Is Duct Excision Still Necessary for All Cases of Suspicious Nipple Discharge?

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.

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.

Evaluation of Breast Problems

Breast disorders arise from a myriad of etiologies. They are frequent reasons for patient encounters in primary care and obstetric and gynecologic practices. The most common complaints include breast pain, nipple discharge and breast lumps or masses. Given widespread and well-known screening recommendations, breast cancers are regularly diagnosed during routine screening. Regardless of the presenting complaint, a patient's presentation, physical examination, and diagnostic imaging may require a unique framework for adequate and timely diagnosis for appropriate intervention and treatment. This manuscript aims to discuss and guide assessment to manage breast disorders.

Diagnostic performance of digital breast tomosynthesis in female patients with nipple discharge

Background

Nipple discharge is one of the most common symptoms related to the breast, but it is a presenting feature of breast cancer in 5%–12% of women.

Aims

The purpose of this study was to determine the diagnostic performance of digital breast tomosynthesis (DBT) in the evaluation of patients with nipple discharge and to compare it with mammography (MMG), ultrasound (US), and magnetic resonance imaging (MRI).

Methods and Results

This retrospective study included 53 patients with nipple discharge. All patients underwent DBT, and results were compared to MMG, breast US, and MRI. Radiological findings for each method were categorized according to BI‐RADS classification: categories 1–2 were considered negative and categories 3–5 positive. If a tissue specimen was obtained, the final diagnosis was established based on the results of histopathological analysis; otherwise, a clinical follow‐up was required for at least 2 years to confirm benign radiological findings. Measures of diagnostic accuracy of DBT, MMG, US, and MRI were calculated and compared.

Results

Final histopathological analysis revealed six malignant breast lesions, all of which were detected in patients with pathologic nipple discharge. DBT and MRI exhibited high sensitivity (100%) and high negative predictive value (100%) for the detection of breast cancer in patients with nipple discharge. DBT showed higher specificity compared to MRI (82.9% vs. 61.9%). Sensitivity and specificity of MMG were 83.3% and 76.6%, respectively. Breast US was determined to have a sensitivity of 66.7% and specificity of 57.5%.

Conclusion

DBT exhibited higher specificity than MRI at the same level of sensitivity and negative predictive value. Therefore, the use of DBT should be considered as an alternative to MRI in the assessment of patients with nipple discharge.

Prevalence of different breast lesions in women of southern Punjab, Pakistan, characterized on high-resolution ultrasound and mammography

Background

The aim of the study is to characterize the breast lesions on high-resolution Ultrasound and digital mammography to find the patterns and prevalence of different breast lesions in different age groups of our population.

Results

This prospective study was conducted at a breast care clinic of a tertiary care hospital from Jan 2018 to Dec 2019. Patients with breast-related complaints were enrolled. Patients under the 35 years of age were evaluated on High-Resolution Ultrasound (HR-USG) and those over 35 years of age on digital Mammography. Any lesion on digital mammography was characterized on HR-USG. Fine Needle Aspiration (FNAC) and Trucut biopsy was done where pathological correlation required. Data of all enrolled patients were recorded and analyzed. Patients with known cases of carcinoma breast on follow-up were excluded from the study. Total 6850 patients enrolled in our breast care clinic during study period. 5111 were above the age of 35 years while 1739 were under the age of 35 years. No lesion could be found in 3915 patients and were reported normal. 2935 patients were found to have different breast lesions. The frequency of different lesions was different in both age groups. The overall frequency of lesions was as malignancy 16.2%, benign lesions including Fibroadenoma, simple cysts, Lipoma and Galactocele 16%, inflammatory lesions including abscess 7.86% and Duct Ectasia 2.75%.

Conclusions

In developing countries where mass screening programs are deficient, Breast Care clinics in tertiary care hospitals have a noteworthy role in early detection of breast cancer and other breast lesions.

The accuracy of nipple discharge cytology in detecting breast cancer

OBJECTIVES

This study aimed to disclose the importance of nipple discharge (ND) and the accuracy of its economic and fast cytological interpretation.

