Welcome to First Incision, the podcast about preparing for the General Surgery Fellowship exam. I'm your host, Amanda Nikolic. Thanks for joining me for today's episode. Let's do our team timeout. Our patient today is the breast module from the general surgical curriculum. We are definitely not ready to move on yet. There is a lot more to cover.
The operation or topics for today are going to be nipple discharge, breast abscesses and other inflammatory breast conditions, and the humble galactocele. Let's get started with our first topic of nipple discharge. Nipple discharge is something that's pretty commonly seen in the breast clinic. And to be honest, when I was a junior registrar, I didn't really know how to approach these patients.
The most important thing to know is that 95% of presentations with nipple discharge are benign. Patients are very concerned when they notice discharge because they think that this may be a sign of underlying cancer. And part of the assessment is making sure that you rule that out, but also being aware of the range of other reasons why patients present with nipple discharge. So a couple of definitions to start.
Discharge is a spontaneous fluid that comes out of the nipple. And secretion is fluid that's present in the ducts and that can be collected or aspirated by massaging the breast or using a breast pump. In the curriculum, one of the things that's stated is that trainees need to be able to differentiate between
physiological and pathological causes of nipple discharge. And this is a key way to break up in your mind how you think about nipple discharge. So physiological nipple discharge is very common in about two out of three non-lactating women. A small amount of fluid can be expressed from the ducts of the nipple. If the nipple is cleaned, the breast is massaged and suction is placed on the nipple.
This is a, as it said, physiological process. And the fluid that comes out is usually a mixture of colors. So it can be white, clear, milky, yellow. green, brown, or even a blue-black color. And it's thought to be a natural secretion from the apocrine glands within the ducts. Usually this would come out of multiple ducts on the surface of the nipple. So if you have a look at the nipple, you'll be able to see that there's multiple points that the fluid is coming out.
And like I said, it's very common. It can also be normal during pregnancy prior to the birth of the child. And it's also very common post-menopause after the normal involution. of the breast tissue. A couple of other causes to talk about. So another aberration of normal development and involution of the breast is a condition called mammary duct ectasia.
And this is very common postmenopausally. And during that involution of the breast after menopause and leading up to 60, 70 years of age, the major ducts underneath the nipple will dilate and shorten. And this can cause nipple retraction or sort of excessive shortening of these ducts will cause retraction of the nipple and a palpable mass. And this can...
cause a sort of cheesy-like discharge, which is sort of a thick, yellowy discharge and can be unilateral or bilateral. And the typical appearance of the nipple is that you get a slit-like symmetrical retraction. of the nipple. So some more pathological causes of nipple discharge. We touched in the benign breast diseases topic about intraductal papillomas. These are those small papillary tumors that grow within the duct itself around the fibrovascular stalk.
They are usually found centrally under the nipple in the major subareola ducts, but we did also comment on those more peripheral papillomas or multiple papillomas that can occur. is the most common lesion that causes discharge from the nipple. And typically the fluid that comes out is serosanguinous, so a bloody type fluid. And usually if it's due to a ductal papilloma, you will see that the discharge is just coming from one duct because it's the duct that's affected.
It's most common in women who are 30 to 40 years of age, and obviously the older you are, the higher the chance of an underlying malignancy. So that needs to be considered. Other causes of nipple discharge that are not physiological includes nipple discharge that's stimulated by drugs or medications. And there is a number of medications that can cause nipple discharge. You can look up your own list.
Some common ones that I came across included the contraceptive pill, opiates, SSRIs, dopamine agonists. metoclopramide and antihistamines. And usually by stopping the drug, the nipple discharge will cease and sometimes you can reintroduce the drug at a smaller dose and the nipple discharge won't recur. The next cause to talk about is actually a condition called galactorrhea, which is the secretion of milk from the breast, which is not related to pregnancy or breastfeeding.
There are a number of causes of galacteria. It can be physiological due to stress, menarche or menopause, but we'll focus more on drugs and... conditions that increase prolactin. So drugs that can cause galactorrhea mostly include those that will interfere with dopamine activity. So these are centrally acting drugs like haloperidol. chlorpromazine or metoclopramide and can also include other drugs such as opiates and oral contraceptives. There's a really great article.
on American Family Physician called Diagnosis and Management of Galacteria, if you want to read about this in a little bit more depth, and they go into some more drugs that can cause this condition. In addition, we can... Think about things that increase prolactin release. So this can include primary prolactin secreting tumours, and this can be found either in the pituitary gland or also in lung cancers.
