https://orcid.org/0000-0002-1440-5290
Abstract
Nipple discharge, a relatively common presenting symptom for women of all ages, may be due to both benign and malignant conditions. Men can also present with nipple discharge, and when they do, they have a higher likelihood of malignancy than women. Radiologists vary in their evaluation of patients with nipple discharge, although the American College of Radiology practice guidelines for nipple discharge provides data-driven appropriate algorithms. In patients with physiologic discharge, imaging is not typically indicated. For those with pathologic nipple discharge, imaging typically starts with diagnostic mammography and retroareolar ultrasound for women over 40 years of age, diagnostic mammogram or ultrasound for women aged 30–39 years, and ultrasound for women younger than 30 years. Finally, contrast-enhanced breast MRI or galactography are usually reserved for identifying the cause of discharge when initial imaging with mammography and ultrasound is unrevealing.
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Key Messages
Nipple discharge, a relatively common presenting symptom for women of all ages, may be due to both benign and malignant conditions.
Men presenting with nipple discharge have a higher likelihood of malignancy than women.
Initial imaging evaluation for pathologic nipple discharge depends on the patient’s age and sex. For women over 40 and for men over 25 years of age imaging starts with diagnostic mammography and retroareolar ultrasound. For women 30–39 years of age imaging starts with diagnostic mammography or ultrasound. For women less than 30 and for men less than 25 years of age imaging starts with ultrasound.
Contrast-enhanced breast MRI or galactography may be helpful in identifying a cause for the discharge if the initial imaging with mammography and ultrasound is unrevealing.
Introduction
Nipple discharge is the third most common breast complaint after breast pain and palpable abnormalities (1, 2). Between 5% and 10% of women presenting for a routine health maintenance examination will report nipple discharge (3), and as many as 80% of women will experience at least one episode of nipple discharge during their reproductive years (3). Although most cases of nipple discharge are caused by benign conditions, such as physiologic causes, papillomas, or duct ectasia, this symptom can be alarming for patients because it can be a presenting symptom of breast cancer. In fact, between 5% and 28% of patients with pathologic nipple discharge may have an underlying malignancy (4, 5), and the chance of breast malignancy is even higher for men (23%–57%) who present with nipple discharge (6, 7).
Among U.S. radiologists, there is significant variability in the choice of imaging modality for evaluation of physiologic and pathologic nipple discharge. Although the American College of Radiology (ACR) has published evidence-based guidelines to assist providers in choosing the most appropriate imaging for patients presenting with nipple discharge, a recent survey demonstrated that radiologists do not uniformly follow these practice guidelines, and this potentially leads to unnecessary workups and health care costs (8).
Evaluation of nipple discharge
The specific details of the evidence-based guidelines for the evaluation of patients presenting with nipple discharge can be found on the ACR website (9). Essentially, it is divided into five variants as follows: (1) physiologic nipple discharge in women of any age; (2) pathologic nipple discharge in men or women 40 years of age or older; (3) pathologic nipple discharge in men or women 30–39 years of age; (4) pathologic nipple discharge in women younger than 30 years of age; and (5) pathologic nipple discharge in men younger than 30 years of age, with subgroups of men 25–30 years and men under 25 years. Figure 1 summarizes the recommendations for the initial imaging evaluation of each of these clinical scenarios.
Flowchart summarizing initial imaging choices based on the American College of Radiology’s appropriateness criteria (9). Variants are shown in brackets.
Patient Evaluation
The initial evaluation of a patient presenting with nipple discharge starts with a careful history and physical examination by the referring clinician. This approach allows a physician to differentiate physiologic from pathologic causes (Table 1). This differentiation is critical, as patient management varies depending on the etiology.
Common Presentations of Physiologic and Pathologic Nipple Discharge
| Physiologic (ACR Variant 1) | Pathologica (ACR Variants 2–5) |
|---|---|
| Bilateral | Unilateral |
| Multiple duct orifices | From a single orifice |
| Nonspontaneous | Spontaneous |
| White or milky, green, yellow | Bloody or serous (clear) |
| Physiologic (ACR Variant 1) | Pathologica (ACR Variants 2–5) |
|---|---|
| Bilateral | Unilateral |
| Multiple duct orifices | From a single orifice |
| Nonspontaneous | Spontaneous |
| White or milky, green, yellow | Bloody or serous (clear) |
Abbreviation: ACR, American College of Radiology.
