Nipple Discharge Overview
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Our next symptom is nipple discharge.
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And again, there's an ACR appropriateness
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criteria for evaluation of nipple discharge.
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So I advise you to check that out
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in JACR and on the ACR website.
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Nipple discharge can be physiological.
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Usually, when it's physiological, it's bilateral
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and coming from multiple duct orifices.
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It can be white, yellow, or green.
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Pathological nipple discharge is usually clear
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or bloody and, um, generally unilateral coming
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from a single duct opening and spontaneous.
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The ACR recommends that for physiological
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nipple discharge, um, the referring
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provider should do a clinical evaluation,
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but really no imaging is indicated.
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For pathological nipple discharge,
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that's the clear or bloody unilateral discharge.
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If the patient's under age 30,
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ultrasound is recommended first with mammography
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at the radiologist's discretion.
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Again, we have that intermediate age,
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age 30 to 39, where ultrasound and mammogram,
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as the first test, both get equal.
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Ratings and then age 40 and up.
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It's recommended to start with a
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mammogram and then perform an ultrasound.
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Our protocol for under age 30, we'll do the
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ultrasound first and then age 30 and up.
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We'll start with the mammogram
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and then go to ultrasound.
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So it's just that age 30 to 39
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where we've decided for our group.
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It makes more sense to start with the mammogram.
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And then go to ultrasound.
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Uh, we'll do full bilateral CC and MLO
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views, and we perform retroareolar spot
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magnification views with the nipple in
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profile in both the CC and lateral projection.
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Sometimes that helps us with, um,
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masses right behind the nipple and
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calcifications behind the nipple.
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And then we do an ultrasound of the retroareolar
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and periareolar breast, paying specific
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attention to the, um, subareolar ducts.
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And, um, trying to figure out if
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there's a mass inside the duct that
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may be causing the patient's discharge.
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There are a few different causes of discharge.
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I mean, obviously, it occurs
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physiologically, but then for these, um,
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pathological, uh, nipple discharge, it can
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be related to intraductal papillomas.
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That's a very frequent cause.
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Sometimes just duct ectasia
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or wide ducts can cause it.
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And then malignancy, um, um, is
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reported in 5 to 21 percent of cases.
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So that's a pretty wide range.
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But we know that the risk of
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malignancy increases with age.
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So it's really only about 3 percent at age 40,
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but 32 percent if the patient's over age 60.
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So we want to be careful about this,
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especially in our older patient population.
Lisa Ann Mullen, MD
Assistant Professor; Breast Imaging Fellowship Director
Johns Hopkins Medicine
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