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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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Zhang C, Li J, Jiang H, Li M. Use of fiberoductoscopy for the management of pathological nipple discharge: ten years follow up of a single center in China. Gland Surg 2020; 9:2035-2043. [PMID: 33447554 PMCID: PMC7804554 DOI: 10.21037/gs-20-738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 10/29/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND Pathological nipple discharge (PND) is usually associated with benign intraductal papilloma, which has a higher malignant rate than other benign tumors in most cases. Fiberoductoscopy (FDS) is an alternative possibility in diagnostic and finding lesions in PND patients. Previously, the bloody discharge was presumed to show papilloma or breast cancer. However, as we started using FDS, papilloma or cancer also can be found in the cases with a transparent or yellow discharge. This study investigated the value of FDS for the diagnosis and locating of intraductal lesions in cases with nipple discharge. METHODS A retrospective analysis of 3,696 cases that initially presented with pathologic nipple discharge was performed. There were 4,456 FDSs performed, and the correlations between the FDS findings for distinct types of lesions and the pathological diagnosis were determined. RESULTS Among the 2,816 cases of elevated lesions, FDS confirmed 1,933 cases of intraductal papilloma, 584 cases of intraductal papillomatosis, and 299 cases of intraductal carcinoma. Among the 880 cases of non-elevated lesions, FDS confirmed 380 cases of duct dilation, 350 cases of duct inflammation, 136 cases of duct dilation and inflammation, and 14 cases of ductal carcinoma in situ (DCIS). All patients followed up 3 months to 12 years. There were 241 DCIS in total, and 8 cases had local recurrence, 2 cases had metastasis. Invasive ductal carcinoma, 41 cases, 3 had recurrence and 3 had metastases, and 1 for death. Invasive lobular carcinoma 23 cases, recurrence 2 cases, metastasis 1 case. CONCLUSIONS FDS has a high positive predictive rate and correlates well with the results of the pathological examination. The advantage of FDS is that it can observe the lesions, increasing the detection rate of early stage breast cancer, simple to operate, low cost, and no need for the appointment, appropriate for Chinese conditions.
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Affiliation(s)
- Chao Zhang
- Breast Cancer Department, Beijing Chaoyang Hospital, Beijing, China
| | - Jie Li
- Breast Cancer Department, Beijing Chaoyang Hospital, Beijing, China
| | - Hongchuan Jiang
- Breast Cancer Department, Beijing Chaoyang Hospital, Beijing, China
| | - Mengxin Li
- Breast Cancer Department, Beijing Chaoyang Hospital, Beijing, China
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Evaluation and management of pathological nipple discharges without using intraductal imaging methods. Ir J Med Sci 2019; 189:451-460. [PMID: 31631245 DOI: 10.1007/s11845-019-02107-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 09/21/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND The most common cause of pathological nipple discharge (PND) is single papilloma, which is a benign intraductal lesion (BIL). However, underlying malign (MIL) or high-risk intraductal lesions (HIL) should be considered during examination. AIM To reveal the value of conventional imaging methods (CIM), discharge characteristics, and cytology in lack of intraductal imaging methods to detect intraductal lesions (IL) and MIL that cause PND. METHODS We compared the pathological findings with the characteristics of discharge, CIM, and cytology findings of the patients who admitted to our clinic with nipple discharge and underwent duct excision (n = 111). RESULTS IL were detected in 69 (62.2%) patients as BIL (n = 31), HIL (n = 23), and MIL (n = 15). Most of the IL was observed with bloody, serosanguineous, and serous discharges (83.3%, 76.2%, and 69.2%, respectively). The sensitivities of ultrasonography, MRI, and cytology in detecting IL were found to be 50.7%, 42.6%, and 74.1%, while their specificities were found to be 73.8%, 88.2%, and 48.6%, respectively. None of the CIM was sufficient to detect MIL in 5 (33.3%) patients. The appearance of red blood cells detailed in cytology was significantly related to IL (p < 0.01), whereas the presence of inflammatory cells was related to ductal ectasia and periductal mastitis (p < 0.001). CONCLUSIONS Although patients' physical examinations, CIM, and cytology findings were normal, duct excision procedures should be applied to exclude MIL or HIL, which can be a cause of discharge in case of suspicious color. The details in cytology reports have a role in increasing the value of cytology.
