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	Relative Radiation Level
US breast	Usually Not Appropriate	O
Digital breast tomosynthesis diagnostic	Usually Not Appropriate	☢☢
Ductography	Usually Not Appropriate	☢☢
Mammography diagnostic	Usually Not Appropriate	☢☢
Image-guided core biopsy breast	Usually Not Appropriate	Varies
Image-guided fine needle aspiration breast	Usually Not Appropriate	Varies
MRI breast without and with IV contrast	Usually Not Appropriate	O
MRI breast without IV contrast	Usually Not Appropriate	O
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	Relative Radiation Level
US breast	Usually Appropriate	O
Digital breast tomosynthesis diagnostic	Usually Appropriate	☢☢
Mammography diagnostic	Usually Appropriate	☢☢
Ductography	Usually Not Appropriate	☢☢
Image-guided core biopsy breast	Usually Not Appropriate	Varies
Image-guided fine needle aspiration breast	Usually Not Appropriate	Varies
MRI breast without and with IV contrast	Usually Not Appropriate	O
MRI breast without IV contrast	Usually Not Appropriate	O
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	Relative Radiation Level
US breast	Usually Appropriate	O
Digital breast tomosynthesis diagnostic	Usually Appropriate	☢☢
Mammography diagnostic	Usually Appropriate	☢☢
Ductography	Usually Not Appropriate	☢☢
Image-guided fine needle aspiration breast	Usually Not Appropriate	Varies
MRI breast without and with IV contrast	Usually Not Appropriate	O
MRI breast without IV contrast	Usually Not Appropriate	O
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	Relative Radiation Level
US breast	Usually Appropriate	O
Digital breast tomosynthesis diagnostic	Usually Appropriate	☢☢
Mammography diagnostic	Usually Appropriate	☢☢
Ductography	Usually Not Appropriate	☢☢
Image-guided core biopsy breast	Usually Not Appropriate	Varies
Image-guided fine needle aspiration breast	Usually Not Appropriate	Varies
MRI breast without and with IV contrast	Usually Not Appropriate	O
MRI breast without IV contrast	Usually Not Appropriate	O
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	Relative Radiation Level
US breast	Usually Appropriate	O
Digital breast tomosynthesis diagnostic	Usually Not Appropriate	☢☢
Ductography	Usually Not Appropriate	☢☢
Mammography diagnostic	Usually Not Appropriate	☢☢
Image-guided core biopsy breast	Usually Not Appropriate	Varies
Image-guided fine needle aspiration breast	Usually Not Appropriate	Varies
MRI breast without and with IV contrast	Usually Not Appropriate	O
MRI breast without IV contrast	Usually Not Appropriate	O
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	Relative Radiation Level
US breast	Usually Appropriate	O
Digital breast tomosynthesis diagnostic	Usually Appropriate	☢☢
Mammography diagnostic	Usually Appropriate	☢☢
Ductography	Usually Not Appropriate	☢☢
Image-guided core biopsy breast	Usually Not Appropriate	Varies
Image-guided fine needle aspiration breast	Usually Not Appropriate	Varies
MRI breast without and with IV contrast	Usually Not Appropriate	O
MRI breast without IV contrast	Usually Not Appropriate	O
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	Relative Radiation Level
US breast	Usually Appropriate	O
Digital breast tomosynthesis diagnostic	Usually Appropriate	☢☢
Mammography diagnostic	Usually Appropriate	☢☢
Ductography	Usually Not Appropriate	☢☢
Image-guided core biopsy breast	Usually Not Appropriate	Varies
Image-guided fine needle aspiration breast	Usually Not Appropriate	Varies
MRI breast without and with IV contrast	Usually Not Appropriate	O
MRI breast without IV contrast	Usually Not Appropriate	O
FDG-PET breast dedicated	Usually Not Appropriate	☢☢☢
Sestamibi MBI	Usually Not Appropriate	☢☢☢

Panel Members

Summary of Literature Review

Introduction/Background

Special Imaging Considerations

Initial Imaging Definition

Discussion of Procedures by Variant

Variant 1: Adult female or male or transfeminine (male-to-female) or transmasculine (female-to-male). Physiologic nipple discharge. Initial imaging.

