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Makineli S, van Wijnbergen JWM, Vriens MR, van Diest PJ, Witkamp AJ. Role of duct excision surgery in the treatment of pathological nipple discharge and detection of breast carcinoma: systematic review. BJS Open 2023; 7:zrad066. [PMID: 37459137 PMCID: PMC10351572 DOI: 10.1093/bjsopen/zrad066] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 03/16/2023] [Accepted: 05/16/2023] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND The role of duct excision surgery is not clearly defined in patients with pathological nipple discharge without other clinical and radiological abnormalities. The primary aim of this systematic review was to determine the malignancy rate in patients with pathological nipple discharge after duct excision surgery (microdochectomy/major duct excision). The secondary aims were to determine the recurrence rate of pathological nipple discharge after surgery and to assess breast cancer development after surgery. METHODS MEDLINE and Embase were searched from inception to March 2023, using search terms related to 'nipple discharge', 'nipple fluid', 'microdochectomy', 'duct excision', and 'minimally invasive surgical procedure'. Studies reporting data about women who underwent duct excision surgery for pathological nipple discharge without clinical and radiological suspicion of breast cancer, as well as reporting data on women diagnosed with breast cancer after duct excision surgery, were included. RESULTS A total of 318 titles were identified, of which nine publications were included in the analysis. This resulted in 1108 patients with pathological nipple discharge who underwent a duct excision. The weighted mean rate of malignancy after duct excision surgery was 8.1 per cent (ranging from 2.3 to 13.5 per cent). Three studies described the recurrence rate of pathological nipple discharge (ranging from 0 to 12 per cent) and two studies reported breast cancer development in the follow-up in a total of three patients (less than 1 per cent). CONCLUSION The malignancy rate after duct excision surgery for pathological nipple discharge was low in patients with pathological nipple discharge without radiological and clinical abnormalities and approximately 9 of 10 patients undergo surgery for a benign cause. Improvement of the diagnostic and therapeutic workup is needed to prevent patients from undergoing (unnecessary) exploratory surgery.
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Affiliation(s)
- Seher Makineli
- Correspondence to: Seher Makineli, Department of Surgical Oncology, University Medical Center, PO Box 85500, 3508 GA, Utrecht, The Netherlands (e-mail: )
| | | | - Menno R Vriens
- Department of Surgical Oncology, University Medical Center, Utrecht, The Netherlands
| | - Paul J van Diest
- Department of Pathology, University Medical Center, Utrecht, The Netherlands
| | - Arjen J Witkamp
- Department of Surgical Oncology, University Medical Center, Utrecht, The Netherlands
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2
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Vavolizza RD, Dengel LT. Management of Nipple Discharge. Surg Clin North Am 2022; 102:1077-1087. [DOI: 10.1016/j.suc.2022.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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3
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Kamalı GH, Kamali S. The Role of Ductal Lavage Cytology in the Diagnosis of Breast Cancer. ARCHIVES OF IRANIAN MEDICINE 2022; 25:748-754. [PMID: 37543900 PMCID: PMC10685857 DOI: 10.34172/aim.2022.118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 11/07/2021] [Indexed: 08/08/2023]
Abstract
BACKGROUND Nipple discharge is a common finding which may be a symptom of breast cancer, but it is mostly caused by benign causes. A surgical biopsy followed by a histopathological examination is considered to be the gold standard for the diagnosis of pathological nipple discharge. Non-surgical diagnostic methods should be considered to reduce the need for intervention. Ductal lavage cytology (DLC) is performed by washing and examining the ductal discharge. The usefulness of examining spontaneous discharge is controversial. This study's aim is to evaluate the usefulness in surgical decision-making of ultrasonography (USG), mammography (MMG), magnetic resonance imaging (MRI), ductography, and DLC in patients with pathological nipple discharge. METHODS Between 2011 and 2018, we retrospectively analyzed 141 patients with pathological nipple discharge who were planned to undergo a surgical procedure and were found to have pathology. In our study, the diagnostic efficiency of DLC for breast cancer diagnosis was compared with USG, MMG, MRI, and ductography. RESULTS USG was performed in all patients, MMG in 51, MRI in 56, ductography in 46 patients, and cytological samples were taken from 63 patients. Twelve of 17 patients with malignant pathology were reported cytologically as suspected malignancy. The sensitivity of DLC was 70.5% (95% CI: 0.489-0.922), and its specificity was 94.1% (95% CI: 0.862-1.020). CONCLUSION Numerous studies report that cytology is not adequate for final diagnosis. Negative cytology does not exclude the possibility of malignancy, and positive results do not help in the differential diagnosis.
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Affiliation(s)
- Gülçin Harman Kamalı
- Department of Pathology, University of Health Sciences Prof. Dr. Cemil Taşcıoğlu City Hospital, İstanbul, Turkey
| | - Sedat Kamali
- Department of General Surgery, University of Health Sciences Prof. Dr. Cemil Taşcıoğlu City Hospital, İstanbul, Turkey
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Sanford MF, Slanetz PJ, Lewin AA, Baskies AM, Bozzuto L, Branton SA, Hayward JH, Le-Petross HT, Newell MS, Scheel JR, Sharpe RE, Ulaner GA, Weinstein SP, Moy L. ACR Appropriateness Criteria® Evaluation of Nipple Discharge: 2022 Update. J Am Coll Radiol 2022; 19:S304-S318. [PMID: 36436958 DOI: 10.1016/j.jacr.2022.09.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 09/07/2022] [Indexed: 11/27/2022]
Abstract
The type of nipple discharge dictates the appropriate imaging study. Physiologic nipple discharge is common and does not require diagnostic imaging. Pathologic nipple discharge in women, men, and transgender patients necessitates breast imaging. Evidence-based guidelines were used to evaluate breast imaging modalities for appropriateness based on patient age and gender. For an adult female or male 40 years of age or greater, mammography or digital breast tomosynthesis (DBT) is performed initially. Breast ultrasound is usually performed at the same time with rare exception. For males or females 30 to 39 years of age, mammography/DBT or breast ultrasound is performed based on institutional preference and individual patient considerations. For young women less than 30 years of age, ultrasound is performed first with mammography/DBT added if there are suspicious findings or if the patient is at elevated lifetime risk for developing breast cancer. There is a high incidence of breast cancer in males with pathologic discharge. Men 25 years and older should be evaluated using mammography/DBT and ultrasound added when indicted. In transfeminine (male-to-female) patients, mammography/DBT and ultrasound are useful due to the increased incidence of breast cancer. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
- Matthew F Sanford
- Lead Interpreting Physician, Sanford Health of Northern Minnesota, Bemidji, Minnesota.
| | - Priscilla J Slanetz
- Panel Chair, Boston University School of Medicine, Boston, Massachusetts; Vice Chair, Academic Affairs, Department of Radiology, Associate Program Director, BMC Diagnostic Radiology Residency and Program Director, Academic Writing Program Boston Medical Center, Boston, Massachusetts
| | - Alana A Lewin
- Panel Vice-Chair, New York University School of Medicine, New York, New York
| | - Arnold M Baskies
- Virtua Willingboro Hospital, Willingboro, New Jersey; American College of Surgeons; Clinical Professor, Surgery, Rowan School of Medicine, Stratford, New Jersey
| | - Laura Bozzuto
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; American College of Obstetricians and Gynecologists
| | - Susan A Branton
- Medical Directo, Breast Health Center and Medical Staff President, UPMC North Central, Pittsburgh, Pennsylvania; American College of Surgeons
| | | | - Huong T Le-Petross
- Breast MRI Director, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - John R Scheel
- Vice-Chair, Global Health, University of Washington, Seattle, Washington
| | | | - Gary A Ulaner
- James & Pamela Muzzy Endowed Chair, Molecular Imaging and Therapy, Hoag Family Cancer Institute, Newport Beach, California
| | - Susan P Weinstein
- Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania; Associate Chair for Radiology Network Strategic Projects
| | - Linda Moy
- Specialty Chair, NYU Clinical Cancer Center, New York, New York
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5
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Chung HL, Bevers TB, Legha RS, Speer ME, Tso HH, Sun J, Leung JW. Nipple Discharge Imaging Evaluation with Mammography, Ultrasound, Galactography, and MRI. Acad Radiol 2022; 30:783-797. [PMID: 35760711 DOI: 10.1016/j.acra.2022.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 05/20/2022] [Accepted: 05/22/2022] [Indexed: 11/26/2022]
Abstract
RATIONALE AND OBJECTIVE To determine the diagnostic yield of various imaging tests used to evaluate nipple discharge. MATERIALS AND METHODS A single institution, IRB-approved, retrospective study was performed of 320 consecutive patients presenting with nipple discharge. Imaging and pathology were reviewed to determine the yield for malignancy, atypical high-risk lesions (HRLs), and intraductal papillomas (IDPs). RESULTS Of the 320 patients, pathology or follow up confirmed 40 breast malignancies (40/320, 12.5%),14 atypical HRLs (14/320, 4.4%), 71 IDPs (71/320, 22.2%), 48 other benign pathologies (48/320,15.0%), and 147 unknown but benign cases (147/320, 45.9%). Physiologic discharge characteristics were observed in a minority of malignant cases: nonspontaneous (4/40, 10.0%); neither bloody nor clear (4/40, 10.0%); bilateral (3/40, 7.5%). Malignancy was associated with older age (p < 0.001) and bloody discharge (odds ratio 6.5, p < 0.0001). The combination of digital mammography and ultrasound had a 93% sensitivity and a 98% NPV, while contrast enhanced MRI (CE-MRI) had a 100% sensitivity and a 100% NPV for malignancy. Only three galactography examinations were performed among the malignant cohort, with minimal contribution (1 of 3) to the diagnostic evaluation. In this case, galactography findings helped determine imaging-pathology discordance, prompting a recommendation for surgical excision and subsequently a malignant diagnosis. CONCLUSION The combination of mammography and ultrasonography detected 93% of breast malignancies associated with nipple discharge and had a 98% NPV for malignancy. The value of CE-MRI is its ability to detect the remaining malignancies, not detected on mammography or ultrasound, and its ability to obviate the need for surgical duct excision.
