Nipple discharge: The role of imaging

Nipple Discharge: When is it Worrisome?

Nipple discharge is the third most common breast related complaint seen in the breast clinics. Although the majority of cases are due to a benign etiology, 5%-12% cases of pathological nipple discharge may be harboring an underlying malignancy. A thorough radiological workup in cases of pathological nipple discharge is thus of utmost importance, with the initial imaging modality depending on the age of the patient. The imaging modalities include mammogram (MG) and ultrasound (US) with addition of breast MRI if the nipple discharge is clinically suspicious and no MG or US correlate is identified. Magnetic Resonance Imaging (MRI) also holds promise in demonstrating the exact extent of a pathology detected on US and thus aids in the planning of further management.

What is the role of breast MRI in the management of women with pathologic nipple discharge and normal conventional imaging?

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.

The added role of contrast-enhanced spectral mammography in the evaluation of pathological nipple discharge

Background

Nipple discharge is one of the commonest encountered complaints in the field of breast imaging. Excluding malignancy as a cause of pathological nipple discharge is of utmost importance. Our aim in this study was to assess the role of contrast-enhanced spectral mammography (CESM) in the diagnostic workup of patients with pathological nipple discharge (PND).

Results

In the current prospective study, 59/140 lesions were benign and 81/140 lesions were malignant. Analysis of CESM had achieved a higher sensitivity of 97.5% and a similar specificity of 54.2% as compared to sono-mammography, which achieved a sensitivity of 92.6% and specificity of 54.2%. The diagnostic accuracy of CESM was higher (79.3%) than sono-mammography (76.3%). CESM performed better than sono-mammography in the assessment of disease extent, as it was able to detect multifocality, multicentricity, and diffuse abnormalities, which were found in 24.1%, 43.0% and 8.9% of cases, respectively, as compared to 20.5%, 37.2%, and 3.8% of cases by sono-mammography.

Conclusion

CESM can be a valuable diagnostic imaging tool in the detection of malignancy associated with PND if sono-mammographic findings are equivocal. Its greater impact is on the delineation of disease extent, which will alter the treatment strategy.

The Value of Adding Ductography to Ultrasonography for the Evaluation of Pathologic Nipple Discharge in Women with Negative Mammography

Objective

The optimal imaging approach for evaluating pathological nipple discharge remains unclear. We investigated the value of adding ductography to ultrasound (US) for evaluating pathologic nipple discharge in patients with negative mammography findings.

Materials and Methods

From July 2003 to December 2018, 101 women (mean age, 46.3 ± 12.2 years; range, 23–75 years) with pathologic nipple discharge were evaluated using pre-ductography (initial) US, ductography, and post-ductography US. The imaging findings were reviewed retrospectively. The standard reference was surgery (70 patients) or > 2 years of follow-up with US (31 patients). The diagnostic performances of initial US, ductography, and post-ductography US for detecting malignancy were compared using the McNemar’s test or a generalized estimating equation.

Results

In total, 47 papillomas, 30 other benign lesions, seven high-risk lesions, and 17 malignant lesions were identified as underlying causes of pathologic nipple discharge. Only eight of the 17 malignancies were detected on the initial US, while the remaining nine malignancies were detected by ductography. Among the nine malignancies detected by ductography, eight were detected on post-ductography US and could be localized for US-guided intervention. The sensitivities of ductography (94.1% [16/17]) and post-ductography US (94.1% [16/17]) were significantly higher than those of initial US (47.1% [8/17]; p = 0.027 and 0.013, respectively). The negative predictive value of post-ductography US (96.9% [31/32]) was significantly higher than that of the initial US (83.3% [45/54]; p = 0.006). Specificity was significantly higher for initial US than for ductography and post-ductography US (p = 0.001 for all).

Conclusion

The combined use of ductography and US has a high sensitivity for detecting malignancy in patients with pathologic nipple discharge and negative mammography. Ductography findings enable lesion localization on second-look post-ductography US, thus facilitating the selection of optimal treatment plans.

