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Nipple Discharge
Katie M. Davis, DO; Robin N. Sobolewski, MD; Wendie A. Berg, MD, PhD
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KEY FACTS

  • Terminology

    • Imaging

      • Top Differential Diagnoses

        • Clinical Issues

          TERMINOLOGY

          • Definitions

            • Pathologic nipple discharge (PND) requires imaging work-up and usually tissue diagnosis
              • Unilateral, uniductal, single orificial
              • Suspicious (any of following)
                • Bloody: Requires further evaluation
                • Spontaneous serosanguineous or serous
                • Watery (clear)
                • Discharge of any color in association with palpable lump, skin retraction, nipple retraction
              • Nonbloody discharge only with stimulation, or incidental during mammogram, is usually of no significance
            • Physiologic nipple discharge
              • Usually bilateral, multiductal, spontaneous or stimulated
              • White, green, or cloudy yellow
              • Galactorrhea: Discharge of milk from breast
                • Physiologic: Associated with pregnancy, breastfeeding, induced by stimulation
                • Nonphysiologic: Due to underlying abnormality (hypothyroidism, pituitary adenoma) or exposure to some drugs (e.g., antihypertensive, antiemetic, histamine-2 receptor antagonists)

          IMAGING

          • General Features

            • Mammographic Findings

              • Ultrasonographic Findings

                • Ductography

                  • MR Findings

                    • Imaging Recommendations

                      DIFFERENTIAL DIAGNOSIS

                        PATHOLOGY

                        • General Features

                          • Microscopic Features

                            CLINICAL ISSUES

                            • Presentation

                              • Demographics

                                • Treatment

                                  • Alternative Procedures

                                    DIAGNOSTIC CHECKLIST

                                    • Consider

                                      • Image Interpretation Pearls

                                        Selected References

                                        1. Grimm LJ et al: Concordant, non-atypical breast papillomas do not require surgical excision: a 10-year multi-institution study and review of the literature. Clin Imaging. 51:180-185, 2018
                                        2. Li GZ et al: Evaluating the risk of underlying malignancy in patients with pathologic nipple discharge. Breast J. 24(4):624-627, 2018
                                        3. Patel BK et al: Nipple discharge: imaging variability among U.S. radiologists. AJR Am J Roentgenol. 211(4):920-925, 2018
                                        4. Bahl M et al: Journal club: diagnostic utility of MRI after negative or inconclusive mammography for the evaluation of pathologic nipple discharge. AJR Am J Roentgenol. 209(6):1404-1410, 2017
                                        5. Berger N et al: Diagnostic performance of MRI versus galactography in women with pathologic nipple discharge: a systematic review and meta-analysis. AJR Am J Roentgenol. 209(2):465-471, 2017
                                        6. Castellano I et al: The impact of malignant nipple discharge cytology (NDc) in surgical management of breast cancer patients. PLoS One. 12(8):e0182073, 2017
                                        7. Expert Panel on Breast Imaging:. et al: ACR Appropriateness Criteria® evaluation of nipple discharge. J Am Coll Radiol. 14(5S):S138-S153, 2017
                                        8. Lesetedi C et al: Indicators of breast cancer in patients undergoing microdochectomy for a pathological nipple discharge in a middle-income country. J Surg Res. 220:336-340, 2017
                                        9. Bahl M et al: Diagnostic value of ultrasound in female patients with nipple discharge. AJR Am J Roentgenol. 205(1):203-8, 2015
                                        10. Manganaro L et al: Breast MRI in patients with unilateral bloody and serous-bloody nipple discharge: a comparison with galactography. Biomed Res Int. 2015:806368, 2015
                                        11. Patel BK et al: Management of nipple discharge and the associated imaging findings. Am J Med. 128(4):353-60, 2015
                                        12. Albrecht C et al: Nipple discharge: role of ductoscopy in comparison with standard diagnostic tests. Onkologie. 36(1-2):12-6, 2013
                                        13. Kaplan R et al: Cytological evaluation of bloody nipple discharge fluid. Diagn Cytopathol. 41(2):183-5, 2013
                                        14. Chen L et al: Bloody nipple discharge is a predictor of breast cancer risk: a meta-analysis. Breast Cancer Res Treat. 132(1):9-14, 2012
                                        15. Ferris-James DM et al: Imaging approaches to diagnosis and management of common ductal abnormalities. Radiographics. 32(4):1009-30, 2012
