Nipple discharge: The state of the art

Abstract

Over 80% of females experience nipple discharge during their life. Differently from lactational (milk production) and physiological (white, green, or yellow), which are usually bilateral and involving multiple ducts, pathologic nipple discharge (PND) is a spontaneous commonly single-duct and unilateral, clear, serous, or bloody secretion. Mostly caused by intraductal papilloma(s) or ductal ectasia, in 5-33% of cases is due to an underlying malignancy. After clinical history and physical examination, mammography is the first step after 39, but its sensitivity is low (7–26%). Ultrasound shows higher sensitivity (63–100%). Nipple discharge cytology is limited by a false negative rate over 50%. Galactography is an invasive technique that may cause discomfort and pain; it can be performed only when the duct discharge is demonstrated at the time of the study, with incomplete/failed examination rate up to 15% and a difficult differentiation between malignant and benign lesions. Ductoscopy, performed under local anesthesia in outpatients, provides a direct visualization of intraductal lesions, allowing for directed excision and facilitating a targeted surgery. Its sensitivity reaches 94%; however, it is available in only few centers and most clinicians are unfamiliar with its use. PND has recently emerged as a new indication for contrast-enhanced breast MRI, showing sensitivity superior to galactography, with an overall sensitivity up to 96%, also allowing tailored surgery. Surgery no longer can be considered the standard approach to PND. We propose a state-of-the art flowchart for the management of nipple discharge, including ductoscopy and breast MRI as best options.

DBT-galactography: a promising tool for improving the diagnostic workup of nipple discharge

“…According to the patient age, clinical examination with mammography, US and cytological examination of the nipple discharge should be the first line diagnostic approaches. However, no general consensus exists in the medical literature, and cytological examination of nipple discharge has not been found to provide any significant complementary value [1,6]. In case of inconclusive mammographic or ultrasonography findings, a second line examination should be considered [17].…”

“…Although DBT-galactography could represent a fast, quite inexpensive, widely available and accurate examination in the field of pathologic nipple discharge, it still remains an invasive procedure to be performed only in case of nipple discharge at the time of the examination and could cause discomfort and pain [1]. On the other side, DBT-galactography uses the same conventional projections of FFD-galactography without significant technical difference.…”

“…We have also to consider that contraindications do exist for DBT-galactography mainly represented by severe allergy to iodinated contrast material, nipple retraction or a history of a prior nipple surgery that would invalidate the examination, as is for conventional galactography [1].…”

“…Ultrasonography of papillary lesions typically shows a solid, oval, intra-ductal mass, often associated with duct dilatation. A cystic component is also commonly seen [1,8,9].…”

Breast imaging and cancer diagnosis during the COVID-19 pandemic: recommendations from the Italian College of Breast Radiologists by SIRM

“…All efforts should be made to avoid delayed diagnosis in patients considered at high priority, due to the potential impact on cancer outcome. Suspicious symptoms, clinical or imaging findings are listed below: new onset of a breast palpable nodule [ 16 ]; new bloody or watery, unilateral, unifocal, nipple discharge [ 17 , 18 ]; orange peel skin [ 16 ]; skin or nipple retraction [ 16 ]; search for carcinoma of unknown primary (CUP) syndrome [ 19 ]; breast abscess, hematoma, or infected seroma [ 20 ]; clinical suspicion of inflammatory or locally advanced breast cancer [ 16 ]; suspicion of breast cancer in pregnant women [ 21 ]; preoperative imaging for local/contralateral staging [ 22 ]; imaging for monitoring the effect of neoadjuvant therapy [ 23 ]; recall from screening for further workup [ 24 ]; indication to breast and/or loco-regional lymph node needle biopsy [ 20 ]. …”