METHODS

All ND cytology cases for Saudi patients done between 2004 and 2013 were retrieved from the Pathology e-system. Only cases that have subsequent tissue diagnoses were included in this study (n = 228). Age and bloody nature of the ND were both tested for association with a higher chance of carcinoma. Diagnostic accuracy of ND cytology was calculated twice, including and excluding the "atypical" cases.

RESULTS

Specificity and positive predictive value were 100% for ND cytology in both cases. Sensitivity (34.6%; 52.9%), negative predictive value (93.15 %; 96.1%), false-negative rate (65.4%; 47.1%), accuracy rate (93.4%; 96.2%), when atypical cases were included and excluded; respectively. Only 10.5% of the patients complaining from nipple discharge had breast cancer. For those who had cancer, nipple discharge cytology was positive and showed the cancer cells in only 37.5%, while the rest were false negative. Bloody ND disclosed a significant association with malignancy (p < 0.001), but the association was statistically not significant for old age (p = 0.062).

CONCLUSIONS

The prospect of having breast cancer with the presentation of ND is low, and it can be missed by studying the ND cytology alone in a high proportion of cases. Excluding the atypical category did not make a significant improvement in the test's accuracy.

Magnetic resonance imaging in the evaluation of pathologic nipple discharge: indications and imaging findings

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.

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.

Predicting Patients Found to Have Malignancy at Nipple Duct Surgery

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.

Diagnosis and surgical treatment of pathologic nipple discharge using ultrasound-guided wire localization of focal ductal dilatation

Nipple discharge is the third breast complaint after pain and lumps. The modern high-resolution ultrasound techniques are becoming more sensitive for the visualization of intraductal changes especially focal ductal dilatation (FDD), hypothesized as a radiographic manifestation of the lesion itself and that ultrasound-guided wire localization of this finding would enable identification and excision of the causative lesion. The aim of this study was to evaluate the safety, feasibility, efficiency and outcome of ultrasound-guided wire localization of FDD as possible cause of pathological nipple discharge (PND). The present study was conducted on 56 patients with PND presented to Surgical Oncology Unit at General Surgery Department, Tanta University Hospital from January 2018 to January 2019. The patients subjected to ultrasound-guided wire localization of FDD on the day of surgery, the involved duct was cannulated with a lacrimal duct probe, the targeted tissue was excised, and the specimen was sent for histopathological examination. The patients' age ranged between 26 and 71 years with a mean age of 48 years. The bloody nipple discharge was the commonest presenting symptom in 44 out of 56 patients (78.5%). The duct dilatation on study ultrasound ranged from 2.1 to 3.7 mm with a mean of 2.6 mm. Preoperative ultrasound-guided wire localization of the site of FDD was successfully performed in all cases. Papilloma alone founded in 40 out of 56 patients (71.4%), papilloma + ductal carcinoma in situ (DCIS) in six patients (10.7%), papilloma + invasive ductal carcinoma in six patients (10.7%), DCIS in two patients (3.6%) and duct ectasia in two patients (3.6%). Ultrasound-guided wire localization of FDD is an easy and safe technique for evaluation, precise localization, and targeted excision of the underlying lesions of PND.

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.

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.

Ex vivo feasibility study of endoscopic intraductal laser ablation of the breast

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.

Bioinformatics analysis of dysregulated microRNAs in the nipple discharge of patients with breast cancer

