"For about the last 2 months I have been
having a severe burning, some swelling and a rust
colored discharge from one nipple. That breast is
also very tender. My GYN ordered a mammogram which
was ok, then he ordered a ductogram, which the radiologist
says can't be performed since " my nipples are
too small". My GYN has now recommended that I
see a surgeon. No one has said yet what this could
be. How is it treated? Also, the radiologist made
me feel as if I was a freak, because he complained
so forcefully that my nipples were too small. Is there
such a thing as too little? What is the appropriate
treatment for this breast and nipple problem?"
Terry
Rust colored nipple discharge implies blood in the
secretions from the gland and ducts of the breast.
Bloody discharge is worrisome for basically two conditions:
intraductal papilloma (about 90% of bloody nipple
discharge) and intraductal or other types of breast
cancer (about 10% of bloody nipple discharge). Rarely
it can indicate other benign or inflammatory conditions
but intraductal papilloma and cancer are the main
two to rule in or rule out.
Almost always, a rust colored or bloody nipple discharge
come from only one of the breast ducts. A ductogram
is an xray procedure in which a very small, blunt-ended
plastic tube is placed in the nipple duct that is
producing the discharge in order to inject dye and
see if there is a papilloma in the duct.
I have not heard that size of nipples affects the
ability to perform a ductogram and certainly your
recent radiologist was a clod about making such an
issue about it even if it was the case. It is possible
that there are other radiologists in the area that
have more experience with this and can perform the
procedure for you. Ask the breast surgeon if there
is some other radiologist he or she has worked with
that could be recommended.
The usual contraindications to ductogram are:
history of dye allergies
previous surgery disconnecting the ducts from the
openings on the nipple
severe retraction of the nipple
In either case, whether an intraductal papilloma is
seen or not, you will likely have surgery to remove
the duct that is bleeding to be examined for possible
malignancy or premalignancy (in situ carcinoma) or
to remove the papilloma. The likelihood of finding
the precise cause of the discharge is increased significantly
by preoperative ductograms (galactography) (1) but
until recently ductography was not ever performed.
You will need to see the breast surgeon about this
and be sure to ask any questions you have. Write them
down beforehand if you need to so you will not forget.
While bloody nipple discharge is the most concerning
for possible malignancy, 4 other types of nipple discharge,
clear (watery) or yellowish, milky, pus-like (purulent)
or greenish black and sticky, also need to be evaluated.
If the cause is not due to cancer, about 75% of breast
nipple discharge goes away within about 5 years (1).
Any time a nipple discharge comes from just one duct
in a nipple, it needs to be investigated as a possible
sign of breast cancer. When you express discharge
from the nipple, you can see if it comes from just
one point (duct) on the nipple or whether there are
multiple droplets from several ducts or more. For
example, a milky, lactational discharge which is hormonal
in origin always comes from several ducts and it may
even be bilateral. Clear or yellowish discharge due
to fibrocystic condition often comes from multiple
ducts and may be bilateral. When it is unilateral
and from only one duct, an exam, mammogram, a ductogram
if there is no mass and sometimes cytology (a Pap
smear of the breast) should be done to look for a
cancer.
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