Nipple Discharge: Current Clinical and Imaging Evaluation
Dipti Gupta, MD1, Ellen B. Mendelson, MD, Ingolf Karst, MD, PhD
Breast Imaging · Review
Keywords
central duct excision, ductography, nipple
discharge, pathologic discharge, physiolog-
ic discharge
Submitted: Jul 16, 2019
Revision requested: Aug 10, 2019
Revision received: Sep 18, 2019
Accepted: May 15, 2020
First published online: Dec 9, 2020
The authors declare that they have no
disclosures relevant to the subject matter of
American Journal of Roentgenology 2021.216:330-339.
this article.
Gupta et al.
Nipple Discharge
Breast Imaging
Review
Gupta D, Mendelson EB, Karst I
doi.org/10.2214/AJR.19.22025
AJR 2021; 216:330–339
ISSN-L 0361–803X/21/2162–330
© American Roentgen Ray Society
330 | www.ajronline.org
OBJECTIVE. Nipple discharge is a common complaint that is first evaluated with
clinical assessment. Physiologic discharge does not require imaging other than routine
screening mammography. Initial evaluation of pathologic nipple discharge involves
mammography and ultrasound. evaluation of pathologic nipple discharge involves
mammography and ultrasound. Because of its high sensitivity in detecting breast ma-
lignancy and its biopsy capability, MRI is increasingly used in lieu of ductography.
CONCLUSION. The problem-solving algorithm for evaluating suspicious nipple
discharge is evolving. When diagnostic imaging for evaluation of pathologic nipple
discharge is negative, management is based on clinical suspicion. If additional im-
aging is warranted, MRI is preferred because of its increased sensitivity, specificity,
and patient comfort. Although central duct excision is the current standard for eval-
uation of malignancy in patients with pathologic nipple discharge, studies suggest
that, given the high negative predictive value of MRI, surveillance may be a reason-
able alternative to surgery.
Nipple discharge accounts for 2–5% of medical visits among women and is the pre-
senting feature of breast cancer in 5–12% of women [1]. Nipple discharge involves direct
drainage from the ducts due to excess secretions, which may be caused by intraductal le-
sions that partially interfere with drainage.
Evaluation of nipple discharge begins with clinical assessment. The patient’s history
and physical examination findings can help differentiate normally occurring physiologic
discharge from benign and malignant pathologic discharge. Diagnostic breast imaging
evaluation is not necessary for patients with clinical features of physiologic discharge but
is required for patients with suspicious discharge. Mammography and retroareolar ultra-
sound (US) are first-line examinations when imaging is indicated [2].
The problem-solving algorithm for evaluating suspicious nipple discharge is evolving.
Historically, when mammography and US results were negative, ductography, central
duct excision, or both were standard. However, advances in breast imaging technology
have led to a preference for less invasive procedures and a need to reevaluate manage-
ment of nipple discharge [1, 3–5].
Clinical Evaluation of Nipple Discharge
Physiologic Nonpathologic Discharge
Physiologic discharge may be yellow, green, or white. It is typically bilateral, and non-
spontaneous, and occurs in multiple ducts [6–8]. Many women can express discharge
during reproductive years. Galactorrhea is milky nipple discharge unrelated to the nor-
mal milk production of breastfeeding that may occur 1 year or longer after lactation has
ceased. Colostrum, which is a yellowish-clear and sticky discharge, is also considered
physiologic during the third trimester of pregnancy. In patients without a history of preg-
nancy and lactation, galactorrhea is most commonly caused by hyperprolactinemia and
may indicate an endocrinopathy [1]. Commonly prescribed medications such as antide-
pressants, antipsychotics, and oral contraceptives can also cause galactorrhea. In pre-
menopausal women, galactorrhea accompanied by amenorrhea and relative infertility
can suggest a pituitary microadenoma [9] (Fig. 1).
Duct ectasia is nonspecific dilatation, greater than 3 mm in diameter, of one or more
ducts [10]. Mild duct ectasia is a manifestation of normal involution of the breast that oc-
curs with aging [11]. When stagnant secretions accumulate in dilated ducts, the r­esult
All authors: Lynn Sage Comprehensive Breast Center, Prentice Hospital, Northwestern Medicine, 250 E Superior St,
1
Chicago, IL 60611. Address correspondence to D. Gupta (dipti.gupta@nm.org).
AJR:216, February 2021
 Nipple Discharge

