Validation study of a modern treatment algorithm for nipple discharge

Can Molecular Breast Imaging With Tc-99m Sestamibi Safely Rule Out Malignancy in Pathologic Nipple Discharge?

PURPOSE

Nipple discharge is the third most common breast-related complaint. It is recommended to exclude malignancy in pathologic nipple discharge (PND). Mammography and ultrasound are the first-line conventional diagnostic (CD) imaging. Although magnetic resonance is often used as a complementary modality, molecular breast imaging (MBI) with Tc-99m sestamibi may be a suitable alternative. Considering the lack of information on this subject and its clinical importance, this study aimed to evaluate the role of MBI in ruling out malignancy in patients with PND and negative/indeterminate CD.

PATIENTS AND METHODS

Retrospective cohort single-center study including all patients with PND evaluated by CD and MBI between 2012 and 2020. Pathology was considered the gold standard. Follow-up was used when pathology was not available.

RESULTS

Of the 96 cases of PND included, 78 were benign, and 18 (20%) corresponded to breast cancer (BC). Although CD and MBI were concordant in the BIRADS classification in 81% (78/96), half of BC were detected by MBI only. BC was located directly behind the nipple in a minority of patients (11%), meaning that MBI could significantly prevent futile central ductal excision. MBI presented higher sensitivity (83% vs. 33%) and negative predictive value (96% vs. 86%) than CD alone, with similar specificity (89% vs. 92%) and positive predictive value (63% vs. 50%). The area under the curve of MBI and CD was 0,86 (P-value<0.001 [95% CI: 0.75-0.97]) and 0.63 (P-value=0.091 [95% CI: 0.47-0.79]), respectively.

CONCLUSIONS

MBI showed good diagnostic accuracy for detecting BC in patients with PND with negative/indeterminate findings on CD imaging.

Dual contrast-enhanced ultrasound for diagnosing pathologic nipple discharge associated with papillary lesions

BACKGROUND

The goal of this research study is to determine the efficacy of dual contrast-enhanced ultrasound (US) in evaluating ductal papillary lesions associated with pathological nipple discharge.

METHODS

A prospective multicenter study was conducted between January 2020 and December 2022. All participants were examined using dual contrast-enhanced US and had re-adjustment of BI-RADS classification. Genuine ductal papillary lesions were identified using US features and subsequently subjected to biopsy or excision. Using pathological results and clinical follow-up as the reference standard as a standard reference, we compared the diagnostic efficacy of dual contrast-enhanced US to conventional US in detecting papillary lesions.

RESULTS

The study included 102 female participants ranging in age from 29 to 80 years (average 47.6 ± 9.4), of whom 87 were retained for analysis. We precisely localized discharging ducts with papillary lesions in 85 patients, with 68 showing varying degrees of enhancement in papillary lesions. Compared to conventional US, dual contrast-enhanced US was more accurate in locating and detecting papillary lesions (P < 0.001). The optimized BI-RADS classification allowed for a more informed prediction of the malignancy risk associated with papillary lesions. Multivariate logistic regression analysis revealed that ductal continuity, the boundary between the nodule and duct, and peak intensity are independent risk factors for malignancy. The area under the curve for detecting malignant papillary lesions was 0.937.

CONCLUSIONS

Dual contrast-enhanced US is effective at precisely locating lactiferous ducts in pathological nipple discharge, detecting and differentiating papillary lesions, and improving the accuracy of BI-RADS classification.

Clinical Significance of Contrast-Enhanced Ultrasound Galactography in Pre-operative Diagnosis of Patients With Pathologic Nipple Discharge

OBJECTIVE

The aim of the work described here was to investigate the feasibility and diagnostic value of using contrast-enhanced ultrasound (CEUS) galactography with SonoVue in patients with pathologic nipple discharge (PND).

METHODS

Twenty-eight patients who underwent breast surgery for PND from May 2019 to August 2021 were included. Routine ultrasound, ductoscopy and CEUS galactography were performed successively. Lesions were diagnosed and localized. The sensitivity, specificity and pre-operative localization value of each examination method were evaluated on post-operative pathology.

