Anthony Visioni and Julian A. Kim

Introduction

Nipple discharge is a common complaint for women, with the possibility of intraductal cancer the greatest concern. However, benign disease is more often the cause of nipple discharge. It is therefore important to identify patients who might be at risk for malignancy and would be candidates for surgical resection. Nipple discharge can be defined as physiologic versus pathologic. Pathologic nipple discharge (PND) usually requires surgery to rule out malignancy. PND is typically unilateral, spontaneous, bloody or serous, and from a single duct. Green, creamy, bilateral, nonspontaneous drainage or drainage from multiple ducts usually indicates a nonmalignant process that does not require surgery.

Preoperative Workup

Diagnostic mammography is currently the test of choice in the workup of PND and is generally indicated in all patients. Ultrasound, magnetic resonance imaging (MRI), and ductography are being studied for prediction of malignant disease in PND, although no consensus exists on their use. Also under investigation is ductoscopy, real-time endoscopic imaging of the ductal system. Ductoscopy can differentiate normal ducts from intraductal papilloma and provide therapeutic options (Fig. 47-1, A). Although great advances have been made in the equipment and success of ductoscopy, its use is still limited to specialized centers.

Cytology is of limited use for the diagnosis of PND. Even in properly selected patients, cytology is not extremely sensitive or specific.

There are several algorithms for the workup of PND, but the most important aspect of the evaluation is to prove that the discharge is not caused by a malignancy (Fig. 47-1, B and C). This often requires surgical resection and pathologic examination of the duct.