aPresence of any one of these features indicates pathologic nipple discharge
Common Presentations of Physiologic and Pathologic Nipple Discharge
| Physiologic (ACR Variant 1) | Pathologica (ACR Variants 2–5) |
|---|---|
| Bilateral | Unilateral |
| Multiple duct orifices | From a single orifice |
| Nonspontaneous | Spontaneous |
| White or milky, green, yellow | Bloody or serous (clear) |
| Physiologic (ACR Variant 1) | Pathologica (ACR Variants 2–5) |
|---|---|
| Bilateral | Unilateral |
| Multiple duct orifices | From a single orifice |
| Nonspontaneous | Spontaneous |
| White or milky, green, yellow | Bloody or serous (clear) |
Abbreviation: ACR, American College of Radiology.
aPresence of any one of these features indicates pathologic nipple discharge
Physiologic nipple discharge is usually bilateral, multiductal, nonbloody, white, green, cloudy, or milky, and, although it can be spontaneous, it is usually associated with nipple stimulation or breast compression. Most women can express fluid from their breasts during their reproductive years. During pregnancy and lactation, the mammary glands excrete milk or colostrum in response to estrogen, progesterone, prolactin, and oxytocin. This physiologic discharge may persist for up to one year after pregnancy and cessation of breastfeeding (10, 11). Medications associated with physiologic discharge include hormonal preparations; psychotropic, antihypertensive, and antiemetic drugs; and histamine H2-receptor antagonists (1, 2). Physiologic discharge is not associated with breast cancer, and therefore no imaging is indicated (4, 12). Avoidance of nipple compression and stimulation may expedite resolution (10). Galactorrhea is the presence of spontaneous bilateral lactation in males or in females outside of pregnancy or the postpartum period. Galactorrhea does not represent intrinsic breast disease and is commonly caused by hyperprolactinemia (10). Elevated prolactin levels may be due to hypothalamic or pituitary lesions (most commonly pituitary adenomas), systemic disease (such as hypothyroidism), or some medications. Workup of galactorrhea includes ruling out pregnancy, followed by measurement of prolactin and thyroid-stimulating hormone levels, and a medication review. To summarize, if the patient history and physical examination suggests physiologic nipple discharge and routine screening mammography is up to date, no imaging investigation is needed (Figures 1 and 2) (13).
41-year-old woman with no family history of breast cancer with recent onset of bilateral spontaneous milky nipple discharge and up-to-date negative screening mammogram (above). Galactorrhea was thought to be secondary to newly prescribed risperidone.
Pathologic nipple discharge is typically unilateral, from a single orifice, bloody, or spontaneous and clear and requires imaging workup (Table 1, Figure 1). Cytological evaluation of discharge is neither sufficiently sensitive nor specific to be useful for the evaluation of potential malignancy and therefore is not routinely performed (14–16). Bloody and high-volume nipple discharge has been linked to a higher likelihood of cancer (17), although the absence of blood is not helpful in excluding malignancy. On physical exam, a “trigger point” can sometimes be found, the compression of which reliably produces nipple discharge (18, 19). Tissue diagnosis is necessary in most patients with pathologic nipple discharge. Initial imaging workup differs depending on the patient’s age and sex. The goal of imaging is to localize the underlying cause, determine the extent of the anatomic abnormality, and plan appropriate treatment. In most cases of pathologic nipple discharge, the underlying cause is benign. Intraductal papilloma is the most common cause of pathologic nipple discharge, accounting for 35%–48% of cases, followed by duct ectasia (17%–36% cases) (13). However, an underlying malignancy can be found in 5%–21% of cases (2, 4, 20). Other less common causes of nipple discharge include papillomatosis, nipple adenoma, Paget disease of the nipple, fibrocystic changes, and benign ductal hyperplasia (Table 2). The presence of a palpable mass in association with nipple discharge has been reported to have a higher malignancy rate (1, 2).