RESULTS

CEUS galactography was successfully conducted in all 28 patients and revealed negative ductal ectasia, filling stop and filling defect. Ductoscopy revealed positive nodules in 21 cases and negative nodules in 7 cases. A total of 18 nodules were found by routine ultrasound, and the relationship between all nodules and the discharge duct was confirmed after CEUS galactography. Compared with the other two methods, CEUS galactography had higher sensitivity, positive predictive value and negative predictive value (100%, 81.82% and 100%, respectively), while it has the same specificity as routine ultrasound (both 60%). The pre-operative location of the nipple duct was consistent with the intra-operative findings in 28 patients after CEUS galactography.

CONCLUSION

The ultrasound contrast agent SonoVue can be used for CEUS galactography in patients with PND. CEUS galactography can improve the detection of ductal nodules and locate the nipple discharge duct pre-operatively. As the technique does not emit radiation and SonoVue is easily metabolized and safe, CEUS galactography is better than conventional imaging for PND patients.

Nipple Discharge: When is it Worrisome?

Nipple discharge is the third most common breast related complaint seen in the breast clinics. Although the majority of cases are due to a benign etiology, 5%-12% cases of pathological nipple discharge may be harboring an underlying malignancy. A thorough radiological workup in cases of pathological nipple discharge is thus of utmost importance, with the initial imaging modality depending on the age of the patient. The imaging modalities include mammogram (MG) and ultrasound (US) with addition of breast MRI if the nipple discharge is clinically suspicious and no MG or US correlate is identified. Magnetic Resonance Imaging (MRI) also holds promise in demonstrating the exact extent of a pathology detected on US and thus aids in the planning of further management.

The "Trunk sign": A novel X-ray sign in galactography of patients with nipple discharge suggesting malignancy

The etiology of nipple discharge is often unclear, and there are few studies exploring diagnostic approaches of nipple discharge. Galactography is a common method for clinical diagnosis of patients with nipple discharge. Therefore, this study aimed to evaluate the use of galactography in differentiating between benign and malignant lesions in patients with nipple discharge. A retrospective study of 161 patients with nipple discharges, who were evaluated with galactography and underwent surgery in Qilu Hospital of Shangdong University between January 2018 and December 2019, was conducted. Baseline characteristics were obtained from their electronic records including age, menstruation status, physical examination, galactography, cytology, and pathology. There were 110 cases of benign disease, 12 cases of high-risk disease, and 39 cases of malignant disease. With respect to benign diseases there were 26 (23.6%) patients with hyperplasia and ductal ectasia, and 94 (76.4%) with intraductal papilloma. With respect to high risk diseases, there were 2 (16.7%) patients with atypical intraductal papilloma and 10 (83.4%) with atypical hyperplasia. With respect to malignant lesions, 19 (48.7%) patients had intraductal carcinoma, 4 (10.3%) had solid papillary carcinoma, and 16 (41.0%) had invasive carcinoma. The significant findings of our study are as follows: patients with malignant diseases had a higher proportion of concomitant masses (74.4% vs 41.7% vs 22.7%, P < .001), positive spill cytology (51.3% vs 41.7% vs 2.7%, P < .001), and trunk signs (71.8% vs 33.3% vs 10.9%, P < .001). A forest plot revealed that trunk signs were related to an increased risk of malignant diseases in almost all the subgroups. Galactography is important for the differential diagnosis of benign and malignant lesions in nipple discharge, and the "Trunk sign" is an important radiographic sign of malignant lesions. Combining galactography with other methods is advisable to improve the accuracy of diagnosis in patients with nipple discharge.

A comparative analysis of diagnostic values of high-frequency ultrasound and fiberoptic ductoscopy for pathologic nipple discharge

BACKGROUND

This study aimed to compare the diagnostic accuracy of high-frequency ultrasound (HFUS) and fiberoptic ductoscopy (FDS) for pathologic nipple discharge (PND).

