Journal of Surgical Oncology 43:228-230 (1990)
Bloody Nipple Discharge During Pregnancy: A Rationale for Conservative Treatment RENE LAFRENIERE, MD, CM, FKCSC, FACS From the Division o f Surgical Oncology, Department o f Surgery, University of Calgary, Calgary, Alberta, Canada
Five cases of bloody nipple discharge during pregnancy without associated breast masses were seen over the past 3 years by the author. Because of the reported association of breast cancer with bloody nipple discharge, close follow-up of these women at monthly intervals during pregnancy and trimonthly during the postpartum period was carried out. In all instances, the discharge appeared late during the second trimester or during the third trimester of pregnancy. It was unilateral and spontaneous and arose from multiple ducts, and it was associated with an increase in breast size and always with the larger breast of the two. The discharge cytologic study done on all cases was negative for neoplastic cells and the discharges resolved spontaneously within 2 months of onset. Postpartum follow-up ranging from 6 months to 3 years has revealed no evidence of neoplastic changes thus far. Mammograms ordered before these patients were referred were not helpful due to the increase in density of the breast tissue secondary to the pregnancy. Because a few cases of breast cancer during pregnancy have presented solely with a bloody nipple discharge, I recommend extremely close follow-up of these women and no surgical intervention unless a mass is discovered or the nipple discharge cytology is either suspicious or positive at the initial visit or during follow-up. KEY WORDS:breast disorders, carcinoma, breast cancer
INTRODUCTION A colorless secretion from the nipple of the breast is commonly observed during pregnancy. A serosanguinous discharge is, however, an uncommon occurrence, and its presence leads clinicians to a dilemma because of the reported association of breast cancer and bloody nipple discharge in nonpregnant women [ 1,2]. The clinical dilemma of course focuses on what one should do if faced with a bloody nipple discharge when no masses are felt within the breast, what diagnostic tools are available if any to help manage these patients, and what it means to have a bloody nipple discharge during pregnancy in terms of clinical course of the disease process. Over the past 3 years, five cases of bloody nipple discharge during pregnancy have been seen by the author, and this has prompted a review of this clinical entity and prompted a plan for management that takes into consideration the possible presence of a subclinical 0 1990 Wiley-Liss, Inc.
carcinoma. Cases of bloody nipple discharge during pregnancy, pathophysiology associated with this disease process, and recommendations for management are outlined in this paper.
MATERIALS AND METHODS Five patients were referred for evaluation of a bloody nipple discharge occurring during pregnancy. A detailed case history was obtained from each and included age, parity, location of the discharge (left or right breast, uniductal or multiductal), family history of breast cancer, past history of bloody nipple discharge, gestational age at presentation of the discharge, spontaneity of the
Accepted for publication November 30, 1989. Address reprint requests to Rene Lafreniere, University of Calgary, Health Sciences Center, Room 1432, 3330 Hospital Drive N.W., Calgary, Alberta, Canada T2N 4N l .
Bloody Nipple Discharge During Pregnancy
229
TABLE I. Cases of Bloody Nipple Discharge Recorded During Pregnancy Case
Age (years)
Gravida
Breast
1
28 31 22 21 30
1 2 1
-
-
Left Right Right Left Right -
2 3 4 5 6 I 8 9
-
21
1 1
-
-
10 11
-
-
-
12-25 26 21 28
-
-
-
discharge, amount and color of the discharge, presence of masses or pain felt by the patient, and whether any sudden enlargement of the breast had occurred prior to the bloody discharge appearing. A complete physical examination was then carried out, including the head, neck, and chest, along with a multipositional examination of the breasts done in the sitting and supine positions to determine the presence of masses within the breast, the location of the bloody discharge, and whether the discharge was uniductal or multiductal. All patients were referred with mammograms and these were reviewed by a radiologist for any evidence of pathology. All bloody discharges seen at examination were smeared on a glass slide and were sent for cytological examination. Subsequently all patients were followed at monthly intervals during their gestation. Postgestation they were also seen monthly if they had decided to breastfeed and trimonthly after breast feeding or if they had decided not to breastfeed.
