- Nipple discharge is common:
- With more than half of women of reproductive age able to express discharge with manipulation
- A thorough history to determine whether a discharge is:
- Physiologic or pathologic:
- Is important to determine the need for additional workup
- Physiologic or pathologic:
- Characteristics of pathologic nipple discharge include:
- Spontaneous
- Bloody or clear
- Unilateral / single duct
- Presence of a palpable mass associated with the discharge
- Nipple discharge should be further evaluated if considered pathologic with:
- Diagnostic mammography
- Retroareolar ultrasound
- Clinical examination
- The differential diagnosis of focal dilation on ultrasound includes:
- Lactational changes
- Duct ectasia
- Malignancy
- Based on ultrasound findings and if the nature of the nipple discharge is concerning that it is pathologic:
- It should be further evaluated with tissue sampling:
- An image-guided excisional biopsy of the duct in question:
- Is a minimally invasive simple technique to definitively rule out malignancy and establish the diagnosis:
- This can be accomplished with placement of an intraoperative probe into the offending duct, or by placement of a preoperative wire or seed marker into the imaging abnormalities
- Is a minimally invasive simple technique to definitively rule out malignancy and establish the diagnosis:
- An image-guided excisional biopsy of the duct in question:
- It should be further evaluated with tissue sampling:
- Failure to identify a cause of the discharge warrants further work-up:
- Ductogram and MRI have also been considered in the routine workup of nipple discharge:
- Though data is inconclusive on their effectiveness
- Ductogram can be considered operator dependent:
- Has a reported positive predictive value of 19%
- Negative predictive value of 63%
- Successful localization of an offending lesion by ductogram:
- Occurs in 50% to 60% of cases
- MRI, on the other hand, has a reported:
- Positive predictive value of 24% to 56%
- Negative predictive value of 87% to 98%
- Suggesting discussion of the technique may be reasonable in some situations but the limitations should also be reviewed with patients
- Ductogram and MRI have also been considered in the routine workup of nipple discharge:
- In the absence of any palpable concerns on examination or suspicious findings on conventional mammogram and ultrasound imaging:
- Duct excision reveals an intraductal papilloma:
- As the cause of the discharge about 50% of the time
- Duct excision reveals an intraductal papilloma:
- While most studies suggest that duct excision is indicated for patients with pathologic nipple discharge for both diagnosis and treatment:
- Observation may be appropriate for selected patients with pathologic discharge who have:
- A normal examination, mammogram, and subareolar ultrasound:
- In whom the risk of carcinoma is 3%
- A normal examination, mammogram, and subareolar ultrasound:
- Observation may be appropriate for selected patients with pathologic discharge who have:
- References:
- Cabioglu N, Hunt KK, Singletary SE, et al. Surgical decision making and factors determining a diagnosis of breast carcinoma in women presenting with nipple discharge. J Am Coll Surg. 2003;196:354-364.
- Vargas HI, Vargas MP, Eldrageely K, Gonzalez KD, Khalkhali I. Outcomes of clinical and surgical assessment of women with pathologic nipple discharge. Am Surg. 2006;72:124-128.
- Romanoff A, Nulsen B, Mester J, Jaffer S, Weltz C. Ultrasound‐guided wire localization of focal ductal dilatation in the evaluation and treatment of pathologic nipple discharge. Breast J. 2018;24(3):356–359.
- Morrogh M, Morris EA, Liberman L, Borgen PI, King TA. The predictive value of ductography and magnetic resonance imaging in the management of nipple discharge. Ann Surg Oncol. 2007;14(12):3369-3377.
- Woodward S, Daly CP, Patterson SK, Joe AI, Helvie MA. Ensuring excision of intraductal lesions: marker placement at time of ductography. Acad Radiol. 2010;17(11):1444-1448.
- Sanders LM, Daigle M. The rightful role of MRI after negative conventional imaging in the management of bloody nipple discharge. Breast J. 2016;22(2):209-212.
- Nelson RS, Hoehn JL. Twenty-year outcome following central duct resection for bloody nipple discharge. Ann Surg. 2006;243(4):522-524.
- Gray RJ, Pockaj BA, Karstaedt PJ. Navigating murky waters: a modern treatment algorithm for nipple discharge. Am J Surg. 2007;194(6):850-854.
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Rodrigo Arrangoiz MS, MD, FACS, FSSO 