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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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Rahmat K, Mumin NA, Hamid MTR, Hamid SA, Ng WL. MRI Breast: Current Imaging Trends, Clinical Applications, and Future Research Directions. Curr Med Imaging 2022; 18:1347-1361. [PMID: 35430976 DOI: 10.2174/1573405618666220415130131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 02/11/2022] [Accepted: 03/02/2022] [Indexed: 01/25/2023]
Abstract
Magnetic Resonance Imaging (MRI) is the most sensitive and advanced imaging technique in diagnosing breast cancer and is essential in improving cancer detection, lesion characterization, and determining therapy response. In addition to the dynamic contrast-enhanced (DCE) technique, functional techniques such as magnetic resonance spectroscopy (MRS), diffusion-weighted imaging (DWI), diffusion kurtosis imaging (DKI), and intravoxel incoherent motion (IVIM) further characterize and differentiate benign and malignant lesions thus, improving diagnostic accuracy. There is now an increasing clinical usage of MRI breast, including screening in high risk and supplementary screening tools in average-risk patients. MRI is becoming imperative in assisting breast surgeons in planning breast-conserving surgery for preoperative local staging and evaluation of neoadjuvant chemotherapy response. Other clinical applications for MRI breast include occult breast cancer detection, investigation of nipple discharge, and breast implant assessment. There is now an abundance of research publications on MRI Breast with several areas that still remain to be explored. This review gives a comprehensive overview of the clinical trends of MRI breast with emphasis on imaging features and interpretation using conventional and advanced techniques. In addition, future research areas in MRI breast include developing techniques to make MRI more accessible and costeffective for screening. The abbreviated MRI breast procedure and an area of focused research in the enhancement of radiologists' work with artificial intelligence have high impact for the future in MRI Breast.
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Affiliation(s)
- Kartini Rahmat
- Department of Biomedical Imaging, University Malaya Research Imaging Centre, Faculty of Medicine, Kuala Lumpur, Malaysia
| | - Nazimah Ab Mumin
- Department of Radiology, Faculty of Medicine, University Teknologi MARA, Sungai Buloh, Selangor, Malaysia
| | - Marlina Tanty Ramli Hamid
- Department of Radiology, Faculty of Medicine, University Teknologi MARA, Sungai Buloh, Selangor, Malaysia
| | - Shamsiah Abdul Hamid
- Department of Radiology, Faculty of Medicine, University Teknologi MARA, Sungai Buloh, Selangor, Malaysia
| | - Wei Lin Ng
- Department of Biomedical Imaging, University Malaya Research Imaging Centre, Faculty of Medicine, Kuala Lumpur, Malaysia
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Chakrabarthi S, Panwar S, Singh T, Lad S, Srikala J, Khandelwal N, Misra S, Thulkar S. Best Practice Guidelines for Breast Imaging: Breast Imaging Society, India: Part—2. ANNALS OF THE NATIONAL ACADEMY OF MEDICAL SCIENCES (INDIA) 2022. [DOI: 10.1055/s-0042-1744392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
AbstractBreast imaging is one of the prerequisites for providing high-quality breast health care. Choosing the appropriate investigation is central to diagnosing breast disease or the absence of it in women and men who present to health professionals for treatment. Patients with breast disease present to doctors of different subspecialties as well as general practitioners in our country. It is important, therefore, to provide uniform guidance to doctors in different health care setups of our country, urban and rural, and government and private, for breast diseases to be diagnosed and treated optimally. These guidelines framed by the task group set up by the Breast Imaging Society, India, have been formulated focusing primarily on the Indian patients and health care infrastructures. These guidelines aim to provide a framework for the referring doctors and practicing radiologists to enable them to choose the appropriate investigation for patients with breast symptoms and signs. The guidelines encompass all aspects of breast imaging including mammography, breast ultrasound, breast magnetic resonance imaging, as well as breast interventions. Algorithms for the investigation of specific common breast symptoms and signs have been provided in this document. The aim has been to keep this framework simple and practical so that it can guide not only subspecialists in breast care but also help doctors who do not routinely deal with breast diseases so that breast cancer is not missed. Breast screening is an integral part of breast imaging, and guidelines for the same have been incorporated in this document. In the absence of a population-based screening program in India, the guidelines to be followed for those women who wish to be screened by mammography have been provided. Overall, the aim of this document is to provide a holistic approach to standardize breast care imaging services in India.
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Affiliation(s)
- Suma Chakrabarthi
- Department of Radiology and Imaging, Peerless Hospitex Hospital and Research Center Limited, Kolkata, West Bengal, India
| | - Shikha Panwar
- Department of Radiology, Mahajan Imaging, Delhi, India
| | - Tulika Singh
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Shilpa Lad
- Department of Radiology, NM Medical, Mumbai, Maharashtra, India
| | - Jwala Srikala
- Department of Radiology and Imaging, Krishna Institute of Medical Sciences, Secunderabad, India
| | - Niranjan Khandelwal
- Former Head, Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sanjeev Misra
- Department of Surgical Oncology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Sanjay Thulkar
- Department of Radiology, Dr BRA IRCH, All India Institute of Medical Sciences, New Delhi, India
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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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Meta-analysis and cost-effectiveness of ductoscopy, duct excision surgery and MRI for the diagnosis and treatment of patients with pathological nipple discharge. Breast Cancer Res Treat 2021; 186:285-293. [PMID: 33475877 PMCID: PMC7990840 DOI: 10.1007/s10549-021-06094-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 01/04/2021] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Pathological nipple discharge (PND) is a common breast-related complaint for referral to a surgical breast clinic because of its association with breast cancer. The aim of this meta-analysis was to compare the diagnostic efficacy of magnetic resonance imaging (MRI) and ductoscopy in patients with PND. Additionally, we determined the most cost-efficient strategy for the treatment of PND and the detection of breast cancer in PND patient without radiological suspicion for malignancy. MATERIALS AND METHODS PubMed and EMBASE were searched to collect the relevant literature from the inception of both diagnostic methods until January 27th 2020. The search yielded 815 original citations, of which 10 studies with 894 patients were finally included for analysis. Costs of ductoscopy, MRI and duct excision surgery were obtained from the UMC Utrecht as established in the year 2019. These costs included: medical personnel, overhead costs, material costs and sterilisation costs. RESULTS The meta-analysis showed no significant difference in sensitivity between ductoscopy (44%) and MRI (76%) for the detection of malignancy in patients with PND. However, ductoscopy (98%) had a statistically significantly higher specificity than MRI (84%). Individual costs were €1401.33, €822.13 and €6494.27 for ductoscopy, MRI and duct excision surgery, respectively. Full diagnostic strategy involving ductoscopy was on average €1670.97, while with MRI it was €2070.27. CONCLUSION Patients undergoing MRI are more often (false) positive which more often leads to duct excision surgery referrals compared to ductoscopy. This makes ductoscopy significantly more cost-effective compared MRI in patients with PND without radiological suspicion for malignancy.