B
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C D
Fig. 1—57-year-old woman with history of bilateral milky nipple discharge because of known pituitary microadenoma who presented for evaluation of right
retroareolar redness and swelling.
A and B, Retroareolar ultrasound images of right (A) and left (B) breasts show extensive bilateral symmetric duct ectasia with echogenic debris (arrows) and no
evidence of abscess.
C, Axial T2-weighted MR image shows ducts filled with fatty debris from milk products. Volume loss and distortion (arrow) from prior surgical incision and drainage are
seen in right periareolar area.
D, Sagittal T2-weighted MR image of right breast shows ducts filled with low-signal-intensity fatty debris (arrow).

may be a thick, creamy discharge of off-white, gray, green, or
brown color.
Lactating women can experience blocked ducts due to stasis of
milk. A persistent buildup of milk without release can result in mas-
titis, which may progress to abscess formation.
When medical history and physical examination suggest phys-
iologic discharge, the American College of Radiology Appropri-
ateness Criteria recommend routine screening mammography
[2]. However, in an online survey of U.S. radiologists, Patel et al.
[12] found significant variability in the choice of imaging modality
for evaluation of nipple discharge. These authors found that non-
academic breast imaging radiologists and those who read breast
images less than 50% of their clinical time were more likely to rec-
ommend diagnostic mammography with or without US for phys-
iologic nipple discharge [12].
Benign and Malignant Pathologic Discharge
Pathologic nipple discharge resulting from both benign and
malignant causes tends to occur unilaterally and spontaneous-
ly from a single duct orifice and is usually clear or blood-stained.
Fecal occult blood testing of the discharge is not necessary, be-
cause both serous and blood-tinged discharge may be associat-
ed with malignancy [13]. Cytologic assessment of the discharge is
not recommended because it is neither sensitive nor specific and
adds to the cost of the evaluation [14, 15].
Patient demographics can help determine the degree of sus-
picion regarding pathologic nipple discharge. For example, the
risk of underlying breast malignancy in women with nipple dis-
charge increases with age [8, 16–18]. Seltzer et al. [19] found that
only 3% of women with breast cancer who were younger than 40
years old presented with nipple discharge as their only symptom,