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Boisserie-Lacroix M, Doutriaux-Dumoulin I, Chopier J, Boyer B, Depetiteville MP, Hoppe S, Brouste V, Chamming's F. Diagnostic accuracy of breast MRI for patients with suspicious nipple discharge and negative mammography and ultrasound: a prospective study. Eur Radiol 2021; 31:7783-7791. [PMID: 33846843 DOI: 10.1007/s00330-021-07790-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 01/15/2021] [Accepted: 02/15/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVES To evaluate the diagnostic accuracy of breast MRI in identifying lesions requiring excision for patients with suspicious nipple discharge but normal mammograms and ultrasounds. METHODS Between September 2013 and May 2019, 106 female participants (mean age 57.9 years) were consecutively included in this prospective multicenter study; 102 were retained for analysis. MRI was considered negative in the absence of suspicious enhancement and positive in cases of ipsilateral abnormal enhancement (BI-RADS 3 to 5). Final diagnoses were based on histological findings of surgical or percutaneous biopsies or at 1-year follow-up. We considered all lesions requiring excision found on pathology (papilloma, atypia, nipple adenomatosis, or cancer) as positive results. We considered spontaneous resolution of the discharge at 1 year as a negative result. RESULTS MRI showed ipsilateral abnormal enhancement in 54 patients (53%) revealing 46 lesions requiring excision (31 benign papillomas, 5 papillomas with atypia, 2 nipple adenomatosis, and 8 cancers) and 8 benign lesions not requiring excision. No suspicious enhancement was found in the remaining 48 participants (47%). Forty-two were followed up at 1 year with spontaneous resolution of the discharge and six underwent surgery (revealing 2 benign papillomas). MRI diagnostic accuracy for the detection of a lesion requiring excision was as follows: sensitivity 96%, specificity 85%, positive predictive value 85%, and negative predictive value 96%. CONCLUSION In patients with suspicious nipple discharge and normal mammogram and ultrasound, MRI demonstrates excellent performance to identify lesions for which excision is required. Normal MRI indicates it is safe to propose follow-up only management, thus avoiding unnecessary duct excision. TRIAL REGISTRATION ClinicalTrials.gov NCT02819362 KEY POINTS: • Breast MRI can be useful for the management of patients with suspicious nipple discharge and negative mammogram and ultrasound. • MRI detected a lesion requiring excision in 46 participants (45%) with unexplained discharge. • If breast MRI is negative, follow-up is a safe alternative for these patients.
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Affiliation(s)
| | - Isabelle Doutriaux-Dumoulin
- Department of Radiology, Institut de Cancérologie de l'Ouest, Comprehensive Cancer Centre, F-44000, Saint-Herblain, France
| | - Jocelyne Chopier
- Department of Radiology, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, F-75020, Paris, France
| | - Bruno Boyer
- Breast Imaging Clinic, 6 place d'Italie, F-75013, Paris, France
| | | | - Stéphanie Hoppe
- Clinical and Epidemiological Research Unit, Institut Bergonié, Comprehensive Cancer Centre, F-33076, Bordeaux, France
| | - Véronique Brouste
- Clinical and Epidemiological Research Unit, Institut Bergonié, Comprehensive Cancer Centre, F-33076, Bordeaux, France
| | - Foucauld Chamming's
- Department of Radiology, Institut Bergonié, Comprehensive Cancer Centre, F-33076, Bordeaux, France
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Samreen N, Madsen LB, Chacko C, Heller SL. Magnetic resonance imaging in the evaluation of pathologic nipple discharge: indications and imaging findings. Br J Radiol 2021; 94:20201013. [PMID: 33544650 DOI: 10.1259/bjr.20201013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Pathologic nipple discharge (PND) is typically unilateral, spontaneous, involves a single duct, and is serous or bloody in appearance. In patients with PND, breast MRI can be helpful as an additional diagnostic tool when conventional imaging with mammogram and ultrasound are negative. MRI is able to detect the etiology of nipple discharge in 56-61% of cases when initial imaging with mammogram and ultrasound are negative. Advantages to using MRI in evaluation of PND include good visualization of the retroareolar breast and better evaluation of posterior lesions which may not be well evaluated on mammograms and galactograms. It is also less invasive compared to central duct excision. Papillomas and nipple adenomas are benign breast masses that can cause PND and are well visualized on MRI. Ductal ectasia, and infectious etiologies such as mastitis, abscess, and fistulas are additional benign causes of PND that are well evaluated with MRI. MRI is also excellent for evaluation of malignant causes of PND including Paget's disease, ductal carcinoma in-situ and invasive carcinoma. MRI's high negative predictive value of 87-98.2% is helpful in excluding malignant etiologies of PND.
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Affiliation(s)
- Naziya Samreen
- New York University Long Island Division, Long Island, NY, USA
| | | | - Celin Chacko
- New York University Long Island Division, Long Island, NY, USA
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8
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Abstract
OBJECTIVE. Nipple discharge is a common complaint that is first evaluated with clinical assessment. Physiologic discharge does not require imaging other than routine screening mammography. Initial evaluation of pathologic nipple discharge involves mammography and ultrasound. evaluation of pathologic nipple discharge involves mammography and ultrasound. Because of its high sensitivity in detecting breast malignancy and its biopsy capability, MRI is increasingly used in lieu of ductography. CONCLUSION. The problem-solving algorithm for evaluating suspicious nipple discharge is evolving. When diagnostic imaging for evaluation of pathologic nipple discharge is negative, management is based on clinical suspicion. If additional imaging is warranted, MRI is preferred because of its increased sensitivity, specificity, and patient comfort. Although central duct excision is the current standard for evaluation of malignancy in patients with pathologic nipple discharge, studies suggest that, given the high negative predictive value of MRI, surveillance may be a reasonable alternative to surgery.
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9
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Waaijer L, Filipe MD, Simons J, van der Pol CC, de Boorder T, van Diest PJ, Witkamp AJ. Detection of breast cancer precursor lesions by autofluorescence ductoscopy. Breast Cancer 2020; 28:119-129. [PMID: 32725533 PMCID: PMC7796885 DOI: 10.1007/s12282-020-01136-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 07/16/2020] [Indexed: 12/26/2022]
Abstract
PURPOSE Autofluorescence is an image enhancement technique used for the detection of cancer precursor lesions in pulmonary and gastrointestinal endoscopy. This study evaluated the feasibility of addition of autofluorescence to ductoscopy for the detection of intraductal breast cancer precursor lesions. METHODS An autofluorescence imaging system, producing real-time computed images combining fluorescence intensities, was coupled to a conventional white light ductoscopy system. Prior to surgery, ductoscopy with white light and autofluorescence was evaluated under general anaesthesia in women scheduled for therapeutic or prophylactic mastectomy. Endoscopic findings in both modes were compared, marked and correlated with histology of the surgical specimen. RESULTS Four breast cancer patients and five high-risk women, with a median age of 47 years (range 23-62) were included. In autofluorescence mode, two intraductal lesions were seen in two breast cancer patients, which had an increase in the red-to-green fluorescence intensity compared with the surrounding tissue. One lesion had initially been missed by white light ductoscopy but was clearly visible in subsequent autofluorescence mode. One endoscopic finding was classified as suspicious by white light, but was negative in autofluorescence mode and showed normal histology. CONCLUSIONS This study demonstrates for the first time the in vivo feasibility of autofluorescence ductoscopy to detect pathologically confirmed breast cancer precursor lesions in both breast cancer patients and high-risk women that were occult under white light.
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Affiliation(s)
- Laurien Waaijer
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Mando D Filipe
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Janine Simons
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Carmen C van der Pol
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Tjeerd de Boorder
- Department of Medical Technology and Clinical Physics, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Paul J van Diest
- Department of Pathology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Arjen Joost Witkamp
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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10
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Karimova EJ, Slanetz PJ. Charged with Discharge: A Case-based Review of Nipple Discharge Using the American College of Radiology's Appropriateness Guidelines. JOURNAL OF BREAST IMAGING 2020; 2:275-284. [PMID: 38424981 DOI: 10.1093/jbi/wbaa014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Indexed: 03/02/2024]
Abstract
Nipple discharge, a relatively common presenting symptom for women of all ages, may be due to both benign and malignant conditions. Men can also present with nipple discharge, and when they do, they have a higher likelihood of malignancy than women. Radiologists vary in their evaluation of patients with nipple discharge, although the American College of Radiology practice guidelines for nipple discharge provides data-driven appropriate algorithms. In patients with physiologic discharge, imaging is not typically indicated. For those with pathologic nipple discharge, imaging typically starts with diagnostic mammography and retroareolar ultrasound for women over 40 years of age, diagnostic mammogram or ultrasound for women aged 30-39 years, and ultrasound for women younger than 30 years. Finally, contrast-enhanced breast MRI or galactography are usually reserved for identifying the cause of discharge when initial imaging with mammography and ultrasound is unrevealing.