Differential Diagnosis for Pathologic Nipple Dischargea
| Differential Diagnosis | Incidence of Pathologic Nipple Discharge Cases |
|---|---|
| Papilloma | 35%–70% |
| Duct ectasia | 17%–36% |
| Carcinoma (DCIS > invasive) | 5%–21%, age dependent |
| Nipple adenoma | <1% |
| Paget disease of the nipple | <1% |
| Ductal hyperplasia +/- atypia | <10% |
| Fibrocystic changes | <10% |
| Differential Diagnosis | Incidence of Pathologic Nipple Discharge Cases |
|---|---|
| Papilloma | 35%–70% |
| Duct ectasia | 17%–36% |
| Carcinoma (DCIS > invasive) | 5%–21%, age dependent |
| Nipple adenoma | <1% |
| Paget disease of the nipple | <1% |
| Ductal hyperplasia +/- atypia | <10% |
| Fibrocystic changes | <10% |
Differential Diagnosis for Pathologic Nipple Dischargea
| Differential Diagnosis | Incidence of Pathologic Nipple Discharge Cases |
|---|---|
| Papilloma | 35%–70% |
| Duct ectasia | 17%–36% |
| Carcinoma (DCIS > invasive) | 5%–21%, age dependent |
| Nipple adenoma | <1% |
| Paget disease of the nipple | <1% |
| Ductal hyperplasia +/- atypia | <10% |
| Fibrocystic changes | <10% |
| Differential Diagnosis | Incidence of Pathologic Nipple Discharge Cases |
|---|---|
| Papilloma | 35%–70% |
| Duct ectasia | 17%–36% |
| Carcinoma (DCIS > invasive) | 5%–21%, age dependent |
| Nipple adenoma | <1% |
| Paget disease of the nipple | <1% |
| Ductal hyperplasia +/- atypia | <10% |
| Fibrocystic changes | <10% |
Imaging evaluation of nipple discharge
Mammography and Breast Ultrasound
Mammography, using digital mammography or digital breast tomosynthesis, is the standard imaging modality for evaluation of pathologic nipple discharge for women over 40 years of age and men over 25 years of age. Mammography usually consists of the standard bilateral craniocaudal and mediolateral oblique views, with additional spot compression views (with or without magnification) of the subareolar breast of the symptomatic side to evaluate for calcifications and masses (4). For detection of malignancy, the reported sensitivity of mammography varies between 15% and 68%, with a specificity between 38% and 98% (2, 4, 16, 21). Cabioglu et al reported the positive predictive value (PPV) of 42% and the negative predictive value (NPV) of 90% in the detection of cancer among patients with pathologic nipple discharge (21). Mammography has been reported to have low (20%–25%) sensitivity in cases of nipple discharge, likely because the associated lesions are usually retroareolar, small, intraductal, and noncalcified (4, 22, 23). Although low in sensitivity and PPV, mammography remains useful in the evaluation of pathologic nipple discharge because of its high specificity and high NPV. It should be noted, however, that negative mammography results do not exclude the possibility of underlying disease (23). The primary mammographic finding is calcifications; however, masses, focal asymmetry, and duct ectasia can also be seen in patients with nipple discharge (23).
Ultrasound (US) is very useful in the identification of invasive cancer and the estimation of its extent, but it has a lower sensitivity for the detection of ductal carcinoma in situ (DCIS) (4, 24–26). US can identify lesions not visible on mammography and also helps with identification, assessment, and biopsy. In several studies of women with pathologic discharge, US identified lesions not visible on mammography in 63%–68% of cases (3, 27). The reported sensitivity of US alone for detection of underlying malignancy in patients with pathologic nipple discharge is 56%–80%, specificity is 61%–75%, PPV is 29%–39%, and NPV is 90%–91% (2, 4, 13, 21). Although more sensitive than mammography, US suffers from lower specificity. US findings include duct ectasia, solid or complex breast masses, intraductal masses, or fluid collections (4). Using high-frequency linear array probes, the scanning technique has been well described by Stavros (28). Using a stand-off pad or abundant gel can also help with evaluation of the retroareolar region (13).
Age and sex influence the choice of the initial imaging study. Excluding a malignant lesion is of primary importance in patients presenting with pathologic nipple discharge, as the risk of malignancy increases with age (16, 29, 30). Seltzer et al showed that malignancy was present in 3% of patients 40 years or younger with no palpable mass, 10% of patients 40–60 years of age, and 32% of those over 60 years (29). Morrogh et al reported the incidence of malignancy as 7%, 9%, and 14% in these same age categories, respectively (17). Therefore, for men over 25 years of age and women over 40 years of age, the imaging evaluation starts with diagnostic mammography complemented with US (Figures 3 and 4). At the same time, given that breast cancer is rare in women younger than 30 years and the overall increased mammographic breast density can obscure lesions (13), US is the recommended initial imaging exam for younger women (Figure 5) (31, 32). In women younger than 30 years of age with average risk, mammography should be performed only if US revealed a concerning finding. In women aged 30–39 years, either diagnostic mammogram or US could be used for initial evaluation (Figure 6).
