DOI: 10.1148/rg.27si075501
RadioGraphics 2007;27:S183-S196
© RSNA, 2007
MR Ductography: Comparison with Conventional Ductography as a Diagnostic Method in Patients with Nipple Discharge1
Masanori Hirose, MD,
Hiroshi Nobusawa, MD, and
Takehiko Gokan, MD
1 From the Department of Radiology, School of Medicine, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, 142-8666 Tokyo, Japan. Recipient of a Certificate of Merit award for an education exhibit at the 2006 RSNA Annual Meeting. Received February 1, 2007; revision requested March 13; final revision received May 14; accepted May 30. All authors have no financial relationships to disclose.
Address correspondence to M.H. (e-mail: mnhirose{at}med.showa-u.ac.jp).
 |
Abstract
|
|---|
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.
© RSNA, 2007
|
LEARNING OBJECTIVES FOR TEST 5
|
|---|
After reading this article and taking the test, the reader will be able to:
- Describe the causes of nipple discharge and the diagnostic strategy.
- List the findings at conventional ductography, MR ductography, and fusion imaging in patients with nipple discharge.
- Discuss the advantages and disadvantages of conventional ductography and MR ductography.
|
Introduction
|
|---|
Nipple discharge is a relatively common symptom. Most nipple discharges are physiologic and are not associated with an underlying benign or malignant breast neoplasm (1). A benign condition, such as an intraductal papilloma (1), is the most frequently encountered cause of a pathologic nipple discharge. The most important cause of pathologic discharge is breast cancer, which has been reported to occur in 1%–45% of cases in several large clinical series (2). This significantly high prevalence of a malignant cause necessitates accurate identification of ductal abnormalities. The diagnostic imaging methods most frequently used to evaluate a pathologic discharge from the nipple are mammography, conventional ductography, and, more recently, ultrasonography (US) (3).
Conventional ductography has been recommended as a method for identification of lesions in patients with nipple discharge (4,5). Conventional ductography has proved to be effective in locating and identifying intraductal lesions (1,3). A conventional ductographic study is a mammographic examination performed after retrograde filling of the lactiferous ducts with contrast material. Being invasive, conventional ductography thus has attendant complications and contraindications.
Magnetic resonance (MR) hydrography can noninvasively depict fluid-filled tubular structures. The hydrographic image is derived from heavy T2 weighting, which accentuates the visibility of structures containing fluids with long T2 relaxation times (6). No contrast material, either instilled directly or injected intravenously, is necessary. We applied MR hydrography for MR ductography in our patients. MR ductography demonstrates a dilated duct as a high-signal tubular structure, as does conventional ductography (7).
Only the interface between the lesion and the fluid-filled duct is identified at conventional and MR ductography. The lesion outlined may represent only the tip of the iceberg, with much more extending beyond the confines of the duct. Investigators have reported that MR imaging of the breast with intravenously injected contrast material has the potential for high sensitivity in detection of an intraductal lesion (3,8). We created fusion images using MR ductography and MR mammography. These fused images not only display the existence of intraductal abnormalities but also reveal the precise extent of the lesion on one image, allowing us to readily understand the relationship between the dilated duct and the intraductal lesion in the breast.
In this article, we review the causes of pathologic nipple discharge and discuss the diagnostic strategy. We demonstrate and explain the findings at conventional ductography, MR ductography, and fusion imaging with MR ductography and MR mammography in patients with pathologic nipple discharge. Finally, we discuss the advantages and disadvantages of conventional ductography and MR ductography.
|
Causes of Nipple Discharge
|
|---|
Nipple discharge is the third most common breast complaint after breast pain and a breast mass (9). The prevalence of symptomatic nipple discharge in referral breast clinics is reported to be 4.8%–7.4% (9). Spontaneous nipple discharge makes up nearly 7% of all breast symptoms (10). Nipple discharge is first characterized clinically as physiologic or pathologic (11). A physiologic discharge is typically white or green, emanates from many ducts, and occurs in both breasts (9,10). Causes of physiologic discharge include hypothyroidism, pituitary adenoma, and medication side effects. Medications associated with physiologic discharge from the nipple include hormonal preparations; psychotropic, antihypertensive, and anti-emetic drugs; and the H2 receptor antagonist group (9,11).
A pathologic discharge is spontaneous and unilateral and is discharged from a single duct opening on the nipple (9). Pathologic discharges are typically bloody or serous (12,13). 
Most of the common pathologic causes of nipple discharge are benign (9,12). The most frequently documented cause is a benign papilloma (48.1% of cases), followed by ductal ectasia (15%–20%). Carcinoma is the cause in 1%–45% of patients (2). In some cases, a discharge from the nipple is the only sign of carcinoma (12). A clear or watery discharge has been associated with breast cancer in up to 7% of cases (14).
|
Imaging Methods for Evaluation of Pathologic Nipple Discharge
|
|---|
Mammography is indicated for all women with unilateral spontaneous nipple discharge (9). Mammography often fails to demonstrate lesions because they are small, lack calcifications, or are located entirely within the duct (1). Mammographic findings have been reported to be positive in 50%–90% of patients with malignancy and in less than 50% of patients with a benign papilloma (3).
When performed by an experienced sonologist, US may assist in the detection of intraductal lesions. In standard practice, US is seldom useful in establishing the cause of nipple discharge (4).
MR imaging of the breast, when combined with intravenous injection of contrast material, has been reported to be 86%–100% sensitive for detection of invasive breast carcinoma (3). MR imaging of the breast exhibits the potential for high sensitivity in detection of intraductal disease, further increasing the value of this technique in examination of the patient with pathologic nipple discharge (3,8).
