Pitarch Mireia, Alcantara Rodrigo, Comerma Laura, Vázquez de Las Heras Ivonne, Azcona Javier, Wiedemann Antonia, Prutki Maja, Fallenberg Eva Maria
Department of Radiology and Nuclear Medicine, Hospital del Mar, Passeig Marítim de la Barceloneta, 25-29, 08003, Barcelona, Spain.
Department of Pathology, Hospital del Mar, Passeig Marítim de la Barceloneta, 25-29, 08003, Barcelona, Spain.
Insights Imaging. 2025 Mar 24;16(1):70. doi: 10.1186/s13244-025-01947-1.
Nipple discharge affects over 80% of women at some point in their lives, with malignancy detected in up to 23% of cases. This review highlights the shift from traditional surgical approaches to advanced imaging techniques, which enhance diagnostic accuracy and reduce unnecessary procedures. Diagnosis begins with a thorough medical history and physical examination to assess the need for imaging. Physiological nipple discharge, which is bilateral, multiductal, and non-spontaneous, typically requires no imaging. Conversely, pathological nipple discharge (PND), characteristically unilateral, uniductal, and spontaneous, requires imaging to rule out malignancy. Bloody PND is frequently associated with breast cancer, and up to 12% of non-bloody PND cases also involve malignancy. For women over 40 years, the first-line imaging modality is full-field digital mammography (FFDM) or digital breast tomosynthesis (DBT), usually combined with ultrasound (US). Men with PND undergo FFDM/DBT starting at age 25 years due to their higher risk of breast cancer. For women aged 30-39 years, US is the first assessment tool, with FFDM/DBT added, if necessary, while US is preferred for younger women and men. When initial imaging is negative or inconclusive, magnetic resonance imaging (MRI) is useful, often replacing galactography. With its high sensitivity and negative predictive value of almost 100%, a negative MRI can often obviate the need for surgery. Contrast-enhanced mammography (CEM) offers a viable alternative when MRI is not feasible. Although invasive, ductoscopy helps identify patients who may not require duct excision. This review consolidates the latest evidence and proposes an updated diagnostic algorithm for managing PND effectively. CRITICAL RELEVANCE STATEMENT: Effective management of nipple discharge requires recognising when imaging tests are needed and selecting the most appropriate diagnostic technique to rule out malignancy and avoid unnecessary interventions. KEY POINTS: First-line imaging for pathological nipple discharge (PND) assessment includes ultrasound and mammography. MRI is recommended for patients with PND and negative conventional imaging. A negative MRI is sufficient to justify surveillance rather than surgery. Contrast-enhanced mammography (CEM) is an alternative when MRI is unavailable or contraindicated.
乳头溢液在超过80%的女性一生中的某个阶段都会出现，其中高达23%的病例可检测出恶性病变。本综述强调了从传统手术方法向先进成像技术的转变，这些技术提高了诊断准确性并减少了不必要的手术。诊断始于全面的病史采集和体格检查，以评估成像的必要性。生理性乳头溢液为双侧、多导管且非自发性，通常无需成像检查。相反，病理性乳头溢液（PND）的特征为单侧、单导管且自发性，需要成像以排除恶性病变。血性PND常与乳腺癌相关，高达12%的非血性PND病例也涉及恶性病变。对于40岁以上的女性，一线成像方式是全视野数字化乳腺摄影（FFDM）或数字乳腺断层合成（DBT），通常联合超声（US）。由于患乳腺癌风险较高，患有PND的男性从25岁起接受FFDM/DBT检查。对于30 - 39岁的女性，US是首选评估工具，必要时增加FFDM/DBT，而对于年轻女性和男性，US更受青睐。当初始成像结果为阴性或不确定时，磁共振成像（MRI）很有用，常可替代乳腺导管造影。由于其高敏感性和近100%的阴性预测值，MRI阴性结果通常可避免手术。当MRI不可行时，对比增强乳腺摄影（CEM）是一种可行的替代方法。尽管乳腺导管镜检查具有侵入性，但有助于识别可能无需进行导管切除的患者。本综述整合了最新证据，并提出了一种更新的诊断算法，以有效管理PND。关键相关声明：乳头溢液的有效管理需要识别何时需要进行成像检查，并选择最合适的诊断技术以排除恶性病变并避免不必要的干预。要点：病理性乳头溢液（PND）评估的一线成像包括超声和乳腺摄影。对于PND且传统成像结果为阴性的患者，推荐进行MRI检查。MRI阴性结果足以证明进行监测而非手术是合理的。当MRI不可用或禁忌时，对比增强乳腺摄影（CEM）是一种替代方法。
