nipple discharge
Introduction
Introduction Nipple discharge 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 a natural discharge from one or more catheters on one or both sides unrelated to pregnancy or breastfeeding in a non-physiological situation, intermittent, persistent from months to years. Nipple discharge mainly refers to pathological discharge.
Cause
Cause
the reason:
There are two kinds of nipple discharge: true discharge and pseudo-discharge. True discharge refers to non-pregnancy and non-lactating nipple natural discharge; pseudo-discharge refers to superficial erosion of nipple or exudate of chyle. The cause of true nipple discharge can be caused by hemophilia, purpura, endocrine disorders, ductal lesions and intramammary lesions. Such as intraductal papilloma, cystic hyperplasia of the breast, ductal dilatation of the breast, ductal ductitis of the breast, intraductal carcinoma of the breast, etc., and account for more than 80% of all nipple discharge.
Nipple discharge is an abnormal secretion of fluid of different nature and is excreted by the mammary duct. The lesions occur in or involve the mammary gland. The true nipple discharge causes the basic pathological changes of the nipple discharge. The large duct system of the breast is invaded by different lesions, resulting in inflammation, erosion and other phenomena, or malignant tumor invasion. The catheter produces the above pathological changes.
The nipple discharge is often unilateral, and the milk tube that can simultaneously overflow on both sides can be a single tube or multiple tubes. Unilateral single-tube nipple discharge is common in intraductal papilloma unilateral multi-tube discharge is common in breast ductal dilatation, cystic hyperplasia of the breast; bilateral polyhepatic discharge is more common in endocrine disorders, drug reactions, Amenorrhea - galactorrhea syndrome or some benign breast disease.
Diseases that cause breast discharge:
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 inside the tube is constantly increasing, causing the catheter to expand. Its clinical features are: 1 occurs in 40-60 years of non-lactation or menopausal women, with a history of breast-feeding disorders, the cause is common on one side; 2 nipple discharge is the first initial symptom, often multiple catheter discharge, It is brownish-yellow or grayish-white thick; 3 often touches the areola area, the diameter of the mass is less than 3cm, and the edge is regular. It often sticks to the skin in the early stage. Ipsilateral axillary lymph nodes are not enlarged; 4 Selective mammography shows the location, extent and extent of dilatation catheter; 5 nipple discharge and tumor aspiration cytology can be seen in a large number of ductal epithelium, foam cells, plasma cell lymphocytes, cells Residual nucleus and necrosis.
2. Intraductal papilloma: The tumors of middle-aged people who are more common in 40 to 50 years old are mostly located in the larger lactiferous duct below the areola. It can be used for single or multiple large catheters at the same time. The tumor is composed of many small branches of papillary neoplasms, which resemble small red bayberry, pedicled and connected to the affected dilated catheter wall. Its main clinical manifestations: 1 intermittently naturally discharge old blood from the nipple, a few are brown or yellow serum; 2 about 1/3 of the patients in the areola area can be licked and lumps, round, soft, smooth, less than 1cm in diameter 3 Selective mammography showed a round or elliptical filling defect with a sand size in the 1st to 2nd catheter, proximal catheter dilatation, no complete interruption of the lumen; 4 effusion cytology and tumor aspiration cytology Check for visible 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. The lesions mainly involve small ducts and glandular cells, and may also involve large and medium catheters. Its clinical features are: 1 breast pain associated with the menstrual cycle, sometimes the breast has pain, stinging; 2 two milk can be licked and single or multiple cystic mass or segmental granular nodules; 3 a few have nipple discharge It is serous serous bloody and bloody; 4 mammography X-ray photography shows that there is cotton or frosted glass in the milk, and the density of the boundary is blurred. If there is cyst formation, round and translucent shadows are visible; 5 near-infrared mammary gland scan shows dot-like, flaky gray shadow, blood vessel thickening and increase; 6B super shows uneven hyperechoic area and no echogenic cyst in hyperplasia.