Another condition that can cause galactorrhea is hypothyroidism. It's thought that the increase in TSH can also stimulate prolactin release. And also galactorrhea can be seen. In chronic renal failure, about 30% of patients with chronic renal failure will have elevated prolactin levels and some of these patients will present with galactorrhea.
Of course, we need to talk about malignant causes of nipple discharge. Breast cancer can cause a nipple discharge, but less than 5% of patients with breast cancer will present with this symptom. Usually if there is a malignant underlying cause, the discharge will be from a single duct. watery or serous, can be bloodstained and is usually related to an invasive tumour that's close to the nipple areola complex.
DCIS can also be associated with nipple discharge in the same way and it's thought that this is because the DCIS is within the ducts itself and that fluid that can then spread along the ducts towards the nipple. Other causes of nipple discharge that need to be considered include a breast infection, Paget's disease of the nipple, and also nipple eczema. So who should have further testing?
What is the role of imaging in nipple discharge? And the curriculum specifically says who needs further investigation. So the patients who you should be worried about and who... really need further investigation, are patients who are presenting with persistent unilateral spontaneous discharge, especially if it's out of one duct. Patients should initially be investigated with a history and examination. History should include the patient's individual history of any previous breast.
conditions whether they have had children whether they breastfed or currently breastfeeding whether they have any past medical history themselves, whether they have any family history of breast disease, and should also include a history of their risk factors for breast cancer. A history of the presenting complaint should be taken, which should include
Delving into whether this is spontaneous discharge or whether it's happening with manipulation of the breast. Whether or not the fluid is coming out of one duct or multiple ducts. Whether it's unilateral or bilateral. the type of discharge, whether it's watery, serous, blood-stained, clear, milky, green or blue-black, and also the frequency of discharge. If a concern is therefore...
Galactorrhea, history should be taken for whether there's any underlying neurological symptoms such as headache, visual changes or seizures, whether there's any hormonal changes such as evidence of hyper or hypo. thyroidism, and also a history of their medication use. An examination should then be done. This should include general examination looking for any neurological or hormonal issues.
A breast examination should include firm pressure around the areola to identify the site of any dilated ducts. firm pressure on the nipple and often the patient can do this for you as that's more comfortable and you should review where the fluid is expressed from, the sight and character, whether or not it's bilateral or from a single duct.
Imaging should be performed if there's any concern. So if this patient has any of those high risk features on history and examination that I've mentioned, if they're older, if... anything doesn't line up, then you should at least start with a mammogram and retroareolar ultrasound. Mammograms are useful for patients over about 35 years old.
And we're looking for any evidence of a mass dilated duct or a mass within the duct like a papilloma. If you have a younger patient... who has a very strong family history or is very high risk for a malignancy, then you could consider other imaging such as an MRI. Other testing, especially if you're concerned about galactorrhea, could be done. This can include blood tests, looking for elevated prolactin level and elevated TSH levels.
Normal prolactin level is less than 20 micrograms per liter. And if there's any values seen that are greater than that, then an MRI brain should be performed to look at the pituitary. And you can also look at... whether the patient has any evidence of visual disturbances or amenorrhea as a sign that you should be further investigating the pituitary gland. There are other special tests that can be used to investigate nipple discharge. One of these is discharge cytology.
where essentially the nipple discharge is placed onto a glass slide and spread thinly and fixed with an alcohol spray. And the... fluid itself can be looked at under the microscope to investigate the cellularity and any abnormalities of the cells in that fluid. Limitations include the fact that it's very difficult to get a diagnostic sample because there can be not very many cells in the fluid. A negative cytology doesn't exclude a malignant cause.
And there is quite a high false positive and false negative rate. In addition, it's important to note that in the post-ovulatory phase, the proliferative changes found in the lining of... the ducts of the breast can mimic atibia or malignancy. So it's really important if you are going to do cytology of this fluid that you do it in the pre-ovulatory phase of the menstrual cycle.
Another test that can be done is galactography, which can also be called ductography. And as the name suggests, this is an imaging study of the ducts of the breast. Essentially... a small cannula is placed into the suspicious duct with a small sort of catheter. Contrast is then injected to fill the duct and magnification, x-ray mammogram views basically are taken to investigate that duct.
It can be a little bit difficult to cannulate the duct. And if the lesion is very close to the nipple, then the cannula itself can obscure a lesion. And it also doesn't give you information about if there is a lesion in the duct, whether this is malignant or benign. But it can be useful because you may see a cutoff sign. You may see the obstruction or a filling defect in the duct.
You may see ductal dilatation, which gives you an indication of where the issue is, irregularity of the duct wall or ductal narrowing. And this can give you an indication of where a lesion may be if you haven't been able to, especially if you haven't been able to see it with conventional mammogram or ultrasound imaging.
