Learning objectives
Discuss characteristics of physiologic and pathologic nipple discharge.
Review benign and malignant ductal pathologies that can cause nipple discharge including duct ectasia,
intraductal papillomas,
DCIS and invasive cancer.
Review diagnostic workup paradigm and management of pathologic nipple discharge according to age and gender as follows: males and females <30 years,
30-39 years,
>40 years.
Evaluate utility and accuracy of imaging modalities used in evaluation of nipple discharge including mammography and digital breast tomosynthesis,
ultrasound,and MRI.
Background
Nipple discharge is the third most common breast complaint after breast pain and breast mass.
It encompasses 5% percent of all breast symptoms with a prevalence of 4.8-7.4% [1].
Many lesions involving the nipple-areolar complex and the periareolar ducts can result in nipple discharge.
Physiologic nipple discharge is typically bilateral,
involves multiple ducts,
and is seen as white,
yellow,
or green in color.
Pathologic nipple discharge is unilateral,
involves a single duct,
is spontaneous,
and serous or blood stained in color.
Pathologic nipple discharge requires...
Findings and procedure details
Intraductal papillomas,
histologically characterized as epithelial proliferation on a fibrovascular stalk,
are the most common cause of pathologic nipple discharge,
seen in 35-48% of cases (figure 1 and 2).
They can present with serous or bloody nipple discharge and are historically considered high risk lesions,
with an upgrade risk of 3-14% at surgery.
Risk is higher if lesion is >1cm in size,
located >3m from the nipple,
and patient age is >50 years [1].
Decision to excise these lesions is variable by institution.
Duct ectasia...
Conclusion
In conclusion,
nipple discharge can be physiologic orpathologic.
Pathologic discharge can be due to malignant or benign causes.
Work up of nipple discharge depends on the patient's age,
with mammogram and ultrasound constitutingthe main initial work up andMRI used for problem solving.
References
1. Lee,
S.-J.,
et al.,
ACR Appropriateness Criteria® Evaluation of Nipple Discharge. Journal of the American College of Radiology,
2017.
14(5,
Supplement): p.
S138-S153.
2. Ferris-James,
D.M.,
et al.,
Imaging Approaches to Diagnosis and Management of Common Ductal Abnormalities. RadioGraphics,
2012.
32(4): p.
1009-1030.
3. Adusumilli,
S.,
E.S.
Siegelman,
and M.D.
Schnall,
MR Findings of Nipple Adenoma. American Journal of Roentgenology,
2002.
179(3): p.
803-804.
4. Mahoney,
M.C.
and A.D.
Ingram,
Breast Emergencies: Types,
Imaging Features,
and Management. American Journal of Roentgenology,
2014.
202(4): p....
