Book
NIPPLE DISCHARGE
- Executive Summary
The scope of this guideline is concerned with imaging of female patients in the adult age group >18 years presenting with nipple discharge either physiologic or pathologic.
The recommendations according to the type of nipple discharge as well as the age group of the patient are as follows:
ADULT FEMALE, PHYSIOLOGIC NIPPLE DISCHARGE:
1. Digital Mammography:
If clinical findings are consistent with physiologic nipple discharge, routine screening mammography for patients 40 years of age or older is recommended. No further radiologic investigation is required and diagnostic breast imaging is unnecessary (3).
Strong recommendation
2. Image-guided Core Biopsy/ Fine Needle Aspiration:
We recommend against the use of image guided core biopsy or fine needle aspiration in these cases.
Strong recommendation
ADULT FEMALE, 40 YEARS OF AGE OR OLDER, PATHOLOGIC NIPPLE DISCHARGE:
1. Digital Mammography:
Mammography is the initial imaging modality in this age group. Both breasts should be imaged in two views; craniocaudal and mediolateral oblique views enabling the entire breast to be completely screened for any additional lesions. Additional mammographic views with spot compression and magnification are required for better evaluation of the retroareolar region when necessary (6).
Strong recommendation
2. Digital Breast Tomosynthesis:
It is recommended as an initial diagnostic tool if available. Many studies have proposed the use of DBT in assessing nipple discharge (7). It has also been proven that the sensitivity of DBT is higher than that of mammography with better detection rate and diagnosis of breast cancer.
Strong recommendation
3. Breast ultrasound:
Breast US is recommended as a complementary tool for mammography in initial evaluation and assessing extent of involvement.
US is also an important tool to guide for biopsy and localization for surgical excision.
Strong recommendation
4. MRI Breast:
MRI is not recommended as initial imaging for patients with pathologic nipple discharge. in patients with pathologic nipple discharge and negative mammography/ ultrasound, MRI is recommended to detect lesions of concern preoperatively. Imaging follow-up can be safely recommended for patients with normal MRI findings, thus avoiding unnecessary surgical duct excision (8).
Strong recommendation
5. Contrast enhanced mammography:
With CEM, lesions could be identified according to their density, morphologic as well as enhancement characteristics (9). It is currently being used for diagnostic purposes especially in dense breasts, preoperative evaluation, assessment of extent of disease and MRI contraindication. Ongoing studies also propose future directions in breast cancer screening (10). It may be considered in patients with pathologic nipple discharge and negative mammography/ ultrasound according to its availability.
Conditional recommendation
6. Image-Guided Core Biopsy:
Image-guided core needle biopsy is not recommended for initial evaluation of patients with pathologic nipple discharge.
Biopsy procedures can be guided by stereotactic mammography, contrast enhanced mammography, or US, depending on the imaging modality which best depicts the abnormality detected.
Vacuum-assisted core biopsy (VAB) is useful in complete sampling/ removing of small intraductal papillary lesions which may be therapeutic and can lead to cessation of nipple discharge in 90-97.2% of cases (11). Surgical major duct excision remains the gold standard for exclusion of malignancy in patients with unremarkable imaging.
Strong recommendation
7. Image-Guided Fine Needle Aspiration:
It is not recommended as the initial examination for evaluation of pathologic nipple discharge. Studies have shown that core needle biopsy is superior to fine needle aspiration (FNA) regarding accuracy and precise histological grading of breast cancer (12).
Conditional recommendation
ADULT FEMALE, 30 to 39 YEARS OF AGE, PATHOLOGIC NIPPLE DISCHARGE:
Same guidelines as adult female 40 years or older with the following consideration;
US is recommended as the initial imaging modality in this age group with the addition of mammography when necessary.
Strong recommendation
ADULT FEMALE, YOUNGER THAN 30 YEARS OF AGE, PATHOLOGIC NIPPLE DISCHARGE:
1. Breast ultrasound:
US is the initial imaging modality of choice in this age group.
Strong recommendation
2. Digital Mammography or Digital Breast Tomosynthesis:
Diagnostic mammography or DBT is beneficial if US shows a suspicious finding.
Strong recommendation
3. Contrast studies (contrast enhanced mammography/MRI):
Not recommended as initial imaging for patients with pathologic nipple discharge.
In women with dense breasts, CEM or contrast MRI should be recommended for proper staging and to exclude multicentricity/bilaterality.
Conditional recommendation
4. Image-guided Core Biopsy
If an imaging abnormality is seen, US can be used to guide biopsy.
Good practice statement
