2. Nipple discharge may occur in a male or in a non-lactating female and is the symptom caused by several situations. In males there is usually an endocrine abnormality and in females the etiologies are more variable.

3. By the way the nipple discharge represents an abnormal symptom and the underlying disease should be diagnosed. Different kinds of nipple dischare Frankly bloody BloodyPurulent Serous ( yellow & clear ) Watery Milky

4. The causes of nipple discharge in women Malignancy Breast carcinoma Benign lesionsPapillomaDuctectasia Endocrine disturbances Pituitary adenoma

5. Fine needle aspiration biopsy Open biopsy There is a mass in the breast exam Fine needle aspiration biopsy Open biopsy A mass is found in mamography Cytologic examination of the discharge Measurement of prolactin level in serum There is not any evidence of tumor What is the next step for evaluation of nipple discharge in a non-lactating woman?

6. How is the discharge of the nipple collected for cytopathologic examination? With special pump With pressure on areola

7. The benign lesions causing nipple discharge : DuctectasiaPapillomaTuberculosis Others (as fungal infections)

8. The prevalence of malignancy when nipple discharge is seen 0.83%0.13% 3.96%0.16% Serous discharge Bloody discharge Purulent discharge Milky discharge

9. The breast cancers which induce nipple discharge: Ductal carcinoma Paget’s disease

10. 47% Diagnosis of cancer 45% Suspicious cancer 8% Wrong diagnosis as a benign lesion The sensitivity of the cytopathologic examination of the nipple discharge. The Cytopathologic results of the nipple discharges were as below in women with breast carcinoma:

11. Except the cytopatologic examination of the nipple discharge the values of the other tests ( as biochemistry or microbiology) are Inappreciable. Variation of biochemical parameters in non- malignant and malignant discharge Parameters Non-malignant malignant CEA (µg mL-1) 5.0 10.0 LDH (µ L-1) 50.0 120.0 Protein (mg dL-1) 20.0 10.0 Cholesterol (mg dL-1) 80.0 40.0 Triglyceride (mg dL-1) 45.0 20.0 Occult blood (%) 25.0 Nil

12. Cytopathology of the nipple secretion ( and touch imprint preparations of the biopsy samples) can predict the patient’s survival who has breast cancer. The presence of the sex chromatin ( arrows ) in 20% or more of the malignant cells which are seen in the cythopathologic or touch imprint samples means a favorable behavior of tumor regardless of tumor grade or stage at the time of biopsy.

13. References: 1 Koss. Leopold G. Diagnostic Cytology. 4 th edition. Philadelphia. J.B. Lippincott Company. 1992. Volume 2. 1221-1232 2 www.allamericanpatriots.com/news_topics/tuberculosis http://health.allrefer.com/health/tinea-cruris-fungus.html http://t1.gstatic.com/images?q=tbn:ANd9GcQupYvuGiY56UkPWALWDrOe2 cCeXRtC6uBPx_lt3qs2V54Bv6Aj 3 INTERNATIONAL JOURNAL OF AGRICULTURE & BIOLOGY 1560-8530/2001/03-2-195-196 http://www.ijab.org 4 http://www.medscape.org/viewarticle/713539_7