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Affiliation(s)
- E Jane Karimova
- Brigham and Women's Hospital, Department of Radiology, Boston, MA
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11
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Alshurbasi N, Cartlidge CWJ, Kohlhardt SR, Hadad SM. Predicting Patients Found to Have Malignancy at Nipple Duct Surgery. Breast Care (Basel) 2019; 15:491-497. [PMID: 33223992 DOI: 10.1159/000504528] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 11/02/2019] [Indexed: 01/03/2023] Open
Abstract
Introduction The unexpected diagnosis of breast cancer following total duct excision is distressing for patients. Despite advances in radiology and the description of suspicious nipple discharge, pre-operative diagnosis of malignancy still evades us. The aim of this study was to review the pathological findings of total duct excision and microdochectomy with reference to pre-operative symptoms, ultrasound, or mammographic findings and identify features associated with increased likelihood of malignant disease. Methods Data were collected retrospectively of all patients who underwent total duct excision surgery in a single centre (2011-2017). Pre-operative demographics, symptoms, and imaging findings were recorded and correlated with subsequent pathology. Results 214 patients underwent total duct excision; data were available for 211. Median age was 53 years. 175/211 (82.9%) patients had benign pathology (duct ectasia, papilloma without atypia, fibrocystic change) on final histological examination, 21/211 (10%) had "risk" lesions (papilloma with atypia, atypical ductal hyperplasia), and 15/211 (7.1%) had malignancy (ductal carcinoma in situ). Of the 15 patients with malignant lesions, 6/15 (40%) had normal imaging (M1, U1). 71/211 (33.6%) had normal imaging (M1, U1): 60/71 (84.5%) had benign disease, 5/71 (7%) had "risk" lesions, and 6/71 (8.5%) had malignant lesions. 83/211 (39.3%) patients presented with bloody discharge: 64/83 (77.1%) had benign pathology, 9/83 (10.8%) risk, and 10/83 (12%) malignancy. 38/211 (18%) patients presented with non-bloody discharge: 32/38 (84.2%) had benign disease, 4/38 (10.5%) risk, and 2/38 (5.3%) malignant lesions. Conclusion Neither imaging nor presenting symptoms correlate with the likelihood of malignant disease being present at final pathology. Even with advances in pre-operative diagnosis, total duct excision remains an essential diagnostic and therapeutic procedure.
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Affiliation(s)
- Nour Alshurbasi
- Department of Breast and Plastic Surgery, Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, United Kingdom
| | - Christopher W J Cartlidge
- Department of Breast and Plastic Surgery, Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, United Kingdom
| | - Stanley R Kohlhardt
- Department of Breast and Plastic Surgery, Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, United Kingdom
| | - Sirwan M Hadad
- Department of Breast and Plastic Surgery, Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, United Kingdom
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12
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Evaluation and management of pathological nipple discharges without using intraductal imaging methods. Ir J Med Sci 2019; 189:451-460. [PMID: 31631245 DOI: 10.1007/s11845-019-02107-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 09/21/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND The most common cause of pathological nipple discharge (PND) is single papilloma, which is a benign intraductal lesion (BIL). However, underlying malign (MIL) or high-risk intraductal lesions (HIL) should be considered during examination. AIM To reveal the value of conventional imaging methods (CIM), discharge characteristics, and cytology in lack of intraductal imaging methods to detect intraductal lesions (IL) and MIL that cause PND. METHODS We compared the pathological findings with the characteristics of discharge, CIM, and cytology findings of the patients who admitted to our clinic with nipple discharge and underwent duct excision (n = 111). RESULTS IL were detected in 69 (62.2%) patients as BIL (n = 31), HIL (n = 23), and MIL (n = 15). Most of the IL was observed with bloody, serosanguineous, and serous discharges (83.3%, 76.2%, and 69.2%, respectively). The sensitivities of ultrasonography, MRI, and cytology in detecting IL were found to be 50.7%, 42.6%, and 74.1%, while their specificities were found to be 73.8%, 88.2%, and 48.6%, respectively. None of the CIM was sufficient to detect MIL in 5 (33.3%) patients. The appearance of red blood cells detailed in cytology was significantly related to IL (p < 0.01), whereas the presence of inflammatory cells was related to ductal ectasia and periductal mastitis (p < 0.001). CONCLUSIONS Although patients' physical examinations, CIM, and cytology findings were normal, duct excision procedures should be applied to exclude MIL or HIL, which can be a cause of discharge in case of suspicious color. The details in cytology reports have a role in increasing the value of cytology.
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13
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Srinivasan A, Nia E, Gupta M, Sun J, Leung JW. Retrospective statistical analysis on the diagnostic value of ductography based on lesion pathology in patients presenting with nipple discharge. Breast J 2019; 25:585-589. [PMID: 31087380 DOI: 10.1111/tbj.13298] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 10/25/2018] [Accepted: 10/25/2018] [Indexed: 11/29/2022]
Abstract
PURPOSE To compare sensitivities and specificities of ductography to noninvasive imaging studies in determining the cause of nipple discharge and assess the value of ductography on the basis of pathologic results. METHODS In this retrospective review of women with nipple discharge who underwent ductography between January 1, 2005 and October 30, 2015, at our institution, we compared ductography with noninvasive imaging results (mammography, ultrasound, MRI) to determine its relative diagnostic sensitivity, specificity, and relative accuracy. Diagnosis was defined from pathology results, clinical notes, and minimum of 1-year follow-up monitoring. The primary endpoints include accuracy, sensitivity, specificity, positive predictive value, and negative predictive value. The analyses were carried out in different configurations to compare results by the following pathologic categories: cancer, high-risk lesion, intraductal papilloma (IP) without atypia, and benign pathology and/or normal imaging results. RESULTS In patients with breast cancer, ductography and noninvasive breast imaging had similar sensitivities. In patients with a high-risk lesion, ductography was significantly more sensitive than noninvasive imaging modalities. In patients with intraductal papilloma without atypia, ductography was more sensitive than noninvasive imaging, but the difference was of only borderline significance. For women with benign pathology and/or normal imaging, noninvasive imaging showed a significantly higher specificity than ductography. CONCLUSION In the absence of standard diagnostic algorithm for patients presenting with nipple discharge, the clinician has numerous options to choose a diagnostic approach that will yield the most accurate information with the least disruption to the patient. Our results indicate the value of ductography compared to value of noninvasive imaging modalities when cancer is suspected and when high risk lesion is suspected. While we show the sensitivity of ductography is similar to noninvasive imaging modalities in the setting of cancer, the sensitivity of ductography is statistically valuable for diagnosing high-risk lesions. Our hope is that this study will emphasize more research and more understanding in clinical utility and management of high-risk lesions, leading to patient-focused algorithm for diagnosing the etiology of abnormal nipple discharge.
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Affiliation(s)
| | - Emily Nia
- University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Monali Gupta
- University of Arizona College of Medicine-Phoenix V.A. Health Care System, Phoenix, Arizona
| | - Jia Sun
- University of Texas MD Anderson Cancer Center, Houston, Texas
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14
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MacInnes EG, Haigh I, Nijhawan A, Hogan B. Bloody Nipple Discharge in a Man with Benign Papillomas: A Case Report. Cureus 2019; 11:e4431. [PMID: 31245218 PMCID: PMC6559693 DOI: 10.7759/cureus.4431] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Blood-stained nipple discharge in a man would usually be proved to be male breast cancer. We present a case where this unusual presentation was associated with benign intraductal papillomas, managed with simple duct excision, preserving the patient’s nipple whilst adequately investigating and managing the condition.
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Affiliation(s)
| | - Isobel Haigh
- Breast Radiology, Leeds Teaching Hospitals Trust, Leeds, GBR
| | - Anju Nijhawan
- Pathology, Leeds Teaching Hospitals Trust, Leeds, GBR
| | - Brian Hogan
- Breast Surgery, Leeds Teaching Hospitals Trust, Leeds, GBR
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Lustig DB, Warburton R, Dingee CK, Kuusk U, Pao JS, McKevitt EC. Is microductectomy still necessary to diagnose breast cancer: a 10-year study on the effectiveness of duct excision and galactography. Breast Cancer Res Treat 2019; 174:703-709. [DOI: 10.1007/s10549-018-05109-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 12/16/2018] [Indexed: 12/27/2022]
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Panzironi G, Pediconi F, Sardanelli F. Nipple discharge: The state of the art. BJR Open 2018; 1:20180016. [PMID: 33178912 PMCID: PMC7592406 DOI: 10.1259/bjro.20180016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 10/02/2018] [Accepted: 10/24/2018] [Indexed: 11/05/2022] Open
Abstract
Over 80% of females experience nipple discharge during their life. Differently from lactational (milk production) and physiological (white, green, or yellow), which are usually bilateral and involving multiple ducts, pathologic nipple discharge (PND) is a spontaneous commonly single-duct and unilateral, clear, serous, or bloody secretion. Mostly caused by intraductal papilloma(s) or ductal ectasia, in 5-33% of cases is due to an underlying malignancy. After clinical history and physical examination, mammography is the first step after 39, but its sensitivity is low (7-26%). Ultrasound shows higher sensitivity (63-100%). Nipple discharge cytology is limited by a false negative rate over 50%. Galactography is an invasive technique that may cause discomfort and pain; it can be performed only when the duct discharge is demonstrated at the time of the study, with incomplete/failed examination rate up to 15% and a difficult differentiation between malignant and benign lesions. Ductoscopy, performed under local anesthesia in outpatients, provides a direct visualization of intraductal lesions, allowing for directed excision and facilitating a targeted surgery. Its sensitivity reaches 94%; however, it is available in only few centers and most clinicians are unfamiliar with its use. PND has recently emerged as a new indication for contrast-enhanced breast MRI, showing sensitivity superior to galactography, with an overall sensitivity up to 96%, also allowing tailored surgery. Surgery no longer can be considered the standard approach to PND. We propose a state-of-the art flowchart for the management of nipple discharge, including ductoscopy and breast MRI as best options.