Several researchers have advocated use of conventional ductography to assist in identification of a breast lesion in the patient with nipple discharge (4,5).
|
Conventional Ductography
|
|---|
The primary indication for use of conventional ductography is the occurrence of a spontaneous, unilateral, single-pore nipple discharge, regardless of the appearance of the discharge (5,15).
No absolute contraindication to conventional ductography exists (5). It should not be performed in patients with mastitis or breast abscess, as the inflammation may become severe (2,5). Given the small amount of intraductal contrast agent required, known hypersensitivity to iodinated contrast material is considered a relative contraindication; however, no serious complications have been reported, to our knowledge (2,4,5).
Conventional ductography does have potential complications. If too much contrast material is injected or if too much pressure is applied during injection, perforation of the duct, extravasation of contrast material, and lymphatic opacification may be seen (2,5). Mastitis may occur, and this may require antibiotic therapy (4).
|
Performing MR Ductography
|
|---|
MR hydrography can depict fluid-filled tubular structures noninvasively. No contrast material is necessary because the hydrographic image contrast derives from heavy T2 weighting, which accentuates the structures that contain fluid with long T2 relaxation times (6). We applied MR hydrography for MR ductography. The dilated ducts were imaged and observed as tubular structures with high signal intensity at MR ductography. Like conventional ductography, MR ductography reveals the intraductal lesion as a signal defect in the duct, an irregular duct wall, or a ductal obstruction (7).
MR imaging was performed with patients in the prone position on a 1.5-T imaging unit (Signa; GE Yokogawa Medical System, Tokyo, Japan) by using a commercially available prone dedicated breast coil (GE Yokogawa Medical System). A three-dimensional fat-saturated heavily T2-weighted fast spin-echo sequence was used. Imaging parameters were as follows: repetition time msec/echo time msec = 7000/287; 28 sections obtained in 208 seconds; field of view = 16 cm; matrix = 256 x 192; number of signals acquired = two; and 1.5-mm section thickness with no intersection gap (7).
|
MR Mammography in Patients with Nipple Discharge
|
|---|
The utility of MR imaging for the evaluation of patients with nipple discharge has been reported by several investigators. A solitary intraductal papilloma in women with nipple discharge may be identified at MR imaging as a small, well-circumscribed, enhancing mass (8). MR imaging can be used as an adjunctive imaging modality for the identification of mammographically occult benign or malignant breast abnormality (3).
With three-dimensional MR ductography, dilated ducts are imaged as tubular structures with high signal intensity, and abnormalities are seen as a signal defect. This appearance is similar to that displayed with conventional ductography. MR ductography reveals the existence of an intraductal abnormality; however, it does not reveal the intraductal lesion itself (7). The technique of MR mammography with intravenously injected contrast material demonstrates the lesion itself as an enhancing lesion (3,7,8).
|
Fusion Imaging with MR Ductography and MR Mammography
|
|---|
The technique of fusion imaging with MR ductography and MR mammography demonstrates not only a ductal abnormality but the intraductal lesion as well. By combining data from these studies into a single image, it is possible to clarify the relationship between the duct and the intraductal lesion. This allows evaluation of the size and shape of the lesion and reveals any extension of the lesion into the surrounding breast tissue (7).
We created multivolume fusion images from MR ductography and MR mammography by using a Virtual Place Advance workstation (Office AZE/Medical Imaging Laboratory, Tokyo, Japan). Fusion images were created with the following procedure: We created a three-dimensional volume-rendered image from MR ductography and colored the high-signal-intensity structure (the dilated duct) green. We also created a three-dimensional volume-rendered image from MR mammography and colored high-signal-intensity lesions (intraductal abnormalities) red or yellow. Finally, we fused these two volume data sets using the multivolume fusion function of the workstation. All image processing was performed with the Virtual Place Advance workstation. It took about 10 minutes to create fusion images.
|
Findings at Conventional Ductography and MR Ductography
|
|---|
An intraductal lesion is evident in a conventional ductographic study as the presence of an intraductal filling defect, a complete ductal obstruction, or a wall irregularity (13,15,16). MR ductography demonstrates an intraductal lesion in the same ways as conventional ductography (7). No specific ductographic findings have been proved to differentiate benign from malignant disease (15). In addition, neither conventional ductography nor MR ductography can demonstrate the precise nature or extent of disease accurately (17). MR mammography with intravenous injection of contrast material may reveal the precise extent of disease, and a dynamic study may be helpful in distinguishing malignant disease from benign.
|
Intraductal Papilloma
|
|---|
At conventional ductography, an intraductal papilloma is seen as a round or lobulated filling defect, with a localized smooth surface, in a dilated duct (12,16). Figures 1 and 2 are conventional ductographic images of an intraductal papilloma. The intraductal papilloma is seen as a lobulated filling defect within a dilated duct. In Figure 1, the contrast material–filled duct is completely obstructed; in Figure 2, it is almost completely obstructed.