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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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Lyons D, Wahab RA, Vijapura C, Mahoney MC. The nipple-areolar complex: comprehensive imaging review. Clin Radiol 2020; 76:172-184. [PMID: 33077158 DOI: 10.1016/j.crad.2020.09.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 09/11/2020] [Indexed: 10/23/2022]
Abstract
The nipple-areolar complex can be affected by a variety of benign and malignant entities that can present with non-specific symptoms. Benign pathologies commonly affecting the nipple-areolar complex include nipple calcifications, nipple adenoma, abscess of Montgomery tubercles, ductal ectasia, periductal mastitis, and papilloma. Malignant pathologies that affect the nipple-areolar complex include Paget's disease of the breast, ductal carcinoma in-situ, and invasive ductal carcinoma. Clinical history and examination, imaging, and tissue sampling when appropriate are co-dependent factors that guide the assessment of nipple-areolar pathologies. This article provides a review of the normal anatomy, common anatomical variants, benign and malignant pathologies, and imaging techniques to guide the diagnostic assessment of the nipple-areolar complex.
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Affiliation(s)
- D Lyons
- Department of Radiology, University of Cincinnati Medical Center, 234 Goodman Street, ML 0772, Cincinnati, OH, 45219-0772, USA.
| | - R A Wahab
- Department of Radiology, University of Cincinnati Medical Center, 234 Goodman Street, ML 0772, Cincinnati, OH, 45219-0772, USA
| | - C Vijapura
- Department of Radiology, University of Cincinnati Medical Center, 234 Goodman Street, ML 0772, Cincinnati, OH, 45219-0772, USA
| | - M C Mahoney
- Department of Radiology, University of Cincinnati Medical Center, 234 Goodman Street, ML 0772, Cincinnati, OH, 45219-0772, USA
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Moschetta M, De Ruvo V, Drago A, Troiano N, Paolicelli S, Rubini G, Stabile Ianora AA, Telegrafo M. DBT-galactography: a promising tool for improving the diagnostic workup of nipple discharge. Eur Radiol Exp 2020; 4:40. [PMID: 32748294 PMCID: PMC7399007 DOI: 10.1186/s41747-020-00170-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Accepted: 06/17/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Our aim was to compare the diagnostic performance of digital breast tomosynthesis (DBT)-galactography with that of full-field digital (FFD)-galactography for detecting intraductal breast lesions using an intra-individual design. METHODS Forty-nine consecutive patients with spontaneous, unilateral, single-pore nipple discharge and inconclusive FFD mammography and ultrasonography underwent galactography with a "COMBO" technique combining FFD- and DBT-galactography acquisitions. Examinations were independently analysed by two breast radiologists with 10-year experience. Sensitivity, specificity, and accuracy for both FFD- and DBT-galactography were calculated having histological examinations of surgical specimens as a reference standard. Data were presented as percentages with their 95% confidence intervals (CI). McNemar test was used. Interobserver agreement was assessed by using Cohen κ test for both techniques. RESULTS Sensitivity was 41/43 (95%, 95% CI 84.2-99.4) for DBT-galactography and 33/43 (77%, 95% CI 61.4-88.2) for FFD-galactography (p = 0.008), specificity 6/6 (100%, 95% CI 54.1-100.0) for both imaging tools, accuracy 47/49 (96%, 95% CI 86.0-99.5) and 39/49 (80%, 95% CI 65.7-89.8) (p = 0.038), respectively. The inter-observer agreement was 0.86 for DBT-galactography and 0.78 for FFD-galactography. The AGD resulted to 1.94 ± 0.64 for the combined technique. CONCLUSION DBT-galactography showed a significantly higher sensitivity and accuracy than FFD-galactography for the identification of the intraductal findings, improving the possibility of a reliable diagnosis in patients with pathologic nipple-discharge.
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Affiliation(s)
- Marco Moschetta
- DETO-Department of Emergency and Organ Transplantation-Breast Care Unit, Aldo Moro University of Bari Medical School, Piazza Giulio Cesare 11, 70124, Bari, Italy.
| | - Vincenzo De Ruvo
- DETO-Department of Emergency and Organ Transplantation-Breast Care Unit, Aldo Moro University of Bari Medical School, Piazza Giulio Cesare 11, 70124, Bari, Italy
| | - Angelica Drago
- DIM-Interdisciplinary Department of Medicine-Section of Diagnostic Imaging, Aldo Moro University of Bari Medical School, Piazza Giulio Cesare 11, 70124, Bari, Italy
| | - Nicoletta Troiano
- DIM-Interdisciplinary Department of Medicine-Section of Diagnostic Imaging, Aldo Moro University of Bari Medical School, Piazza Giulio Cesare 11, 70124, Bari, Italy
| | - Simona Paolicelli
- DIM-Interdisciplinary Department of Medicine-Section of Diagnostic Imaging, Aldo Moro University of Bari Medical School, Piazza Giulio Cesare 11, 70124, Bari, Italy
| | - Giuseppe Rubini
- DIM-Interdisciplinary Department of Medicine-Section of Diagnostic Imaging, Aldo Moro University of Bari Medical School, Piazza Giulio Cesare 11, 70124, Bari, Italy
| | - Amato Antonio Stabile Ianora
- DIM-Interdisciplinary Department of Medicine-Section of Diagnostic Imaging, Aldo Moro University of Bari Medical School, Piazza Giulio Cesare 11, 70124, Bari, Italy
| | - Michele Telegrafo
- DETO-Department of Emergency and Organ Transplantation-Breast Care Unit, Aldo Moro University of Bari Medical School, Piazza Giulio Cesare 11, 70124, Bari, Italy
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Network Meta-analysis for the Diagnostic Approach to Pathologic Nipple Discharge. Clin Breast Cancer 2020; 20:e723-e748. [PMID: 32665191 DOI: 10.1016/j.clbc.2020.05.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 05/27/2020] [Accepted: 05/30/2020] [Indexed: 02/07/2023]
Abstract
Pathologic nipple discharge (PND) is one of the most common breast-related complaints for referral because of its supposed association with breast cancer. The aim of this network meta-analysis (NMA) was to compare the diagnostic efficacy of ultrasound, mammogram, cytology, magnetic resonance imaging (MRI), and ductoscopy in patients with PND, as well as to determine the best diagnostic strategy to assess the risk of malignancy as cause for PND. Cochrane Library, PubMed, and Embase were searched to collect relevant literature from the inception of each of the diagnostic methods until January 27, 2020. The search yielded 1472 original citations, of which 36 studies with 3764 patients were finally included for analysis. Direct and indirect comparisons were performed using an NMA approach to evaluate the combined odd ratios and to determine the surface under the cumulative ranking curves (SUCRA) of the diagnostic value of different imaging methods for the detection of breast cancer in patients with PND. Additionally, a subgroup meta-analysis comparing ductoscopy to MRI when conventional imaging was negative was also performed. According to this NMA, sensitivity for detection of malignancy in patients with PND was highest for MRI (83%), followed by ductoscopy (58%), ultrasound (50%), cytology (38%), and mammogram (22%). Specificity was highest for mammogram (93%) followed by ductoscopy (92%), cytology (90%), MRI (76%), and ultrasound (69%). Diagnostic accuracy was the highest for ductoscopy (88%), followed by cytology (82%), MRI (77%), mammogram (76%), and ultrasound (65%). Subgroup meta-analysis (comparing ductoscopy to MRI when ultrasound and mammogram were negative) showed no significant difference in sensitivity, but ductoscopy was statistically significantly better with regard to specificity and diagnostic accuracy. The results from this NMA indicate that although ultrasound and mammogram may remain low-cost useful first choices for the detection of malignancy in patients with PND, ductoscopy outperforms most imaging techniques (especially MRI) and cytology.