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Affiliation(s)
- Giovanna Panzironi
- Department of Radiological, Oncological and Pathological Sciences, Sapienza, University of Rome, Rome, Italy
| | - Federica Pediconi
- Department of Radiological, Oncological and Pathological Sciences, Sapienza, University of Rome, Rome, Italy
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Istomin A, Masarwah A, Pitkänen M, Joukainen S, Sutela A, Vanninen R, Sudah M. Galactography is not an obsolete investigation in the evaluation of pathological nipple discharge. PLoS One 2018; 13:e0204326. [PMID: 30296280 PMCID: PMC6175274 DOI: 10.1371/journal.pone.0204326] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 09/06/2018] [Indexed: 11/21/2022] Open
Abstract
Purpose To evaluate the malignancy rate and diagnostic performance of galactography in patients with pathological nipple discharge (PND) after negative clinical breast examination, mammography and ultrasound. Materials and methods We retrospectively evaluated all galactograms obtained between January 2006 and December 2014 in women with PND. Galactographic findings were classified into 6 groups according to a modified Galactogram Image Classification system (GICS) to comply with the breast imaging reporting and data system classification. Observers were blinded to the final histology and clinical outcome at the time of analysis. MRI was performed as a problem solving ancillary examination. Imaging findings, pathological diagnosis and follow-up data were evaluated. The diagnostic performance of MRI and technically successful galactography in the detection of neoplastic or risk lesions were separately calculated. Results A total of 146 patients with PND (mean age, 51.5 years; range, 17–93) were examined. Malignant lesions were detected in only 4 patients (2.7%) and risk-lesions in 5 patients (3.4%). Only one low-grade ductal carcinoma in situ was missed by galactography (GICS 1) and MRI. MRI examinations were performed in 21 (14.4%) patients; one of these patients (4.8%) had a malignant finding (GICS 0), two (9.5%) had risk-lesions (GICS 2 and 5). In the detection of neoplastic or risk lesions the sensitivity and specificity of galactography were 77.4% and 75.7% and of MRI 85.7% and 71.4%, consecutively. Conclusion The malignancy rate is negligible if clinical, mammography, ultrasound and galactography examinations are negative. Galactography remains a practical, valuable and cost-effective examination procedure. If galactography is technically unsuccessful, MRI should be considered as an additional ancillary tool to evaluate the possible etiology of symptoms, but the routine use of MRI in all patients cannot be justified.
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Affiliation(s)
- Aleksandr Istomin
- Department of Clinical Radiology, Diagnostic Imaging Centre, Kuopio University Hospital, Kuopio, Finland
- Department of Plastic Surgery, Surgical Division, Kuopio University Hospital, Kuopio, Finland
- * E-mail:
| | - Amro Masarwah
- Department of Clinical Radiology, Diagnostic Imaging Centre, Kuopio University Hospital, Kuopio, Finland
| | - Marja Pitkänen
- Department of Clinical Radiology, Diagnostic Imaging Centre, Kuopio University Hospital, Kuopio, Finland
| | - Sarianna Joukainen
- Department of Plastic Surgery, Surgical Division, Kuopio University Hospital, Kuopio, Finland
| | - Anna Sutela
- Department of Clinical Radiology, Diagnostic Imaging Centre, Kuopio University Hospital, Kuopio, Finland
| | - Ritva Vanninen
- Department of Clinical Radiology, Diagnostic Imaging Centre, Kuopio University Hospital, Kuopio, Finland
- School of Medicine, Clinical Radiology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Mazen Sudah
- Department of Clinical Radiology, Diagnostic Imaging Centre, Kuopio University Hospital, Kuopio, Finland
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Abstract
OBJECTIVE The purpose of this study was to assess radiologists' choice of imaging modality for the evaluation of clinical symptoms of physiologic nipple discharge (e.g., bilateral discharge, multiple-duct orifices, and yellow, green, or white color) and pathologic nipple discharge (e.g., unilateral discharge, single-duct orifices, spontaneous and serous discharge, and clear or bloodstained color). MATERIALS AND METHODS An online survey was sent to lead interpreting physicians at mammography facilities accredited by the American College of Radiology (ACR). Statistical analysis was performed using chi-square tests for frequency data and multinomial logistic regression. RESULTS A total of 849 responses to 8170 distributed surveys were received, for a response rate of 10.4%. For the workup of physiologic nipple discharge, 30% of respondents recommended screening mammography (SM); 24%, diagnostic mammography (DM) only; and 46%, both DM and targeted ultrasound (US) (DM plus US). For the workup of physiologic nipple discharge, practitioners in nonacademic settings and those who read breast images during less than 50% of their practice were significantly more likely to recommend DM (with or without US), compared with SM (the standard recommended by the ACR). Those reading breast images less than 50% of the time were also more likely to recommend MRI after conventional imaging revealed negative results. For the workup of pathologic nipple discharge, 91.0% of respondents recommended DM plus US; 8.5%, DM only; and fewer than 1.0%, SM. Nonacademic providers and those who read breast images less than 50% of the time were significantly less likely to recommend DM plus US (the standard recommended by the ACR), compared with DM only. CONCLUSION The present study shows variability in imaging modality selection among U.S. radiologists handling the imaging workflow for benign and pathologic nipple discharge. Radiologists do not uniformly follow ACR practice guidelines, which potentially leads to unnecessary workups and extra health care costs.
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Schulz-Wendtland R, Preuss C, Fasching PA, Loehberg CR, Lux MP, Emons J, Beckmann MW, Uder M, Mueller-Schimpfle M. Galactography with Tomosynthesis Technique (Galactomosynthesis) - Renaissance of a Method? Geburtshilfe Frauenheilkd 2018; 78:493-498. [PMID: 29880984 PMCID: PMC5986572 DOI: 10.1055/a-0594-2277] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 03/12/2018] [Accepted: 03/18/2018] [Indexed: 11/04/2022] Open
Abstract
Introduction
For decades, conventional galactography was the only imaging technique capable of showing the mammary ducts. Today, diagnosis is based on a multimodal concept which combines high-resolution ultrasound with magnetic resonance (MR) mammography and ductoscopy/galactoscopy and has a sensitivity and specificity of up to 95%. This study used tomosynthesis in galactography for the first time and compared the synthetic digital 2D full-field mammograms generated with this technique with the images created using the established method of ductal sonography. Both methods should be able to detect invasive breast cancers and their precursors such as ductal carcinoma in situ (DCIS) as well as being able to identify benign findings.
Material and Methods
Five patients with pathological nipple discharge were examined using ductal sonography, contrast-enhanced 3D galactography with tomosynthesis and the synthetic digital 2D full-field mammograms generated with the latter method. Evaluation of the images created with the different imaging modalities was done by three investigators with varying levels of experience with complementary breast diagnostics (1, 5 and 15 years), and their evaluations were compared with the histological findings.
Results
All 3 investigators independently evaluated the images created with ductal sonography, contrast-enhanced 3D galactography with tomosynthesis, and generated synthetic digital 2D full-field mammograms. Their evaluations were compared with the histopathological assessment of the surgical specimens resected from the 5 patients. There was 1 case of invasive breast cancer, 2 cases with ductal carcinoma in situ and 2 cases with benign findings. All 3 investigators made more mistakes when they used the standard imaging technique of ductal sonography to diagnose suspicious lesions than when they used contrast-enhanced galactography with tomosynthesis and the generated synthetic digital 2D full-field mammograms.
Conclusion
This is the first time breast tomosynthesis was used in galactography (galactomosynthesis) to create digital 3-dimensional images of suspicious findings. When used together with the generated synthetic digital 2D full-field mammograms, it could be a useful complementary procedure for the diagnosis of breast anomalies and could herald a renaissance of this method. Compared with high-resolution ductal ultrasound, the investigators achieved better results with contrast-enhanced galactography using tomosynthesis and the generated synthetic digital 2D full-field mammograms, as confirmed by histopathological findings.