View larger version (72K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 1. Intraductal papilloma in a 40-year-old woman. Conventional ductogram shows a lobulated filling defect (arrow) within a dilated duct. The contrast material–filled duct is completely obstructed.
|
|
View larger version (120K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 2. Intraductal papilloma in a 54-year-old woman. Conventional ductogram shows a lobulated filling defect (arrow), which almost completely obstructs the contrast material–filled duct.
|
|
An intraductal papilloma is seen as a localized or lobulated signal defect in a dilated duct with either conventional ductography or MR ductography (7). With MR mammography, the intraductal papilloma is demonstrated as a small, well-circumscribed, enhancing mass (8). In Figure 3a, MR ductography shows an intraductal papilloma as a lobulated signal defect within a dilated duct; in Figure 3b, MR mammography demonstrates the papilloma as a well-circumscribed, lobulated, homogeneously enhancing mass.
View larger version (120K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 3a. Intraductal papilloma in a 28-year-old woman. (a) MR ductogram shows a lobulated signal defect (arrow) within a dilated duct. (b) MR mammogram shows a well-circumscribed, lobulated, enhancing mass (arrow).
|
|
View larger version (90K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 3b. Intraductal papilloma in a 28-year-old woman. (a) MR ductogram shows a lobulated signal defect (arrow) within a dilated duct. (b) MR mammogram shows a well-circumscribed, lobulated, enhancing mass (arrow).
|
|
|
Ductal Carcinoma
|
|---|
A malignancy is suggested by conventional ductographic findings of ductal irregularity, encasement, distortion, obstruction, or an irregular filling defect (12,16). Cysts communicating with the discharging ductal system may be filled (15). In Figures 4a and 4b, conventional ductography of a ductal carcinoma in situ displays ductal irregularity, encasement, obstruction, and irregular filling defects. MR mammography demonstrates ductal carcinoma in situ as enhancing lesions along the duct (Fig 4c).
View larger version (95K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 4a. Ductal carcinoma in situ in a 49-year-old woman. (a, b) Mediolateral oblique (a) and craniocaudal (b) conventional ductograms show ductal irregularity (black arrow), encasement (white arrow in a), and obstruction (white arrowhead) and an irregular filling defect (black arrowhead). (c) MR mammogram shows enhancing lesions along the ducts (arrows).
|
|
View larger version (93K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 4b. Ductal carcinoma in situ in a 49-year-old woman. (a, b) Mediolateral oblique (a) and craniocaudal (b) conventional ductograms show ductal irregularity (black arrow), encasement (white arrow in a), and obstruction (white arrowhead) and an irregular filling defect (black arrowhead). (c) MR mammogram shows enhancing lesions along the ducts (arrows).
|
|
View larger version (114K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 4c. Ductal carcinoma in situ in a 49-year-old woman. (a, b) Mediolateral oblique (a) and craniocaudal (b) conventional ductograms show ductal irregularity (black arrow), encasement (white arrow in a), and obstruction (white arrowhead) and an irregular filling defect (black arrowhead). (c) MR mammogram shows enhancing lesions along the ducts (arrows).
|
|
In Figure 5a, conventional ductography of a 40-year-old woman with a bloody discharge and invasive ductal carcinoma shows a dilated and obstructed duct with an irregular wall and multiple filling defects exhibiting irregular surfaces. Also seen is a cyst with a filling defect communicating with the discharging ductal system. In Figure 5b, MR ductography demonstrates multiple cystic and irregularly dilated ducts. MR mammography reveals invasive ductal carcinoma as a diffusely enhancing area (Fig 5c). Fusion imaging clearly demonstrates the extent of invasive ductal carcinoma surrounding multiple dilated ducts on one image (Fig 5d).
View larger version (65K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 5a. Invasive ductal carcinoma in a 40-year-old woman with a bloody nipple discharge. (a) Conventional ductogram shows a dilated and obstructed duct (arrowheads) with an irregular wall and multiple filling defects with irregular surfaces. A cyst with a filling defect (arrow) communicates with the discharging ductal system. (b) MR ductogram (maximum intensity projection [MIP] image) shows multiple cystic and irregularly dilated ducts. The cystic areas appear as high-signal-intensity nodules. (c) MR mammogram (MIP image) shows a diffusely enhancing area (arrows), which represents an invasive ductal carcinoma. (d) Three-dimensional fusion image shows the extent of the carcinoma (yellow) surrounding the dilated ducts (green).
|
|
View larger version (90K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 5b. Invasive ductal carcinoma in a 40-year-old woman with a bloody nipple discharge. (a) Conventional ductogram shows a dilated and obstructed duct (arrowheads) with an irregular wall and multiple filling defects with irregular surfaces. A cyst with a filling defect (arrow) communicates with the discharging ductal system. (b) MR ductogram (maximum intensity projection [MIP] image) shows multiple cystic and irregularly dilated ducts. The cystic areas appear as high-signal-intensity nodules. (c) MR mammogram (MIP image) shows a diffusely enhancing area (arrows), which represents an invasive ductal carcinoma. (d) Three-dimensional fusion image shows the extent of the carcinoma (yellow) surrounding the dilated ducts (green).
|
|
View larger version (105K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 5c. Invasive ductal carcinoma in a 40-year-old woman with a bloody nipple discharge. (a) Conventional ductogram shows a dilated and obstructed duct (arrowheads) with an irregular wall and multiple filling defects with irregular surfaces. A cyst with a filling defect (arrow) communicates with the discharging ductal system. (b) MR ductogram (maximum intensity projection [MIP] image) shows multiple cystic and irregularly dilated ducts. The cystic areas appear as high-signal-intensity nodules. (c) MR mammogram (MIP image) shows a diffusely enhancing area (arrows), which represents an invasive ductal carcinoma. (d) Three-dimensional fusion image shows the extent of the carcinoma (yellow) surrounding the dilated ducts (green).
