SURGERY

BLEEDING FROM THE NIPPLEBy S. M. CHRIS, F.R.C.S.

The Postgraduate Medical School of London

A study of the literature of the past four de-cades reveals a wide divergence of views on thesignificance and management of bleeding from thenipple. At one extreme we find the opinion ofBloodgood (1922) that' discharge from the nipple,like pain, is not an indication of a lesion of thebreast for which operation is indicated,' and that'the prevailing view that a woman with a dis-charge from the nipple should be protected fromcancer by the removal of the breast is based onfear and not fact.' At the other extreme is theview of MacCarty of the Mayo Clinic, quoted byGray and Wood (I94I), that 'a breast with con-tinued serous or bloody discharge should beremoved by simple mastectomy.'

Little dispute exists regarding the treatment ofbleeding from the nipple due to carcinoma. Wherethe lesion concerned is considered to be benign,however, as in papillomatosis or fibro-adenosis, sowe enter the sphere of controversy. Pathologistswho see in these lesions potential or actual malig-nancy have influenced surgical opinion towardsradical treatment; those who consider theselesions to be benign have swayed opinion towardsconservatism. Until we are able to determineaccurately the precise extent to which these be-nign lesions are precancerous, so long will thebleeding nipple remain a subject for dispute.

Recent contributions to the literature (WakeleyI947, Adair I949, Haagensen, Stout and Phillips195I) have favoured the conservative approachin the management of these patients. It wasin an attempt to see how far our own clinicalexperience justifies this view that the records ofHammersmith Hospital were searched for a seriesof patients with bloodstained discharge from thenipple, and a review of this material and a dis-cussion of the management forms the basis of thispaper.

MaterialOver a ten year period from I94I to 1951 the

records of 41 patients in whom bleeding from thenipple occurred during the course of a breastdisease have been traced. In three of these

patients slides of breast tissue are not available formicroscopic examination. They are therefore ex-cluded from the series, leaving a total of 38 patientsin whom there is histological confirmation of thediagnosis.

Before separating these patients into groupsaccording to the cause of bleeding, it is necessaryto define the terms in use, since the terminology ofthe benign lesions of the breast is not as yetstandardized. Apart from rare causes, such astrauma and inflammation, of which no examplesoccurred in our series, the vast majority of blood-stained discharges from the nipple originate frombenign or malignant hyperplasia of the ductepithelium.This epithelial hyperplasia may be seen in all

gradations, the simplest being found in fibro-adenosis, where a heaping up of the duct epitheliuminto several layers occurs. In the same or differentbreasts we may see multiple microscopic epithelialpolypi sprouting like fingers or fronds into thelumen of the ducts tFig. i). This process of polypformation proceeds until one or more attain con-siderable proportions and present as papillomata inthe ducts or in cystic expansions of the ducts andthen become visible with the naked eye (Fig. 3).Less commonly, a single polyp arises in a duct,usually close to the nipple, where it constitutes asolitary duct papilloma and may reach a size ofseveral centimetres in diameter (Fig. 2).

In more perilous fashion, the process ofepithelial hyperplasia may proceed until the ductsare filled and distended with solid masses of cellswhich cytologically show all the characters ofmalignancy and can only be distinguished frominvasive carcinoma by the absence of penetrationof these cells into the surrounding tissues. Thisis the condition described by Muir as intraductcarcinoma (Fig. 4).Those breasts in which the sections showed

fibroadenosis without epithelial polyp formationhave been grouped together as simple fibroadenosis.

Epithelial polyp formation in the breast has beenclassified as papillomatosis and is subdivided intothree groups according to degree:

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30 POSTGRADUATE MEDICAL JOURNAL January 1952

(a) Multiple microscopic polypi.(b) Multiple macroscopic polypi.(c) Solitary duct papilloma.-Intraduct carcinoma has been placed in a

separate group, as has overt carcinoma of thebreast.

In the presence of an eczema of the nipple thediagnosis of Paget's disease is foremost in thesurgeon's mind and the subsequent occurrence ofbleeding will not decisively affect the managementof the condition. For this reason patients withPaget's disease are excluded from this series ex-cept for one instance in which a true bloodstaineddischarge preceded the appearance of the eczemaand in which, for a short time before her arrival inhospital, the patient was an example of bleedingfrom the nipple without obvious cause. Thispatient is included with the carcinomata (Table i).