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 isola mass hard, often adhesion to the skin; 3 about 1/4 of patients have bloody nipple discharge, often single tube discharge; 4 selection Sexual mammography showed that there was a bumpy filling defect in the wall of the proximal catheter, and the obstruction of the wall was completely interrupted. 5 The cytological examination of the effusion showed cancer cells. 6 The near-infrared mammography scan showed the gray shadow and abnormal blood vessels. .
Examine
an examination
Related inspection
Chest B super breast palpation mammography X-ray examination breast ductoscopy
Laboratory inspection:
1. Effluent cytology examination: The cytological examination of effusion is simple and convenient, and it can detect breast cancer at an early stage, which is a diagnostic method that is easy for patients to accept. Some scholars have suggested that all nipple discharges should be routinely cytologically examined.
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 to diagnose the cause of nipple discharge, especially for early micro-tumor, when the imaging and cytological diagnosis is negative and the clinical is suspicious, a reliable method for further diagnosis is needed. If the biopsy can be performed on the basis of imaging, the diagnosis rate can be improved.
Other auxiliary inspections:
1. Near-infrared breast scan: 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 re-examined. Some scholars have reported that when using near-infrared mammography, the intracavitary injection of 2% Meilan catheter can show the relationship between the discharge and the catheter, which can improve the areola area. The cause of the diagnosis of catheter disease.
2. 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 breast malignant 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 compliance rate of breast diseases. This method has no damage and no pain to patients. Simple and easy to have high resolution.
3. Selective mammary ductography: It has a great diagnostic value for both benign and malignant breast diseases of nipple discharge, especially those with nipple discharge without physical examination and other features, or other tests are negative. Selective mammography can determine the location, nature, and extent of the spill before surgery. Intraductal papilloma is mostly located in the main duct and the 2nd and 3rd grade branch ducts. The angiographic features are single or multiple limited circular or elliptical filling defects, distal duct dilatation, and rare duct obstruction. If the main catheter obstruction is visible, there is a curved cup-shaped mass in the obstruction, and the wall is smooth, intact, and non-infiltrating. Imaging of cystic hyperplasia of the breast showed that the terminal duct and glandular cells showed a relatively uniform small cystic or beaded expansion, or the milk duct and its branches became thin and linear, and the small branches reduced the smooth lumen of the tube wall. Mammary duct dilatation manifests as a significant expansion and distortion of the large duct under the areola, and a severe cystic appearance. The angiography of breast cancer showed catheter obstruction, irregular infiltration of the wall, stiffness, stenosis and truncation.
Diagnosis
Differential diagnosis
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 milk during pregnancy and lactation, other nipple discharges are pathological discharges. The assessment of the amount of spill can be divided into 5 levels.
a: Naturally flow out without squeezing.
b: When lightly pressed, the filaments are ejected.
c: 2 to 3 drops during strong pressure.
d: It is barely visible when pressed.
e: 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.
Breast type identification:
1. Is the discharge true or false:
True discharge refers to the flow of liquid from the mammary duct. False discharge is common in the nipple depression, because the exfoliated cells of the nipple epidermis accumulate in the depression, causing a small amount of liquid-like bean dregs-like exudation, often smelly. Once the concave nipple is pulled out and kept clean, the "discharge" will disappear.
2. Is the discharge double or single:
Bilateral discharge is physiological. If you stop breastfeeding for a year, most women still have a small amount of milk secretion. In the middle and late pregnancy, some pregnant women's nipple discharge double milk can squeeze out a little light colostrum. A small number of women have a short period of galactorrhea after a strong orgasm due to high blood pressure in the breast, breast enlargement, and erection of the nipple. Women enter menopause, and some women secrete a small amount of milk due to endocrine disorders. All of the above are physiological conditions, not morbid. However, bilateral nipple discharge can also be pathological, such as a disease called amenorrhea-galactorrhea syndrome, caused by pituitary microadenomas, in addition to galactorrhea, accompanied by amenorrhea, headache, narrow vision, blood prolactin rise higher. A CT scan of the brain can confirm the diagnosis. Another type of double nipple discharge is seen in a small number of patients with hyperplasia of the breast.