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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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Zielinski J, Jaworski R, Irga-Jaworska N, Pikula M, Hunerbein M, Jaskiewicz J. Use of fiberoductoscopy for the management of patients with pathological nipple discharge: experience of a single center in Poland. Breast Cancer 2018; 25:753-758. [PMID: 29938367 PMCID: PMC6208849 DOI: 10.1007/s12282-018-0883-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 06/21/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Pathological nipple discharge (PND) is associated with serious clinical and diagnostic issues. Fiberoductoscopy (FDS) is a new diagnostic option in PND patients. This study summarizes our initial experience of FDS for the management of PND patients in a single center in Poland and assesses its safety. METHODS A total of 256 women with PND were included in this prospective, case-controlled, single-center study between 2006 and 2014. Of the 250 patients who underwent FDS, 154 had mammary duct lesions and 96 had no visible lesions. Subsequently, 129 patients with lesions identified by FDS underwent microductectomy and the lesions were pathologically evaluated. RESULTS The mean duration of FDS examination was 17 min. The most frequent intraductal lesion was amputation of a duct (35.1%), followed by circular narrowing or hyperplasia (22.7%). Final histological findings were unremarkable in 11.6% of cases, whereas mammary duct papilloma, duct ectasia, and ductal carcinoma in situ were detected in 71.3, 10.9, and 6.2% of cases, respectively. CONCLUSIONS FDS is an innovative method for visualizing intraductal mammary lesions and allows accurate selection of mammary ducts with suspicious lesions that require surgical removal in women with PND.
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Affiliation(s)
- Jacek Zielinski
- Department of Surgical Oncology, Medical University of Gdansk, Smoluchowski Str 17, 80-214, Gdansk, Poland.
| | - Radoslaw Jaworski
- Department of Cardiac Surgery, Children's Health Memorial Institute, Warsaw, Poland
| | - Ninela Irga-Jaworska
- Department of Pediatrics, Hematology and Oncology, Medical University of Gdansk, Gdansk, Poland
| | - Michal Pikula
- Department of Clinical Immunology and Transplantology, Medical University of Gdansk, Gdansk, Poland
| | - Michael Hunerbein
- Department of General, Visceral and Cancer Surgery, Helios Klinikum Berlin-Buch, Berlin, Germany
| | - Janusz Jaskiewicz
- Department of Surgical Oncology, Medical University of Gdansk, Smoluchowski Str 17, 80-214, Gdansk, Poland
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de Boorder T, Waaijer L, van Diest PJ, Witkamp AJ. Ex vivo feasibility study of endoscopic intraductal laser ablation of the breast. Lasers Surg Med 2017; 50:137-142. [PMID: 28990682 DOI: 10.1002/lsm.22745] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2017] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To determine the feasibility and safety of breast endoscopic thulium laser ablation for treatment of intraductal neoplasia. STUDY DESIGN Ductoscopy is a minimally invasive endoscopic approach of the milk ducts of the breast via the nipple. Besides diagnosis in women with pathologic nipple discharge (PND), it allows non-invasive removal of intraductal lesions with a stalk like papillomas. Removal, however, is often incomplete and flat lesions cannot be targeted. We therefore developed laser ductoscopy. METHODS Dosimetry of laser ductoscopy was assessed in thirteen mastectomy specimens, applying power settings of 1-5 W with 100-1000 ms pulsed exposure to a 375-μm outer diameter thulium fiber laser. Subsequently histology was obtained from the breast tissue that was treated with the Thulium laser. RESULTS Endoscopic view was maintained during ductoscopic laser ablation at 1-3 W. Increasing power to 4-5 W caused impaired vision due to shrinkage of the main duct around the ductoscope tip. Histology revealed localized ablation of the duct wall. CONCLUSION We show for the first time that laser ductoscopy is technically feasible. The Thulium laser enables a superficial intraductal ablation and is a useful tool for intraductal interventions. An in vivo prospective study is needed to further demonstrate its potential. Lasers Surg. Med. 50:137-142, 2018. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- Tjeerd de Boorder
- Departments of Medical Technology and Clinical Physics, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Laurien Waaijer
- Departments of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Paul J van Diest
- Departments of Pathology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Arjen J Witkamp
- Departments of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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Waaijer L, Simons JM, Borel Rinkes IHM, van Diest PJ, Verkooijen HM, Witkamp AJ. Systematic review and meta-analysis of the diagnostic accuracy of ductoscopy in patients with pathological nipple discharge. Br J Surg 2016; 103:632-643. [DOI: 10.1002/bjs.10125] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 11/07/2015] [Accepted: 01/06/2016] [Indexed: 11/06/2022]
Abstract
Abstract
Background
Invasive surgery remains the standard for diagnosis of pathological nipple discharge (PND). Only a minority of patients with nipple discharge and an unsuspicious finding on conventional breast imaging have cancer. Ductoscopy is a minimally invasive alternative for evaluation of PND. This systematic review and meta-analysis was designed to evaluate the diagnostic accuracy of ductoscopy in patients with PND.
