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

Evaluating acute nipple inversion, imaging findings and outcomes

PURPOSE

Acute nipple inversion can be unsettling for patients and is sometimes associated with an underlying breast malignancy. It also poses a diagnostic challenge with lack of consensus management guidelines. This study reviewed institutional experience with new nipple inversion, including malignant association, imaging utilization, and outcomes, in an effort to improve management.

METHODS

A multisite institutional retrospective review was conducted of all breast imaging reports from 1/2010 to 6/2022 mentioning nipple inversion as an indication or finding. Patients with new nipple inversion, defined as arising since the time of last breast imaging exam or if reported as new by the patient/provider, were included for analysis. Retroareolar imaging findings, BI-RADS assessments/recommendations, pathology obtained from percutaneous or excisional biopsies, and follow-up imaging and clinical exams were collated. Cases of chronic or stable nipple inversion were excluded. Descriptive statistics were performed.

RESULTS

A total of 414 patients had new nipple inversion, 387/414 (93.5 %) with benign or negative results at initial imaging and 27/414 (6.5 %) with malignant lesions. Diagnostic mammography/ultrasound detected 25/27 (92.6 %) cancers (sensitivity 92.6 %, specificity 75.5 %, PPV 20.8 %, NPV 99.3 %). Of 62 breast MRI exams performed in patients with negative mammogram/ultrasound, no cancers were detected in the retroareolar space with 2 incidental malignant lesions discovered distant from the nipple.

CONCLUSION

Diagnostic mammography/ultrasound is reliable in workups of acute nipple inversion, with a high sensitivity and NPV for excluding malignancy. Breast MRI and surgical referral should be reserved for patients with suspicious associated symptoms or clinical findings.

ESR Essentials: diagnostic work-up in patients with symptomatic breast disease-practice recommendations by the European Society of Breast Imaging

Breast complaints are frequent reasons for consultations in primary care or breast clinics. Breast pain, breast lumps, and nipple discharge are the most common complaints. Less common symptoms such as skin changes and axillary abnormalities also require specific diagnostic approaches. Imaging the symptomatic breast should be performed by appropriately trained breast radiologists following the best practice guidelines and quality standards. Full-field digital mammography (FFDM), digital breast tomosynthesis (DBT), and breast ultrasound (US) are the main modalities used in this primary setting. The choice depends on the patient's age and symptoms. Women younger than 30-years-old are first imaged by US, whereas women over 40-years-old usually require both FFDM or DBT and US. For women between 30-years-old and 40-years-old, the US is the modality of choice, whereas FFDM or DBT might also be performed if needed. Pregnant or lactating women with palpable lesions or nipple discharge are imaged with US as the first method; FFDM or DBT can also be performed depending on the degree of suspicion as the dose to the fetus is minimal, and shielding may even further reduce the dose. More advanced techniques such as breast magnetic resonance imaging or contrast-enhanced mammography are not indicated in this first diagnostic setting and are reserved for cases of established malignancy (local staging) or rare cases of equivocal findings not otherwise resolved or inflammatory breast cancer. Last, but not least, male breast symptoms should also be addressed with US and/or FFDM. CLINICAL RELEVANCE STATEMENT: It is equally important to correctly diagnose an underlying malignancy and to avoid false positives that would lead to unnecessary biopsies, increased costs, and anxiety for the patient. Proper use of imaging modalities ensures optimal diagnostic approach and minimizes false negatives. KEY POINTS: Ultrasound, full-field digital mammography, or digital breast tomosynthesis are the main imaging modalities in the diagnostic setting, while MRI or contrast-enhanced mammography should be reserved to selected cases. Initial imaging modality includes ultrasound combined with mammography or digital breast tomosynthesis depending on women's age and the presence (or not) of inconclusive findings. A negative imaging evaluation should not deter biopsy when a highly suspicious finding is found on physical examination.

Multimodality Imaging of Benign and Malignant Diseases of the Nipple-Areolar Complex

The nipple-areolar complex (NAC), a unique anatomic structure of the breast, encompasses the terminal intramammary ducts and skin appendages. Several benign and malignant diseases can arise within the NAC. As several conditions have overlapping symptoms and imaging findings, understanding the distinctive nipple anatomy, as well as the clinical and imaging features of each NAC disease process, is essential. A multimodality imaging approach is optimal in the presence or absence of clinical symptoms. The authors review the ductal anatomy and anomalies, including congenital abnormalities and nipple retraction. They then discuss the causes of nipple discharge and highlight best practices for the imaging workup of pathologic nipple discharge, a common condition that can pose a diagnostic challenge and may be the presenting symptom of breast cancer. The imaging modalities used to evaluate and differentiate benign conditions (eg, dermatologic conditions, epidermal inclusion cyst, mammary ductal ectasia, periductal mastitis, and nonpuerperal abscess), benign tumors (eg, papilloma, nipple adenoma, and syringomatous tumor of the nipple), and malignant conditions (eg, breast cancer and Paget disease of the breast) are reviewed. Breast MRI is the current preferred imaging modality used to evaluate for NAC involvement by breast cancer and select suitable candidates for nipple-sparing mastectomy. Different biopsy techniques (US -guided biopsy and stereotactic biopsy) for sampling NAC masses and calcifications are described. This multimodality imaging approach ensures an accurate diagnosis, enabling optimal clinical management and patient outcomes. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.

