International Journal of Breast Cancer Age 32 43 51 58 60 68 69 72 74 78 88 Discharge type Fresh blood Fresh blood Fresh blood/serous Fresh blood Fresh blood Fresh blood Fresh blood History of fresh blood; serous discharge identiﬁed, dipstick +++ for blood Altered blood Fresh blood Fresh blood Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Micro TDE TDE TDE Micro TDE Micro TDE TDE TDE TDE DCIS DCIS DCIS IDC DCIS IDC DCIS IDC IDC DCIS DCIS 3 Treatment Mx + ANS + recon Mx + ANS + recon Mx + ANS Mx + ANC + recon Mx + ANS Mx + ANC Mx + ANS Intermediate grade DCIS Extensive intermediate grade DCIS High grade DCIS 3 mm grade 3 IDC + extensive DCIS High grade DCIS 3 mm grade 2 IDC + DCIS Multifocal intermediate grade DCIS 10 mm grade 2 IDC + DCIS Mx+ ANC 10 mm grade 2 IDC + widespread DCIS Multifocal intermediate grade DCIS Low grade DCIS Mx and ANC Simple Mx Simple Mx Table 2: Breast cancers identiﬁed following surgery for spontaneous isolated nipple discharge. Single duct? Initial surgery Initial histology Final histology Initial operation: Micro: microdochectomy; TDE: total duct excision. Histology: DCIS: ductal carcinoma insitu; IDC: invasive ductal carcinoma. Treatment: Mx: mastectomy; ANS: axillary node sampling; ANC: axillary node clearance; Recon: reconstruction. Eleven of the 108 (10.2%) patients who had some form of bloodstained nipple discharge were found to have invasive or insitu breast cancer following duct excision (Table 3). No cases of coloured discharge were associated with cancer. Three patients were found to have atypical duct hyper- plasia (ADH), of which 2 had frank bloodstained discharge and 1 serous discharge with blood on dipstick testing. Eight women with benign pathology at duct excision have subsequently developed invasive breast cancer, 4 in the ipsilateral and 4 in the contralateral breast, including 2 of the 3 with ADH (Table 4). Based on the national registration rate for breast cancer, in the 50–54 age group, (the median age of patients in this study), in 2001 (the midpoint of this study), 3.2 breast cancers would be expected to develop during the median follow-up period of 6 years [20]. A further 24 women with benign pathology at duct excision reattended the Breast Clinic. Eighteen had symp- toms on the same side as the duct excision, 4 contralateral, and 2 bilateral (1 multiple papillomatosis and 1 requesting bilateral reduction mammoplasty). The symptoms and signs at representation were similar to the original pathologies in 13 (54.2%), which was most commonly sepsis, previous surgery having demonstrated subclinical periductal mastitis. 4. Discussion The management of patients with spontaneous bloodstained nipple discharge in the absence of other detectable abnor- malities remains controversial. Reports have not shown an increased risk of breast cancer in patients with nipple dis- charge, with no other abnormality on triple assessment [21]. Table 3: Histology compared to type of discharge. Histology All Malignant IDC DCIS Benign Duct ectasia Papilloma Periductal mastitis Fibrocystic disease ADH Normal Number 194 11 4 7 183 76 65 21 12 3 6 Number with frank bloodstained discharge (% of diagnostic group) 108 (56%) 11 (100%) 97 (53%) 43 36 4 7 8 5 2 4 Several policies have been proposed, including conservative management [22], or surgery for patients with suspicious or bothersome discharge [4, 21]. Our ﬁndings do not support a policy of conservative management of spontaneous bloodstained nipple discharge, as 10.2% of patients were diagnosed to have breast cancer in the absence of other clinical or radiological abnormality. The median age of patients with bloodstained discharge due to breast cancer was higher than that of the patients with benign disease (68 versus 55 years) but with a large overlap of ages. It has been suggested that a conservative policy could be adopted for women under the age of 40 years [2]. However, in our series this would have led us to missing a case