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Avdan Aslan A, Gültekin S. What is the role of breast MRI in the management of women with pathologic nipple discharge and normal conventional imaging? Ir J Med Sci 2023; 192:2331-2335. [PMID: 36409422 DOI: 10.1007/s11845-022-03230-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 11/13/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND/AIMS To investigate the diagnostic performance of breast MRI in revealing mammographically and sonographically occult lesions requiring excision in patients with pathologic nipple discharge. MATERIALS AND METHODS In this retrospective study, 57 women with pathologic nipple discharge who had normal or inconclusive mammography and ultrasonography results and underwent breast MRI were determined. Patients who had histopathological diagnosis or ≥ 1-year imaging follow-up were included. MRIs were classified as positive and negative according to final BI-RADS assessment categories. Diagnostic performance of MRI, including sensitivity, specificity, negative predictive value, and positive predictive value, was calculated for detecting both malignancy and lesions requiring surgery. RESULTS Abnormal contrast enhancement on the pathologic nipple discharge side was detected in 29 MRIs (50.8%), categorized as BI-RADS 4. Abnormal findings were solid masses in 17 cases (58.6%) and non-mass enhancement in 12 cases (41.3%). Despite normal conventional imaging results, 4 malignant lesions and 16 lesions requiring surgery were detected with MRI. The sensitivity and specificity of MRI for detecting lesions requiring surgery were 100% and 68.2%, respectively. The positive predictive value (PPV) and negative predictive value were 55.1% and 100%, respectively. CONCLUSION In conclusion, this study confirmed that MRI is a reliable tool to detect lesions requiring surgery in patients with pathologic nipple discharge. MRI should be used in routine workup in patients with normal conventional imaging and imaging follow-up can be safely applied in patients with negative MRI.
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Affiliation(s)
- Aydan Avdan Aslan
- Department of Radiology, Faculty of Medicine, Gazi University, Emniyet, Mevlana Blv. No:29, Yenimahalle, Ankara, 06560, Turkey.
| | - Serap Gültekin
- Department of Radiology, Faculty of Medicine, Gazi University, Emniyet, Mevlana Blv. No:29, Yenimahalle, Ankara, 06560, Turkey
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Vavolizza RD, Dengel LT. Management of Nipple Discharge. Surg Clin North Am 2022; 102:1077-1087. [DOI: 10.1016/j.suc.2022.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Sanford MF, Slanetz PJ, Lewin AA, Baskies AM, Bozzuto L, Branton SA, Hayward JH, Le-Petross HT, Newell MS, Scheel JR, Sharpe RE, Ulaner GA, Weinstein SP, Moy L. ACR Appropriateness Criteria® Evaluation of Nipple Discharge: 2022 Update. J Am Coll Radiol 2022; 19:S304-S318. [PMID: 36436958 DOI: 10.1016/j.jacr.2022.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 09/07/2022] [Indexed: 11/27/2022]
Abstract
The type of nipple discharge dictates the appropriate imaging study. Physiologic nipple discharge is common and does not require diagnostic imaging. Pathologic nipple discharge in women, men, and transgender patients necessitates breast imaging. Evidence-based guidelines were used to evaluate breast imaging modalities for appropriateness based on patient age and gender. For an adult female or male 40 years of age or greater, mammography or digital breast tomosynthesis (DBT) is performed initially. Breast ultrasound is usually performed at the same time with rare exception. For males or females 30 to 39 years of age, mammography/DBT or breast ultrasound is performed based on institutional preference and individual patient considerations. For young women less than 30 years of age, ultrasound is performed first with mammography/DBT added if there are suspicious findings or if the patient is at elevated lifetime risk for developing breast cancer. There is a high incidence of breast cancer in males with pathologic discharge. Men 25 years and older should be evaluated using mammography/DBT and ultrasound added when indicted. In transfeminine (male-to-female) patients, mammography/DBT and ultrasound are useful due to the increased incidence of breast cancer. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
- Matthew F Sanford
- Lead Interpreting Physician, Sanford Health of Northern Minnesota, Bemidji, Minnesota.
| | - Priscilla J Slanetz
- Panel Chair, Boston University School of Medicine, Boston, Massachusetts; Vice Chair, Academic Affairs, Department of Radiology, Associate Program Director, BMC Diagnostic Radiology Residency and Program Director, Academic Writing Program Boston Medical Center, Boston, Massachusetts
| | - Alana A Lewin
- Panel Vice-Chair, New York University School of Medicine, New York, New York
| | - Arnold M Baskies
- Virtua Willingboro Hospital, Willingboro, New Jersey; American College of Surgeons; Clinical Professor, Surgery, Rowan School of Medicine, Stratford, New Jersey
| | - Laura Bozzuto
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; American College of Obstetricians and Gynecologists
| | - Susan A Branton
- Medical Directo, Breast Health Center and Medical Staff President, UPMC North Central, Pittsburgh, Pennsylvania; American College of Surgeons
| | | | - Huong T Le-Petross
- Breast MRI Director, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - John R Scheel
- Vice-Chair, Global Health, University of Washington, Seattle, Washington
| | | | - Gary A Ulaner
- James & Pamela Muzzy Endowed Chair, Molecular Imaging and Therapy, Hoag Family Cancer Institute, Newport Beach, California
| | - Susan P Weinstein
- Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania; Associate Chair for Radiology Network Strategic Projects
| | - Linda Moy
- Specialty Chair, NYU Clinical Cancer Center, New York, New York
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Chung HL, Bevers TB, Legha RS, Speer ME, Tso HH, Sun J, Leung JW. Nipple Discharge Imaging Evaluation with Mammography, Ultrasound, Galactography, and MRI. Acad Radiol 2022; 30:783-797. [PMID: 35760711 DOI: 10.1016/j.acra.2022.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 05/20/2022] [Accepted: 05/22/2022] [Indexed: 11/26/2022]
Abstract
RATIONALE AND OBJECTIVE To determine the diagnostic yield of various imaging tests used to evaluate nipple discharge. MATERIALS AND METHODS A single institution, IRB-approved, retrospective study was performed of 320 consecutive patients presenting with nipple discharge. Imaging and pathology were reviewed to determine the yield for malignancy, atypical high-risk lesions (HRLs), and intraductal papillomas (IDPs). RESULTS Of the 320 patients, pathology or follow up confirmed 40 breast malignancies (40/320, 12.5%),14 atypical HRLs (14/320, 4.4%), 71 IDPs (71/320, 22.2%), 48 other benign pathologies (48/320,15.0%), and 147 unknown but benign cases (147/320, 45.9%). Physiologic discharge characteristics were observed in a minority of malignant cases: nonspontaneous (4/40, 10.0%); neither bloody nor clear (4/40, 10.0%); bilateral (3/40, 7.5%). Malignancy was associated with older age (p < 0.001) and bloody discharge (odds ratio 6.5, p < 0.0001). The combination of digital mammography and ultrasound had a 93% sensitivity and a 98% NPV, while contrast enhanced MRI (CE-MRI) had a 100% sensitivity and a 100% NPV for malignancy. Only three galactography examinations were performed among the malignant cohort, with minimal contribution (1 of 3) to the diagnostic evaluation. In this case, galactography findings helped determine imaging-pathology discordance, prompting a recommendation for surgical excision and subsequently a malignant diagnosis. CONCLUSION The combination of mammography and ultrasonography detected 93% of breast malignancies associated with nipple discharge and had a 98% NPV for malignancy. The value of CE-MRI is its ability to detect the remaining malignancies, not detected on mammography or ultrasound, and its ability to obviate the need for surgical duct excision.
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Boisserie-Lacroix M, Doutriaux-Dumoulin I, Chopier J, Boyer B, Depetiteville MP, Hoppe S, Brouste V, Chamming's F. Diagnostic accuracy of breast MRI for patients with suspicious nipple discharge and negative mammography and ultrasound: a prospective study. Eur Radiol 2021; 31:7783-7791. [PMID: 33846843 DOI: 10.1007/s00330-021-07790-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 01/15/2021] [Accepted: 02/15/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVES To evaluate the diagnostic accuracy of breast MRI in identifying lesions requiring excision for patients with suspicious nipple discharge but normal mammograms and ultrasounds. METHODS Between September 2013 and May 2019, 106 female participants (mean age 57.9 years) were consecutively included in this prospective multicenter study; 102 were retained for analysis. MRI was considered negative in the absence of suspicious enhancement and positive in cases of ipsilateral abnormal enhancement (BI-RADS 3 to 5). Final diagnoses were based on histological findings of surgical or percutaneous biopsies or at 1-year follow-up. We considered all lesions requiring excision found on pathology (papilloma, atypia, nipple adenomatosis, or cancer) as positive results. We considered spontaneous resolution of the discharge at 1 year as a negative result. RESULTS MRI showed ipsilateral abnormal enhancement in 54 patients (53%) revealing 46 lesions requiring excision (31 benign papillomas, 5 papillomas with atypia, 2 nipple adenomatosis, and 8 cancers) and 8 benign lesions not requiring excision. No suspicious enhancement was found in the remaining 48 participants (47%). Forty-two were followed up at 1 year with spontaneous resolution of the discharge and six underwent surgery (revealing 2 benign papillomas). MRI diagnostic accuracy for the detection of a lesion requiring excision was as follows: sensitivity 96%, specificity 85%, positive predictive value 85%, and negative predictive value 96%. CONCLUSION In patients with suspicious nipple discharge and normal mammogram and ultrasound, MRI demonstrates excellent performance to identify lesions for which excision is required. Normal MRI indicates it is safe to propose follow-up only management, thus avoiding unnecessary duct excision. TRIAL REGISTRATION ClinicalTrials.gov NCT02819362 KEY POINTS: • Breast MRI can be useful for the management of patients with suspicious nipple discharge and negative mammogram and ultrasound. • MRI detected a lesion requiring excision in 46 participants (45%) with unexplained discharge. • If breast MRI is negative, follow-up is a safe alternative for these patients.