Contrast-enhanced breast imaging: Current status and future challenges

BACKGROUND

Contrast-enhanced breast MRI and recently also contrast-enhanced mammography (CEM) are available for breast imaging. The aim of the current overview is to explore existing evidence and ongoing challenges of contrast-enhanced breast imaging.

METHODS

This narrative provides an introduction to the contrast-enhanced breast imaging modalities breast MRI and CEM. Underlying principle, techniques and BI-RADS reporting of both techniques are described and compared, and the following indications and ongoing challenges are discussed: problem-solving, high-risk screening, supplemental screening in women with extremely dense breast tissue, breast implants, neoadjuvant systemic therapy (NST) response monitoring, MRI-guided and CEM- guided biopsy.

RESULTS

Technique and reporting for breast MRI are standardised, for the newer CEM standardisation is in progress. Similarly, compared to other modalities, breast MRI is well established as superior for problem-solving, screening women at high risk, screening women with extremely dense breast tissue or with implants; and for monitoring response to NST. Furthermore, MRI-guided biopsy is a reliable technique with low long-term false negative rates. For CEM, data is as yet either absent or limited, but existing results in these settings are promising.

CONCLUSION

Contrast-enhanced breast imaging achieves highest diagnostic performance and should be considered essential. Of the two contrast-enhanced modalities, evidence of breast MRI superiority is ample, and preliminary results on CEM are promising, yet CEM warrants further study.

European guidelines for the diagnosis, treatment and follow-up of breast lesions with uncertain malignant potential (B3 lesions) developed jointly by EUSOMA, EUSOBI, ESP (BWG) and ESSO

INTRODUCTION

Breast lesions of uncertain malignant potential (B3) include atypical ductal and lobular hyperplasias, lobular carcinoma in situ, flat epithelial atypia, papillary lesions, radial scars and fibroepithelial lesions as well as other rare miscellaneous lesions. They are challenging to categorise histologically, requiring specialist training and multidisciplinary input. They may coexist with in situ or invasive breast cancer (BC) and increase the risk of subsequent BC development. Management should focus on adequate classification and management whilst avoiding overtreatment. The aim of these guidelines is to provide updated information regarding the diagnosis and management of B3 lesions, according to updated literature review evidence.

METHODS

These guidelines provide practical recommendations which can be applied in clinical practice which include recommendation grade and level of evidence. All sections were written according to an updated literature review and discussed at a consensus meeting. Critical appraisal by the expert writing committee adhered to the 23 items in the international Appraisal of Guidelines, Research and Evaluation (AGREE) tool.

RESULTS

Recommendations for further management after core-needle biopsy (CNB) or vacuum-assisted biopsy (VAB) diagnosis of a B3 lesion reported in this guideline, vary depending on the presence of atypia, size of lesion, sampling size, and patient preferences. After CNB or VAB, the option of vacuum-assisted excision or surgical excision should be evaluated by a multidisciplinary team and shared decision-making with the patient is crucial for personalizing further treatment. De-escalation of surgical intervention for B3 breast lesions is ongoing, and the inclusion of vacuum-assisted excision (VAE) will decrease the need for surgical intervention in further approaches. Communication with patients may be different according to histological diagnosis, presence or absence of atypia, or risk of upgrade due to discordant imaging. Written information resources to help patients understand these issues alongside with verbal communication is recommended. Lifestyle interventions have a significant impact on BC incidence so lifestyle interventions need to be suggested to women at increased BC risk as a result of a diagnosis of a B3 lesion.

CONCLUSIONS

These guidelines provide a state-of-the-art overview of the diagnosis, management and prognosis of B3 lesions in modern multidisciplinary breast practice.

Problem-solving Breast MRI

Breast MRI has high sensitivity and negative predictive value, making it well suited to problem solving when other imaging modalities or physical examinations yield results that are inconclusive for the presence of breast cancer. Indications for problem-solving MRI include equivocal or uncertain imaging findings at mammography and/or US; suspicious nipple discharge or skin changes suspected to represent an abnormality when conventional imaging results are negative for cancer; lesions categorized as Breast Imaging Reporting and Data System 4, which are not amenable to biopsy; and discordant radiologic-pathologic findings after biopsy. MRI should not precede or replace careful diagnostic workup with mammography and US and should not be used when a biopsy can be safely performed. The role of MRI in characterizing calcifications is controversial, and management of calcifications should depend on their mammographic appearance because ductal carcinoma in situ may not appear enhancing on MR images. In addition, ductal carcinoma in situ detected solely with MRI is not associated with a higher likelihood of an upgrade to invasive cancer compared with ductal carcinoma in situ detected with other modalities. MRI for triage of high-risk lesions is a subject of ongoing investigation, with a possible future role for MRI in decreasing excisional biopsies. The accuracy of MRI is likely to increase with the use of advanced techniques such as deep learning, which will likely expand the indications for problem-solving MRI. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Breast MRI - The champion in the millimeter league: MIO breast MRI - The method of choice in women with dense breasts