RESULTS The five cases described in this paper are briefly outlined in Table I (cases 1-5). At the time of the writing of this paper, the cases had been followed for from 6 months to 3 years, with a median of 2 years. The median age at presentation was 28 years, with a range of 22-31 years. Most women were gravida one (four of five), and the discharges occurred either from the left or right breast with no dominance seen in our five patients. However, the breast with the discharge was always the larger of the two. All women had recently undergone a rapid increase in breast size beginning 2-3 weeks before the bloody discharge had occurred. All cases began late during the second trimester or during the third trimester (range of gestational age 22-39 weeks, median 27 weeks). One patient had a family history of breast cancer, with her mother developing postmenopausal breast cancer. None
Time during pregnancy 21 Weeks 39 Weeks 22 Weeks 26 Weeks 31 Weeks
Cancer
Reference
No
This paper This paper This paper This paper This paper 2 2 3 3 3 3
NO
No No NO
-
-
-
-
Eighth month Third trimester Third trimester Third trimester Second or third trimester -
NO No No No No Yes Yes Yes
-
4
5 5 5
had a previous history of bloody nipple discharge, and case 2 had no recollection of such a discharge during her first pregnancy. All discharges were spontaneous and frankly bloody, staining the patient’s undergarment. On examination, all discharges were multiductal and unilateral in character. No excessive pain was associated with the pregnancy or the discharge, and no dominant unilateral masses of the breasts were found in any of the cases. A review of all mammograms done revealed that these were not helpful because of the increased density of breast tissue associated with pregnancy. Cytological examination of all discharges revealed only epithelial cells, histiocytes, foam cells, white blood cells, and red blood cells and no cytological evidence of neoplasia. A follow-up of these patients ranging from 6 months to 3 years, with a median of 2 years, revealed no evidence of neoplastic changes on physical examination. All the bloody nipple discharges spontaneously resolved within 2 months of onset, and lactation was achieved successfully in all women who intended to breastfeed (four of five).
LITERATURE REVIEW A review of cases of bloody nipple discharges associated with pregnancy uncovered an additional 23 cases [2-51 (Table I, cases 6-28). Unfortunately, very little information can be gathered from these cases, but some facts can be stated. In the cases described by Kline and Lash [3] and Haagensen [4], the bloody discharge occurred during the second or third trimester of the pregnancy. Age, parity, status and location of the discharge were not available. Except for those cases described by King et al. [5] (cases 26-28), the outcome was favorable, with no development of carcinoma. The cases of King et al. were associated with cancer of the breast without the presence of masses, so, in three of 28 available cases, cancer was associated with a bloody nipple
230
Lafreniere
discharge. For the patients of King et al., however, we do not know if the discharge was spontaneous, if cytology was done, or if the discharge was uni- or multiductal or if it resolved spontaneously.
DISCUSSION A bloody nipple discharge has been associated with the presence of breast cancer [1,2]. In Devitt’s [2] excellent review, 47 of 249 nipple discharges were bloody (19%), and among these, 45 five were secondary to carcinoma, so 10% of all bloody nipple discharges may be associated with carcinoma. Breast cancer during pregnancy is a rare event. Among 160,000deliveries, Betson and Golden [6] reported that 16 (0.01%) had an associated cancer of the breast, If one reviews the overall number of cancers of the breasts associated with pregnancy compared to those not associated with pregnancy, the percentages are quite low and range from 1.3% to 2.1 % of all breast cancers [7,8]. Cytologic and histologic studies of breasts with nipple discharges have been done during pregnancy and lactation by Kline and Lash [3,9]. Although they reported only four cases with frankly bloody discharges [3], they documented cytologically that 10 of 50 pregnant patients with discharges had red blood cells (RBCs) in the discharge and that 17 of 72 lactating women had RBCs in their nipple secretion [9]. Biopsies performed on a patient with a frankly bloody discharge revealed on histological section many newly formed lobules and moderate-sized to large dilated ducts [3]. These ducts were often lined with a single layer of cells. When the ducts were followed by serial histological sections, Kline and Lash found spurs of tissue projecting into the ducts. These spurs were made of loose fibrous tissue, with a single central capillary, and they were also covered with a single layer of epithelial cells. Many of these spurs were found at the origin of newly formed alveoli. Kline and Lash commented that these spurs resembled minute papillomas and postulated that, as in true papillomas, the thin capillary wall of spurs could rupture and give rise to a serosanguinous discharge of the nipple. Based on our cases and cases 6-25, one could surmise that a bloody nipple discharge during pregnancy is not pathological. However, King et al. [S] did describe three cases of breast cancer during pregnancy apparently associated only with a bloody nipple discharge (cases 2628).
If no masses are felt at the time of the examination, I believe that these patients should be followed closely at monthly intervals for the development of cancer as long as the cytological smear of the discharge is negative for malignancy. Such cytological examination in trained hands has been shown to be useful [ 10,111. Mammography should be discouraged and is of no benefit, as shown by our cases and as described by Feig [12]. If the discharge continues throughout pregnancy or if a mass appears or cytology is positive or suspicious, then proper surgical exploration should be carried out; otherwise, close follow-up is all that is necessary.