Another test that can be done, which I've never seen done, so I'm not sure how frequently it's used in Australia, is ductoscopy. This is direct visualization of the duct with a very, very, very small camera. It's done under local anesthetic and involves a dilation of the duct with a lacrimal probe and then insertion of a small fiber optic scope and the use of fluid to irrigate the duct. It can be difficult to find the problem.
especially if there's multiple ducts involved. And also because there's a lot of shared openings of different ducts into the main duct that's coming out of the nipple. So you have to be pretty lucky to go down the specific duct that has the problem. But obviously if you do see a problem, problem then you can get a really good indication of where it is and what its character may be. But like I said I haven't seen this widely used.
taking a step back for a minute because there has been a lot of information. Basically, there are some patients that you don't need to investigate. So if you do a complete history and examination and you find non-spontaneous multi-duct discharge in a young patient, This is most likely physiological and you can just provide reassurance and education for that patient, encouraging them to stop manipulating the nipple and send them back to the GP.
If the patient has no red flags on the history of examination and again has non-spontaneous multi-duct discharge, but they're older than 35 or 40 years old, then you could consider a mammogram, which if it's then normal, you can reassure and organise the patient to have some education and to follow up with the GP or if there is an abnormal. then you would go down the normal investigatory pathway. In the patients that you're more concerned about, so those patients who have spontaneous single...
duct discharge or milky discharge like galactorrhea or abnormalities on your examination. Those are the patients that need further investigation. Those patients would have, you'd start with a diagnostic mammogram and ultrasound, as we've talked about. And if you did find any lesion on those imaging studies, then you would then target your further investigation, most likely with a biopsy of those lesions.
If you have done all of that and you haven't found a lesion, then you can consider ductography if that's something that is done in your center. The next step, however, in these patients is... usually a surgical excision of the duct, as this will be both curative and also will identify whether there is any underlying pathological problem.
Surgical excision could also be considered in an older patient who has distressing symptoms, so who has a lot of discharge or is very concerned about it, in which case you could consider removing the ducts to cure their problem. There are two main operations that are talked about when we talk about duct excision, and this includes a microdicectomy, which is removal of the single duct that's causing the problem.
or a total duct excision, also called a Hadfields procedure. A microdicectomy is performed under either local or general anaesthetic and involves... identifying the specific duct that is discharging, inserting a lacrimal probe or injecting it with methylene blue so that you can then identify it, performing an incision.
around the areola, no more than 50% to avoid devascularization, and dissecting out the involved duct circumferentially and ligating the duct proximally at the dermis of the nipple and distally. The distal extent of the excision should be guided by previous imaging and whether or not you have identified a lesion and how deep in the breast it is. And ductography, as I mentioned before, could be useful to identify where that point is.
This should be tailored depending on the individual patient. The tissue is then mobilized to fill that resection deficit and skin is closed. This procedure could be considered for patients who haven't yet breastfed or who are planning to have children and breastfeed in the future because if you remove all of the ducts under the nipple, this will obviously impact on their ability to breastfeed out of that breast.
A total central duct excision or Hadfield procedure involves removal of all of the ducts underneath the nipple with... a conical resection of tissue extending two to three centimetres into the breast tissue, again guided by whether or not there is an underlying lesion. The University of Texas MD Anderson Candice Center has a nice flow chart for how you would investigate and manage patients who present with nipple discharge if you want to have a further look at that.
Moving on now to breast infections. I thought when I started this topic that it wasn't going to be too complex having managed a lot of breast abscesses being a general surgical registrar. However, the more that I read, the more that I realized that actually it does encompass quite a number of conditions that we should know about as general surgical doctors. So the first one I'll briefly touch on is a breast.
Abscess, we've all seen them before. They present typically with evidence of infection, with redness, fever, tenderness, potentially a fluctuant mass there, pain. On examination, we'll find a mass with overlying warmth, redness of the skin, potential skin thickening and tenderness. The investigation most commonly done for these is a bedside or a formal ultrasound scan which will
Identify the presence of an abscess, whether or not it's loculated, whether there's multiple abscesses, and rarely a mammogram would be done in this situation due to patient's pain. It is important to consider that... Inflammatory breast cancer presents as redness and warmth and erythema over a third of the breast, and especially after treatment of a breast abscess, a mammogram should be scheduled to rule out an underlying malignancy.
