2 resonance imaging (MRI) may play an adjunctive role, aiding in the diﬀerentiation of benign ductal abnormalities from malignant ones but remains under investigation and is not the method of choice presently in evaluating nipple discharge in the UK [16–19]. Only duct excision provides a deﬁnitive histological diag- nosis and remains the gold standard. However, a signiﬁcant number of patients with benign conditions undergo surgery, which is a concern particularly in women of child bearing age due to the implications associated with breastfeeding. The aim of this study was to analyse our experience of duct excision for nipple discharge, in an attempt to identify features that raise the suspicion of breast cancer, and to identify features indicative of benign disease where duct excision can be avoided. 2. Methods All patients who underwent microdochectomy or total duct excision for spontaneous nipple discharge between 1995 and 2005 were analysed. Patients were managed by two consultant breast surgeons, who performed or supervised all surgical procedures. Data that was collected prospectively on the British Association of Surgical Oncology Database was retrieved and analysed. During this period, 1964 patients presented with sponta- neous nipple discharge, either alone or in combination with other symptoms. Triple assessment diagnosed breast cancer in 62 patients and benign causes in 1708. In the absence of a clinical or radiological abnormality to allow a deﬁnite benign or malignant diagnosis, duct excision was performed if the nature of the discharge caused concern. One hundred and ninety-four patients, including 1 man, underwent duct excision for spontaneous nipple discharge alone, median age 51, range 17–88 years (Figure 1). Two women had a previous history of breast carcinoma; both pre- sented with discharge on the contralateral side to a previous mastectomy. Fifty-eight patients had a past history of benign breast disease. 3. Results One hundred and ninety-four duct excisions were performed for spontaneous nipple discharge alone, 135 total duct exci- sion, and 59 microdochectomies. Breast cancer was identiﬁed in 11 (5.7%) patients: 4 invasive and 7 insitu (Table 1). Duct ectasia and duct papilloma were the most common benign diagnoses. The median age of patients found to have bloodstained discharge diagnosed to be breast cancer was 68 with a range of 32–88. This was higher than that for patients who were found to have benign disease, median age 50 with a range 17–84 years for patients with benign disease. All patients diagnosed with breast cancer, following duct excision (Table 2), subsequently underwent mastectomy with either axillary sampling or clearance. One patient was initially treated by central wide local excision, but disease- free margins could not be obtained. All 4 cases of invasive International Journal of Breast Cancer Age distribution of patients undergoing surgery for isolated nipple discharge 50 44 41–50 51–60 Age category 32 61–70 22 >70 60 50 re 40 bm30 uN20 10 0 10 <30 36 31–40 Histology Malignant IDC DCIS Benign Duct ectasia Papilloma Periductal mastitis Fibrocystic disease ADH Normal IDC: invasive ductal carcinoma. DCIS: ductal carcinoma insitu. ADH: atypical ductal hyperplasia. 11 4 7 183 76 65 21 12 3 6 6% 2% 4% 94% 39% 34% 11% 6% 1% 3% Median age (range) 68 (32–88) 72 (68–74) 59 (32–88) 50 (17–84) 50 (22–84) 56 (26–84) 39 (17–59) 48 (35–65) 61 (35–76) 43 (24–67) Figure 1: Age distribution of patients undergoing surgery for spontaneous isolated nipple discharge. Table 1: Histology of duct excision specimens. Number % of total (195) carcinoma were grade 2 or 3 invasive ductal with associated ductal carcinoma insitu. Two cases of DCIS were high grade, 4 intermediate grade, and 1 low grade. Nodal involvement was not identiﬁed in any cases. There were no major dis- crepancies between the histological diagnoses from the duct excision and the subsequent therapeutic surgery, in 1 case, the grade of DCIS was increased from low to intermediate. None of these patients developed recurrent disease during the 24–130 months followup. Ten patients with breast cancer had unilateral single- duct discharge, 1 had unilateral multiple duct discharge and was found to have extensive intermediate grade DCIS. All 11 patients had some form of bloodstained discharge: 9 frankly bloodstained discharge, 1 altered blood, and 1 serous discharge that was positive for blood on dipstick testing. Discharge due to malignant disease was signiﬁcantly more likely to be bloodstained than that due to benign causes (Fisher’s exact test, 2-tailed P value = 0.001). One hundred and eight patients (56%) who underwent duct excision had bloodstained discharge. The median age of patients with bloodstained discharge was higher than those with nonbloodstained discharge: 55, range 24–88 years, versus 47, range 17–74 years, but did not reach statistical signiﬁcance (Mann-Whitney test, P = 0.295).