                                        16. Kalu ON et al: The diagnostic value of nipple discharge cytology: breast imaging complements predictive value of nipple discharge cytology. J Surg Oncol. 106(4):381-5, 2012
                                        17. Kamali S et al: Diagnostic and therapeutic value of ductoscopy in nipple discharge and intraductal proliferations compared with standard methods. Breast Cancer. 21(2):154-61, 2012
                                        18. Sabel MS et al: Is duct excision still necessary for all cases of suspicious nipple discharge? Breast J. 18(2):157-62, 2012
                                        19. Lorenzon M et al: Magnetic resonance imaging in patients with nipple discharge: should we recommend it? Eur Radiol. 21(5):899-907, 2011
                                        20. Seow JH et al: Nipple discharge in a screening programme: imaging findings with pathological correlation. J Med Imaging Radiat Oncol. 55(6):577-86, 2011
                                        21. Dolan RT et al: Nipple discharge and the efficacy of duct cytology in evaluating breast cancer risk. Surgeon. 8(5):252-8, 2010
                                        22. Morrogh M et al: Lessons learned from 416 cases of nipple discharge of the breast. Am J Surg. 200:73-80, 2010
                                        23. Sarica O et al: Evaluation of nipple-areola complex with ultrasonography and magnetic resonance imaging. J Comput Assist Tomogr. 34(4):575-86, 2010
                                        24. Zervoudis S et al: Nipple discharge screening. Womens Health (Lond Engl). 6(1):135-51, 2010
                                        25. Chang JM et al: Does ultrasound-guided directional vacuum-assisted removal help eliminate abnormal nipple discharge in patients with benign intraductal single mass? Korean J Radiol. 10(6):575-80, 2009
                                        26. Kim SH et al: Galactography acquired with digital mammography in patients with nipple discharge: a retrospective analysis. Arch Gynecol Obstet. 280(2):217-22, 2009
                                        27. Maxwell AJ: Ultrasound-guided vacuum-assisted excision of breast papillomas: review of 6-years experience. Clin Radiol. 64(8):801-6, 2009
                                        28. Nicholson BT et al: Nipple-areolar complex: normal anatomy and benign and malignant processes. Radiographics. 29(2):509-23, 2009
                                        29. Tokuda Y et al: Evaluation of suspicious nipple discharge by magnetic resonance mammography based on breast imaging reporting and data system magnetic resonance imaging descriptors. J Comput Assist Tomogr. 33(1):58-62, 2009
                                        30. Da Costa D et al: Common and unusual diseases of the nipple-areolar complex. Radiographics. 27 Suppl 1():S65-77, 2007
                                        31. Hirose M et al: MR ductography: comparison with conventional ductography as a diagnostic method in patients with nipple discharge. Radiographics. 27 Suppl 1:S183-96, 2007
                                        32. Morrogh M et al: The predictive value of ductography and magnetic resonance imaging in the management of nipple discharge. Ann Surg Oncol. 14(12):3369-77, 2007
                                        33. Rissanen T et al: Breast sonography in localizing the cause of nipple discharge: comparison with galactography in 52 patients. J Ultrasound Med. 26(8):1031-9, 2007
                                        34. Escobar PF et al: The clinical applications of mammary ductoscopy. Am J Surg. 191(2):211-5, 2006
                                        35. Yang WT et al: Sonographic, mammographic, and histopathologic correlation of symptomatic ductal carcinoma in situ. AJR Am J Roentgenol. 182(1):101-10, 2004
                                        36. Daniel BL et al: Magnetic resonance imaging of intraductal papilloma of the breast. Magn Reson Imaging. 21(8):887-92, 2003
                                        37. Dennis MA et al: Incidental treatment of nipple discharge caused by benign intraductal papilloma through diagnostic Mammotome biopsy. AJR Am J Roentgenol. 174(5):1263-8, 2000
                                        38. Orel SG et al: MR imaging in patients with nipple discharge: initial experience. Radiology. 216(1):248-54, 2000
                                        39. Sickles EA: Galactography and other imaging investigations of nipple discharge. Lancet. 356(9242):1622-3, 2000
                                        40. Hild F et al: Ductal orientated sonography improves the diagnosis of pathological nipple discharge of the female breast compared with galactography. Eur J Cancer Prev. 7 Suppl 1:S57-62, 1998
                                        41. Cardenosa G et al: Ductography of the breast: technique and findings. AJR Am J Roentgenol. 162(5):1081-7, 1994
                                        42. Tabár L et al: Galactography: the diagnostic procedure of choice for nipple discharge. Radiology. 149(1):31-8, 1983
                                        Related Anatomy
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                                        Related Differential Diagnoses
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                                        References
                                        Tables