The common bacteria that cause breast abscesses are the same bacteria that would cause usual skin infections, so staphs and streps, the most common bug being staph aureus. There are some rare bugs that can cause breast abscesses, including Pseudomonas, Proteus, Srirachis, Klebsiella, and Actinomyces. A number of cultures of breast abscesses will be sterile. It's difficult to know whether this is because of treatment and obviously they're more common in patients who smoke.
patients with diabetes and also common after nipple piercing. The management of a breast abscess will... be different depending on where you work. Most units that I've worked on recently will have a protocol where if an abscess is identified the patient will be placed on oral antibiotics and scheduled for aspiration of the abscess. If it's a very, very large abscess, then we would more likely go to surgery. But in small abscesses and well patients, we manage them as an outpatient.
Aspiration of the abscess versus incision and drainage obviously leads to a better cosmetic outcome, removes the requirement for packing and can be successful in up to 85% of cases. It is potentially required that the patient may need multiple ultrasound guided aspirations and early reassessment and follow-up of the patient should be scheduled.
Incision and drainage can be done if the abscess is very large. Usually if it's more than three centimetres in size, it's less likely to resolve with aspiration and especially if there's multiple loculations. So these patients would be booked for theatre for... a incision and drainage most likely done under sedation or general anesthetic with packing of the cavity.
An abscess that develops in relation to breastfeeding is common, especially in the early breastfeeding period or when the patient is trying to wean breastfeeding. It's thought to occur due to milk components blocking a duct, causing stasis of the milk proximal to that blockage and crack or sore in the skin from breastfeeding, causing bacteria to enter into that area.
and infection. It can be managed similarly to a non-breastfeeding related abscess with antibiotics and drainage either through aspiration or open. An important thing to know about in this situation is that an uncommon complication can be the development of a milk fistula. This is where there's a tract between the skin surface and a duct of the breast that leaks milk.
This is more common after incision and drainage than aspiration. Most of these will close spontaneously. However, rarely the patient may need to stop breastfeeding in order to allow the fistula to heal. I now want to discuss two topics that I came across when reading up about breast infection and breast abscesses that I hadn't really come across that much in clinical practice but are important to know.
The first one is the development of a perioductal abscess or a chronic subareolar abscess. This is a condition that can also be known as Zuzka's disease, Z-U-S-K-A. and is a presentation with chronic and recurring abscesses underneath the nipple areola complex with an associated fistula draining in the areola. It can happen... in a range of patients between 20 to 70 years old and is sometimes associated with a nipple discharge or inversion as well. Clinically,
The patients will often present with an acute subareolar abscess and they'll also have a draining sinus which will be located at the edge of the areola. An ultrasound often will demonstrate the underlying. abscess and is important to rule out an underlying malignancy. This condition is not really well understood. It's thought to be multifactorial, but one... is that the subareola ducts change their epithelial lining from their normal cuboidal epithelium into squamous epithelium.
And that squamous epithelium then can produce keratin, and this can cause a plug or an obstruction in that duct. And the duct will then dilate proximally to that. and can rupture with the tissue around it, then getting involved in a chronic inflammatory response and development of inflammation and an abscess. with the shortest route for that abscess to drain being at the edge of the areola. This condition is most associated with patients who smoke, and usually the...
Organisms will be mixed, anaerobes and aerobes, including staph aureus, coagulase negative staph, streptococcus and other anaerobes. The initial treatment should be drainage of the abscess. So that can either be with aspiration or incision and drainage. However, given recurrence of the condition is likely or they may present with already having had multiple recurrences, a discussion...
should be had with the patient about planning a definitive operation, usually after the inflammation has settled down. The operation... you would offer that patient would be excision of the fistula tract, including the diseased duct and the surrounding inflammatory tissue. So this is sort of similar to the micro duct.
that we talked about earlier when we were discussing nipple discharge. You would start with identifying the... involved duct by either using a lacrimal probe down the fistula tract or injecting methylene blue down the fistula tract to therefore identify the corresponding duct that is connecting with the fistula. and basically performing an incision around the areola and resecting the entire disease portion of the duct and surrounding tissue as well as the fistula.
If multiple ducts are involved or this subareolar abscess continues to recur despite the original ductectomy, then a resection of all of the major ducts can be performed, which again I discussed earlier when we were talking about.
nipple discharge the incision is made around the areola or an incision can be made below the areola and the nipple areola complex is elevated and the major ducts are separated from the base of the nipple as well as a core of tissue into the breast to remove all of those ducts. It's pretty rare but if this were to continue to recur then a resection of the entire nipple and ducts may be required for a definitive cure.
The last topic I'm going to discuss under breast abscess is a condition called idiopathic granulomatous mastitis. This is a benign inflammatory condition of the breast that I have not ever come across in clinical practice. It is a condition that doesn't really have a known cause and is a diagnosis of exclusion.
