Page 79 - IDF Journal 2023

50% of women can illicit nipple discharge with 15% being spontaneous. The
colour can vary but doesn’t indicate any particular diagnosis. The most common cause is duct ectasia in perimenopausal women. The discharge is usually coloured, multi-duct and can be bilateral. Galactorrhoea (copious, milky, bilateral spontaneous nipple discharge, not related to pregnancy or breast feeding) can be caused by a high prolactin as well as medications, including psychotropics, antidepressants, antihypertensives, anticonvulsants and H2 blockers, as
well as recreational drugs. Physiological discharge is also very common and
can persist for several years after
breast feeding has ceased. Single duct discharge may indicate a papilloma and in pregnancy these can cause brisk blood- stained discharge that usually settles spontaneously. Fewer than 1% of breast cancers present with nipple discharge as the only sign.
There are a variety of infective conditions too. Lactating mastitis tends to
occur in the first 6 weeks of breast feeding. Antibiotics can be helpful if it
is caught early but, in the case of an established abscess, serial ultrasound guided aspiration is the treatment of choice. Breast feeding can continue. Non lactating mastitis, with infection around the nipple, is usually due to peri-ductal mastitis. This is a recurrent, indolent condition, that presents with an abscess and may lead to a mamillary
fistula. 90% of cases are in smokers. A “peripheral”, non-lactating abscess is less common but can occur in diabetes, rheumatoid arthritis or in those that are immunosuppressed. Granulomatous mastitis is a rare form of infection, usually idiopathic (but it can be infective or related to pituitary tumours), with runs a prolonged course of recurrent abscess. The key is to rule out malignancy and
try to avoid surgery if possible. Neonatal mastitis is uncommon, occurring in the first few weeks of life. Antibiotics is the preferred treatment in each case with surgery a last resort. Metaplastic breast cancer has been known to present
as a peripheral breast “abscess” in
older women3. Other causes of “breast infection” include a variety of skin related conditions, including cellulitis, epidermal cysts, and hidradenitis suppurativa as well as factitial disease and other, rare, infections such as TB, and syphilis. Severe trauma, with associated bruising, can result in fat necrosis (which can also mimic malignancy) whilst other trauma related conditions include “jogger’s nipple” and “tassel dancers nipple”! It is even possible to get a pilonidal sinus in the skin of the breast. Two occupations potentially prone to this are hairdressers and sheep shearers!
So, most of the time, when we see women with breast problems, we can tell them: “it’s not breast cancer”.
REFERENCES
1. Marsh SK, Archer TJ. The accuracy
of general practitioner referrals to a specialist breast clinic. Annals of the Royal College of Surgeons 1996;78:203- 205.
2. Potter S, Govidarajulu S, Shere M, Braddon F, Curran G, Greenwood R, Sahu A, Cawthorn S. Referral patterns, cancer diagnoses, and waiting times after introduction of two week wait rule for breast cancer: prospective cohort study BMJ 2007; 335:288
3. Wong C, Wright C, Colclough A, Marsh S. Metaplastic carcinoma presenting as a breast abscess. International Seminars in Surgical Oncology 2006, 3:23
EDUCATIONAL OFFERINGS
Mr Simon Marsh
BA MB Bchir MA MD FRCSEng FRCSGenSurg
Consultant Surgeon
108 Harley Street
T: 0277 563 1234
E: info@108harleystreet.co.uk
W: https://108harleystreet.co.uk/
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