Anthony Visioni and Julian A. Kim

Introduction

Nipple discharge is a common complaint for women, with the possibility of intraductal cancer the greatest concern. However, benign disease is more often the cause of nipple discharge. It is therefore important to identify patients who might be at risk for malignancy and would be candidates for surgical resection. Nipple discharge can be defined as physiologic versus pathologic. Pathologic nipple discharge (PND) usually requires surgery to rule out malignancy. PND is typically unilateral, spontaneous, bloody or serous, and from a single duct. Green, creamy, bilateral, nonspontaneous drainage or drainage from multiple ducts usually indicates a nonmalignant process that does not require surgery.

Preoperative Workup

Diagnostic mammography is currently the test of choice in the workup of PND and is generally indicated in all patients. Ultrasound, magnetic resonance imaging (MRI), and ductography are being studied for prediction of malignant disease in PND, although no consensus exists on their use. Also under investigation is ductoscopy, real-time endoscopic imaging of the ductal system. Ductoscopy can differentiate normal ducts from intraductal papilloma and provide therapeutic options (Fig. 47-1, A). Although great advances have been made in the equipment and success of ductoscopy, its use is still limited to specialized centers.

Cytology is of limited use for the diagnosis of PND. Even in properly selected patients, cytology is not extremely sensitive or specific.

There are several algorithms for the workup of PND, but the most important aspect of the evaluation is to prove that the discharge is not caused by a malignancy (Fig. 47-1, B and C). This often requires surgical resection and pathologic examination of the duct.

Surgical Principles

Duct anatomy is complex, and therefore an attempt should be made to identify the duct from which there is pathologic discharge. Several methods are used to achieve this. First, the nipple can be expressed in the operating room and the draining duct cannulated with a lacrimal probe (Fig. 47-2). Another method is to inject methylene blue preoperatively to guide the dissection of the correct duct. Some authors suggest preoperative ductography to distend the duct of interest and determine the distance needed to dissect from the ductal orifice to the lesion. Some centers equipped with ductoscopy can attempt to visualize and remove the lesion endoscopically; if this is not successful, a standard duct excision is done.

Excision Technique

If the affected duct cannot be identified on the day of surgery, a central duct excision can be performed. This procedure removes all the duct tissue, as opposed to a major duct excision that removes only the affected duct. Some authors argue that this method is overaggressive and recommend breast MRI and close follow-up if no abnormality is noted.

Once the duct is identified, the standard incision for a major duct excision is curvilinear around the nipple-areolar complex. If there is a palpable mass, a curvilinear or radial incision over the mass may be used.

After incision, the nipple-areolar complex is sharply dissected and raised as a flap. Major ducts should be divided close to the nipple. Care must be taken to ensure proper thickness of the flap; a buttonhole or necrosis can occur if the flap is too thin, and segments of duct containing pathology can be left behind if it is too thick.

A cone of tissue surrounding the duct of interest is dissected down to the gland lobule (Fig. 47-2). After the duct and surrounding tissue are removed, the remaining defect can be closed with absorbable suture. Before closing the skin, the nipple should be checked to ensure it is everted. If not, a subcutaneous stitch can be placed to evert the nipple.

Summary

Surgeons must differentiate pathologic from physiologic nipple discharge and therefore surgical from nonsurgical candidates. The duct should be transected close to the nipple and dissected to the gland lobule to ensure that the lesion is removed. Women should be counseled preoperatively about the impact on breastfeeding and cosmesis.

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