82-year-old man with bloody right nipple discharge and a palpable breast lump. A: Diagnostic mammogram of the right breast with magnification view (B) reveals a high density irregular subareolar mass with indistinct margins and internal calcifications (arrows). C: Targeted ultrasound shows an irregular solid and cystic mass with calcifications (arrow), assessed as BI-RADS category 5 – highly suggestive of malignancy. Biopsy demonstrated invasive ductal carcinoma. Case courtesy of Tejas Mehta, M.D.
29-year-old man with serous left nipple discharge and palpable area in the periareolar breast. A: Diagnostic mammogram with a spot compression view of the right breast (B) reveals mild bilateral gynecomastia but no suspicious findings. C: Antiradial ultrasound image at the 10–11 o’clock position in the area of palpable abnormality. There is a suspicious hypoechoic irregular mass (arrow), BI-RADS 4 – suspicious. Biopsy demonstrated scarring, chronic inflammation and foreign body giant cell reaction. The patient subsequently recalled a prior nipple piercing in this location.
20-year-old woman presented with spontaneous, clear left nipple discharge from a single orifice. Ultrasound performed at 3 o’clock, 2 centimeters from the nipple (A, radial view) shows a round complex solid and cystic mass with irregular margins associated with a duct (arrow). Color Doppler (B, radial view) shows vascularity within the mass (arrow). The finding was assessed as BI-RADS 4 – suspicious. Biopsy demonstrated papilloma.
38-year-old woman with no family history of breast cancer presents with clear, spontaneous right nipple discharge. Ultrasound (A, antiradial) performed in the subareolar region at 4–5 o’clock showed several dilated ducts with solid hypoechoic masses vs. debris. Color Doppler (B, radial view) shows increased vascularity surrounding the duct (arrows). The finding was assessed as BI-RADS-4 – suspicious. Biopsy demonstrated duct ectasia.
Although nipple discharge in men is rare and not as extensively studied as in women, two studies showed carcinoma in 23%–57% of men presenting with nipple discharge (6, 7). In a retrospective study by Morrogh et al, 57% of men presenting with nipple discharge had an underlying malignancy, contrasted with 16% in the female cohort (6). In addition, 9% of men with breast cancer presented with nipple discharge as their chief complaint (6). Therefore, as nipple discharge in a man is strongly associated with malignancy, both mammography and US are recommended for men over the age of 25 years (Figures 3 and 4) (13).
Galactography and Breast MRI
Further workup is needed in patients with suspicious nipple discharge when the conventional evaluation with mammography and US is negative. Despite negative mammographic and sonographic imaging, an underlying cancer may be seen in 6%–14% of patients with pathologic nipple discharge (16, 33, 34). Although major duct excision is considered the gold standard to exclude malignancy in patients with nipple discharge and a negative initial imaging evaluation, nondirected central duct excision may miss multiple or peripheral lesions. Additionally, major duct excision may be undesirable in women of child-bearing age (17). Several studies have shown that both galactography and contrast-enhanced MRI may be useful in this setting (13). In addition, surgery guided by imaging localization of the targeted lesion is more likely to remove the specific underlying cause than in patients who undergo blind central duct excision (13, 21, 35).
Galactography, often referred to as ductography, is performed after the secreting duct is cannulated by a 30-gauge blunt sialogram needle and a small volume (0.1–1.5 mL) of water-soluble iodinated contrast material is injected. Following injection, multiple mammographic images are obtained, usually including subareolar orthogonal magnification images (18, 19). However, in order to be successful, the discharge must be reproducible on the day of the procedure (5). Although galactography can be technically challenging, published studies have shown that it can localize 76% of otherwise occult malignant and high-risk lesions (17). Findings suspicious for carcinoma or papilloma include ductal filling defects, obstruction, and ductal wall irregularities (Figure 7). As galactography has relatively low specificity due to its inability to reliably distinguish between malignant and benign lesions, it can be useful in identifying the presence and location of the causative abnormality, thereby facilitating preoperative localization (19, 36). Unfortunately, the rate of incomplete or failed galactography can be as high as 15%–23% (17, 34). Possible complications of galactography are perforation of the duct, contrast extravasation, vasovagal reaction, and potentially a contrast reaction (which is quite rare). Although no significant contrast reactions have been reported following ductography, severe allergy to contrast material should be considered as a contraindication. An underlying mental disorder or even debilitating anxiety might preclude patient cooperation. Prior surgery disconnecting the nipple orifices from the ducts will also usually lead to an unsuccessful procedure (19). Finally, galactography should not be performed in patients with mastitis or breast abscess, as it can cause the inflammation to become more severe.