|
|
View larger version (87K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 5d. Invasive ductal carcinoma in a 40-year-old woman with a bloody nipple discharge. (a) Conventional ductogram shows a dilated and obstructed duct (arrowheads) with an irregular wall and multiple filling defects with irregular surfaces. A cyst with a filling defect (arrow) communicates with the discharging ductal system. (b) MR ductogram (maximum intensity projection [MIP] image) shows multiple cystic and irregularly dilated ducts. The cystic areas appear as high-signal-intensity nodules. (c) MR mammogram (MIP image) shows a diffusely enhancing area (arrows), which represents an invasive ductal carcinoma. (d) Three-dimensional fusion image shows the extent of the carcinoma (yellow) surrounding the dilated ducts (green).
|
|
|
Case Studies in Use of Fusion Imaging
|
|---|
Case 1
In a 75-year-old woman, conventional ductography (Fig 6a) and MR ductography (Fig 6b) revealed a dilated duct and an intraductal papilloma, which created a filling or signal defect. An MR mammographic study displayed the tiny intraductal papilloma as a well-circumscribed enhancing lesion (Fig 6c). Three-dimensional fusion imaging demonstrated the dilated duct and intraductal lesion on one image (Fig 6d).
View larger version (111K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 6a. Intraductal papilloma in a 75-year-old woman. (a, b) Conventional ductogram (a) and MR ductogram (MIP image) (b) show a dilated duct with a filling or signal defect (arrow), which represents an intraductal papilloma. (c) MR mammogram (MIP image) shows a well-circumscribed enhancing lesion (arrow), which represents the tiny papilloma. (d) Three-dimensional fusion image shows the dilated duct (green) and the intraductal lesion (red). (Fig 6a–6c reprinted, with permission, from reference 7.)
|
|
View larger version (73K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 6b. Intraductal papilloma in a 75-year-old woman. (a, b) Conventional ductogram (a) and MR ductogram (MIP image) (b) show a dilated duct with a filling or signal defect (arrow), which represents an intraductal papilloma. (c) MR mammogram (MIP image) shows a well-circumscribed enhancing lesion (arrow), which represents the tiny papilloma. (d) Three-dimensional fusion image shows the dilated duct (green) and the intraductal lesion (red). (Fig 6a–6c reprinted, with permission, from reference 7.)
|
|
View larger version (106K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 6c. Intraductal papilloma in a 75-year-old woman. (a, b) Conventional ductogram (a) and MR ductogram (MIP image) (b) show a dilated duct with a filling or signal defect (arrow), which represents an intraductal papilloma. (c) MR mammogram (MIP image) shows a well-circumscribed enhancing lesion (arrow), which represents the tiny papilloma. (d) Three-dimensional fusion image shows the dilated duct (green) and the intraductal lesion (red). (Fig 6a–6c reprinted, with permission, from reference 7.)
|
|
View larger version (91K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 6d. Intraductal papilloma in a 75-year-old woman. (a, b) Conventional ductogram (a) and MR ductogram (MIP image) (b) show a dilated duct with a filling or signal defect (arrow), which represents an intraductal papilloma. (c) MR mammogram (MIP image) shows a well-circumscribed enhancing lesion (arrow), which represents the tiny papilloma. (d) Three-dimensional fusion image shows the dilated duct (green) and the intraductal lesion (red). (Fig 6a–6c reprinted, with permission, from reference 7.)
|
|
Case 2
In a 46-year-old woman with an intraductal papilloma, conventional ductography (Fig 7a) and MR ductography (Fig 7b) showed a slightly dilated and completely obstructed duct with an intraductal filling or signal defect. These images did not reveal the extent of the intraductal lesion. MR mammography revealed the intraductal lesion and its precise size as a small, linear, enhancing lesion (Fig 7c). Fusion imaging demonstrated the slightly dilated duct and the precise extent and location of the intraductal papilloma on one image (Fig 7d).
View larger version (84K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 7a. Intraductal papilloma in a 46-year-old woman. (a, b) Conventional ductogram (a) and MR ductogram (MIP image) (b) show a slightly dilated and completely obstructed duct with a filling or signal defect (arrow). The extent of the intraductal lesion is not demonstrated. On the MR ductogram, the small bright lesion deep to the fluid-filled duct may be a tiny cyst, and the tubular bright lesion (arrowhead in b) is a vessel. (c) MR mammogram shows the intraductal lesion as a linear enhancing lesion (arrow) and demonstrates its exact size. (d) Three-dimensional fusion image shows the slightly dilated duct (green) and the precise location and extent of the intraductal papilloma (red).
|
|
View larger version (83K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 7b. Intraductal papilloma in a 46-year-old woman. (a, b) Conventional ductogram (a) and MR ductogram (MIP image) (b) show a slightly dilated and completely obstructed duct with a filling or signal defect (arrow). The extent of the intraductal lesion is not demonstrated. On the MR ductogram, the small bright lesion deep to the fluid-filled duct may be a tiny cyst, and the tubular bright lesion (arrowhead in b) is a vessel. (c) MR mammogram shows the intraductal lesion as a linear enhancing lesion (arrow) and demonstrates its exact size. (d) Three-dimensional fusion image shows the slightly dilated duct (green) and the precise location and extent of the intraductal papilloma (red).