We perform MRI of the breast as a first pass technique. We successfully established 10-minute-protocols (including T2 images) with a fixed dosage of 5 ml 1 M CM. A high spatial resolution of 526 × 526, better 672 × 672 or maximum (1.024 × 1.024, MIO MRI) is vital to achieve best results. We use fixation tools to avoid motion artifacts. Motion correction algorithms can, however, often eliminate such artifacts when they are present. In initial breast MRI exams, morphologic features are the most important criteria for lesion evaluation. If previous exams are available for comparison, the main criteria indicating a suspicious lesion are an increase in lesion size or the depiction of new lesions. High quality HR MRI of the breast is the method of choice in women with dense or extremely dense breasts in all cases (screening, assessment, follow up). In density type A or B, MRI can be helpful in defined constellations, e.g. when MX and US are limited or contraindicated. According to our experience, 95% or more of all carcinomas of the breast are detectable on MRI. The remaining 5% of MRI-occult lesions are intraductal tumors or very small invasive carcinomas depicted with mammography due to associated microcalcifications. MRI is, however, superior to all other imaging modalities in the detection of the clinically relevant DCIS (high risk DCIS, intermediate type). Consecutive MRI examinations in intervals of 12 to 24 months allow a reliable detection of invasive breast cancer with an average size of 7-8 mm. This corresponds to a rate of metastasis-free locoregional lymph nodes in >95% of cases. The rate of interval cancers is <2%. In conclusion, this strategy may increase the overall-lifetime survival of breast cancer patients to more than 95%. Inversely, mortality may be reduced to <5%. Taking these improvements in early breast cancer detection and survival that can be achieved through the implementation of QA HR MRI of the breast into account, it should be discussed to modify oncologic guidelines for the treatment of breast cancer. MRI is the best diagnostic tool we have and according to our experience, a first pass, quality-assured high-resolution breast MRI protocol provides best diagnostic results at minimal procedural effort.

What is the role of breast MRI in the management of women with pathologic nipple discharge and normal conventional imaging?

BACKGROUND/AIMS

To investigate the diagnostic performance of breast MRI in revealing mammographically and sonographically occult lesions requiring excision in patients with pathologic nipple discharge.

MATERIALS AND METHODS

In this retrospective study, 57 women with pathologic nipple discharge who had normal or inconclusive mammography and ultrasonography results and underwent breast MRI were determined. Patients who had histopathological diagnosis or ≥ 1-year imaging follow-up were included. MRIs were classified as positive and negative according to final BI-RADS assessment categories. Diagnostic performance of MRI, including sensitivity, specificity, negative predictive value, and positive predictive value, was calculated for detecting both malignancy and lesions requiring surgery.

RESULTS

Abnormal contrast enhancement on the pathologic nipple discharge side was detected in 29 MRIs (50.8%), categorized as BI-RADS 4. Abnormal findings were solid masses in 17 cases (58.6%) and non-mass enhancement in 12 cases (41.3%). Despite normal conventional imaging results, 4 malignant lesions and 16 lesions requiring surgery were detected with MRI. The sensitivity and specificity of MRI for detecting lesions requiring surgery were 100% and 68.2%, respectively. The positive predictive value (PPV) and negative predictive value were 55.1% and 100%, respectively.

CONCLUSION

In conclusion, this study confirmed that MRI is a reliable tool to detect lesions requiring surgery in patients with pathologic nipple discharge. MRI should be used in routine workup in patients with normal conventional imaging and imaging follow-up can be safely applied in patients with negative MRI.

Differential Diagnosis of Benign and Malignant Breast Papillary Neoplasms on MRI With Non-mass Enhancement

RATIONALE AND OBJECTIVES

To explore the differential diagnosis of benign and malignant papillary neoplasms on MRI with non-mass enhancement.

MATERIALS AND METHODS

A total of 48 patients with surgically confirmed papillary neoplasms showing non-mass enhancement were included. Clinical findings, mammography and MRI features were retrospectively analyzed, and lesions were described according to the breast imaging report and data system (BI-RADS). Multivariate analysis of variance was used to compare the clinical and imaging features of benign and malignant lesions.