Diagnostic performance of digital breast tomosynthesis in female patients with nipple discharge

Background

Nipple discharge is one of the most common symptoms related to the breast, but it is a presenting feature of breast cancer in 5%–12% of women.

Aims

The purpose of this study was to determine the diagnostic performance of digital breast tomosynthesis (DBT) in the evaluation of patients with nipple discharge and to compare it with mammography (MMG), ultrasound (US), and magnetic resonance imaging (MRI).

Methods and Results

This retrospective study included 53 patients with nipple discharge. All patients underwent DBT, and results were compared to MMG, breast US, and MRI. Radiological findings for each method were categorized according to BI‐RADS classification: categories 1–2 were considered negative and categories 3–5 positive. If a tissue specimen was obtained, the final diagnosis was established based on the results of histopathological analysis; otherwise, a clinical follow‐up was required for at least 2 years to confirm benign radiological findings. Measures of diagnostic accuracy of DBT, MMG, US, and MRI were calculated and compared.

Results

Final histopathological analysis revealed six malignant breast lesions, all of which were detected in patients with pathologic nipple discharge. DBT and MRI exhibited high sensitivity (100%) and high negative predictive value (100%) for the detection of breast cancer in patients with nipple discharge. DBT showed higher specificity compared to MRI (82.9% vs. 61.9%). Sensitivity and specificity of MMG were 83.3% and 76.6%, respectively. Breast US was determined to have a sensitivity of 66.7% and specificity of 57.5%.

Conclusion

DBT exhibited higher specificity than MRI at the same level of sensitivity and negative predictive value. Therefore, the use of DBT should be considered as an alternative to MRI in the assessment of patients with nipple discharge.

An Improved Nomogram to Reduce False-Positive Biopsy Rates of Breast Imaging Reporting and Data System Ultrasonography Category 4A Lesions

BACKGROUND

The NCCN clinical guidelines recommended core needle biopsy for breast lesions classified as Breast Imaging Reporting and Data System (BI-RADS) 4, while category 4A lesions are only 2-10% likely to be malignant. Thus, a large number of biopsies of BI-RADS 4A lesions were ultimately determined to be benign, and those unnecessary biopsies may incur additional costs and pains. However, it is important to emphasize that the current risk prediction model focuses primarily on the details and complex risk features of US or MG findings, which may be difficult to apply in order to benefit from the model. To stratify and manage BI-RADS 4A lesions effectively and efficiently, a more effective and practical predictive model must be developed.

METHODS

We retrospectively analyzed 465 patients with BI-RADS ultrasonography (US) category 4A lesions, diagnosed between January 2019 and July 2019 in Tianjin Medical University Cancer Institute and Hospital and National Clinical Research Center for Cancer. Univariate and multivariate logistic regression analyses were conducted to identify risk factors. To stratify and predict the malignancy of BI-RADS 4A lesions, a nomogram combining the risk factors was constructed based on the multivariate logistic regression results. In order to determine the predictive performance of our predictive model, we used the concordance index (C-index), calibration curve, and receiver operating characteristic (ROC), and the decision curve analysis (DCA) to assess the clinical benefits.

RESULTS

Based on our analysis, 16.3% (76 out of 465) of patients were pathologically diagnosed with malignant lesions, while 83.6% (389 out of 465) were diagnosed with benign lesions. According to univariate and multivariate logistic regression analysis, age (OR = 3.414, 95%CI:1.849-6.303), nipple discharge (OR = .326, 95%CI:0.157-.835), palpable lesions (OR = 1.907, 95%CI:1.004-3.621), uncircumscribed margin (US) (OR = 1.732, 95%CI:1.033-2.905), calcification (mammography, MG) (OR = 2.384, 95%CI:1.366-4.161), BI-RADS(MG) (OR = 5.345, 95%CI:2.934-9.736) were incorporated into the predictive nomogram (C-index = .773). There was good agreement between the predicted risk and the observed probability of recurrence. Furthermore, we determined that 153 was the best cutoff score for distinguishing between patients in the low- and high-risk groups. Malignant lesions were significantly more prevalent in high-risk patients than in low-risk patients.

