Galactography in patients with nipple discharge

Breast ductography: to do or not to do? A pictorial essay

Nipple discharge is a frequent breast disease clinical presentation. Although most cases of nipple discharge are physiologic, pathologic nipple discharge is not uncommon. Eight to 15% of pathological nipple discharge is associated with malignancy, requiring investigation. Some specialists believe that ductography is a challenging procedure that is better to be substituted by other methods, such as MRI. However, an experienced physician can perform ductography quickly and easily and still play an essential role in some clinical scenarios. Conventional imaging, such as mammography and sonography, commonly fails to detect the underlying causes of pathological nipple discharge. MRI has limitations of low specificity, cost, lengthy exam duration, accessibility, and patient factors such as claustrophobia. In addition, we can make a specific diagnosis and appropriate treatment by coupling ductography with other methods, such as ultrasound-guided or stereotactic biopsy. This study aims to present the ductography technique, possible findings, and the clinical settings where ductography is useful.Critical relevance statement Although ductography is currently less used in breast imaging, it still plays an essential role in some clinical scenarios. These clinical scenarios include pathological nipple discharge with negative conventional imaging, contraindicated MRI, unavailable MRI, unremarkable MRI results, and multiple MRI findings.Key points• Conventional imaging commonly fails to detect the underlying causes of pathological nipple discharge.• MRI in the setting of nipple discharge has some limitations.• Ductography still plays an essential role in some clinical scenarios.• Coupling ductography with other methods helps make a specific diagnosis.

Galactogram Grading System for Identifying Breast Cancer With Nipple Discharge

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.

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.

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.

What Help Could Ultrasound Elastography Give to the Diagnosis of Breast Papillary Lesions?

On the basis of results of our previous studies and the findings of other scholars, the most common histologic type of false-positive diagnosis with strain elastography (SE) was papilloma. The objectives of our study were to evaluate whether SE could contribute to conventional ultrasound differentiation between benign and malignant papillary lesions and between papillary lesions and other common benign breast lesions. Data on 89 papillary lesions at our hospital, including 74 benign and 15 malignant papillary lesions, were included in our study. In addition, 198 non-papillary benign tumors were selected as the control group, including 126 fibroadenomas and 72 cases of fibrocystic mastopathy. All patients gave written informed consent. All patients with breast lesions underwent conventional ultrasound and SE examination. Breast Imaging Recording and Data System (BI-RADS) category and SE score were compared with respect to sensitivity, specificity and accuracy in differentiating between benign and malignant papillary lesions. We then explored the possibility of using BI-RADS combined with SE to differentiate papillary lesions from non-papillary benign tumors. For differentiating between benign and malignant papillary lesions, the area under the receiver operating characteristic curve (AUC) of BI-RADS was 0.568, whereas the AUC values of SE score, strain ratio and BI-RADS combined with SE were 0.517, 0.584 and 0.509, respectively (p > 0.05). For differentiating between papillary lesions and non-papillary benign lesions, the AUC of BI-RADS combined with SE was 0.835, which was higher than the values for BI-RADS (0.775) and SE (SE score: 0.648, strain ratio: 0.661) (p < 0.001). The specificity and accuracy of BI-RADS combined with SE were significantly higher than those for BI-RADS alone without a decrease in sensitivity (p < 0.05). SE could not improve the diagnostic efficiency of BI-RADS in differentiating between benign and malignant papillary lesions. However, BI-RADS combined with SE could improve the specificity of BI-RADS without decrease in sensitivity for differentiating breast papillary lesions from non-papillary benign lesions.

Management of nipple discharge and the associated imaging findings

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.

Role of galactography in the early diagnosis of breast cancer

BACKGROUND

The purpose of this study was to evaluate the usefulness of galactography (GL) in the early diagnosis of breast cancer in patients with pathologic nipple discharge (PND).