METHODS

HFUS and FDS were conducted in 210 patients with PND (248 lesions) treated at our hospital. The diagnostic accuracy of these two methods was compared using pathological diagnosis as the standard.

RESULTS

Among 248 lesions, 16 and 15 of 16 malignant lesions were accurately diagnosed by HFUS and FDS, respectively. Of 232 benign lesions, 183 and 196 cases were accurately diagnosed by HFUS and FDS, respectively. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of HFUS in diagnosis of intraductal lesions were 84.36% (95% CI 79.26-88.39%), 60% (95% CI 23.07-92.89%), 96.03% (95% CI 96.55-99.83%), and 7.31% (95% CI 2.52-19.4%) respectively. The sensitivity, specificity, PPV, and NPV of FDS in diagnosis of intraductal lesions were 86.83% (95% CI 82.00-90.52%), 100% (95% CI 56.55-100%), 100% (95% CI 98.21-100%), and 13.51% (95% CI 5.91-27.98%) respectively. Diagnostic accuracy rates of HFUS and FDS were 83.87% (208/248) and 85.08% (211/248), respectively, exhibiting no statistically differences (χ² = 0.80, P > 0.05). The accuracy of HFUS combined with FDS was 93.14% (231/248), showing statistically differences (χ² = 10.91, P < 0.05).

CONCLUSIONS

Both HFUS and FDS demonstrated high diagnostic values for PND. HFUS has the advantage of non-invasive for nipple discharge with duct ectasia, exhibited good qualitative and localization diagnostic values. It is the preferred evaluation method for patients with nipple discharge. When HFUS cannot identify the cause of PND, FDS can be considered.

The Value of Adding Ductography to Ultrasonography for the Evaluation of Pathologic Nipple Discharge in Women with Negative Mammography

Objective

The optimal imaging approach for evaluating pathological nipple discharge remains unclear. We investigated the value of adding ductography to ultrasound (US) for evaluating pathologic nipple discharge in patients with negative mammography findings.

Materials and Methods

From July 2003 to December 2018, 101 women (mean age, 46.3 ± 12.2 years; range, 23–75 years) with pathologic nipple discharge were evaluated using pre-ductography (initial) US, ductography, and post-ductography US. The imaging findings were reviewed retrospectively. The standard reference was surgery (70 patients) or > 2 years of follow-up with US (31 patients). The diagnostic performances of initial US, ductography, and post-ductography US for detecting malignancy were compared using the McNemar’s test or a generalized estimating equation.

Results

In total, 47 papillomas, 30 other benign lesions, seven high-risk lesions, and 17 malignant lesions were identified as underlying causes of pathologic nipple discharge. Only eight of the 17 malignancies were detected on the initial US, while the remaining nine malignancies were detected by ductography. Among the nine malignancies detected by ductography, eight were detected on post-ductography US and could be localized for US-guided intervention. The sensitivities of ductography (94.1% [16/17]) and post-ductography US (94.1% [16/17]) were significantly higher than those of initial US (47.1% [8/17]; p = 0.027 and 0.013, respectively). The negative predictive value of post-ductography US (96.9% [31/32]) was significantly higher than that of the initial US (83.3% [45/54]; p = 0.006). Specificity was significantly higher for initial US than for ductography and post-ductography US (p = 0.001 for all).

Conclusion

The combined use of ductography and US has a high sensitivity for detecting malignancy in patients with pathologic nipple discharge and negative mammography. Ductography findings enable lesion localization on second-look post-ductography US, thus facilitating the selection of optimal treatment plans.

Nipple Discharge Imaging Evaluation with Mammography, Ultrasound, Galactography, and MRI

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.

Diagnostic accuracy of breast MRI for patients with suspicious nipple discharge and negative mammography and ultrasound: a prospective study

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.

Nipple Discharge: Current Clinical and Imaging Evaluation

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.

Charged with Discharge: A Case-based Review of Nipple Discharge Using the American College of Radiology's Appropriateness Guidelines

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.

