Incidence of Breast Cancer in Patients Undergoing Diagnostic Duct Excision for Pathological Nipple Discharge.
Authors: Yassin N. , Hoar F. 
Published: December 2010

Abstract
BackgroundWomen with pathological nipple discharge (PND), defined as single duct, blood stained or serous discharge, usually undergo diagnostic surgery to exclude breast cancer. The purpose of this study was to ascertain the incidence of breast cancer in women undergoing such surgery in our unit and examine the use of nipple discharge cytology.MethodsPatients who underwent either total duct excision (Hadfield's procedure) or microdochectomy at City Hospital, Birmingham between January 2005 & April 2009 were identified from hospital computer records. In total 139 women were identified but 37 were excluded as they did not have PND and underwent surgery for indications such as recurrent episodes of sepsis due to peri-ductal mastitis, for symptomatic relief of nipple discharge and for correction of nipple inversion.Overall, 102 patients with PND and no other clinical signs of malignancy underwent diagnostic duct surgery. Data collected included patient age, laterality of surgery, radiological imaging undertaken, nipple discharge cytology results and final pathology from the resection specimen.ResultsThe majority of patients (99%) were female. Patient age ranged from 21 – 81 years, with a median of 50 years. Fifty nine patients (57.8%) had surgery for left breast symptoms, 41 (40.2%) for the right side and 2 patients (2%) had bilateral surgery. Most patients had imaging – 50 patients (49.0%) had mammography, 41 (40.2%) had mammography plus ultrasound whilst 7 (6.9%) had ultrasound alone. Only 4 patients (3.9%) had no imaging and all these patients were &lt; 35 years. Imaging did not show any features of breast cancer in any of the patients.Nipple discharge cytology showed benign changes (C1/C2) in 65 patients (63.7%), atypical cells (C3) in 21 patients (20.6%) and suspicious or malignant cells (C4/C5) in 4 patients (3.9%) whilst 12 patients (11.8%) did not have cytology performed. Hadfield's was the most common operation (61.8%) and was performed in an older age group (median age 55yrs) compared to microdochectomy (median age 43 yrs) (p=0.02 Mann-Whitney test).The most frequent primary pathological findings were intraduct papilloma (39.2%) and duct ectasia (38.2%). Other benign changes including fibrocystic disease accounted for 8.9% whilst 14 patients (13.7%) had either invasive or in-situ breast cancer. All patients with suspicious or malignant cytology were found to have an underlying breast cancer, but of note, 13.8% of patients with benign cytology were found to have breast cancer. One male patient who did not have nipple cytology performed was found to have DCIS. Of the 14 patients diagnosed with breast cancer, 8 (57%) had pure ductal carcinoma in situ whilst 6 (43%) had foci of invasive disease in additional to the DCIS.Result of Nipple Discharge Cytology & Final PathologyCytology Resultn=No. Patients with breast cancerNo cytology121 (8.3%)Benign (C1/C2)659 (13.8%)Atypical (C3)210 (0%)Suspicious / Malignant (C4/C5)44 (100%) ConclusionsNipple discharge cytology is unreliable in diagnosing the cause of pathological nipple discharge and its routine use should be reconsidered. All patients with pathological nipple discharge require diagnostic surgery.
Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 6014.