International Journal of Breast Cancer Table 4: Patients with benign diagnoses at duct excision, who subsequently represented with breast cancer. Age at original Initial presentation Initial diagnosis presentation pTrimeseenttoatrieo-n Side Subsequent presentation 4 63 77 49 52 59 62 67 76 Further histology 2 mm grade 2 node negative IDC +DCIS + duct papilloma 23 mm grade 2 node negative IDC + DCIS Treatment Mx + ANC Mx + ANC Mx + ANC + reconstruction. Recurrence in reconstructio 15 months later treated with WLE + DXT (15 mm grade 3 IDC) ANC WLE + ANC + DXT Mx + ANC WLE + ANS + DXT Mx + ANC Bloodstained single-duct nipple discharge Bloodstained single-duct nipple discharge ADH ADH 16 months Serous nipple Contralateral discharge dipstick +++ for blood 48 months Ipsilateral sAeseynmomnestcrriecedneinngsity 1n6odmemneggraatdivee2 mammogram follow IDC up Serous single-duct nipple discharge Duct papilloma, duct ectasia and ﬁbrocystic disease 84 months Contralateral nBoredausltapriatiyn and Bloodstained single-duct nipple discharge Bloodstained single-duct nipple discharge Brown single-duct nipple discharge Serous single-duct nipple discharge Fibrocystic disease 94 months Duct ectasia 54 months Duct papilloma 56 months Duct papilloma 26 months Clear single-duct nipple discharge dDuuccttepcatapsiilaloma + 6 weeks Metastatic adenocarcinoma Ipsilateral Lump in axilla from presumed occult breast primary 22 mm grade 2 Ipsilateral Lump node negative IDC Two adjacent Ipsilateral dBilsocohdasrtgaeined nipple n<o5dmemneggraatdivee2 IDC 13 mm grade 2 Bloodstained nipple node negative Contralateral discharge and IDC, DCIS + nodularity multiple duct papillomas 14 mm grade 2 Contralateral New lump node negative IDC Histology: DCIS: ductal carcinoma in situ; IDC: Invasive ductal carcinoma. Treatment: Mx: mastectomy; ANS: axillary node sampling; ANC: axillary node clearance; WLE: wide local excision; DXT: radiotherapy. of widespread intermediate grade DCIS that necessitated mastectomy. From our data it would appear appropriate to advocate conservative management for women under 30, but this would only have avoided 9 of 194 operations. Locker et al. [23] advocated conservative management of patients with all types of nipple discharge, suggesting reinvestigation 1 year after presentation. They claimed that any breast cancer not identiﬁed at presentation would still be at a very early stage when a clinical or radiological abnormality became apparent, which would not adversely aﬀect the outcome. If this had been applied to our series, four women with grade 2 invasive breast carcinoma would have had a delayed diagnosis. It is not possible to predict when their cancers would have become clinically or radiologically detectable or what eﬀect that this would have had on prog- nosis, but a delay in diagnosing breast cancer of more than three months is considered to have prognostic signiﬁcance [24]. Reviews have reported that DCIS progresses to invasive cancer in 14–53% of cases over a period of at least 10 years [25], that DCIS presenting with nipple discharge tends to be extensive and has a high rate of local recurrence if treated with breast conservation [26], and that higher grades of DCIS are more likely to recur and to progress to high- grade invasive disease [27]. Only 1 patient had low-grade DCIS which would not support a policy of conservative management. Atypical ductal hyperplasia is associated with a risk of developing breast carcinoma of around 10% within 10 years [2]. Two of the 3 women were found to have ADH following duct excision developed breast cancer within 4 years, 1 in the contralateral breast. This raises the question of whether symptomatic ADH may impart a higher risk of developing