TABLE I

No.Pathological Cause of

Cases

Simple fibroadenosis .. ...... . 7

Papillomatosis:(a) Microscopic polypi .. .. .. 5(b) Macroscopic polypi .. .. .. 6(c) Solitary duct papilloma .. .. I

Total .. .. ... . I2

Intraduct carcinoma .. .. .. 3

Carcinoma .. .. . .. . .I 16

Total .. ....... . 38

The ages of the patients, all women, rangedfrom I6 to 81 years. The incidence of each typeof disease in successive decades is shown inTable 2.

Table 2 shows that bleeding from the nippleoccurred from benign causes in a younger group(average age 44.5 years) than in the group withmalignant disease (average age 64.8 years).

Excluding the patient with Paget's disease ofthe nipple in whom the diagnosis was made oninspection at her first visit to hospital, 31 patientspresented with one or more masses in the breastwhilst six had no masses of any sort palapable atthe first examination. It is of interest to note thatall the patients with proven cancer presented witha palpable mass in the breast but that the sixpatients without a palpable mass had benignlesions.

In a lesion of the periphery of the breast re-traction of the nipple is regarded as a sign ofmalignancy. In patients with bleeding from thenipple the causative lesion frequently lies close tothe areola and retraction, although common, doesnot appear to be a sign of diagnostic significance.Retraction occurred ten times in this series, sixtimes in patients with benign conditions and fourtimes in those with malignant disease.

Patients with carcinoma of the breast in theseries were treated by methods appropriate to thestage of the disease and to the general condition ofthe patient according to principles which do notcome within the scope of this paper.Muir considered intraduct carcinoma to be a

benign condition but it is here regarded as alesion of disputed malignancy. Should such adiagnosis be confirmed, we believe that a simplemastectomy is the minimum surgical procedurenecessary. Three patients in this series werediagnosed as intraduct carcinoma and all weretreated by simple mastectomy followed by post-operative prophylactic irradiation. The value ofradiotherapy in this condition must remain amatter for conjecture but its administration is anindication of the tendency amongst surgeons toregard intraduct carcinoma as a lesion closely re-lated to invasive cancer.The treatment of bleeding from the nipple due

to benign lesions is, however, of present interest,and our survey reflects a change in the attitudetowards the management of this group at Hammer-smith Hospital during the past decade.Up to the end of 1947, 13 patients with bleeding

from innocent lesions were subjected to amputation

TABLE 2

Io 20 30 40 50 6o 70 8oAge to to to to to to to to Totals

19 29 39 49 59 69 79 89Simple fibroadenosis .. .. .. 3 2 I 7Microscopic papillomatosis I 2 2 5Macroscopic papillomatosis .. .. . 2 3 I 6Solitary duct papilloma .. .. . . IIntraduct carcinoma .. .. .. .. 3Qarcinoma ...... 5 2 7 I 16

Totals .. .. .. . 6 5 6 8 I 38Kx 6--8--

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Janufry I 95g ClHRIS: Bleedingfrom the Nipple ,It

FIG. 3.-Macroscopic papillomatosis. Photornicro-graph of a section through the breast (x 45) show-ing a duct beneath the areola visiblv distendcdbv a large papilloma.

--LI-i- -

IL

..........................

414

-N-

FIG. 4.-Intraduct carcinoma. Photomicrograph of a section of the breast (x 54) showingseveral ducts filled and distended by masses of cells which cytologically have thecharacters of malignancy. This is the intraduct carcinoma of Muir.

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POSTGRADUATE MEDICAL JOURNAL Yanuary 1952

!l

FIG. 5.-(Mr. Selwyn Taylor's patient.) Mammo-gram of right breast showing lipiodol in the ductsystem of a lobule, outlining an oval filling defectin the right branch about 12 mm. long. Thelobule when removed was shown to contain agroup of large papillomata

of the breast; in ten cases simple, and in threeradical mastectomy was performed. These patientsare, then, of little value to this series for followup purposes since the removal of the breast haseradicated the problem of the premalignancy orotherwise of the benign lesions.

