Breast imaging in patients with nipple discharge

Nipple discharge is a common symptom in clinical practice, representing the third leading breast complaint, after pain and lumps. It is usually limited and has a benign etiology. The risk of malignancy is higher when the discharge is uniductal, unilateral, spontaneous, persistent, bloody, or serous, as well as when it is accompanied by a breast mass. The most common causes of pathologic nipple discharge are papilloma and ductal ectasia. However, there is a 5% risk of malignancy, mainly ductal carcinoma in situ. The clinical examination is an essential part of the patient evaluation, allowing benign nipple discharge to be distinguished from suspicious nipple discharge, which calls for imaging. Mammography and ultrasound should be used together as first-line imaging methods. However, mammography has low sensitivity in cases of nipple discharge, because, typically, the lesions are small, are retroareolar, and contain no calcifications. Because the reported sensitivity and specificity of ultrasound, it is important to use the correct technique to search for intraductal lesions in the retroareolar region. Recent studies recommend the use of magnetic resonance imaging in cases of suspicious nipple discharge in which the mammography and ultrasound findings are normal. The most common magnetic resonance imaging finding is non-mass enhancement. Surgery is no longer the only solution for patients with suspicious nipple discharge, because short-time follow-up can be safely proposed.