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Affiliation(s)
| | - Isabelle Doutriaux-Dumoulin
- Department of Radiology, Institut de Cancérologie de l'Ouest, Comprehensive Cancer Centre, F-44000, Saint-Herblain, France
| | - Jocelyne Chopier
- Department of Radiology, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, F-75020, Paris, France
| | - Bruno Boyer
- Breast Imaging Clinic, 6 place d'Italie, F-75013, Paris, France
| | | | - Stéphanie Hoppe
- Clinical and Epidemiological Research Unit, Institut Bergonié, Comprehensive Cancer Centre, F-33076, Bordeaux, France
| | - Véronique Brouste
- Clinical and Epidemiological Research Unit, Institut Bergonié, Comprehensive Cancer Centre, F-33076, Bordeaux, France
| | - Foucauld Chamming's
- Department of Radiology, Institut Bergonié, Comprehensive Cancer Centre, F-33076, Bordeaux, France
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Abstract
OBJECTIVE. Nipple discharge is a common complaint that is first evaluated with clinical assessment. Physiologic discharge does not require imaging other than routine screening mammography. Initial evaluation of pathologic nipple discharge involves mammography and ultrasound. evaluation of pathologic nipple discharge involves mammography and ultrasound. Because of its high sensitivity in detecting breast malignancy and its biopsy capability, MRI is increasingly used in lieu of ductography. CONCLUSION. The problem-solving algorithm for evaluating suspicious nipple discharge is evolving. When diagnostic imaging for evaluation of pathologic nipple discharge is negative, management is based on clinical suspicion. If additional imaging is warranted, MRI is preferred because of its increased sensitivity, specificity, and patient comfort. Although central duct excision is the current standard for evaluation of malignancy in patients with pathologic nipple discharge, studies suggest that, given the high negative predictive value of MRI, surveillance may be a reasonable alternative to surgery.
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Jiang L, Li X, Kong X, Ma T, Yang Q. Galactogram Grading System for Identifying Breast Cancer With Nipple Discharge. Clin Breast Cancer 2019; 20:e214-e219. [PMID: 31587961 DOI: 10.1016/j.clbc.2019.07.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 07/23/2019] [Accepted: 07/27/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Galactography is a primary recommendation in the management of nipple discharge (ND), which may be caused by benign or malignant lesions. We aimed to establish a galactogram grading system (GGS) and investigate its role in identifying breast cancer with ND. PATIENTS AND METHODS A total of 350 patients were included in our study. All patients received preoperative mammographic galactography successfully and underwent surgery at Qilu Hospital of Shandong University between January 2011 and August 2015. We first performed a retrospective study in a consecutive series of 250 patients with ND to establish a GGS. Then the subsequent consecutive series of 100 patients was analyzed to validate the grading system. RESULTS Our data showed that the GGS can well assess the risk of a galactogram's being malignant. Galactograms classified into grade I have a lower risk of being malignant, while those classified into grade III have a higher risk of being malignant. Thus, our GGS was useful for distinguishing malignant from benign lesions. CONCLUSION We established a scoring system for breast disease with ND. This GGS may be a novel approach for identifying breast cancer with ND.
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Affiliation(s)
- Liyu Jiang
- Department of Breast Surgery, Qilu Hospital, Shandong University, Jinan, PR China
| | - Xiaoyan Li
- Department of Breast Surgery, Qilu Hospital, Shandong University, Jinan, PR China
| | - Xiaoli Kong
- Department of Breast Surgery, Qilu Hospital, Shandong University, Jinan, PR China
| | - Tingting Ma
- Department of Breast Surgery, Qilu Hospital, Shandong University, Jinan, PR China
| | - Qifeng Yang
- Department of Breast Surgery, Qilu Hospital, Shandong University, Jinan, PR China; Department of Pathology Tissue Bank, Qilu Hospital, Shandong University, Jinan, PR China.
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Baydoun S, Gonzalez P, Whitman GJ, Dryden M, Xi Y, Dogan B. Is Ductography Still Warranted in the 21st century? Breast J 2019; 25:654-662. [PMID: 31087408 DOI: 10.1111/tbj.13302] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Revised: 09/15/2018] [Accepted: 09/18/2018] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To determine the utility of ductography in conjunction with mammography and ultrasound in patients with pathologic nipple discharge, and the incremental role of MRI after triple-modality evaluation. MATERIALS AND METHODS We retrospectively reviewed the medical records of patients who had presented with pathologic nipple discharge and had undergone mammography and/or ultrasound and ductography between January 1, 2005, and October 31, 2010. We tested the diagnostic sensitivity, specificity and accuracy of combined triple-modality evaluation as well as of MRI performed in addition to these imaging techniques. We used the gold standard of image-guided biopsies, surgical excision, or long-term clinical and imaging follow-up. RESULTS Among 94 study patients, benign papillomas were identified in 42 (44.7%), abscess in one (1%), duct ectasia in four (4.3%), and malignancy (invasive ductal carcinoma or ductal carcinoma in situ) or high-risk lesion (atypical ductal hyperplasia) in 10 (10.6%). Forty-six patients (49%) underwent surgical excision; 89.1% of which had presurgical planning with ductography. In 35 (37.2%) with negative imaging, resolution of nipple discharge was confirmed on median clinical and imaging follow-up of 36 months. Two patients with negative imaging were lost to follow-up. Sensitivity, specificity, PPV, and NPV for accurately demonstrating the etiology of pathologic nipple discharge were 13%, 97%, 89%, and 37% respectively for mammography; 73%, 97%, 98%, and 64% respectively for ultrasound; 76%, 72%, 84%, and 61% respectively for ductography; 86%, 70%, 85%, and 72% respectively for combined ultrasound and ductography; and 75%, 100%, 100% and 67% respectively for DCE-MRI. CONCLUSION The combination of mammography, ultrasound and ductography is highly accurate for identifying the etiology of pathologic nipple discharge. DCE-MRI can be used as an alternate to ductography if necessary.
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Affiliation(s)
- Serine Baydoun
- Department of Diagnostic Radiology, American University of Beirut, Beirut, Lebanon
| | - Pedro Gonzalez
- Breast Imaging Department, CT Radiology Complex, Bayamon, Puerto Rico
| | - Gary J Whitman
- Department of Diagnostic Radiology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mark Dryden
- Department of Diagnostic Radiology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Yin Xi
- Department of Biostatistics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Basak Dogan
- Department of Diagnostic Radiology, University of Texas Southwestern Medical Center, Dallas, Texas
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Srinivasan A, Nia E, Gupta M, Sun J, Leung JW. Retrospective statistical analysis on the diagnostic value of ductography based on lesion pathology in patients presenting with nipple discharge. Breast J 2019; 25:585-589. [PMID: 31087380 DOI: 10.1111/tbj.13298] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 10/25/2018] [Accepted: 10/25/2018] [Indexed: 11/29/2022]
Abstract
PURPOSE To compare sensitivities and specificities of ductography to noninvasive imaging studies in determining the cause of nipple discharge and assess the value of ductography on the basis of pathologic results. METHODS In this retrospective review of women with nipple discharge who underwent ductography between January 1, 2005 and October 30, 2015, at our institution, we compared ductography with noninvasive imaging results (mammography, ultrasound, MRI) to determine its relative diagnostic sensitivity, specificity, and relative accuracy. Diagnosis was defined from pathology results, clinical notes, and minimum of 1-year follow-up monitoring. The primary endpoints include accuracy, sensitivity, specificity, positive predictive value, and negative predictive value. The analyses were carried out in different configurations to compare results by the following pathologic categories: cancer, high-risk lesion, intraductal papilloma (IP) without atypia, and benign pathology and/or normal imaging results. RESULTS In patients with breast cancer, ductography and noninvasive breast imaging had similar sensitivities. In patients with a high-risk lesion, ductography was significantly more sensitive than noninvasive imaging modalities. In patients with intraductal papilloma without atypia, ductography was more sensitive than noninvasive imaging, but the difference was of only borderline significance. For women with benign pathology and/or normal imaging, noninvasive imaging showed a significantly higher specificity than ductography. CONCLUSION In the absence of standard diagnostic algorithm for patients presenting with nipple discharge, the clinician has numerous options to choose a diagnostic approach that will yield the most accurate information with the least disruption to the patient. Our results indicate the value of ductography compared to value of noninvasive imaging modalities when cancer is suspected and when high risk lesion is suspected. While we show the sensitivity of ductography is similar to noninvasive imaging modalities in the setting of cancer, the sensitivity of ductography is statistically valuable for diagnosing high-risk lesions. Our hope is that this study will emphasize more research and more understanding in clinical utility and management of high-risk lesions, leading to patient-focused algorithm for diagnosing the etiology of abnormal nipple discharge.