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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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Ambinder EB, Eisner D. Copious watery nipple discharge caused by a discontinuous ventriculoperitoneal shunt. Breast J 2019; 26:1013-1014. [DOI: 10.1111/tbj.13690] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 10/31/2019] [Indexed: 12/12/2022]
Affiliation(s)
- Emily B. Ambinder
- Russell H. Morgan Department of Radiology and Radiological Science Johns Hopkins Medical Institutions Baltimore Maryland
| | - David Eisner
- Russell H. Morgan Department of Radiology and Radiological Science Johns Hopkins Medical Institutions Baltimore Maryland
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Au FWF, Ghai S, Lu FI, Lu H. Clinical Value of Shear Wave Elastography Added to Targeted Ultrasound (Second-Look Ultrasound) in the Evaluation of Breast Lesions Suspicious of Malignancy Detected on Magnetic Resonance Imaging. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2019; 38:2395-2406. [PMID: 30666681 DOI: 10.1002/jum.14936] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 12/07/2018] [Accepted: 12/20/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVES To determine the value of shear wave elastography (SWE) added to targeted ultrasound (US) after breast magnetic resonance imaging (MRI). METHODS From July 2015 to October 2017, 40 patients who underwent targeted US evaluations of suspicious MRI-detected American College of Radiology Breast Imaging Reporting and Data System category 4 lesions (mass or nonmass enhancement) were enrolled in this prospective study. B-mode US and SWE examinations were performed to detect US correlates to MRI-detected lesions; their Breast Imaging Reporting and Data System categories were recorded; lesions that were dark blue on a 6-point color scale or had maximum elasticity of 30 kPa or less were categorized as soft. Biopsy was performed with US or MRI guidance, with the pathologic findings correlated with MRI, US, and SWE findings. The value of SWE for lesion detection and identification of benign lesions was determined. RESULTS The mean age of the 40 patients was 51.1 years. There were 48 MRI-detected lesions (20 cancers, 3 high-risk lesions, and 25 benign lesions). Ultrasound correlates (8 category 3 and 25 category 4) were shown for 33 lesions (69%; P < .0001), with 16 cancers (80%; P < .0001) and 17 benign lesions. Shear wave elastography assisted detection of 3 (19%) cancers on US imaging. All 7 soft US category 3 lesions were benign (7 of 33 [21%]; P = .0014). CONCLUSIONS Shear wave elastography was useful with targeted US after breast MRI to increase cancer detection by US. A significant number of US correlates to MRI-detected lesions could have been identified as benign (category 3 and soft) before biopsy, with the potential of short-interval follow-up of MRI-detected lesions with benign US correlates instead of biopsy.
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Affiliation(s)
- Frederick Wing-Fai Au
- Joint Department of Medical Imaging, Toronto General Hospital, Toronto, Ontario, Canada
| | - Sandeep Ghai
- Joint Department of Medical Imaging, Women's College Hospital, Toronto, Ontario, Canada
| | - Fang-I Lu
- Department of Pathology, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Hua Lu
- University of Toronto, Toronto, Ontario, Canada
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Zacharioudakis K, Kontoulis T, Vella JX, Zhao J, Ramakrishnan R, Cunningham DA, Mufti RA, Leff DR, Thiruchelvam P, Hogben K, Hadjiminas DJ. Can we see what is invisible? The role of MRI in the evaluation and management of patients with pathological nipple discharge. Breast Cancer Res Treat 2019; 178:115-120. [PMID: 31352554 PMCID: PMC6790184 DOI: 10.1007/s10549-019-05321-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 06/11/2019] [Indexed: 01/03/2023]
Abstract
Introduction The aim of this study was to determine the ability of MRI to identify and assess the extent of disease in patients with pathological nipple discharge (PND) with an occult malignancy not evident on standard pre-operative evaluation with mammography and ultrasound. Methods Patients presenting to the breast unit of Imperial College Healthcare NHS Trust between December 2009 and December 2018 with PND and normal imaging were enrolled in the study. Pre-operative bilateral breast MRI was performed in all patients as part of our protocol and all patients were offered diagnostic microdochectomy. Results A total of 82 patients fulfilled our selection criteria and were enrolled in our study. The presence of an intraductal papilloma (IDP) was identified as the cause of PND in 38 patients (46.3%), 14 patients had duct ectasia (DE-17%) and 5 patients had both an IDP and DE. Other benign causes were identified in 11 patients (13.4%). Despite normal mammography and ultrasound a malignancy was identified in 14 patients (17%). Eleven patients had DCIS (13.4%), two had invasive lobular carcinoma and one patient had an invasive ductal carcinoma. The sensitivity of MRI in detecting an occult malignancy was 85.71% and the specificity was 98.53%. The positive predictive value was 92.31% and the negative predictive value was 97.1%. Conclusions Although a negative MRI does not exclude the presence of an occult malignancy the high sensitivity and specificity of this diagnostic modality can guide the surgeon and alter the management of patients with PND.
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Affiliation(s)
- Konstantinos Zacharioudakis
- Breast Unit, Charring Cross Hospital, Imperial College Healthcare NHS Trust, Fulham Palace Rd, Hammersmith, London, W6 8RF, UK. .,Breast Unit, Nightingale Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Southmoor Road, Wythenshawe, Manchester, M23 9LT, UK.