CONCLUSION

Based on clinical, US, and MG features, we present a predictive nomogram to reliably predict the malignancy risk of BI-RADS(US) 4A lesions, which may assist clinicians in the selection of patients at low risk of malignancy and reduce the number of false-positive biopsies.

Diagnostic accuracy of breast MRI for patients with suspicious nipple discharge and negative mammography and ultrasound: a prospective study

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.

Galactography Combined with Sonogalactography for Improving the Evaluation of Pathological Nipple Discharge

Diagnosing patients with pathological nipple discharge (PND) is controversial, and therefore a standardized diagnosis algorithm is needed. The objective of this study was to investigate the usefulness of galactography (GL) combined with sonogalactography (SGL) for the evaluation of PND patients. A retrospective study was conducted of 51 patients with PND who were evaluated with GL and SGL. The findings from the galactograms of the patients in this study were assigned to different categories of the Galactogram Image Classification System. Additionally, the sensitivity, specificity, and the positive predictive values and negative predictive values of the GL and SGL tests were calculated, considering the gold standard of pathology diagnosis. The results obtained show that GL combined with SGL improved the diagnostic efficiency of ductal lesions, especially for borderline and malignant lesions. Papilloma was diagnosed in 19 cases, and ductal carcinoma in situ in 8 patients. Conclusions: To the best of our knowledge, this is the first study in which the combination of GL and SGL improves the diagnostic efficiency of ductal lesions of patients with PND. A diagnosis algorithm is recommended for women with PND.

Accuracy for cytological evaluation in the detection of breast cancer among patients with pathologic nipple discharge: a PRISMA-compliant meta-analysis

Background:

Nipple discharge cytology is a simple non-invasive method that may provide valuable information for detecting underlying malignancy. Several studies have investigated the diagnostic value of cytology in breast cancer patients with pathological nipple discharge, but the results have been highly variable. Herein we presented a systematic review and meta-analysis of published studies pertaining to the diagnostic capacity of nipple discharge cytology in patients with breast cancer.

Methods:

A systematic literature search was performed (Medline/PubMed, Embase, Cochrane Library databases, and Google Scholar) to identify studies that investigated the diagnostic capacity of cytology with regard to breast cancer in patients with pathologic nipple discharge. Two independent researchers identified articles that assessed the sensitivity and specificity of cytological evaluation for breast cancer detection in patients with pathologic nipple discharge published between January 2000 and October 2018. Articles were only included in the meta-analysis if they met predetermined criteria. The characteristics of each study and the data they yielded were summarized. Quality assessment of all articles included was performed using the Methodological Index for Non-randomized Studies Criteria (MINORS) and the Quality Assessment of Diagnostic Accuracy Study 2 (QUADAS-2). Heterogeneity was tested via Cochran Q test and the I² statistic using Stata 12.0 and Meta-DiSc 1.4 software, and meta-analysis was performed.

Results:

A total of 286 articles were identified, of which 12 articles including a total of 1476 patients were deemed eligible for inclusion in the meta-analysis. A random-effects model assessing the capacity of nipple discharge cytology to predict breast cancer yielded pooled sensitivity 63% (95% confidence interval [CI]: 53%–72%), specificity 95% (95% CI: 87%–98%), positive likelihood ratio 12.35 (95% CI: 4.87–31.34), and negative likelihood ratio 0.39 (95% CI: 0.30–0.50). The diagnostic odds ratio was 31.88 (95% CI: 11.30–89.98). The area under the summary receiver operating characteristic curve was 0.79 (95% CI: 0.75–0.82).

Conclusion:

The current meta-analysis suggests that nipple discharge cytology is a useful diagnostic modality for detection of breast cancer in patients with pathological nipple discharge, with moderate sensitivity and high specificity.