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Affiliation(s)
- Rüdiger Schulz-Wendtland
- Radiologisches Institut, Universitätsklinikum Erlangen, CCC ER-EMN, Universitäts-Brustzentrum Franken, Erlangen, Germany
| | - Caroline Preuss
- Frauenklinik, Universitätsklinikum Erlangen, CCC ER-EMN, Universitäts-Brustzentrum Franken, Erlangen, Germany
| | - Peter A Fasching
- Frauenklinik, Universitätsklinikum Erlangen, CCC ER-EMN, Universitäts-Brustzentrum Franken, Erlangen, Germany
| | - Christian R Loehberg
- Frauenklinik, Universitätsklinikum Erlangen, CCC ER-EMN, Universitäts-Brustzentrum Franken, Erlangen, Germany
| | - Michael P Lux
- Frauenklinik, Universitätsklinikum Erlangen, CCC ER-EMN, Universitäts-Brustzentrum Franken, Erlangen, Germany
| | - Julius Emons
- Frauenklinik, Universitätsklinikum Erlangen, CCC ER-EMN, Universitäts-Brustzentrum Franken, Erlangen, Germany
| | - Matthias W Beckmann
- Frauenklinik, Universitätsklinikum Erlangen, CCC ER-EMN, Universitäts-Brustzentrum Franken, Erlangen, Germany
| | - Michael Uder
- Radiologisches Institut, Universitätsklinikum Erlangen, CCC ER-EMN, Universitäts-Brustzentrum Franken, Erlangen, Germany
| | - Markus Mueller-Schimpfle
- Klinik für Radiologie - Klinikum Frankfurt Hoechst, DKG-zertifiziertes Brustzentrum, Frankfurt am Main, Germany
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20
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Lee SJ, Trikha S, Moy L, Baron P, diFlorio RM, Green ED, Heller SL, Holbrook AI, Lewin AA, Lourenco AP, Niell BL, Slanetz PJ, Stuckey AR, Vincoff NS, Weinstein SP, Yepes MM, Newell MS. ACR Appropriateness Criteria ® Evaluation of Nipple Discharge. J Am Coll Radiol 2018; 14:S138-S153. [PMID: 28473070 DOI: 10.1016/j.jacr.2017.01.030] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 01/18/2017] [Accepted: 01/20/2017] [Indexed: 10/19/2022]
Abstract
Appropriate imaging evaluation of nipple discharge depends the nature of the discharge. Imaging is not indicated for women with physiologic nipple discharge. For evaluation of pathologic nipple discharge, multiple breast imaging modalities are rated for evidence-based appropriateness under various scenarios. For women age 40 or older, mammography or digital breast tomosynthesis (DBT) should be the initial examination. Ultrasound is usually added as a complementary examination, with some exceptions. For women age 30 to 39, either mammogram or ultrasound may be used as the initial examination on the basis of institutional preference. For women age 30 or younger, ultrasound should be the initial examination, with mammography/DBT added when ultrasound shows suspicious findings or if the patient is predisposed to developing breast cancer. For men age 25 or older, mammography/DBT should be performed initially, with ultrasound added as indicated, given the high incidence of breast cancer in men with pathologic nipple discharge. Although MRI and ductography are not usually appropriate as initial examinations, each may be useful when the initial standard imaging evaluation is negative. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - Su-Ju Lee
- Principal Author, University of Cincinnati Medical Center, Cincinnati, Ohio.
| | | | - Linda Moy
- Panel Vice-Chair, NYU Clinical Cancer Center, New York, New York
| | - Paul Baron
- Roper St. Francis Physician Partners Breast Surgery, Charleston, South Carolina; American College of Surgeons
| | | | - Edward D Green
- The University of Mississippi Medical Center, Jackson, Mississippi
| | | | | | - Alana A Lewin
- New York University School of Medicine, New York, New York
| | | | | | | | - Ashley R Stuckey
- Women and Infants Hospital, Providence, Rhode Island; American Congress of Obstetricians and Gynecologists
| | - Nina S Vincoff
- Hofstra Northwell School of Medicine, Manhasset, New York
| | - Susan P Weinstein
- Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Mary S Newell
- Panel Chair, Emory University Hospital, Atlanta, Georgia
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Cohen E, Leung JWT. Problem-Solving MR Imaging for Equivocal Imaging Findings and Indeterminate Clinical Symptoms of the Breast. Magn Reson Imaging Clin N Am 2018; 26:221-233. [PMID: 29622127 DOI: 10.1016/j.mric.2017.12.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Breast MR imaging is commonly used for high-risk screening and for assessing the extent of disease in patients with newly diagnosed breast cancer, but its utility for assessing suspicious symptoms and equivocal imaging findings is less widely accepted. The authors review current literature and guidelines regarding the use of breast MR imaging for these indications. Overall, problem-solving breast MR imaging is best reserved for pathologic nipple discharge and sonographically occult architectural distortion with limited biopsy options. Further study is necessary to define the role of problem-solving MR imaging for calcifications, mammographic asymmetries, and surgical scarring.
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Affiliation(s)
- Ethan Cohen
- Department of Diagnostic Radiology, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1350, Houston, TX 77030-4009, USA.
| | - Jessica W T Leung
- Department of Diagnostic Radiology, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1350, Houston, TX 77030-4009, USA
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22
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Abstract
Discovery of a breast mass, nipple discharge, or breast pain is a common, anxiety-producing occurrence for many women. Although most irregularities are benign, every woman presenting with a breast complaint should be evaluated to exclude or establish a diagnosis of cancer. The patient visit to the provider for a breast complaint can also present an opportunity for the NP to address and update any needed breast screenings.
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Affiliation(s)
- Mary Alison Smania
- Mary Alison Smania is an assistant professor at Michigan State University, East Lansing, Mich
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de Boorder T, Waaijer L, van Diest PJ, Witkamp AJ. Ex vivo feasibility study of endoscopic intraductal laser ablation of the breast. Lasers Surg Med 2017; 50:137-142. [PMID: 28990682 DOI: 10.1002/lsm.22745] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2017] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To determine the feasibility and safety of breast endoscopic thulium laser ablation for treatment of intraductal neoplasia. STUDY DESIGN Ductoscopy is a minimally invasive endoscopic approach of the milk ducts of the breast via the nipple. Besides diagnosis in women with pathologic nipple discharge (PND), it allows non-invasive removal of intraductal lesions with a stalk like papillomas. Removal, however, is often incomplete and flat lesions cannot be targeted. We therefore developed laser ductoscopy. METHODS Dosimetry of laser ductoscopy was assessed in thirteen mastectomy specimens, applying power settings of 1-5 W with 100-1000 ms pulsed exposure to a 375-μm outer diameter thulium fiber laser. Subsequently histology was obtained from the breast tissue that was treated with the Thulium laser. RESULTS Endoscopic view was maintained during ductoscopic laser ablation at 1-3 W. Increasing power to 4-5 W caused impaired vision due to shrinkage of the main duct around the ductoscope tip. Histology revealed localized ablation of the duct wall. CONCLUSION We show for the first time that laser ductoscopy is technically feasible. The Thulium laser enables a superficial intraductal ablation and is a useful tool for intraductal interventions. An in vivo prospective study is needed to further demonstrate its potential. Lasers Surg. Med. 50:137-142, 2018. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- Tjeerd de Boorder
- Departments of Medical Technology and Clinical Physics, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Laurien Waaijer
- Departments of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Paul J van Diest
- Departments of Pathology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Arjen J Witkamp
- Departments of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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The impact of malignant nipple discharge cytology (NDc) in surgical management of breast cancer patients. PLoS One 2017; 12:e0182073. [PMID: 28806416 PMCID: PMC5555566 DOI: 10.1371/journal.pone.0182073] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 06/28/2017] [Indexed: 11/23/2022] Open
Abstract
Background The role of nipple discharge cytology (NDc) in the surgical management of breast cancer patients is unclear. We aimed: (i) to evaluate the effect of malignant NDc on the surgical approach to the nipple-areola complex, and (ii) to verify the association between malignant NDc and nipple malignancy. Methods We retrospectively analyzed a case series of 139 patients with NDc who underwent breast surgery. The clinical and histological findings, types of surgery with emphasis on nipple-areola complex amputation, immunohistochemical phenotypes of the carcinomas and measurements of the tumor-nipple distance were recorded. Additionally, in patients who showed HER2-positive lesions on definitive surgery, we evaluated the HER2 immunocytochemistry of the NDc smears. Results Thirty-two malignant and 107 benign/borderline NDc diagnoses were identified. All 32 malignant-NDc cases were histologically confirmed as malignant. Thirty borderline/benign-NDc cases were histologically diagnosed as malignant (sensitivity 58%). The majority of the patients with malignant NDc were treated with nipple-areola complex amputations in both the mastectomy and conservative surgery groups (P<0.001, χ251.77). Nipple involvement was strongly associated with HER2-positive ductal carcinoma in-situ (P<0.001, χ211.98). HER2 immunocytochemistry on the NDc revealed a 100% correlation with the immunocytochemistry performed on the surgical tissues. Conclusions Malignant NDc influenced surgical management. The association of malignant NDc with nipple involvement is highly related to ductal carcinoma in-situ with HER2 overexpression. In case of HER2 positive NDc, nipple-areola complex involvement is more likely than in HER2 negative cases.
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Yoon JH, Yoon H, Kim EK, Moon HJ, Park YV, Kim MJ. Ultrasonographic evaluation of women with pathologic nipple discharge. Ultrasonography 2017; 36:310-320. [PMID: 28494526 PMCID: PMC5621808 DOI: 10.14366/usg.17013] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 04/03/2017] [Accepted: 04/09/2017] [Indexed: 11/13/2022] Open
Abstract
Nipple discharge is a common symptom that is alarming for the patient since it can be a presenting symptom of breast cancer. Breast imaging is used to examine women with pathologic nipple discharge in order to detect any lesions that may be present and to assist in the differential diagnosis. The modalities of breast imaging include mammography, breast ultrasonography (US), and magnetic resonance imaging. Breast US is currently considered to be useful for the visualization of ductal structures and intraductal lesions that cause nipple discharge. In this review, we discuss US techniques that assist in the clear visualization of ductal structures and intraductal lesions in patients with nipple discharge. Controversy remains regarding the evaluation and management of patients with nipple discharge, and we summarize the results available in the currently published literature.