The investigation and management of unilateral nipple discharge

INTRODUCTION

Between 16,000 and 48,000 women are estimated to present to UK breast clinics with nipple discharge each year. The incidence of malignancy in these women is 2.7-24.2%. Currently, there is no consensus on the best way to investigate and manage these women. The aim of this study was to assess the rate of malignancy in women presenting with unilateral nipple discharge, and to evaluate the role of examination, imaging and cytology in reliably predicting outcome.

METHODS

Breast units were asked to prospectively collect data on all new patients with unilateral nipple discharge. Data collected included discharge colour, whether it was uniductal or multiductal, examination and imaging findings, cytology results and outcome.

RESULTS

Complete datasets were submitted by 5 units on 228 patients. The incidence of malignancy was 4.4%. Clinical examination was valuable in detecting malignancy and multiductal discharge was not related to malignancy. The positive predictive value for detecting malignancy for an abnormality found on mammography was 53.5% and for ultrasonography, it was 65.2%. The role of cytology in detecting malignancy was inconclusive with positive predictive values of the presence of red blood cells and epithelial cells at 6.1% and 10.7% respectively.

CONCLUSIONS

A large number of women are investigated for nipple discharge (with huge resource implications) but there is little reliable evidence on the best way to investigate and manage these patients. A larger study is needed to evaluate the role of investigations in nipple discharge to produce guidelines on optimal management.

Evaluation and management of pathological nipple discharges without using intraductal imaging methods

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.

Is Ductography Still Warranted in the 21st century?

OBJECTIVE

To determine the utility of ductography in conjunction with mammography and ultrasound in patients with pathologic nipple discharge, and the incremental role of MRI after triple-modality evaluation.

MATERIALS AND METHODS

We retrospectively reviewed the medical records of patients who had presented with pathologic nipple discharge and had undergone mammography and/or ultrasound and ductography between January 1, 2005, and October 31, 2010. We tested the diagnostic sensitivity, specificity and accuracy of combined triple-modality evaluation as well as of MRI performed in addition to these imaging techniques. We used the gold standard of image-guided biopsies, surgical excision, or long-term clinical and imaging follow-up.

RESULTS

Among 94 study patients, benign papillomas were identified in 42 (44.7%), abscess in one (1%), duct ectasia in four (4.3%), and malignancy (invasive ductal carcinoma or ductal carcinoma in situ) or high-risk lesion (atypical ductal hyperplasia) in 10 (10.6%). Forty-six patients (49%) underwent surgical excision; 89.1% of which had presurgical planning with ductography. In 35 (37.2%) with negative imaging, resolution of nipple discharge was confirmed on median clinical and imaging follow-up of 36 months. Two patients with negative imaging were lost to follow-up. Sensitivity, specificity, PPV, and NPV for accurately demonstrating the etiology of pathologic nipple discharge were 13%, 97%, 89%, and 37% respectively for mammography; 73%, 97%, 98%, and 64% respectively for ultrasound; 76%, 72%, 84%, and 61% respectively for ductography; 86%, 70%, 85%, and 72% respectively for combined ultrasound and ductography; and 75%, 100%, 100% and 67% respectively for DCE-MRI.

CONCLUSION

The combination of mammography, ultrasound and ductography is highly accurate for identifying the etiology of pathologic nipple discharge. DCE-MRI can be used as an alternate to ductography if necessary.

Retrospective statistical analysis on the diagnostic value of ductography based on lesion pathology in patients presenting with nipple discharge

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.

Nipple discharge: The state of the art

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.

Nipple Discharge: Imaging Variability Among U.S. Radiologists

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.

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

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.