MicroRNAs (miRNAs/miRs) have been reported to be associated with the tumorigenesis and progression of various types of human cancer; however, the underlying mechanisms of this association remain unclear. The aim of the present study was to explore the potential functions of miRNAs in the development of breast cancer using bioinformatics analysis, based on the miRNA expression profile in nipple discharge. A previous study demonstrated the upregulation of miR-3646 and miR-4484, and the downregulation of miR-4732-5p in the nipple discharge of patients with breast cancer, compared with patients with benign breast lesions. In the present study, the target genes of miR-3646, −4484 and −4732-5p were predicted using TargetScan and the MicroRNA Target Prediction and Functional Study Database. The predicted target genes were further analyzed by Gene Ontology term enrichment analysis, Kyoto Encyclopedia of Genes and Genomes pathway enrichment analysis and protein-protein interaction analysis. Numerous carcinoma-associated genes, including ADIPOQ, CPEB1, DNAJB4, EIF4E, APP and BCLAF1, were revealed to be putative targets of miR-3646, −4484 and −4732-5p. Bioinformatics analysis associated miR-3646 with the Rap1 and TGF-β signaling pathways, miR-4484 with the ErbB, estrogen and focal adhesion signaling pathways, and miR-4732-5p with the proteoglycan signaling pathway. Notably, protein-protein interaction analysis identified that numerous predicted targets of these miRNAs were associated with one other. In addition, the target genes of the miRNAs were identified to be under the regulation of a number of transcription factors (TFs). The predicted target genes of miR-3646, −4484 and −4732-5p were identified to serve a role in cancer-associated signaling pathways and TF-mRNA networks, indicating that they serve a role in breast carcinogenesis and progression. These results provide a comprehensive view of the functions and molecular mechanisms of miR-3646, −4484 and −4732-5p, and will aid in future studies.

Diagnostic accuracy of shear wave elastography for prediction of breast malignancy in patients with pathological nipple discharge

OBJECTIVES

Pathological nipple discharge (PND) may indicate malignant breast lesions. As the role of shear wave elastography (SWE) in predicting these malignant lesions has not yet been evaluated, we aim to evaluate the diagnostic value of SWE for this condition.

DESIGN

Prospective diagnostic accuracy study comparing a combination of qualitative and quantitative measurements of SWE (index test) to a ductoscopy and microdochectomy for histological diagnosis (reference test).

SETTING

Fuzhou General Hospital of Nanjing military command.

PARTICIPANTS

A total of 379 patients with PND were finally included from January, 2011 to March 2014, after we screened 1084 possible candidates. All participants were evaluated through SWE, with qualitative parameters generated by Virtual Touch tissue imaging (VTI) and quantitative parameters generated by Virtual Touch tissue quantification (VTQ). All the patients were consented to receive a ductoscopy and microdochectomy for histological diagnosis, and the results were set as a reference test.

OUTCOME MEASURES

Sensitivity and specificity of the combined VTI and VTQ of the SWE for detection of malignancy in patients with PND.

RESULTS

The 379 participants presented with 404 lesions. The results of pathological examination showed that 326 (80.7%) of the 404 lesions were benign and the other 78 (19.3%) were malignant. An area under the curve of elasticity score, VTQm and VTQc, were 0.872, 0.825 and 0.857, respectively, with the corresponding cut-off point as 2.50, 2.860 m/s and 3.015 m/s, respectively. After a combination of these measurements, the sensitivity, specificity, and positive and negative predictive value (PPV and NPV), were 89.7%, 72.1%, 43.5% and 96.7%, respectively. The sensitivity analysis showed 82% of the sensitivity and 96.8% of the specificity, in which patients with no pathological findings in ductoscopy were excluded.

CONCLUSIONS

Ultrasonographic elastography is sensitive for patients with PND and could be used as a triage test before ductoscopy examination. Studies for further improvement of diagnostic sensitivity are warranted.

[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).

A Novel Light-Emitting Wire Enhances the Marking and Visualization of Pathologic Mammary Ducts During Selective Microdochectomy

BACKGROUND

Methylene blue injection of lesions often is inaccurate, and ductoscopic wire marking does not facilitate easy identification of lesions during microdochectomy in patients with pathologic nipple discharge. The authors designed a light-emitting wire that can be inserted into pathologic mammary ducts to facilitate intraoperative duct identification and evaluated the efficacy of this device in patients undergoing selective microdochectomy.

METHODS

In this study, 69 patients being evaluated for pathologic discharge were randomized to undergo selective microdochectomy with either methylene blue pathologic duct marking or light-emitting wire pathologic duct marking. The patient clinical characteristics and surgical outcomes were compared and evaluated.

