American College of Radiology
ACR Appropriateness Criteria®

Evaluation of Nipple Discharge

Variant 1: Physiologic nipple discharge. Woman of any age. Initial imaging examination.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Mammography diagnostic Usually not appropriate ☢☢ 0.1-1mSv 1 n/a 0 0 0 0 0 0 0 0 0
Ductography Usually not appropriate ☢☢ 0.1-1mSv 1 n/a 0 0 0 0 0 0 0 0 0
Digital breast tomosynthesis diagnostic Usually not appropriate ☢☢ 0.1-1mSv 1 n/a 0 0 0 0 0 0 0 0 0
US breast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Tc-99m sestamibi MBI Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
MRI breast without IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
MRI breast without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Image-guided fine needle aspiration breast Usually not appropriate Varies Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
Image-guided core biopsy breast Usually not appropriate Varies Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
FDG-PEM Usually not appropriate ☢☢☢☢ 10-30 mSv 1 n/a 0 0 0 0 0 0 0 0 0
Variant 2: Pathologic nipple discharge. Man or woman 40 years of age or older. Initial imaging examination.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Mammography diagnostic Usually appropriate ☢☢ 0.1-1mSv 9 n/a 0 0 0 0 0 0 0 0 0
Digital breast tomosynthesis diagnostic Usually appropriate ☢☢ 0.1-1mSv 9 n/a 0 0 0 0 0 0 0 0 0
US breast Usually appropriate O 0 mSv O 0 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
Ductography Usually not appropriate ☢☢ 0.1-1mSv 1 n/a 0 0 0 0 0 0 0 0 0
Tc-99m sestamibi MBI Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
MRI breast without IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
MRI breast without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Image-guided fine needle aspiration breast Usually not appropriate Varies Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
Image-guided core biopsy breast Usually not appropriate Varies Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
FDG-PEM Usually not appropriate ☢☢☢☢ 10-30 mSv 1 n/a 0 0 0 0 0 0 0 0 0
Variant 3: Pathologic nipple discharge. Man or woman 30 to 39 years of age. Initial imaging examination.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Mammography diagnostic Usually appropriate ☢☢ 0.1-1mSv 9 n/a 0 0 0 0 0 0 0 0 0
Digital breast tomosynthesis diagnostic Usually appropriate ☢☢ 0.1-1mSv 9 n/a 0 0 0 0 0 0 0 0 0
US breast Usually appropriate O 0 mSv O 0 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
Ductography Usually not appropriate ☢☢ 0.1-1mSv 1 n/a 0 0 0 0 0 0 0 0 0
Tc-99m sestamibi MBI Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
MRI breast without IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
MRI breast without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Image-guided fine needle aspiration breast Usually not appropriate Varies Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
Image-guided core biopsy breast Usually not appropriate Varies Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
FDG-PEM Usually not appropriate ☢☢☢☢ 10-30 mSv 1 n/a 0 0 0 0 0 0 0 0 0
Variant 4: Pathologic nipple discharge. Woman younger than 30 years of age. Initial imaging examination.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US breast Usually appropriate O 0 mSv O 0 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
Mammography diagnostic May be appropriate ☢☢ 0.1-1mSv 5 n/a 0 0 0 0 0 0 0 0 0
Digital breast tomosynthesis diagnostic May be appropriate ☢☢ 0.1-1mSv 5 n/a 0 0 0 0 0 0 0 0 0
Ductography Usually not appropriate ☢☢ 0.1-1mSv 1 n/a 0 0 0 0 0 0 0 0 0
Tc-99m sestamibi MBI Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
MRI breast without IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
MRI breast without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Image-guided fine needle aspiration breast Usually not appropriate Varies Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
Image-guided core biopsy breast Usually not appropriate Varies Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
FDG-PEM Usually not appropriate ☢☢☢☢ 10-30 mSv 1 n/a 0 0 0 0 0 0 0 0 0
Variant 5: Pathologic nipple discharge. Man younger than 30 years of age. Initial imaging examination.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US breast Usually appropriate O 0 mSv O 0 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
Mammography diagnostic Usually appropriate ☢☢ 0.1-1mSv 8 n/a 0 0 0 0 0 0 0 0 0
Digital breast tomosynthesis diagnostic Usually appropriate ☢☢ 0.1-1mSv 8 n/a 0 0 0 0 0 0 0 0 0
Ductography Usually not appropriate ☢☢ 0.1-1mSv 1 n/a 0 0 0 0 0 0 0 0 0
Tc-99m sestamibi MBI Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
MRI breast without IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
MRI breast without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Image-guided fine needle aspiration breast Usually not appropriate Varies Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
Image-guided core biopsy breast Usually not appropriate Varies Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
FDG-PEM Usually not appropriate ☢☢☢☢ 10-30 mSv 1 n/a 0 0 0 0 0 0 0 0 0
Appendix Key

A more complete discussion of the items presented below can be found by accessing the supporting documents at the designated hyperlinks.

Appropriateness Category:The panel’s recommendation for a procedure based on the assessment of the risks and benefits of performing the procedure for the specified clinical scenario.

SOE: Strength of Evidence. The assessment of the amount and quality of evidence found in the peer reviewed medical literature for an appropriateness recommendation.

  • References: The citation number and PMID for the reference(s) associated with the recommendation.
  • Study Quality: The assessment of the quality of an individual reference based on the number of study quality elements described in the reference.

RRL: Relative Radiation Level. A population based assessment of the amount of radiation a typical patient may be exposed to during the specified procedure.

Rating: The final rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Median: The median rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Final tabulations: A histogram showing the number of panel members who rated the procedure as noted in the column heading (ie, 1, 2, 3, etc.).

Additional supporting documents about the AC methodology and processes can be found at www.acr.org/ac.