Suspicious Nipple Discharge Diagnostic Evaluation

The diagnosis of ND begins with its characterization as either a physiological or pathological condition (Simmons et al., 2003). Physiological discharge, often a manifestation of breast manipulation, is usually bilateral, is white or green, and emanates from many ducts (Simmons et al., 2003). Possible causes of persistent physiological discharge include oral contraceptives, antihypertensives, tranquilizers, hypothyroidism, and pituitary adenoma (Simmons et al., 2003). Most NDs are physiological and are not associated with an underlying benign or malignant breast neoplasm (Sickles, 2000). A pathological discharge is generally unilateral, spontaneous, persistent, clear, watery, serous or bloody in appearance, and emanates from a single duct (Morrogh et al., 2007). Most of the common pathological causes of ND are benign (Hou et al., 2001; Hussain et al., 2006), and the most frequently encountered benign causes are intraductal papilloma, followed by ductal ectasia and fibrocystic disease (Hou et al., 2001; Morrogh et al., 2010; Sickles, 2000). The most important cause of pathological discharge is breast cancer. For single duct nipple discharges, the incidence of malignant or high-risk pathology is reported to be as high as 15% (Orel et al., 2000 citing Carty et al., 1994; Fung et al., 1990; Leis et al., 1989; Piccoli et al., 1998; Tabar et al., 1983; Winchester et al., 1996). In some cases, ND is the only sign of carcinoma (Hou et al., 2001). NDs that are bloody or serous in appearance, associated with a mass, and present in an elderly patient are more likely to be caused by malignant tumors (Das et al., 2001; El-Daly & Gudi, 2010; Pritt et al., 2004; Tabar, 1983; Tjalma, 2004 citing Seltzer et al., 1970).