| | - Theodoros Kontoulis
- Breast Unit, Charring Cross Hospital, Imperial College Healthcare NHS Trust, Fulham Palace Rd, Hammersmith, London, W6 8RF, UK
| | - John X Vella
- Breast Unit, Charring Cross Hospital, Imperial College Healthcare NHS Trust, Fulham Palace Rd, Hammersmith, London, W6 8RF, UK
| | - Jade Zhao
- Breast Unit, Charring Cross Hospital, Imperial College Healthcare NHS Trust, Fulham Palace Rd, Hammersmith, London, W6 8RF, UK
| | - Rathi Ramakrishnan
- Breast Unit, Charring Cross Hospital, Imperial College Healthcare NHS Trust, Fulham Palace Rd, Hammersmith, London, W6 8RF, UK
| | - Deborah A Cunningham
- Breast Unit, Charring Cross Hospital, Imperial College Healthcare NHS Trust, Fulham Palace Rd, Hammersmith, London, W6 8RF, UK
| | - Ragheed Al Mufti
- Breast Unit, Charring Cross Hospital, Imperial College Healthcare NHS Trust, Fulham Palace Rd, Hammersmith, London, W6 8RF, UK
| | - Daniel Richard Leff
- Breast Unit, Charring Cross Hospital, Imperial College Healthcare NHS Trust, Fulham Palace Rd, Hammersmith, London, W6 8RF, UK.,Department of Surgery and Cancer Imperial College London, Ayrton Rd, Kensington, London, SW7 5NH, UK
| | - Paul Thiruchelvam
- Breast Unit, Charring Cross Hospital, Imperial College Healthcare NHS Trust, Fulham Palace Rd, Hammersmith, London, W6 8RF, UK
| | - Katy Hogben
- Breast Unit, Charring Cross Hospital, Imperial College Healthcare NHS Trust, Fulham Palace Rd, Hammersmith, London, W6 8RF, UK
| | - Dimitri J Hadjiminas
- Breast Unit, Charring Cross Hospital, Imperial College Healthcare NHS Trust, Fulham Palace Rd, Hammersmith, London, W6 8RF, UK
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Baydoun S, Gonzalez P, Whitman GJ, Dryden M, Xi Y, Dogan B. Is Ductography Still Warranted in the 21st century? Breast J 2019; 25:654-662. [PMID: 31087408 DOI: 10.1111/tbj.13302] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Revised: 09/15/2018] [Accepted: 09/18/2018] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Serine Baydoun
- Department of Diagnostic Radiology, American University of Beirut, Beirut, Lebanon
| | - Pedro Gonzalez
- Breast Imaging Department, CT Radiology Complex, Bayamon, Puerto Rico
| | - Gary J Whitman
- Department of Diagnostic Radiology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mark Dryden
- Department of Diagnostic Radiology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Yin Xi
- Department of Biostatistics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Basak Dogan
- Department of Diagnostic Radiology, University of Texas Southwestern Medical Center, Dallas, Texas
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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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Yılmaz R, Bender Ö, Çelik Yabul F, Dursun M, Tunacı M, Acunas G. Diagnosis of Nipple Discharge: Value of Magnetic Resonance Imaging and Ultrasonography in Comparison with Ductoscopy. Balkan Med J 2018; 34:119-126. [PMID: 28418338 PMCID: PMC5394292 DOI: 10.4274/balkanmedj.2016.0184] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background: Pathologic nipple discharge, which is a common reason for referral to the breast imaging service, refers to spontaneous or bloody nipple discharge that arises from a single duct. The most common cause of nipple discharge is benign breast lesions, such as solitary intraductal papilloma and papillomatosis. Nevertheless, in rare cases, a malignant cause of nipple discharge can be found. Aims: To study the diagnostic value of ultrasonography, magnetic resonance imaging, and ductoscopy in patients with pathologic nipple discharge, compare their efficacy, and investigate the importance of magnetic resonance imaging in the diagnosis of intraductal pathologies. Study Design: Diagnostic accuracy study. Methods: Fifty patients with pathologic nipple discharge were evaluated by ultrasonography and magnetic resonance imaging. Of these, 44 ductoscopic investigations were made. The patients were classified according to magnetic resonance imaging, ultrasonography, and ductoscopy findings. A total of 25 patients, whose findings were reported as intraductal masses, underwent surgery oincluding endoscopic excision for two endoscopic excision. Findings were compared with the pathology results that were accepted as the gold standard in the description of the aetiology of nipple discharge. In addition, magnetic resonance imaging, ultrasonography and ductoscopy findings were analysed comparatively in patients who had no surgery. Results: Intraductal masses were reported in 26 patients, 20 of whom operated and established accurate diagnosis of 18 patients on magnetic resonance imaging. According to the ultrasonography, intraductal masses were identified in 22 patients, 17 of whom underwent surgery. Ultrasonography established accurate diagnoses in 15 patients. Intraductal mass was identified in 22 patients and ductoscopy established accurate diagnoses based on histopathologic results in 16 patients. The sensitivities of methods were 75% in ultrasonography, 90% in magnetic resonance imaging, and 94.6% in ductoscopy. The specificities were 66.7% in ultrasonography, 66.7% in magnetic resonance imaging, and 40% in ductoscopy. Intraductal papillomas were mostly observed as oval nodules with well-circumscribed smooth margins within dilated ducts and persistant in the dynamic analysis. Lesions that protruded into the lumen of the ducts, either solitary or multiple, were characteristic ductoscopy findings of our patients who were diagnosed as having papilloma/papillomatosis. Conclusion: Magnetic resonance imaging and ductoscopy had no statistical superiority over each other, however they were superior to ultrasonography in the diagnosis of pathologic nipple discharge. Magnetic resonance imaging may be highly sensitive for diagnosing nipple discharge with new techniques and sequences and a non-invasive method that more advantageous for showing ductal tree visualization and is able to detect completely obstructed intraductal lesions.
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Affiliation(s)
- Ravza Yılmaz
- Department of Radiology, İstanbul University İstanbul School of Medicine, İstanbul, Turkey
| | - Ömer Bender
- Clinic of General Surgery, Okmeydanı Training and Research Hospital, İstanbul, Turkey
| | - Fatma Çelik Yabul
- Department of Radiology, Bakırkoy Dr. Sadi Konuk Training and Research Hospital, İstanbul, Turkey
| | - Menduh Dursun
- Department of Radiology, İstanbul University İstanbul School of Medicine, İstanbul, Turkey
| | - Mehtap Tunacı
- Department of Radiology, İstanbul University İstanbul School of Medicine, İstanbul, Turkey
| | - Gülden Acunas
- Department of Radiology, İstanbul University İstanbul School of Medicine, İstanbul, Turkey
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17
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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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18
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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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JOURNAL CLUB: Diagnostic Utility of MRI After Negative or Inconclusive Mammography for the Evaluation of Pathologic Nipple Discharge. AJR Am J Roentgenol 2017; 209:1404-1410. [PMID: 28898125 DOI: 10.2214/ajr.17.18139] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this study is to determine the diagnostic utility of MRI after negative or inconclusive mammography for the evaluation of pathologic nipple discharge. MATERIALS AND METHODS We conducted a retrospective review of breast MRI examinations from January 1, 2006, through December 31, 2015, that were performed after negative or inconclusive mammography for the evaluation of nipple discharge. Clinical notes, imaging findings, and pathology outcomes were reviewed. RESULTS One hundred eighteen women (mean age, 49 years; range, 23-82 years) underwent MRI for evaluation of nipple discharge, 105 (89.0%) of whom had surgical excision or at least 2-year imaging follow-up. A total of six patients (6/105; 5.7%) were diagnosed with malignancy (ductal carcinoma in situ [DCIS] or invasive malignancy). Of 27 patients with positive MRI findings (final assessment of BI-RADS category 4), three (11.1%) were diagnosed with malignancy: DCIS grade 2-3, DCIS with focus of microinvasive ductal carcinoma, and invasive papillary carcinoma. An additional three patients (without suspicious findings at MRI) were diagnosed with malignancy at surgical excision, all of which were grade 1 DCIS. For patients with negative MRI findings (BI-RADS category 1, 2, or 3), the negative predictive value of MRI for malignancy was 96.2% (75/78). CONCLUSION In women with nipple discharge and negative or inconclusive mammography findings, the risk of malignancy is low, at 5.7%. With negative MRI findings (BI-RADS category 1, 2, or 3), the risk of malignancy is less than 4%. Surveillance rather than surgical excision may be a reasonable option for patients without suspicious findings at MRI.
