Imaging evaluation of nipple discharge: Review of literature and management considerations.

Nipple discharge is a common and problematic symptom reported by many women seeking evaluation in primary care practices, surgery clinics, and breast radiology facilities. Discharge has been cited as the second to third most commonly reported breast symptom, next to palpable lumps and tenderness.^1-3 Numerous groups have discussed management strategies regarding nipple discharge, and there has been a significant evolution away from surgical intervention. For the radiologist, nipple discharge can be a dilemma for many reasons. For academic medical centers with the availability of a network of clinical breast care personnel, subspecialty trained breast radiologists, and breast surgeons, a comprehensive evaluation and management strategy is more realistic. In the community setting, managing a patient with nipple discharge can be challenging due to limited time and resources. Fortunately, the vast majority of patients presenting with nipple discharge can be appropriately triaged with a thorough history and physical exam. For those requiring imaging, mammography and ultrasound are widely available for initial work-up. Magnetic Resonance Imaging (MRI) has also become more commonplace in recent years and has become an important tool in the evaluation process of nipple discharge. Ductography, which is decreasing in popularity, may continue to play a specific role in managing nipple discharge; however, the availability of skilled practitioners may be limited. Our aim in this review is to discuss features that differentiate physiologic from pathologic nipple discharge, provide a literature summary to guide imaging recommendations, and introduce a flow chart as an overview for step-by-step management.