Original Investigation| Volume 30, ISSUE 5, P783-797, May 2023

Download started.


Nipple Discharge Imaging Evaluation with Mammography, Ultrasound, Galactography, and MRI

      Rationale and Objective

      To determine the diagnostic yield of various imaging tests used to evaluate nipple discharge.

      Materials and Methods

      A single institution, IRB-approved, retrospective study was performed of 320 consecutive patients presenting with nipple discharge. Imaging and pathology were reviewed to determine the yield for malignancy, atypical high-risk lesions (HRLs), and intraductal papillomas (IDPs).


      Of the 320 patients, pathology or follow up confirmed 40 breast malignancies (40/320, 12.5%),14 atypical HRLs (14/320, 4.4%), 71 IDPs (71/320, 22.2%), 48 other benign pathologies (48/320,15.0%), and 147 unknown but benign cases (147/320, 45.9%). Physiologic discharge characteristics were observed in a minority of malignant cases: nonspontaneous (4/40, 10.0%); neither bloody nor clear (4/40, 10.0%); bilateral (3/40, 7.5%). Malignancy was associated with older age (p < 0.001) and bloody discharge (odds ratio 6.5, p < 0.0001).
      The combination of digital mammography and ultrasound had a 93% sensitivity and a 98% NPV, while contrast enhanced MRI (CE-MRI) had a 100% sensitivity and a 100% NPV for malignancy. Only three galactography examinations were performed among the malignant cohort, with minimal contribution (1 of 3) to the diagnostic evaluation. In this case, galactography findings helped determine imaging-pathology discordance, prompting a recommendation for surgical excision and subsequently a malignant diagnosis.


      The combination of mammography and ultrasonography detected 93% of breast malignancies associated with nipple discharge and had a 98% NPV for malignancy. The value of CE-MRI is its ability to detect the remaining malignancies, not detected on mammography or ultrasound, and its ability to obviate the need for surgical duct excision.

