ACR Appropriateness Criteria ® Evaluation of Nipple Discharge

Abstract

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.

Is Ductography Still Warranted in the 21st century?

“…Despite low mammographic sensitivity, our findings support the ACR Appropriateness Criteria for the evaluation of pathologic nipple discharge, which advocates that imaging work up should start with mammography in women aged 30 years and older . In our study, one micropapillary DCIS was identified only on mammography as suspicious calcifications, despite negative ductography, ultrasound, and DCE‐MRI work up.…”

“…According to the American College of Radiology's (ACR) Appropriateness Criteria, diagnostic mammography is the standard initial step in evaluating pathologic nipple discharge in patients 30 years of age or older . Since mammography has a low sensitivity (7%‐10%) for the detection of malignancy in this setting, ultrasound complements diagnostic evaluation by allowing for detailed evaluation of the sub‐areolar ducts and providing guidance for subsequent needle biopsy, if needed . In the setting of a negative mammogram and ultrasound, ductography or dynamic contrast‐enhanced (DCE) magnetic resonance imaging (MRI) may be performed to further evaluate the etiology of pathologic nipple discharge.…”

Interventional Ductoscopy as an Alternative for Major Duct Excision or Microdochectomy in Women Suffering Pathologic Nipple Discharge: A Single-center Experience

“…Furthermore, outcome of an MRI has little effect on therapeutic choice for PND because a (surgical) biopsy is usually needed when a possible causing lesion is found. 12,14,34 Sensitivity of MRI varies, when ultrasound and mammography are negative, from 40% to 86%. The specificity of MRI to rule out breast cancer in patients with PND also ranges from 76% to 99%.…”

“…11,12 Therefore, the value of MRI is limited in patients with PND, and core needle biopsy or surgical excision is still indicated when MRI shows a suspicious lesion. 13,14 Because PND is regarded as a possible sign of breast cancer, and standard radiologic imaging often fails to reveal the underlying cause, most women suffering PND undergo surgical procedures, such as microdochectomy or major duct excision, to rule out malignancy. 8,10,11 These surgical procedures are performed under general anesthesia and are associated with scarring, which may result in breastfeeding difficulties in fertile women.…”

Copious watery nipple discharge caused by a discontinuous ventriculoperitoneal shunt

“…We present a case of a VP shunt malfunction following a fall resulting in copious clear nipple discharge. In a patient over 40 presenting with unilateral spontaneous nipple discharge, the American College of Radiology Appropriateness Criteria recommends initial evaluation with mammography and ultrasound . If an underlying cause of nipple discharge is not identified with these modalities, breast MRI or ductography may be indicated .…”