45-year-old woman with new onset of unilateral spontaneous, bloody nipple discharge. Initial workup with mammogram and ultrasound was unrevealing. As the patient had severe claustrophobia, she was unable to undergo MRI. A: Galactogram craniocaudal view revealed multiple abnormalities, including numerous filling defects (arrow, zoomed view, B), apple-core-like duct narrowing (dashed arrow, zoomed view, C), and duct obstructions (A, open arrow). After galactography, “second-look” ultrasound (D) identified the most suspicious areas, corresponding to the findings seen on ductography. Ultrasound showed multiple dilated ducts with surrounding vascularity (power Doppler, E), thickened walls, and intraductal hypoechoic material (arrows), BI-RADS 4 – suspicious. Biopsy demonstrated ductal carcinoma in-situ.
Contrast-enhanced MRI can be very helpful when conventional imaging fails to demonstrate a lesion (Figure 8). MRI has high sensitivity for the detection of malignancy and other benign causes such as papilloma (37–42). The spectrum of imaging findings on MRI include enhancing masses or nonmass enhancement in a segmental or linear distribution. MRI readily allows for biopsy of the suspected lesion and has become preferred over galactography due to its higher sensitivity and specificity (20, 25, 34, 43, 44). A recent meta-analysis of 10 studies investigating the diagnostic performance of MRI versus galactography in the setting of pathologic nipple discharge showed a higher diagnostic performance for MRI, with a pooled sensitivity of 92% for MRI as compared to 69% for galactography and a pooled specificity of 76% for MRI versus 39% for galactography (43). This meta-analysis also showed high sensitivity (92%) and specificity (97%) of MRI for cancer detection. However, in addition to its relatively high cost, MRI is typically difficult to perform in claustrophobic patients or in patients with known contraindications or an allergy to gadolinium-based contrast material (43). Although surgical duct excision is still often performed to relieve symptoms even if imaging is unrevealing, more recent data suggests that the high negative predictive value of a negative MRI may help select patients who could be safely managed with observation rather than surgery, potentially reducing morbidity and costs associated with surgery in women with nipple discharge (2, 33, 34, 45)
34-year-old woman with a personal history of right breast cancer status postbreast conservation therapy, with a new onset of intermittent clear and occasionally bloody left nipple discharge. Mammography and ultrasound were normal. MRI revealed linear nonmass enhancement in the central left breast (solid arrow) and abnormal left nipple enhancement (dashed arrow), suspicious for Paget’s disease, BI-RADS 4 – suspicious. MRI-guided biopsy of the nonmass enhancement showed ductal carcinoma in situ.
Case Examples
Case 1: Milky Discharge. History: 41-year-old woman with no family history of breast cancer with recent onset of bilateral spontaneous milky nipple discharge and up-to-date screening mammogram (Figure 2). Management: Bilateral milky nipple discharge is physiologic. Therefore, no diagnostic imaging is needed according to ACR Variant 1: Physiologic nipple discharge. Woman of any age (9).
Case 2: Bloody Discharge. History: 82-year-old man with spontaneous, bloody right nipple discharge and a palpable breast lump he attributes to recent trauma (Figure 3). Management: This patient has pathologic nipple discharge and should be managed according to the ACR Variant 2: Pathologic nipple discharge. Man or woman 40 years of age or older. Initial imaging examination (9). Because of the higher likelihood of cancer in men and women over 40 with pathologic nipple discharge, the initial imaging should start with diagnostic mammography supplemented with US. Although nipple discharge in males is uncommon, it is strongly associated with malignancy. The presence of a palpable mass in association with nipple discharge has been reported to have an even higher malignancy rate (3). US-guided core needle biopsy confirmed invasive ductal carcinoma.
Case 3: Serous Discharge. History: 29-year-old man with serous left nipple discharge and palpable area in the periareolar breast. (Figure 4). Management: This patient has pathologic nipple discharge and should be managed according to the ACR Variant 5: Pathologic nipple discharge. Man younger than 30 years of age. Initial imaging examination. Diagnostic mammography should be the initial imaging study for male patients over 25 years of age with nipple discharge. US can be useful in diagnosis and in guiding biopsy (13, 46). For male patients younger than 25 years of age, the examination should start with US (46). In this case an US-guided biopsy revealed adipose tissue with scarring, chronic inflammation, and foreign body giant cell reaction, which was considered benign and concordant. The patient subsequently recalled a remote history of nipple piercing.