RESULTS

Fifty-three papillary neoplasms were shown on MR images with non-mass enhancement, including 33 intraductal papilloma and 20 papillary carcinomas (9 intraductal papillary carcinoma, 6 solid papillary carcinomas, and 5 invasive papillary carcinoma). Mammography showed amorphous calcification in 20% (6/30), of which 4 were in papilloma and 2 were in papillary carcinoma. On MRI, papilloma mostly showed linear distribution in 54.55% (18/33), clumped enhancement in 36.36% (12/33). Papillary carcinoma showed segmental distribution in 50% (10/20), clustered ring enhancement in 75% (15/20). ANOVA showed age (p = 0.025), clinical symptoms (p < 0.001), apparent diffusion coefficient (ADC) value (p = 0.026), distribution pattern (p = 0.029) and internal enhancement pattern (p < 0.001) were statistically significant between benign and malignant of papillary neoplasms. Multivariate analysis of variance suggested that the internal enhancement pattern was the only statistically significant factor (p = 0.010).

CONCLUSIONS

Papillary carcinoma on MRI with non-mass enhancement mostly showed internal clustered ring enhancement, while papilloma mostly showed internal clumped enhancement; additional mammography is of limited diagnostic value, and suspected calcification occurs mostly in papilloma.

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

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

Diagnostic Accuracy of Magnetic Resonance Imaging Features and Tumor-to-Nipple Distance for the Nipple-Areolar Complex Involvement of Breast Cancer: A Systematic Review and Meta-Analysis

OBJECTIVE

This systematic review and meta-analysis evaluated the accuracy of preoperative breast magnetic resonance imaging (MRI) features and tumor-to-nipple distance (TND) for diagnosing occult nipple-areolar complex (NAC) involvement in breast cancer.

MATERIALS AND METHODS

The MEDLINE, Embase, and Cochrane databases were searched for articles published until March 20, 2022, excluding studies of patients with clinically evident NAC involvement or those treated with neoadjuvant chemotherapy. Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Two reviewers independently evaluated studies that reported the diagnostic performance of MRI imaging features such as continuity to the NAC, unilateral NAC enhancement, non-mass enhancement (NME) type, mass size (> 20 mm), and TND. Summary estimates of the sensitivity and specificity curves and the summary receiver operating characteristic (SROC) curve of the MRI features for NAC involvement were calculated using random-effects models. We also calculated the TND cutoffs required to achieve predetermined specificity values.

RESULTS

Fifteen studies (n = 4002 breast lesions) were analyzed. The pooled sensitivity and specificity (with 95% confidence intervals) for NAC involvement diagnosis were 71% (58-81) and 94% (91-96), respectively, for continuity to the NAC; 58% (45-70) and 97% (95-99), respectively, for unilateral NAC enhancement; 55% (46-64) and 83% (75-88), respectively, for NME type; and 88% (68-96) and 58% (40-75), respectively, for mass size (> 20 mm). TND had an area under the SROC curve of 0.799 for NAC involvement. A TND of 11.5 mm achieved a predetermined specificity of 85% with a sensitivity of 64%, and a TND of 12.3 mm yielded a predetermined specificity of 83% with a sensitivity of 65%.

CONCLUSION

Continuity to the NAC and unilateral NAC enhancement may help predict occult NAC involvement in breast cancer. To achieve the desired diagnostic performance with TND, a suitable cutoff value should be considered.

The Role of Ductal Lavage Cytology in the Diagnosis of Breast Cancer

BACKGROUND

Nipple discharge is a common finding which may be a symptom of breast cancer, but it is mostly caused by benign causes. A surgical biopsy followed by a histopathological examination is considered to be the gold standard for the diagnosis of pathological nipple discharge. Non-surgical diagnostic methods should be considered to reduce the need for intervention. Ductal lavage cytology (DLC) is performed by washing and examining the ductal discharge. The usefulness of examining spontaneous discharge is controversial. This study's aim is to evaluate the usefulness in surgical decision-making of ultrasonography (USG), mammography (MMG), magnetic resonance imaging (MRI), ductography, and DLC in patients with pathological nipple discharge.

METHODS

Between 2011 and 2018, we retrospectively analyzed 141 patients with pathological nipple discharge who were planned to undergo a surgical procedure and were found to have pathology. In our study, the diagnostic efficiency of DLC for breast cancer diagnosis was compared with USG, MMG, MRI, and ductography.

RESULTS

USG was performed in all patients, MMG in 51, MRI in 56, ductography in 46 patients, and cytological samples were taken from 63 patients. Twelve of 17 patients with malignant pathology were reported cytologically as suspected malignancy. The sensitivity of DLC was 70.5% (95% CI: 0.489-0.922), and its specificity was 94.1% (95% CI: 0.862-1.020).

CONCLUSION

Numerous studies report that cytology is not adequate for final diagnosis. Negative cytology does not exclude the possibility of malignancy, and positive results do not help in the differential diagnosis.

MRI Breast: Current Imaging Trends, Clinical Applications, and Future Research Directions

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.