Variant 1: Adult female or male or transfeminine (male-to-female) or transmasculine (female-to-male). Physiologic nipple discharge. Initial imaging.
A. Mammography Diagnostic

Variant 1: Adult female or male or transfeminine (male-to-female) or transmasculine (female-to-male). Physiologic nipple discharge. Initial imaging.
B. Digital Breast Tomosynthesis Diagnostic

Variant 1: Adult female or male or transfeminine (male-to-female) or transmasculine (female-to-male). Physiologic nipple discharge. Initial imaging.
C. US Breast

Variant 1: Adult female or male or transfeminine (male-to-female) or transmasculine (female-to-male). Physiologic nipple discharge. Initial imaging.
D. Ductography

Variant 1: Adult female or male or transfeminine (male-to-female) or transmasculine (female-to-male). Physiologic nipple discharge. Initial imaging.
E. MRI Breast

Variant 1: Adult female or male or transfeminine (male-to-female) or transmasculine (female-to-male). Physiologic nipple discharge. Initial imaging.
F. FDG-PET Breast Dedicated

Variant 1: Adult female or male or transfeminine (male-to-female) or transmasculine (female-to-male). Physiologic nipple discharge. Initial imaging.
G. Image-guided Core Biopsy Breast

Variant 1: Adult female or male or transfeminine (male-to-female) or transmasculine (female-to-male). Physiologic nipple discharge. Initial imaging.
H. Image-Guided Fine Needle Aspiration Breast

Variant 1: Adult female or male or transfeminine (male-to-female) or transmasculine (female-to-male). Physiologic nipple discharge. Initial imaging.
I. Sestamibi MBI

Variant 2: Adult male or female 40 years of age or older. Pathologic nipple discharge. Initial imaging.

Variant 2: Adult male or female 40 years of age or older. Pathologic nipple discharge. Initial imaging.
A. Mammography Diagnostic

Variant 2: Adult male or female 40 years of age or older. Pathologic nipple discharge. Initial imaging.
B. Digital Breast Tomosynthesis Diagnostic

Variant 2: Adult male or female 40 years of age or older. Pathologic nipple discharge. Initial imaging.
C. US Breast

Variant 2: Adult male or female 40 years of age or older. Pathologic nipple discharge. Initial imaging.
D. Ductography

Variant 2: Adult male or female 40 years of age or older. Pathologic nipple discharge. Initial imaging.
E. MRI Breast

Variant 2: Adult male or female 40 years of age or older. Pathologic nipple discharge. Initial imaging.
F. FDG-PET Breast Dedicated

Variant 2: Adult male or female 40 years of age or older. Pathologic nipple discharge. Initial imaging.
G. Image-Guided Core Biopsy Breast

Variant 2: Adult male or female 40 years of age or older. Pathologic nipple discharge. Initial imaging.
H. Image-Guided Fine Needle Aspiration Breast

Variant 2: Adult male or female 40 years of age or older. Pathologic nipple discharge. Initial imaging.
I. Sestamibi MBI

Variant 3: Adult male or female 30 to 39 years of age. Pathologic nipple discharge. Initial imaging.

Variant 3: Adult male or female 30 to 39 years of age. Pathologic nipple discharge. Initial imaging.
A. Mammography Diagnostic

Variant 3: Adult male or female 30 to 39 years of age. Pathologic nipple discharge. Initial imaging.
B. Digital Breast Tomosynthesis Diagnostic

Variant 3: Adult male or female 30 to 39 years of age. Pathologic nipple discharge. Initial imaging.
C. US Breast

Variant 3: Adult male or female 30 to 39 years of age. Pathologic nipple discharge. Initial imaging.
D. Ductography

Variant 3: Adult male or female 30 to 39 years of age. Pathologic nipple discharge. Initial imaging.
E. MRI Breast

Variant 3: Adult male or female 30 to 39 years of age. Pathologic nipple discharge. Initial imaging.
F. FDG-PET Breast Dedicated

Variant 3: Adult male or female 30 to 39 years of age. Pathologic nipple discharge. Initial imaging.
G. Image-Guided Core Biopsy Breast

Variant 3: Adult male or female 30 to 39 years of age. Pathologic nipple discharge. Initial imaging.
H. Image-Guided Fine Needle Aspiration Breast

Variant 3: Adult male or female 30 to 39 years of age. Pathologic nipple discharge. Initial imaging.
I. Sestamibi MBI

Variant 4: Adult male younger than 30 years of age. Pathologic nipple discharge. Initial imaging.

Variant 4: Adult male younger than 30 years of age. Pathologic nipple discharge. Initial imaging.
A. Mammography Diagnostic

Variant 4: Adult male younger than 30 years of age. Pathologic nipple discharge. Initial imaging.
B. Digital Breast Tomosynthesis Diagnostic

Variant 4: Adult male younger than 30 years of age. Pathologic nipple discharge. Initial imaging.
C. US Breast

Variant 4: Adult male younger than 30 years of age. Pathologic nipple discharge. Initial imaging.
D. Ductography

Variant 4: Adult male younger than 30 years of age. Pathologic nipple discharge. Initial imaging.
E. MRI Breast

Variant 4: Adult male younger than 30 years of age. Pathologic nipple discharge. Initial imaging.
F. FDG-PET Breast Dedicated

Variant 4: Adult male younger than 30 years of age. Pathologic nipple discharge. Initial imaging.
G. Image-guided Core Biopsy Breast

Variant 4: Adult male younger than 30 years of age. Pathologic nipple discharge. Initial imaging.
H. Image-Guided Fine Needle Aspiration Breast

Variant 4: Adult male younger than 30 years of age. Pathologic nipple discharge. Initial imaging.
I. Sestamibi MBI

Variant 5: Adult female younger than 30 years of age. Pathologic nipple discharge. Initial imaging.