                                        Tables

                                        KEY FACTS

                                        • Terminology

                                          • Imaging

                                            • Top Differential Diagnoses

                                              • Clinical Issues

                                                TERMINOLOGY

                                                • Definitions

                                                  • Pathologic nipple discharge (PND) requires imaging work-up and usually tissue diagnosis
                                                    • Unilateral, uniductal, single orificial
                                                    • Suspicious (any of following)
                                                      • Bloody: Requires further evaluation
                                                      • Spontaneous serosanguineous or serous
                                                      • Watery (clear)
                                                      • Discharge of any color in association with palpable lump, skin retraction, nipple retraction
                                                    • Nonbloody discharge only with stimulation, or incidental during mammogram, is usually of no significance
                                                  • Physiologic nipple discharge
                                                    • Usually bilateral, multiductal, spontaneous or stimulated
                                                    • White, green, or cloudy yellow
                                                    • Galactorrhea: Discharge of milk from breast
                                                      • Physiologic: Associated with pregnancy, breastfeeding, induced by stimulation
                                                      • Nonphysiologic: Due to underlying abnormality (hypothyroidism, pituitary adenoma) or exposure to some drugs (e.g., antihypertensive, antiemetic, histamine-2 receptor antagonists)

                                                IMAGING

                                                • General Features

                                                  • Mammographic Findings

                                                    • Ultrasonographic Findings

                                                      • Ductography

                                                        • MR Findings

                                                          • Imaging Recommendations

                                                            DIFFERENTIAL DIAGNOSIS

                                                              PATHOLOGY

                                                              • General Features

                                                                • Microscopic Features

                                                                  CLINICAL ISSUES

                                                                  • Presentation

                                                                    • Demographics

                                                                      • Treatment

                                                                        • Alternative Procedures

                                                                          DIAGNOSTIC CHECKLIST

                                                                          • Consider

                                                                            • Image Interpretation Pearls

                                                                              Selected References

                                                                              1. Grimm LJ et al: Concordant, non-atypical breast papillomas do not require surgical excision: a 10-year multi-institution study and review of the literature. Clin Imaging. 51:180-185, 2018
                                                                              2. Li GZ et al: Evaluating the risk of underlying malignancy in patients with pathologic nipple discharge. Breast J. 24(4):624-627, 2018
                                                                              3. Patel BK et al: Nipple discharge: imaging variability among U.S. radiologists. AJR Am J Roentgenol. 211(4):920-925, 2018
                                                                              4. Bahl M et al: Journal club: diagnostic utility of MRI after negative or inconclusive mammography for the evaluation of pathologic nipple discharge. AJR Am J Roentgenol. 209(6):1404-1410, 2017
                                                                              5. Berger N et al: Diagnostic performance of MRI versus galactography in women with pathologic nipple discharge: a systematic review and meta-analysis. AJR Am J Roentgenol. 209(2):465-471, 2017
                                                                              6. Castellano I et al: The impact of malignant nipple discharge cytology (NDc) in surgical management of breast cancer patients. PLoS One. 12(8):e0182073, 2017
                                                                              7. Expert Panel on Breast Imaging:. et al: ACR Appropriateness Criteria® evaluation of nipple discharge. J Am Coll Radiol. 14(5S):S138-S153, 2017
                                                                              8. Lesetedi C et al: Indicators of breast cancer in patients undergoing microdochectomy for a pathological nipple discharge in a middle-income country. J Surg Res. 220:336-340, 2017
                                                                              9. Bahl M et al: Diagnostic value of ultrasound in female patients with nipple discharge. AJR Am J Roentgenol. 205(1):203-8, 2015
                                                                              10. Manganaro L et al: Breast MRI in patients with unilateral bloody and serous-bloody nipple discharge: a comparison with galactography. Biomed Res Int. 2015:806368, 2015
                                                                              11. Patel BK et al: Management of nipple discharge and the associated imaging findings. Am J Med. 128(4):353-60, 2015
                                                                              12. Albrecht C et al: Nipple discharge: role of ductoscopy in comparison with standard diagnostic tests. Onkologie. 36(1-2):12-6, 2013