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Affiliation(s)
| | - Emily Nia
- University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Monali Gupta
- University of Arizona College of Medicine-Phoenix V.A. Health Care System, Phoenix, Arizona
| | - Jia Sun
- University of Texas MD Anderson Cancer Center, Houston, Texas
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Panzironi G, Pediconi F, Sardanelli F. Nipple discharge: The state of the art. BJR Open 2018; 1:20180016. [PMID: 33178912 PMCID: PMC7592406 DOI: 10.1259/bjro.20180016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 10/02/2018] [Accepted: 10/24/2018] [Indexed: 11/05/2022] Open
Abstract
Over 80% of females experience nipple discharge during their life. Differently from lactational (milk production) and physiological (white, green, or yellow), which are usually bilateral and involving multiple ducts, pathologic nipple discharge (PND) is a spontaneous commonly single-duct and unilateral, clear, serous, or bloody secretion. Mostly caused by intraductal papilloma(s) or ductal ectasia, in 5-33% of cases is due to an underlying malignancy. After clinical history and physical examination, mammography is the first step after 39, but its sensitivity is low (7-26%). Ultrasound shows higher sensitivity (63-100%). Nipple discharge cytology is limited by a false negative rate over 50%. Galactography is an invasive technique that may cause discomfort and pain; it can be performed only when the duct discharge is demonstrated at the time of the study, with incomplete/failed examination rate up to 15% and a difficult differentiation between malignant and benign lesions. Ductoscopy, performed under local anesthesia in outpatients, provides a direct visualization of intraductal lesions, allowing for directed excision and facilitating a targeted surgery. Its sensitivity reaches 94%; however, it is available in only few centers and most clinicians are unfamiliar with its use. PND has recently emerged as a new indication for contrast-enhanced breast MRI, showing sensitivity superior to galactography, with an overall sensitivity up to 96%, also allowing tailored surgery. Surgery no longer can be considered the standard approach to PND. We propose a state-of-the art flowchart for the management of nipple discharge, including ductoscopy and breast MRI as best options.
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Affiliation(s)
- Giovanna Panzironi
- Department of Radiological, Oncological and Pathological Sciences, Sapienza, University of Rome, Rome, Italy
| | - Federica Pediconi
- Department of Radiological, Oncological and Pathological Sciences, Sapienza, University of Rome, Rome, Italy
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Schulz-Wendtland R, Preuss C, Fasching PA, Loehberg CR, Lux MP, Emons J, Beckmann MW, Uder M, Mueller-Schimpfle M. Galactography with Tomosynthesis Technique (Galactomosynthesis) - Renaissance of a Method? Geburtshilfe Frauenheilkd 2018; 78:493-498. [PMID: 29880984 PMCID: PMC5986572 DOI: 10.1055/a-0594-2277] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 03/12/2018] [Accepted: 03/18/2018] [Indexed: 11/04/2022] Open
Abstract
Introduction
For decades, conventional galactography was the only imaging technique capable of showing the mammary ducts. Today, diagnosis is based on a multimodal concept which combines high-resolution ultrasound with magnetic resonance (MR) mammography and ductoscopy/galactoscopy and has a sensitivity and specificity of up to 95%. This study used tomosynthesis in galactography for the first time and compared the synthetic digital 2D full-field mammograms generated with this technique with the images created using the established method of ductal sonography. Both methods should be able to detect invasive breast cancers and their precursors such as ductal carcinoma in situ (DCIS) as well as being able to identify benign findings.
Material and Methods
Five patients with pathological nipple discharge were examined using ductal sonography, contrast-enhanced 3D galactography with tomosynthesis and the synthetic digital 2D full-field mammograms generated with the latter method. Evaluation of the images created with the different imaging modalities was done by three investigators with varying levels of experience with complementary breast diagnostics (1, 5 and 15 years), and their evaluations were compared with the histological findings.
Results
All 3 investigators independently evaluated the images created with ductal sonography, contrast-enhanced 3D galactography with tomosynthesis, and generated synthetic digital 2D full-field mammograms. Their evaluations were compared with the histopathological assessment of the surgical specimens resected from the 5 patients. There was 1 case of invasive breast cancer, 2 cases with ductal carcinoma in situ and 2 cases with benign findings. All 3 investigators made more mistakes when they used the standard imaging technique of ductal sonography to diagnose suspicious lesions than when they used contrast-enhanced galactography with tomosynthesis and the generated synthetic digital 2D full-field mammograms.
Conclusion
This is the first time breast tomosynthesis was used in galactography (galactomosynthesis) to create digital 3-dimensional images of suspicious findings. When used together with the generated synthetic digital 2D full-field mammograms, it could be a useful complementary procedure for the diagnosis of breast anomalies and could herald a renaissance of this method. Compared with high-resolution ductal ultrasound, the investigators achieved better results with contrast-enhanced galactography using tomosynthesis and the generated synthetic digital 2D full-field mammograms, as confirmed by histopathological findings.
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Affiliation(s)
- Rüdiger Schulz-Wendtland
- Radiologisches Institut, Universitätsklinikum Erlangen, CCC ER-EMN, Universitäts-Brustzentrum Franken, Erlangen, Germany
| | - Caroline Preuss
- Frauenklinik, Universitätsklinikum Erlangen, CCC ER-EMN, Universitäts-Brustzentrum Franken, Erlangen, Germany
| | - Peter A Fasching
- Frauenklinik, Universitätsklinikum Erlangen, CCC ER-EMN, Universitäts-Brustzentrum Franken, Erlangen, Germany
| | - Christian R Loehberg
- Frauenklinik, Universitätsklinikum Erlangen, CCC ER-EMN, Universitäts-Brustzentrum Franken, Erlangen, Germany
| | - Michael P Lux
- Frauenklinik, Universitätsklinikum Erlangen, CCC ER-EMN, Universitäts-Brustzentrum Franken, Erlangen, Germany
| | - Julius Emons
- Frauenklinik, Universitätsklinikum Erlangen, CCC ER-EMN, Universitäts-Brustzentrum Franken, Erlangen, Germany
| | - Matthias W Beckmann
- Frauenklinik, Universitätsklinikum Erlangen, CCC ER-EMN, Universitäts-Brustzentrum Franken, Erlangen, Germany
| | - Michael Uder
- Radiologisches Institut, Universitätsklinikum Erlangen, CCC ER-EMN, Universitäts-Brustzentrum Franken, Erlangen, Germany
| | - Markus Mueller-Schimpfle
- Klinik für Radiologie - Klinikum Frankfurt Hoechst, DKG-zertifiziertes Brustzentrum, Frankfurt am Main, Germany
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12
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Lee SJ, Trikha S, Moy L, Baron P, diFlorio RM, Green ED, Heller SL, Holbrook AI, Lewin AA, Lourenco AP, Niell BL, Slanetz PJ, Stuckey AR, Vincoff NS, Weinstein SP, Yepes MM, Newell MS. ACR Appropriateness Criteria ® Evaluation of Nipple Discharge. J Am Coll Radiol 2018; 14:S138-S153. [PMID: 28473070 DOI: 10.1016/j.jacr.2017.01.030] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 01/18/2017] [Accepted: 01/20/2017] [Indexed: 10/19/2022]
Abstract
Appropriate imaging evaluation of nipple discharge depends the nature of the discharge. Imaging is not indicated for women with physiologic nipple discharge. For evaluation of pathologic nipple discharge, multiple breast imaging modalities are rated for evidence-based appropriateness under various scenarios. For women age 40 or older, mammography or digital breast tomosynthesis (DBT) should be the initial examination. Ultrasound is usually added as a complementary examination, with some exceptions. For women age 30 to 39, either mammogram or ultrasound may be used as the initial examination on the basis of institutional preference. For women age 30 or younger, ultrasound should be the initial examination, with mammography/DBT added when ultrasound shows suspicious findings or if the patient is predisposed to developing breast cancer. For men age 25 or older, mammography/DBT should be performed initially, with ultrasound added as indicated, given the high incidence of breast cancer in men with pathologic nipple discharge. Although MRI and ductography are not usually appropriate as initial examinations, each may be useful when the initial standard imaging evaluation is negative. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - Su-Ju Lee
- Principal Author, University of Cincinnati Medical Center, Cincinnati, Ohio.
| | | | - Linda Moy
- Panel Vice-Chair, NYU Clinical Cancer Center, New York, New York
| | - Paul Baron
- Roper St. Francis Physician Partners Breast Surgery, Charleston, South Carolina; American College of Surgeons
| | | | - Edward D Green
- The University of Mississippi Medical Center, Jackson, Mississippi
| | | | | | - Alana A Lewin
- New York University School of Medicine, New York, New York
| | | | | | | | - Ashley R Stuckey
- Women and Infants Hospital, Providence, Rhode Island; American Congress of Obstetricians and Gynecologists
| | - Nina S Vincoff
- Hofstra Northwell School of Medicine, Manhasset, New York
| | - Susan P Weinstein
- Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Mary S Newell
- Panel Chair, Emory University Hospital, Atlanta, Georgia
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Cohen E, Leung JWT. Problem-Solving MR Imaging for Equivocal Imaging Findings and Indeterminate Clinical Symptoms of the Breast. Magn Reson Imaging Clin N Am 2018; 26:221-233. [PMID: 29622127 DOI: 10.1016/j.mric.2017.12.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Breast MR imaging is commonly used for high-risk screening and for assessing the extent of disease in patients with newly diagnosed breast cancer, but its utility for assessing suspicious symptoms and equivocal imaging findings is less widely accepted. The authors review current literature and guidelines regarding the use of breast MR imaging for these indications. Overall, problem-solving breast MR imaging is best reserved for pathologic nipple discharge and sonographically occult architectural distortion with limited biopsy options. Further study is necessary to define the role of problem-solving MR imaging for calcifications, mammographic asymmetries, and surgical scarring.