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Affiliation(s)
- Jung Hyun Yoon
- Department of Radiology and Research Institute of Radiologic Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Haesung Yoon
- Department of Radiology and Research Institute of Radiologic Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Eun-Kyung Kim
- Department of Radiology and Research Institute of Radiologic Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hee Jung Moon
- Department of Radiology and Research Institute of Radiologic Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Youngjean Vivian Park
- Department of Radiology and Research Institute of Radiologic Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Min Jung Kim
- Department of Radiology and Research Institute of Radiologic Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Waaijer L, Simons JM, Borel Rinkes IHM, van Diest PJ, Verkooijen HM, Witkamp AJ. Systematic review and meta-analysis of the diagnostic accuracy of ductoscopy in patients with pathological nipple discharge. Br J Surg 2016; 103:632-643. [DOI: 10.1002/bjs.10125] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 11/07/2015] [Accepted: 01/06/2016] [Indexed: 11/06/2022]
Abstract
Abstract
Background
Invasive surgery remains the standard for diagnosis of pathological nipple discharge (PND). Only a minority of patients with nipple discharge and an unsuspicious finding on conventional breast imaging have cancer. Ductoscopy is a minimally invasive alternative for evaluation of PND. This systematic review and meta-analysis was designed to evaluate the diagnostic accuracy of ductoscopy in patients with PND.
Methods
A systematic search of electronic databases for studies addressing ductoscopy in patients with PND was conducted. Two classification systems were assessed. For DSany, all visualized ductoscopic abnormalities were classified as positive, whereas for DSsusp, only suspicious findings were considered positive. After checking heterogeneity, pooled sensitivity and specificity of DSany and DSsusp were calculated.
Results
The search yielded 4642 original citations, of which 20 studies were included in the review. Malignancy rates varied from 0 to 27 per cent. Twelve studies, including 1994 patients, were eligible for meta-analysis. Pooled sensitivity and specificity of DSany were 94 (95 per cent c.i. 88 to 97) per cent and 47 (44 to 49) per cent respectively. Pooled sensitivity and specificity of DSsusp were 50 (36 to 64) and 83 (81 to 86) per cent respectively. Heterogeneity between studies was moderate to large for sensitivity (DSany: I2 = 17·5 per cent; DSsusp: I2 = 37·9 per cent) and very large for specificity (DSany: I2 = 96·8 per cent; DSsusp: I2 = 92·6 per cent).
Conclusion
Ductoscopy detects about 94 per cent of all underlying malignancies in patients with PND, but does not permit reliable discrimination between malignant and benign findings.
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Affiliation(s)
- L Waaijer
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - J M Simons
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - I H M Borel Rinkes
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - P J van Diest
- Department of Pathology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - H M Verkooijen
- Imaging Division, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - A J Witkamp
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
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Waaijer L, van Diest PJ, Verkooijen HM, Dijkstra NE, van der Pol CC, Borel Rinkes IHM, Witkamp AJ. Interventional ductoscopy in patients with pathological nipple discharge. Br J Surg 2015; 102:1639-48. [PMID: 26447629 DOI: 10.1002/bjs.9950] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2015] [Revised: 06/21/2015] [Accepted: 08/25/2015] [Indexed: 11/12/2022]
Abstract
BACKGROUND Surgery is the intervention of choice for definitive diagnosis and treatment in women with pathological nipple discharge (PND). Ductoscopy has been reported to improve diagnosis, but as an interventional procedure it may also reduce the need for surgery. This study evaluated interventional ductoscopy in patients with PND. METHODS A prospective study on ductoscopy was conducted in consecutive patients with PND, but without a suspected malignancy on routine diagnostic evaluation. Intraductal lesions were removed by ductoscopic extraction. Surgery was undertaken if there were suspicious ductoscopic findings or at the patient's request. Therapeutic efficacy was determined by cannulation success, detection and removal rates, symptom resolution and avoided surgery. RESULTS Ductoscope introduction was successful in 71 (87 per cent) of 82 patients, with abnormalities visualized in 53 (65 per cent); these were mostly polypoid lesions (29 patients). The lesion was removed in 27 of 34 attempted ductoscopic extractions. Twenty-six (32 per cent) of the 82 patients underwent surgery, whereas surgery was avoided in 56 (68 per cent). After a median follow-up of 17 (range 3-45) months, 40 patients (49 per cent) no longer experienced symptoms of PND, 13 of 34 patients experienced an insufficient therapeutic effect after attempted ductoscopic extraction, and the outcome was unknown in two (2 per cent). Malignancy was diagnosed in four patients (5 per cent); two had been missed at ductoscopy and two at initial surgery after ductoscopy. CONCLUSION Interventional ductoscopy is technically feasible and may help to avoid surgery in the majority of patients. As endoscopic removal of intraductal lesions is not always possible and malignancy can be the underlying cause of PND, ductoscopic instruments should be further optimized to allow definitive histological diagnosis.
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Affiliation(s)
- L Waaijer
- Departments of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - P J van Diest
- Departments of Pathology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - H M Verkooijen
- Imaging Division, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - N-E Dijkstra
- Departments of Pathology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - C C van der Pol
- Departments of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - I H M Borel Rinkes
- Departments of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - A J Witkamp
- Departments of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
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Scheurlen K, Schnitzer A, Krammer J, Kaiser C, Schönberg SO, Wasser K. [Value of galactography for the diagnostic work-up of pathological nipple discharge in multimodal breast diagnostics. Part 2: a systematic review of the literature]. Radiologe 2015; 54:160-6. [PMID: 24233402 DOI: 10.1007/s00117-013-2573-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The survey results of a previous study showed that galactography is now rarely used in Germany and newer methods are applied. The evidential value of galactography should be established and opposed to the evidential value of ultrasound (US) and magnetic resonance mammography (MRM). MATERIALS AND METHODS A search was carried out in PubMed and Cochrane involving studies written in English or German. The level of evidence was measured according to the Oxford Centre for Evidence-based Medicine. RESULTS A total of 19 studies were included, 14 with results on galactography, 10 on US and 5 on MRM. Almost all studies were retrospective with an evidence assigned to level 3b or lower. The results on the diagnostic values showed a very wide range. Because of very variable numbers of cases and consideration of various pathologies, the studies are only comparable to a limited extent. CONCLUSION Galactography, US and MRM all show a weak level of evidence and no superiority of a particular method can be derived. Therefore, galactography can no longer be considered as a mandatory standard in modern multimodal imaging of the breast. Recommendations for the diagnostic work-up of pathological nipple discharge have to be included in current guidelines and must consider these facts.
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Affiliation(s)
- K Scheurlen
- Institut für Klinische Radiologie und Nuklearmedizin, Universitätsmedizin Mannheim, Medizinische Fakultät Mannheim der Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
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Bahl M, Baker JA, Greenup RA, Ghate SV. Evaluation of Pathologic Nipple Discharge: What is the Added Diagnostic Value of MRI? Ann Surg Oncol 2015; 22 Suppl 3:S435-41. [PMID: 26249144 DOI: 10.1245/s10434-015-4792-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Indexed: 11/18/2022]
Abstract
PURPOSE To determine the diagnostic value of magnetic resonance imaging (MRI) for the evaluation of patients with pathologic nipple discharge. METHODS We performed a retrospective review of women with nipple discharge who underwent breast MRI between January 1, 2004, and December 31, 2013. Radiographic findings, pathology results, and clinical notes were reviewed. Sensitivity, specificity, positive predictive value, and negative predictive value of MRI were calculated. RESULTS Over a 10-year period, 103 women (mean age 46 years, range 25-72 years) underwent MRI for evaluation of nipple discharge. Ninety-one patients (88 %) underwent surgical excision or had clinical and/or radiographic follow-up at least 2 years after presentation and thus comprise the study population. Eleven (30 %) of 37 patients with MRIs coded as American College of Radiology Breast Imaging-Reporting and Data System (BI-RADS) 4 of 5 were diagnosed with ductal carcinoma in situ (n = 6) or invasive adenocarcinoma (n = 5). Seven (64 %) of 11 patients diagnosed with malignancy had a negative mammographic and sonographic workup. None of the patients with MRIs coded as BI-RADS 1, 2, or 3 was diagnosed with malignancy immediately after presentation or during the 2-year follow-up period. The sensitivity and specificity of MRI for the detection of malignancy were 100 % (11 of 11) and 68 % (54 of 80), respectively. The positive predictive value and negative predictive value were 37 and 100 %, respectively. CONCLUSIONS MRI is a valuable additional diagnostic tool for the evaluation of pathologic nipple discharge when conventional imaging is negative. A negative MRI in this symptomatic population may obviate the need for duct exploration and excision.