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Abstract
Background Imaging the breast is a vital component not only for breast cancer screening, but also for diagnosis, evaluation, treatment, and follow-up of patients with breast cancer. Methods The author reviews recent advances and also provides her personal experience in describing the status of digital mammography, computer-aided detection, dedicated magnetic resonance imaging (MRI), and positron-emission mammography for evaluating the breast. Results Full-field digital mammography is superior to standard mammography in women under 50 years of age and in those with dense breasts. Computer-aided detection assists inexperienced mammographers and enhances detection of microcalcifications in dense breasts. Breast MRI is useful in preoperative evaluation, clarification of indeterminate mammograms, and follow-up of BRCA mutation carriers. The specificity of MRI remains problematic, however. Positron-emission mammography promises enhanced detection of ductal carcinoma in situ (DCIS), even when not associated with microcalcifications, and should aid surgical planning. Conclusions These four significant advances in breast imaging have all improved the sensitivity of detecting breast abnormalities. Cost issues, however, may limit the widespread application of these advances.
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Affiliation(s)
- Claudia G Berman
- Radiology Service, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA.
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21
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Lesetedi C, Rayne S, Kruger D, Benn CA. Indicators of breast cancer in patients undergoing microdochectomy for a pathological nipple discharge in a middle-income country. J Surg Res 2017; 220:336-340. [PMID: 29180200 DOI: 10.1016/j.jss.2017.06.046] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 05/26/2017] [Accepted: 06/16/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND The management of a pathological nipple discharge often involves surgery for the exclusion of a malignant etiology. This study aimed to determine the prevalence of cancer in patients who had microdochectomy for pathological nipple discharge in a population in South Africa and to evaluate patients' demographics and clinical characteristics as indicators of underlying cancer and make recommendations for their management in resource-limited settings. MATERIALS AND METHODS Clinical, radiological, and histological data from 153 patients who underwent a microdochectomy for a pathological nipple discharge at two South African breast clinics was collected. RESULTS Invasive or in situ cancer was found in 12 patients (7.84%), and in all patients, cancer was associated with a bloody nipple discharge. Bloody discharge had a sensitivity of 100% in indicating cancer, specificity of 55.32%, positive predictive value of 16%, and negative predictive value of 100%. Patients with breast cancer were also more likely to be aged 55 y or older (P = 0.04). Preoperative mammogram and ultrasound were poor in detecting cancer (0/12). CONCLUSIONS In our population, a bloody discharge in women aged 55 years or older should mandate a microdochectomy, with selective surgery for younger women and those with nonbloody discharges. Thorough clinical examination to determine the true color and nature of the discharge is vital in the initial assessment of these patients. Preoperative radiology is not helpful in determining the presence of cancer (in an isolated pathological nipple discharge), and microdochectomy still remains the gold standard in diagnosing cancer in these patients.
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Affiliation(s)
- Chiapo Lesetedi
- Department of Surgery, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sarah Rayne
- Department of Surgery, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Helen Joseph Breast Care Clinic, Helen Joseph Hospital, Johannesburg, South Africa.
| | - Deirdre Kruger
- Department of Surgery, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Carol-Ann Benn
- Department of Surgery, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Helen Joseph Breast Care Clinic, Helen Joseph Hospital, Johannesburg, South Africa; Netcare Breast Care Centre, Milpark Hospital, Johannesburg, South Africa
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Diagnostic Performance of MRI Versus Galactography in Women With Pathologic Nipple Discharge: A Systematic Review and Meta-Analysis. AJR Am J Roentgenol 2017; 209:465-471. [PMID: 28537847 DOI: 10.2214/ajr.16.16682] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
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.
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Ouldamer L, Kellal I, Legendre G, Ngô C, Chopier J, Body G. [Management of breast nipple discharge: Recommendations]. ACTA ACUST UNITED AC 2015; 44:927-37. [PMID: 26545854 DOI: 10.1016/j.jgyn.2015.09.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 09/18/2015] [Indexed: 10/22/2022]
Abstract
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).
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Affiliation(s)
- L Ouldamer
- Département de gynécologie, hôpital Bretonneau, CHRU de Tours, 2, boulevard Tonnellé, 37044 Tours, France; Faculté de médecine François-Rabelais, 37044 Tours, France; Unité Inserm 1069, 37044 Tours, France.
| | - I Kellal
- Département de gynécologie, hôpital Bretonneau, CHRU de Tours, 2, boulevard Tonnellé, 37044 Tours, France
| | - G Legendre
- CESP Inserm U1018, service de gynécologie obstétrique, CHU d'Angers, 49000 Angers, France
| | - C Ngô
- Service de chirurgie cancérologique, gynécologique et du sein, hôpital européen Georges-Pompidou, AP-HP, 15, rue Leblanc, 75015 Paris, France; Université Paris-Descartes, Paris, France
| | - J Chopier
- Service de radiologie, hôpital Tenon, AP-HP, 4, rue de la Chine, 75020 Paris, France
| | - G Body
- Département de gynécologie, hôpital Bretonneau, CHRU de Tours, 2, boulevard Tonnellé, 37044 Tours, France; Faculté de médecine François-Rabelais, 37044 Tours, France
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Abstract
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.
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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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van Gelder L, Bisschops RHC, Menke-Pluymers MBE, Westenend PJ, Plaisier PW. Magnetic resonance imaging in patients with unilateral bloody nipple discharge; useful when conventional diagnostics are negative? World J Surg 2015; 39:184-6. [PMID: 25123174 DOI: 10.1007/s00268-014-2701-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Unilateral bloody nipple discharge (UBND) is mostly caused by benign conditions such as papilloma or ductal ectasia. However, in 7-33 % of all nipple discharge, it is caused by breast cancer. Conventional diagnostic imaging like mammography (MMG) and ultrasonography (US) is performed to exclude malignancy. Preliminary investigations of breast magnetic resonance imaging (MRI) assume that it has additional value. With an increasing availability of MRI, it is of clinical importance to evaluate this. We evaluated the additional diagnostic value of MRI in patients with UBND in the absence of a palpable mass, with normal conventional imaging. METHODS All women with UBND in the period November 2007-July 2012 were included. In addition to the standard work-up (patient's history, physical examination, MMG, and US), MRI was performed. Data from these examinations and treatment were collected retrospectively. RESULTS A total of 111 women (mean age 52 years; range 23-80) were included. In nine (8 %) patients, malignancy was suspected on MRI while conventional imaging was normal. In eight (89 %) of these patients, histology was obtained, two by core biopsy and six by terminal duct excision. Benign conditions were found in six patients (86 %) and a (pre-) malignant lesion in two patients. In both cases, it concerned a ductal carcinoma in situ, which was treated with breast-conserving therapy. Moreover, in two cases of (pre)malignancy, the MRI was interpreted as negative. CONCLUSION In patients with UBND who show no signs of a malignancy on conventional diagnostic examinations, the added value of a breast MRI is limited, since a malignancy can be demonstrated in <2 %.