Methods
A systematic search of electronic databases for studies addressing ductoscopy in patients with PND was conducted. Two classification systems were assessed. For DSany, all visualized ductoscopic abnormalities were classified as positive, whereas for DSsusp, only suspicious findings were considered positive. After checking heterogeneity, pooled sensitivity and specificity of DSany and DSsusp were calculated.
Results
The search yielded 4642 original citations, of which 20 studies were included in the review. Malignancy rates varied from 0 to 27 per cent. Twelve studies, including 1994 patients, were eligible for meta-analysis. Pooled sensitivity and specificity of DSany were 94 (95 per cent c.i. 88 to 97) per cent and 47 (44 to 49) per cent respectively. Pooled sensitivity and specificity of DSsusp were 50 (36 to 64) and 83 (81 to 86) per cent respectively. Heterogeneity between studies was moderate to large for sensitivity (DSany: I2 = 17·5 per cent; DSsusp: I2 = 37·9 per cent) and very large for specificity (DSany: I2 = 96·8 per cent; DSsusp: I2 = 92·6 per cent).
Conclusion
Ductoscopy detects about 94 per cent of all underlying malignancies in patients with PND, but does not permit reliable discrimination between malignant and benign findings.
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Affiliation(s)
- L Waaijer
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - J M Simons
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - I H M Borel Rinkes
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - P J van Diest
- Department of Pathology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - H M Verkooijen
- Imaging Division, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - A J Witkamp
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
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Wong Chung JERE, Jeuriens-van de Ven SAH, van Helmond N, Wauters CAP, Duijm LEM, Strobbe LJA. Does Nipple Discharge Color Predict (pre-) Malignant Breast Pathology? Breast J 2016; 22:202-8. [PMID: 26799061 DOI: 10.1111/tbj.12544] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Unilateral single-duct nipple discharge is associated with an increased risk for underlying breast malignancy. There is no consensus whether color of nipple discharge independently indicates the risk of malignancy. We sought to assess the relationship between the color of discharge and the risk of malignancy. Patients with unilateral single-duct nipple discharge without abnormalities on clinical and radiologic examination were included. Prior to diagnostic microdochectomy nipple discharge characteristics were registered. Multiple logistic regressions were performed to assess the relationship between color of nipple discharge and malignancy, corrected for age. During a mean follow-up period of 7.1 years we determined complication rate and false-negative rate of microdochectomy. A total of 184 patients were included (median age 53 years, range 19-84). Histologic examination revealed (in situ or invasive) breast carcinoma in 10.9% (20) of patients and high-risk lesions in 11.4% (21). Malignancy or high-risk lesions were found in 25% (OR: 1.37; 95% CI: 0.62-3.00) of patients with bloody discharge. Risk of underlying malignancy increased in patients >60 years (OR: 2.35; 95% CI: 1.14-4.83). Complication rate of microdochectomy was 2.7%. Single-duct, unilateral nipple discharge is a sign of underlying malignancy in a substantial proportion of cases. The majority of patients with unilateral single-duct nipple discharge, diagnosed with breast cancer, present with bloody discharge. However, the association between bloody nipple discharge and malignancy is not strong enough to distinguish high-risk patients. Therefore, invasive diagnostic procedures like microdochectomy should be offered to all patients with unilateral uniductal nipple discharge to search for underlying malignancy.
