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Introduction ⬇

Nipple discharge is abnormal, except during lactation. When it occurs, the breasts should be examined for mastitis, duct papilloma, and intraductal cancer. (However, certain situations increase the possibility of finding a normal nipple discharge, such as pregnancy, perimenopausal state, and use of birth control pills.) About 3% of breast cancers and 10% of benign lesions of the breast are associated with abnormal nipple discharge.

Fluid from a breast cyst is obtained by FNA biopsy and is examined to detect malignant cells. FNA of the periareolar breast, along with the Breast Cancer Risk Assessment Tool and certain biomarkers, is used to predict cancer development in high-risk individuals.

Procedure ⬆ ⬇

Nipple Discharge

  1. Limit this procedure to patients who have no palpable masses in the breast or other evidence of breast cancer.

  2. Wash the nipple with a cotton pledget and pat dry.

  3. Gently strip, or milk, the nipple until a pea-sized drop of discharge appears. The patient may assist by holding a bottle of fixative beneath the breast so that the slide may be dropped in immediately.

  4. Spread the nipple discharge directly on glass slides and then drop into the fixative bottle containing 95% alcohol, or spray-fix the slide.

  5. Identify the specimen with pertinent data, including from which breast it was obtained, and send it without delay to the laboratory.

  6. For all procedures, see Chapter 1 guidelines for intratest care.

FNA of Breast Cyst

  1. Administer buffered lidocaine (1%) as a local anesthetic agent. Use a 1.5-inch, 21-gauge needle with attached 10- to 12-mL syringe prewetted with tissue culture medium. Position needle directly adjacent to areola, avoiding superficial blood vessels. A number of aspirations may be performed in the upper, outer, and inner quadrants of the breast.

  2. All cells, if from multiple aspirations, may be pooled in 5 mL of an ice-cold medium in an ice bath and fixed in acetone, methanol, or formalin until stained. Part of the specimen is used for cytologic study, and the rest is used for expression of biomarkers.

  3. Use sterile measures and standard precautions.

Clinical Implications ⬆ ⬇

Abnormal results are helpful in identifying:

  1. Benign breast conditions, such as mastitis or intraductal papilloma.

  2. Malignant breast conditions, such as intraductal cancer or intracystic infiltrating cancer.

  3. FNA results of hyperplasia with atypia are associated with a greater risk for future development of breast cancer.

  4. Expression of DNA aneuploidy (≥2+ intensity), p53 expression (≥2+ intensity), HER2/neu expression (≥2+ intensity), nER expression (≥1+ intensity), and EGFR expression (≥2+ intensity).

  5. Also, see breast biopsy prognostic markers and ER, PR, and DNA ploidy.

Interventions ⬆ ⬇

Pretest Patient Care

  1. Explain the purpose and procedure of the nipple discharge procedure. Administer oral sedative for anxiety, if ordered.

  2. Obtain or confirm that a signed consent is in the patient’s medical record.

  3. Wash the nipple with a cotton pledget and pat dry.

  4. Follow guidelines in Chapter 1 for safe, effective, informed pretest care.

Clinical Alert

The only contraindication is an uncooperative patient

Posttest Patient Care

  1. Review test results; report and record findings. Modify the nursing care plan as needed. Counsel the patient appropriately about possible further testing (e.g., biopsy) and treatment.

  2. After FNA, monitor for hematoma formation and infection. Apply cold packs for approximately 10 minutes, bind breast and chest wall with gauze, and instruct patient to wear a tight-fitting sports bra.

  3. Follow guidelines in Chapter 1 for safe, effective, informed posttest care.

Clinical Alert

  1. Any nipple discharge, regardless of color, should be reported and examined. A bloody or blood-tinged discharge is especially significant.

  2. After FNA, a large hematoma may require surgery, and infection may require antibiotic drugs.

Interfering Factors ⬆ ⬇

Use of drugs that alter hormone balance (e.g., phenothiazines, digitalis, diuretic agents, steroids) often results in a clear nipple discharge.

Reference Values ⬆

Normal

Negative for neoplasia or hyperplasia with atypia

No evidence of high-risk results

No expression of select biomarkers as predictors of future cancer development