Management of Nipple Discharge.

Nipple discharge is the third most common breast-related complaint but is rarely the presenting symptom of breast cancer. Distinguishing patients with physiologic versus pathologic nipple discharge, and treating the later according to the underlying pathologic condition is of utmost importance. Nipple discharge is categorized as lactational, physiologic, or pathologic. Physiologic nipple discharge (galactorrhea) is typically caused by hyperprolactinemia due to medications (ie, antipsychotics), pituitary tumors, and endocrine disorders. When a suspicious radiologic lesion is identified, pathologic assessment of the lesion is indicated. Patients with pathologic nipple discharge should be referred to a breast surgeon for definitive treatment and follow-up.

Clinical, Hormonal, and Neuroradiological Characteristics and Therapeutic Outcomes of Prolactinomas in Children and Adolescents at a Single Center.

Background/Purpose: A prolactinoma is the most common pituitary adenoma, but it is relatively rare in childhood and adolescence. There is only limited research about the clinical spectrum, treatment, and outcomes of prolactinomas in childhood and adolescence. In this single-center cohort study, we assessed the clinical, hormonal, and neuroradiological characteristics and therapeutic outcomes of children and adolescents with prolactinomas. Methods: This retrospective cohort study included 25 patients with prolactinomas diagnosed before 19 years of age, who presented at Samsung Medical Center during a 15-year period (March 2005 to August 2019). Results: The median age at diagnosis was 16.9 (range 10.1-18.5) years, and 80% of the patients were female. The common clinical manifestations at diagnosis were galactorrhea (10/20, 50%) and amenorrhea (9/20, 45%) among females and visual field defects (3/5, 60%) and headaches (2/5, 40%) among males. In our cohort, macroadenomas accounted for 56% of cases, and the rate of overall responsiveness to dopamine agonists (DAs) was 56% (10/18). Male gender, the prolactin (PRL) level at diagnosis, and the presence of panhypopituitarism were positively correlated with maximum tumor diameter (r = 0.443, P = 0.026; r = 0.710, P < 0.001; and r = 0.623, P = 0.001, respectively). After the trans-sphenoidal approach (TSA), 53% (8/15) of patients showed normalization of the PRL level. Three patients, who underwent gamma knife surgery (GKS) owing to either resistance or intolerance to DAs or recurrence after the TSA, achieved a normal PRL level accompanied with marked tumor reduction and symptom remission. Conclusions: A macroprolactinoma is more prevalent than a microprolactinoma in children and adolescents than in adults. Male gender, increased PRL levels, and the presence of panhypopituitarism at diagnosis are closely related to macroprolactinomas in children and adolescents.

An Adoptive Mother Who Became a Human Milk Donor.

Inducing lactation in the absence of pregnancy (nonpuerperal lactation) is not always successful and, in many cases, only partial breastfeeding is achieved. Different protocols have been described, but scientific evidence and research are lacking in this area. The authors describe the case of a woman with a history of a miscarriage, for whom the lactation induction process was so effective that she became a milk donor even before she received her adopted child. She had not previously used hormone treatment. She was given domperidone as a galactogogue for 1 month. The pumping protocol began with a double electric breast pump combined with manual pumping 6 months before her child was delivered, and 3 months later, she was accepted as a donor by our milk bank. This highlights the importance of regular stimulation as a milk production mechanism. This is the first case of human milk donation in an adoptive mother described in the literature.

Pathological postpartum breast engorgement: prediction, prevention, and resolution.

BACKGROUND: Severe breast engorgement can cause substantial discomfort for mothers and interfere with an infant's ability to feed at the breast. This study explored the possibility of prediction of pathological postpartum breast engorgement in lactating women in relation to intense breast engorgement at the end of the luteal phase of the menstrual cycle and the possibility of prevention and resolution of postpartum breast engorgement with expression with a breast pump of colostrum before the appearance of transitional milk. SUBJECTS AND METHODS: The first group included 70 women with pathological postpartum breast engorgement. The second group included 52 postpartum women, with 24 women having colostrum extracted by the breast pump from each breast once or twice for a duration of 20-25 minutes sequentially in the first 2-3 days after delivery in addition to the removal of colostrum by the baby, before engorgement developed. Twenty-eight women had colostrum removed only by the baby. The degree of breast engorgement was assessed using the previously published Robson four-level scale. RESULTS: Of the 70 patients with severe postpartum engorgement studied in the first group, 90% showed intense breast engorgement in the late luteal phase of the menstrual cycle. Expression of colostrum milk in the first experimental group from each breast eliminated excessive breast engorgement in breastfeeding mothers. CONCLUSIONS: Presence of intense breast engorgement at the end of the luteal phase of the menstrual cycle may be one of the most important indicators useful for predicting severe postpartum breast engorgement. Extraction of colostrum before the appearance of transitional milk lowers the risk of excessive engorgement in breastfeeding women.

