Overview
Definition:
Duct excision is a surgical procedure involving the removal of one or more lactiferous ducts from the breast, typically performed to investigate or treat pathologic nipple discharge.
Epidemiology:
Pathologic nipple discharge affects a small percentage of women
While most cases are benign (e.g., duct ectasia, papilloma), a small proportion can be malignant
The incidence of malignancy increases with age.
Clinical Significance:
Accurate diagnosis and appropriate management of nipple discharge are crucial to rule out underlying malignancy and to resolve symptoms that significantly impact a patient's quality of life
Duct excision provides tissue for definitive diagnosis and therapeutic relief.
Clinical Presentation
Symptoms:
Spontaneous, unilateral, and persistent nipple discharge
Discharge can be serous, bloody, or serosanguinous
Nipple pain or tenderness may be present
Palpable mass in the subareolar region in some cases.
Signs:
Visual inspection of the nipple may reveal discharge
Palpation may reveal subareolar thickening or a discrete mass
Tenderness may be elicited
Careful examination of discharge character and origin from nipple pores.
Diagnostic Criteria:
Pathologic nipple discharge is typically defined by unilateral, spontaneous, and persistent discharge that is not related to lactation or pregnancy
The character of discharge (bloody, serous, serosanguinous) and the presence of a mass are significant indicators.
Diagnostic Approach
History Taking:
Detailed history of discharge characteristics (color, consistency, unilateral/bilateral, spontaneous/expressible)
Onset and duration of symptoms
Association with menstrual cycle
Previous breast surgery or mastitis
Family history of breast cancer
Medications (e.g., hormonal).
Physical Examination:
Bilateral breast examination including inspection for skin changes, nipple abnormalities, and masses
Palpation for masses, lymphadenopathy, and tenderness, focusing on the subareolar region
Gentle expression of discharge from nipple pores to observe character and origin.
Investigations:
Cytology of nipple discharge: useful to detect malignant cells, though sensitivity is limited
Mammography and ultrasonography: essential for detecting underlying masses or architectural distortion, especially in cases with a palpable mass or suspicious discharge
MRI breast: may be indicated if imaging is inconclusive but suspicion remains high
Ductogram: historically used but largely replaced by imaging
can sometimes delineate duct abnormalities.
Differential Diagnosis:
Physiologic discharge (bilateral, milky)
Mammary duct ectasia
Intraductal papilloma
Subareolar abscess or mastitis
Drug-induced discharge
Breast cancer (DCIS, invasive carcinoma)
Nipple adenoma.
Management
Initial Management:
Conservative management may be considered for benign-appearing, non-bloody discharge if patient is asymptomatic otherwise
However, for unilateral, spontaneous, or bloody discharge, further investigation and likely surgical intervention are warranted.
Medical Management:
Antibiotics for suspected infection/abscess
Discontinuation of offending medications if applicable
Analgesics for pain management.
Surgical Management:
Surgical indications include: bloody or serosanguinous discharge, persistent discharge not resolving with conservative measures, palpable mass, or suspicious findings on imaging
Procedures include: Subareolar duct excision (to remove suspicious ducts), Segmental mastectomy (if a larger lesion is identified)
Techniques involve careful dissection of ducts from the nipple-areolar complex.
Supportive Care:
Postoperative wound care
Pain management
Monitoring for signs of infection or hematoma
Psychological support for patients concerned about breast cancer.
Complications
Early Complications:
Bleeding and hematoma formation
Seroma
Wound infection
Nipple-areolar complex necrosis (rare)
Pain
Scarring.
Late Complications:
Nipple sensory changes or numbness
Breast asymmetry
Recurrence of discharge if not all affected ducts are excised
Fibrosis and tethering of the nipple.
Prevention Strategies:
Meticulous surgical technique to preserve blood supply to the nipple
Adequate hemostasis
Prompt recognition and management of infection
Careful wound closure.
Prognosis
Factors Affecting Prognosis:
The underlying cause of the discharge is the primary prognostic factor
Benign causes generally have an excellent prognosis
Malignant causes depend on the stage and type of cancer
The success of surgical excision in resolving symptoms is generally high for benign conditions.
Outcomes:
For benign conditions like duct ectasia or papilloma, excision provides symptomatic relief and definitive diagnosis
For malignancy, prognosis is tied to cancer treatment protocols.
Follow Up:
Follow-up involves wound checks, symptom assessment, and consideration for adjuvant therapy if malignancy is diagnosed
Long-term follow-up for breast cancer surveillance is essential
For benign causes, regular breast self-examination and clinical breast exams are recommended.
Key Points
Exam Focus:
Always suspect malignancy with unilateral, spontaneous, bloody discharge
Differentiate between physiologic and pathologic discharge
Understand indications for duct excision and other breast procedures
Recognize imaging findings suspicious for malignancy.
Clinical Pearls:
When expressing discharge, apply gentle pressure quadrant by quadrant to locate the origin of the discharge
Thoroughly palpate the subareolar region
Do not miss the possibility of underlying malignancy, even with benign-appearing discharge.
Common Mistakes:
Dismissing unilateral, bloody nipple discharge as benign without adequate investigation
Incomplete excision of involved ducts leading to recurrence
Inadequate workup for underlying malignancy, especially in older patients or those with suspicious imaging.