SAGE-Hindawi Access to Research International Journal of Breast Cancer Volume 2011, Article ID 495315, 6 pages doi:10.4061/2011/495315 Research Article Duct Excision is Still Necessary to Rule out Breast Cancer in Patients Presenting with Spontaneous Bloodstained Nipple Discharge R. E. Foulkes, G. Heard, T. Boyce, R. Skyrme, P. A. Holland, and C. A. Gateley Royal Gwent Hospital, Newport, South Wales, NP20 2UB, UK Correspondence should be addressed to R. E. Foulkes, foulkesre@doctors.org.uk Received 15 May 2011; Accepted 5 July 2011 Academic Editor: Mahmoud B. El-Tamer Copyright © 2011 R. E. Foulkes et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Introduction. Spontaneous nipple discharge is the third most common reason for presentation to a symptomatic breast clinic. Benign and malignant causes of spontaneous nipple discharge continue to be diﬃcult to distinguish. We analyse our experience of duct excisions for spontaneous nipple discharge to try to identify features that raise suspicion of breast cancer and to identify features indicative of benign disease that would be suitable for nonoperative management. Methods. Details of one hundred and ninety-four patients who underwent duct excision for spontaneous nipple discharge between 1995 and 2005 were analysed. Results. Malignant disease was identiﬁed in 11 (5.7%) patients, 4 invasive and 7 insitu, which was 10.2% of those presenting with bloodstained discharge. All patients with malignant disease had bloodstained discharge. Discharge due to malignant disease was more likely to be bloodstained than that due to benign causes (Fisher’s exact test, 2-tailed P value = 0.00134). Conclusion. Our ﬁndings do not support a policy of conservative management of spontaneous bloodstained nipple discharge. Cases of demonstrable spontaneous bloodstained nipple discharge should undergo duct excision to prevent malignant lesions being missed. 1. Introduction Nipple discharge is the third most common symptom pre- senting to breast clinics, following lumps and pain [1], accounting for 3 to 10% of referrals [2]. Nipple discharge causes considerable anxiety, but it is a presenting symptom in only 5 to 12% of cases of breast cancer [2]. Suspicious discharge is described as being unilateral, single duct, spontaneous, and persistent [3]. Discharge that is clear, serous, sero-sanguinous, or bloodstained is more likely to be due to breast cancer [4]. Approximately, 55% of patients presenting with nipple discharge have an associated mass, 19% of which are malignant [3]. These patients should be investigated by the triple assessment. In some patients who do not have a pal- pable breast lesion, mammography identiﬁes an abnormality which requires further investigation. The remainder will have neither a palpable nor a radiological abnormality. Where the nature of the discharge is suspicious, duct excision is required to exclude breast cancer. Although not routine practice in the United Kingdom, a number of techniques have been used to determine the cause of nipple discharge, beyond the triple assessment. Nipple discharge cytology has a low sensitivity for the detection of breast cancer [4, 5] and is unlikely to alter the management of patients with nipple discharge [4, 6]. Fluorescent insitu hybridization analysis of the discharge has not yet entered clinical practice however, a small pilot study has shown that it has a 100% speciﬁcity in making a deﬁnitive diagnosis of malignancy in patients with indeterminate cytologic results, suggesting that it could be a good adjunct to cytology [7]. Ductography has a high-positive predictive factor in the diagnosis of intraductal lesions, papilloma, and carcinoma; however, it has a low sensitivity and is painful [8]. Breast ductoscopy is an evolving technology, which is a promising tool as it can allow identiﬁcation of the site of any lesion in younger women, allowing excision of the benign lesions while retaining the ability to lactate. However, further studies are required to deﬁne its role more clearly, as there are still limitations in clinical practice [8–15]. Magnetic