Nipple Discharge? Is it breast Cancer?

Nipple discharge can be a scary experience for all men and for women who are not breast feeding. The biggest concern when a person experience nipple discharge is the possibility of carcinoma. Even though breast carcinomas often present with nipple discharge, all nipple discharges are not due to breast cancer. If you are experiencing nipple discharge, the following information will help you to find out the cause for the nipple discharge. 

So, you are experiencing nipple discharge. The first thing you should clarify when you are having nipple discharge is whether it is from one nipple or from the both. If you have discharges form both your nipples, it is most probably due to a systemic disease more than a local disease, such as carcinoma. 

• Bilateral Nipple Discharge 

If you are having bilateral nipple discharge, you are having one of the following conditions. Bilateral nipple discharge does not indicate breast cancer unless the cancer has spread to the both breasts.

• Lactation
• Pituitary tumor

Out of these, pituitary  tumor should take immediate attention because they should be ablated. Some people with pituitary tumor experience some specific symptoms which can be used as diagnostic tools. Pituitary tumors enlarge  in size and increases the intracranial pressure. As a result, the person experiences early morning headache, nausea and vomiting. The visual pathway runs close to the pituitary gland. Tumors arising from the gland compress the visual pathway. As a result, the affected person looses vision of his both temporal sides. This is called bitemporal hemianopia. If you are having bitemporal hemianopia, when you are looking at something, you will feel like you are looking through a tunnel. This is called tunnel vision. 

• Unilateral Nipple Discharge 

If you are having discharge only from one breast, it is due to a local pathology affecting only that breast. You should also consider your age because carcinomas are very rare in younger ages. If you are in your twenties or early thirties and there is no family history of breast cancer among first degree relatives, there is very low chances for you to develop breast cancer. If you are very young there is nothing to worry about. If you are still anxious, you can consult a doctor. He will also reassure you after doing the triple assesment. Consulting a doctor is important because he can analyse your data decide on the possibility of cancer. 

The next thing you can do to know whether it is due to cancer or not is by looking for a lump. To do this you will have to carry out a self breast examination. A careful self breast examination can detect most of the lumps in the breast, but some breast cancers are very small and therefore, cannot be palpated. If you are more than 40 years of age and have a family history of breast cancer, you should immediately see a doctor even you do not feel any lump.

Then the next thing you should focus on is the color of the discharge. The color of the discharge gives diagnostic clues. As mentioned earlier, breast cancers can give rise to nipple discharge, but not all discharges are due to cancer. There are many benign conditions that can give rise to nipple discharge. These benign conditions are,

• Duct ectasia
• Papilloma of the duct 
• Mammory dyslasia
• Fibrocystic disease (fibroadenosis)
• Infection
• Hypothyroidism
• Pituitary tumor

The nature of the secretion is very important in differentiating each of these condition. Blood stained discharge is suggestive of cancer, but benign conditions such as duct ectasia, papilloma of the duct, fibrocystic disease can also give rise to blood stained nipple discharge. 

The commonest form of nipple discharge is serous discharge. This is commonly physiological and sometimes due to duct papilloma, duct ectasia, mammory dysplasia or fibrocystic disease.

If the discharge is black or green, it is due to duct ectasia. This is a benign condition which does not progress to breast cancer. If the discharge is purulent (pus), it is due to an infection. In infection,   in addition to the discharge you may also experience pain, fever, warmth of the breast. 

Milky discharge is due to lactation, hyperthyroidism or pituitary tumor. One of the commonest pituitary tumors are prolacting secreting tumors. Prolactin stimulates milk production and gives rise to galactorrhea. 

Above mentioned are the possible causes of nipple discharge. According to these information it is vivid that nipple discharge is not always due to breast cancer. There are many benign diseases that can cause nipple discharge. 

How Obesity Gives Rise to Hernia

Obesity is major health threat that gives rise to various health problems. It is associated with many systemic illnesses such as dyslipidemia, hypertension, diabetes mellitus etc. Apart from that, obesity can cause many other surgical problems as well. One such problem is formation of hernia.