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Affiliation(s)
- Manisha Bahl
- Division of Breast Imaging, Department of Radiology, Duke University Medical Center, Durham, NC, USA.
| | - Jay A Baker
- Division of Breast Imaging, Department of Radiology, Duke University Medical Center, Durham, NC, USA
| | - Rachel A Greenup
- Division of Advanced Oncologic and GI Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Sujata V Ghate
- Division of Breast Imaging, Department of Radiology, Duke University Medical Center, Durham, NC, USA
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Patel BK, Falcon S, Drukteinis J. Management of nipple discharge and the associated imaging findings. Am J Med 2015; 128:353-60. [PMID: 25447625 DOI: 10.1016/j.amjmed.2014.09.031] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Revised: 09/29/2014] [Accepted: 09/30/2014] [Indexed: 11/16/2022]
Abstract
Nipple discharge is commonly encountered by health care providers, accounting for 2%-5% of medical visits by women. Because nipple discharge is the presenting symptom in 5% to 12% of breast cancers, it causes considerable anxiety for both patient and providers. Furthermore, the work-up and management of nipple discharge can be confusing. Fortunately, the cause of nipple discharge is usually benign, so the primary goal of evaluation and management is separation of patients with pathologic causes of discharge from those with benign or physiologic causes. The evaluation of nipple discharge requires a thorough history, careful physical examination, and an informed approach that selects the most suitable diagnostic modality. Primary care providers, working with their radiologists and surgeons, are well positioned to design appropriate diagnostic and management protocols to assess and treat nipple discharge. A thoughtful and prudent approach to nipple discharge should alleviate patient anxiety by efficiently and effectively defining the underlying etiology.
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Affiliation(s)
- Bhavika K Patel
- Department of Radiology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Fla; Department of Oncological Sciences, University of South Florida, Tampa.
| | - Shannon Falcon
- Department of Radiology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Fla; Department of Oncological Sciences, University of South Florida, Tampa
| | - Jennifer Drukteinis
- Department of Radiology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Fla; Department of Oncological Sciences, University of South Florida, Tampa
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Lubina N, Schedelbeck U, Roth A, Weng AM, Geissinger E, Hönig A, Hahn D, Bley TA. 3.0 Tesla breast magnetic resonance imaging in patients with nipple discharge when mammography and ultrasound fail. Eur Radiol 2014; 25:1285-93. [PMID: 25433415 DOI: 10.1007/s00330-014-3521-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Revised: 10/08/2014] [Accepted: 11/18/2014] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To compare 3.0 Tesla breast magnetic resonance imaging (MRI) with galactography for detection of benign and malignant causes of nipple discharge in patients with negative mammography and ultrasound. METHODS We prospectively evaluated 56 breasts of 50 consecutive patients with nipple discharge who had inconspicuous mammography and ultrasound, using 3.0 Tesla breast MRI with a dedicated 16-channel breast coil, and then compared the results with galactography. Histopathological diagnoses and follow-ups were used as reference standard. Lesion size estimated on MRI was compared with the size at histopathology. RESULTS Sensitivity and specificity of MRI vs. galactography for detecting pathologic findings were 95.7 % vs. 85.7 % and 69.7 % vs. 33.3 %, respectively. For the supposed concrete pathology based on MRI findings, the specificity was 67.6 % and the sensitivity 77.3 % (PPV 60.7 %, NPV 82.1 %). Eight malignant lesions were detected (14.8 %). The estimated size at breast MRI showed excellent correlation with the size at histopathology (Pearson's correlation coefficient 0.95, p < 0.0001). CONCLUSIONS MRI of the breast at 3.0 Tesla is an accurate imaging test and can replace galactography in the workup of nipple discharge in patients with inconspicuous mammography and ultrasound. KEY POINTS • Breast MRI is an excellent diagnostic tool for patients with nipple discharge. • MRI of the breast reveals malignant lesions despite inconspicuous mammography and ultrasound. • MRI of the breast has greater sensitivity and specificity than galactography. • Excellent correlation of lesion size measured at MRI and histopathology was found.
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Affiliation(s)
- Nóra Lubina
- Department of Diagnostic and Interventional Radiology, University of Würzburg, Oberdürrbacher Strasse 6, 97080, Würzburg, Germany
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Ashfaq A, Senior D, Pockaj BA, Wasif N, Pizzitola VJ, Giurescu ME, Gray RJ. Validation study of a modern treatment algorithm for nipple discharge. Am J Surg 2014; 208:222-7. [PMID: 24767970 DOI: 10.1016/j.amjsurg.2013.12.035] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Revised: 11/04/2013] [Accepted: 12/22/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND Nipple discharge occurs in 2% to 5% of women. We evaluated the effectiveness of a previously proposed treatment algorithm for these patients. METHODS Patients with pathologic nipple discharge and a negative mammogram and subareolar ultrasound were offered follow-up from 2005 to 2011 according to the algorithm. RESULTS A total of 192 patients, mean age 56 years, were studied. Risk of carcinoma among the entire cohort was 5%. Breast surgeon was consulted for 142 (74%) patients: 48 (34%) underwent initial subareolar excision and 94 (66%) were clinically followed. The rate of carcinoma was 17% (8/48) after initial subareolar excision, 0% (0/13) for those without imaging abnormalities, 23% (8/35) with imaging abnormalities, and 1% (1/94) with clinical follow-up. Of patients who underwent follow-up, 21% (n = 20) underwent subareolar excision because of imaging abnormality (n = 1, 1%) or persistent discharge (n = 19, 20%). Most patients had ductal carcinoma in situ (n = 5, 56%). CONCLUSIONS Patients with nipple discharge can be prospectively identified based on radiographic findings and clinical examination for safe clinical follow-up. Most will have resolution avoiding a surgical procedure.
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Affiliation(s)
- Awais Ashfaq
- Department of Surgery, Mayo Clinic, 5777 E. Mayo Blvd, Phoenix, AZ, USA
| | - Derek Senior
- Department of Surgery, Mayo Clinic, 5777 E. Mayo Blvd, Phoenix, AZ, USA
| | - Barbara A Pockaj
- Department of Surgery, Mayo Clinic, 5777 E. Mayo Blvd, Phoenix, AZ, USA
| | - Nabil Wasif
- Department of Surgery, Mayo Clinic, 5777 E. Mayo Blvd, Phoenix, AZ, USA
| | - Victor J Pizzitola
- Department of Radiology, Mayo Clinic, 5777 E. Mayo Blvd, Phoenix, AZ, USA
| | - Marina E Giurescu
- Department of Radiology, Mayo Clinic, 5777 E. Mayo Blvd, Phoenix, AZ, USA
| | - Richard J Gray
- Department of Surgery, Mayo Clinic, 5777 E. Mayo Blvd, Phoenix, AZ, USA.
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Berná-Serna JD, Torres-Ales C, Berná-Mestre JD, Polo L. Role of galactography in the early diagnosis of breast cancer. ACTA ACUST UNITED AC 2014; 8:122-6. [PMID: 24419050 DOI: 10.1159/000350779] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND The purpose of this study was to evaluate the usefulness of galactography (GL) in the early diagnosis of breast cancer in patients with pathologic nipple discharge (PND). PATIENTS AND METHODS We retrospectively studied all galactograms obtained in 117 women with PND, who subsequently had a biopsy. The findings detected in the galactograms of the patients in this study were assigned to different categories of the Galactogram Image Classification System (GICS): GICS 2, benign; GICS 3, probably benign; GICS 4, suspicious for malignancy; and GICS 5, highly suspicious for malignancy. RESULTS The galactograms were classified into GICS 2 (29 cases; 24.7%), GICS 3 (42 cases; 35.8%), GICS 4 (30 cases; 25.6%), and GICS 5 (16 cases; 13.6%). A good correlation was observed between histological diagnosis and GICS categories (p < 0.05). All cases diagnosed with carcinoma (n = 18) were classified in GICS categories 4-5: ductal carcinoma in situ in 14 cases (11.9%) and invasive carcinoma in 4 cases (3.4%). CONCLUSION GL is a useful procedure in the early diagnosis of breast cancer in patients with PND.
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Affiliation(s)
- Juan D Berná-Serna
- Department of Radiology, Virgen de la Arrixaca University Hospital, El Palmar (Murcia), Spain
| | - Carolina Torres-Ales
- Department of Radiology, Virgen de la Arrixaca University Hospital, El Palmar (Murcia), Spain
| | - Juan D Berná-Mestre
- Department of Radiology, Virgen de la Arrixaca University Hospital, El Palmar (Murcia), Spain
| | - Luis Polo
- Department of Pathology, Virgen de la Arrixaca University Hospital, El Palmar (Murcia), Spain
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Sarica O, Ozturk E, Demirkurek HC, Uluc F. Comparison of ductoscopy, galactography, and imaging modalities for the evaluation of intraductal lesions: a critical review. Breast Care (Basel) 2013; 8:348-54. [PMID: 24415988 PMCID: PMC3862052 DOI: 10.1159/000355833] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Today, in cases of nipple discharge of unclear origin, the abundance of diagnostic procedures - a, diagnostic dilemma' - becomes apparent, because unequivocal indications and a current, standardized examination sequence are presently not available. The diagnostic workup of patients with nipple discharge usually includes the clinical history, physical examination, mammography, ultrasonography, galactography, and nipple discharge cytology, but not ductoscopy. METHODS In this review we analyze and discuss the possible role of ductoscopy in evaluating intraductal pathologies and its combined use with diagnostic imaging modalities. For this purpose, we reviewed and compared the results of the radiological, pathological, and surgical studies independently. CONCLUSIONS Currently, there is no solitary accurate modality to reach our definitive purpose. Being aware of the capability of each diagnostic modality may take us closer to our target. Therefore, adjunct and appropriate use of multiple imaging modalities and ductoscopy is necessary to evaluate patients with nipple discharge.
