Fiberoptic ductoscopy (FDS), or lactoscopy for short. It is both fast and accurate in the diagnosis and treatment of nipple overflow. A lactoscope is a miniature endoscope with a diameter of only 0.75 mm. mm. It is inserted into the milk duct through a small hole in the patient’s nipple overflow to observe the lesion in the milk duct.
When is a lactoscopy and treatment needed?
Patients with nipple discharge of various colors, especially bloody discharge, yellow discharge and clear water discharge, have a one-third to one-half incidence of neoplastic lesions in the milk ducts. In addition, there are many cases of white discharge due to intraductal masses, which require lactoscopy.
Most of the masses in the areola area without nipple discharge are intraductal tumors or fibroadenomas, which are closely related to the milk ducts, and can be clearly identified through ductoscopy, thus guiding the surgery to accurately remove the masses and the diseased milk ducts and reducing the chance of local recurrence after surgery.
In patients with plasmacytic mastitis in and around the areola area, plasmacytic mastitis is caused by obstruction of the proximal end of the milk ducts and the accumulation of secretions, exfoliated cells, and inflammatory cells in the milk ducts, which results in acute and chronic inflammation of the breast. In addition, if the inflammation is limited, the diseased ducts can be identified under the ductoscope and the diseased ducts and local scar tissue can be surgically removed.
During non-pregnancy and non-lactation periods, fluid flowing out of the nipple when squeezed is called nipple discharge. Nipple overflow is one of the common symptoms of breast disease. According to statistics, those who visit the doctor with nipple overflow as the first symptom account for 3% to 14% of breast diseases, and the incidence is second only to breast lumps and breast pain.
Etiology of nipple overflow.
1, the mammary gland is the lactating organ of women. Under normal circumstances, milk is secreted only during lactation, and no fluid is generally secreted during non-lactation. Clinically, the incidence of nipple overflow during non-lactation is about 5-8%.
2, There are many causes of nipple overflow, which can be physiological or pathological.
3, pathological nipple overflow is divided into 2 kinds of systemic and breast lesions.
4, certain systemic diseases can cause nipple overflow, such as pituitary tumors, hyperthyroidism or oral hormonal drugs.
5. Non-neoplastic breast diseases such as ductal dilation; tumorigenic or neoplastic lesions of the breast such as intraductal papilloma, breast cancer, etc. can cause nipple overflow.
Common diseases of nipple overflow.
1. Ductal dilatation of the breast:
The first symptom of early onset is nipple overflow. The color of the overflow is mostly brown, a few are bloody; laboratory tests of the overflow show a large number of plasma cells and lymphocytes without tumor cells. The disease is more common in non-lactating or menopausal women over 40 years of age. The lump is often less than 3 cm in diameter and the ipsilateral axillary lymph nodes may be enlarged, soft and painful to the touch. If the lump is complicated by infection, the inflammatory manifestation of the lump is red, swollen, hot and painful.
2. Intraductal papilloma:
This disease is common in people aged 40~50 years old. 75% of the tumors occur in the area adjacent to the papillae, and the tumors are small, with tips and villi, and there are many thin-walled blood vessels, so they bleed easily. The tumor cells can be found in the overflow of laboratory test. Sometimes patients can find a cherry-sized mass under the areola when they palpate the breast carefully, which is soft, smooth and active.
3.Cystic hyperplasia of the breast:
It is common in women of childbearing age. Some patients have yellow-green, brown, bloody or colorless plasma-like nipple discharge, and there are no tumor cells in the discharge on laboratory examination. The disease has two characteristics: First, it is characterized by periodic swelling and pain in the breast, which often occurs or is aggravated during the premenstrual period, and is not minded by the patient in mild cases, but can affect work and life in severe cases. The second is that breast lumps are often multiple and can be seen on one or both sides, or can be confined to a part of the breast or scattered throughout the breast. The lumps are nodular in shape and vary in size, tough and not hard, not adherent to the skin, and not well defined from the surrounding tissues.