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

Objective

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

Materials and Methods

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

Results

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

Conclusion

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

Use of Diagnostic Imaging Modalities in Modern Screening, Diagnostics and Management of Breast Tumours 1st Central-Eastern European Professional Consensus Statement on Breast Cancer

Breast radiologists and nuclear medicine specialists updated their previous recommendation/guidance at the 4th Hungarian Breast Cancer Consensus Conference in Kecskemét. A recommendation is hereby made that breast tumours should be screened, diagnosed and treated according to these guidelines. These professional guidelines include the latest technical developments and research findings, including the role of imaging methods in therapy and follow-up. It includes details on domestic development proposals and also addresses related areas (forensic medicine, media, regulations, reimbursement). The entire material has been agreed with the related medical disciplines.

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

RATIONALE AND OBJECTIVE

To determine the diagnostic yield of various imaging tests used to evaluate nipple discharge.

MATERIALS AND METHODS

A single institution, IRB-approved, retrospective study was performed of 320 consecutive patients presenting with nipple discharge. Imaging and pathology were reviewed to determine the yield for malignancy, atypical high-risk lesions (HRLs), and intraductal papillomas (IDPs).

RESULTS

Of the 320 patients, pathology or follow up confirmed 40 breast malignancies (40/320, 12.5%),14 atypical HRLs (14/320, 4.4%), 71 IDPs (71/320, 22.2%), 48 other benign pathologies (48/320,15.0%), and 147 unknown but benign cases (147/320, 45.9%). Physiologic discharge characteristics were observed in a minority of malignant cases: nonspontaneous (4/40, 10.0%); neither bloody nor clear (4/40, 10.0%); bilateral (3/40, 7.5%). Malignancy was associated with older age (p < 0.001) and bloody discharge (odds ratio 6.5, p < 0.0001). The combination of digital mammography and ultrasound had a 93% sensitivity and a 98% NPV, while contrast enhanced MRI (CE-MRI) had a 100% sensitivity and a 100% NPV for malignancy. Only three galactography examinations were performed among the malignant cohort, with minimal contribution (1 of 3) to the diagnostic evaluation. In this case, galactography findings helped determine imaging-pathology discordance, prompting a recommendation for surgical excision and subsequently a malignant diagnosis.

CONCLUSION

The combination of mammography and ultrasonography detected 93% of breast malignancies associated with nipple discharge and had a 98% NPV for malignancy. The value of CE-MRI is its ability to detect the remaining malignancies, not detected on mammography or ultrasound, and its ability to obviate the need for surgical duct excision.

Persistent post-galactogram intraductal iodinated contrast detected on contrast-enhanced mammography (CEM) in a patient with nipple discharge

Nipple discharge is a common complaint among adult women and is often evaluated by galactography. Contrast-enhanced mammography (CEM) is an emerging breast imaging modality that is useful in the evaluation of patients with nipple discharge who have a negative galactogram, especially if they are not good candidates for contrast-enhanced MRI. Here we present a case of a 37-year-old female who was 22 weeks pregnant and presented with suspicious nipple discharge. The patient initially underwent galactography, which was negative, and was subsequently referred for CEM for further evaluation. One week after the galactogram, the patient underwent CEM which revealed persistent intraductal iodinated contrast from the galactogram. The retained intraductal contrast obscured the area of concern on the CEM and limited evaluation for underlying areas of enhancement. Given the increasing popularity of CEM in breast imaging practice and its utility in the evaluation of patients with nipple discharge, recognition of retained intraductal contrast as a source of artifact on CEM is important so that steps can be taken to prevent acquiring a limited and/or non-diagnostic CEM. We suggest several practical steps the radiologist can take when planning the diagnostic workup of patients with nipple discharge to ensure the patient will be able to successfully undergo CEM, if needed. These steps will help reduce unnecessary patient exposure to radiation and intravenous contrast and avoid a delay in diagnosis and treatment.

Evaluation of Breast Galactography Using Digital Breast Tomosynthesis: A Clinical Exploratory Study

Objectives: To compare the application value of digital breast tomosynthesis (DBT) and full-field digital mammography (FFDM) in breast galactography. Materials and Methods: A total of 128 patients with pathological nipple discharge (PND) were selected to undergo galactography. DBT and FFDM were performed for each patient after injecting the contrast agent; the radiation dose of DBT and FFDM was calculated, and the image quality was evaluated in consensus by two senior breast radiologists. Histopathologic data were found in 49 of the 128 patients. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for both FFDM- and DBT-galactography were calculated using histopathologic results as a reference standard. Data were presented as percentages along with their 95% confidence intervals (CI). Results: The average age of the 128 patients was 46.53 years. The average glandular dose (AGD) of DBT-galactography was slightly higher than that of FFDM-galactography (p < 0.001). DBT-galactography was 30.7% higher than FFDM-galactography in CC view, while DBT-galactography increased by 21.7% compared with FFDM-galactography in ML view. Regarding catheter anatomic distortion, structure detail, and overall image quality groups, DBT scores were higher than FFDM scores, and the differences were significant for all measures (p < 0.05). In 49 patients with pathological nipple discharge, we found that the DBT-galactography had higher sensitivity, specificity, PPV, and NPV (93.3%, 75%, 97.7%, and 50%, respectively) than FFDM-galactography (91.1%, 50%, 95.3%, and 33.3%, respectively). Conclusions: Compared to FFDM-galactography, within the acceptable radiation dose range, DBT-galactography increases the sensitivity and specificity of lesion detection by improving the image quality, providing more confidence for the diagnosis of clinical ductal lesions.