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Affiliation(s)
- Ozgur Sarica
- Department of Radiology, Taksim Education and Research Hospital, Istanbul, Turkey
| | - Enis Ozturk
- Department of Radiology, Bakirkoy Education and Research Hospital, Istanbul, Turkey
| | - Huseyin C. Demirkurek
- Department of Nuclear Medicine, Taksim Education and Research Hospital, Istanbul, Turkey
| | - Fatih Uluc
- Department of Radiology, Taksim Education and Research Hospital, Istanbul, Turkey
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Pruthi S, Bundrick JB, Litin SC. Clinical Pearls in breast disease. Mayo Clin Proc 2012; 87:1015-20. [PMID: 22980163 PMCID: PMC3498122 DOI: 10.1016/j.mayocp.2012.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2012] [Revised: 07/02/2012] [Accepted: 07/05/2012] [Indexed: 10/27/2022]
Affiliation(s)
- Sandhya Pruthi
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA.
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Torres-Alés C, Berná-Serna JDD, Berná-Mestre JDD, Sola-Pérez J. Inter- and intra-observer assessment of the Galactogram Imaging Classification System (GICS). Acta Radiol 2011; 52:829-33. [PMID: 21724840 DOI: 10.1258/ar.2011.110118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND A new system for the classification of galactograms is reported. To date, there is no universally accepted classification system. PURPOSE To evaluate inter- and intra-observer agreement of the Galactogram Imaging Classification System (GICS) MATERIAL AND METHODS: Six observers with different levels of experience retrospectively evaluated 30 galactograms using the GICS. Images were reviewed independently twice within a four-week period. The kappa statistic was calculated for intra- and inter-observer variability. RESULTS The kappa for inter-observer agreement was moderate to substantial (range 0.41-0.72). Overall, the intra-observer kappa values were excellent (range 0.80-0.94). CONCLUSION The present study shows a good to very good inter- and intra-observer agreement with the GICS. We believe the GICS can be incorporated into daily practice.
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Affiliation(s)
| | | | | | - Joaquín Sola-Pérez
- Department of Patology, Virgen de la Arrixaca University Hospital, El Palmar (Murcia), Spain
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Khan SA, Mangat A, Rivers A, Revesz E, Susnik B, Hansen N. Office ductoscopy for surgical selection in women with pathologic nipple discharge. Ann Surg Oncol 2011; 18:3785-90. [PMID: 21626081 DOI: 10.1245/s10434-011-1791-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2011] [Indexed: 11/18/2022]
Abstract
BACKGROUND Pathologic nipple discharge (PND) is diagnosed clinically and managed by diagnostic duct excision (DDE). Mammary ductoscopy in the office setting may change this standard. We performed a prospective study to assess the utility of office ductoscopy for surgical selection in women with nipple discharge. METHODS Women with nipple discharge meeting at least 2 of 3 criteria of PND (spontaneous, single duct, bloody or serous) underwent office ductoscopy. Those showing papillomatous lesions underwent DDE in the operating room (surgical group, n = 38); if no lesion was present, women were followed clinically (observation group, n = 21). RESULTS A papillomatous lesion was identified in 79% of women with 3-criteria PND and in 21% with 2 criteria (P = .001). DDE yielded a proliferative lesion in 35 of 38 women (92%). Of the 38, 27 (71%) had papillomata, 2 (5%) had florid hyperplasia, and 6 (16%) had ductal carcinoma in situ (DCIS) on final pathology. Also, 11 women with papilloma and 1 with DCIS presented with 2-criteria PND. Ductoscopy findings were a better predictor of the presence of intraductal neoplasia (area under curve [AUC] 0.9, 95% confidence interval [95% CI] 0.8-0.98) compared with 3-criteria PND (AUC 0.7, 95% CI 0.6-0.8). The 21 women in the observation group did not develop signs of malignancy or need biopsy during a 48-month follow-up period. CONCLUSIONS Our findings suggest that office ductoscopy provides accurate surgical selection of women with nipple discharge and should be considered for women with 2 criteria of PND, and those with negative ductoscopy can be safely observed. These findings need confirmation in a larger study with longer follow-up.
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Affiliation(s)
- Seema A Khan
- Department of Surgery, Lynn Sage Breast Center, Northwestern Feinberg School of Medicine, Chicago, IL, USA.
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Yau EJ, Gutierrez RL, DeMartini WB, Eby PR, Peacock S, Lehman CD. The Utility of Breast MRI as a Problem-Solving Tool. Breast J 2011; 17:273-80. [DOI: 10.1111/j.1524-4741.2011.01075.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Jain A, Crawford S, Larkin A, Quinlan R, Rahman RL. Management of nipple discharge: technology chasing application. Breast J 2010; 16:451-2. [PMID: 20443787 DOI: 10.1111/j.1524-4741.2010.00933.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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40
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Zervoudis S, latrakis G, Economides P, Polyzos D, Navrozoglou I. Nipple Discharge Screening. WOMENS HEALTH 2010; 6:135-51. [DOI: 10.2217/whe.09.81] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Stefanos Zervoudis
- Stefanos Zervoudis, Lito Hospital, Department of Mastology, Athens, Greece
- Technological Educational Institution of Athens, Athens, Greece
- Universiry of Ioannina, Department of Obstetrics/Gynecology, Breast Unit, Ioannina, Greece, Tel.: +69 44 308 777, Fax: +210 898 1178,
| | - Georgos latrakis
- Georgos Iatrakis, Lito Hospital, Department of Mastology, Athens, Greece
- Technological Educational Institution of Athens, Athens, Greece, Tel.: +210 661 1178, Fax: +210 661 3986,
| | - Panagiotis Economides
- Panagiotis Economides, Lito Hospital, Department of Mastology, Athens, Greece, Tel.: +69 36 121 158, Fax: +210 690 2417,
| | - Demetrios Polyzos
- Demetrios Polyzos, Lito Hospital, Department of Mastology, Athens, Greece, Tel.: +69 44 81 2923, Fax: +210 690 2417,
| | - Iordanis Navrozoglou
- Iordanis Navrozoglou, Universiry of Ioannina, Department of Obstetrics/Gynecology, Breast Unit, Ioannina, Greece, Tel.: +69 44 308 777, Fax: +210 898 1178,
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Fackler MJ, Rivers A, Teo WW, Mangat A, Taylor E, Zhang Z, Goodman S, Argani P, Nayar R, Susnik B, Sukumar S, Khan SA. Hypermethylated Genes as Biomarkers of Cancer in Women with Pathologic Nipple Discharge. Clin Cancer Res 2009; 15:3802-11. [DOI: 10.1158/1078-0432.ccr-08-1981] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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The diagnostic value of nipple discharge cytology in 618 consecutive patients. Eur J Surg Oncol 2008; 35:573-7. [PMID: 18986790 DOI: 10.1016/j.ejso.2008.09.009] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2008] [Revised: 09/22/2008] [Accepted: 09/30/2008] [Indexed: 11/23/2022] Open
Abstract
AIM Preoperative stratification of patients presenting with nipple discharge (ND) according to malignancy risk has proven difficult. Nevertheless, cytological examination is considered to be a diagnostic aid. The aim of this study was to determine its complementary value in clinical decision-making in patients presenting with ND. METHODS We retrospectively collected data on macroscopic ND colour, ND cytology, physical examination, mammography, ultrasound and fine-needle aspiration cytology results. On ND cytology, benign diagnoses were considered negative, whereas suspicious and malignant diagnoses were considered positive for malignancy. RESULTS From 1992 to 2006, 618 patients had an ND smear, of those 163 patients had a biopsy. Sensitivity and specificity were 16.7% and 66.1%, respectively. These values were lower when ND was bloody than when ND was non-bloody (p=0.66 and p<0.05 for sensitivity and specificity, respectively). When macroscopically defining bloody ND as positive and non-bloody ND as negative, macroscopic ND colour examination had a remarkably higher sensitivity (60.6 vs. 18.2%, p<0.001) and only a slightly lower specificity (53.6 vs. 65.0%, p=0.07) when compared to cytological ND examination. Only 1 malignant lesion was designated positive solely by ND cytology (unique sensitivity (95% CI), 2.8% (0.0-8.4%)) and 3 lesions were correctly classified as negative by ND cytology (unique specificity (95% CI), 1.6%, 0.0-3.7%)). CONCLUSION Nipple discharge cytology has little complementary diagnostic value. Therefore, its routine use for detection of ND-related breast pathology should be reconsidered carefully. Nipple discharge cytology may redirect patient management well in some cases, but it may confuse work-up in the majority.
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Mortellaro VE, Marshall J, Harms SE, Hochwald SN, Copeland EM, Grobmyer SR. Breast MR for the Evaluation of Occult Nipple Discharge. Am Surg 2008. [DOI: 10.1177/000313480807400813] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Pathologic nipple discharge often presents a diagnostic and therapeutic dilemma for clinicians. We present two patients with pathologic nipple discharge in whom breast MR facilitated preoperative identification of and management of otherwise occult index lesions. Breast MR should be considered in the toolbox for evaluation of occult nipple discharge when other available strategies have failed to demonstrate an underlying etiology for the pathologic discharge. The use of breast MR in this setting may permit directed evaluation and management of potentially malignant lesions.
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Affiliation(s)
| | - Julia Marshall
- Department of Radiology, University of Florida College of Medicine, Gainesville, Florida; and the
| | | | - Steven N. Hochwald
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, and the
| | - Edward M. Copeland
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, and the
| | - Stephen R. Grobmyer
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, and the
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