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Affiliation(s)
| | | | - Noud van Helmond
- Faculty of Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Carla A P Wauters
- Department of Clinical Pathology, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Lucien E M Duijm
- Department of Radiology, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Luc J A Strobbe
- Department of Surgery, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
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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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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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High Risk Lesions. Breast Cancer 2014. [DOI: 10.1007/978-1-4614-8063-1_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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12
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Dooley WC. Who wants a blind breast surgeon? Ann Surg Oncol 2011; 18 Suppl 3:S337-8. [PMID: 22238780 DOI: 10.1245/s10434-008-0040-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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13
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Mátrai Z, Tóth L, Bidlek M, Szabó É, Farkas E, Sávolt Á, Góbor L, Bartal A, Kásler M. [The role of ductoscopy in the modern diagnostics and therapy of breast diseases]. Orv Hetil 2011; 152:1284-93. [PMID: 21803726 DOI: 10.1556/oh.2011.29163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Mammary ductoscopy is a modern, minimally invasive procedure that enables direct, in vivo observation of the mammary ductal system, primarily by nipple discharge. The rapidly developing device is suitable for aimed biopsy for further cytological or molecular examinations. High-tech equipments facilitate polypectomy or laser vaporization of certain intraluminal lesions, and play an important role in the direct surgical excision of the duct or the so-called terminal duct-lobular unit. The above listed facilitate the early diagnosis of malignancies even before imaging could detect them, and the control of high risk patients. Ductoscopy can foster surgical removal of ductal in situ tumors as anatomical units, thus enabling the optimization of radicality of breast conserving surgeries. Authors give a detailed description of the surgical techniques, and provide a wide review of the literature, for the first time in the Hungarian language. Orv. Hetil., 2011, 152, 1284-1293.
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Affiliation(s)
- Zoltán Mátrai
- Országos Onkológiai Intézet Általános és Mellkassebészeti Osztály, Budapest, Ráth Gy. u. 7-9. 1122.
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Khan SA, Mangat A, Rivers A, Revesz E, Susnik B, Hansen N. Office ductoscopy for surgical selection in women with pathologic nipple discharge. Ann Surg Oncol 2011; 18:3785-90. [PMID: 21626081 DOI: 10.1245/s10434-011-1791-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2011] [Indexed: 11/18/2022]
Abstract
BACKGROUND Pathologic nipple discharge (PND) is diagnosed clinically and managed by diagnostic duct excision (DDE). Mammary ductoscopy in the office setting may change this standard. We performed a prospective study to assess the utility of office ductoscopy for surgical selection in women with nipple discharge. METHODS Women with nipple discharge meeting at least 2 of 3 criteria of PND (spontaneous, single duct, bloody or serous) underwent office ductoscopy. Those showing papillomatous lesions underwent DDE in the operating room (surgical group, n = 38); if no lesion was present, women were followed clinically (observation group, n = 21). RESULTS A papillomatous lesion was identified in 79% of women with 3-criteria PND and in 21% with 2 criteria (P = .001). DDE yielded a proliferative lesion in 35 of 38 women (92%). Of the 38, 27 (71%) had papillomata, 2 (5%) had florid hyperplasia, and 6 (16%) had ductal carcinoma in situ (DCIS) on final pathology. Also, 11 women with papilloma and 1 with DCIS presented with 2-criteria PND. Ductoscopy findings were a better predictor of the presence of intraductal neoplasia (area under curve [AUC] 0.9, 95% confidence interval [95% CI] 0.8-0.98) compared with 3-criteria PND (AUC 0.7, 95% CI 0.6-0.8). The 21 women in the observation group did not develop signs of malignancy or need biopsy during a 48-month follow-up period. CONCLUSIONS Our findings suggest that office ductoscopy provides accurate surgical selection of women with nipple discharge and should be considered for women with 2 criteria of PND, and those with negative ductoscopy can be safely observed. These findings need confirmation in a larger study with longer follow-up.
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Affiliation(s)
- Seema A Khan
- Department of Surgery, Lynn Sage Breast Center, Northwestern Feinberg School of Medicine, Chicago, IL, USA.