Variant 5: Adult female younger than 30 years of age. Pathologic nipple discharge. Initial imaging.
A. Mammography Diagnostic

Variant 5: Adult female younger than 30 years of age. Pathologic nipple discharge. Initial imaging.
B. Digital Breast Tomosynthesis Diagnostic

Variant 5: Adult female younger than 30 years of age. Pathologic nipple discharge. Initial imaging.
C. US Breast

Variant 5: Adult female younger than 30 years of age. Pathologic nipple discharge. Initial imaging.
D. Ductography

Variant 5: Adult female younger than 30 years of age. Pathologic nipple discharge. Initial imaging.
E. MRI Breast

Variant 5: Adult female younger than 30 years of age. Pathologic nipple discharge. Initial imaging.
F. FDG-PET Breast Dedicated

Variant 5: Adult female younger than 30 years of age. Pathologic nipple discharge. Initial imaging.
G. Image-guided Core Biopsy Breast

Variant 5: Adult female younger than 30 years of age. Pathologic nipple discharge. Initial imaging.
H. Image-Guided Fine Needle Aspiration Breast

Variant 5: Adult female younger than 30 years of age. Pathologic nipple discharge. Initial imaging.
I. Sestamibi MBI

Variant 6: Adult transfeminine (male-to-female) patient 30 years of age or older. Pathologic nipple discharge. Initial imaging.

Variant 6: Adult transfeminine (male-to-female) patient 30 years of age or older. Pathologic nipple discharge. Initial imaging.
A. Mammography Diagnostic

Variant 6: Adult transfeminine (male-to-female) patient 30 years of age or older. Pathologic nipple discharge. Initial imaging.
B. Digital Breast Tomosynthesis Diagnostic

Variant 6: Adult transfeminine (male-to-female) patient 30 years of age or older. Pathologic nipple discharge. Initial imaging.
C. US Breast

Variant 6: Adult transfeminine (male-to-female) patient 30 years of age or older. Pathologic nipple discharge. Initial imaging.
D. Ductography

Variant 6: Adult transfeminine (male-to-female) patient 30 years of age or older. Pathologic nipple discharge. Initial imaging.
E. MRI Breast

Variant 6: Adult transfeminine (male-to-female) patient 30 years of age or older. Pathologic nipple discharge. Initial imaging.
F. FDG-PET Breast Dedicated

Variant 6: Adult transfeminine (male-to-female) patient 30 years of age or older. Pathologic nipple discharge. Initial imaging.
G. Image-guided Core Biopsy Breast

Variant 6: Adult transfeminine (male-to-female) patient 30 years of age or older. Pathologic nipple discharge. Initial imaging.
H. Image-Guided Fine Needle Aspiration Breast

Variant 6: Adult transfeminine (male-to-female) patient 30 years of age or older. Pathologic nipple discharge. Initial imaging.
I. Sestamibi MBI

Variant 7: Adult transfeminine (male-to-female) patient younger than 30 years of age. Pathologic nipple discharge. Initial imaging.

Variant 7: Adult transfeminine (male-to-female) patient younger than 30 years of age. Pathologic nipple discharge. Initial imaging.
A. Mammography Diagnostic

Variant 7: Adult transfeminine (male-to-female) patient younger than 30 years of age. Pathologic nipple discharge. Initial imaging.
B. Digital Breast Tomosynthesis Diagnostic

Variant 7: Adult transfeminine (male-to-female) patient younger than 30 years of age. Pathologic nipple discharge. Initial imaging.
C. US Breast

Variant 7: Adult transfeminine (male-to-female) patient younger than 30 years of age. Pathologic nipple discharge. Initial imaging.
D. Ductography

Variant 7: Adult transfeminine (male-to-female) patient younger than 30 years of age. Pathologic nipple discharge. Initial imaging.
E. MRI Breast

Variant 7: Adult transfeminine (male-to-female) patient younger than 30 years of age. Pathologic nipple discharge. Initial imaging.
F. FDG-PET Breast Dedicated

Variant 7: Adult transfeminine (male-to-female) patient younger than 30 years of age. Pathologic nipple discharge. Initial imaging.
G. Image-guided Core Biopsy Breast

Variant 7: Adult transfeminine (male-to-female) patient younger than 30 years of age. Pathologic nipple discharge. Initial imaging.
H. Image-Guided Fine Needle Aspiration Breast

Variant 7: Adult transfeminine (male-to-female) patient younger than 30 years of age. Pathologic nipple discharge. Initial imaging.
I. Sestamibi MBI

Summary of Recommendations

Supporting Documents

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 Names and Definitions

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.

Relative Radiation Level Information

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Disclaimer

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