Hernia and obesity usually go hand in hand. Hernia is defined as protrusion of an organ from its containing cavity. This is either due to weakened coverings of the cavity or due to increased pressure inside the cavity. Obesity causes hernia by both of these mechanisms. Obese people have fat not only in the skin but also inside the abdomen, within the mesenteries. As a result the intra-abdominal pressure increases. Fat also deposits within the muscle fibers.  They separate each muscle fiber from one another and make them weak. Fat also deposits within the aponeurosis and weakens it too. As a result, para-umbilical, direct inguinal and hiatus hernia occurs. 

Is hernia repair is enough to cure hernia?

Is hernia repair is enough to cure a hernia? The answer is no. If you have a hernia, you might think that everything will be OK after getting it operated, but this is not true. There are a lot of things that you have to do. The surgeon can only repair the hernia. It is up to you to make sure it does not come back. 

So, what are the things you should do to prevent hernia from coming back? The first thing you should do is to identify the cause for hernia. Everybody do not get hernia. So, what went wrong in your case? One of the commonest cause of herniae is smoking. Smoking causes collagen deficiency. As a result, the strength of the abdominal wall reduces and predisposes for  formation of hernia. Therefore, if you want to prevent recurrent hernia, you should stop smoking. 

The next most commonest predisposing factor for hernia is chronically raised intra-abdominal pressure. Several things can lead to raised intra-abdominal pressure. They are chronic cough, straining during urination as well as straining during defecation. 

In conclusion, hernia repair is not enough to cure hernia. It also requires elimination of predisposing factors. Therefore, if you have a hernia, first think whether you have any of above mentioned predisposing factors. If you do, you must take necessary steps to eliminate them. It might require consulting a doctor and taking appropriate steps. 

Most of the time your doctor will inquire about these factors and refer you to take necessary treatments. Therefore, you don't have to worry too much about it. But, you should pay more attention to eliminate these predisposing factors by following the medical instructions correctly.

How can a strangulated hernia get reduced on its own after taking pain killers?

Hernia is a common surgical problem. Hernia can be complicated with many things. Strangulation is one such thing. A hernia gets strangulated when the contents of the abdomen comes out and twists. As a result the vessels supplying the hernial contents get crushed and the blood supply is cut off. If your hernia has got strangulated, you will feel colicky abdominal pain, with nausea, vomiting, abdominal distention and constipation. This is a surgical emergency that requires immediate attention. Unless, the contents can become gangrenous and rupture. 

If you have a strangulated hernia, the doctors will advice you to have strict bed rest and elevate the foot end of the bed. They will also prescribe you analgesics. Surprisingly, some people improve with the provision of pain killers. This occurs as a result of relaxation of the muscles surrounding the neck of the hernia. Analgesics can relax the muscles. The same thing happens when your are taken to the theater and anaesthesia. Anasthetics are also muscle relaxants. Sometimes the muscles can get too loose and the hernial contents can get back in to the abdominal cavity. This can be an disadvantage, because the surgeon might have to open into the abdominal cavity, in order to find the strangulated bowel loops and look for possible perforation. 

Is Mammography equally sensitive to all Women?

Mammography is one of the widely used investigation modality of breast cancer. But is it equally sensitive to all the women. The answer is “No” due to several reasons. That is because the detection rate of a breast cancer depends on so many factors. Some of them are listed below.

·         The size, stage and grade of the tumor.

·         The age of the woman – As a women’s age increases the breast also gets changed. Reduction of the density of the breast tissue is one such change. This is good news for old women because the reduction of the density increases the sensitivity of mammography. However it is a bed news for younger women whose breasts are more denser than the old ones.

Occurrence of breast cancer in young age is very rare and therefore, the risks probably go down. For them ultrasound scan is very useful in investigating any breast apthology.

Diseases of the Nipple

1.      Absence of nipple with or without amazia (Congenital absence of breast)

2.      Supernumerary nipples

3.      Nipple Retraction

4.      Cracked Nipple

·         This usually occurs during lactation and if it occur the breast should be rested for at least 24-48 hours. It should b emptied and breast feeding should be resumed as soon as possible.