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Affiliation(s)
- Ethan Cohen
- Department of Diagnostic Radiology, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1350, Houston, TX 77030-4009, USA.
| | - Jessica W T Leung
- Department of Diagnostic Radiology, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1350, Houston, TX 77030-4009, USA
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14
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Lesetedi C, Rayne S, Kruger D, Benn CA. Indicators of breast cancer in patients undergoing microdochectomy for a pathological nipple discharge in a middle-income country. J Surg Res 2017; 220:336-340. [PMID: 29180200 DOI: 10.1016/j.jss.2017.06.046] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 05/26/2017] [Accepted: 06/16/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND The management of a pathological nipple discharge often involves surgery for the exclusion of a malignant etiology. This study aimed to determine the prevalence of cancer in patients who had microdochectomy for pathological nipple discharge in a population in South Africa and to evaluate patients' demographics and clinical characteristics as indicators of underlying cancer and make recommendations for their management in resource-limited settings. MATERIALS AND METHODS Clinical, radiological, and histological data from 153 patients who underwent a microdochectomy for a pathological nipple discharge at two South African breast clinics was collected. RESULTS Invasive or in situ cancer was found in 12 patients (7.84%), and in all patients, cancer was associated with a bloody nipple discharge. Bloody discharge had a sensitivity of 100% in indicating cancer, specificity of 55.32%, positive predictive value of 16%, and negative predictive value of 100%. Patients with breast cancer were also more likely to be aged 55 y or older (P = 0.04). Preoperative mammogram and ultrasound were poor in detecting cancer (0/12). CONCLUSIONS In our population, a bloody discharge in women aged 55 years or older should mandate a microdochectomy, with selective surgery for younger women and those with nonbloody discharges. Thorough clinical examination to determine the true color and nature of the discharge is vital in the initial assessment of these patients. Preoperative radiology is not helpful in determining the presence of cancer (in an isolated pathological nipple discharge), and microdochectomy still remains the gold standard in diagnosing cancer in these patients.
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Affiliation(s)
- Chiapo Lesetedi
- Department of Surgery, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sarah Rayne
- Department of Surgery, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Helen Joseph Breast Care Clinic, Helen Joseph Hospital, Johannesburg, South Africa.
| | - Deirdre Kruger
- Department of Surgery, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Carol-Ann Benn
- Department of Surgery, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Helen Joseph Breast Care Clinic, Helen Joseph Hospital, Johannesburg, South Africa; Netcare Breast Care Centre, Milpark Hospital, Johannesburg, South Africa
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15
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Yoon JH, Yoon H, Kim EK, Moon HJ, Park YV, Kim MJ. Ultrasonographic evaluation of women with pathologic nipple discharge. Ultrasonography 2017; 36:310-320. [PMID: 28494526 PMCID: PMC5621808 DOI: 10.14366/usg.17013] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 04/03/2017] [Accepted: 04/09/2017] [Indexed: 11/13/2022] Open
Abstract
Nipple discharge is a common symptom that is alarming for the patient since it can be a presenting symptom of breast cancer. Breast imaging is used to examine women with pathologic nipple discharge in order to detect any lesions that may be present and to assist in the differential diagnosis. The modalities of breast imaging include mammography, breast ultrasonography (US), and magnetic resonance imaging. Breast US is currently considered to be useful for the visualization of ductal structures and intraductal lesions that cause nipple discharge. In this review, we discuss US techniques that assist in the clear visualization of ductal structures and intraductal lesions in patients with nipple discharge. Controversy remains regarding the evaluation and management of patients with nipple discharge, and we summarize the results available in the currently published literature.
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Affiliation(s)
- Jung Hyun Yoon
- Department of Radiology and Research Institute of Radiologic Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Haesung Yoon
- Department of Radiology and Research Institute of Radiologic Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Eun-Kyung Kim
- Department of Radiology and Research Institute of Radiologic Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hee Jung Moon
- Department of Radiology and Research Institute of Radiologic Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Youngjean Vivian Park
- Department of Radiology and Research Institute of Radiologic Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Min Jung Kim
- Department of Radiology and Research Institute of Radiologic Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Park CJ, Kim EK, Moon HJ, Yoon JH, Kim MJ. Reliability of Breast Ultrasound BI-RADS Final Assessment in Mammographically Negative Patients with Nipple Discharge and Radiologic Predictors of Malignancy. J Breast Cancer 2016; 19:308-315. [PMID: 27721881 PMCID: PMC5053316 DOI: 10.4048/jbc.2016.19.3.308] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 06/11/2016] [Indexed: 11/30/2022] Open
Abstract
Purpose The purpose of this study was to retrospectively investigate the reliability of breast ultrasound (US) Breast Imaging Reporting and Data System (BI-RADS) final assessment in mammographically negative patients with pathologic nipple discharge, and to determine the clinical and ultrasonographic variables associated with malignancy in this group of patients. Methods A total of 65 patients with 67 mammographically negative breast lesions that were pathologically confirmed through US-guided biopsy were included. Results Of the 53 BI-RADS category 4 and 5 lesions, eight (15.1%) were malignant (six ductal carcinomas in situ, one invasive ductal carcinoma, and one solid papillary carcinoma). There was no malignancy among the remaining 14 category 3 lesions. Malignant lesions more frequently displayed a round or irregular shape (75.0%, 6/8; p=0.030) and nonparallel orientation (33.3%, 4/12; p=0.029) compared to the benign lesions. The increase in the BI-RADS category corresponded with a rise in the malignancy rate (p=0.004). Conclusion The BI-RADS lexicon and final assessment of breast US reliably detect and characterize malignancy in mammographically negative patients with pathologic nipple discharge.
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Affiliation(s)
- Chae Jung Park
- Department of Radiology, Breast Cancer Clinic, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Korea
| | - Eun-Kyung Kim
- Department of Radiology, Breast Cancer Clinic, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Korea
| | - Hee Jung Moon
- Department of Radiology, Breast Cancer Clinic, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Korea
| | - Jung Hyun Yoon
- Department of Radiology, Breast Cancer Clinic, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Korea
| | - Min Jung Kim
- Department of Radiology, Breast Cancer Clinic, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Korea
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Moennich J, Ort R, High W, Brown M. Breast carcinoma masquerading as basal cell carcinoma of the nipple. JAAD Case Rep 2016; 1:361-3. [PMID: 27051781 PMCID: PMC4809382 DOI: 10.1016/j.jdcr.2015.08.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
| | - Richard Ort
- Dermatology and Laser Institute of Colorado, Lone Tree, Colorado
| | - Whitney High
- Department of Dermatology, University of Colorado School of Medicine, Aurora, Colorado
| | - Mariah Brown
- Department of Dermatology, University of Colorado School of Medicine, Aurora, Colorado
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Ouldamer L, Kellal I, Legendre G, Ngô C, Chopier J, Body G. [Management of breast nipple discharge: Recommendations]. ACTA ACUST UNITED AC 2015; 44:927-37. [PMID: 26545854 DOI: 10.1016/j.jgyn.2015.09.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 09/18/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To investigate diagnostic value of imaging procedures and management strategies of the patients with nipple discharge (ND) to establish management recommendations. METHODS Bibliographical search in French and English languages by consultation of PubMed, Cochrane and Embase databases. RESULTS Although, all ND require an systematic evaluation guided by clinical data, bloody ND could be a predictor of breast cancer risk among different colors of discharge particularly in patients of more than 50 years (LE2). The mammography and breast ultrasography are the imaging procedures to realize in first intention (grade C) but they turn out useful only when they detect radiological abnormalities (LE4). Galactography has only a localizing value of possible ductal abnormalities (when standard imaging procedures is not contributive) (LE4). Thus, in the diagnostic investigation of a suspicious ND, galactography it is not recommended in standard practice (grade C). The breast Magnetic Resonance Imaging (MRI) is recommended when breast standard imaging procedures are not contributive (grade C). The ND cytology is useful only if it is positive (i.e. reveal cancer cells). There is no proof on the diagnostic performance of the cytological analysis of the ND to allow a recommendation on its realization or not. In front of a suspicious ND, when breast-imaging procedures reveals an associated radiological lesion, an adapted percutaneous biopsy is recommended by percutaneous way (grade C). Vacuum-assisted breast biopsies is a diagnostic tool but can also be therapeutic allowing to avoid surgery in case of benign lesion but current literature data do not allow recommendations on the therapeutic aspect of vacuum-assisted breast biopsy (LE4). In the absence of associated radiological signal, and in case of reproducible bloody persistent ND, a pyramidectomy is recommended (grade C).
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Affiliation(s)
- L Ouldamer
- Département de gynécologie, hôpital Bretonneau, CHRU de Tours, 2, boulevard Tonnellé, 37044 Tours, France; Faculté de médecine François-Rabelais, 37044 Tours, France; Unité Inserm 1069, 37044 Tours, France.
| | - I Kellal
- Département de gynécologie, hôpital Bretonneau, CHRU de Tours, 2, boulevard Tonnellé, 37044 Tours, France
| | - G Legendre
- CESP Inserm U1018, service de gynécologie obstétrique, CHU d'Angers, 49000 Angers, France
| | - C Ngô
- Service de chirurgie cancérologique, gynécologique et du sein, hôpital européen Georges-Pompidou, AP-HP, 15, rue Leblanc, 75015 Paris, France; Université Paris-Descartes, Paris, France
| | - J Chopier
- Service de radiologie, hôpital Tenon, AP-HP, 4, rue de la Chine, 75020 Paris, France
| | - G Body
- Département de gynécologie, hôpital Bretonneau, CHRU de Tours, 2, boulevard Tonnellé, 37044 Tours, France; Faculté de médecine François-Rabelais, 37044 Tours, France
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19
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Scheurlen K, Schnitzer A, Krammer J, Kaiser C, Schönberg SO, Wasser K. [Value of galactography for the diagnostic work-up of pathological nipple discharge in multimodal breast diagnostics. Part 2: a systematic review of the literature]. Radiologe 2015; 54:160-6. [PMID: 24233402 DOI: 10.1007/s00117-013-2573-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The survey results of a previous study showed that galactography is now rarely used in Germany and newer methods are applied. The evidential value of galactography should be established and opposed to the evidential value of ultrasound (US) and magnetic resonance mammography (MRM). MATERIALS AND METHODS A search was carried out in PubMed and Cochrane involving studies written in English or German. The level of evidence was measured according to the Oxford Centre for Evidence-based Medicine. RESULTS A total of 19 studies were included, 14 with results on galactography, 10 on US and 5 on MRM. Almost all studies were retrospective with an evidence assigned to level 3b or lower. The results on the diagnostic values showed a very wide range. Because of very variable numbers of cases and consideration of various pathologies, the studies are only comparable to a limited extent. CONCLUSION Galactography, US and MRM all show a weak level of evidence and no superiority of a particular method can be derived. Therefore, galactography can no longer be considered as a mandatory standard in modern multimodal imaging of the breast. Recommendations for the diagnostic work-up of pathological nipple discharge have to be included in current guidelines and must consider these facts.