3. Is the discharge single or porous:
The nipple has 15 to 20 openings for the milk duct. When there is an overflow, observe which one or several openings the liquid overflows. Single-hole discharge is mostly intraductal papilloma of the breast. Porous discharges may be physiological, medicinal, systemic benign diseases or mammary gland hyperplasia.
Whether the overflow overflows by itself or after extrusion.
The former is mostly pathological, and about 13% of breast cancer patients have a history of spontaneous discharge. A benign or physiological discharge is more common after squeezing.
4. Characteristics of the discharge:
Different diseases of the breast, the traits of the discharge are also inconsistent.
(1) Milky. Mostly physiological, such as the recent after weaning or after abortion, is not a manifestation of cancer.
(2) purulent discharge, mostly ductal dilatation, plasma cell mastitis.
(3) Light yellow discharge is the most common type of discharge, which is almost common in various breast diseases, and is more common in breast hyperplasia. Some are also intraductal papilloma or breast cancer. Therefore, this is a need to be vigilant.
(4) Bloody discharge, which can be different colors such as bright red, brown, light yellow, and brown. This type of discharge is a dangerous sign and should be highly vigilant, with 50% to 75% of intraductal papilloma and 15% of breast cancer. If bloody discharge occurs after menopause, 75% is breast cancer.
(5) Clear water spill, colorless and transparent, occasionally sticky, leaving no trace after overflow. This discharge may be a sign of breast cancer and should be further examined.
In short, nipple discharge is an important breast symptom, of which 10% to 15% may be breast cancer. If symptoms appear, you should go to the hospital in time to do a smear cytology examination. The positive diagnosis rate of ductal lesions in the areola area by near-infrared mammography can reach 80%-95%. B-ultrasound and molybdenum target photos also have considerable accuracy. Selective lesion catheterization is a commonly used examination method for nipple discharge. It is of great value for the differential diagnosis of benign and malignant nipple discharge. It can also provide physicians with accurate positioning of surgical resection.
Identification of diseases causing breast discharge
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. Identification of mammary duct dilatation and intraductal papilloma: the latter only involves one catheter, and the nodules or lesions near the areola area are seen, and bloody secretions are seen. Selective mammography, showing a single or multiple grit-sized circular or elliptical filling defect proximal catheter dilatation. Mammary duct dilatation often involves multiple catheter discharges mostly brown or grayish white sticky. Selective mammography, significant enlargement, distortion, or cystic changes in the large duct under the areola.
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 ductal dilatation of the breast and intraductal papillary carcinoma: the latter is more common in middle-aged and elderly women, with slow onset and frequent bloody discharges in the nipple. The upper or lower inner quadrant of the milk can reach the painless mass. As the disease progresses, the mass can adhere to the skin and melt into a mass. X-ray mammography showed that the shadow of the tumor and the calcification of the angiography showed that the catheter was blocked, the lumen was filled, and the wall was destroyed. In the near-infrared mammary gland scan, see the gray shadow of the tumor and abnormal blood vessels. Cancer cells can be found by needle and cytology of the discharge and mass. In the case of ductal dilatation of the breast, the middle-aged person sees the discharge as a pale yellow or gray-white viscous substance. The mass is often located in the areola area, and the early stage may have tenderness, and the axillary lymph node does not enlarge at an early stage. If it is swollen and soft, it can disappear as the inflammation subsides. The catheter is seen as an expanded catheter with a smooth wall. Near-infrared mammography scan, visible gray shadow, normal vascular phase discharge and needle aspiration cytology, can find ductal epithelium, foam cells, plasma cells, lymphocytes and so on.
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 is relieved or disappeared after menstruation. A number of different sizes of nodules can be touched on both sides of the milk, 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, it is more difficult to identify the latter with a longer course and slower development, older than 50 years old . The intra-milk mass is larger in diameter, up to 5-8 cm, and hard. Overflow cytology can find cancer cells. Patients with positive detection of effervescent carcinoembryonic antigen (CEA) are often diagnosed as cancer. If only the nipple is spilled without a lump, the likelihood of cancer is less. Selective ductal angiography has obvious differences in the diseased tissue when necessary, and the biopsy is taken to confirm the diagnosis.