5.      Papilloma of nipple

6.      Retraction cysts of the gland of Montgomary

7.      Eczema

8.      Paget’s Disease

9.      Discharge from nipple

                                                              i.      Clear serous discharge –This is can be physiological, due to ductal papilloma or due to mammary dysplasia

                                                            ii.      Blood stained – due to duct ectasia, duct papilloma or carcinoma

                                                          iii.      Black/green – due to duct ectasia

                                                           iv.      Purulent – infection

Treatment – Microdochectomy or cone excision of the major ducts

ANATOMY OF THE BREAST
EXAMINATION OF THE BREAST
INVESTIGATION OF BREAST SYMPTOMS

Investigation of Breast Symptoms

1.      Mammography

a.      Sensitivity of mammography increases with age as the density of the breasts reduces with age.

b.      Digital mammography and tomo mammography are now available with more sensitivity.

2.      Ultrasound

a.      Used in young women with dense breasts

b.      Can be used to identify cysts from solid lesions

c.       Can also be used to impalpable areas of pathology

d.      Used to scan axillary tissues

e.      Useful in guided percutaneous biopsy

3.      MRI (Magnetic Resonant Imaging)

a.      Used to distinguish scar from recurrence

b.       Best modality to investigate women with implants

c.       Useful as screening tool for high risk women

4.      Needle biopsy/Cytology

a.      Biopsy is taken under local anaesthesia

b.      Histology – By taking a spring loaded core needle biopsy device – Core cut biopsy of the Breast

c.       Fine Needle Aspiration Cytology – 21G or 23G needle with 10 ml syringe, sample is taken by passing the needle several times through the lump with negative pressure. Then it is smeared on to slide and air dried or fixed.  

5.      Large needle biopsy with vacuum system

a.      8G or 11G needles are used

b.      Useful in the management of the micro calcification or complete excision of fibroadenomas

Triple Assessment of Breast Symptoms

1.      Clinical Assessment

a.      Age

b.      Examination

2.      Radiological Imaging

a.      Ultrasound Scan

b.      Mammography

3.      Cytology or Histology

a.      Fine Needle Aspiration Cytology

b.      Core cut

ANATOMY OF BREAST

EXAMINATION OF BREAST

Examination of the Breast

·         Inspection

o   Patient sitting

§  Assess – asymmetry

§  Visible masses

§  Distortion or skin tethering

§  Nipple discharge

§  Ulceration

§  Oedema and erythema of skin (Paeu d’orange)

·         Palpation

o   Patient lying in near supine position, or in semi recumbent position if the breast are large

§  Arms raised

§  Hand behind the head

o   Palpate the four quadrants including the axillary tail.

o   If a mass is detected examine it further with the thumb and the forefinger

§  Site

§  Size

§  Surface

§  Shape

§  Mobility

§  Consistency

§  Tenderness

§  Transilluminating or not

§   Enlargement of the lymph nodes

·         Examine axillary and cervical draining nodes

·         Examine abdominal organs for metastatic involvement 

 ANATOMY OF THE BREASTS

The Breast

The Anatomy

General borders-

·         Upper border – second rib

·         Lower border – sixth rib

·         Medial border – lateral border of the sternum

·         Lateral border – anterior axillary line

Actual borders –

o   Upper border – clavicle

o   Lower border – seventh or eighth rib

o   Medial border – midline

o   Lateral border – edge of latissimus dorsi

Important parts of the breasts

·         Breast lobe

·         Ductile

·         Lactiferous duct and ampulla

·         Areola

·         Cooper ligament

·         Axillary tail

·         Lobule – structural unit of the mammary gland

1.      Lobule à Ductules à lactiferous duct à terminal papilla

·         Ligaments of Cooper

o   Apices are attached to the superficial facial

o   Account for the dimpling of skin overlying carcinoma

·         Areola

o   Contain involuntary muscles

o   Epithelium contains sweat glands and sebaceous glands

o   Sebaceous glands enlarge during lactation. Then it is called “Montgomary tubercle”

·         Nipple

o   An erectile structure pointing upwards

·         Lymphatics

o   To axillary and internal mammary lymph nodes

o   Axillary lymph nodes have six groups

1.      Lateral – along the axillary vein

2.      Anterior – along lateral thoracic vessels

3.      Posterior – along the sub capsular vessels

4.      Central

5.      Interpectoral

6.      Apical à Supraclavicular nodes à Subclavian lymph trunk à Thoracic duct or Jugular trunk

·         Sentinel node is the first node draining the tumour bearing area of the breast

EXAMINATION OF BREAST