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Affiliation(s)
- K Scheurlen
- Institut für Klinische Radiologie und Nuklearmedizin, Universitätsmedizin Mannheim, Medizinische Fakultät Mannheim der Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
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Abstract
OBJECTIVE The purpose of this study was to assess the contribution of ultrasound to the evaluation of patients with pathologic nipple discharge. MATERIALS AND METHODS A retrospective review was conducted of the records of females who presented with nipple discharge between January 1, 2009, and December 31, 2011. Pathologic nipple discharge was defined as discharge with one or more of the following features: unilateral, clear or bloody, and spontaneous. Patients underwent bilateral mammography followed by ultrasound directed at the subareolar portion of the affected breast. Radiologic findings and pathologic results were reviewed. RESULTS Over a 3-year period, 327 females (mean age, 48 years; range, 13-88 years) presented with nipple discharge. Among these patients, 273 (83%) underwent surgical excision or clinical or radiographic follow-up at least 2 years after presentation and composed the study population. Among the 273 patients, 262 (96%) underwent mammography and 246 (90%) underwent sonography. Among 252 patients who had at least one pathologic feature of nipple discharge and underwent surgical excision or at least 2 years of follow-up, a total of 20 (8%) cases of ductal carcinoma in situ (DCIS) or invasive adenocarcinoma were diagnosed. DCIS or invasive adenocarcinoma was diagnosed in eight patients with normal sonographic findings. For the detection of DCIS and invasive adenocarcinoma, the sensitivity and specificity of ultrasound were 56% (10/18) and 75% (170/228); the sensitivity and specificity of mammography were 15% (3/20) and 98% (237/242). CONCLUSION For females presenting with pathologic nipple discharge, ultrasound is a useful diagnostic tool and may be worth including in the routine evaluation.
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21
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Dupont SC, Boughey JC, Jimenez RE, Hoskin TL, Hieken TJ. Frequency of diagnosis of cancer or high-risk lesion at operation for pathologic nipple discharge. Surgery 2015; 158:988-94; discussion 994-5. [PMID: 26243343 DOI: 10.1016/j.surg.2015.05.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2015] [Revised: 05/01/2015] [Accepted: 05/02/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND Pathologic nipple discharge is managed customarily with diagnostic subareolar duct excision. We evaluated for features predictive of malignancy to identify cases where operation might be avoided. METHODS We studied 311 consecutive subareolar duct excisions for pathologic nipple discharge from January 2008 to July 2014. χ(2) tests were used to test for associations with final pathology. RESULTS In 27 cases, cancer was diagnosed preoperatively. Among the remaining 284, 26 (9%) were diagnosed with cancer and 8 (3%) with atypia at operation. At greatest risk of upstage to cancer were patients with prior ipsilateral breast cancer (3/8; 38%), BRCA mutation (2/3; 67%) or atypia on core needle biopsy (CNB; 3/8 [38%]). Excluding these patients lowered cancer and atypia upstages (7% [18/265] and 3% [7/265]), with bloody (versus serous) discharge (P = .001), and focal imaging abnormality (P = .02), the strongest risk factors. Serous discharge and either normal imaging or a benign CNB had a 1.3% cancer upstage rate. CONCLUSION Despite contemporary imaging, pathologic nipple discharge upstage rates to malignancy and atypia remain high, especially with prior ipsilateral breast cancer, BRCA mutation, or atypia on CNB. Absent these risk factors, patients with serous discharge and a benign CNB or normal imaging (cancer risk <2%) may be considered for nonoperative management.
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Affiliation(s)
| | | | - Rafael E Jimenez
- Department of Pathology and Laboratory Medicine, Mayo Clinic, Rochester, MN
| | - Tanya L Hoskin
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
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Yoon H, Yoon JH, Kim EK, Moon HJ, Park BW, Kim MJ. Adding Ultrasound to the Evaluation of Patients with Pathologic Nipple Discharge to Diagnose Additional Breast Cancers: Preliminary Data. ULTRASOUND IN MEDICINE & BIOLOGY 2015; 41:2099-2107. [PMID: 25952162 DOI: 10.1016/j.ultrasmedbio.2015.03.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2014] [Revised: 03/25/2015] [Accepted: 03/28/2015] [Indexed: 06/04/2023]
Abstract
The aim of this study was to assess the malignancy yield of ultrasound Breast Imaging Reporting and Data System (BI-RADS) classification and the diagnostic value of adding ultrasound to diagnosis of breast cancer in patients with pathologic nipple discharge. Of 267 patients with pathologic nipple discharge seen from February 2003 to March 2011, 198 with histopathologic confirmation and follow-up data were included. Ultrasound images and mammograms were analyzed according to BI-RADS. The malignancy rate for each BI-RADS category and the difference in diagnostic performance resulting from the addition of ultrasound to mammography were calculated. Of the 198 enrolled patients, 34 were diagnosed with a malignancy. The malignancy rates obtained with the addition of ultrasound to mammography were 0.0% (0 of 27) for category 1, 5.9% (1/17) for category 2, 9.4% (5/53) for category 3, 21.5% (20/93) for category 4 and 100% (8/8) for category 5. The malignancy rates for mammography alone were 7.7%-9.0% for categories 1-3, 68.5% (13/19) for category 4 and 100.0% (5/5) for category 5. Adding US to mammography did not significantly increase sensitivity compared with mammography alone. Other diagnostic performance markers such as specificity and positive predictive value were not improved. Among patients for whom mammograms were available, ultrasound detected 5 breast cancers (26.3%) in addition to the 19 breast cancers found by positive mammography. Although it did not increase overall diagnostic performance in patients with pathologic nipple discharge, addition of ultrasound to mammography did detect an additional 26.3% of malignant lesions.
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Affiliation(s)
- Haesung Yoon
- Department of Radiology, Research Institute of Radiologic Science, Yonsei University College of Medicine, Seodaemun-gu, Seoul, Korea
| | - Jung Hyun Yoon
- Department of Radiology, Research Institute of Radiologic Science, Yonsei University College of Medicine, Seodaemun-gu, Seoul, Korea
| | - Eun-Kyung Kim
- Department of Radiology, Research Institute of Radiologic Science, Yonsei University College of Medicine, Seodaemun-gu, Seoul, Korea
| | - Hee Jung Moon
- Department of Radiology, Research Institute of Radiologic Science, Yonsei University College of Medicine, Seodaemun-gu, Seoul, Korea
| | - Byeong-Woo Park
- Department of Surgery, Yonsei University College of Medicine, Seodaemun-gu, Seoul, Korea
| | - Min Jung Kim
- Department of Radiology, Research Institute of Radiologic Science, Yonsei University College of Medicine, Seodaemun-gu, Seoul, Korea.
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Liu M, Guo G, Xie F, Wang S, Yang H, Wang S. Mammary ductoscopy and follow-up avoid unnecessary duct excision in patients with pathologic nipple discharge. J Surg Oncol 2015; 112:139-43. [PMID: 26186164 DOI: 10.1002/jso.23972] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 06/22/2015] [Indexed: 11/09/2022]
Abstract
BACKGROUND AND OBJECTIVES The goal of this study was to evaluate the efficacy of ductoscopy and follow-up for the diagnoses of intraductal lesions and the concomitant advantages of avoiding surgery for patients with pathologic nipple discharge (PND). METHODS Two hundred and sixty-six ductoscopies were performed for 238 women. Patients with positive ductoscopies underwent surgery. If no positive lesions were present upon ductoscopy, the women were followed. RESULTS Of 266 ductoscopic examinations, 168 (63.2%, 168/266) breasts from 165 patients were found to have positive images. The final histopathological results revealed that 93 patients with intraductal papilloma, 42 with intraductal papillomatosis, 15 with ADH lesions, DCIS in 9 patients, 1 case with invasive ductal carcinoma (IDC), 6 cases with duct ectasia, and 2 cases with inflammation. Seventy-three patients with negative results upon ductoscopy were followed with a median time of 48 months. Twelve patients had PND recurrence and were diagnosed as papilloma or papillomatosis based on pathology after surgery. PND disappeared for 51 patients after ductoscopy, and no recurrence or disease evolvement was founded for them. CONCLUSION Ductoscopy and follow-up were advantageous for selecting patients to undergo surgery or surveillance. The recurrence of PND after ductoscopy might be a strong predictor for having intraductal disease.