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Affiliation(s)
- L van Gelder
- Department of Surgery, Albert Schweitzer Hospital, Albert Schweitzerplaats 25, 3318 AT, Dordrecht, The Netherlands,
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Nicholson BT, Harvey JA, Patrie JT, Mugler JP. 3D-MR Ductography and Contrast-Enhanced MR Mammography in Patients with Suspicious Nipple Discharge; a Feasibility Study. Breast J 2015; 21:352-62. [DOI: 10.1111/tbj.12417] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Brandi T Nicholson
- Department of Radiology & Medical Imaging; University of Virginia; Charlottesville Virginia
| | - Jennifer A Harvey
- Department of Radiology & Medical Imaging; University of Virginia; Charlottesville Virginia
| | - James T Patrie
- Department of Public Health Sciences; University of Virginia; Charlottesville Virginia
| | - John P Mugler
- Department of Radiology & Medical Imaging; University of Virginia; Charlottesville Virginia
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Blum KS, Rubbert C, Antoch G, Mohrmann S, Obenauer S. Diagnostic accuracy of abnormal galactographic and sonographic findings in the diagnosis of intraductal pathology in patients with abnormal nipple discharge. Clin Imaging 2015; 39:587-91. [PMID: 25778387 DOI: 10.1016/j.clinimag.2015.03.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Revised: 02/26/2015] [Accepted: 03/01/2015] [Indexed: 11/25/2022]
Abstract
The purpose of the study was to compare the diagnostic accuracy of the combination of galactography and ultrasound in patients with pathologic nipple discharge. Fifty-six patients with pathologic nipple discharge were included in the study. Sensitivity, specificity, and positive (PPV) and negative predictive value (NPV) for each method and the combination of both were calculated. Both methods together had a sensitivity, specificity, PPV, and NPV of 91%, 17%, 61%, and 57%. The combined sensitivity of galactography and ultrasound for intraductal pathologies is higher than either modality alone, with a low specificity. No specific signs exist to predict benign or malignant lesions.
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Affiliation(s)
- Katrin S Blum
- University Dusseldorf, Medical Faculty, Department of Diagnostic and Interventional Radiology, Dusseldorf, Germany.
| | - Christian Rubbert
- University Dusseldorf, Medical Faculty, Department of Diagnostic and Interventional Radiology, Dusseldorf, Germany
| | - Gerald Antoch
- University Dusseldorf, Medical Faculty, Department of Diagnostic and Interventional Radiology, Dusseldorf, Germany
| | - Svjetlana Mohrmann
- University Dusseldorf, Medical Faculty, Department of Gynecology, Dusseldorf, Germany
| | - Silvia Obenauer
- University Dusseldorf, Medical Faculty, Department of Diagnostic and Interventional Radiology, Dusseldorf, Germany
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Wang W, Ding J, Yang W, Li Y, Zhou L, Zhang S, Zhu H, Mao J, Tang J, Gu Y, Peng W. MRI characteristics of intraductal papilloma. Acta Radiol 2015; 56:276-83. [PMID: 24696194 DOI: 10.1177/0284185114526590] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Intraductal papilloma (IDP) is the most common pathological finding in women with pathological nipple discharge. Magnetic resonance imaging (MRI) has shown potential for characterizing breast tumors; however, MRI findings of IDPs are inconclusive, and certain diagnostic standards are lacking. PURPOSE To characterize the MRI features of IDP from a relatively large cohort. MATERIAL AND METHODS We retrospectively reviewed from 358 women with IDPs that were confirmed by histopathology. The clinical and imaging findings in 70 patients who underwent preoperative MRI were analyzed. MRI analyses included morphology and dynamic contrast-enhanced MRI. RESULTS In 70 patients, 77 IDPs were detected on MRI, which revealed the following three patterns: small luminal mass papillomas; tumor-like papillomas; and MRI-occult papillomas. Fourteen IDPs involved small, oval, smooth, and contrast-enhanced masses at the posterior end of the enlarged duct corresponding to small luminal mass papillomas. Seven IDPs had large diameters along the direction of the breast duct, indicating the typical MRI findings for IDP. Of 47 tumor-like papillomas, 16 cases showed large diameters along the direction of the breast duct and close to the nipple (within 4 cm), seven cases resembled invasive breast cancer on MRI, and the remaining 24 were (24/47) undistinguishable from other benign breast diseases. Sixteen IDPs were MRI-occult papillomas that could not be distinguished from the surrounding benign disease by either contrast-enhanced MRI or fat-suppressed T2-weighted MRI. CONCLUSION Small luminal mass papillomas or tumor-like papillomas with the largest diameters along the direction of the breast duct and close to the nipple (within 4 cm) might be the typical MRI findings for IDPs.
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Affiliation(s)
- Wei Wang
- Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai, PR China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, PR China
| | - Jianhui Ding
- Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai, PR China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, PR China
| | - Wentao Yang
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, PR China
- Department of Pathology, Fudan University Shanghai Cancer Center, Shanghai, PR China
| | - Yuan Li
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, PR China
- Department of Pathology, Fudan University Shanghai Cancer Center, Shanghai, PR China
| | - Liangping Zhou
- Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai, PR China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, PR China
| | - Shengjian Zhang
- Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai, PR China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, PR China
| | - Hui Zhu
- Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai, PR China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, PR China
| | - Jian Mao
- Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai, PR China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, PR China
| | - Jie Tang
- Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai, PR China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, PR China
| | - Yajia Gu
- Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai, PR China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, PR China
| | - Weijun Peng
- Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai, PR China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, PR China
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Breast MRI in patients with unilateral bloody and serous-bloody nipple discharge: a comparison with galactography. BIOMED RESEARCH INTERNATIONAL 2015; 2015:806368. [PMID: 25685810 PMCID: PMC4317598 DOI: 10.1155/2015/806368] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Revised: 09/25/2014] [Accepted: 09/29/2014] [Indexed: 11/17/2022]
Abstract
Purpose. Assessing the role of breast MRI compared to galactography in patients with unilateral bloody or serous-bloody nipple discharge. Materials and Methods. Retrospective study including 53 unilateral discharge patients who performed galactography and MRI. We evaluated the capability of both techniques in identifying pathology and distinguishing between nonmalignant and malignant lesions. Lesions BIRADS 1/2 underwent follow-up, while the histological examination after surgery has been the gold standard to assess pathology in lesions BIRADS 3/4/5. The ROC analysis was used to test diagnostic MRI and galactography ability. Results. After surgery and follow-up, 8 patients had no disease (15%), 23 papilloma (43%), 11 papillomatosis (21%), 5 ductal cancer in situ (10%), and 6 papillary carcinoma (11%) diagnoses. Both techniques presented 100% specificity; MRI sensitivity was 98% versus 49% of galactography. Considering MRI, we found a statistical association between mass enhancement and papilloma (P < 0.001; AUC 0.957; CI 0.888–1.025), ductal enhancement and papillomatosis (P < 0.001; AUC 0.790; CI 0.623–0.958), segmental enhancement and ductal cancer in situ (P = 0.007; AUC 0.750; CI 0.429–1.071), and linear enhancement and papillary cancer (P = 0.011). Conclusions. MRI is a valid tool to detect ductal pathologies in patients with suspicious bloody or serous-bloody discharge showing higher sensitivity and specificity compared to galactography.
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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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Swayampakula AK, Dillis C, Abraham J. Role of MRI in screening, diagnosis and management of breast cancer. Expert Rev Anticancer Ther 2014; 8:811-7. [DOI: 10.1586/14737140.8.5.811] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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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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Breast imaging of the pregnant and lactating patient: physiologic changes and common benign entities. AJR Am J Roentgenol 2013; 200:329-36. [PMID: 23345354 DOI: 10.2214/ajr.12.9845] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this article is to review key clinical, histologic, and imaging features of expected physiologic changes within the breast and common benign breast disease in the pregnant and lactating patient. CONCLUSION A thorough understanding of expected physiologic changes and common benign breast abnormalities of pregnancy and lactation is required to differentiate these entities from pregnancy-associated breast cancer and to appropriately guide patient management.
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Intraductal Mass on Breast Ultrasound: Final Outcomes and Predictors of Malignancy. AJR Am J Roentgenol 2013; 200:932-7. [DOI: 10.2214/ajr.12.9093] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Sabel MS, Helvie MA, Breslin T, Curry A, Diehl KM, Cimmino VM, Chang AE, Newman LA. Is Duct Excision Still Necessary for All Cases of Suspicious Nipple Discharge? Breast J 2011; 18:157-62. [DOI: 10.1111/j.1524-4741.2011.01207.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Does direct MR galactography have the potential to become an alternative diagnostic tool in patients with pathological nipple discharge? Clin Imaging 2011; 35:85-93. [PMID: 21377045 DOI: 10.1016/j.clinimag.2010.03.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2009] [Accepted: 02/01/2010] [Indexed: 11/22/2022]
Abstract
PURPOSE To compare direct magnetic resonance galactography (dMRG) and conventional galactography (CGal). MATERIALS AND METHODS Thirty women underwent CGal and dMRG. Duct localization and the depth of the assumed underlying pathology in CGal and dMRG were analyzed. RESULTS Comparing CGal and dMRG, there was no significant difference regarding sector localization, but for depth of pathology (P=.023). CONCLUSION Duct localization with dMRG was possible with the same reliability as with CGal. Thus, dMRG may have the potential to become an alternative method to CGal.
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Management of breast magnetic resonance imaging-detected lesions. Can Assoc Radiol J 2011; 63:192-206. [PMID: 21798693 DOI: 10.1016/j.carj.2010.11.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2010] [Revised: 11/09/2010] [Accepted: 11/12/2010] [Indexed: 11/21/2022] Open
Abstract
Breast magnetic resonance imaging (MRI) has become an essential component of breast imaging. Whether it is used as a problem-solving tool or a screening test or for staging patients with breast cancer, it detects many lesions in the breast. The challenge for the radiologist is to distinguish significant from insignificant lesions and to direct their management. A brief summary of the terminology according to the American College of Radiologists lexicon will be provided. This review article will cover the differential diagnosis of enhancing lesions, including masses and nonmass enhancement, from benign and malignant causes. Some of the specific morphologic and kinetic features that help to differentiate benign from malignant lesions will be illustrated, and positive predictive values of these features will be reviewed. The various methods of investigating enhancing lesions of the breast will be discussed, including second-look ultrasound, ultrasound-guided biopsy, stereotactic biopsy, and MRI-guided biopsy. A practical approach to the management of MRI-detected lesions will include timing of follow-up, when to biopsy and when to ignore enhancing lesions in the breast.
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Berment H, Dolores M, Genevois A, Dacher JN. [MR-galactography: a new way to explore nipple discharges]. ACTA ACUST UNITED AC 2011; 39:315-20. [PMID: 21514201 DOI: 10.1016/j.gyobfe.2011.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2010] [Accepted: 02/09/2011] [Indexed: 11/18/2022]
Abstract
Nipple discharge is a common breast complaint that justifies an etiologic check-up in order to identify and characterize the underlying intraductal lesion. The low sensitivity and specificity of the existing imaging exams led to the search of new, more efficient ways to explore nipple discharge. MR-Galactography is one of these emerging techniques. Recent literature tends to prove that MR-Galactography could be an interesting technique for localizing and characterizing lesions causing nipple discharge.
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Affiliation(s)
- H Berment
- Radiodiagnostic, Hôpital René-Huguenin, Institut Curie, 35 rue Dailly, 92210 Saint-Cloud, France.
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Abstract
BACKGROUND This study was a retrospective analysis of patients who underwent minor or major duct surgery for pathological nipple discharge. The results of clinical examination, mammography, ultrasonography and cytodiagnosis of the nipple discharge were studied in order to predict those patients at risk of underlying or occult malignancy. METHODS Between January 2004 and December 2006, 55 female patients aged between 24 and 82 years old underwent major or minor duct excision, 49 of which were for pathological nipple discharge. Results of several preoperative investigations were compared with the surgical pathology to determine how their sensitivity and specificity faired in predicting malignant ductal pathology. RESULTS Of the 49 patients undergoing surgery for nipple discharge, 21 were diagnosed with intraductal papilloma, 19 with duct ectasia, 6 with carcinoma, 2 with benign breast disease and 1 with lobular carcinoma in situ. In all of the patients determined to have malignancy, none demonstrated malignant changes on mammography or ultrasonography. Only 2 of the 6 patients with malignancy were found to have atypical cells on cytological analysis. The sensitivity of blood detected in nipple discharge at predicting malignancy was 0.83, specificity of 0.53, positive predictive value of 0.20 and negative predictive value 0.96. CONCLUSIONS Despite the various tests used in the assessment of pathological nipple discharge, this study highlights their limited help at predicting the cause. This, together with several other studies, demonstrates that ductal surgery remains the only reliable way of providing a diagnosis, in addition to being the major therapeutic measure.
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Affiliation(s)
- Chris Alcock
- Department of Breast Surgery, The Royal Surrey County Hospital, Guildford, GU2 7XX, UK Postgraduate Medical School, University of Surrey, UK.
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Lorenzon M, Zuiani C, Linda A, Londero V, Girometti R, Bazzocchi M. Magnetic resonance imaging in patients with nipple discharge: should we recommend it? Eur Radiol 2010; 21:899-907. [DOI: 10.1007/s00330-010-2009-y] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2010] [Revised: 10/05/2010] [Accepted: 10/14/2010] [Indexed: 11/30/2022]
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Weinstein S, Rosen M. Breast MR imaging: current indications and advanced imaging techniques. Radiol Clin North Am 2010; 48:1013-42. [PMID: 20868898 DOI: 10.1016/j.rcl.2010.06.011] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Breast cancer is the most common solid tumor diagnosed in women. In the past decades, great strides have been made in breast cancer screening. While multiple screening trials have shown the benefits of screening mammography, there are limitations to x-ray mammography. Given these inherent limitations, efforts have been made to develop adjunctive imaging techniques, including screening ultrasonography, gamma-specific breast imaging, breast tomosynthesis, dedicated breast computed tomography, and breast magnetic resonance (MR) imaging. This article addresses the current indications and advanced imaging applications of breast MR imaging.