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 Gupta et al.
A B
Fig. 2—42-year-old woman with spontaneous bloody discharge from left nipple.
A, Gray-scale ultrasound image of subareolar region of left breast shows intraductal hypoechoic mass (arrows).
B, Color Doppler ultrasound image shows ample flow within mass. Follow-up ultrasound-guided biopsy indicated intraductal papilloma.
American Journal of Roentgenology 2021.216:330-339.
Fig. 3—42-year-old woman with previously diagnosed multiple peripheral
papillomas who presented for follow-up MRI evaluation. Axial contrast-
enhanced subtraction maximum-intensity-projection breast MR image shows
numerous bilateral enhancing masses (arrows), which had remained stable
since prior MRI examinations. Previous biopsy of two masses in left breast and
one mass in right breast had led to diagnosis of papilloma.
whereas 32% of women with breast cancer who were 60 years old
or more had nipple discharge as the presenting symptom.
Any nipple discharge associated with a palpable abnormality
or new nipple inversion warrants diagnostic imaging [20]. Also,
nipple discharge in a male patient is always suspicious. Although
discharge is uncommon in men, it is associated with breast can-
cer in 23–57% of cases [21, 22].
Papillomas are the most common cause of pathologic nip-
ple discharge, accounting for 35–58% of cases [23, 24]. They
can be classified as solitary intraductal or multiple peripheral
papillomas (Figs. 2 and 3). Papillomas causing nipple discharge
are excised. Surgical excision of papillomas with atypia is wide-
ly accepted with the upgrade rate to malignancy on excisional
biopsy ranging between 21–38% [25–29]. The management of
asymptomatic papillomas without atypia is controversial, with
upgrade rate to malignancy ranging between 2–12% [25, 29–
31]. Although some physicians still recommend excision of all
papillomas, observation of asymptomatic papillomas is increas-
ingly suggested when radiologic and histopathologic findings
are in agreement [27, 31–33].
332
At times, processes thought to be physiologic may overlap
with pathologic causes. The second most common cause of
pathologic discharge is duct ectasia, which accounts for 17–36%
of cases [23, 24]. Duct ectasia can cause both physiologic (bilat-
eral yellow or brown) and pathologic (unilateral clear or bloody)
discharge. Imaging features of nonphysiologic duct ectasia that
may indicate malignancy include irregularity of the duct margin,
a peripherally dilated duct, focal wall thickening, and adjacent
hypoechoic tissue that may represent a mass [10].
The combination of a postoperative fluid collection in the first
few years after breast conservation therapy and lactiferous ducts
may result in serous or serosanguineous discharge. Patients may
also note bloody nipple discharge after a needle biopsy of the
retroareolar region. Informing patients of this expected sequela
of retroareolar biopsy at the time of informed consent would pre-
vent them from becoming alarmed when discharge occurs.
Cancer is found in 5–15% of patients with pathologic nipple
discharge, the most common type being ductal carcinoma in situ
(DCIS) [34–36]. Up to 12% of patients with DCIS present with nip-
ple discharge [37]. Several studies have found that the rate of ma-
lignancy increases when a palpable abnormality or radiographic
abnormality is associated with the discharge [6, 38].
Imaging Evaluation of Pathologic Nipple Discharge
Mammography
Diagnostic breast imaging, including mammography and ret-
roareolar breast US, is the first step in evaluation of pathologic
nipple discharge for women who are 30 years old and older [2,
6, 13, 34]. Mammography may be complementary to US in wom-
en under 30 years old if they are BRCA positive or have another
gene mutation predisposing them to breast cancer [2]. Addition-
ally, according to the American College of Radiology Appropri-
ateness Criteria, mammography should be performed initially for
men 25 years old or older with nipple discharge, with US added
as indicated [2].
Despite having low sensitivity (7–26%) for detecting malignant
and high-risk lesions as the cause of nipple discharge, mammog-
raphy still plays an important role in breast imaging [24, 34, 36].
Because DCIS is the malignancy most commonly associated with
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 Nipple Discharge
Fig. 4—60-year-old woman with bloody discharge from right nipple.
A, Craniocaudal mammography image shows area of architectural distortion (arrow) in right retroareolar
region of breast.
B and C, Radial (B) and antiradial (C) targeted breast ultrasound images show irregular hypoechoic mass
(arrows) in area of distortion. Ultrasound-guided core needle biopsy yielded grade 2 invasive ductal
carcinoma.
American Journal of Roentgenology 2021.216:330-339.
pathologic nipple discharge, mammograms must be carefully eval-
uated for suspicious calcifications. Underlying malignancy may also
present as a mass or architectural distortion on mammography
(Fig. 4). The presence of a new solitary dilated duct on mammog-
raphy is considered suspicious, is classified as BI-RADS category 4,
and is associated with a malignancy rate of 6–24% [39, 40].
Bilateral mammography, with or without digital breast tomo-
synthesis (DBT), should also be performed in women younger than
30 years old who have suspicious masses on US. This is especially
important when calcifications are seen in the surrounding tissues
on US or in the mass or the ducts, because the extent, pattern, and
morphology of calcifications are best seen on mammograms [41–
43]. To our knowledge, evidence of a specific role for DBT in the
evaluation of nipple discharge is not present in the literature.
Ultrasound
Mammography and US are complementary examinations in
the initial evaluation of pathologic nipple discharge. The sensi-
tivity of US alone in detecting underlying malignancy in patients
with pathologic nipple discharge is 56–80%, which is higher than
mammography [2]. In one study, US examination in patients with
pathologic discharge but negative mammographic imaging
led to detection of underlying malignancy in 15% of the cases
[44]. Retroareolar lesions causing discharge are often intraductal
masses that are noncalcified, although occasionally a few echo-
genic foci appear as calcifications. US can depict ductal abnor-
malities smaller than a centimeter and associated ductal chang-
es that are occult on mammography, especially in women with
dense breast tissue [45].
When an intraductal mass is identified, its size, clockface posi-
tion, and distance from the nipple should be reported along with
the distance between the mass and the nipple base (Fig. 5). A di-
AJR:216, February 2021
B C
lated duct should be imaged as peripherally as possible to assess
the extent of involvement.
US is an important tool not only for the initial evaluation of
duct discharge but also to guide biopsy for obtaining a diagnosis
and, if needed, guide localization for surgical excision.
Ductography
Traditionally, ductography has been the imaging test of choice
when mammography and US findings are negative for patholog-
ic nipple discharge. In the setting of negative findings with con-
ventional imaging, ductography can localize 76% of otherwise
occult high-risk and malignant lesions [46].
Ductography is performed with a 30-gauge blunt-tipped
straight or angled cannula. First, the nipple is gently cleansed us-
ing an alcohol swab. A warming pad may be used to relax the
tissues and facilitate cannulation. A small amount of discharge is
elicited by squeezing the nipple or applying pressure at the trig-
ger point. Once the discharging pore is identified, the tip of the
cannula is placed on the orifice, where it should pass easily into
the duct. Then, 1–3 mL of nonionic iodinated contrast medium
is slowly administered, and two orthogonal views are obtained,
with additional views obtained as indicated [47]. Ductography
findings that suggest a malignancy or a papillary lesion include
an intraluminal mass, partial or complete duct obstruction, duct
expansion, or duct wall irregularity [48] (Fig. 6).
In a retrospective study of 168 patients with pathologic nipple
discharge, Adepoju et al. [49] reported a sensitivity of 75% and a
specificity of 49% for the detection of malignancy with ductogra-
phy (Table 1). Cabioglu et al. [38] reported an even higher sensi-
tivity (100%) of ductography for detecting malignancy in anoth-
er retrospective study of 147 patients. However, given that only
three cases had cancer, the 95% CI was wide at 75.3–100% [38].
333
 Gupta et al.