|
|
View larger version (87K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 7c. Intraductal papilloma in a 46-year-old woman. (a, b) Conventional ductogram (a) and MR ductogram (MIP image) (b) show a slightly dilated and completely obstructed duct with a filling or signal defect (arrow). The extent of the intraductal lesion is not demonstrated. On the MR ductogram, the small bright lesion deep to the fluid-filled duct may be a tiny cyst, and the tubular bright lesion (arrowhead in b) is a vessel. (c) MR mammogram shows the intraductal lesion as a linear enhancing lesion (arrow) and demonstrates its exact size. (d) Three-dimensional fusion image shows the slightly dilated duct (green) and the precise location and extent of the intraductal papilloma (red).
|
|
View larger version (127K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 7d. Intraductal papilloma in a 46-year-old woman. (a, b) Conventional ductogram (a) and MR ductogram (MIP image) (b) show a slightly dilated and completely obstructed duct with a filling or signal defect (arrow). The extent of the intraductal lesion is not demonstrated. On the MR ductogram, the small bright lesion deep to the fluid-filled duct may be a tiny cyst, and the tubular bright lesion (arrowhead in b) is a vessel. (c) MR mammogram shows the intraductal lesion as a linear enhancing lesion (arrow) and demonstrates its exact size. (d) Three-dimensional fusion image shows the slightly dilated duct (green) and the precise location and extent of the intraductal papilloma (red).
|
|
Case 3
In a 40-year-old woman with an intraductal papilloma, conventional ductography (Fig 8a) and MR ductography (Fig 8b) showed a dilated duct with a lobulated filling or signal defect just below the nipple. The MR ductographic study was performed in April 2004. MR mammography revealed an enhancing intraductal lesion just below the nipple (Fig 8c). No other enhancing lesion was seen at MR mammography. Fusion imaging demonstrated the dilated duct and the intraductal papilloma on one image (Fig 8d). The surgeon chose observation instead of surgery because the cytologic diagnosis at discharge of this patient was papilloma with no malignancy. Follow-up studies were performed in September 2004 (Fig 8e) and April 2006 (Fig 8f). The intraductal papilloma showed no significant interval change.
View larger version (62K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 8a. Intraductal papilloma in a 40-year-old woman. (a, b) Conventional ductogram (a) and MR ductogram obtained in April 2004 (MIP image) (b) show a dilated duct with a lobulated filling or signal defect (arrow) just below the nipple. (c) MR mammogram (MIP image) shows an enhancing intraductal lesion (arrow) just below the nipple. No other enhancing lesion is seen. (d) Three-dimensional fusion image shows the dilated duct (green) and the intraductal papilloma (red). (e, f) Follow-up MR ductograms (MIP images) obtained in September 2004 (e) and April 2006 (f) show no significant interval change in the papilloma (arrow). (Fig 8a–8d reprinted, with permission, from reference 7.)
|
|
View larger version (62K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 8b. Intraductal papilloma in a 40-year-old woman. (a, b) Conventional ductogram (a) and MR ductogram obtained in April 2004 (MIP image) (b) show a dilated duct with a lobulated filling or signal defect (arrow) just below the nipple. (c) MR mammogram (MIP image) shows an enhancing intraductal lesion (arrow) just below the nipple. No other enhancing lesion is seen. (d) Three-dimensional fusion image shows the dilated duct (green) and the intraductal papilloma (red). (e, f) Follow-up MR ductograms (MIP images) obtained in September 2004 (e) and April 2006 (f) show no significant interval change in the papilloma (arrow). (Fig 8a–8d reprinted, with permission, from reference 7.)
|
|
View larger version (59K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 8c. Intraductal papilloma in a 40-year-old woman. (a, b) Conventional ductogram (a) and MR ductogram obtained in April 2004 (MIP image) (b) show a dilated duct with a lobulated filling or signal defect (arrow) just below the nipple. (c) MR mammogram (MIP image) shows an enhancing intraductal lesion (arrow) just below the nipple. No other enhancing lesion is seen. (d) Three-dimensional fusion image shows the dilated duct (green) and the intraductal papilloma (red). (e, f) Follow-up MR ductograms (MIP images) obtained in September 2004 (e) and April 2006 (f) show no significant interval change in the papilloma (arrow). (Fig 8a–8d reprinted, with permission, from reference 7.)
|
|
View larger version (97K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 8d. Intraductal papilloma in a 40-year-old woman. (a, b) Conventional ductogram (a) and MR ductogram obtained in April 2004 (MIP image) (b) show a dilated duct with a lobulated filling or signal defect (arrow) just below the nipple. (c) MR mammogram (MIP image) shows an enhancing intraductal lesion (arrow) just below the nipple. No other enhancing lesion is seen. (d) Three-dimensional fusion image shows the dilated duct (green) and the intraductal papilloma (red). (e, f) Follow-up MR ductograms (MIP images) obtained in September 2004 (e) and April 2006 (f) show no significant interval change in the papilloma (arrow). (Fig 8a–8d reprinted, with permission, from reference 7.)
|
|
View larger version (87K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 8e. Intraductal papilloma in a 40-year-old woman. (a, b) Conventional ductogram (a) and MR ductogram obtained in April 2004 (MIP image) (b) show a dilated duct with a lobulated filling or signal defect (arrow) just below the nipple. (c) MR mammogram (MIP image) shows an enhancing intraductal lesion (arrow) just below the nipple. No other enhancing lesion is seen. (d) Three-dimensional fusion image shows the dilated duct (green) and the intraductal papilloma (red). (e, f) Follow-up MR ductograms (MIP images) obtained in September 2004 (e) and April 2006 (f) show no significant interval change in the papilloma (arrow). (Fig 8a–8d reprinted, with permission, from reference 7.)
