Evaluation of Nipple Discharge

Variant: 1   Adult female or male or transfeminine (male-to-female) or transmasculine (female-to-male). Physiologic nipple discharge. Initial imaging.
Procedure Appropriateness Category
US breast Usually Not Appropriate
Digital breast tomosynthesis diagnostic Usually Not Appropriate
Ductography Usually Not Appropriate
Mammography diagnostic Usually Not Appropriate
Image-guided core biopsy breast Usually Not Appropriate
Image-guided fine needle aspiration breast Usually Not Appropriate
MRI breast without and with IV contrast Usually Not Appropriate
MRI breast without IV contrast Usually Not Appropriate
FDG-PET breast dedicated Usually Not Appropriate
Sestamibi MBI Usually Not Appropriate
Variant: 2   Adult male or female 40 years of age or older. Pathologic nipple discharge. Initial imaging.
Procedure Appropriateness Category
US breast Usually Appropriate
Digital breast tomosynthesis diagnostic Usually Appropriate
Mammography diagnostic Usually Appropriate
Ductography Usually Not Appropriate
Image-guided core biopsy breast Usually Not Appropriate
Image-guided fine needle aspiration breast Usually Not Appropriate
MRI breast without and with IV contrast Usually Not Appropriate
MRI breast without IV contrast Usually Not Appropriate
FDG-PET breast dedicated Usually Not Appropriate
Sestamibi MBI Usually Not Appropriate
Variant: 3   Adult male or female 30 to 39 years of age. Pathologic nipple discharge. Initial imaging.
Procedure Appropriateness Category
US breast Usually Appropriate
Digital breast tomosynthesis diagnostic Usually Appropriate
Mammography diagnostic Usually Appropriate
Ductography Usually Not Appropriate
Image-guided fine needle aspiration breast Usually Not Appropriate
MRI breast without and with IV contrast Usually Not Appropriate
MRI breast without IV contrast Usually Not Appropriate
FDG-PET breast dedicated Usually Not Appropriate
Sestamibi MBI Usually Not Appropriate
Variant: 4   Adult male younger than 30 years of age. Pathologic nipple discharge. Initial imaging.
Procedure Appropriateness Category
US breast Usually Appropriate
Digital breast tomosynthesis diagnostic Usually Appropriate
Mammography diagnostic Usually Appropriate
Ductography Usually Not Appropriate
Image-guided core biopsy breast Usually Not Appropriate
Image-guided fine needle aspiration breast Usually Not Appropriate
MRI breast without and with IV contrast Usually Not Appropriate
MRI breast without IV contrast Usually Not Appropriate
FDG-PET breast dedicated Usually Not Appropriate
Sestamibi MBI Usually Not Appropriate
Variant: 5   Adult female younger than 30 years of age. Pathologic nipple discharge. Initial imaging.
Procedure Appropriateness Category
US breast Usually Appropriate
Digital breast tomosynthesis diagnostic Usually Not Appropriate
Ductography Usually Not Appropriate
Mammography diagnostic Usually Not Appropriate
Image-guided core biopsy breast Usually Not Appropriate
Image-guided fine needle aspiration breast Usually Not Appropriate
MRI breast without and with IV contrast Usually Not Appropriate
MRI breast without IV contrast Usually Not Appropriate
FDG-PET breast dedicated Usually Not Appropriate
Sestamibi MBI Usually Not Appropriate
Variant: 6   Adult transfeminine (male-to-female) patient 30 years of age or older. Pathologic nipple discharge. Initial imaging.
Procedure Appropriateness Category
US breast Usually Appropriate
Digital breast tomosynthesis diagnostic Usually Appropriate
Mammography diagnostic Usually Appropriate
Ductography Usually Not Appropriate
Image-guided core biopsy breast Usually Not Appropriate
Image-guided fine needle aspiration breast Usually Not Appropriate
MRI breast without and with IV contrast Usually Not Appropriate
MRI breast without IV contrast Usually Not Appropriate
FDG-PET breast dedicated Usually Not Appropriate
Sestamibi MBI Usually Not Appropriate
Variant: 7   Adult transfeminine (male-to-female) patient younger than 30 years of age. Pathologic nipple discharge. Initial imaging.
Procedure Appropriateness Category
US breast Usually Appropriate
Digital breast tomosynthesis diagnostic Usually Appropriate
Mammography diagnostic Usually Appropriate
Ductography Usually Not Appropriate
Image-guided core biopsy breast Usually Not Appropriate
Image-guided fine needle aspiration breast Usually Not Appropriate
MRI breast without and with IV contrast Usually Not Appropriate
MRI breast without IV contrast Usually Not Appropriate
FDG-PET breast dedicated Usually Not Appropriate
Sestamibi MBI Usually Not Appropriate

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Appropriateness Category Name

Appropriateness Rating

Appropriateness Category Definition

Usually Appropriate

7, 8, or 9

The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.

May Be Appropriate

4, 5, or 6

The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.

May Be Appropriate (Disagreement)

5

The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.

Usually Not Appropriate

1, 2, or 3

The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.







































































The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked.  Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document.  The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged.  The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination