(Radiographics. 2001;21:133-150.)
© RSNA, 2001
Ductography: How To and What If?1
S. Horatio Slawson, MD and
Bradley A. Johnson, MD
1 From the Susan G. Komen Breast Center, 4911 Executive Dr, Peoria, IL 61614; the Department of Radiology, University of Illinois College of Medicine at Peoria; the Department of Radiology, OSF Saint Francis Medical Center, Peoria; and Peoria Radiology Associates. Recipient of a Certificate of Merit award and an Excellence in Design award for a scientific exhibit at the 1999 RSNA scientific assembly. Received March 1, 2000; revision requested May 16 and received July 19; accepted August 3. Address correspondence to S.H.S. (e-mail: sslawson@pol.net).
 |
Abstract
|
|---|
Ductography of the breast is an underused procedure that often helps define the cause of unilateral, single-pore, spontaneous nipple discharge. Since nipple discharge may be caused by benign tumors, such as papillomas, or by carcinoma, such as ductal carcinoma in situ, identification of intraductal abnormalities with ductography is important. Further, diagnostic ductography and preoperative ductography help guide accurate surgical intervention. Without prior ductography, central duct excision may not result in removal of the abnormal ductal tissue or may result in removal of only a portion of the abnormal ductal system, causing the extent of disease to be effectively understaged. Once fundamental ductographic principles are learned, the procedure is easy to perform. If extravasation occurs, ductography is rescheduled for 7–14 days later. Elimination of air bubbles from the cannula, syringe, and extension tubing is vital. When reflux occurs, radiologists must be aware of a possible tumor in the distal-most duct. When ductal ectasia or fibrocystic changes are the cause of the discharge, conservative follow-up may be considered. Diagnostic radiologists who learn the technique of ductography and include it in their evaluation of nipple discharge will improve their interdisciplinary approach to this important sign of breast cancer.
Index Terms: Breast, ducts, 00.127 • Breast neoplasms, diagnosis, 00.312, 00.324 • Galactography, 00.127
|
LEARNING OBJECTIVES
|
|---|
After reading this article and taking the test, the reader will be able to:
- Discuss the benefits of ductography of the breast and which patients should be selected for the procedure.
- Describe the technique of ductography and how to apply problem-solving methods if complications arise.
- Recognize the basic imaging findings for common processes discovered with ductography, describe the limitations of the examination, and discuss techniques for preoperative localization of the abnormal ductal system prior to surgical removal.
|
Introduction
|
|---|
Ductography of the breast (galactography, ductogalactography) is an underused procedure that often helps define the cause of unilateral, single-pore, spontaneous nipple discharge. Ductography allows diagnosis of the underlying condition, definition of the extent of disease, identification of central and peripheral lesions, and guidance of surgical excision. Without prior ductography, central duct excision may not result in removal of the abnormal ductal tissue or may result in removal of only a portion of the abnormal duct, causing the extent of disease to be effectively understaged. Preoperative ductography also allows removal of less breast tissue by selective identification of the abnormal ductal system. When ductal ectasia or fibrocystic changes are the cause of the discharge, conservative follow-up can be considered and surgery may be avoided in selected patients (1). Ductography has been called the "diagnostic procedure of choice" in the evaluation of nipple discharge (2,3).
Some radiologists maintain that ductography is difficult and time-consuming to perform. However, we believe that radiologists who learn the technique of ductography and include it in their evaluation of nipple discharge will improve their interdisciplinary approach to this important sign of breast cancer. Once fundamental ductographic principles are learned, the procedure is surprisingly easy to perform. This article presents the technique of ductography and problem-solving tools necessary for successful ductography. Specific topics discussed are performing ductography, extravasation, artifacts, obstruction and reflux, normal ducts, ductal ectasia, fibrocystic changes, papillomas, carcinoma, and follow-up and treatment. The images were selected after review of images from over 400 ductography examinations performed at the Susan G. Komen Breast Center.
|
Performing Ductography
|
|---|
Patients with unilateral, single-pore, spontaneous nipple discharge are selected for ductography. Categories of more suspicious unilateral spontaneous discharge include serosanguineous, bloody (sanguineous), and colorless or clear discharge. Categories of less suspicious unilateral spontaneous discharge include blood-negative, yellow, green, blue, and black discharge. Fluid of these colors is usually thick, tenacious, or sticky. Cysts that communicate with the ducts often are the cause of blue or black discharge. Leis (4) retrospectively reviewed the results of 8,703 breast operations; nipple discharge was the abnormal finding in 7.4% of cases. He divided the types of discharge into seven categories: milky, multicolored/sticky, purulent, clear/watery, yellow/serous, pink/serosanguineous, and bloody/sanguineous. The last four categories were considered surgically significant. Of 586 patients with surgically significant discharge, 14.3% had biopsy-proved carcinoma. Cancer was found in 33.3% of patients with clear/watery discharge, 5.9% of patients with yellow/serous discharge, 12.9% of patients with pink/serosanguineous discharge, and 27.5% of patients with bloody/sanguineous discharge. In our patients, when there were no suspicious imaging findings and any category of "surgically significant" nipple discharge was present, carcinoma was the cause less often than reported by Leis (4).
Before cannulation, a craniocaudal subareolar magnification view is obtained and assessed for suspicious calcifications or masses.
Gentle periareolar pressure is used to elicit discharge. Pressure on one area of the breast may reliably produce discharge; this area is known as the "trigger point" or "trigger zone" (Fig 1a). The trigger point is defined as a focal area in or on the breast that, when compressed, reliably and reproducibly produces nipple discharge. It is helpful to note this point on the patient data sheet or mark the point on a breast diagram to aid in the presurgical localizing ductography performed at a later date. Breast surgeons may use the trigger point to aid in their physical examination. Breast tissue beneath the skin trigger point may be considered for inclusion in the surgical excision. Testing for the presence of blood is useful to identify suspicious discharge (5); a standard test strip (Hemastix; Bayer, Elkhart, Ind) may be used (Fig 1b). In 1989, Leis (4) reported a false-negative rate of 9.5% for mammography and 17.8% for cytologic assessment in patients with carcinoma-associated nipple discharge. Thus, we do not perform cytologic assessment prior to ductography.
View larger version (98K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 1a. Technique of ductography. (a) Pressure is used to elicit discharge. One spot on the breast may reliably produce discharge; this spot is the trigger point. (b) A test strip is used to detect the presence of blood. (c) With the aid of a magnifying lens, a cannula tip is placed on the discharging orifice and very gentle downward guidance or pressure is applied. (d) The nipple may be stabilized between the thumb and forefinger. (e) Once the cannula descends into the duct orifice, 0.2-0.3 mL of contrast material is administered. (f) The cannula is taped in place in preparation for imaging. Note the "double-L" configuration of the two tape strips and the syringe taped to the skin. (g) A standard magnified craniocaudal view is obtained with the cannula taped in place and the breast in compression.
|
|
View larger version (103K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 1b. Technique of ductography. (a) Pressure is used to elicit discharge. One spot on the breast may reliably produce discharge; this spot is the trigger point. (b) A test strip is used to detect the presence of blood. (c) With the aid of a magnifying lens, a cannula tip is placed on the discharging orifice and very gentle downward guidance or pressure is applied. (d) The nipple may be stabilized between the thumb and forefinger. (e) Once the cannula descends into the duct orifice, 0.2-0.3 mL of contrast material is administered. (f) The cannula is taped in place in preparation for imaging. Note the "double-L" configuration of the two tape strips and the syringe taped to the skin. (g) A standard magnified craniocaudal view is obtained with the cannula taped in place and the breast in compression.
|
|
View larger version (100K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 1c. Technique of ductography. (a) Pressure is used to elicit discharge. One spot on the breast may reliably produce discharge; this spot is the trigger point. (b) A test strip is used to detect the presence of blood. (c) With the aid of a magnifying lens, a cannula tip is placed on the discharging orifice and very gentle downward guidance or pressure is applied. (d) The nipple may be stabilized between the thumb and forefinger. (e) Once the cannula descends into the duct orifice, 0.2-0.3 mL of contrast material is administered. (f) The cannula is taped in place in preparation for imaging. Note the "double-L" configuration of the two tape strips and the syringe taped to the skin. (g) A standard magnified craniocaudal view is obtained with the cannula taped in place and the breast in compression.
|
|
View larger version (104K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 1d. Technique of ductography. (a) Pressure is used to elicit discharge. One spot on the breast may reliably produce discharge; this spot is the trigger point. (b) A test strip is used to detect the presence of blood. (c) With the aid of a magnifying lens, a cannula tip is placed on the discharging orifice and very gentle downward guidance or pressure is applied. (d) The nipple may be stabilized between the thumb and forefinger. (e) Once the cannula descends into the duct orifice, 0.2-0.3 mL of contrast material is administered. (f) The cannula is taped in place in preparation for imaging. Note the "double-L" configuration of the two tape strips and the syringe taped to the skin. (g) A standard magnified craniocaudal view is obtained with the cannula taped in place and the breast in compression.
|
|
View larger version (101K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 1e. Technique of ductography. (a) Pressure is used to elicit discharge. One spot on the breast may reliably produce discharge; this spot is the trigger point. (b) A test strip is used to detect the presence of blood. (c) With the aid of a magnifying lens, a cannula tip is placed on the discharging orifice and very gentle downward guidance or pressure is applied. (d) The nipple may be stabilized between the thumb and forefinger. (e) Once the cannula descends into the duct orifice, 0.2-0.3 mL of contrast material is administered. (f) The cannula is taped in place in preparation for imaging. Note the "double-L" configuration of the two tape strips and the syringe taped to the skin. (g) A standard magnified craniocaudal view is obtained with the cannula taped in place and the breast in compression.
|
|
View larger version (97K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 1f. Technique of ductography. (a) Pressure is used to elicit discharge. One spot on the breast may reliably produce discharge; this spot is the trigger point. (b) A test strip is used to detect the presence of blood. (c) With the aid of a magnifying lens, a cannula tip is placed on the discharging orifice and very gentle downward guidance or pressure is applied. (d) The nipple may be stabilized between the thumb and forefinger. (e) Once the cannula descends into the duct orifice, 0.2-0.3 mL of contrast material is administered. (f) The cannula is taped in place in preparation for imaging. Note the "double-L" configuration of the two tape strips and the syringe taped to the skin. (g) A standard magnified craniocaudal view is obtained with the cannula taped in place and the breast in compression.
|
|
View larger version (91K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 1g. Technique of ductography. (a) Pressure is used to elicit discharge. One spot on the breast may reliably produce discharge; this spot is the trigger point. (b) A test strip is used to detect the presence of blood. (c) With the aid of a magnifying lens, a cannula tip is placed on the discharging orifice and very gentle downward guidance or pressure is applied. (d) The nipple may be stabilized between the thumb and forefinger. (e) Once the cannula descends into the duct orifice, 0.2-0.3 mL of contrast material is administered. (f) The cannula is taped in place in preparation for imaging. Note the "double-L" configuration of the two tape strips and the syringe taped to the skin. (g) A standard magnified craniocaudal view is obtained with the cannula taped in place and the breast in compression.
|
|
At this time, the remainder of the breast and nipple is examined for other breast abnormalities, including nipple retraction, ulceration, and excoriation. The contralateral nipple is assessed because bilateral, multipore, blood-negative, expressed-only nipple discharge need not be assessed with ductography. Such a pattern is common and is best categorized as benign physiologic discharge. Examination of the surface of the nipple requires a quiet, private room equipped with a high-intensity lamp. An examination table is vital because the patient is examined in the oblique supine position, with the ipsilateral arm raised and the hand resting comfortably behind the patient's head. A magnification lens mounted on a headpiece and a high-intensity light are necessary for successful cannulation of the orifice. Some breast centers train technologists to perform ductography; at our center, radiologists perform the procedure.
Contraindications to ductography include a significant history of severe allergy to iodinated contrast material, debilitating anxiety or a mental disorder that precludes patient cooperation for the procedure, and a history of prior nipple surgery that would completely disconnect the nipple pores from the underlying ducts. Relative contraindications include severe nipple retraction (which makes cannulation extremely difficult) and moderate or severe reactions to iodinated contrast material in patients with serious concomitant medical illnesses or in patients who will not tolerate the preprocedure medication regimen that may be indicated. If a patient insists that she will refuse surgical intervention regardless of the ductographic findings, withholding ductography is considered.
The two most popular ductography cannulas currently marketed have varying designs: One is a straight cannula, the second has a right-angled tip. The straight cannula facilitates flexible depth insertion, allows cannulation in deeply inverted nipples or those with fissures or crevices, and is preferred. The cannula illustrated in this article (30-gauge end-port sterile sialography infusion unit; Ranfac, Avon, Mass) is our preferred instrument and was initially designed for sialography. It may be labeled or referred to as a "sialogram needle." We use the term "blunt-tipped cannula" (instead of "needle") for our patients to minimize apprehension and anxiety, which can complicate the procedure and make cannulation more difficult. The cannula with the right-angled tip is known as a Jabczenski cannula; the right-angled design is said to allow easy taping of the device in place after successful cannulation. In our opinion, this is not a significant advantage because taping is easily done with the straight cannula as well.
First, the nipple is gently cleansed and sterilized with an alcohol swab to loosen and remove dried secretions. Some radiologists prefer using povidone-iodine swabs (Betadine; Purdue Frederick, Norwalk, Conn) or povidone-iodine swabs followed by alcohol swab cleansing. A small drop of fluid is again elicited with pressure at the trigger point or by gently squeezing the nipple. The smaller the drop of fluid extracted, the more likely the discharging pore can be discretely and correctly identified. Discrete pore identification greatly facilitates cannulation. Then, the tip of the cannula is placed on the orifice (Fig 1c). If necessary, the nipple may be stabilized between the thumb and forefinger (Fig 1d). The cannula is seamlessly attached to small-volume extension tubing and then to a 1–3-mL syringe filled with full-strength iothalamate meglumine (Conray 60; Mallinckrodt, St Louis, Mo) or iopamidol (Isovue 300; Bristol-Myers Squibb, Princeton, NJ). A 1-mL tuberculin syringe is useful because it avoids excess injection pressure and aids measurement of small-volume injections. However, it is more difficult to fill the extension tubing (which may have a volume of 1 mL as well) and the syringe with contrast material without introducing air bubbles. A 3-mL syringe has enough volume to easily fill the tubing and syringe without refilling the syringe; however, there is the risk of an increase in injection pressure, and it may be difficult to measure small volumes of contrast material. For percutaneous ductography, we use a 1-mL syringe directly attached to the needle. For most diagnostic and localization ductography, we use a 3-mL syringe.
Once the cannula is placed on the discharging pore, the tip usually descends into the duct; no force is needed if placement is correct, and only gentle downward guidance is necessary. A volume of 0.2–0.3 mL of contrast material is slowly administered (Fig 1e). If pain begins, stop. The cannula is secured between two strips of paper tape placed in a double-L configuration (Fig 1f). With the cannula in place, administration of more contrast material is possible without recannulation and contrast material leakage is minimized. Also, the cannula width is a useful internal gauge for normal ductal diameter. However, some radiologists prefer to remove the cannula immediately after administration of contrast material and recannulate if more contrast material is needed (6). Recently, we have begun to use digital spot mammographic techniques to quickly demonstrate intraductal or extravasated contrast material. A single craniocaudal digital spot magnification view is obtained; if intraductal contrast material is demonstrated, either more contrast material is administered or standard orthogonal screen-film magnification views are obtained.
If cannulation is unsuccessful, sterile local anesthetic gel (Xylocaine 2% jelly [lidocaine; Astra, Westborough, Mass]) or warm compresses are applied to the nipple and areola and the procedure is reattempted. The sterile anesthetic gel may also be used to coat the cannula tip and then dabbed into the pore. With clear sterile gel on the nipple and surface of the pore, dark or bloody fluid oozing from the orifice can be easily seen swirling into the viscous anesthetic gel. With this visual marker, the cannula tip can be guided to the origin of the stream of dark discharge, and cannulation may be successful. If a second attempt is unsuccessful, a second radiologist may attempt cannulation. We do not use "lacrimal dilators," which are provided in some ductography sets. In our experience, these dilators do not significantly increase the rate of successful cannulation but do increase the rate of duct wall perforation and extravasation. If ductography is unsuccessful after three attempts, we cancel the procedure and reschedule it for 7–14 days later.
In our experience, difficulty in cannulating the duct represents the most discouraging obstacle for those learning ductography. Successful ductography involves a commitment of time and patience and the sequential use of several creative, individualized techniques. The nipple may be stabilized between the thumb and forefinger and gently elevated and straightened while cannulation is attempted. The nipple may be rotated or angulated and the cannula tip guided into the pore at varying obliquities. The cannula may be carefully rotated or angulated within the pore, since duct openings may be at varying locations within the external channel of the pore. Gentle probing at alternate angles "marching" along the surface of the pore may result in successful cannulation. In some cases, "spreading" the nipple with two fingers on the adjacent skin can assist in visualization of the discharging orifice and allow cannulation. This technique is particularly useful when a crevice is present on the nipple surface. Such crevices can "trap" secretions, and pores will be obscured by dried material or a thick serous film. Warm, moist washcloths often allow relaxation of the nipple surface and adjoining smooth muscle fibers, allowing the elicitation of nipple discharge and easier cannulation. We use moist washcloths heated in a microwave oven, tested on our skin to avoid burning, and then placed on the nipple-areola complex for 5 minutes. In particularly difficult cases, we have been ultimately successful by placing the patient in the steep right or left lateral decubitus position or in the seated, upright position. Finally, if the very superficial rim of the pore is cannulated but further insertion meets with resistance, we avoid forcing the cannula deeper and risking perforation. Occasionally, we have been successful by stabilizing the cannula tip on the rim of the pore, just within the external orifice, and gently administering contrast material. The fluid sensation and reduction of friction may allow deeper cannula insertion without perforation and extravasation.
Once the cannula has been inserted and the contrast material administered, either the cannula is removed and a strip of paper tape is placed over the nipple to minimize contrast material leakage or the cannula is secured in place with two L-shaped strips of paper tape, usually placed in the medial and lateral positions. We take care to not introduce an element of tension or force on the cannula with the strips of tape. In fact, we purposely include a slight laxity to the system so that when compression is applied the cannula will not be forced into a duct side wall, a complication that occurs rarely. Postprocedure, postcannulation standard craniocaudal and 90° mediolateral magnification views are then obtained of the subareolar breast (Fig 1g). If our digital spot unit is available, we first obtain a craniocaudal digital spot view of the subareolar breast tissue. Our technologists are instructed to cease compression in patients experiencing pain and are trained to be alert for possible vasovagal reactions during transfer from the examination table to the mammography unit and during positioning, compression, and film exposure. If superimposition of opacified ducts occurs, radiologists may obtain "rolled" craniocaudal magnification views or a standard magnification mediolateral oblique view to "unfold" the ductal tissue. A slightly lesser degree of compression is used than with standard imaging. If necessary, off-axis oblique views may demonstrate findings without superimposition. When no abnormalities are detected, a distal lesion obscured by the cannula may be present. In such cases, a magnified craniocaudal view of the direct subareolar tissue is performed immediately after cannula removal. In most cases, our technologists remove the tape and gently glide the cannula out from the nipple. For the latter view and any other views obtained with the cannula removed, paper tape is placed over the nipple to minimize leakage. When the procedure is completely ended, the tape is removed and a nursing pad is provided to prevent staining of the patient's clothes by fluid.
When all of the above strategies fail, one technique we consider is percutaneous ductography. This technique is useful when dilated ducts are visualized with ultrasonography (US) and ductography is indicated, but conventional nipple cannulation is unsuccessful or impossible or would opacify ducts significantly distant from the dilated system. We have used the technique when nipple discharge was not present or cannulation was unsuccessful and new-onset subareolar or peripheral ductal dilatation developed (7). Standard US-guided techniques are used with a 27-gauge needle attached to a small-volume (1–3 mL) syringe filled with contrast material (or contrast material and methylene blue in a 1:1 ratio for a preoperative procedure). Extension tubing can also be used, if preferred, but requires an assistant to stabilize the needle or depress the syringe plunger. We prefer a direct connection between syringe and needle because such a connection allows needle stabilization and contrast material administration to be performed with one hand, by the radiologist, as he or she controls the transducer with the alternate hand. A dilated duct is selected and punctured once with the needle tip. Carefully, 0.1–0.2 mL of contrast material is administered. The contrast material may actually be visualized with US as it "rolls" and swirls into the duct. The needle is removed, and standard magnification views are obtained. Inevitably, a small amount of contrast material leaks from the duct (at the wall puncture site) into surrounding tissues. This leakage is minimized by using a 27-gauge needle, a single needle puncture of the duct, and a small volume of contrast material.
Supplies for ductography are shown in Figure 2a, and our ductography procedure tray is shown in Figure 2b. A summary of the procedure for ductography is given in the Table.
View larger version (132K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 2a. Ductography supplies and procedure tray. (a) Ductography supplies include a ductography cannula set, a 2 x 2-inch (5 x 5-cm) gauze pad (sterile), iothalamate or iopamidol, a 1-mL or 3-mL syringe, and a nursing pad. (b) The ductography procedure tray includes the cannula set, the gauze pad, iothalamate or iopamidol, the syringe, the nursing pad, alcohol swabs (sterile), and test strips for blood. Other supplies are a headset magnification device, a high-intensity light source, paper tape, and latex or nonlatex gloves.
|
|
View larger version (117K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 2b. Ductography supplies and procedure tray. (a) Ductography supplies include a ductography cannula set, a 2 x 2-inch (5 x 5-cm) gauze pad (sterile), iothalamate or iopamidol, a 1-mL or 3-mL syringe, and a nursing pad. (b) The ductography procedure tray includes the cannula set, the gauze pad, iothalamate or iopamidol, the syringe, the nursing pad, alcohol swabs (sterile), and test strips for blood. Other supplies are a headset magnification device, a high-intensity light source, paper tape, and latex or nonlatex gloves.
|
|
In the following discussion, the term proximal ducts refers to ducts within the breast tissue or in the central breast, where the terminal ducts lead to lobules (acini). The term distal ducts refers to ducts "downstream" (or toward the nipple) from the proximal ducts. Therefore, the "distal-most ducts" are directly beneath the nipple.
|
Extravasation
|
|---|
If extravasation occurs, patients usually experience focal pain or burning, although the process may be completely asymptomatic. Occasionally, extravasation is heralded by an unimpeded flow of an excessive volume of contrast material (1–2 mL). Radiologists inexperienced in ductography may tend to administer too much contrast material, resulting in extravasation in their first few procedures. If extravasation occurs, we remove the cannula, treat the patient with a mild analgesic (acetaminophen, ibuprofen), and reschedule the ductography for 7–14 days later. Extravasation usually occurs from too forceful contrast material administration or wall perforation by vigorous cannula insertion. Rarely, destruction of ductal integrity by carcinoma leads to extravasation. Types of extravasation include immediate extravasation (Fig 3a), delayed extravasation from excess injection pressure (Fig 3b), and extravasation with subsequent venous filling (Fig 3c).
View larger version (112K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 3a. Extravasation. (a) Craniocaudal ductogram shows immediate extravasation (arrow). (b) Ninety-degree mediolateral ductogram shows delayed extravasation from excess injection pressure (open arrows). Note the cannula tip (solid arrow). (c) Ninety-degree mediolateral ductogram shows extravasation with venous filling.
|
|
View larger version (128K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 3b. Extravasation. (a) Craniocaudal ductogram shows immediate extravasation (arrow). (b) Ninety-degree mediolateral ductogram shows delayed extravasation from excess injection pressure (open arrows). Note the cannula tip (solid arrow). (c) Ninety-degree mediolateral ductogram shows extravasation with venous filling.
|
|
View larger version (129K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 3c. Extravasation. (a) Craniocaudal ductogram shows immediate extravasation (arrow). (b) Ninety-degree mediolateral ductogram shows delayed extravasation from excess injection pressure (open arrows). Note the cannula tip (solid arrow). (c) Ninety-degree mediolateral ductogram shows extravasation with venous filling.
|
|
Contrast material reaction from ductography has not been reported, to our knowledge, and is thought to be rare. We have not encountered a contrast material allergy from ductography in our practice and view vasovagal reactions as a more common concern. Thus, special care is taken during patient transfer to prevent fainting and falls, and we advise patients not to view the cannula when it is in place in the nipple. In theory, intravasation or extravasation with subsequent venous or lymphatic filling could cause an allergic reaction to contrast material in selected, sensitive patients. The risk for contrast material reaction in ductography may be comparable to the risk in patients undergoing intracavitary procedures, such as cystography, sinus tract instillation, or retrograde pyelography. This level of risk is significantly lower than that associated with intravenous injection of contrast material (King B, oral communication, August 2000).
Despite the lack of reported contrast material reactions from ductography, we screen patients for significant allergy to iodinated contrast material. Patients who experience the common side effects of rapid intravenous administration of contrast material (a sensation of warmth, pain, or burning at the injection site) receive reassurance, and we use the standard ductography procedure. Patients with mild to moderate reactions (itching, mild erythema, hives) are considered for standard contrast material pretreatment regimens with diphenhydramine and corticosteroids, and we use nonionic contrast material. Patients with a history of severe contrast material reaction (eg, anaphylaxis, stridor, laryngeal edema, hypotension) or who have had reactions necessitating intubation or hospitalization are considered to be at high risk, and the procedure is canceled. We refer these patients for surgical evaluation and central duct excision without preoperative ductography. Because we use standard latex gloves for the radiologist and technologist performing the procedure, patients are also screened for latex allergy. If it is present, nonlatex gloves are used.
|
Artifacts
|
|---|
Elimination of air bubbles from the cannula, syringe, and extension tubing is vital. Once present, bubbles simulate filling defects or may even obstruct smaller ducts (Fig 4). Air bubbles will change position with orthogonal positioning, rising to the antidependent surface. Acquisition of rolled views or hand pressure may move the air bubbles, excluding fixed filling defects.
View larger version (156K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 4. Air bubbles. Craniocaudal ductogram shows dark air bubbles (straight arrows) within contrast material, which were inadvertently administered. Note the air bubbles obstructing side channels (curved arrows).
|
|
Prior inadvertent administration of fat-soluble ethiodized oil (Ethiodol; Savage Laboratories, Melville, NY) may result in residual material that could obscure ductographic findings (8). Nipple reconstructive disks may prevent ductography or obscure ductographic findings. We have not performed ductography in a patient with a nipple ring and are not aware of a published report on this topic. Silicone or saline augmentation implants may obscure ductographic findings. Patients who have undergone direct silicone injections into breast tissue will have high-density silicone, which can obscure ductographic findings.
|
Obstruction and Reflux
|
|---|
The cannula may pierce solid intraluminal masses, even without pressure, or slide between a mass and the side wall of the duct. Contrast material will then outline the distal surface of the mass and the nipple, and immediate reflux may occur (Fig 5). When reflux occurs, radiologists must be aware of a possible tumor in the distal-most duct and plan imaging accordingly. When immediate reflux occurs, it is important that imaging be performed and not abandoned due to the possible erroneous conclusion that unsuccessful cannulation has occurred.
|
Normal Ducts
|
|---|
Normal ducts vary considerably in appearance. The lactiferous sinus is a dilated, ampullary, fusiform segment immediately posterior to the nipple (Fig 6a). The normal diameter in other parts of the duct approximates the diameter of the cannula. Intercommunication between ducts occurs, and ducts may proceed in unexpected directions from the nipple (Fig 6b); this knowledge is instructive for operating surgeons. Lobular blush is caused by contrast material filling the lobular portion of the terminal ductal lobular unit (Fig 6c). Once this finding is seen, the volume pressure in that ductal system has reached its maximum and additional contrast material administration carries a risk of extravasation.
View larger version (140K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 6a. Ductal ectasia. (a) Direct 90° ductogram shows extension of the ductal system inferiorly from the lactiferous sinus (arrow), which is directly subjacent to the nipple. The system extends 4 cm posteriorly. (b) Craniocaudal ductogram (same patient as in a) shows extension laterally from the lactiferous sinus, 4 cm posteriorly. Thus, the ectatic system extends inferolateral to the nipple, not directly subjacent to the nipple in a central position. (c) Craniocaudal ductogram shows slightly ectatic, tortuous subareolar ducts (white arrows). Otherwise, this is a normal ductal system. Note the normal "lobular blush" (black arrows).
|
|
View larger version (125K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 6b. Ductal ectasia. (a) Direct 90° ductogram shows extension of the ductal system inferiorly from the lactiferous sinus (arrow), which is directly subjacent to the nipple. The system extends 4 cm posteriorly. (b) Craniocaudal ductogram (same patient as in a) shows extension laterally from the lactiferous sinus, 4 cm posteriorly. Thus, the ectatic system extends inferolateral to the nipple, not directly subjacent to the nipple in a central position. (c) Craniocaudal ductogram shows slightly ectatic, tortuous subareolar ducts (white arrows). Otherwise, this is a normal ductal system. Note the normal "lobular blush" (black arrows).
|
|
View larger version (140K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 6c. Ductal ectasia. (a) Direct 90° ductogram shows extension of the ductal system inferiorly from the lactiferous sinus (arrow), which is directly subjacent to the nipple. The system extends 4 cm posteriorly. (b) Craniocaudal ductogram (same patient as in a) shows extension laterally from the lactiferous sinus, 4 cm posteriorly. Thus, the ectatic system extends inferolateral to the nipple, not directly subjacent to the nipple in a central position. (c) Craniocaudal ductogram shows slightly ectatic, tortuous subareolar ducts (white arrows). Otherwise, this is a normal ductal system. Note the normal "lobular blush" (black arrows).
|
|
|
Ductal Ectasia
|
|---|
Ductography may demonstrate a dilated ductal system without filling defects, obstruction, extravasation, epithelial irregularity, or architectural distortion (Fig 7). Ductal ectasia may cause fluid stasis and nipple discharge, which may be mildly positive for the presence of blood. When ductography demonstrates ductal ectasia and no other abnormality, confirmatory follow-up ductography should be considered. Because the orifices on the nipple can be closely positioned and ducts intercommunicate, cannulation occasionally produces opacification of different ductal systems in sequential examinations. If an abnormal system is opacified, surgery is indicated for that region. If ductal ectasia is again demonstrated (without additional abnormality), management may vary. Conservative short-term follow-up may be appropriate in patients with clinical and ductographic findings of ductal ectasia and a discharge pattern of low suspicion or one that resolves, suggesting transient inflammation or mastitis. Thus, in certain carefully selected patients, surgery for benign findings may be avoided.
However, radiologists should be aware that the specific negative predictive value of a negative ductogram (or series of negative ductograms) is unknown. Cases with a strongly blood-positive discharge or a clinical and ductographic pattern of moderate or high suspicion should be considered for surgical referral even in the setting of a ductographic pattern suggesting ductal ectasia. As Leis (4) demonstrated, serosanguineous, sanguineous, and clear or watery discharge may be associated with a 12.9%, 27.5%, and 33.3% respective risk of carcinoma in the absence of ductographic evaluation. His study was performed in 1989, before the significant improvement in mammographic quality of the past decade and the wider use of ductography. However, these results should be considered when patients with nipple discharge and normal or ectatic ductal systems at ductography are evaluated.
|
Fibrocystic Changes
|
|---|
Ducts communicating with cysts may lead to nipple discharge as cyst fluid decompresses into the duct and out to the nipple pore (9). In cases of fibrocystic changes, ductography demonstrates normal ducts communicating with cysts, occasionally with concomitant ductal ectasia (Fig 8).
|
Papillomas
|
|---|
Benign papillomas are soft, friable tumors of the ductal epithelium (10). Soft tumors of the distal duct may be pierced by the 30-gauge cannula without the radiologist sensing any resistance (Fig 5). Of all the causes of unilateral, single-pore, spontaneous ductal discharge, papillomas are the most common. If ductography is not performed, they may remain invisible (11). Occasionally, at standard nonenhanced imaging, a papilloma appears as a well-circumscribed nodule with or without benign calcifications at mammography (Fig 9). Ductography helps define the sites, number, and extent of presumed papillomas (Figs 10, 11). Papillomas secrete fluid profusely, and the duct downstream from the papilloma (that is, toward the nipple from the papilloma) is often dilated (Figs 9, 10). Paradoxically, proximal to the papilloma, the normal duct is usually not dilated (Fig 12). In addition to filling defects and downstream ductal dilatation, papillomas may also cause ductal obstruction or an "amputated" duct (complete obstruction by a ductal abnormality) (Fig 13) or even alteration in the normally smooth duct wall. Papillomas may coexist with fibrocystic changes (Fig 10). Extravasation due to technical factors should be followed by a second ductography attempt (Fig 14), since a study with fully diagnostic results is possible in a significant percentage of such cases.
View larger version (145K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 9a. Papillomas. Ninety-degree mediolateral (a) and craniocaudal (b) ductograms show filling defects (small black arrows and white arrows), which represent papillomas outlined by contrast material. There are probable additional calcified papillomas (large black arrows). Ductography allowed resection of noncalcified intraluminal masses and calcified masses. Histologic analysis demonstrated multiple papillomas.
|
|
View larger version (144K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 9b. Papillomas. Ninety-degree mediolateral (a) and craniocaudal (b) ductograms show filling defects (small black arrows and white arrows), which represent papillomas outlined by contrast material. There are probable additional calcified papillomas (large black arrows). Ductography allowed resection of noncalcified intraluminal masses and calcified masses. Histologic analysis demonstrated multiple papillomas.
|
|
View larger version (130K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 12. Papillomas. Ninety-degree mediolateral ductogram shows multiple filling defects (arrows). The anterior papilloma (arrowhead) causes no significant "upstream," proximal dilatation. Histologic analysis demonstrated papillomas.
|
|
View larger version (136K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 13. Papillomas associated with filling defects. Craniocaudal ductogram shows intraluminal filling defects (open arrow), a mass within a dilated duct (arrowheads), circumferential narrowing of a duct (curved arrow), and an amputated duct (straight solid arrows). Histologic analysis demonstrated multiple papillomas.
|
|
View larger version (114K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 14a. Papilloma. (a) Initial 90° (left image) and craniocaudal (right image) ductograms show extravasation (arrows). Follow-up ductography was rescheduled for 2 weeks later. (b) Follow-up 90° mediolateral ductogram obtained 2 weeks later shows filling defects within a dilated duct (arrow). Histologic analysis demonstrated a papilloma.
|
|
View larger version (150K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 14b. Papilloma. (a) Initial 90° (left image) and craniocaudal (right image) ductograms show extravasation (arrows). Follow-up ductography was rescheduled for 2 weeks later. (b) Follow-up 90° mediolateral ductogram obtained 2 weeks later shows filling defects within a dilated duct (arrow). Histologic analysis demonstrated a papilloma.
|
|
|
Carcinoma
|
|---|
Carcinoma involving the ductal system of the breast may manifest as a ductal discharge. The features of breast carcinoma at ductography may imitate those of papilloma (Fig 15). Additional evidence of carcinoma may be present in tissue adjacent to abnormal ducts (Figs 16–18), and radiologists need to be vigilant against "tunnel vision" when assessing ductograms. At ductography, cysts communicating with the discharging ductal system may be filled. Cysts with filling defects should be excised (Fig 17). Extravasation may be due to technical factors, as described earlier, or to epithelial destruction by invasive carcinoma (Fig 19). If ductal discharge is encountered and is treated with central duct excision without intervening ductography, under- or overexcision is possible (Fig 15). Standard central duct excision results in resection of a cone of tissue approximately 4–5 cm in length directly posterior to the nipple. Abnormal ducts proceeding in atypical patterns from the nipple may not be excised (Figs 6, 15). Extensive multifocal or multicentric intraductal abnormalities may be effectively understaged, especially if they are peripherally located (12). Because the distal ducts have been transected, discharge ceases, yet the underlying cause remains in place.
View larger version (108K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 15. Carcinoma. Craniocaudal ductogram shows large filling defects near the nipple (arrow). Sanguineous spontaneous nipple discharge prompted acquisition of a diagnostic ductogram. The standard central duct excision would have resulted in excision of tissue within a cone limited by the white lines and the nipple. Note the filling defects outside the margin of the standard excision (arrowheads). Histologic analysis demonstrated extensive ductal carcinoma in situ (DCIS) involving much of the area opacified with ductography.
|
|
View larger version (153K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 16a. Carcinoma in a patient with sanguineous, single-pore, spontaneous nipple discharge during pregnancy. (a) Nonmagnified 90° mediolateral ductogram shows filling defects within a dilated distal ductal system (arrow). There are extensive casting and pleomorphic calcifications throughout the breast (arrowheads). Note the correlation between ductal calcifications and obstruction to the retrograde flow of contrast material; subareolar filling defects within the contrast material stream represent calcified and noncalcified DCIS. (b) Magnified craniocaudal ductogram better shows the filling defects within the dilated distal ductal system (arrow) and the obstruction to retrograde flow. Casting and pleomorphic calcifications are seen within ducts not opacified by contrast material (arrowheads). Histologic analysis demonstrated calcified and noncalcified DCIS, comedo carcinoma, and an extensive intraductal component, which were treated with mastectomy.
|
|
View larger version (157K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 16b. Carcinoma in a patient with sanguineous, single-pore, spontaneous nipple discharge during pregnancy. (a) Nonmagnified 90° mediolateral ductogram shows filling defects within a dilated distal ductal system (arrow). There are extensive casting and pleomorphic calcifications throughout the breast (arrowheads). Note the correlation between ductal calcifications and obstruction to the retrograde flow of contrast material; subareolar filling defects within the contrast material stream represent calcified and noncalcified DCIS. (b) Magnified craniocaudal ductogram better shows the filling defects within the dilated distal ductal system (arrow) and the obstruction to retrograde flow. Casting and pleomorphic calcifications are seen within ducts not opacified by contrast material (arrowheads). Histologic analysis demonstrated calcified and noncalcified DCIS, comedo carcinoma, and an extensive intraductal component, which were treated with mastectomy.
|
|
View larger version (117K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 17a. Carcinoma. (a) Preductography craniocaudal mammogram shows a mass (wavy arrow) and indeterminate calcifications (straight arrow). (b) Craniocaudal ductogram shows multiple filling defects within ducts (arrowheads) and within a cystic structure (black arrow). Calcifications are seen to the right of the cystic structure. Histologic analysis demonstrated grade II invasive ductal carcinoma and DCIS. The DCIS was associated with intraductal and intracystic abnormalities and with the calcifications. The invasive ductal carcinoma was present in the region indicated by the white arrow, an area not evaluated prior to ductography.
|
|
View larger version (116K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 17b. Carcinoma. (a) Preductography craniocaudal mammogram shows a mass (wavy arrow) and indeterminate calcifications (straight arrow). (b) Craniocaudal ductogram shows multiple filling defects within ducts (arrowheads) and within a cystic structure (black arrow). Calcifications are seen to the right of the cystic structure. Histologic analysis demonstrated grade II invasive ductal carcinoma and DCIS. The DCIS was associated with intraductal and intracystic abnormalities and with the calcifications. The invasive ductal carcinoma was present in the region indicated by the white arrow, an area not evaluated prior to ductography.
|
|
View larger version (125K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 18a. Carcinoma. (a) Preoperative craniocaudal ductogram shows an outlined intraductal abnormality (arrow). Note the pleomorphic calcifications (arrowheads). (b) Orthogonal preoperative 90° mediolateral ductogram shows the outlined intraductal abnormality (arrow) and pleomorphic calcifications (arrowheads). Histologic analysis demonstrated an intraductal papilloma; the calcifications were associated with low-nuclear-grade DCIS.
|
|
View larger version (135K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 18b. Carcinoma. (a) Preoperative craniocaudal ductogram shows an outlined intraductal abnormality (arrow). Note the pleomorphic calcifications (arrowheads). (b) Orthogonal preoperative 90° mediolateral ductogram shows the outlined intraductal abnormality (arrow) and pleomorphic calcifications (arrowheads). Histologic analysis demonstrated an intraductal papilloma; the calcifications were associated with low-nuclear-grade DCIS.
|
|
View larger version (135K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 19a. Carcinoma. Craniocaudal (a) and 90° mediolateral (b) ductograms show extravasation (*) associated with DCIS and invasive adenocarcinoma. Note the cannula and irregularity of the duct walls (arrow). Histologic analysis demonstrated invasive ductal carcinoma in the region of extravasation and DCIS in the area of duct wall irregularity.
|
|
View larger version (150K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 19b. Carcinoma. Craniocaudal (a) and 90° mediolateral (b) ductograms show extravasation (*) associated with DCIS and invasive adenocarcinoma. Note the cannula and irregularity of the duct walls (arrow). Histologic analysis demonstrated invasive ductal carcinoma in the region of extravasation and DCIS in the area of duct wall irregularity.
|
|
|
Follow-up and Treatment
|
|---|
When ductal ectasia, fibrocystic changes, or normal findings are present at ductography and the radiologist is confident the discharging ductal system has been adequately evaluated, short-term conservative follow-up may be carefully considered if the clinical findings are also benign or have resolved (1). Radiologists may recommend confirmatory follow-up ductography 2–4 weeks later to minimize the risk that a closely adjacent normal orifice was mistakenly cannulated. Before such a recommendation is made, we carefully consider the clinical and imaging findings and the patient's risk factors. For example, patients with a history of carcinoma treated with mastectomy, a strong family history of breast cancer, or a suspicious discharge pattern are considered for central duct excision even if the results of ductography are normal. We make this recommendation because we have encountered rare cases of surgically proved DCIS in patients with a moderate-suspicion or suspicious nipple discharge and relatively normal or equivocal findings at ductography. DCIS can manifest as only minimal surface irregularity of the epithelial duct wall. In addition, benign atypical ductal hyperplasia and malignancy may coexist in breast tissue with normal mammographic findings and spontaneous nipple discharge. Further, nipple discharge in patients with significant risk factors for breast cancer elevates our level of suspicion. Thus, in the setting of strongly blood-positive unilateral, single-pore, spontaneous discharge, a normal ductogram prompts serious consideration for central duct excision.
However, the subset of patients with mild, equivocal serosanguineous or sanguineous unilateral, single-pore, spontaneous nipple discharge and normal ductographic findings or findings of ductal ectasia or fibrocystic changes may be treated differently in various breast centers. Some breast imaging experts would consider short-term follow-up and avoidance of surgery if ductal ectasia or fibrocystic changes are demonstrated (1). Others would opt for a "rating system" approach to risk estimation, prompting surgery or rigorous short-term follow-up and repeat ductography (8). Others may be concerned about the lack of rigorous studies defining the positive or negative predictive value of ductography and would consider standard central duct excision. More studies are needed to investigate this subset of patients.
Pregnancy stimulates the ductal epithelial lining, and tissue may project into alveolar duct lumina. The tissue may desquamate, inducing bloody nipple discharge. Among breast cancer patients, less than 3% of cases occur during pregnancy (13). Yet, in our series, bloody nipple discharge during pregnancy heralded breast cancer in one patient (Fig 16). The majority of pregnant patients are followed up conservatively and the discharge is short-lived, resolving spontaneously within several weeks.
To our knowledge, no controlled studies have been performed to rigorously assess the sensitivity, specificity, or positive and negative predictive values of ductography. However, sanguineous unilateral, single-pore, spontaneous nipple discharge is associated with a prevalence of breast cancer in the range of approximately 5%–28% (4,8). When the results of several studies are averaged, there is an approximate prevalence of 7%–13% (4,8). To stratify risk and address these issues, radiologists have constructed numeric charts that list a weighting factor for each clinical or ductographic finding. The sum total is used to recommend repeat ductography, short-term follow-up, or biopsy (8).
Ductal filling defects, obstruction, or wall irregularity with ductal distortion are suspicious for papilloma or carcinoma, and surgical excision is required. To our knowledge, no specific findings have been proved to allow separation of papilloma from ductal carcinoma (1). Also, to our knowledge, no specific ductographic findings have been proved to allow separation of benign from malignant disease.
Sardanelli et al (14) evaluated US-guided fine-needle aspiration after ductography in 36 patients and concluded that cytologic analysis of the fine-needle aspirate added useful information (as compared with cytologic analysis of nipple discharge) for customized surgical planning. We have not used this technique and, as noted earlier, do not routinely use cytologic analysis of ductal discharge. Magnetic resonance (MR) ductography was assessed in a retrospective review of 23 patients by Orel et al (15). The authors' review did not allow comparison of standard ductography with MR ductography, and they called for a prospective review of US, conventional ductography, and MR ductography. In our community, surgeons rely on standard ductography for guidance, and the technique is readily available and relatively inexpensive.
Preoperative ductography with a 1:1 solution of contrast material and methylene blue allows identification of the abnormal duct for mammography and for the operating surgeon. Ducts are less conspicuous with dilute contrast material than with full-strength contrast material (Fig 20). Once the same abnormal duct has been identified, the cannula is removed and paper tape is applied over the nipple to minimize loss of contrast material and dye. If further localization is desired, standard wire placement techniques may be used with a localizing grid (Fig 21). In some practices, radiologists and surgeons feel comfortable using only the initial diagnostic ductogram as guidance for surgery. Thus, localizing ductography is omitted and anatomic markers are used (eg, distance of the abnormality below the nipple and course of ducts medial, lateral, superior, or inferior).
View larger version (116K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 20. Preoperative craniocaudal ductogram obtained with a 1:1 admixture of methylene blue and iodinated contrast material shows a pale stream of contrast material and filling defects (arrows). We provide distance measurements for our operating surgeons on the magnified views (white line). Histologic analysis demonstrated papillomas.
|
|
View larger version (135K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 21a. Localization. (a) Craniocaudal localizing ductogram shows a small, subtle filling defect (arrow) pinpointed with an alphanumeric grid. The needle and its hub are seen on end. (b) Ninety-degree mediolateral localizing ductogram shows the filling defect (arrow) localized by means of wire placement through the needle shown in a. The wire tip was deployed by means of standard needle-wire techniques adjacent to the filling defect.
|
|
View larger version (113K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 21b. Localization. (a) Craniocaudal localizing ductogram shows a small, subtle filling defect (arrow) pinpointed with an alphanumeric grid. The needle and its hub are seen on end. (b) Ninety-degree mediolateral localizing ductogram shows the filling defect (arrow) localized by means of wire placement through the needle shown in a. The wire tip was deployed by means of standard needle-wire techniques adjacent to the filling defect.
|
|
Van Zee et al (16) found that only 67% of patients who underwent duct excision without preoperative ductography had a specific diagnosis determined at histopathologic review. All 16 patients who underwent duct excision after preoperative ductography had a specific cause and diagnosis determined at histopathologic review. The authors concluded that preoperative ductography increases the likelihood that a specific pathologic entity and cause of discharge will be documented at surgical excision. In our community, preoperative localizing ductography is preferred. Extensive cooperation between the radiologist, operating surgeon, and pathologist is important to be confident that all lesions are removed (17).