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Affiliation(s)
- Susan Weinstein
- Division of Breast Imaging, Department of Radiology, University of Pennsylvania School of Medicine, 1 Silverstein Building, 3400 Spruce Street, Philadelphia, PA 19104, USA
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Leung JWT. MR imaging in the evaluation of equivocal clinical and imaging findings of the breast. Magn Reson Imaging Clin N Am 2010; 18:295-308, ix-x. [PMID: 20494313 DOI: 10.1016/j.mric.2010.02.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Because of its high negative predictive value in excluding breast cancer, magnetic resonance (MR) imaging plays a role in the evaluation of selected clinical and imaging findings of the breast, especially when biopsy is not technically feasible. Case selection is very important in ensuring the efficacy of this use of MR imaging because of potential false-positive and (albeit less likely) false-negative results. This article examines the clinical scenarios and imaging findings in which MR imaging is contributory to patient management after conventional workup with equivocal results.
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Affiliation(s)
- Jessica W T Leung
- Breast Health Center, California Pacific Medical Center, 3698 California Street, 2nd Floor, San Francisco, CA 94118, USA.
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Baltzer P, Kaiser C, Dietzel M, Vag T, Herzog A, Gajda M, Camara O, Kaiser W. Value of ductal obstruction sign in the differentiation of benign and malignant breast lesions at MR imaging. Eur J Radiol 2010; 75:e18-21. [DOI: 10.1016/j.ejrad.2009.10.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2009] [Accepted: 10/29/2009] [Indexed: 11/17/2022]
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Linda A, Zuiani C, Girometti R, Londero V, Machin P, Brondani G, Bazzocchi M. Unusual malignant tumors of the breast: MRI features and pathologic correlation. Eur J Radiol 2010; 75:178-84. [DOI: 10.1016/j.ejrad.2009.04.038] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2009] [Accepted: 04/15/2009] [Indexed: 11/28/2022]
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Morrogh M, Park A, Elkin EB, King TA. Lessons learned from 416 cases of nipple discharge of the breast. Am J Surg 2010; 200:73-80. [DOI: 10.1016/j.amjsurg.2009.06.021] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2009] [Revised: 06/10/2009] [Accepted: 06/10/2009] [Indexed: 10/19/2022]
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Evaluation of Nipple-Areola Complex With Ultrasonography and Magnetic Resonance Imaging. J Comput Assist Tomogr 2010; 34:575-86. [DOI: 10.1097/rct.0b013e3181d74a88] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Dolan RT, Butler JS, Kell MR, Gorey TF, Stokes MA. Nipple discharge and the efficacy of duct cytology in evaluating breast cancer risk. Surgeon 2010; 8:252-8. [PMID: 20709281 DOI: 10.1016/j.surge.2010.03.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2010] [Revised: 02/28/2010] [Accepted: 03/29/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND Nipple discharge accounts for up to 5% of referrals to breast surgical services. With the vast majority of breast carcinomas originating in the ductal system, symptomatic dysfunction of this system often raises disproportionate clinical concern. The aim of this study is firstly, to evaluate the clinical importance of nipple discharge as an indicator of underlying malignancy and secondly, to assess the diagnostic application of duct cytology in patients presenting with nipple discharge. STUDY DESIGN We performed a retrospective analysis of all patients presenting with nipple discharge as their primary symptom to the symptomatic breast unit at a tertiary referral center over a 30-month period (n = 313). The Hospital Inpatient Enquiry (HIPE) System and BreastHealth database were used to identify our study cohort. Parameters evaluated included patient demographics, clinical presentation, clinical evaluation, radiological assessment and histological/cytological analysis. RESULTS Three-hundred and thirteen patients presented with nipple discharge as their primary complaint. Invasive breast carcinoma was diagnosed by Triple Assessment in 5% of patients. 24% of patients presenting with nipple discharge underwent nipple aspiration and cytological analysis. Duct cytology was diagnostic of the underlying breast carcinoma in 50% of triple assessment diagnosed carcinoma. Four risk factors were identified as having a significant association with breast carcinoma, these included (a) age >50 years (p < 0.0001), (b) bloody nipple discharge (p < 0.008), (c) presence of a breast lump (p < 0.0001) and (d) single duct discharge (p < 0.006). CONCLUSIONS Nipple discharge is a poor indicator of an underlying malignancy. Use of nipple aspiration and duct cytology for the assessment of nipple discharge is of limited diagnostic benefit. However, by utilizing the systematic, gold standard approach of Triple Assessment (clinical, radiological and cytological evaluation), the risk of underlying carcinoma can be accurately defined.
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Affiliation(s)
- Roisin T Dolan
- Department of Breast & Endocrine Surgery, Mater Misericordiae University Hospital, Dublin, Ireland.
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Camps Herrero J. [Controversies in breast MRI]. RADIOLOGIA 2010; 52 Suppl 1:26-9. [PMID: 20189615 DOI: 10.1016/j.rx.2010.01.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2009] [Accepted: 11/02/2009] [Indexed: 10/19/2022]
Affiliation(s)
- J Camps Herrero
- Servicio de Radiología, Hospital de la Ribera, Alzira, Valencia, España.
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Balakrishnan A, Kacher DF, Gombos E, Smith DN, Carretero M, Leon B, Freyre CV, Chavoustie SE. Negative pressure fixation device to reduce motion artifacts on contrast-enhanced MRI of the breast: a clinical feasibility study. J Magn Reson Imaging 2009; 30:430-6. [PMID: 19629972 DOI: 10.1002/jmri.21796] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
PURPOSE To investigate the effect of a negative pressure fixation device on misregistration artifacts in contrast-enhanced (CE) MR subtraction images. MATERIALS AND METHODS Nine patients, two of which had been previously diagnosed with breast cancer, were examined with T2-weighted (T2-w) turbo spin-echo (TSE) and three-dimensional (3D) spoiled gradient-recalled echo (SPGR) CE dynamic MRI. Baselines images were subtracted from the dynamic images. A device consisting of two stiff plastic domes was placed on the breasts of each patient. Negative pressure of 27 to 37 mmHg within the domes was maintained. The patient was positioned prone in the coil without the device and imaged as a baseline. Subsequently, the patient was placed into the negative pressure domes and reimaged. One of the nine patients was also imaged supine to establish feasibility for this positioning. RESULTS With the use of the negative pressure fixation device, a reduction in misregistration artifact has been demonstrated in prone imaging. Patients reported improved comfort with the device and feasibility has been shown for supine imaging. CONCLUSION The device was shown to be MRI-compatible and successfully applied in this pilot study, opening other avenues of exploration. Supine positioning for breast imaging makes possible better access for biopsy and intervention. Further modifications to the device are in order for this purpose and to eliminate motion due to breathing in the prone position.
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Affiliation(s)
- Asha Balakrishnan
- Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
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