The nipple-areolar complex: comprehensive imaging review

The nipple-areolar complex can be affected by a variety of benign and malignant entities that can present with non-specific symptoms. Benign pathologies commonly affecting the nipple-areolar complex include nipple calcifications, nipple adenoma, abscess of Montgomery tubercles, ductal ectasia, periductal mastitis, and papilloma. Malignant pathologies that affect the nipple-areolar complex include Paget's disease of the breast, ductal carcinoma in-situ, and invasive ductal carcinoma. Clinical history and examination, imaging, and tissue sampling when appropriate are co-dependent factors that guide the assessment of nipple-areolar pathologies. This article provides a review of the normal anatomy, common anatomical variants, benign and malignant pathologies, and imaging techniques to guide the diagnostic assessment of the nipple-areolar complex.

Low-dose CT combined mammography in diagnosis of overflow breast disease: A protocol of systematic review

BACKGROUND

Overflow breast disease (OBD), also known as breast nipple discharge, refers fluid or liquid that comes out of nipple. Many patients with breast cancer experience such condition. However, it is not easy to detect it at early stage, especially for pathological OBD. Previous study found low-dose CT combined mammography (LDCTMG) could help in diagnosis of OBD. However, there is no systematic review investigating this issue. Therefore, this study will examine the accuracy of LDCTMG in diagnosis of OBD.

METHODS

This study protocol will search literature sources in electronic databases and other sources. The electronic databases will be retrieved in The Cochrane Library, the Cochrane Register of Diagnostic Test Accuracy Studies, PUBMED, EMBASE, Web of Science, CINAHL, CNKI, and WANGFANG from inception to the present. We will also search other sources. All literature sources will be sought without restrictions to the language and publication status. Two researchers will independently carry out study selection, data extraction, and study quality assessment. Statistical analysis will be performed using RevMan 5.3.

RESULTS

This study will exert a high-quality synthesis of eligible studies on the analysis of LDCTMG in diagnosis of OBD.

CONCLUSIONS

The results of this study may provide evidence to help judge whether LDCTMG is accurate in diagnosis of OBD.

STUDY REGISTRATION

INPLASY202050116.

Is Ductography Still Warranted in the 21st century?

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.

Retrospective statistical analysis on the diagnostic value of ductography based on lesion pathology in patients presenting with nipple discharge

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.

Nipple discharge: The state of the art

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.

Nipple Discharge: Imaging Variability Among U.S. Radiologists

OBJECTIVE

The purpose of this study was to assess radiologists' choice of imaging modality for the evaluation of clinical symptoms of physiologic nipple discharge (e.g., bilateral discharge, multiple-duct orifices, and yellow, green, or white color) and pathologic nipple discharge (e.g., unilateral discharge, single-duct orifices, spontaneous and serous discharge, and clear or bloodstained color).

MATERIALS AND METHODS

An online survey was sent to lead interpreting physicians at mammography facilities accredited by the American College of Radiology (ACR). Statistical analysis was performed using chi-square tests for frequency data and multinomial logistic regression.

RESULTS

A total of 849 responses to 8170 distributed surveys were received, for a response rate of 10.4%. For the workup of physiologic nipple discharge, 30% of respondents recommended screening mammography (SM); 24%, diagnostic mammography (DM) only; and 46%, both DM and targeted ultrasound (US) (DM plus US). For the workup of physiologic nipple discharge, practitioners in nonacademic settings and those who read breast images during less than 50% of their practice were significantly more likely to recommend DM (with or without US), compared with SM (the standard recommended by the ACR). Those reading breast images less than 50% of the time were also more likely to recommend MRI after conventional imaging revealed negative results. For the workup of pathologic nipple discharge, 91.0% of respondents recommended DM plus US; 8.5%, DM only; and fewer than 1.0%, SM. Nonacademic providers and those who read breast images less than 50% of the time were significantly less likely to recommend DM plus US (the standard recommended by the ACR), compared with DM only.