Breast imaging in patients with nipple discharge

Nipple discharge is a common symptom in clinical practice, representing the third leading breast complaint, after pain and lumps. It is usually limited and has a benign etiology. The risk of malignancy is higher when the discharge is uniductal, unilateral, spontaneous, persistent, bloody, or serous, as well as when it is accompanied by a breast mass. The most common causes of pathologic nipple discharge are papilloma and ductal ectasia. However, there is a 5% risk of malignancy, mainly ductal carcinoma in situ. The clinical examination is an essential part of the patient evaluation, allowing benign nipple discharge to be distinguished from suspicious nipple discharge, which calls for imaging. Mammography and ultrasound should be used together as first-line imaging methods. However, mammography has low sensitivity in cases of nipple discharge, because, typically, the lesions are small, are retroareolar, and contain no calcifications. Because the reported sensitivity and specificity of ultrasound, it is important to use the correct technique to search for intraductal lesions in the retroareolar region. Recent studies recommend the use of magnetic resonance imaging in cases of suspicious nipple discharge in which the mammography and ultrasound findings are normal. The most common magnetic resonance imaging finding is non-mass enhancement. Surgery is no longer the only solution for patients with suspicious nipple discharge, because short-time follow-up can be safely proposed.

Evaluation of common breast complaints in primary care

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.

Diagnostic Performance of MRI Versus Galactography in Women With Pathologic Nipple Discharge: A Systematic Review and Meta-Analysis

OBJECTIVE

The objective of our study was to perform a systematic review of the literature of the diagnostic accuracy of MRI compared with galactography in women with pathologic nipple discharge.

MATERIALS AND METHODS

A systematic literature search was performed (MEDLINE, Embase, Web of Science) for articles evaluating the diagnostic performance of MRI and galactography in patients with pathologic nipple discharge and with histologic verification or clinical follow-up. Distinction between any abnormality and cancer was made. Two independent readers selected eligible articles published until December 2015. The quality of the studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool. Data analyses were performed using the bivariate model.

RESULTS

Ten articles were analyzed for a total of 921 patients. The study quality was high, with a low risk of bias and low concerns regarding applicability. The pooled sensitivity for any abnormality was significantly higher for MRI, with 92% (95% CI, 85-96%), than for galactography, with 69% (95% CI, 59-78%) (p < 0.001). The pooled specificity was 76% (95% CI, 49-92%) for MRI versus 39% (95% CI, 16-69%) for galactography (p < 0.001). The pooled sensitivity and specificity for cancer detection were calculated for MRI only and were 92% (95% CI, 74-98%) and 97% (95% CI, 80-100%), respectively.

CONCLUSION

This meta-analysis shows a higher diagnostic performance of MRI compared with that of galactography in the detection of any kind of lesion in patients with pathologic nipple discharge. Moreover, high sensitivity and very high specificity for cancer by MRI could be confirmed in this clinical setting. If mammography and ultrasound are negative, MRI should be preferred over galactography for further evaluation.

Ultrasonographic evaluation of women with pathologic nipple discharge

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.

The Rightful Role of MRI after Negative Conventional Imaging in the Management of Bloody Nipple Discharge

Nipple discharge is a frequent presenting complaint at breast clinics. Bloody nipple discharge (BND) has the highest risk of malignancy, albeit low. If mammogram and ultrasound are unrevealing, central duct excision (CDE) has been considered the gold standard in its management. Magnetic resonance imaging (MRI) has been widely confirmed as a highly sensitive test for detection of breast cancer, with an accompanying high negative predictive value. This article presents a retrospective review of patients with BND and negative conventional imaging, comparing outcome of patients who went directly to CDE without MRI to those patients who underwent preoperative MRI. Of 115 patients who underwent mammography and US alone prior to CDE, eight cancers were detected (seven ductal carcinoma in situ [DCIS] and 1 IDC, 7 mm [T1b]; incidence: 7%). Of 85 patients who underwent conventional imaging followed by MRI prior to surgery, eight cancers were detected (all DCIS; incidence: 9.4%), seven of which were identified by MRI. The one false-negative MRI had subtle findings which, in retrospect, were misinterpreted; however, a clinically apparent nipple lesion prompted surgical biopsy. Of 56 patients with a negative or benign MRI, CDE was negative for malignancy in all but that one patient. Sensitivity and specificity were 87.5%/71.4%. Positive predictive value and negative predictive value (NPV) were 24.1%/98.2%. MRI should be performed in all patients with BND and negative conventional imaging. The extremely high NPV of MRI suggests that a negative study could obviate CDE in most patients unless overriding clinical factors prevail.