|
|
View larger version (78K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 8f. Intraductal papilloma in a 40-year-old woman. (a, b) Conventional ductogram (a) and MR ductogram obtained in April 2004 (MIP image) (b) show a dilated duct with a lobulated filling or signal defect (arrow) just below the nipple. (c) MR mammogram (MIP image) shows an enhancing intraductal lesion (arrow) just below the nipple. No other enhancing lesion is seen. (d) Three-dimensional fusion image shows the dilated duct (green) and the intraductal papilloma (red). (e, f) Follow-up MR ductograms (MIP images) obtained in September 2004 (e) and April 2006 (f) show no significant interval change in the papilloma (arrow). (Fig 8a–8d reprinted, with permission, from reference 7.)
|
|
Case 4
In a 64-year-old woman with atypical hyperplasia, conventional ductography (Fig 9a) and MR ductography (Fig 9b) showed a dilated and obstructed duct with an intraductal filling or signal defect. The images did not show the extent of the intraductal lesion or the number of lesions present. MR mammography revealed atypical hyperplasia as tiny enhancing nodules (Fig 9c). Fusion imaging demonstrated the dilated duct, two intraductal lesions, and three additional tiny lesions on one image (Fig 9d).
View larger version (73K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 9a. Atypical hyperplasia in a 64-year-old woman. (a, b) Conventional ductogram (a) and MR ductogram (MIP image) (b) show a dilated and obstructed duct with a filling or signal defect (arrow). The number of intraductal lesions and their extents are not demonstrated. (c) MR mammogram (MIP image) shows tiny enhancing nodules (arrows), which represent atypical hyperplasia. (d) Three-dimensional fusion image shows the dilated duct (green) and the five tiny lesions (red), two of which are intraductal.
|
|
View larger version (61K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 9b. Atypical hyperplasia in a 64-year-old woman. (a, b) Conventional ductogram (a) and MR ductogram (MIP image) (b) show a dilated and obstructed duct with a filling or signal defect (arrow). The number of intraductal lesions and their extents are not demonstrated. (c) MR mammogram (MIP image) shows tiny enhancing nodules (arrows), which represent atypical hyperplasia. (d) Three-dimensional fusion image shows the dilated duct (green) and the five tiny lesions (red), two of which are intraductal.
|
|
View larger version (98K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 9c. Atypical hyperplasia in a 64-year-old woman. (a, b) Conventional ductogram (a) and MR ductogram (MIP image) (b) show a dilated and obstructed duct with a filling or signal defect (arrow). The number of intraductal lesions and their extents are not demonstrated. (c) MR mammogram (MIP image) shows tiny enhancing nodules (arrows), which represent atypical hyperplasia. (d) Three-dimensional fusion image shows the dilated duct (green) and the five tiny lesions (red), two of which are intraductal.
|
|
View larger version (76K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 9d. Atypical hyperplasia in a 64-year-old woman. (a, b) Conventional ductogram (a) and MR ductogram (MIP image) (b) show a dilated and obstructed duct with a filling or signal defect (arrow). The number of intraductal lesions and their extents are not demonstrated. (c) MR mammogram (MIP image) shows tiny enhancing nodules (arrows), which represent atypical hyperplasia. (d) Three-dimensional fusion image shows the dilated duct (green) and the five tiny lesions (red), two of which are intraductal.
|
|
|
Advantages and Disadvantages of Conventional and MR Ductography
|
|---|
Advantages of Conventional Ductography
The cost of conventional ductography is less than that of MR ductography. Preoperative conventional ductography performed with methylene blue dye allows identification of the abnormal duct for the surgeon (15,18). Ductography can be used for preoperative ductography-aided stereo-tactic wire localization (19). US-guided fine-needle aspiration or core biopsy after ductography can add useful information when compared with a cytologic analysis of the duct (20).
Disadvantages of Conventional Ductography
A conventional ductographic study is an invasive and potentially painful procedure. Performing ductography may be difficult, complicated, and time-consuming (2,4,15); however, it can often be done quickly and easily performed by an experienced physician. Approximately 10% of cases of nipple discharge are technically inadequate for conventional ductography (1). The discharge must be present on the day of ductography, and difficulty may be encountered in cannulation of the duct (3). The incorrect duct may be cannulated. If the discharge is scant, identification of the discharging duct can be challenging.
Complications associated with conventional ductography include duct perforation, extravasation, mastitis, and hypersensitivity to iodinated contrast material (2,4,5). When duct perforation and contrast material extravasation occur, the procedure should be immediately ended and rescheduled in 10–14 days. No serious complication due to hypersensitivity to iodinated contrast material has been reported, to our knowledge (2,4,5). The primary contraindication is that ductography should not be performed in patients with mastitis or breast abscess, as the inflammation may become severe (2,5). The images of conventional ductography are two-dimensional.
Advantages of MR Ductography
MR ductography is noninvasive, uses no radiation, and has no complications. This technique may be useful for follow-up study (7). Figure 8e (September 2004) and Figure 8f (April 2006) are follow-up MR ductograms of an intraductal papilloma, which was initially studied in April 2004 (Fig 8b) (7). These images show no significant interval change. No contrast material, either intravenously injected or directly instilled, is necessary because the hydrographic image contrast is derived from heavy T2 weighting (6).
Imaging with MR ductography is three-dimensional. MR ductography can show the distal part of a duct obstructed by an intraductal lesion (7). For example, in one case conventional ductography showed an obstructed duct and no other abnormality (Fig 10a). However, MR ductography demonstrated the dilated duct and multiple cystic dilated ducts that were not seen at conventional ductography (Fig 10b).