RESULTS

Of the 69 study patients, 36 underwent selective microdochectomy guided by methylene blue injection, and 33 underwent light-emitting wire marking. No differences existed between the clinical and histologic characteristics or the diagnostic accuracies of the groups. In 11 (30.56%) of the 36 patients who underwent methylene blue marking, the ducts ruptured after the methylene blue was injected, and normal tissue around the duct was stained. Light-emitting wire marking was associated with a shorter surgical time and smaller surgical specimens.

CONCLUSIONS

The use of light-emitting wire marking enabled selective microdochectomy of pathologic ducts under visual guidance. Resection volume was reduced, and blinded extended resection was avoided.

Interventional ductoscopy in patients with pathological nipple discharge

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.

Diagnostic Value of Ultrasound in Female Patients With Nipple Discharge

OBJECTIVE

The purpose of this study was to assess the contribution of ultrasound to the evaluation of patients with pathologic nipple discharge.

MATERIALS AND METHODS

A retrospective review was conducted of the records of females who presented with nipple discharge between January 1, 2009, and December 31, 2011. Pathologic nipple discharge was defined as discharge with one or more of the following features: unilateral, clear or bloody, and spontaneous. Patients underwent bilateral mammography followed by ultrasound directed at the subareolar portion of the affected breast. Radiologic findings and pathologic results were reviewed.

RESULTS

Over a 3-year period, 327 females (mean age, 48 years; range, 13-88 years) presented with nipple discharge. Among these patients, 273 (83%) underwent surgical excision or clinical or radiographic follow-up at least 2 years after presentation and composed the study population. Among the 273 patients, 262 (96%) underwent mammography and 246 (90%) underwent sonography. Among 252 patients who had at least one pathologic feature of nipple discharge and underwent surgical excision or at least 2 years of follow-up, a total of 20 (8%) cases of ductal carcinoma in situ (DCIS) or invasive adenocarcinoma were diagnosed. DCIS or invasive adenocarcinoma was diagnosed in eight patients with normal sonographic findings. For the detection of DCIS and invasive adenocarcinoma, the sensitivity and specificity of ultrasound were 56% (10/18) and 75% (170/228); the sensitivity and specificity of mammography were 15% (3/20) and 98% (237/242).

CONCLUSION

For females presenting with pathologic nipple discharge, ultrasound is a useful diagnostic tool and may be worth including in the routine evaluation.

Evaluation of Pathologic Nipple Discharge: What is the Added Diagnostic Value of MRI?

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.

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.

Adding Ultrasound to the Evaluation of Patients with Pathologic Nipple Discharge to Diagnose Additional Breast Cancers: Preliminary Data

The aim of this study was to assess the malignancy yield of ultrasound Breast Imaging Reporting and Data System (BI-RADS) classification and the diagnostic value of adding ultrasound to diagnosis of breast cancer in patients with pathologic nipple discharge. Of 267 patients with pathologic nipple discharge seen from February 2003 to March 2011, 198 with histopathologic confirmation and follow-up data were included. Ultrasound images and mammograms were analyzed according to BI-RADS. The malignancy rate for each BI-RADS category and the difference in diagnostic performance resulting from the addition of ultrasound to mammography were calculated. Of the 198 enrolled patients, 34 were diagnosed with a malignancy. The malignancy rates obtained with the addition of ultrasound to mammography were 0.0% (0 of 27) for category 1, 5.9% (1/17) for category 2, 9.4% (5/53) for category 3, 21.5% (20/93) for category 4 and 100% (8/8) for category 5. The malignancy rates for mammography alone were 7.7%-9.0% for categories 1-3, 68.5% (13/19) for category 4 and 100.0% (5/5) for category 5. Adding US to mammography did not significantly increase sensitivity compared with mammography alone. Other diagnostic performance markers such as specificity and positive predictive value were not improved. Among patients for whom mammograms were available, ultrasound detected 5 breast cancers (26.3%) in addition to the 19 breast cancers found by positive mammography. Although it did not increase overall diagnostic performance in patients with pathologic nipple discharge, addition of ultrasound to mammography did detect an additional 26.3% of malignant lesions.