CONCLUSIONS A bloody nipple discharge during pregnancy should be followed closely at monthly intervals as long as there is no evidence of a breast mass or a positive cytological smear associated with the discharge. As long as these two factors that have been associated with malignancy are negative, conservative follow-up at monthly intervals without surgical intervention is indicated, along with reassurance of the patient that these discharges are usually not associated with a malignant process. REFERENCES 1 . Lewison EF: “Breast Cancer and Its Diagnosis and Treatment.”
Baltimore: Williams and Wilkins Co., 1955. 2. Devitt JE: Management of nipple discharge by clinical findings. Am J Surg 149:789-792, 1985. 3. Kline TS, Lash S: Nipple secretion in pregnancy. A cytologic and histologic study. Am J Clin Patho1 37:626-632, 1962. 4. Haagensen CD: “Diseases of the Breast.” Philadelphia: WB Saunders Co., 1986. 5 . King RM, Welch JS, Martin JK, Coulam CB: Carcinoma of the breast associated with pregnancy. Surg Gynecol Obstet 160:228232, 198.5. 6. Betson JR, Golden ML: Cancer and pregnancy. Am J Obstet Gynecol. 81:718-728, 1961. 7. Nugent P, O’Connell TX: Breast cancer and pregnancy. Arch Surg 120:1221-1224, 1985. 8. Sahni K , Sanyal B, Agrawal MS, Pant GC, Kaanna NN, Khanna S: Carcinoma of the breast associated with pregnancy and lactation. J Surg Oncol 16:167-173, 1981. 9. Kline TS, Lash SR: The bleeding nipple of pregnancy and postpartum. A cytologic and histologic study. Am J Pathol 8:336340, 1964. 10. Knight DC, Lowell DM, Heimann A , Dunn E: Aspiration of the breast and nipple discharge cytology. Surg Gynecol Obstet 163: 415-420, 1986. 11. Petrakis NL, Wrensch MR, Ernster VL, Miike R, King EB, Goodson WH: Prognostic significance of atypical epithelial hyperplasia in nipple aspirates of breast fluid. Lancet 2:505. 1987. 12. Feig SA: The breast. In Grainger RG, Allison DJ (eds): “Diagnostic Radiology: An Anglo-American Textbook of Imaging.” Edinburgh: Churchill Livingston, 1986, pp 1631-1688.
Bloody Nipple Discharge During Pregnancy: A Rationale for Conservative Treatment RENE LAFRENIERE, MD, CM, FKCSC, FACS From the Division o f Surgical Oncology, Department o f Surgery, University of Calgary, Calgary, Alberta, Canada
Five cases of bloody nipple discharge during pregnancy without associated breast masses were seen over the past 3 years by the author. Because of the reported association of breast cancer with bloody nipple discharge, close follow-up of these women at monthly intervals during pregnancy and trimonthly during the postpartum period was carried out. In all instances, the discharge appeared late during the second trimester or during the third trimester of pregnancy. It was unilateral and spontaneous and arose from multiple ducts, and it was associated with an increase in breast size and always with the larger breast of the two. The discharge cytologic study done on all cases was negative for neoplastic cells and the discharges resolved spontaneously within 2 months of onset. Postpartum follow-up ranging from 6 months to 3 years has revealed no evidence of neoplastic changes thus far. Mammograms ordered before these patients were referred were not helpful due to the increase in density of the breast tissue secondary to the pregnancy. Because a few cases of breast cancer during pregnancy have presented solely with a bloody nipple discharge, I recommend extremely close follow-up of these women and no surgical intervention unless a mass is discovered or the nipple discharge cytology is either suspicious or positive at the initial visit or during follow-up. KEY WORDS:breast disorders, carcinoma, breast cancer
INTRODUCTION A colorless secretion from the nipple of the breast is commonly observed during pregnancy. A serosanguinous discharge is, however, an uncommon occurrence, and its presence leads clinicians to a dilemma because of the reported association of breast cancer and bloody nipple discharge in nonpregnant women [ 1,2]. The clinical dilemma of course focuses on what one should do if faced with a bloody nipple discharge when no masses are felt within the breast, what diagnostic tools are available if any to help manage these patients, and what it means to have a bloody nipple discharge during pregnancy in terms of clinical course of the disease process. Over the past 3 years, five cases of bloody nipple discharge during pregnancy have been seen by the author, and this has prompted a review of this clinical entity and prompted a plan for management that takes into consideration the possible presence of a subclinical 0 1990 Wiley-Liss, Inc.
carcinoma. Cases of bloody nipple discharge during pregnancy, pathophysiology associated with this disease process, and recommendations for management are outlined in this paper.