                                                                              13. Kaplan R et al: Cytological evaluation of bloody nipple discharge fluid. Diagn Cytopathol. 41(2):183-5, 2013
                                                                              14. Chen L et al: Bloody nipple discharge is a predictor of breast cancer risk: a meta-analysis. Breast Cancer Res Treat. 132(1):9-14, 2012
                                                                              15. Ferris-James DM et al: Imaging approaches to diagnosis and management of common ductal abnormalities. Radiographics. 32(4):1009-30, 2012
                                                                              16. Kalu ON et al: The diagnostic value of nipple discharge cytology: breast imaging complements predictive value of nipple discharge cytology. J Surg Oncol. 106(4):381-5, 2012
                                                                              17. Kamali S et al: Diagnostic and therapeutic value of ductoscopy in nipple discharge and intraductal proliferations compared with standard methods. Breast Cancer. 21(2):154-61, 2012
                                                                              18. Sabel MS et al: Is duct excision still necessary for all cases of suspicious nipple discharge? Breast J. 18(2):157-62, 2012
                                                                              19. Lorenzon M et al: Magnetic resonance imaging in patients with nipple discharge: should we recommend it? Eur Radiol. 21(5):899-907, 2011
                                                                              20. Seow JH et al: Nipple discharge in a screening programme: imaging findings with pathological correlation. J Med Imaging Radiat Oncol. 55(6):577-86, 2011
                                                                              21. Dolan RT et al: Nipple discharge and the efficacy of duct cytology in evaluating breast cancer risk. Surgeon. 8(5):252-8, 2010
                                                                              22. Morrogh M et al: Lessons learned from 416 cases of nipple discharge of the breast. Am J Surg. 200:73-80, 2010
                                                                              23. Sarica O et al: Evaluation of nipple-areola complex with ultrasonography and magnetic resonance imaging. J Comput Assist Tomogr. 34(4):575-86, 2010
                                                                              24. Zervoudis S et al: Nipple discharge screening. Womens Health (Lond Engl). 6(1):135-51, 2010
                                                                              25. Chang JM et al: Does ultrasound-guided directional vacuum-assisted removal help eliminate abnormal nipple discharge in patients with benign intraductal single mass? Korean J Radiol. 10(6):575-80, 2009
                                                                              26. Kim SH et al: Galactography acquired with digital mammography in patients with nipple discharge: a retrospective analysis. Arch Gynecol Obstet. 280(2):217-22, 2009
                                                                              27. Maxwell AJ: Ultrasound-guided vacuum-assisted excision of breast papillomas: review of 6-years experience. Clin Radiol. 64(8):801-6, 2009
                                                                              28. Nicholson BT et al: Nipple-areolar complex: normal anatomy and benign and malignant processes. Radiographics. 29(2):509-23, 2009
                                                                              29. Tokuda Y et al: Evaluation of suspicious nipple discharge by magnetic resonance mammography based on breast imaging reporting and data system magnetic resonance imaging descriptors. J Comput Assist Tomogr. 33(1):58-62, 2009
                                                                              30. Da Costa D et al: Common and unusual diseases of the nipple-areolar complex. Radiographics. 27 Suppl 1():S65-77, 2007
                                                                              31. Hirose M et al: MR ductography: comparison with conventional ductography as a diagnostic method in patients with nipple discharge. Radiographics. 27 Suppl 1:S183-96, 2007
                                                                              32. Morrogh M et al: The predictive value of ductography and magnetic resonance imaging in the management of nipple discharge. Ann Surg Oncol. 14(12):3369-77, 2007
                                                                              33. Rissanen T et al: Breast sonography in localizing the cause of nipple discharge: comparison with galactography in 52 patients. J Ultrasound Med. 26(8):1031-9, 2007
                                                                              34. Escobar PF et al: The clinical applications of mammary ductoscopy. Am J Surg. 191(2):211-5, 2006
                                                                              35. Yang WT et al: Sonographic, mammographic, and histopathologic correlation of symptomatic ductal carcinoma in situ. AJR Am J Roentgenol. 182(1):101-10, 2004
                                                                              36. Daniel BL et al: Magnetic resonance imaging of intraductal papilloma of the breast. Magn Reson Imaging. 21(8):887-92, 2003
                                                                              37. Dennis MA et al: Incidental treatment of nipple discharge caused by benign intraductal papilloma through diagnostic Mammotome biopsy. AJR Am J Roentgenol. 174(5):1263-8, 2000
                                                                              38. Orel SG et al: MR imaging in patients with nipple discharge: initial experience. Radiology. 216(1):248-54, 2000
                                                                              39. Sickles EA: Galactography and other imaging investigations of nipple discharge. Lancet. 356(9242):1622-3, 2000
                                                                              40. Hild F et al: Ductal orientated sonography improves the diagnosis of pathological nipple discharge of the female breast compared with galactography. Eur J Cancer Prev. 7 Suppl 1:S57-62, 1998
                                                                              41. Cardenosa G et al: Ductography of the breast: technique and findings. AJR Am J Roentgenol. 162(5):1081-7, 1994
                                                                              42. Tabár L et al: Galactography: the diagnostic procedure of choice for nipple discharge. Radiology. 149(1):31-8, 1983