Since 947 a moe conservative approach hasbeen adopted in the management of bleeding fromthe nipple due to benign causes. Six patients haeebeen treated either by wedge excision or biopsy ofthe affected zone of the breast. These patientshave since shown no further bleeding or evidenceof malignant change in the remainder of the breast.This corresponds with the recently recorded re-sultshe of larger series, particularly those of aagen-sen et al. (1951). They describe a series of 72patients with intraduct papilloma of the breasttreated by wedge excision and followed for at leastfive years, 31 of them for more than ten years, inwhom no malignancy subsequently developed. Inaddition Adair (I949) has followed up to eightyears 416 patients with 'papillomatosis' treatedconservatively, in none of whom has carcinomadeveloped. These results and those of Wakeley

(1947) and Estes and Phillips (I949) show thatthe danger of carcinoma developing in the remain-der of the affected breast following the localexcision of a benign lesion for bleeding is verysmall indeed, and provides ample justification foradopting the more conservative approach. Thisis particularly welcome in the younger patientsin whom removal of a breast may represent soserious a psychological trauma.

ManagementThe patient with bleeding from the nipple

should have a full history taken followed by athorough physical examination. Certain specialinvestigations may also be required but finally, onthe basis of these clinical investigations, the patientis placed into one of three groups each requiringsomewhat different management. It is not pro-posed to deal with every detail of the routine ex-amination of the breast but only with those pointswhich in the case of bleeding from the nipplerequire particular attention.

Palpation. On palpation of the breast the greatmajority of patients with bleeding from the nipplewill show clear physical signs of disease. Thesesigns may consist either of a definite mass, a smalllocalized swelling deep to the areola, or the local-ized or diffuse nodularity associated with fibro-adenosis. Pressure on any of these locations mayproduce a drop or two of blood at the nipple,sometimes with disappearance of the mass. Inany of these circumstances the management isstraightforward and treatment is directed towardsthe mass in the breast exactly as if no bleeding hadoccurred.

In other cases, no mass is palpable but pressureon a particular sector constantly produces thedischarge from the nipple. In such a case thatsector should be completely excised and submittedfor histology. If the section is benign, no furthertreatment is necessary; if malignant, which ishighly unlikely, a radical mastectomy. will benecessary.The problem in management arises in those

patients, fortunately a minority, in which all thesetests of palpation and pressure are negative andlocalization of the disease to any one part of thebreast is impossible. The temptation, in suchpatients, to perform an immediate simple mastec-tomy should be avoided and they should be askedto attend at weekly intervals for repeated examina-tion. Frequently, in a few weeks, localizing signswill appear in the breast and wedge excision of thearea can then be performed. The chances of abreast with no palpable abnormality harbouring acancer is very small (less than i per cent. accordingto Bloodgood, 1922), and the danger to the patientof a few weeks of observation is negligible.

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January 1952 CHRIS: Bleeding from the Nipple 33It is important to advise patients attending for

these repeated examinations not to examine orsqueeze their breasts in the intervals, in order toavoid emptying the involved lobules. Wakeley(1947) recommended painting the affected nipplewith collodion in order to seal the orifices of theducts and so permit a recognizable distension ofthe lobule in the interval. Sometimes the bluntend of a fine straight surgical needle may be in-serted into the orifice of the nipple duct which isseen to emit the discharge and can be introducedalong the lactiferous duct into the affected lobule,enabling it to be identified at operation (Babcock).

In the few remaining patients in whom nolocalizing signs are clinically demonstrable evenafter repeated examination, we may avail ourselvesof transillumination of the breast or mammo-graphy as aids in localization.

Transillumination of the breast is performed ina darkened room with a specially constructedsource of light placed behind the breast. Thisoccasionally reveals the presence of a zone ofdisease which is not palpable with the hand.

Papillomatosis of the ducts in its microscopicform, for example, is an impalpable lesion whichwill transmit light. When bleeding occurs, how-ever, a duct distended with blood may show up asan opaque zone on transillumination (Adair, I930;Campbell, I946).Mammography is a recently devised radio-

logical technique whereby a lesion of the mammaryducts may be outlined by the injection of contrastmedia. Hicken et al. (I938) have reported over6oo roentgenographic studies of the breast usingradio-opaque fluids in the ducts with or withoutsimultaneous carbon dioxide gas inflation of thebreast to give a double contrast effect. They claimmammography as a safe technique of considerablevalue in the diagnosis and location of benign,space-occupying lesions in the ducts. However,others who have tried this technique have con-cluded to the contrary. Romano and McFetridge(I938) in a series of 25 patients submitted tomammography found the suggested X-ray diag-nosis misleading in ten, and in three patients thereaction to the introduction of the radio-opaquefluid was so severe that a simple mastectomy hadto be performed for the resulting' mastitis.' Theyconsider that mammography is misleading, un-justifiable and even dangerous.