MATERIALS AND METHODS Five patients were referred for evaluation of a bloody nipple discharge occurring during pregnancy. A detailed case history was obtained from each and included age, parity, location of the discharge (left or right breast, uniductal or multiductal), family history of breast cancer, past history of bloody nipple discharge, gestational age at presentation of the discharge, spontaneity of the
Accepted for publication November 30, 1989. Address reprint requests to Rene Lafreniere, University of Calgary, Health Sciences Center, Room 1432, 3330 Hospital Drive N.W., Calgary, Alberta, Canada T2N 4N l .
Bloody Nipple Discharge During Pregnancy
229
TABLE I. Cases of Bloody Nipple Discharge Recorded During Pregnancy Case
Age (years)
Gravida
Breast
1
28 31 22 21 30
1 2 1
-
-
Left Right Right Left Right -
2 3 4 5 6 I 8 9
-
21
1 1
-
-
10 11
-
-
-
12-25 26 21 28
-
-
-
discharge, amount and color of the discharge, presence of masses or pain felt by the patient, and whether any sudden enlargement of the breast had occurred prior to the bloody discharge appearing. A complete physical examination was then carried out, including the head, neck, and chest, along with a multipositional examination of the breasts done in the sitting and supine positions to determine the presence of masses within the breast, the location of the bloody discharge, and whether the discharge was uniductal or multiductal. All patients were referred with mammograms and these were reviewed by a radiologist for any evidence of pathology. All bloody discharges seen at examination were smeared on a glass slide and were sent for cytological examination. Subsequently all patients were followed at monthly intervals during their gestation. Postgestation they were also seen monthly if they had decided to breastfeed and trimonthly after breast feeding or if they had decided not to breastfeed.
RESULTS The five cases described in this paper are briefly outlined in Table I (cases 1-5). At the time of the writing of this paper, the cases had been followed for from 6 months to 3 years, with a median of 2 years. The median age at presentation was 28 years, with a range of 22-31 years. Most women were gravida one (four of five), and the discharges occurred either from the left or right breast with no dominance seen in our five patients. However, the breast with the discharge was always the larger of the two. All women had recently undergone a rapid increase in breast size beginning 2-3 weeks before the bloody discharge had occurred. All cases began late during the second trimester or during the third trimester (range of gestational age 22-39 weeks, median 27 weeks). One patient had a family history of breast cancer, with her mother developing postmenopausal breast cancer. None
Time during pregnancy 21 Weeks 39 Weeks 22 Weeks 26 Weeks 31 Weeks
Cancer
Reference
No
This paper This paper This paper This paper This paper 2 2 3 3 3 3
NO
No No NO
-
-
-
-
Eighth month Third trimester Third trimester Third trimester Second or third trimester -
NO No No No No Yes Yes Yes
-
4
5 5 5
had a previous history of bloody nipple discharge, and case 2 had no recollection of such a discharge during her first pregnancy. All discharges were spontaneous and frankly bloody, staining the patient’s undergarment. On examination, all discharges were multiductal and unilateral in character. No excessive pain was associated with the pregnancy or the discharge, and no dominant unilateral masses of the breasts were found in any of the cases. A review of all mammograms done revealed that these were not helpful because of the increased density of breast tissue associated with pregnancy. Cytological examination of all discharges revealed only epithelial cells, histiocytes, foam cells, white blood cells, and red blood cells and no cytological evidence of neoplasia. A follow-up of these patients ranging from 6 months to 3 years, with a median of 2 years, revealed no evidence of neoplastic changes on physical examination. All the bloody nipple discharges spontaneously resolved within 2 months of onset, and lactation was achieved successfully in all women who intended to breastfeed (four of five).
LITERATURE REVIEW A review of cases of bloody nipple discharges associated with pregnancy uncovered an additional 23 cases [2-51 (Table I, cases 6-28). Unfortunately, very little information can be gathered from these cases, but some facts can be stated. In the cases described by Kline and Lash [3] and Haagensen [4], the bloody discharge occurred during the second or third trimester of the pregnancy. Age, parity, status and location of the discharge were not available. Except for those cases described by King et al. [5] (cases 26-28), the outcome was favorable, with no development of carcinoma. The cases of King et al. were associated with cancer of the breast without the presence of masses, so, in three of 28 available cases, cancer was associated with a bloody nipple
230
Lafreniere
discharge. For the patients of King et al., however, we do not know if the discharge was spontaneous, if cytology was done, or if the discharge was uni- or multiductal or if it resolved spontaneously.
