If the main catheter obstruction is visible, there is a curved cup-shaped mass in the obstruction. The wall is smooth, intact, and non-invasive. The cystic hyperplasia of the breast is angiographically showing the terminal catheter and the gland. It has a relatively uniform small cystic or beaded expansion, or the milk duct and its branches become thinner, linear, with small branches, smooth wall, smooth lumen, and ductal dilatation of the mammary duct. , distortion, severe cystic, breast cancer angiography showed catheter obstruction, irregular wall infiltration, stiffness, stenosis and truncation.
Diagnosis
Diagnosis and identification of nipple discharge
diagnosis
1. Etiology diagnosis: In the diagnosis of the cause of nipple discharge patients, in addition to a detailed understanding of medical history and physical examination, it is necessary to carefully observe the type of discharge and whether it is single-tube discharge or multi-tube discharge, in addition, relevant auxiliary examination should be carried out. To help diagnose.
2. Assessment of the amount of spill: In addition to the normal secretion of lactating milk during pregnancy, other nipple discharges are pathological discharges, and the assessment of the amount of spill can be divided into 5 grades.
+++: No squeezing, it naturally flows out.
++: When it is lightly pressed, it is spewed out.
+: 2 to 3 drops are emitted during strong pressure.
±: barely visible when pressed.
-: There is no spill in the oppression.
Evaluation of the amount of nipple discharge after treatment can also be used as a reference for evaluation of therapeutic effects.
Differential diagnosis
Nipple discharge is a common symptom of many breast diseases. In clinical diagnosis, it is necessary to ask the medical history in detail, perform physical examination and various auxiliary examinations, carefully observe the nature of the spill, and conduct comprehensive comparative analysis to obtain common discharge. Diagnosis and differential diagnosis of the disease.
The main diseases with nipple discharge include mammary duct dilatation, cystic hyperplasia of the breast, intraductal papilloma of the breast, and intraductal papillary carcinoma. The main points of identification are as follows.
1. The differential diagnosis of ductal dilatation of the breast and intraductal papilloma, the latter involving only one catheter, nodules or lesions near the areola area, visible bloody secretions, selective mammography, showing single or Multiple round or oval filling defects, proximal duct dilatation, ductal dilatation of the breast often involve multiple catheters, the discharge is mostly brown or grayish white, selective mammography, significant expansion of the large duct under the areola , distorted or cystic.
2. Breast duct dilatation abscess stage and acute mastitis identification: the latter is more common in postpartum lactation, less than the full primipara women, the lesions are more extensive, not limited to the areola area, nipples have purulent discharge changes.
3. Identification of mammary duct dilatation and intraductal papillary carcinoma: the latter is more common in middle-aged and elderly women, with slow onset, often with bloody discharge in the nipple, and a painless mass in the upper or upper quadrant of the milk. Development, the mass can adhere to the skin, melt into a mass, mammography can see the shadow and calcification of the tumor, catheterization can be seen interrupted catheter obstruction, lumen filling defect, wall destruction, near-infrared mammary gland scan see the tumor gray shadow and Abnormal blood vessels, discharge and aspiration needle cytology can be found in cancer cells. Breast duct dilatation is more common in middle-aged people. The discharge is light yellow or gray-white viscous material. The mass is often located in the areola area. Pain, axillary lymph nodes do not enlarge at the early stage, if swollen, soft, can disappear with inflammation subsided, catheter angiography see dilated catheter, tube wall smooth, near-infrared mammary gland scan, visible gray shadow, normal vascular phase, overflow Needle aspiration cytology of fluids and tumors can be found in ductal epithelium, foam cells, plasma cells, lymphocytes, etc.
4. Identification of mammary duct dilatation and cystic hyperplasia of the breast: the latter nipple discharge is watery or pale yellow, and the pain is related to the menstrual cycle. It is aggravated before menstruation, and then reduced or disappeared afterwards. A number of scattered nodules of varying sizes, accompanied by tenderness.
5. Intraductal papilloma of the breast and intraductal papillary carcinoma: The two diseases are difficult to identify clinically, especially in the early stage of intraductal papillary carcinoma, which is more difficult to identify. The latter has a longer course and slower development, and the age is greater than 50. Years old, the size of the breast mass is large, up to 5 ~ 8cm, hard, overflow cytology, can find cancer cells, positive for detection of effervescent carcinoembryonic antigen (CEA), often diagnosed as cancer, if only nipple overflow If there is no lumps in the liquid, the possibility of cancer is smaller. The selective mammography is obviously different. If necessary, the biopsy is finally diagnosed at the diseased tissue.