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Affiliation(s)
- Miao Liu
- Breast Center, Peking University People's Hospital, Beijing, China
| | - Giagia Guo
- Breast Center, Peking University People's Hospital, Beijing, China
| | - Fei Xie
- Breast Center, Peking University People's Hospital, Beijing, China
| | - Siyuan Wang
- Breast Center, Peking University People's Hospital, Beijing, China
| | - Houpu Yang
- Breast Center, Peking University People's Hospital, Beijing, China
| | - Shu Wang
- Breast Center, Peking University People's Hospital, Beijing, China
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van Gelder L, Bisschops RHC, Menke-Pluymers MBE, Westenend PJ, Plaisier PW. Magnetic resonance imaging in patients with unilateral bloody nipple discharge; useful when conventional diagnostics are negative? World J Surg 2015; 39:184-6. [PMID: 25123174 DOI: 10.1007/s00268-014-2701-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Unilateral bloody nipple discharge (UBND) is mostly caused by benign conditions such as papilloma or ductal ectasia. However, in 7-33 % of all nipple discharge, it is caused by breast cancer. Conventional diagnostic imaging like mammography (MMG) and ultrasonography (US) is performed to exclude malignancy. Preliminary investigations of breast magnetic resonance imaging (MRI) assume that it has additional value. With an increasing availability of MRI, it is of clinical importance to evaluate this. We evaluated the additional diagnostic value of MRI in patients with UBND in the absence of a palpable mass, with normal conventional imaging. METHODS All women with UBND in the period November 2007-July 2012 were included. In addition to the standard work-up (patient's history, physical examination, MMG, and US), MRI was performed. Data from these examinations and treatment were collected retrospectively. RESULTS A total of 111 women (mean age 52 years; range 23-80) were included. In nine (8 %) patients, malignancy was suspected on MRI while conventional imaging was normal. In eight (89 %) of these patients, histology was obtained, two by core biopsy and six by terminal duct excision. Benign conditions were found in six patients (86 %) and a (pre-) malignant lesion in two patients. In both cases, it concerned a ductal carcinoma in situ, which was treated with breast-conserving therapy. Moreover, in two cases of (pre)malignancy, the MRI was interpreted as negative. CONCLUSION In patients with UBND who show no signs of a malignancy on conventional diagnostic examinations, the added value of a breast MRI is limited, since a malignancy can be demonstrated in <2 %.
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Affiliation(s)
- L van Gelder
- Department of Surgery, Albert Schweitzer Hospital, Albert Schweitzerplaats 25, 3318 AT, Dordrecht, The Netherlands,
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25
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Sheiman LS, Levesque PH. The In's and Out's of Ductography: A Comprehensive Review. Curr Probl Diagn Radiol 2015; 45:61-70. [PMID: 26163736 DOI: 10.1067/j.cpradiol.2015.05.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Accepted: 05/30/2015] [Indexed: 11/22/2022]
Abstract
Nipple discharge is a common clinical problem, which is most frequently benign. However, nipple discharge may be the presenting symptom of an underlying malignancy. Ductography can provide valuable information in identifying the cause of the discharge. As ductography is a relatively low-volume procedure in most practices, many radiologists and trainees often lack familiarity and experience with the procedure. This article is intended to review the indications, technique, relevant ductal anatomy, and potential imaging findings of ductography.
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Affiliation(s)
- Laura S Sheiman
- Department of Diagnostic Radiology, Yale University School of Medicine, New Haven, CT.
| | - Paul H Levesque
- Department of Diagnostic Radiology, Yale University School of Medicine, New Haven, CT
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Patel BK, Falcon S, Drukteinis J. Management of nipple discharge and the associated imaging findings. Am J Med 2015; 128:353-60. [PMID: 25447625 DOI: 10.1016/j.amjmed.2014.09.031] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Revised: 09/29/2014] [Accepted: 09/30/2014] [Indexed: 11/16/2022]
Abstract
Nipple discharge is commonly encountered by health care providers, accounting for 2%-5% of medical visits by women. Because nipple discharge is the presenting symptom in 5% to 12% of breast cancers, it causes considerable anxiety for both patient and providers. Furthermore, the work-up and management of nipple discharge can be confusing. Fortunately, the cause of nipple discharge is usually benign, so the primary goal of evaluation and management is separation of patients with pathologic causes of discharge from those with benign or physiologic causes. The evaluation of nipple discharge requires a thorough history, careful physical examination, and an informed approach that selects the most suitable diagnostic modality. Primary care providers, working with their radiologists and surgeons, are well positioned to design appropriate diagnostic and management protocols to assess and treat nipple discharge. A thoughtful and prudent approach to nipple discharge should alleviate patient anxiety by efficiently and effectively defining the underlying etiology.
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Affiliation(s)
- Bhavika K Patel
- Department of Radiology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Fla; Department of Oncological Sciences, University of South Florida, Tampa.
| | - Shannon Falcon
- Department of Radiology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Fla; Department of Oncological Sciences, University of South Florida, Tampa
| | - Jennifer Drukteinis
- Department of Radiology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Fla; Department of Oncological Sciences, University of South Florida, Tampa
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Lian ZQ, Wang Q, Zhang AQ, Zhang JY, Han XR, Yu HY, Xie SM. A nomogram based on mammary ductoscopic indicators for evaluating the risk of breast cancer in intraductal neoplasms with nipple discharge. Breast Cancer Res Treat 2015; 150:373-80. [PMID: 25749733 DOI: 10.1007/s10549-015-3320-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2014] [Accepted: 02/23/2015] [Indexed: 10/23/2022]
Abstract
Mammary ductoscopy (MD) is commonly used to detect intraductal lesions associated with nipple discharge. This study investigated the relationships between ductoscopic image-based indicators and breast cancer risk, and developed a nomogram for evaluating breast cancer risk in intraductal neoplasms with nipple discharge. A total of 879 consecutive inpatients (916 breasts) with nipple discharge who underwent selective duct excision for intraductal neoplasms detected by MD from June 2008 to April 2014 were analyzed retrospectively. A nomogram was developed using a multivariate logistic regression model based on data from a training set (687 cases) and validated in an independent validation set (229 cases). A Youden-derived cut-off value was assigned to the nomogram for the diagnosis of breast cancer. Color of discharge, location, appearance, and surface of neoplasm, and morphology of ductal wall were independent predictors for breast cancer in multivariate logistic regression analysis. A nomogram based on these predictors performed well. The P value of the Hosmer-Lemeshow test for the prediction model was 0.36. Area under the curve values of 0.812 (95 % confidence interval (CI) 0.763-0.860) and 0.738 (95 % CI 0.635-0.841) was obtained in the training and validation sets, respectively. The accuracies of the nomogram for breast cancer diagnosis were 71.2 % in the training set and 75.5 % in the validation set. We developed a nomogram for evaluating breast cancer risk in intraductal neoplasms with nipple discharge based on MD image findings. This model may aid individual risk assessment and guide treatment in clinical practice.
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Affiliation(s)
- Zhen-Qiang Lian
- Breast Disease Center, Guangdong Women and Children Hospital of Jinan University, Guangzhou, 511400, People's Republic of China,
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Lubina N, Schedelbeck U, Roth A, Weng AM, Geissinger E, Hönig A, Hahn D, Bley TA. 3.0 Tesla breast magnetic resonance imaging in patients with nipple discharge when mammography and ultrasound fail. Eur Radiol 2014; 25:1285-93. [PMID: 25433415 DOI: 10.1007/s00330-014-3521-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Revised: 10/08/2014] [Accepted: 11/18/2014] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To compare 3.0 Tesla breast magnetic resonance imaging (MRI) with galactography for detection of benign and malignant causes of nipple discharge in patients with negative mammography and ultrasound. METHODS We prospectively evaluated 56 breasts of 50 consecutive patients with nipple discharge who had inconspicuous mammography and ultrasound, using 3.0 Tesla breast MRI with a dedicated 16-channel breast coil, and then compared the results with galactography. Histopathological diagnoses and follow-ups were used as reference standard. Lesion size estimated on MRI was compared with the size at histopathology. RESULTS Sensitivity and specificity of MRI vs. galactography for detecting pathologic findings were 95.7 % vs. 85.7 % and 69.7 % vs. 33.3 %, respectively. For the supposed concrete pathology based on MRI findings, the specificity was 67.6 % and the sensitivity 77.3 % (PPV 60.7 %, NPV 82.1 %). Eight malignant lesions were detected (14.8 %). The estimated size at breast MRI showed excellent correlation with the size at histopathology (Pearson's correlation coefficient 0.95, p < 0.0001). CONCLUSIONS MRI of the breast at 3.0 Tesla is an accurate imaging test and can replace galactography in the workup of nipple discharge in patients with inconspicuous mammography and ultrasound. KEY POINTS • Breast MRI is an excellent diagnostic tool for patients with nipple discharge. • MRI of the breast reveals malignant lesions despite inconspicuous mammography and ultrasound. • MRI of the breast has greater sensitivity and specificity than galactography. • Excellent correlation of lesion size measured at MRI and histopathology was found.
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Affiliation(s)
- Nóra Lubina
- Department of Diagnostic and Interventional Radiology, University of Würzburg, Oberdürrbacher Strasse 6, 97080, Würzburg, Germany
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Ohlinger R, Stomps A, Paepke S, Blohmer JU, Grunwald S, Hahndorf W, Camara O, Deichert U, Peisker U, Kohlmann T, Buchholz I, Hegenscheid K, Utpatel K, Zygmunt M, Hahn M. Ductoscopic Detection of Intraductal Lesions in Cases of Pathologic Nipple Discharge in Comparison with Standard Diagnostics: The German Multicenter Study. Oncol Res Treat 2014; 37:628-32. [DOI: 10.1159/000368338] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Accepted: 09/03/2014] [Indexed: 11/19/2022]
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Ashfaq A, Senior D, Pockaj BA, Wasif N, Pizzitola VJ, Giurescu ME, Gray RJ. Validation study of a modern treatment algorithm for nipple discharge. Am J Surg 2014; 208:222-7. [PMID: 24767970 DOI: 10.1016/j.amjsurg.2013.12.035] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Revised: 11/04/2013] [Accepted: 12/22/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND Nipple discharge occurs in 2% to 5% of women. We evaluated the effectiveness of a previously proposed treatment algorithm for these patients. METHODS Patients with pathologic nipple discharge and a negative mammogram and subareolar ultrasound were offered follow-up from 2005 to 2011 according to the algorithm. RESULTS A total of 192 patients, mean age 56 years, were studied. Risk of carcinoma among the entire cohort was 5%. Breast surgeon was consulted for 142 (74%) patients: 48 (34%) underwent initial subareolar excision and 94 (66%) were clinically followed. The rate of carcinoma was 17% (8/48) after initial subareolar excision, 0% (0/13) for those without imaging abnormalities, 23% (8/35) with imaging abnormalities, and 1% (1/94) with clinical follow-up. Of patients who underwent follow-up, 21% (n = 20) underwent subareolar excision because of imaging abnormality (n = 1, 1%) or persistent discharge (n = 19, 20%). Most patients had ductal carcinoma in situ (n = 5, 56%). CONCLUSIONS Patients with nipple discharge can be prospectively identified based on radiographic findings and clinical examination for safe clinical follow-up. Most will have resolution avoiding a surgical procedure.