View larger version (85K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 10a. Fibrocystic disease in a 25-year-old woman. (a) Conventional ductogram shows an obstructed duct (arrow) but no other abnormality. (b) MR ductogram (MIP image) shows the dilated duct (arrow), as well as multiple cystic dilated ducts (arrowhead) that were not seen at conventional ductography. (c) Fusion image shows the dilated ducts (green) and fibrocystic disease (red). (Fig 10a and 10b reprinted, with permission, from reference 7.)
|
|
View larger version (72K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 10b. Fibrocystic disease in a 25-year-old woman. (a) Conventional ductogram shows an obstructed duct (arrow) but no other abnormality. (b) MR ductogram (MIP image) shows the dilated duct (arrow), as well as multiple cystic dilated ducts (arrowhead) that were not seen at conventional ductography. (c) Fusion image shows the dilated ducts (green) and fibrocystic disease (red). (Fig 10a and 10b reprinted, with permission, from reference 7.)
|
|
View larger version (57K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 10c. Fibrocystic disease in a 25-year-old woman. (a) Conventional ductogram shows an obstructed duct (arrow) but no other abnormality. (b) MR ductogram (MIP image) shows the dilated duct (arrow), as well as multiple cystic dilated ducts (arrowhead) that were not seen at conventional ductography. (c) Fusion image shows the dilated ducts (green) and fibrocystic disease (red). (Fig 10a and 10b reprinted, with permission, from reference 7.)
|
|
Fusion imaging in the same patient demonstrated the dilated ducts and fibrocystic disease on one image (Fig 10c). By melding the images of MR ductography with the images of contrast material–enhanced MR mammography, a fusion image is generated. This single three-dimensional fused image not only demonstrates the existence of an intraductal abnormality but also reveals the shape, size, and extent of the lesion. This allows us to easily understand the relationship between the dilated ducts and any intraductal lesions in the breast with one image (7).
Disadvantages of MR Ductography
MR ductography is more costly than conventional ductography and is contraindicated in some patients (eg, those with a pacemaker). MR ductography does not reveal a duct when the duct is not dilated, although conventional ductography may show a duct after cannulation of the undilated duct. For example, in one case conventional ductography showed a nondilated duct (Fig 11a); however, MR ductography revealed no duct (Fig 11b).
View larger version (70K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 11a. Nondilated duct in a 38-year-old woman with a clear nipple discharge. (a) Conventional ductogram shows a nondilated duct (arrow). (b) MR ductogram (MIP image) does not show the duct.
|
|
View larger version (76K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 11b. Nondilated duct in a 38-year-old woman with a clear nipple discharge. (a) Conventional ductogram shows a nondilated duct (arrow). (b) MR ductogram (MIP image) does not show the duct.
|
|
In some cases, the fluid within the duct has high signal intensity on T1-weighted images (Fig 12b) and low signal intensity on heavily T2-weighted images (Fig 12a), suggesting either hemorrhage or the presence of proteinaceous contents (5). Figure 12 is the case of a 44-year-old woman with a bloody discharge and invasive ductal carcinoma (7). No dilated duct was seen at MR ductography (Fig 12a); however, precontrast MR mammography (Fig 12b) showed the dilated duct as a high-signal-intensity structure.
View larger version (115K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 12a. Invasive ductal carcinoma in a 44-year-old woman with a bloody nipple discharge. (a) MR ductogram (MIP image) shows no dilated duct. (b) Precontrast T1-weighted MR mammogram (MIP image) shows a high-signal-intensity structure (arrows), which represents a dilated duct. (c) Postcontrast MR mammogram (MIP image) shows an enhancing area (arrows), which represents an invasive ductal carcinoma. (d) Three-dimensional fusion image shows the relationship between the dilated ducts (green) and the carcinoma (red) and the exact extent of the carcinoma in the breast. (Fig 12b–12d reprinted, with permission, from reference 7.)
|
|
View larger version (109K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 12b. Invasive ductal carcinoma in a 44-year-old woman with a bloody nipple discharge. (a) MR ductogram (MIP image) shows no dilated duct. (b) Precontrast T1-weighted MR mammogram (MIP image) shows a high-signal-intensity structure (arrows), which represents a dilated duct. (c) Postcontrast MR mammogram (MIP image) shows an enhancing area (arrows), which represents an invasive ductal carcinoma. (d) Three-dimensional fusion image shows the relationship between the dilated ducts (green) and the carcinoma (red) and the exact extent of the carcinoma in the breast. (Fig 12b–12d reprinted, with permission, from reference 7.)
|
|
View larger version (87K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 12c. Invasive ductal carcinoma in a 44-year-old woman with a bloody nipple discharge. (a) MR ductogram (MIP image) shows no dilated duct. (b) Precontrast T1-weighted MR mammogram (MIP image) shows a high-signal-intensity structure (arrows), which represents a dilated duct. (c) Postcontrast MR mammogram (MIP image) shows an enhancing area (arrows), which represents an invasive ductal carcinoma. (d) Three-dimensional fusion image shows the relationship between the dilated ducts (green) and the carcinoma (red) and the exact extent of the carcinoma in the breast. (Fig 12b–12d reprinted, with permission, from reference 7.)