[Management of breast nipple discharge: Recommendations]

OBJECTIVES

To investigate diagnostic value of imaging procedures and management strategies of the patients with nipple discharge (ND) to establish management recommendations.

METHODS

Bibliographical search in French and English languages by consultation of PubMed, Cochrane and Embase databases.

RESULTS

Although, all ND require an systematic evaluation guided by clinical data, bloody ND could be a predictor of breast cancer risk among different colors of discharge particularly in patients of more than 50 years (LE2). The mammography and breast ultrasography are the imaging procedures to realize in first intention (grade C) but they turn out useful only when they detect radiological abnormalities (LE4). Galactography has only a localizing value of possible ductal abnormalities (when standard imaging procedures is not contributive) (LE4). Thus, in the diagnostic investigation of a suspicious ND, galactography it is not recommended in standard practice (grade C). The breast Magnetic Resonance Imaging (MRI) is recommended when breast standard imaging procedures are not contributive (grade C). The ND cytology is useful only if it is positive (i.e. reveal cancer cells). There is no proof on the diagnostic performance of the cytological analysis of the ND to allow a recommendation on its realization or not. In front of a suspicious ND, when breast-imaging procedures reveals an associated radiological lesion, an adapted percutaneous biopsy is recommended by percutaneous way (grade C). Vacuum-assisted breast biopsies is a diagnostic tool but can also be therapeutic allowing to avoid surgery in case of benign lesion but current literature data do not allow recommendations on the therapeutic aspect of vacuum-assisted breast biopsy (LE4). In the absence of associated radiological signal, and in case of reproducible bloody persistent ND, a pyramidectomy is recommended (grade C).

Frequency of diagnosis of cancer or high-risk lesion at operation for pathologic nipple discharge

BACKGROUND

Pathologic nipple discharge is managed customarily with diagnostic subareolar duct excision. We evaluated for features predictive of malignancy to identify cases where operation might be avoided.

METHODS

We studied 311 consecutive subareolar duct excisions for pathologic nipple discharge from January 2008 to July 2014. χ(2) tests were used to test for associations with final pathology.

RESULTS

In 27 cases, cancer was diagnosed preoperatively. Among the remaining 284, 26 (9%) were diagnosed with cancer and 8 (3%) with atypia at operation. At greatest risk of upstage to cancer were patients with prior ipsilateral breast cancer (3/8; 38%), BRCA mutation (2/3; 67%) or atypia on core needle biopsy (CNB; 3/8 [38%]). Excluding these patients lowered cancer and atypia upstages (7% [18/265] and 3% [7/265]), with bloody (versus serous) discharge (P = .001), and focal imaging abnormality (P = .02), the strongest risk factors. Serous discharge and either normal imaging or a benign CNB had a 1.3% cancer upstage rate.

CONCLUSION

Despite contemporary imaging, pathologic nipple discharge upstage rates to malignancy and atypia remain high, especially with prior ipsilateral breast cancer, BRCA mutation, or atypia on CNB. Absent these risk factors, patients with serous discharge and a benign CNB or normal imaging (cancer risk <2%) may be considered for nonoperative management.

Management of nipple discharge and the associated imaging findings

Nipple discharge is commonly encountered by health care providers, accounting for 2%-5% of medical visits by women. Because nipple discharge is the presenting symptom in 5% to 12% of breast cancers, it causes considerable anxiety for both patient and providers. Furthermore, the work-up and management of nipple discharge can be confusing. Fortunately, the cause of nipple discharge is usually benign, so the primary goal of evaluation and management is separation of patients with pathologic causes of discharge from those with benign or physiologic causes. The evaluation of nipple discharge requires a thorough history, careful physical examination, and an informed approach that selects the most suitable diagnostic modality. Primary care providers, working with their radiologists and surgeons, are well positioned to design appropriate diagnostic and management protocols to assess and treat nipple discharge. A thoughtful and prudent approach to nipple discharge should alleviate patient anxiety by efficiently and effectively defining the underlying etiology.