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Leung JWT. MR imaging in the evaluation of equivocal clinical and imaging findings of the breast. Magn Reson Imaging Clin N Am 2010; 18:295-308, ix-x. [PMID: 20494313 DOI: 10.1016/j.mric.2010.02.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Because of its high negative predictive value in excluding breast cancer, magnetic resonance (MR) imaging plays a role in the evaluation of selected clinical and imaging findings of the breast, especially when biopsy is not technically feasible. Case selection is very important in ensuring the efficacy of this use of MR imaging because of potential false-positive and (albeit less likely) false-negative results. This article examines the clinical scenarios and imaging findings in which MR imaging is contributory to patient management after conventional workup with equivocal results.
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Affiliation(s)
- Jessica W T Leung
- Breast Health Center, California Pacific Medical Center, 3698 California Street, 2nd Floor, San Francisco, CA 94118, USA.
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16
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Microdochectomy in the management of pathologic nipple discharge. Arch Gynecol Obstet 2010; 283:851-4. [PMID: 20458490 DOI: 10.1007/s00404-010-1481-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2010] [Accepted: 04/12/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND There is a debate in the literature whether a pathologic nipple discharge is a distinct sign of breast carcinoma. Our own results obtained by the use of microdochectomy as a minimally invasive operative procedure in 184 patients with pathologic nipple discharge were analysed. The aim of this retrospective 20-year study was to assess the efficacy of microdochectomy in detecting early stages of intraductal breast carcinoma. PATIENTS AND METHODS The study included data on 184 patients aged 24-77 years (median 46.6) divided into two groups of premenopausal (n = 123) and postmenopausal (n = 61) women. There were 139 patients with unilateral single-duct sanguinolent discharge and 45 patients with other types of nipple discharge. The operative procedure consisted of the discharging duct excision by use of a guide probe, preceded by cytology and ductography studies. RESULTS Histopathology of the excised ducts revealed only three carcinomas in premenopausal women and ten carcinomas in postmenopausal women. In a total of 13 carcinomas, there were 4 ductal carcinomas in situ, detected in patients aged 41-72 (median 66) years. Twelve carcinomas were associated with sanguinolent nipple discharge. Papilloma was the most common histology finding (56.5%). CONCLUSION Results of the study suggested mainly the association of sanguinolent single-duct nipple discharge and papilloma, whereas the rate of malignancies detected (7.0%) was consistent with literature reports. Microdochectomy proved to be a highly efficient operative method free from any impairment of the breast integrity. Conservative treatment with close clinical monitoring of the patient with cytology and ultrasonographic assessment might be possible in selected cases.
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Zervoudis S, latrakis G, Economides P, Polyzos D, Navrozoglou I. Nipple Discharge Screening. WOMENS HEALTH 2010; 6:135-51. [DOI: 10.2217/whe.09.81] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Stefanos Zervoudis
- Stefanos Zervoudis, Lito Hospital, Department of Mastology, Athens, Greece
- Technological Educational Institution of Athens, Athens, Greece
- Universiry of Ioannina, Department of Obstetrics/Gynecology, Breast Unit, Ioannina, Greece, Tel.: +69 44 308 777, Fax: +210 898 1178,
| | - Georgos latrakis
- Georgos Iatrakis, Lito Hospital, Department of Mastology, Athens, Greece
- Technological Educational Institution of Athens, Athens, Greece, Tel.: +210 661 1178, Fax: +210 661 3986,
| | - Panagiotis Economides
- Panagiotis Economides, Lito Hospital, Department of Mastology, Athens, Greece, Tel.: +69 36 121 158, Fax: +210 690 2417,
| | - Demetrios Polyzos
- Demetrios Polyzos, Lito Hospital, Department of Mastology, Athens, Greece, Tel.: +69 44 81 2923, Fax: +210 690 2417,
| | - Iordanis Navrozoglou
- Iordanis Navrozoglou, Universiry of Ioannina, Department of Obstetrics/Gynecology, Breast Unit, Ioannina, Greece, Tel.: +69 44 308 777, Fax: +210 898 1178,
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19
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Mammary ductoscopy: current issues and perspectives. Breast Cancer 2008; 16:93-6. [DOI: 10.1007/s12282-008-0083-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2008] [Accepted: 09/30/2008] [Indexed: 11/27/2022]
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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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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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