We routinely review the diagnostic and localizing preoperative ductograms with the surgeon immediately before the operation. In addition, we provide a representative ductogram sequence (craniocaudal and mediolateral), marked for medial and lateral orientation, for consultation in the operating room and by the consulting pathologist. Ductographic abnormalities are circled, and the distance in centimeters between the nipple and the tissue targeted for excision is noted. Specimen radiography or US is not helpful because loss of the contrast material or dye prevents visualization of the ductal abnormality after excision, unless large adjacent abnormalities, regional calcifications, or intracystic masses are slated for excision as well.
Dennis et al (18) performed biopsy in 43 patients with nipple discharge and underlying intraductal abnormalities using US-guided automated core biopsy or biopsy with an 11-gauge mammotomy device. The authors concluded that the procedure was effective in alleviating subsequent nipple discharge and in obtaining diagnostic histologic material without significant complications. Additional studies are needed to assess this technique in comparison with ductography-guided surgical excision and MR imaging of ductal abnormalities.
|
Conclusions
|
|---|
Ductography is a useful procedure that is currently underused. Radiologists may use many techniques to perfect their performance of ductography, to the benefit of their patients and referring surgeons.
|
Acknowledgments
|
|---|
This work would not have been possible without the contributions of the previous physicians of the Susan G. Komen Breast Center. The authors recognize the contributions of those physicians in performing ductography for these patients and popularizing the technique for radiologists. The authors gratefully acknowledge the assistance of G. W. Eklund, MD, Danette Doubet, and Karol Burton in the preparation of this article and the support of Peoria Radiology Associates.
|
Footnotes
|
|---|
Abbreviations: DCIS = ductal carcinoma in situ
|
References
|
|---|
-
Cardenosa G, Doudna C, Eklund GW. Ductography of the breast: technique and findings. AJR Am J Roentgenol 1994; 162:1081-1087.[Abstract/Free Full Text]
-
Tabar L, Dean RB, Zoltan P. Galactography: the diagnostic procedure of choice for nipple discharge. Radiology 1983; 149:31-38.[Abstract/Free Full Text]
-
Rongione AJ, Evans BD, Kling KM, McFarden DW. Ductography is a useful technique in evaluation of abnormal breast discharge. Am Surg 1996; 62:785-788.[Medline]
-
Leis HP. Management of nipple discharge. World J Surg 1989; 13:736-742.[Medline]
-
Choudary MA, Millis RR, Davies GC, Hayward IL. Nipple discharge: the diagnostic value of testing for occult blood. Ann Surg 1982; 196:651-655.[Medline]
-
Fajardo LL, Jackson VP, Hunter TB. Interventional procedures in diseases of the breast: needle biopsy, pneumocystography, and galactography. AJR Am J Roentgenol 1992; 158:1231-1238.[Abstract/Free Full Text]
-
Huynh PT, Parellada JA, Shaw de Paredes E , et al. Dilated duct pattern at mammography. Radiology 1997; 204:137-141.[Abstract/Free Full Text]
-
Logan-Young W, Hoffman NY. Breast cancer: a practical guide to diagnosis Rochester, NY: Mount Hope, 1994; 194.
-
Cardenosa G, Eklund GW. Ductography. Appl Radiol 1992; 21:24-29.
-
Cardenosa G, Eklund GW. Benign papillary neoplasms of the breast: mammographic findings. Radiology 1991; 181:751-755.[Abstract/Free Full Text]
-
Woods ER, Helvie MA, Ikeda DM, Mandell SH. Solitary breast papilloma: comparison of mammographic, galactographic, and pathologic findings. AJR Am J Roentgenol 1992; 159:487-491.[Abstract/Free Full Text]
-
Dawes LG, Bowen C, Venta LA, Morrow M. Ductography for nipple discharge: no replacement for ductal excision. Surgery 1998; 124:675-691.
-
Fiorica JV. Nipple discharge. Obstet Gynecol Clin North Am 1994; 21:453-460.[Medline]
-
Sardanelli F, Imperiale A, Zandrino F, et al. Breast intraductal masses: US-guided fine-needle aspiration after galactography. Radiology 1997; 204:143-148.[Abstract/Free Full Text]
-
Orel SG, Dougherty CS, Reynolds C, et al. MR imaging in patients with nipple discharge: initial experience. Radiology 2000; 216:248-254.[Abstract/Free Full Text]
-
Van Zee KJ, Perez GO, Minnaro E, Cohen MA. Preoperative galactography increases the diagnostic yield of major duct excision for nipple discharge. Cancer 1998; 82:1874-1880.[Medline]
-
Baker KS, Davey DD, Stelling CB. Ductal abnormalities detected with galactography: frequency of adequate excisional biopsy. AJR Am J Roentgenol 1994; 162:821-824.[Abstract/Free Full Text]
-
Dennis MA, Parker S, Kaske TI, Stavros AT, Camp J. Incidental treatment of nipple discharge caused by benign intraductal papilloma through diagnostic mammotome biopsy. AJR Am J Roentgenol 2000; 174:1263-1268.[Abstract/Free Full Text]
This article has been cited by other articles:
|
|
|
|
 
M. Hirose, H. Nobusawa, and T. Gokan
MR Ductography: Comparison with Conventional Ductography as a Diagnostic Method in Patients with Nipple Discharge
RadioGraphics,
October 1, 2007;
27(suppl_1):
S183 - S196.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
C. K. Kuhl
Current Status of Breast MR Imaging * Part 2. Clinical Applications
Radiology,
September 1, 2007;
244(3):
672 - 691.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. Koskela, M. Berg, T. Pietilainen, P. Mustonen, and R. Vanninen
Breast Lesions Causing Nipple Discharge: Preoperative Galactography-Aided Stereotactic Wire Localization
Am. J. Roentgenol.,
June 1, 2005;
184(6):
1795 - 1798.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
Y. Kanemaki, Y. Kurihara, D. Itoh, K. Kamijo, Y. Nakajima, M. Fukuda, and M. Van Cauteren
MR Mammary Ductography Using a Microscopy Coil for Assessment of Intraductal Lesions
Am. J. Roentgenol.,
May 1, 2004;
182(5):
1340 - 1342.
[Full Text]
[PDF]
|
|
|
|
|
|
|
W. K. Moon, J. S. Myung, Y. J. Lee, I. A. Park, D.-Y. Noh, and J.-G. Im
US of Ductal Carcinoma In Situ
RadioGraphics,
March 1, 2002;
22(2):
269 - 281.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
W. C. Dooley, B.-M. Ljung, U. Veronesi, M. Cazzaniga, R. M. Elledge, J. A. O'Shaughnessy, H. M. Kuerer, D. T. Hung, S. A. Khan, R. F. Phillips, et al.
Ductal Lavage for Detection of Cellular Atypia in Women at High Risk for Breast Cancer
J Natl Cancer Inst,
November 7, 2001;
93(21):
1624 - 1632.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
LEARNING OBJECTIVES
