0:00

Our next symptom is nipple discharge.

0:05

And again, there's an ACR appropriateness

0:08

criteria for evaluation of nipple discharge.

0:11

So I advise you to check that out

0:13

in JACR and on the ACR website.

0:19

Nipple discharge can be physiological.

0:21

Usually, when it's physiological, it's bilateral

0:24

and coming from multiple duct orifices.

0:27

It can be white, yellow, or green.

0:30

Pathological nipple discharge is usually clear

0:33

or bloody and, um, generally unilateral coming

0:37

from a single duct opening and spontaneous.

0:43

The ACR recommends that for physiological

0:46

nipple discharge, um, the referring

0:49

provider should do a clinical evaluation,

0:51

but really no imaging is indicated.

0:54

For pathological nipple discharge,

0:56

that's the clear or bloody unilateral discharge.

0:59

If the patient's under age 30,

1:02

ultrasound is recommended first with mammography

1:04

at the radiologist's discretion.

1:06

Again, we have that intermediate age,

1:08

age 30 to 39, where ultrasound and mammogram,

1:12

as the first test, both get equal.

1:15

Ratings and then age 40 and up.

1:18

It's recommended to start with a

1:20

mammogram and then perform an ultrasound.

1:25

Our protocol for under age 30, we'll do the

1:28

ultrasound first and then age 30 and up.

1:30

We'll start with the mammogram

1:33

and then go to ultrasound.

1:34

So it's just that age 30 to 39

1:36

where we've decided for our group.

1:38

It makes more sense to start with the mammogram.

1:41

And then go to ultrasound.

1:43

Uh, we'll do full bilateral CC and MLO

1:46

views, and we perform retroareolar spot

1:49

magnification views with the nipple in

1:51

profile in both the CC and lateral projection.

1:55

Sometimes that helps us with, um,

1:57

masses right behind the nipple and

2:00

calcifications behind the nipple.

2:02

And then we do an ultrasound of the retroareolar

2:05

and periareolar breast, paying specific

2:07

attention to the, um, subareolar ducts.

2:10

And, um, trying to figure out if

2:13

there's a mass inside the duct that

2:15

may be causing the patient's discharge.

2:18

There are a few different causes of discharge.

2:20

I mean, obviously, it occurs

2:22

physiologically, but then for these, um,

2:25

pathological, uh, nipple discharge, it can

2:29

be related to intraductal papillomas.

2:31

That's a very frequent cause.

2:32

Sometimes just duct ectasia

2:35

or wide ducts can cause it.

2:37

And then malignancy, um, um, is

2:39

reported in 5 to 21 percent of cases.

2:42

So that's a pretty wide range.

2:44

But we know that the risk of

2:46

malignancy increases with age.

2:48

So it's really only about 3 percent at age 40,

2:51

but 32 percent if the patient's over age 60.

2:55

So we want to be careful about this,

2:57

especially in our older patient population.

Nipple Discharge Overview

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0:00

Our next symptom is nipple discharge.

0:05

And again, there's an ACR appropriateness

0:08

criteria for evaluation of nipple discharge.

0:11

So I advise you to check that out

0:13

in JACR and on the ACR website.

0:19

Nipple discharge can be physiological.

0:21

Usually, when it's physiological, it's bilateral

0:24

and coming from multiple duct orifices.

0:27

It can be white, yellow, or green.

0:30

Pathological nipple discharge is usually clear

0:33

or bloody and, um, generally unilateral coming

0:37

from a single duct opening and spontaneous.

0:43

The ACR recommends that for physiological

0:46

nipple discharge, um, the referring

0:49

provider should do a clinical evaluation,

0:51

but really no imaging is indicated.

0:54

For pathological nipple discharge,

0:56

that's the clear or bloody unilateral discharge.

0:59

If the patient's under age 30,

1:02

ultrasound is recommended first with mammography

1:04

at the radiologist's discretion.

1:06

Again, we have that intermediate age,

1:08

age 30 to 39, where ultrasound and mammogram,

1:12

as the first test, both get equal.

1:15

Ratings and then age 40 and up.

1:18

It's recommended to start with a

1:20

mammogram and then perform an ultrasound.

1:25

Our protocol for under age 30, we'll do the

1:28

ultrasound first and then age 30 and up.

1:30

We'll start with the mammogram

1:33

and then go to ultrasound.

1:34

So it's just that age 30 to 39

1:36

where we've decided for our group.

1:38

It makes more sense to start with the mammogram.

1:41

And then go to ultrasound.

1:43

Uh, we'll do full bilateral CC and MLO

1:46

views, and we perform retroareolar spot

1:49

magnification views with the nipple in

1:51

profile in both the CC and lateral projection.

1:55

Sometimes that helps us with, um,

1:57

masses right behind the nipple and

2:00

calcifications behind the nipple.

2:02

And then we do an ultrasound of the retroareolar

2:05

and periareolar breast, paying specific

2:07

attention to the, um, subareolar ducts.

2:10

And, um, trying to figure out if

2:13

there's a mass inside the duct that

2:15

may be causing the patient's discharge.

2:18

There are a few different causes of discharge.

2:20

I mean, obviously, it occurs

2:22

physiologically, but then for these, um,

2:25

pathological, uh, nipple discharge, it can

2:29

be related to intraductal papillomas.

2:31

That's a very frequent cause.

2:32

Sometimes just duct ectasia

2:35

or wide ducts can cause it.

2:37

And then malignancy, um, um, is

2:39

reported in 5 to 21 percent of cases.

2:42

So that's a pretty wide range.

2:44

But we know that the risk of

2:46

malignancy increases with age.

2:48

So it's really only about 3 percent at age 40,

2:51

but 32 percent if the patient's over age 60.

2:55

So we want to be careful about this,

2:57

especially in our older patient population.

Report

Faculty

Lisa Ann Mullen, MD

Assistant Professor; Breast Imaging Fellowship Director

Johns Hopkins Medicine

Lesson

Sample Lesson

Lesson

Palpable Lumps

Lesson

Breast Pain

Lesson