Mammary ductoscopy and follow-up avoid unnecessary duct excision in patients with pathologic nipple discharge

BACKGROUND AND OBJECTIVES

The goal of this study was to evaluate the efficacy of ductoscopy and follow-up for the diagnoses of intraductal lesions and the concomitant advantages of avoiding surgery for patients with pathologic nipple discharge (PND).

METHODS

Two hundred and sixty-six ductoscopies were performed for 238 women. Patients with positive ductoscopies underwent surgery. If no positive lesions were present upon ductoscopy, the women were followed.

RESULTS

Of 266 ductoscopic examinations, 168 (63.2%, 168/266) breasts from 165 patients were found to have positive images. The final histopathological results revealed that 93 patients with intraductal papilloma, 42 with intraductal papillomatosis, 15 with ADH lesions, DCIS in 9 patients, 1 case with invasive ductal carcinoma (IDC), 6 cases with duct ectasia, and 2 cases with inflammation. Seventy-three patients with negative results upon ductoscopy were followed with a median time of 48 months. Twelve patients had PND recurrence and were diagnosed as papilloma or papillomatosis based on pathology after surgery. PND disappeared for 51 patients after ductoscopy, and no recurrence or disease evolvement was founded for them.

CONCLUSION

Ductoscopy and follow-up were advantageous for selecting patients to undergo surgery or surveillance. The recurrence of PND after ductoscopy might be a strong predictor for having intraductal disease.

3.0 Tesla breast magnetic resonance imaging in patients with nipple discharge when mammography and ultrasound fail

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.

Breast ultrasonography: state of the art

Ultrasonography (US) is an indispensable tool in breast imaging and is complementary to both mammography and magnetic resonance (MR) imaging of the breast. Advances in US technology allow confident characterization of not only benign cysts but also benign and malignant solid masses. Knowledge and understanding of current and emerging US technology, along with the application of meticulous scanning technique, is imperative for image optimization and diagnosis. The ability to synthesize breast US findings with multiple imaging modalities and clinical information is also necessary to ensure the best patient care. US is routinely used to guide breast biopsies and is also emerging as a supplemental screening tool in women with dense breasts and a negative mammogram. This review provides a summary of current state-of-the-art US technology, including elastography, and applications of US in clinical practice as an adjuvant technique to mammography, MR imaging, and the clinical breast examination. The use of breast US for screening, preoperative staging for breast cancer, and breast intervention will also be discussed.

Comparison of ductoscopy, galactography, and imaging modalities for the evaluation of intraductal lesions: a critical review

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.

Interventional ductoscopy for pathological nipple discharge

BACKGROUND

Despite the low likelihood of malignancy, it is recommended that patients who have pathologic nipple discharge (PND) undergo duct excision. Intraductal papilloma is well-known most frequent cause of PND. Our goal is to determine whether the ductoscopic retrieval of a solitary papilloma is feasible and/or therapeutic for patients with PND. The accompanying video demonstrates this interventional ductoscopic approach.

METHODS

Consented patients who had been diagnosed with PND were recruited to have ductoscopic exploration. Patients with palpable masses and suspicion of malignancy on ultrasound or mammography were excluded. Under local anesthesia, ductoscopy was performed using LaDuScope-T flex with an outer diameter of 1.1 mm, which allows extraction of a single papilloma with a microbasket (380 μm) via a working channel. Patients with sessile single papilloma or failure on ductoscopic extraction underwent ductoscopically guided microductectomy. Success was determined by recurrence of PND and by standard radiological examinations.

RESULTS

Three patients presented in the video had negative cytology and normal conventional diagnostic imaging. Two patients diagnosed with a nonsessile single papilloma underwent successful ductoscopic extraction. The interventional examination times of those patients were 30 and 35 min. Patient who had a sessile papilloma underwent ductoscopically guided microductectomy. These patients had no recurrence of discharge or suspicious of malignancy after 5 years follow-up.

CONCLUSIONS

Interventional ductoscopy provides an incisionless therapeutic option for patients diagnosed with a papillary nonsessile benign lesion that causes PND.