Clinical and radiological findings in macroprolactinemia.

Hyperprolactinemia is the most common abnormality of the hypothalamic-pituitary axis. The aim of this study was to investigate the clinical and radiological features of patients with macroprolactinemia. The study population consisted of patients with elevated serum prolactin (PRL) concentrations who presented to our Endocrinology outpatient clinic. Detection of macroprolactin (macroPRL) was performed using the polyethylene glycol precipitation method. Patients in which macroPRL made up more than 60% of total PRL levels were stratified into the macroPRL group, while the remaining patients were placed in the monomeric prolactin (monoPRL) group. A total of 337 patients were enrolled with a mean age of 33.8 ± 10.8 (16-66) years and a male/female ratio of 29/308. Eighty-eight of the patients (26.1%) had an elevated macroPRL level. The mean age in the monoPRL group was higher than in the macroPRL group (35.0 ± 10.1 vs. 30.7 ± 9.8, P = 0.016). The mean PRL levels (ng/ml) in the macroPRL and monoPRL groups were similar (168.0 ± 347.0 vs. 238.8 ± 584.9, P = 0.239). Frequency of amenorrhea, infertility, irregular menses, gynecomastia, and erectile dysfunction were also similar in both groups. More patients in the macroPRL group were asymptomatic compared to the monoPRL group (30.2 vs. 12.0%, P = 0.006). Compared to the macroPRL group, the monoPRL group had a higher frequency of galactorrhea (39.2 vs. 57.1%, P = 0.04) and abnormal magnetic resonance imaging findings (65.3 vs. 81.1%, P = 0.02). Elevated macroPRL levels should be considered a pathological biochemical variant of hyperprolactinemia that may present with any of the conventional symptoms and radiological findings generally associated with elevated PRL levels.

Ductoscopy-based descriptors of intraductal lesions and their histopathologic correlates.

BACKGROUND: In order to elucidate criteria for distinguishing benign from malignant lesions, this study correlated the ductoscopy-based macroscopic description of intraductal lesions with histopathologic results. MATERIALS AND METHODS: Aiming to use diagnostic criteria consistent with previous publications, we analyzed the literature and established a uniform set of diagnostic descriptors. Based on these criteria, we subsequently analyzed and catalogued video and photographic material from 68 patients with nipple discharge, who had undergone ductoscopy followed by open surgery. For all breast lesions, the factors lesion type, number of lesions, lesion color, surface characteristics, and presence of blood or atypical vessels were reported. Based on the frequency distribution and the odds ratio, we were able to evaluate the differential diagnostic value of ductoscopic criteria in comparison with the respective histopathologic results. RESULTS: Among the ductoscopic criteria, a fissured surface, hemorrhage or atypical vessels, and a polypoid appearance were important predictors for malignant lesions. In contrast, a smooth surface, the absence of hemorrhage and atypical vessels and a level appearance of the lesions predicted benign lesions. CONCLUSIONS: For predicting the benign versus malignant character of ductoscopic lesions, the following criteria should be used: presence or absence of blood and atypical vessels, surface type, and level versus polypoid appearance.

Clinical profile and long term follow up of children and adolescents with prolactinomas.