PATIENTS AND METHODS

We retrospectively studied all galactograms obtained in 117 women with PND, who subsequently had a biopsy. The findings detected in the galactograms of the patients in this study were assigned to different categories of the Galactogram Image Classification System (GICS): GICS 2, benign; GICS 3, probably benign; GICS 4, suspicious for malignancy; and GICS 5, highly suspicious for malignancy.

RESULTS

The galactograms were classified into GICS 2 (29 cases; 24.7%), GICS 3 (42 cases; 35.8%), GICS 4 (30 cases; 25.6%), and GICS 5 (16 cases; 13.6%). A good correlation was observed between histological diagnosis and GICS categories (p < 0.05). All cases diagnosed with carcinoma (n = 18) were classified in GICS categories 4-5: ductal carcinoma in situ in 14 cases (11.9%) and invasive carcinoma in 4 cases (3.4%).

CONCLUSION

GL is a useful procedure in the early diagnosis of breast cancer in patients with PND.

A look into the ductoscope: its role in pathologic nipple discharge

OBJECTIVE

Mammary ductoscopy allows direct visualization of the ductal system and a method for directed excision and pathologic diagnosis. We reviewed our experience with mammary ductoscopy in the evaluation of pathologic nipple discharge.

METHODS

We reviewed all patients who underwent ductoscopy for pathologic nipple discharge at our institution from 2006-2010. All procedures were performed by a single surgeon. Data included patient and imaging characteristics, indications, operative findings, and pathologic outcomes. Descriptive statistics were used for data summary.

RESULTS

During the study period, 121 patients underwent ductoscopy and directed duct excision for pathologic nipple discharge, including 66 (55%) with bloody discharge. Breast imaging [mammography, ultrasound, and/or magnetic resonance imaging (MRI)] revealed BIRADS category I/II/III findings in 112 (93%), BIRADS category IV findings in 6 (5%), and was unknown in 3 (2%) patients. Final pathology revealed papillomas in 64 (53%) patients, duct ectasia and associated benign findings in 48 (40%) patients, ductal carcinoma in situ (DCIS) in 7 (6%) patients, and atypical ductal hyperplasia in 2 (1%) patients. None of the patients with DCIS underwent preductoscopy MRI, but all had BIRADS category I/II/III breast imaging. The extent of DCIS identified by ductoscopy and subsequent surgical excision ranged from <1 cm to 10 cm (median 3 cm).

CONCLUSIONS

The majority of patients with pathologic nipple discharge have benign nonproliferative findings or benign papillomas. Although atypia and malignancy were diagnosed in only 7% of patients who underwent ductoscopy for pathologic nipple discharge, there were no routine imaging findings indicative of these diagnoses preoperatively.

Breast MR for the Evaluation of Occult Nipple Discharge

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.

MR ductography: comparison with conventional ductography as a diagnostic method in patients with nipple discharge

Nipple discharge is a common symptom that mostly results from benign conditions. The most significant cause is carcinoma, which accounts for 1%-45% of cases. Therefore, identification of intraductal lesions is important. Conventional ductography, the recommended method of identifying lesions, is invasive and has inherent limitations. Magnetic resonance (MR) ductography is performed with heavily T2-weighted sequences; it is noninvasive and requires neither radiation nor contrast media. Like conventional ductography, MR ductography shows the dilated ducts as tubular structures with high signal intensity. Intraductal lesions appear as a signal defect, duct wall irregularity, or ductal obstruction. No specific conventional ductographic or MR ductographic finding allows differentiation between benign and malignant disease, and neither technique can demonstrate the extent of disease. MR mammography with intravenous injection of contrast material reveals the extent of disease, and a dynamic study may help distinguish between malignant and benign lesions. Fusion imaging with MR ductography and MR mammography demonstrates not only the presence of an intraductal abnormality but also the extent of the lesion on one image, thus clearly showing the relationship between the dilated duct and the intraductal lesion.

The Predictive Value of Ductography and Magnetic Resonance Imaging in the Management of Nipple Discharge

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.