      Key Words


      IDP (intraductal papilloma), DCIS (ductal carcinoma in situ), ACR (American College of Radiology), CE-MRI (contrast enhanced-magnetic resonance imaging), BI-RADS (Breast Imaging Reporting and Data System), US (ultrasound), FNA (fine needle aspiration), HRL (High Risk Lesion), CI (confidence interval), TP (true positive), FP (false positive), TN (true negative), FN (false negative), PPV (positive predictive value), NPV (negative predictive value), ADH (atypical ductal hyperplasia), ALH (atypical lobular hyperplasia), LCIS (lobular carcinoma in situ)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Academic Radiology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Leis Jr., HP
        Management of nipple discharge.
        World J Surg. 1989; 13: 736-742
        • Clark SE
        • Agrawal A
        • Laws S
        • et al.
        The Investigation and management of unilateral nipple discharge.
        Ann R Coll Surg Engl. 2020; 102: 369-374
        • Patel BK
        • Falcon S
        • Drukteinis J
        Management of nipple discharge and the associated imaging findings.
        Am J Med. 2015; 128: 353-360
        • Montroni I
        • Santini D
        • Zucchini G
        • et al.
        Nipple discharge: is its significance as a risk factor for breast cancer fully understood? Observational study including 915 consecutive patients who underwent selective duct excision.
        Breast Cancer Res Treat. 2010; 123: 895-900
        • Venkatesh SL
        • Oseni TO
        • Bahl M
        Symptomatic ductal carcinoma in situ (DCIS): upstaging risk and predictors.
        Clin Imaging. 2021; 73: 101-107
        • Lee SJ
        • Trikha S
        • Moy L
        • et al.
        ACR Appropriateness Criteria® evaluation of nipple discharge.
        J Am Coll Radiol. 2017; 14: S138-S153
        • Patel BK
        • Ferraro C
        • Kosiorek HE
        • et al.
        Nipple discharge: imaging variability among U.S. radiologists.
        AJR Am J Roentgenol. 2018; 211: 920-925
        • Sakr R
        • Rouzier R
        • Salem C
        • et al.
        Risk of breast cancer associated with papilloma.
        Eur J Surg Oncol. 2008; 34: 1304-1308
        • Limberg J
        • Kucher W
        • Fasano G
        • et al.
        Intraductal papilloma of the breast: prevalence of malignancy and natural history under active surveillance.
        Ann Surg Oncol. 2021; 28: 6032-6040
        • Moynihan A
        • Quinn EM
        • Smith CS
        • et al.
        Benign breast papilloma: is surgical excision necessary?.
        Breast J. 2020; 26: 705-710
        • Choi HY
        • Kim SM
        • Jang M
        • et al.
        Benign breast papilloma without atypia: outcomes of surgical excision versus US-guided directional vacuum-assisted removal or US follow-up.
        Radiology. 2019; 293: 72-80
        • Hawley JR
        • Lawther H
        • Erdal BS
        • et al.
        Outcomes of benign breast papillomas diagnosed at image-guided vacuum-assisted core needle biopsy.
        Clin Imaging. 2015; 39: 576-581
        • D'Orsi CJ
        • Sickles EA
        • Mendelson EB
        • et al.
        ACR BI-RADS atlas, breast imaging reporting and data system.
        American College of Radiology, Reston, VA2013
        • Wong Chung JE
        • Jeuriens-van de Ven SA
        • van Helmond N
        • et al.
        Does nipple discharge color predict (pre-) malignant breast pathology?.
        Breast J. 2016; 22: 202-208
        • Chen L
        • Zhou WB
        • Zhao Y
        • et al.
        Bloody nipple discharge is a predictor of breast cancer risk: a meta-analysis.
        Breast Cancer Res Treat. 2012; 132: 9-14
        • Sauter ER
        • Winn JN
        • Dale PS
        • et al.
        Nipple aspirate fluid color is associated with breast cancer.
        Cancer Detect Prev. 2006; 30: 322-328
        • Li GZ
        • Wong SM
        • Lester S
        • et al.
        Evaluating the risk of underlying malignancy in patients with pathologic nipple discharge.
        Breast J. 2018; 24: 624-627
        • Hou MF
        • Huang CJ
        • Huang YS
        • et al.
        Evaluation of galactography for nipple discharge.
        Clin Imaging. 1998; 22: 89-94
        • Alshurbasi N
        • Cartlidge CWJ
        • Kohlhardt SR
        • et al.
        Predicting patients found to have malignancy at nipple duct surgery.
        Breast Care (Basel). 2020; 15: 491-497
        • Lang JE
        • Kuerer HM
        Breast ductal secretions: clinical features, potential uses, and possible applications.
        Cancer Control. 2007; 14: 350-359
        • Adepoju LJ
        • Chun J
        • El-Tamer M
        • et al.
        The value of clinical characteristics and breast-imaging studies in predicting a histopathologic diagnosis of cancer or high-risk lesion in patients with spontaneous nipple discharge.
        Am J Surg. 2005; 190: 644-646
        • Morrogh M
        • Park A
        • Elkin EB
        • et al.
        Lessons learned from 416 cases of nipple discharge of the breast.
        Am J Surg. 2010; 200: 73-80