A B
Fig. 5—Reporting intraductal masses found on examination of 42-year-old woman with spontaneous clear discharge from right nipple.
A, Radial targeted breast ultrasound image shows intraductal mass (white arrow) at 9-o’clock position in retroareolar region of right breast and portion of duct (black
arrow) from nipple (blue arrow) to mass.
B, Radial targeted breast ultrasound image shows length of duct from nipple base to mass (11.25 mm, long solid line) and length of duct segment affected by mass
(4.50 mm, short solid line). Report of this examination should include clockface position of intraductal mass, distance of mass from nipple, and size of intraductal mass.
Ultrasound-guided biopsy yielded intraductal papilloma.
American Journal of Roentgenology 2021.216:330-339.

TABLE 1: Utility of Breast Imaging Studies in 168

Patients With Spontaneous Single-Duct
Discharge
Performance
Measure Mammography Ultrasound Ductography
Sensitivity 10 36 75
Fig. 6—36-year-
Specificity 94 68 49
old woman
with recurrent PPV 18 14 18
spontaneous
clear discharge NPV 88 89 93
from left nipple. Note—Data were originally reported by Adepoju et al. [49]. Cancer was present
Mammography and in 20 patients. Values are percentages. PPV = positive predictive value, NPV =
targeted retroareolar negative predictive value.
ultrasound results
(not shown) were
negative. Discharging TABLE 2: Predictive Value of Ductography and MRI
duct was cannulated in 186 Patients With Suspicious Nipple
for ductography, and
1.5 mL of contrast
Discharge
medium was Ductography
injected. Magnified
mediolateral Parameter (n = 163) MRI (n = 52)
mammogram of No. of cancers detected 12 7
left breast shows
abrupt cutoff (arrow). No. of high-risk lesions detected 7 3
Intraductal papilloma
was confirmed on Positive predictive value (%) 19 56
excision. Negative predictive value (%) 63 87
Note—Data were originally reported by Morrogh et al. [52].

Ductography is an unreliable predictor of the benignancy or
malignancy of an intraductal abnormality [50–52]. In a retrospec-
tive study of 186 patients with negative conventional imaging re-
sults, Morrogh et al. [52] reported a positive predictive value of
19% and a negative predictive value (NPV) of 63% for ductography
when detecting cancers and high-risk lesions (Table 2). The sensi-
tivity and specificity were 75% and 11%, respectively. Because an
underlying malignancy was found in 10% of patients with a nega-
tive ductogram, the authors concluded that a negative ductogram
does not exclude malignancy or a high-risk lesion [52].
Ductography can be a technically challenging procedure and
uncomfortable for patients. The rate of incomplete or failed duc-
tograms may be as high as 15–23% [53]. Discharge must be pres-
ent on the day of the procedure for successful identification and
cannulation of the discharging duct. Additionally, a lesion proxi-
mal to the discharging duct may prevent cannulation of the duct,