It's found in women between 20 and 60 years of age, and often there'll be a history of pregnancy and breastfeeding in the last five years. It's mostly unilateral, but it can be bilateral, and clinically it presents with... multiple abscesses and sinus tracts to the skin and breast edema that clinically mimics a bacterial abscess or can mimic a breast cancer. They can be nipple inversion.
or retraction due to the inflammation of Cooper's ligaments. And there can also be palpable auxiliary nodes due to inflammation and reactive process. Often, like I said, there's sinus tract formation and... The presence of multiple fistulas or sinuses with sterile abscesses and chronic relapsing process is the sort of presenting picture of this syndrome.
Imaging-wise, mammograms will often demonstrate multiple ill-defined densities associated with these sort of abscess cavities and can show speculated margins and overlying skin thickening. An ultrasound will demonstrate hypoechoic masses or abscesses, can show in large lymph nodes, and MRIs will show multiple masses with ring or nodular enhancement. I did mention that it's a diagnosis of exclusion. So there's a number of differentials and...
Each of these should be considered based on the imaging findings as well as aspiration of the abscesses and core biopsies of the wall of the mass or abscess cavity. Differentials include infections, so the fluid should be sent for gram stain, periodic acid shift for fungal infection, and also acid fast bacilli for TB. Chronic inflammatory conditions such as sarcoidosis, Wegener's granulomatosis, and polyarteritis nodosa should also be considered, as well as breast cancers, periodontal mastitis.
foreign body reactions, and other autoimmune conditions. So like I just mentioned, a further biopsy is often done to try to differentiate what the cause of this presentation is, and this should involve a core needle biopsy of a mass or of the wall of the abscess cavity. The typical findings for idiopathic granulomatous mastitis are non-caseating granulomatous inflammation of the lobular units of the breast with the presence of giant cells.
polymorphonuclear leukocytes, plasma cells, lymphocytes, and occasionally sterile micro abscesses. The underlying autoimmune causes should be looked for, so patients should have blood tests that include CRP. ana rheumatoid factor but like i said the cause of this condition is not known although there is a relapsing natural history of this disease
It does seem to be mostly self-limiting with time and the management is quite controversial and really should be done at a specialized breast unit. Firstly, if patients present with... what is clinically thought to be an abscess, they should be treated expectantly as so with antibiotics and aspiration to make sure that you're not missing an underlying infection.
There is some evidence that oral steroids can help with the disease and about 80% of patients will have some success with oral steroids. If the condition recurs, they can have further courses. There has been some investigation into other disease-modifying drugs, such as methotrexate, but they should be reserved for patients who are not responsive to steroids.
And surgery should really be a last result only for patients who have failed other approaches as there are high relapse rates. And some operations that could be considered include open drainage of an abscess, a wide excision of an abscess and fistula. tract or even a mastectomy. But like I said, these cases are rare and complex and should be managed by a multidisciplinary team.
The last condition that I'm going to briefly touch on today is that of the galactoseal. A galactoseal is a common benign breast lesion that presents in... young women typically who are either starting or weaning from breastfeeding. It essentially is a retention cyst. which is thought to be caused by milk components blocking a duct and the duct proximal to that blockage filling with milk and dilating into a milk cyst.
The diagnosis is easily made on aspiration with either aspiration of milk or looking at the biochemistry of that liquid, which will demonstrate proteins, fat and lactose. The liquid that's aspirated can be either thin if fresh or thickened if it's an older liquid. And typically these patients will present with a painless breast lump.
and can occur over weeks to months in time. It's usually single, can be multi or... unilateral or bilateral because this pathology can obviously occur in multiple aspects of the breast and it can be complicated with an abscess which we did talk about in the last section. Differentials that need to be considered include an abscess, a fibroadenoma, or a cancer, as well as a lactating adenoma, which you would be able to differentiate on ultrasound as it has color flow on Doppler.
So talking about investigations, mammogram usually wouldn't be done in these women as they are lactating. But if it was done, you would see a lesion that could potentially have a... fluid level within it because of the fat and protein content separating out from the liquid content on ultrasound.
It can look very different, again, depending on the fat and protein content of the fluid. It may appear just as a cyst. It could look multicystic, could look mixed, or could appear partially solid. But there shouldn't be any Doppler flow. evidence of vascularity inside. Most galactoseles will spontaneously resolve. A small number of patients may have a residual collection that can look like a fibroadenoma or a cyst.
aspiration will potentially be curative, although the milk may just reaccumulate but can help with diagnosis as we have already discussed. It's time to close up. Thanks for listening to First Incision. If you have any comments or feedback, send us a message at firstincisionpodcast at gmail.com or follow us on Instagram at firstincision. Happy studying!