We report clinical presentation, response to medical treatment, and long-term follow-up of 39 children and adolescents with prolactinoma (F:M; 30:9) (30 macro and 9 microadenoma) diagnosed at the age of 9-20 years. Mean duration of follow up was 56 months. All patients were treated with bromocriptine (BC) at doses ranging from 2.5 to 20 mg/day or by cabergoline at doses ranging from 0.5 to 2 mg/week orally. Two patients received external conventional radiotherapy after surgery. In patients with macroprolactinoma (F:M; 21:9), headache and/or visual defects were the first symptoms. All females had primary or secondary amenorrhea. Growth arrest was not observed in any patient and pubertal development was appropriate for their age. Spontaneous or provocative galactorrhea was observed in 23 patients (all females) and none of male patient had gynecomastia. Mean serum prolactin (PRL) concentration at the time of diagnosis was 322.50 ng/ml in patients with microadenoma, 522.38 ng/ml in patients with macroadenoma and 2,294.86 ng/ml in patients with macroadenoma with suprasellar extension. In 25 patients, BC normalized PRL levels and caused variable, but significant, tumor shrinkage. Cabergoline normalized PRL concentrations in 14 patients. Pregnancy occurred in 6 patients while on treatment. Pregnancies were uncomplicated, and the patients delivered normal newborns at term. Impairment of other pituitary hormone secretion was documented at the time of diagnosis in only one patient. Postoperatively six patients had other pituitary hormone deficiencies. In conclusion, the medical treatment with dopaminergic compounds is effective and safe in patients with prolactinoma with onset in childhood, allowing preservation of the anterior pituitary function.

Cerebrospinal fluid galactorrhea: a rare complication of ventriculoperitoneal shunting.

In this report we describe a 26-year-old woman who had an intra-abdominal pseudocyst located at the peritoneal catheter tip following ventriculo-peritoneal (VP) shunt implantation. Retrograde cerebrospinal fluid (CSF) flowed outside the catheter and communicated with the right breast lactiferous ductal system and leaked from the nipple orifice. CSF galactorrhea only occurs when the lactiferous duct is injured during VP shunt implantation, in combination with the formation of an intra-abdominal CSF pseudocyst prior to lactiferous duct healing. Leakage of CSF from the nipple orifice can be successfully treated by simply guiding the peritoneal catheter tip into the peritoneal cavity through a new laparotomy; that is, shunt revision is not always required.

Diagnostic value of ductoscopy in the diagnosis of nipple discharge and intraductal proliferations in comparison to standard methods.

BACKGROUND: Ductoscopy is gaining increased importance in the diagnosis of nipple discharge of unclear origin and intraductal proliferation. For this reason we compared its diagnostic value and feasibility to standard diagnostic methods. MATERIAL AND METHODS: Ductoscopy was compared to mammography, galactography, sonography, magnetic resonance imaging (MRI), nipple smear, fine needle aspiration cytology (FNAC), and high-speed core biopsy; feasibility, sensitivity, and specificity were investigated for each method. RESULTS: 71 ductoscopies were evaluated, which were followed up by open biopsies. Here, 3 invasive and 8 ductal carcinomas in situ were found, as well as 3 atypical ductal hyperplasias, 44 papillomas/papillomatoses, and 13 benign findings. Feasibility of ductoscopy was in this series 100%. Duct sonography showed the highest sensitivity (67.3%), followed by MRI (65.2%), galactography (56.3%), ductoscopy (55.2%), and FNAC (51.9%). The highest specificity was shown by FNAC, core biopsy, and galactography (each 100.0%), followed by mammography (92.3%), nipple smear (77.8%), ductoscopy, and duct sonography (each 61.5%); the lowest specificity was displayed by MRI (25.0%). CONCLUSION: The results confirm that ductoscopy can be performed within the same range of sensitivity and specificity as other techniques. In order to make conclusive statements about ductoscopy, especially in order to precisely define the indications for this method, a prospective multicenter study was initiated.

Concurrent lymphocytic hypophysitis and pituitary adenoma. Case report and review of the literature.