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

OBJECTIVES

To evaluate the diagnostic accuracy of breast MRI in identifying lesions requiring excision for patients with suspicious nipple discharge but normal mammograms and ultrasounds.

METHODS

Between September 2013 and May 2019, 106 female participants (mean age 57.9 years) were consecutively included in this prospective multicenter study; 102 were retained for analysis. MRI was considered negative in the absence of suspicious enhancement and positive in cases of ipsilateral abnormal enhancement (BI-RADS 3 to 5). Final diagnoses were based on histological findings of surgical or percutaneous biopsies or at 1-year follow-up. We considered all lesions requiring excision found on pathology (papilloma, atypia, nipple adenomatosis, or cancer) as positive results. We considered spontaneous resolution of the discharge at 1 year as a negative result.

RESULTS

MRI showed ipsilateral abnormal enhancement in 54 patients (53%) revealing 46 lesions requiring excision (31 benign papillomas, 5 papillomas with atypia, 2 nipple adenomatosis, and 8 cancers) and 8 benign lesions not requiring excision. No suspicious enhancement was found in the remaining 48 participants (47%). Forty-two were followed up at 1 year with spontaneous resolution of the discharge and six underwent surgery (revealing 2 benign papillomas). MRI diagnostic accuracy for the detection of a lesion requiring excision was as follows: sensitivity 96%, specificity 85%, positive predictive value 85%, and negative predictive value 96%.

CONCLUSION

In patients with suspicious nipple discharge and normal mammogram and ultrasound, MRI demonstrates excellent performance to identify lesions for which excision is required. Normal MRI indicates it is safe to propose follow-up only management, thus avoiding unnecessary duct excision.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02819362 KEY POINTS: • Breast MRI can be useful for the management of patients with suspicious nipple discharge and negative mammogram and ultrasound. • MRI detected a lesion requiring excision in 46 participants (45%) with unexplained discharge. • If breast MRI is negative, follow-up is a safe alternative for these patients.

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

Pathologic nipple discharge (PND) is typically unilateral, spontaneous, involves a single duct, and is serous or bloody in appearance. In patients with PND, breast MRI can be helpful as an additional diagnostic tool when conventional imaging with mammogram and ultrasound are negative. MRI is able to detect the etiology of nipple discharge in 56-61% of cases when initial imaging with mammogram and ultrasound are negative. Advantages to using MRI in evaluation of PND include good visualization of the retroareolar breast and better evaluation of posterior lesions which may not be well evaluated on mammograms and galactograms. It is also less invasive compared to central duct excision. Papillomas and nipple adenomas are benign breast masses that can cause PND and are well visualized on MRI. Ductal ectasia, and infectious etiologies such as mastitis, abscess, and fistulas are additional benign causes of PND that are well evaluated with MRI. MRI is also excellent for evaluation of malignant causes of PND including Paget's disease, ductal carcinoma in-situ and invasive carcinoma. MRI's high negative predictive value of 87-98.2% is helpful in excluding malignant etiologies of PND.

Nipple Discharge: Current Clinical and Imaging Evaluation

OBJECTIVE. Nipple discharge is a common complaint that is first evaluated with clinical assessment. Physiologic discharge does not require imaging other than routine screening mammography. Initial evaluation of pathologic nipple discharge involves mammography and ultrasound. evaluation of pathologic nipple discharge involves mammography and ultrasound. Because of its high sensitivity in detecting breast malignancy and its biopsy capability, MRI is increasingly used in lieu of ductography. CONCLUSION. The problem-solving algorithm for evaluating suspicious nipple discharge is evolving. When diagnostic imaging for evaluation of pathologic nipple discharge is negative, management is based on clinical suspicion. If additional imaging is warranted, MRI is preferred because of its increased sensitivity, specificity, and patient comfort. Although central duct excision is the current standard for evaluation of malignancy in patients with pathologic nipple discharge, studies suggest that, given the high negative predictive value of MRI, surveillance may be a reasonable alternative to surgery.

The nipple-areolar complex: comprehensive imaging review

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.