334 AJR:216, February 2021

 Nipple Discharge

or duct perforation and contrast medium extravasation may oc-
cur [54]. Given the procedural limitations of ductography and the
increasing accessibility of MRI, proceeding directly to MRI for di-
agnosis has become a more common practice.
Breast MRI
Conventional mammography and US findings may be nega-
tive in up to half of patients with pathologic nipple discharge [53].
A negative ductogram does not rule out an underlying malignan-
cy, and a positive ductogram cannot reliably distinguish between
a benign and malignant abnormality. Given its high NPV, MRI is
emerging as the next step in the management of patients with
nipple discharge and negative imaging findings. MRI also allows
visualization of lesions in the peripheral ducts that are not clearly
visualized on US and not included in a central duct excision.
Normal-caliber ducts are not apparent on breast MRI. The lu-
mina of dilated ducts, however, are visible on T1- and T2-weight-
ed sequences as high-intensity branching tubular structures (Fig.
7). In these cases, the contrast-enhanced subtraction images can
show enhancement of the obstructed duct wall or lumen, sug-
American Journal of Roentgenology 2021.216:330-339.
gesting a proliferative, inflammatory, or neoplastic process [10].
Malignant lesions may present as enhancing intraductal masses
or nonmass enhancement in a ductal or segmental distribution.
Breast MRI is the most sensitive modality for detecting breast
cancer, with sensitivity ranging between 93% and 100% [2]. In a
retrospective study of 103 women who underwent MRI evalu-
ation for nipple discharge, the sensitivity and specificity of MRI
were 100% and 63%, respectively, and NPV was 100% [4]. Oth-
er studies have also reported high sensitivity and NPV of MRI for
nipple discharge [36, 52, 55–57] (Table 3).
Bahl et al. [58] performed a retrospective review of 118 women
who underwent MRI for nipple discharge after a negative or incon-
clusive mammogram. They found six cancers, three of which were
detected on MRI, yielding an MRI NPV of 96.2% for invasive and
in situ malignancy and 100% for invasive malignancy. Additionally,
three cancers without suspicious MRI findings were diagnosed on
surgical excision as grade 1 DCIS. Most false-negative malignan-
cies found on MRI are low-grade DCIS, as supported by Lubina et
al. [56]. They studied 50 women who underwent 3-T MRI after neg-
ative conventional imaging results and found eight cancers, yield-

A B C
Fig. 7—55-year-old woman with spontaneous clear discharge from left nipple.
A, Diagnostic ultrasound image showing dilated duct at 6-o’clock position in retroareolar region was interpreted as negative.
B, Axial contrast-enhanced subtracted T1-weighted MR image of left breast shows enhancing mass (arrow) at 6-o’clock position.
C, Axial T2-weighted MR image of left breast shows associated duct dilatation (arrow) posterior to mass. Peripheral location of mass in duct explains why only duct
dilatation is seen on ultrasound image in A. MRI-guided biopsy yielded intraductal papilloma.

TABLE 3: Reported Sensitivities of MRI for Detection of Breast Malignancy in Patients With
Nipple Discharge
First Author [Reference] Year of Publication No. of Cases No. of Malignancies Sensitivity for Cancer (%)
Zacharioudakis [70] 2019 82 14 86
Bahl [4] 2015 91 11 100
Lubina [56] 2015 50 8 75
van Gelder [59] 2015 111 5 40
Lorenzon [36] 2011 38 5 100
Morrogh [52] 2007 52 7 88
Nakahara [57] 2003 55 22 100