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Affiliation(s)
- Awais Ashfaq
- Department of Surgery, Mayo Clinic, 5777 E. Mayo Blvd, Phoenix, AZ, USA
| | - Derek Senior
- Department of Surgery, Mayo Clinic, 5777 E. Mayo Blvd, Phoenix, AZ, USA
| | - Barbara A Pockaj
- Department of Surgery, Mayo Clinic, 5777 E. Mayo Blvd, Phoenix, AZ, USA
| | - Nabil Wasif
- Department of Surgery, Mayo Clinic, 5777 E. Mayo Blvd, Phoenix, AZ, USA
| | - Victor J Pizzitola
- Department of Radiology, Mayo Clinic, 5777 E. Mayo Blvd, Phoenix, AZ, USA
| | - Marina E Giurescu
- Department of Radiology, Mayo Clinic, 5777 E. Mayo Blvd, Phoenix, AZ, USA
| | - Richard J Gray
- Department of Surgery, Mayo Clinic, 5777 E. Mayo Blvd, Phoenix, AZ, USA.
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Sarica O, Ozturk E, Demirkurek HC, Uluc F. Comparison of ductoscopy, galactography, and imaging modalities for the evaluation of intraductal lesions: a critical review. Breast Care (Basel) 2013; 8:348-54. [PMID: 24415988 PMCID: PMC3862052 DOI: 10.1159/000355833] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Today, in cases of nipple discharge of unclear origin, the abundance of diagnostic procedures - a, diagnostic dilemma' - becomes apparent, because unequivocal indications and a current, standardized examination sequence are presently not available. The diagnostic workup of patients with nipple discharge usually includes the clinical history, physical examination, mammography, ultrasonography, galactography, and nipple discharge cytology, but not ductoscopy. METHODS In this review we analyze and discuss the possible role of ductoscopy in evaluating intraductal pathologies and its combined use with diagnostic imaging modalities. For this purpose, we reviewed and compared the results of the radiological, pathological, and surgical studies independently. CONCLUSIONS Currently, there is no solitary accurate modality to reach our definitive purpose. Being aware of the capability of each diagnostic modality may take us closer to our target. Therefore, adjunct and appropriate use of multiple imaging modalities and ductoscopy is necessary to evaluate patients with nipple discharge.
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Affiliation(s)
- Ozgur Sarica
- Department of Radiology, Taksim Education and Research Hospital, Istanbul, Turkey
| | - Enis Ozturk
- Department of Radiology, Bakirkoy Education and Research Hospital, Istanbul, Turkey
| | - Huseyin C. Demirkurek
- Department of Nuclear Medicine, Taksim Education and Research Hospital, Istanbul, Turkey
| | - Fatih Uluc
- Department of Radiology, Taksim Education and Research Hospital, Istanbul, Turkey
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Albrecht C, Thele F, Grunwald S, Kohlmann T, Hegenscheid K, Utpatel K, Zygmunt M, Ohlinger R. Nipple discharge: role of ductoscopy in comparison with standard diagnostic tests. ACTA ACUST UNITED AC 2013; 36:12-6. [PMID: 23429326 DOI: 10.1159/000346639] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND This study aims to assess the role of ductoscopy for detecting intraductal anomalies in patients with nipple discharge in comparison to conventional tests and to find an effective combination of both approaches. MATERIALS AND METHODS Prior to duct excision, ductoscopy was performed in 97 women. Histologic and all other diagnostic results were compared. Sensitivity, specificity, and efficiency were calculated for all methods. These parameters were also calculated for all possible test combinations in 12 patients who had completed all tests. RESULTS Breast sonography reached the highest sensitivity (64.1%) and efficiency (64%); mammography had the highest specificity (100%). The sensitivity of ductoscopy was 53.2%, its specificity 60%, and its efficiency 55.1%. Among combinations of all methods, the combination ductoscopy + galactography was the most sensitive (80%). Mammography, magnetic resonance imaging, and ductoscopy were each 100% specific. Ductoscopy was the most efficient (75%) single method. CONCLUSION Ductoscopy is a valuable test for diagnosing intraductal lesions in patients with nipple discharge. It is more efficient than conventional tests in patients undergoing all tests.
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Affiliation(s)
- Christine Albrecht
- Klinik und Poliklinik für Frauenheilkunde und Geburtshilfe, Universität, Greifswald, Germany
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Sabel MS, Helvie MA, Breslin T, Curry A, Diehl KM, Cimmino VM, Chang AE, Newman LA. Is Duct Excision Still Necessary for All Cases of Suspicious Nipple Discharge? Breast J 2011; 18:157-62. [DOI: 10.1111/j.1524-4741.2011.01207.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Berment H, Dolores M, Genevois A, Dacher JN. [MR-galactography: a new way to explore nipple discharges]. ACTA ACUST UNITED AC 2011; 39:315-20. [PMID: 21514201 DOI: 10.1016/j.gyobfe.2011.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2010] [Accepted: 02/09/2011] [Indexed: 11/18/2022]
Abstract
Nipple discharge is a common breast complaint that justifies an etiologic check-up in order to identify and characterize the underlying intraductal lesion. The low sensitivity and specificity of the existing imaging exams led to the search of new, more efficient ways to explore nipple discharge. MR-Galactography is one of these emerging techniques. Recent literature tends to prove that MR-Galactography could be an interesting technique for localizing and characterizing lesions causing nipple discharge.
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Affiliation(s)
- H Berment
- Radiodiagnostic, Hôpital René-Huguenin, Institut Curie, 35 rue Dailly, 92210 Saint-Cloud, France.
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Abstract
BACKGROUND This study was a retrospective analysis of patients who underwent minor or major duct surgery for pathological nipple discharge. The results of clinical examination, mammography, ultrasonography and cytodiagnosis of the nipple discharge were studied in order to predict those patients at risk of underlying or occult malignancy. METHODS Between January 2004 and December 2006, 55 female patients aged between 24 and 82 years old underwent major or minor duct excision, 49 of which were for pathological nipple discharge. Results of several preoperative investigations were compared with the surgical pathology to determine how their sensitivity and specificity faired in predicting malignant ductal pathology. RESULTS Of the 49 patients undergoing surgery for nipple discharge, 21 were diagnosed with intraductal papilloma, 19 with duct ectasia, 6 with carcinoma, 2 with benign breast disease and 1 with lobular carcinoma in situ. In all of the patients determined to have malignancy, none demonstrated malignant changes on mammography or ultrasonography. Only 2 of the 6 patients with malignancy were found to have atypical cells on cytological analysis. The sensitivity of blood detected in nipple discharge at predicting malignancy was 0.83, specificity of 0.53, positive predictive value of 0.20 and negative predictive value 0.96. CONCLUSIONS Despite the various tests used in the assessment of pathological nipple discharge, this study highlights their limited help at predicting the cause. This, together with several other studies, demonstrates that ductal surgery remains the only reliable way of providing a diagnosis, in addition to being the major therapeutic measure.
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Affiliation(s)
- Chris Alcock
- Department of Breast Surgery, The Royal Surrey County Hospital, Guildford, GU2 7XX, UK Postgraduate Medical School, University of Surrey, UK.
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Morrogh M, Park A, Elkin EB, King TA. Lessons learned from 416 cases of nipple discharge of the breast. Am J Surg 2010; 200:73-80. [DOI: 10.1016/j.amjsurg.2009.06.021] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2009] [Revised: 06/10/2009] [Accepted: 06/10/2009] [Indexed: 10/19/2022]
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Montroni I, Santini D, Zucchini G, Fiacchi M, Zanotti S, Ugolini G, Manaresi A, Taffurelli M. Nipple discharge: is its significance as a risk factor for breast cancer fully understood? Observational study including 915 consecutive patients who underwent selective duct excision. Breast Cancer Res Treat 2010; 123:895-900. [PMID: 20354781 DOI: 10.1007/s10549-010-0815-1] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2009] [Accepted: 02/19/2010] [Indexed: 12/01/2022]
Abstract
Nipple discharge (ND) is a common symptom seen in breast cancer clinics. The primary aim of this study was to identify preoperative risk factors for breast cancer in patients with pathologic ND. The secondary aim was to assess the clinical and pathological effectiveness of physical examination, galactography, cytological examination of the discharge, selective duct excision and ductoscopy. All patients operated on between 1975 and 2008 who presented with ND as their only symptom was analyzed. Discharge's characteristics, cytological data and galactography reports were recorded. The relationship between each individual finding and the risk of breast cancer was calculated. For each diagnostic tool, the sensitivity, specificity and complication rates were calculated and compared. Nine-hundred-fifteen patients underwent selective duct excision. Two-hundred-nineteen patients (23.9%) were found to be affected by carcinoma. In 100/330 (30.3%) patients with bloody discharge and in 42/239 (17.6%) patients with serous secretion cancer was detected (P = 0.004, P = 0.013, respectively). Patients with sero-sanguinous or coloured discharge had the same risk of cancer as the population analyzed (23.9%, P = NS). Galactographic finding of irregular stenosis seemed to be associated with a higher risk of cancer (P = 0.0001). Cytological findings C5 and C4 were associated with cancer (P = 0.001). Selective duct excision showed highest sensitivity and specificity. In conclusion, the well established role of bloody secretion is confirmed. The supposed benign aetiology of serous, coloured or sero-sanguinous discharge is questionable. The high specificity of the cytological exam justifies routine examination of the ND. Selective duct excision can be considered as the diagnostic gold-standard.
