ACR Appropriateness Criteria® Evaluation of Nipple Discharge: 2022 Update

The type of nipple discharge dictates the appropriate imaging study. Physiologic nipple discharge is common and does not require diagnostic imaging. Pathologic nipple discharge in women, men, and transgender patients necessitates breast imaging. Evidence-based guidelines were used to evaluate breast imaging modalities for appropriateness based on patient age and gender. For an adult female or male 40 years of age or greater, mammography or digital breast tomosynthesis (DBT) is performed initially. Breast ultrasound is usually performed at the same time with rare exception. For males or females 30 to 39 years of age, mammography/DBT or breast ultrasound is performed based on institutional preference and individual patient considerations. For young women less than 30 years of age, ultrasound is performed first with mammography/DBT added if there are suspicious findings or if the patient is at elevated lifetime risk for developing breast cancer. There is a high incidence of breast cancer in males with pathologic discharge. Men 25 years and older should be evaluated using mammography/DBT and ultrasound added when indicted. In transfeminine (male-to-female) patients, mammography/DBT and ultrasound are useful due to the increased incidence of breast cancer. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

ACR Appropriateness Criteria® Evaluation of Nipple Discharge

Appropriate imaging evaluation of nipple discharge depends the nature of the discharge. Imaging is not indicated for women with physiologic nipple discharge. For evaluation of pathologic nipple discharge, multiple breast imaging modalities are rated for evidence-based appropriateness under various scenarios. For women age 40 or older, mammography or digital breast tomosynthesis (DBT) should be the initial examination. Ultrasound is usually added as a complementary examination, with some exceptions. For women age 30 to 39, either mammogram or ultrasound may be used as the initial examination on the basis of institutional preference. For women age 30 or younger, ultrasound should be the initial examination, with mammography/DBT added when ultrasound shows suspicious findings or if the patient is predisposed to developing breast cancer. For men age 25 or older, mammography/DBT should be performed initially, with ultrasound added as indicated, given the high incidence of breast cancer in men with pathologic nipple discharge. Although MRI and ductography are not usually appropriate as initial examinations, each may be useful when the initial standard imaging evaluation is negative. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

A look into the ductoscope: its role in pathologic nipple discharge

OBJECTIVE

Mammary ductoscopy allows direct visualization of the ductal system and a method for directed excision and pathologic diagnosis. We reviewed our experience with mammary ductoscopy in the evaluation of pathologic nipple discharge.

METHODS

We reviewed all patients who underwent ductoscopy for pathologic nipple discharge at our institution from 2006-2010. All procedures were performed by a single surgeon. Data included patient and imaging characteristics, indications, operative findings, and pathologic outcomes. Descriptive statistics were used for data summary.

RESULTS

During the study period, 121 patients underwent ductoscopy and directed duct excision for pathologic nipple discharge, including 66 (55%) with bloody discharge. Breast imaging [mammography, ultrasound, and/or magnetic resonance imaging (MRI)] revealed BIRADS category I/II/III findings in 112 (93%), BIRADS category IV findings in 6 (5%), and was unknown in 3 (2%) patients. Final pathology revealed papillomas in 64 (53%) patients, duct ectasia and associated benign findings in 48 (40%) patients, ductal carcinoma in situ (DCIS) in 7 (6%) patients, and atypical ductal hyperplasia in 2 (1%) patients. None of the patients with DCIS underwent preductoscopy MRI, but all had BIRADS category I/II/III breast imaging. The extent of DCIS identified by ductoscopy and subsequent surgical excision ranged from <1 cm to 10 cm (median 3 cm).

CONCLUSIONS

The majority of patients with pathologic nipple discharge have benign nonproliferative findings or benign papillomas. Although atypia and malignancy were diagnosed in only 7% of patients who underwent ductoscopy for pathologic nipple discharge, there were no routine imaging findings indicative of these diagnoses preoperatively.