|
|
View larger version (84K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 12d. Invasive ductal carcinoma in a 44-year-old woman with a bloody nipple discharge. (a) MR ductogram (MIP image) shows no dilated duct. (b) Precontrast T1-weighted MR mammogram (MIP image) shows a high-signal-intensity structure (arrows), which represents a dilated duct. (c) Postcontrast MR mammogram (MIP image) shows an enhancing area (arrows), which represents an invasive ductal carcinoma. (d) Three-dimensional fusion image shows the relationship between the dilated ducts (green) and the carcinoma (red) and the exact extent of the carcinoma in the breast. (Fig 12b–12d reprinted, with permission, from reference 7.)
|
|
Postcontrast T1-weighted MR mammography in the same patient revealed invasive ductal carcinoma as enhancing lesions (Fig 12c). A fusion imaging study clearly demonstrated the relationship between the dilated ducts and the invasive ductal carcinoma and the precise extent of the carcinoma in the breast (Fig 12d). In a patient with some concentration of blood in the duct fluid, it is possible that no dilated duct may be observed at MR ductography or on T2- or T1-weighted images (7).
|
Conclusions
|
|---|
A conventional ductographic study requires an invasive procedure with attendant complications. The conventional ductographic image is two-dimensional; thus, it does not show the precise location of the intraductal lesion in the breast. MR ductography is noninvasive and has no complications. MR ductography produces a three-dimensional image and can show the precise shape and location of the abnormal duct and the lesion in the breast. MR ductography can be melded with MR mammography to create a fusion image, which reveals not only the ductal abnormality but also the intraductal lesion on one image.
An MR ductographic study is a useful method for diagnosis in patients with nipple discharge; it is also useful in development of the treatment plan and for follow-up study. After our introduction of MR ductography into the clinical setting, conventional ductography has seldom been used at our institution. We believe that MR ductography provides a significant advantage over conventional ductography as a diagnostic tool in evaluation of patients with pathologic nipple discharge.
|
Acknowledgments
|
|---|
We thank Chikara Noda, RT, for discussing the sequences for MR ductography and for fusing the images.
|
Footnotes
|
|---|
Abbreviations: MIP = maximum intensity projection
|
References
|
|---|
- Sickles EA. Galactography and other imaging investigations of nipple discharge. Lancet 2000;356: 1622–1623.[CrossRef][Medline]
- Tabar L, Dean PB, Pentek Z. Galactography: the diagnostic procedure of choice for nipple discharge. Radiology 1983;149:31–38.[Abstract/Free Full Text]
- Orel SG, Dougherty CS, Reynolds C, Czerniecki BJ, Siegelman ES, Schnall MD. MR imaging in patients with nipple discharge: initial experience. Radiology 2000;216:248–254.[Abstract/Free Full Text]
- Piccoli CW, Feig SA, Vala MA. Benign intraductal papilloma with focal atypical papillomatous hyperplasia. RadioGraphics 1998;18:783–786.[Medline]
- 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]
- Jara H, Barish MA, Yucel EK, Melhem ER, Hussan S, Ferrucci JT. MR hydrography: theory and practice of static fluid. AJR Am J Roentgenol 1998;170:873–882.[Free Full Text]
- Hirose M, Otsuki N, Hayano D, et al. Multivolume fusion imaging of MR ductography and MR mammography for patients with nipple discharge. Magn Reson Med Sci 2006;5:105–112.[CrossRef][Medline]
- Rovno HD, Siegelman ES, Reynolds C, Orel SG, Schnall MD. Solitary intraductal papilloma: findings at MR imaging and MR galactography. AJR Am J Roentgenol 1999;172:151–155.[Abstract/Free Full Text]
- Hussain AN, Policarpio C, Vincent MT. Evaluating nipple discharge. Obstet Gynecol Surv 2006; 61:278–283.[CrossRef][Medline]
- Sauter ER, Schlatter L, Lininger J, Hewett JE. The association of bloody nipple discharge with breast pathology. Surgery 2004;136:780–785.[CrossRef][Medline]
- Simmons R, Adamovich T, Brennan M, et al. Nonsurgical evaluation of pathologic nipple discharge. Ann Surg Oncol 2003;10:113–116.[Abstract/Free Full Text]
- Hou MF, Huang TJ, Liu GC. The diagnostic value of galactography in patients with nipple discharge. Clin Imaging 2001;25:75–81.[CrossRef][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]
- Lamont JP, Dultz RP, Kuhn JA, Grant MD, Jones RC. Galactography in patients with nipple discharge. Proc (Bayl Univ Med Cent) 2000;13:214–216.[Medline]
- Slawson SH, Johnson BA. Ductography: how to and what if? RadioGraphics 2001;21:133–150.[Abstract/Free Full Text]
- Dinkel HP, Trusen A, Gassel AM, et al. Predictive value of galactographic patterns for benign and malignant neoplasms of the breast in patients with nipple discharge. Br J Radiol 2000;73:706–714.[Abstract]
- Hou MF, Huang CJ, Huang YS, et al. Evaluation of galactography for nipple discharge. Clin Imaging 1998;22:89–94.[CrossRef][Medline]
- King TA, Carter KM, Bolton LS, Fuhrman G. A simple approach to nipple discharge. Am Surg 2000;66:960–966.[Medline]
- Koskela A, Berg M, Pietiläinen T, Mustonen P, Vanninen R. Breast lesions causing nipple discharge: preoperative galactography-aided stereo-tactic wire localization. AJR Am J Roentgenol 2005;184:1795–1798.[Abstract/Free Full Text]
- 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]
Top
Abstract
LEARNING OBJECTIVES FOR TEST...