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 Gupta et al.
ing a sensitivity of 75%. Low-grade DCIS was diagnosed in two pa-
tients with false-negative MRI results [56]. Although most of these
studies were retrospective and relatively small, they found that
MRI is highly sensitive for detection of breast malignancy.
One outlier study found lower sensitivity of MRI compared
with other studies [4, 36, 46, 52, 56, 57]. Over a 5-year period, van
Gelder and colleagues [59] retrospectively reviewed 111 women
who underwent MRI for evaluation of unilateral bloody nipple
discharge. Eight additional cancers were detected, two by MRI
and six by duct excision, yielding an overall sensitivity of 40% for
MRI in detecting breast cancer. Malignancy was found exclusive-
ly by MRI in less than 2% of the cases, leading the authors to con-
clude that MRI had limited added value in the setting of negative
conventional imaging results. One possible explanation for the
lower sensitivity of MRI in this study compared with other studies
could be the overall low breast cancer incidence of 5%, the small
number of cases, and differences in diagnostic interpretation.
Unlike ductography, MRI can be combined with percutaneous
biopsy to determine preoperatively whether a lesion is benign
or malignant. A concordant benign biopsy finding can indicate
that surgery is not necessary. Conversely, if an MRI-guided biopsy
yields malignant histopathologic findings, preoperative localiza-
American Journal of Roentgenology 2021.216:330-339.
tion can guide definitive surgical management.
MRI Versus Ductography
Radiologists are performing fewer invasive procedures in an at-
tempt to promote patient comfort and decrease costs. Sialography
and venography have become less popular. Venography has been
replaced by venous duplex US studies, and CT angiography is in-
creasingly performed in lieu of conventional angiography.
An online survey of 177 German breast imaging centers found
that 13% do not perform any ductography examinations, and the
largest proportion (33%) perform a maximum of five ductography
examinations per year [60]. Of the centers surveyed, 70% do not
perform any ductography examinations or perform fewer than 10
per year. Despite the low usage, 56% of the respondents rated the
diagnostic potential of ductography as high or very high. Although
the respondents believed that ductography has potential, they do
not perform the examination. A similar trend has been seen at our
institution, where 12 ductography examinations were performed
in 2012 but only two were performed in 2017 (Fig. 8). The low num-
ber of ductography studies performed, even at academic institu-
tions, raises concerns about appropriate training of residents and
fellows and the quality of the examinations.
In a meta-analysis comparing the diagnostic accuracy of MRI
and ductography in women with pathologic nipple discharge,
Berger et al. [53] found the sensitivity and specificity of MRI to be
significantly higher than ductography. For the detection of any
kind of lesion, they found that the pooled sensitivity and spec-
ificity of ductography were 69% and 39%, respectively, and the
values for MRI were 92% and 76%, respectively. Furthermore, the
specificity of MRI for detection of breast cancer was 97%. In a pro-
spective study of 50 patients with nipple discharge, Lubina et al.
[56] compared MRI with ductography in patients who had nega-
tive conventional imaging results. Ductography was attempted
but could not be performed in 10 of 43 (23%) cases. The sensitivi-
ty of MRI versus ductography for detection of pathologic findings
was 95.7% versus 85.7%.
336
12
9
No. of Ductograms
6
3
0
2012 2013 2014 2015 2016 2017
Year
Fig. 8—Bar graph shows number of ductograms obtained over 6-year period
at one academic institution.
In contrast to ductography, which only identifies abnormalities
in the discharging duct, breast MRI can find additional cancers in
the ipsilateral and contralateral breast (Fig. 9). Several addition-
al studies have also supported the high diagnostic performance
of breast MRI [4, 36, 52]. The overall improved accuracy of MRI,
the ability to obtain biopsy samples when MRI findings are in-
determinate, and the reliability that the examination will be per-
formed successfully have led to an increasing preference for MRI
compared with ductography for evaluation of pathologic nipple
discharge when first-line imaging results are negative.
Future Research
Previous studies have described MRI techniques involving the
cannulation and injection of gadolinium into the discharging
duct, but these techniques result in the same level of patient dis-
comfort as conventional ductography and may fail for the same
reasons [61, 62]. Instead, a new area of research involves MR duc-
tography without gadolinium administration. With conventional
ductography, the offending duct is injected with contrast mate-
rial and assessed for filling defects. On MRI, even without con-
trast administration, the discharging duct is often dilated, filled
with fluid, and visualized on T2-weighted sequences. Similar to
conventional ductography, MR ductography can identify an in-
traluminal filling defect, duct wall irregularity, and ductal ob-
struction [63]. In a feasibility study involving 21 patients, the MR
ductography sequences did not perform well enough to replace
conventional ductography [64]. Further refining the T2-weighted
sequence and the improved signal-to-noise ratio of 3-T magnets
may prove to be a fruitful area of research.
The combination of DBT imaging and conventional ductogra-