Case 4: Clear Discharge. History: 20-year-old average risk woman presenting with spontaneous, clear left nipple discharge from a single orifice (Figure 5). Management: This patient has pathologic nipple discharge and should be managed according to the ACR Variant 4: Pathologic nipple discharge. Woman younger than 30 years of age. Initial imaging examination (9). Because of the low incidence of breast cancer in this age, the high sensitivity of US, and the theoretically increased radiation risk of mammography, diagnostic workup should start with US instead of mammography in women younger than 30 years of age. If the initial US reveals suspicious findings, or if the patient has a genetic mutation that predisposes her to cancer, mammography may be complementary. In this patient, US-guided core needle biopsy revealed an intraductal papilloma without atypia (benign and concordant). Because this papilloma was associated with nipple discharge, a consultation with a surgeon to discuss possible excision was recommended. The patient underwent excision of the papilloma for symptomatic relief.
Case 5: Clear Discharge. History: 38-year-old woman with no family history of breast cancer presents with clear spontaneous right nipple discharge (Figure 6). Management: This patient has pathologic nipple discharge and should be managed according to the ACR Variant 3: Pathologic nipple discharge. Man or woman 30–39 years of age or older. Initial imaging examination (9). In women aged 30–39 years, the risk of cancer is low at 1.4%. The sensitivity of US for breast cancer detection is higher than that of mammography in women in this age group. However, one should keep in mind that mammography is valuable for detecting suspicious calcifications, and there is a relatively high incidence of DCIS among patients presenting with nipple discharge. For women aged 30–39 years, either mammography or US may be used as the initial imaging modality because the suspicion for malignancy is low and US is highly sensitive. It should be noted that for men aged 30–39 years, diagnostic mammography should be the initial imaging modality because nipple discharge in men is more often associated with malignancy. In this case, a diagnostic mammogram was performed prior to US and showed extremely dense breast tissue with no suspicious findings (not shown). US-guided biopsy revealed duct ectasia, which is benign and concordant.
Case 6: Bloody Discharge. History: 45-year-old woman with new onset of unilateral spontaneous, bloody nipple discharge (Figure 7). Management: This patient has pathologic nipple discharge and should be managed according to the ACR Variant 2: Pathologic nipple discharge. Man or woman 40 years of age or older. Initial imaging examination (9). Initial evaluation with mammogram and US was normal. In the setting of pathologic nipple discharge and a negative initial imaging evaluation, MRI or ductography can often identify occult lesions. As this patient was claustrophobic, ductography is the best next step, as it has been shown to localize 76% of malignant or high-risk lesions and 91% of benign lesions. In this patient, a US-guided core needle biopsy confirmed ductal carcinoma in situ, low to intermediate nuclear grade, with cribriform, papillary, and micropapillary patterns.
Case 7: Clear/Bloody Discharge. History: 34-year-old woman with a personal history of right breast cancer status post breast conservation therapy with a new onset of intermittent clear and occasionally bloody left nipple discharge (Figure 8). Management: This patient has pathologic nipple discharge and should be managed according to the ACR Variant 3: Pathologic nipple discharge. Man or woman 30–39 years of age or older. Initial imaging examination (9). Initial evaluation with mammogram and US was benign. In the setting of pathologic nipple discharge and a negative initial imaging evaluation, contrast-enhanced MRI has high sensitivity for detection of papillary lesions and in situ and invasive cancers (2, 42) and is preferred for further evaluation. MRI showed asymmetric left nipple enhancement and linear non-mass enhancement. MRI-guided core needle biopsy of the left breast nonmass enhancement revealed DCIS. The patient subsequently underwent bilateral mastectomies, confirming Paget’s disease of the left nipple and left breast DCIS.
Conclusions
Although nipple discharge is relatively common in women and more likely to represent a symptom of a benign process, it may be the only clinical sign of an underlying breast malignancy. In men, however, nipple discharge is worrisome for breast cancer. Differentiating physiologic from pathologic discharge is essential in determining the most appropriate imaging evaluation. For physiologic discharge, imaging is typically not indicated. However, for suspected pathologic discharge, initial imaging typically entails diagnostic mammography or US based on patient age and clinical presentation. By following the evidence-based recommendations, radiologists will be better equipped to provide cost-effective care and appropriately guide management.
Funding
None declared.
Conflict of interest statement
None declared.
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