4.Breast cancer:
Some patients with breast cancer have bright red or dark red nipple overflow, sometimes clear water overflow, colorless and transparent, occasionally sticky, leaving no trace after overflow, and cancer cells can be found in the overflow. The onset of the disease is slow. Patients may unintentionally find breast lumps, mostly located in the upper inner or upper outer limit, painless and gradually larger. In advanced stages, orange peel-like skin changes and satellite nodules appear at the lesion site. The axillary lymph nodes are enlarged, hard, and fuse with each other to form a mass as the disease progresses.
Notes on nipple overflow.
1. Whether the overflow is real or pseudo.
True overflow refers to the flow of fluid from the ducts of the breast. Pseudo-exudate is common in those with sunken nipples, as the epidermal cells of the nipple accumulate in the sunken area, causing a small amount of liquid-like beanbag-like exudate, often with a foul odor. Once the sunken nipple is pulled out and local cleanliness is maintained, the “overflow” will disappear.
2. Whether the overflow is bilateral or unilateral.
Bilateral overflow is physiological, and most women will still have a small amount of milk secretion if they stop breastfeeding for a year. In the middle and late stages of pregnancy, some pregnant women can squeeze out a little light-colored colostrum from both breasts. A few women may also experience a short period of milk overflow after a strong orgasm due to high blood vessel congestion in the breasts, breast distention, and erect nipples. When women go through menopause, some of them produce small amounts of milk due to endocrine disorders. All of the above are physiological conditions and are not pathological. However, bilateral nipple overflow can also be pathological, such as a condition called amenorrhea-overflow syndrome, which is caused by pituitary microadenoma and is associated with amenorrhea, headache, narrowing of the visual field, and elevated prolactin in the blood, in addition to overflow. CT brain examination can confirm the diagnosis. Another kind of double nipple overflow is seen in patients with few mastopexy.
3. Whether the overflow is uniportal or porous.
The nipple has 15 to 20 openings for the milk ducts. When overflow occurs, it is important to observe from which one or several openings the fluid is overflowing. Single-hole overflow is most often a papilloma in the ducts of the breast. Porous overflow may be physiologic, pharmacologic, systemic benign disease or mastopexy.
4. Is the overflow spontaneous or squeezed?
The former is mostly pathological, and about 13% of breast cancer patients have a history of spontaneous overflow. Benign or physiological overflow is more common after squeezing.
V. Nature of overflow.
Different diseases of the breast have different traits when it comes to overflow.
1, milk-like
Mostly physiological, such as recent after weaning or miscarriage, not a manifestation of cancer.
2.Purulent overflow
Mostly ductal dilatation, plasmacytoid mastitis.
3.Pale yellow overflow
It is the most common type of overflow and is seen in almost all kinds of breast diseases, with mastopexy being the most common. Some of them are also intraductal papilloma or breast cancer. Therefore, it is something to be vigilant about.
4. Bloody overflow
It can be of different colors such as bright red, coffee, yellowish, brown, etc. This kind of overflow is a danger sign and should be highly alerted. 50% to 75% of them are intraductal papilloma and 15% of breast cancer. If bloody overflow occurs after menopause, 75% is breast cancer.
5.Clear fluid
Colorless and transparent, occasionally viscous, leaving no trace after overflow. This kind of overflow may be a sign of breast cancer and should be further examined. In conclusion, nipple overflow is an important breast symptom, 10%-15% of which may be breast cancer. Symptoms should be promptly seen in the hospital for cytological examination of the overflow smear. Near-infrared breast scan has a positive diagnosis rate of 80%-95% for ductal lesions in the areola area, and ultrasound and mammogram also have a comparable accuracy rate. Selective lesion ductography is a commonly used test for nipple overflow and is of greater value in the differential diagnosis of benign and malignant with nipple overflow, it also provides the physician with accurate localization of the extent of surgical excision.