phy also merits investigation. A small study of five patients found
that tomosynthesis imaging after ductography may be a useful
complementary procedure [65]. Others have also suggested that
adding DBT to conventional ductography may improve the inter-
pretation of the ductogram by reducing overlap [66].
Surgical Management of Nipple Discharge Versus
Follow-Up Imaging
Central duct excision has been considered the standard for ex-
cluding malignancy in patients with pathologic nipple discharge
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 Nipple Discharge
Fig. 9—51-year-old woman with history of
intermittent bloody discharge from right nipple.
Mammography result was negative. Previous
ultrasound study (not shown) depicted 0.5-cm mass
in right breast at 1-o’clock position; histopathology
revealed intraductal papilloma. Breast MRI was
performed because of family history of breast cancer.
A and B, Axial contrast-enhanced subtraction
maximum-intensity-projection (A) and axial contrast-
enhanced (B) images of right breast show 5-cm
area of nonmass enhancement (arrows) in upper
outer quadrant. MRI-guided biopsy yielded ductal
carcinoma in situ.
American Journal of Roentgenology 2021.216:330-339.
and negative imaging findings. Potential complications of central
duct excision include interruption of the neurovascular supply to
the nipple-areolar complex, loss of sensation to the nipple, and
(rarely) partial necrosis of the nipple or areola [67, 68]. In addition,
duct excision could limit the ability to breastfeed in women of
childbearing age.
The surgical literature indicates a reliance on duct excision for
diagnosis. Given the high NPV of imaging and the low incidence of
malignancy even with pathologic nipple discharge, imaging stud-
ies in favor of a watch-and-wait approach are increasing. In a sub-
set of 142 patients with pathologic nipple discharge evaluated with
mammography, US, and ductography, malignancy was identified
in seven patients, six of whom had an abnormal mammography
or US finding. Given the low rate of malignancy with negative con-
ventional imaging findings, the authors suggested a selective ap-
proach to duct excision in women who are amenable to follow-up
[5]. This approach is also suggested in a previously proposed algo-
rithm in which patients with pathologic nipple discharge and neg-
ative conventional imaging result are counseled on the low risk of
underlying malignancy and are offered either imaging follow-up
every 6 months for 1–2 years or duct excision [3, 13].
Sanders and Daigle [69] examined the role of breast MRI in
lieu of duct excision in a retrospective review of patients with
bloody nipple discharge and negative conventional imaging
findings who underwent duct excision compared with those
who underwent MRI before excision. Of 85 patients who un-
derwent MRI before excision, eight malignancies were identi-
fied, seven of which were seen on MRI. Given the NPV of 98.2%
for MRI, the authors suggested that a negative MRI can obviate
central duct excision in most patients unless overriding clinical
considerations are present [69].
Despite being considered the reference standard, central duct ex-
cision is unlikely to detect all malignancies. Duct excision may fail to
identify the lesion causing the discharge, especially if the lesion is
far away from the nipple [69]. The excision may not include the en-
AJR:216, February 2021
A B
tire malignancy, and a reexcision may be needed to achieve nega-
tive margins. Additionally, unlike MRI, which can detect additional
malignancies in the ipsilateral and contralateral breast, duct excision
can only identify a malignancy in the retroareolar ducts. MRI is pre-
ferred to duct excision in women with average risk of cancer, given
that the sensitivity of MRI for breast malignancy is extremely high
and the few false-negatives are usually low-grade DCIS.
Conclusion
Breast imaging radiologists are an integral part of the medical
team evaluating nipple discharge. Patients and referring physi-
cians rely on us not only to interpret multimodality radiologic ex-
aminations but also to provide comprehensive breast care. With
a complaint such as nipple discharge, the cause of which may
reflect patient age, stage of life, and physiologic status, prob-
lem-solving includes obtaining a detailed history, performing a
physical examination, choosing the appropriate radiologic exam-
inations to perform, interpreting the examination findings, and
recommending the next steps for management.
The first step in the management of nipple discharge depends
on the characteristics of the discharge and assessing wheth-
er the discharge is physiologic or pathologic. Physiologic dis-
charge does not require imaging evaluation other than routine
screening mammography. Pathologic discharge requires evalu-
ation with diagnostic mammography and US of the retroareolar
breast. If the mammography and US findings are negative, addi-
tional management is based on clinical suspicion. The incidence
of malignancy is low even in patients with pathologic nipple dis-
charge. If additional imaging is warranted, ductography or breast
MRI may be performed, although MRI is preferred because of its
increased sensitivity, specificity, and patient comfort. Although
central duct excision is the current standard for evaluation of ma-
lignancy in patients with pathologic nipple discharge, studies
suggest that, given the high NPV of MRI, surveillance is a reason-
able alternative to surgery.
337
 Gupta et al.
Acknowledgment
We thank Nadine Gottschalk for her assistance in preparation
of the images.
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