        • Ashfaq A
        • Senior D
        • Pockaj BA
        • et al.
        Validation study of a modern treatment algorithm for nipple discharge.
        Am J Surg. 2014; 208: 222-227
        • Gray RJ
        • Pockaj BA
        • Karstaedt PJ
        Navigating murky waters: a modern treatment algorithm for nipple discharge.
        Am J Surg. 2007; 194 (discussion 854-5): 850-854
        • Cabioglu N
        • Hunt KK
        • Singletary SE
        • et al.
        Surgical decision making and factors determining a diagnosis of breast carcinoma in women presenting with nipple discharge.
        J Am Coll Surg. 2003; 196: 354-364
        • Baydoun S
        • Gonzalez P
        • Whitman GJ
        • et al.
        Is ductography still warranted in the 21st century?.
        Breast J. 2019; 25: 654-662
        • Berger N
        • Luparia A
        • Di Leo G
        • et al.
        Diagnostic performance of MRI versus galactography in women with pathologic nipple discharge: a systematic review and meta-analysis.
        AJR Am J Roentgenol. 2017; 209: 465-471
        • Cohen E
        • Leung JWT
        Problem-solving MR imaging for equivocal imaging findings and indeterminate clinical symptoms of the breast.
        Magn Reson Imaging Clin N Am. 2018; 26: 221-233
        • Morrogh M
        • Morris EA
        • Liberman L
        • et al.
        The predictive value of ductography and magnetic resonance imaging in the management of nipple discharge.
        Ann Surg Oncol. 2007; 14: 3369-3377
        • Lubina N
        • Schedelbeck U
        • Roth A
        • et al.
        3.0 Tesla breast magnetic resonance imaging in patients with nipple discharge when mammography and ultrasound fail.
        Eur Radiol. 2015; 25: 1285-1293
        • Gupta D
        • Mendelson EB
        • Karst I.
        Nipple discharge: current clinical and imaging evaluation.
        AJR Am J Roentgenol. 2021; 216: 330-339
        • Mann RM
        • Balleyguier C
        • Baltzer PA
        • et al.
        Breast MRI: EUSOBI recommendations for women's information.
        Eur Radiol. 2015; 25: 3669-3678
        • Bahl M
        • Baker JA
        • Greenup RA
        • et al.
        Evaluation of pathologic nipple discharge: what is the added diagnostic value of MRI?.
        Ann Surg Oncol. 2015; 22 (Suppl): S435-S441
        • Boisserie-Lacroix M
        • Doutriaux-Dumoulin I
        • Chopier J
        • et al.
        Diagnostic accuracy of breast MRI for patients with suspicious nipple discharge and negative mammography and ultrasound: a prospective study.
        Eur Radiol. 2021; 31: 7783-7791
        • Pinder SE
        • Shaaban A
        • Deb R
        • et al.
        NHS Breast screening multidisciplinary working group guidelines for the diagnosis and management of breast lesions of uncertain malignant potential on core biopsy (B3 lesions).
        Clin Radiol. 2018; 73: 682-692
        • Tatarian T
        • Sokas C
        • Rufail M
        • et al.
        Intraductal papilloma with benign pathology on breast core biopsy: to excise or not?.
        Ann Surg Oncol. 2016; 23: 2501-2507
        • Dupont SC
        • Boughey JC
        • Jimenez RE
        • et al.
        Frequency of diagnosis of cancer or high-risk lesion at operation for pathologic nipple discharge.
        Surgery. 2015; 158 (discussion 994-995): 988-994
        • Khan S
        • Diaz A
        • Archer KJ
        • et al.
        Papillary lesions of the breast: to excise or observe?.
        Breast J. 2018; 24: 350-355
        • Nakhlis F
        • Baker GM
        • Pilewskie M
        • et al.
        The incidence of adjacent synchronous invasive carcinoma and/or ductal carcinoma in situ in patients with intraductal papilloma without atypia on core biopsy: results from a prospective multi-institutional registry (TBCRC 034).
        Ann Surg Oncol. 2021; 28: 2573-2578
        • Lee SJ
        • Wahab RA
        • Sobel LD
        • et al.
        Analysis of 612 benign papillomas diagnosed at core biopsy: rate of upgrade to malignancy, factors associated with upgrade, and a proposal for selective surgical excision.
        AJR Am J Roentgenol. 2021; 217: 1299-1311
        • Moseley T
        • Desai B
        • Whitman GJ
        • et al.
        Benign breast intraductal papillomas without atypia at core needle biopsies: is surgical excision Necessary?.
        Ann Surg Oncol. 2021; 28: 1347-1355
        • Rizzo M
        • Linebarger J
        • Lowe MC
        • et al.
        Management of papillary breast lesions diagnosed on core-needle biopsy: clinical pathologic and radiologic analysis of 276 cases with surgical follow-up.
        J Am Coll Surg. 2012; 214: 280-287
        • Speer ME
        • Huang ML
        • Dogan BE
        • et al.
        High risk breast lesions identified on MRI-guided vacuum-assisted needle biopsy: outcome of surgical excision and imaging follow-up.
        Br J Radiol. 2018; 9120180300
        • Schiaffino S
        • Cozzi A
        • Sardanelli F
        An update on the management of breast atypical ductal hyperplasia.
        Br J Radiol. 2020; 9320200117