Nipple Discharge Evaluation

Characterization and Risk Stratification

The American College of Radiology recommends characterizing nipple discharge as physiologic or pathologic, with physiologic discharge being bilateral, multiple ducts, provoked, and white/green/yellow in color, and pathologic discharge being spontaneous, unilateral, single-duct, and serous or bloody 1, 2, 3
The malignancy risk for pathologic nipple discharge ranges from 11-16% in women, with a higher risk of 23-57% in men 2, 3, 4
The American College of Radiology notes that age is a significant factor, with malignancy risk being 3% in patients under 40 years, 10% in ages 40-60, and 32% in those over 60 years 4

The American College of Radiology recommends diagnostic mammography of the symptomatic breast as the first-line imaging modality for pathologic nipple discharge 1, 5
Ultrasound of the retroareolar region with special techniques is recommended as the second-line imaging modality 3, 5
Ductography or breast MRI is recommended as the third-line imaging modality if mammography and ultrasound are negative 4, 5

The American College of Radiology recommends surgical duct excision as the definitive management for pathologic nipple discharge, providing both diagnosis and treatment, even with negative imaging 3