CONCLUSION

The present study shows variability in imaging modality selection among U.S. radiologists handling the imaging workflow for benign and pathologic nipple discharge. Radiologists do not uniformly follow ACR practice guidelines, which potentially leads to unnecessary workups and extra health care costs.

Magnetic resonance imaging findings of high-grade ductal carcinoma in situ of the male breast: A case report

Ductal carcinoma in situ in men is incredibly rare and detection by conventional mammography and ultrasound is often challenging. We report an unusual case of a 50-year-old male, with no family history of breast cancer, who presented with an 8-year history of left-sided breast pain and recurrent bloody nipple discharge without any significant suspicious imaging features in mammography and targeted high-resolution ultrasound. Breast magnetic resonance imaging was performed as an adjunct modality. Magnetic resonance imaging findings revealed a suspicious retroareolar non-mass abnormality of segmental, linear and dendritic pattern, which was highly suspicious for a ductal carcinoma in situ. Stereotactic guided biopsy and subsequent mastectomy were consistent with pure high-grade ductal carcinoma in situ of the left breast. Overall, this case highlights the challenges in diagnosing ductal carcinoma in situ in men and demonstrates the importance for further investigating clinical suspicions of the male breast.

Galactogram for Investigation of Pathological Nipple Discharge: A Forgotten Arrow in the Radiologists’ Quiver?

Conventional X-ray galactogram (CG) is an underutilized procedure in modern breast imaging despite offering the highest spatial resolution among all modalities available for imaging of the breast ducts. The superior diagnostic performance of CG as compared to that of both conventional mammogram and high-resolution ultrasonography makes it a valuable imaging modality for the evaluation of pathological nipple discharge (PND). In addition, CG should always be considered in women with bloody nipple discharge but normal ultrasound and mammogram. CG also has an important role in the preoperative localization of intraductal lesions. CG may be especially useful in resource-restricted settings where breast magnetic resonance imaging is not readily available as it can be easily performed at any mammography facility without the need for additional equipment. In this article, we describe two cases of PND, one of benign and the other of malignant etiology, to demonstrate the value of CG in these cases. We also review the current literature and compare CG with other modalities used for imaging of ductal system of the breast.

Diagnostic Performance of MRI Versus Galactography in Women With Pathologic Nipple Discharge: A Systematic Review and Meta-Analysis

OBJECTIVE

The objective of our study was to perform a systematic review of the literature of the diagnostic accuracy of MRI compared with galactography in women with pathologic nipple discharge.

MATERIALS AND METHODS

A systematic literature search was performed (MEDLINE, Embase, Web of Science) for articles evaluating the diagnostic performance of MRI and galactography in patients with pathologic nipple discharge and with histologic verification or clinical follow-up. Distinction between any abnormality and cancer was made. Two independent readers selected eligible articles published until December 2015. The quality of the studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool. Data analyses were performed using the bivariate model.

RESULTS

Ten articles were analyzed for a total of 921 patients. The study quality was high, with a low risk of bias and low concerns regarding applicability. The pooled sensitivity for any abnormality was significantly higher for MRI, with 92% (95% CI, 85-96%), than for galactography, with 69% (95% CI, 59-78%) (p < 0.001). The pooled specificity was 76% (95% CI, 49-92%) for MRI versus 39% (95% CI, 16-69%) for galactography (p < 0.001). The pooled sensitivity and specificity for cancer detection were calculated for MRI only and were 92% (95% CI, 74-98%) and 97% (95% CI, 80-100%), respectively.

CONCLUSION

This meta-analysis shows a higher diagnostic performance of MRI compared with that of galactography in the detection of any kind of lesion in patients with pathologic nipple discharge. Moreover, high sensitivity and very high specificity for cancer by MRI could be confirmed in this clinical setting. If mammography and ultrasound are negative, MRI should be preferred over galactography for further evaluation.

Ultrasonographic evaluation of women with pathologic nipple discharge

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.