Lymphocytic hypophysitis (LyH) is an uncommon intrasellar lesion characterized by lymphocytic infiltration of the adenohypophysis. Evidence suggests that the cause is autoimmune, and the symptoms are usually related to either a mass effect or endocrine dysfunction. Lymphocytic hypophysitis has been described rarely in the setting of other simultaneous pathological processes that involve the pituitary and sella turcica, and is postulated to arise from an intrinsic inflammatory response. The authors report the case of a 43-year-old woman who presented with a 2-month history of galactorrhea and pseudohyperprolactinemia secondary to a 10-mm lesion within an enlarged pituitary gland. She was nulliparous and had no contributory medical history. Serial neuroimaging performed over a 2-year period demonstrated lesion growth, and visual deficits had developed; together these warranted surgical intervention. A transsphenoidal resection was performed. Microscopic and immunohistopathological examinations revealed a nonsecreting pituitary adenoma with concurrent lymphocytic adenohypophysitis. This is the first documented case of LyH in the setting of a null-cell pituitary adenoma. The authors review the related literature and outline potential mechanisms for the concurrent development of LyH and a pituitary adenoma.

Patología tumoral benigna. Patología intraductal / Benign breast neoplasms. Intraductal disease

En este capítulo de patología benigna de la mama se describen dos tipos de entidades diferentes: aquellas que se manifiestan en forma de tumoración palpable y un segundo grupo cuya forma de presentación clínica más frecuente es la secreción mamaria. En cada caso se hace referencia a a las técnicas diagnósticas específicas, así como a las distintas lesiones que pueden presentarse dentro de cada apartado, haciendo una breve descripción de la clínica, la histología y el tratamiento (AU)

Transsphenoidal surgery for pituitary gigantism and galactorrhea in a 3.5 year old child.

The management of pituitary macroadenomas which lead to gigantism may require multiple therapeutical approaches, including medical treatment, surgery, and radiation therapy. Transsphenoidal surgery (TSS) during early childhood that achieves total removal of a growth hormone (GH) secreting tumor is rarely reported. The surgeon is confronted with special problems regarding the infantile anatomy. In this case, a 3.5 year old child, the youngest successfully treated by TSS so far, suffered from a GH- and prolactin (PRL) secreting macroadenoma of the pituitary gland. The girl initially presented with an increasing growth rate, later with breast development, and finally, at the age of 2.8 years, with galactorrhea and secretion of blood from the nipples. Increased levels of GH [122 micrograms/l], insulin-like growth factor (IGF-1) [830 micrograms/l], insulin-like growth factor binding protein 3 (IGFBP-3) [8.6 mg/l] and PRL [590 micrograms/l] were found. MRI scans revealed a macroadenoma of 2.7 cm diameter. An eight-week trial of relatively low dose dopamine agonists led to a reduction of PRL, while the GH- and IGF-1 levels remained unchanged; the tumor showed only little shrinkage. Since there was chiasma compression, we opted for early TSS. A complete tumor removal was achieved despite the difficulties of a narrow approach. After TSS, low levels of GH, IGF-1, and PRL documented a complete tumor removal, but persistent diabetes insipidus and anterior lobe deficits resulted from surgery. In summary, if primary medical therapy alone is unable to adequately reduce hormone hypersecretion and tumor size in early childhood, TSS is recommended. Thus, radiation therapy may be reserved for surgical failure.

[Digital mammography: experiences in its clinical application]. / Digitale Mammographie: Erfahrungen bei klinischer Anwendung.

TARGET: In 1989 in the Cantonal Hospital of Lucerne conventional film-screen mammography was replaced by digital mammography. With the support of a retrospective study, it was checked whether or not digital mammography represents an equally valid diagnostic procedure in daily routine. METHODS: 1204 patients were examined using digital mammography. A reevaluation of these patients was carried out using clinical and radiological routine controls. Additionally a radiological and histological examination was performed in 127 cases in which excisional biopsies had been done, paying particular attention to detail perception. RESULTS: The sensitivity of digital mammography achieved a total of 85%, whereas the accuracy was 81%. With additional use of ultrasound and galactography the sensitivity attained 91%. By reevaluation the sensitivity amounted to 87%, the accuracy remaining at 81%. The positive predictive value was especially high with 76% and 77%. CONCLUSION: Digital mammography offers satisfactory diagnostic performance.

Galactorrhoea. Report of a case in a male patient.

Galactorrhoea is the secretion of milk from the breast in non-physiological circumstances. It is rare in males of any age. We report the case of an adult male who presented with enlarged breasts and tenderness of the left breast, with milky discharge. Bilateral subcutaneous mastectomies were performed.