DISCUSSION A bloody nipple discharge has been associated with the presence of breast cancer [1,2]. In Devitt’s [2] excellent review, 47 of 249 nipple discharges were bloody (19%), and among these, 45 five were secondary to carcinoma, so 10% of all bloody nipple discharges may be associated with carcinoma. Breast cancer during pregnancy is a rare event. Among 160,000deliveries, Betson and Golden [6] reported that 16 (0.01%) had an associated cancer of the breast, If one reviews the overall number of cancers of the breasts associated with pregnancy compared to those not associated with pregnancy, the percentages are quite low and range from 1.3% to 2.1 % of all breast cancers [7,8]. Cytologic and histologic studies of breasts with nipple discharges have been done during pregnancy and lactation by Kline and Lash [3,9]. Although they reported only four cases with frankly bloody discharges [3], they documented cytologically that 10 of 50 pregnant patients with discharges had red blood cells (RBCs) in the discharge and that 17 of 72 lactating women had RBCs in their nipple secretion [9]. Biopsies performed on a patient with a frankly bloody discharge revealed on histological section many newly formed lobules and moderate-sized to large dilated ducts [3]. These ducts were often lined with a single layer of cells. When the ducts were followed by serial histological sections, Kline and Lash found spurs of tissue projecting into the ducts. These spurs were made of loose fibrous tissue, with a single central capillary, and they were also covered with a single layer of epithelial cells. Many of these spurs were found at the origin of newly formed alveoli. Kline and Lash commented that these spurs resembled minute papillomas and postulated that, as in true papillomas, the thin capillary wall of spurs could rupture and give rise to a serosanguinous discharge of the nipple. Based on our cases and cases 6-25, one could surmise that a bloody nipple discharge during pregnancy is not pathological. However, King et al. [S] did describe three cases of breast cancer during pregnancy apparently associated only with a bloody nipple discharge (cases 2628).
If no masses are felt at the time of the examination, I believe that these patients should be followed closely at monthly intervals for the development of cancer as long as the cytological smear of the discharge is negative for malignancy. Such cytological examination in trained hands has been shown to be useful [ 10,111. Mammography should be discouraged and is of no benefit, as shown by our cases and as described by Feig [12]. If the discharge continues throughout pregnancy or if a mass appears or cytology is positive or suspicious, then proper surgical exploration should be carried out; otherwise, close follow-up is all that is necessary.
CONCLUSIONS A bloody nipple discharge during pregnancy should be followed closely at monthly intervals as long as there is no evidence of a breast mass or a positive cytological smear associated with the discharge. As long as these two factors that have been associated with malignancy are negative, conservative follow-up at monthly intervals without surgical intervention is indicated, along with reassurance of the patient that these discharges are usually not associated with a malignant process. REFERENCES 1 . Lewison EF: “Breast Cancer and Its Diagnosis and Treatment.”
Baltimore: Williams and Wilkins Co., 1955. 2. Devitt JE: Management of nipple discharge by clinical findings. Am J Surg 149:789-792, 1985. 3. Kline TS, Lash S: Nipple secretion in pregnancy. A cytologic and histologic study. Am J Clin Patho1 37:626-632, 1962. 4. Haagensen CD: “Diseases of the Breast.” Philadelphia: WB Saunders Co., 1986. 5 . King RM, Welch JS, Martin JK, Coulam CB: Carcinoma of the breast associated with pregnancy. Surg Gynecol Obstet 160:228232, 198.5. 6. Betson JR, Golden ML: Cancer and pregnancy. Am J Obstet Gynecol. 81:718-728, 1961. 7. Nugent P, O’Connell TX: Breast cancer and pregnancy. Arch Surg 120:1221-1224, 1985. 8. Sahni K , Sanyal B, Agrawal MS, Pant GC, Kaanna NN, Khanna S: Carcinoma of the breast associated with pregnancy and lactation. J Surg Oncol 16:167-173, 1981. 9. Kline TS, Lash SR: The bleeding nipple of pregnancy and postpartum. A cytologic and histologic study. Am J Pathol 8:336340, 1964. 10. Knight DC, Lowell DM, Heimann A , Dunn E: Aspiration of the breast and nipple discharge cytology. Surg Gynecol Obstet 163: 415-420, 1986. 11. Petrakis NL, Wrensch MR, Ernster VL, Miike R, King EB, Goodson WH: Prognostic significance of atypical epithelial hyperplasia in nipple aspirates of breast fluid. Lancet 2:505. 1987. 12. Feig SA: The breast. In Grainger RG, Allison DJ (eds): “Diagnostic Radiology: An Anglo-American Textbook of Imaging.” Edinburgh: Churchill Livingston, 1986, pp 1631-1688.