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Affiliation(s)
- Isacco Montroni
- Department of General Surgery, Emergency Surgery and Organ Transplantation, University of Bologna, Policlinico S.Orsola-Malpighi, Via Massarenti, 9, 40138, Bologna, Italy.
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The diagnostic value of nipple discharge cytology in 618 consecutive patients. Eur J Surg Oncol 2008; 35:573-7. [PMID: 18986790 DOI: 10.1016/j.ejso.2008.09.009] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2008] [Revised: 09/22/2008] [Accepted: 09/30/2008] [Indexed: 11/23/2022] Open
Abstract
AIM Preoperative stratification of patients presenting with nipple discharge (ND) according to malignancy risk has proven difficult. Nevertheless, cytological examination is considered to be a diagnostic aid. The aim of this study was to determine its complementary value in clinical decision-making in patients presenting with ND. METHODS We retrospectively collected data on macroscopic ND colour, ND cytology, physical examination, mammography, ultrasound and fine-needle aspiration cytology results. On ND cytology, benign diagnoses were considered negative, whereas suspicious and malignant diagnoses were considered positive for malignancy. RESULTS From 1992 to 2006, 618 patients had an ND smear, of those 163 patients had a biopsy. Sensitivity and specificity were 16.7% and 66.1%, respectively. These values were lower when ND was bloody than when ND was non-bloody (p=0.66 and p<0.05 for sensitivity and specificity, respectively). When macroscopically defining bloody ND as positive and non-bloody ND as negative, macroscopic ND colour examination had a remarkably higher sensitivity (60.6 vs. 18.2%, p<0.001) and only a slightly lower specificity (53.6 vs. 65.0%, p=0.07) when compared to cytological ND examination. Only 1 malignant lesion was designated positive solely by ND cytology (unique sensitivity (95% CI), 2.8% (0.0-8.4%)) and 3 lesions were correctly classified as negative by ND cytology (unique specificity (95% CI), 1.6%, 0.0-3.7%)). CONCLUSION Nipple discharge cytology has little complementary diagnostic value. Therefore, its routine use for detection of ND-related breast pathology should be reconsidered carefully. Nipple discharge cytology may redirect patient management well in some cases, but it may confuse work-up in the majority.
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Mortellaro VE, Marshall J, Harms SE, Hochwald SN, Copeland EM, Grobmyer SR. Breast MR for the Evaluation of Occult Nipple Discharge. Am Surg 2008. [DOI: 10.1177/000313480807400813] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Pathologic nipple discharge often presents a diagnostic and therapeutic dilemma for clinicians. We present two patients with pathologic nipple discharge in whom breast MR facilitated preoperative identification of and management of otherwise occult index lesions. Breast MR should be considered in the toolbox for evaluation of occult nipple discharge when other available strategies have failed to demonstrate an underlying etiology for the pathologic discharge. The use of breast MR in this setting may permit directed evaluation and management of potentially malignant lesions.
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Affiliation(s)
| | - Julia Marshall
- Department of Radiology, University of Florida College of Medicine, Gainesville, Florida; and the
| | | | - Steven N. Hochwald
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, and the
| | - Edward M. Copeland
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, and the
| | - Stephen R. Grobmyer
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, and the
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Gray RJ, Pockaj BA, Karstaedt PJ. Navigating murky waters: a modern treatment algorithm for nipple discharge. Am J Surg 2007; 194:850-4; discussion 854-5. [DOI: 10.1016/j.amjsurg.2007.08.027] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2007] [Revised: 08/13/2007] [Accepted: 08/13/2007] [Indexed: 11/25/2022]
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Morrogh M, Morris EA, Liberman L, Borgen PI, King TA. The Predictive Value of Ductography and Magnetic Resonance Imaging in the Management of Nipple Discharge. Ann Surg Oncol 2007; 14:3369-77. [PMID: 17896158 DOI: 10.1245/s10434-007-9530-5] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2007] [Revised: 06/25/2007] [Accepted: 06/27/2007] [Indexed: 11/18/2022]
Abstract
BACKGROUND Standard evaluation (physical examination, mammography, sonography) often fails to identify an underlying lesion in patients with suspicious nipple discharge. The aim of this study was to determine the predictive value of ductography (DG) and magnetic resonance imaging (MRI) in this setting. METHODS Using ICD-9 codes, we retrospectively identified 376 patients who presented with suspicious nipple discharge (ND) (1995-2005); 306 patients (68%) had negative standard evaluation. RESULTS Among 306 patients, 186 (61%) underwent further evaluation with DG (n = 163) and/or MRI (n = 52), 35 (11%) underwent major duct excision alone (MDE), and 85 (28%) were followed clinically. Ultimately, 182/306 (59%) patients underwent surgery and/or biopsy. Overall incidence of malignant or high-risk pathology was 15% (46/306). DG was completed in 139/163 (85%) studies and detected 12 cancers and seven high-risk lesions (HRL), but failed to identify four cancers and 2 HRL (PPV 19%, NPV 63%). MRI detected seven cancers and three HRL, but failed to identify one cancer and one HRL (PPV 56%, NPV 87%). MDE alone (n = 35) detected five cancers and three HRL. Of all patients not having surgery, (142/306, 41%), one (0.01%) presented with an invasive cancer at 102 months (median follow-up, 6.3 months; range, 0-124 months). CONCLUSIONS An underlying malignancy was identified in 30/306 (10%) patients with ND and negative standard evaluation. Ductography is a poor predictor of underlying pathology and cannot exclude malignancy. MRI's higher predictive values may allow for improved patient selection and treatment planning; however, MRI should not replace MDE as the gold standard to exclude malignancy in patients with ND and negative standard evaluation.
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Affiliation(s)
- Mary Morrogh
- Breast Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA
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Bhargav RK, Kamal N, Mishra A, Pradeep PV, Agarwal V, Farah A, Verma AK. The value of clinical characteristics and breast imaging studies in predicting a histopathologic diagnosis of cancer or high-risk lesion in patients with spontaneous nipple discharge. Am J Surg 2006; 193:141-2. [PMID: 17188113 DOI: 10.1016/j.amjsurg.2005.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2005] [Accepted: 11/03/2005] [Indexed: 10/23/2022]
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Dillon MF, Mohd Nazri SR, Nasir S, McDermott EW, Evoy D, Crotty TB, O'Higgins N, Hill ADK. The role of major duct excision and microdochectomy in the detection of breast carcinoma. BMC Cancer 2006; 6:164. [PMID: 16796740 PMCID: PMC1539014 DOI: 10.1186/1471-2407-6-164] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2006] [Accepted: 06/23/2006] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The association of nipple discharge with breast carcinoma has resulted in numerous women undergoing exploratory surgery to exclude malignancy. The aim of this study was to determine whether pre-operative factors can identify those patients that are most at risk of carcinoma. METHODS All patients over a 14-year period (1991-2005) who had a microdochectomy or subareolar exploration for the evaluation of nipple discharge were assessed. Patient characteristics, pre-operative imaging and pathological findings were analysed. RESULTS Of the 211 patients included in this study, 116 patients had pathological (unilateral, uniductal serous or bloody) discharge. On excision, 6% (n = 7) of patients with pathological discharge and 2.4% (n = 2) of patients with non-pathological discharge were diagnosed with carcinoma. Overall, major duct excision resulted in the diagnosis of carcinoma in 4.3% (n = 9), ADH/LCIS in 4% (n = 8), papilloma in 39% (n = 83), and duct ectasia or non-specific benign disease in 53% (n = 111) of patients. In the patients determined to have malignancy, 44% (n = 4) were premenopausal. No patient with a non-bloody discharge in the total population analysed (28%; n = 59/211), or in the population with a pathological discharge (21%; n = 24/116) was found to have carcinoma upon excision. CONCLUSION Microdochectomy or major duct excision performed for nipple discharge resulted in a low rate of malignancy on excision. Conservative management of non-bloody nipple discharge can be considered in patients with no other clinical or radiological signs of malignancy.
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Affiliation(s)
- Mary F Dillon
- Department of Surgery, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
- Department of Surgery, University College Dublin, Dublin 4, Ireland
| | - Shah R Mohd Nazri
- Department of Surgery, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Shaaira Nasir
- Department of Surgery, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Enda W McDermott
- Department of Surgery, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
- Department of Surgery, University College Dublin, Dublin 4, Ireland
| | - Denis Evoy
- Department of Surgery, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Thomas B Crotty
- Department of Pathology, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Niall O'Higgins
- Department of Surgery, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
- Department of Surgery, University College Dublin, Dublin 4, Ireland
| | - Arnold DK Hill
- Department of Surgery, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
- Department of Surgery, University College Dublin, Dublin 4, Ireland
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Adenomyoepithelioma of the Breast. J Med Ultrasound 2005. [DOI: 10.1016/s0929-6441(09)60104-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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