Breast imaging and cancer diagnosis during the COVID-19 pandemic: recommendations from the Italian College of Breast Radiologists by SIRM

The Italian College of Breast Radiologists by the Italian Society of Medical Radiology (SIRM) provides recommendations for breast care provision and procedural prioritization during COVID-19 pandemic, being aware that medical decisions must be currently taken balancing patient's individual and community safety: (1) patients having a scheduled or to-be-scheduled appointment for in-depth diagnostic breast imaging or needle biopsy should confirm the appointment or obtain a new one; (2) patients who have suspicious symptoms of breast cancer (in particular: new onset palpable nodule; skin or nipple retraction; orange peel skin; unilateral secretion from the nipple) should request non-deferrable tests at radiology services; (3) asymptomatic women performing annual mammographic follow-up after breast cancer treatment should preferably schedule the appointment within 1 year and 3 months from the previous check, compatibly with the local organizational conditions; (4) asymptomatic women who have not responded to the invitation for screening mammography after the onset of the pandemic or have been informed of the suspension of the screening activity should schedule the check preferably within 3 months from the date of the not performed check, compatibly with local organizational conditions. The Italian College of Breast Radiologists by SIRM recommends precautions to protect both patients and healthcare workers (radiologists, radiographers, nurses, and reception staff) from infection or disease spread on the occasion of breast imaging procedures, particularly mammography, breast ultrasound, breast magnetic resonance imaging, and breast intervention procedures.

Multimodality approach to the nipple-areolar complex: a pictorial review and diagnostic algorithm

The anatomic and histologic characteristics of the nipple-areolar complex make this breast region special. The nipple-areolar complex can be affected by abnormal development and a wide spectrum of pathological conditions, many of which have unspecific clinical and radiological presentations that can present a challenge for radiologists. The nipple-areolar complex requires a specific imaging workup in which a multimodal approach is essential. Radiologists need to know the different imaging modalities used to study the nipple-areolar complex, as well as their advantages and limitations. It is essential to get acquainted with the acquisition technique for each modality and the spectrum of findings for the different conditions. This review describes and illustrates a combined clinical and radiological approach to evaluate the nipple-areolar complex, emphasizing the findings for the normal morphology, developmental abnormalities, and the most common benign and malignant diseases that can affect this region. We also present a diagnostic algorithm that enables a rapid, practical approach to diagnosing condition involving the nipple-areolar complex.

DBT-galactography: a promising tool for improving the diagnostic workup of nipple discharge

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.

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

Nipple discharge, a relatively common presenting symptom for women of all ages, may be due to both benign and malignant conditions. Men can also present with nipple discharge, and when they do, they have a higher likelihood of malignancy than women. Radiologists vary in their evaluation of patients with nipple discharge, although the American College of Radiology practice guidelines for nipple discharge provides data-driven appropriate algorithms. In patients with physiologic discharge, imaging is not typically indicated. For those with pathologic nipple discharge, imaging typically starts with diagnostic mammography and retroareolar ultrasound for women over 40 years of age, diagnostic mammogram or ultrasound for women aged 30-39 years, and ultrasound for women younger than 30 years. Finally, contrast-enhanced breast MRI or galactography are usually reserved for identifying the cause of discharge when initial imaging with mammography and ultrasound is unrevealing.

Variation in Technical Quality of Breast MRI

PURPOSE

Breast magnetic resonance imaging (MRI) quality may vary across the United States. Our aim was to investigate the quality of outside breast MRIs presenting for second opinion at a tertiary cancer center following implementation of the American College of Radiology (ACR) Breast MRI Accreditation Program.

MATERIALS AND METHODS

We retrospectively reviewed the technical quality of the MRI studies of 100 consecutive cases submitted for second opinion in 2013. The image quality was blindly reviewed per ACR Breast MRI Accreditation Program by three fellowship-trained breast radiologists and one breast imaging fellow.

RESULTS

In total, 88 of the 100 cases were referred from facilities in the United States. Sixty (68%) of the 88 cases had at least one technical deficiency. In 10 cases (11%), more than five different technical deficiencies occurred. The most frequently encountered deficiencies were related to artifacts (74%), with shimming (N = 17) and motion (N = 16) being the most common. In total, 38% of cases (N = 33) had a deficient T2-weighted sequence, mostly due to low signal to noise ratio (N = 25). A total of 27% cases (N = 24) had deficiencies in the delayed phase postcontrast T1-weighted sequence, mainly due to low signal to noise ratio (N = 21) and 23% had deficiencies in the early phase postcontrast T1-weighted sequence, predominantly due to low signal to noise ratio as well. (N = 19).

CONCLUSION

Our study demonstrates variability of breast MRI quality across the United States. Radiologists should become familiar with the requirements of the ACR breast MRI accreditation program and strive to meet the expected standards in order to enhance patient quality and safety.

Can we see what is invisible? The role of MRI in the evaluation and management of patients with pathological nipple discharge

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.

Is Ductography Still Warranted in the 21st century?

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

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

PURPOSE

To compare sensitivities and specificities of ductography to noninvasive imaging studies in determining the cause of nipple discharge and assess the value of ductography on the basis of pathologic results.