Fig. 5 shows the mammograph of a woman,aged 32, complaining of an intermittent blood-stained discharge from the right nipple of sixweeks' duration. Examination revealed no palpabletumour in the breast nor would pressure in anysector produce the discharge from the nipple.However when the whole breast was taken be-tween the hands and squeezed some blood ap-

peared at the nipple. The sawn-off end of a finehypodermic needle was inserted into the orifice ofthe bleeding duct in the nipple and 3 ml. oflipiodol were injected. The ducts of a lobule inthe lower outer quadrant of the breast are out-lined and show obstruction of a branch of the ductwith displacement of the patent branches aroundan oval filling defect about 12 mm. long. A re-section of this lobule of the breast was performedand the specimen showed several large papillo-mata in the main duct, one of which was ulceratedon its surface and was presumably the source of thebleeding. In this instance, mammography wassafe and useful, but the information obtainedmight well have been forthcoming from repeatedexamination of the breast.Mammography is not without risk and cannot

be recommended for routine use.The Discharge. Examination of a drop of the

discharge from the nipple should be performed toconfirm the presence of blood cells. When bloodhas been retained in the breast for some time, itundergoes alteration to a dark brown or black fluidand a smear of this may show no recognizableblood cells. In this instance a biochemical ex-amination of the fluid may be of value indifferentiating between those discharges darkenedby altered blood and those which are dark fromcontained melanin or other pigment. (Atkins(1950) reports that the former give oxidase-positive reactions and the latter oxidase-negativereactions.

Papanicolaou staining of the smear of the nippledischarge has been recommended for diagnosticpurposes but cannot be regarded as a reliablemethod since the cytology is considerably moredifficult to interpret, even in expert hands, than a.paraffin section of the lesion which itself is often aproblem in diagnosis.Summary of ManagementThe following is a summary of the scheme

which at present is considered best in the manage-.ment of bleeding from the nipple.

Group I. Patients with bleeding and a mass,which is clinically malignant and operable.The patient is prepared for radical mastectomy

and at operation the mass is incised. If the lesionis macroscopically clearly a malignant one, theoperation is carried out according to plan; Ifthere is any doubt a sector of the breast containingthe tumour is excised, the wound is closed and the!pathological section is awaited. If this is benign,'no further treatment is necessary beyond a regularfollow-up.Group 2. Patients with bleeding either from a

swelling of the breast which is clinically benign or

F1

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34 POSTGRADUATE MEDICAL JOURNAL January 1952

from a localized sector of the breast as determinedby pressure or other test.A wedge resection of the sector of the breast

containing the source of bleeding is carried out,including the corresponding main ducts up to thedeep aspect of the nipple. The specimen is ex-amined histologically. If the result is benign, thepatient is reassured and no further treatment isrequired beyond a careful follow up. In the un-likely event of the result being malignant a radicalmastectomy should be performed.Group 3. Patients with bleeding but without any

tumour or localizing signs even after several ex-aminations,

If the patient is under 50 years of age she iskept under regular observation. If localizing signsdevelop, treatment is as in Groups i or 2, which-ever is appropriate.

If the patient is over 50 years of age a sim-ple mastectomy can be performed with somejustification, since the chances of malignancy aresignificantly greater.AcknowledgmentsThe author wishes to thank Dr. Bernard

Lennox of the Department of Pathology of thePostgraduate Medical School for his valuableadvice, and Mr. K. G. Moreman of the Depart-ment of Photography for the photomicrographs.

BIBLIOGRAPHY

ADAIR, F. E, (1930), Ann. Surg., 91, I97.ADAIR, F. E. (I949), Ann. R. Coll. Surg. Engl., 4, 360.ATKINS, H. J. B. (I95o), Brit. J. Surg., 38, I47.BLOODGOOD, J. C. (I922), J. Amer. med. Ass., 78, 859.CAMPBELL, O. J. (1946), Surgery, 19, 40.SETES, A. C., and C, PHILLIPS (1949), Surg, Gynec, Obstet,, 89,

345,

GRAY, H. K., and G. A. WOOD (I941), Arch. Surg., 42, 203.HAAGENSEN, C. D., STOUT, A. P., and PHILLIPS, J. S.

(195I), Ann. Surg., I33, I8.HICKEN F. N., R. R. BEST, H. B. HUNT, and T. T. HARRIS

(1938), Amer. J. Roentgenol., 39, 321.ROMANO, S. A., and E. M. McFETRIDGE (1938), J. Amer.

med. Ass., IIO, 1905.WAKELEY, SIR CECIL (I947), Lancet, 252, 62,

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