METHODS

In this retrospective review of women with nipple discharge who underwent ductography between January 1, 2005 and October 30, 2015, at our institution, we compared ductography with noninvasive imaging results (mammography, ultrasound, MRI) to determine its relative diagnostic sensitivity, specificity, and relative accuracy. Diagnosis was defined from pathology results, clinical notes, and minimum of 1-year follow-up monitoring. The primary endpoints include accuracy, sensitivity, specificity, positive predictive value, and negative predictive value. The analyses were carried out in different configurations to compare results by the following pathologic categories: cancer, high-risk lesion, intraductal papilloma (IP) without atypia, and benign pathology and/or normal imaging results.

RESULTS

In patients with breast cancer, ductography and noninvasive breast imaging had similar sensitivities. In patients with a high-risk lesion, ductography was significantly more sensitive than noninvasive imaging modalities. In patients with intraductal papilloma without atypia, ductography was more sensitive than noninvasive imaging, but the difference was of only borderline significance. For women with benign pathology and/or normal imaging, noninvasive imaging showed a significantly higher specificity than ductography.

CONCLUSION

In the absence of standard diagnostic algorithm for patients presenting with nipple discharge, the clinician has numerous options to choose a diagnostic approach that will yield the most accurate information with the least disruption to the patient. Our results indicate the value of ductography compared to value of noninvasive imaging modalities when cancer is suspected and when high risk lesion is suspected. While we show the sensitivity of ductography is similar to noninvasive imaging modalities in the setting of cancer, the sensitivity of ductography is statistically valuable for diagnosing high-risk lesions. Our hope is that this study will emphasize more research and more understanding in clinical utility and management of high-risk lesions, leading to patient-focused algorithm for diagnosing the etiology of abnormal nipple discharge.

Asymmetric Ductal Ectasia: An Often Overlooked Sign of Malignancy

OBJECTIVE. The objective of this article is to define the clinical significance of asymmetric ductal ectasia by a review of literature and to describe the imaging findings. CONCLUSION. Asymmetric ductal ectasia has a significant risk for malignancy and high-risk lesions. The findings on conventional imaging may be subtle and easily overlooked. Asymmetric ductal ectasia should be included in the search pattern during image interpretation. Tissue sampling is usually warranted. Ultrasound is critical in identifying ductal abnormalities to guide biopsy.

Nipple discharge: The state of the art

Over 80% of females experience nipple discharge during their life. Differently from lactational (milk production) and physiological (white, green, or yellow), which are usually bilateral and involving multiple ducts, pathologic nipple discharge (PND) is a spontaneous commonly single-duct and unilateral, clear, serous, or bloody secretion. Mostly caused by intraductal papilloma(s) or ductal ectasia, in 5-33% of cases is due to an underlying malignancy. After clinical history and physical examination, mammography is the first step after 39, but its sensitivity is low (7-26%). Ultrasound shows higher sensitivity (63-100%). Nipple discharge cytology is limited by a false negative rate over 50%. Galactography is an invasive technique that may cause discomfort and pain; it can be performed only when the duct discharge is demonstrated at the time of the study, with incomplete/failed examination rate up to 15% and a difficult differentiation between malignant and benign lesions. Ductoscopy, performed under local anesthesia in outpatients, provides a direct visualization of intraductal lesions, allowing for directed excision and facilitating a targeted surgery. Its sensitivity reaches 94%; however, it is available in only few centers and most clinicians are unfamiliar with its use. PND has recently emerged as a new indication for contrast-enhanced breast MRI, showing sensitivity superior to galactography, with an overall sensitivity up to 96%, also allowing tailored surgery. Surgery no longer can be considered the standard approach to PND. We propose a state-of-the art flowchart for the management of nipple discharge, including ductoscopy and breast MRI as best options.

Galactography is not an obsolete investigation in the evaluation of pathological nipple discharge

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.

Nipple Discharge: Imaging Variability Among U.S. Radiologists

OBJECTIVE

The purpose of this study was to assess radiologists' choice of imaging modality for the evaluation of clinical symptoms of physiologic nipple discharge (e.g., bilateral discharge, multiple-duct orifices, and yellow, green, or white color) and pathologic nipple discharge (e.g., unilateral discharge, single-duct orifices, spontaneous and serous discharge, and clear or bloodstained color).

MATERIALS AND METHODS

An online survey was sent to lead interpreting physicians at mammography facilities accredited by the American College of Radiology (ACR). Statistical analysis was performed using chi-square tests for frequency data and multinomial logistic regression.

RESULTS

A total of 849 responses to 8170 distributed surveys were received, for a response rate of 10.4%. For the workup of physiologic nipple discharge, 30% of respondents recommended screening mammography (SM); 24%, diagnostic mammography (DM) only; and 46%, both DM and targeted ultrasound (US) (DM plus US). For the workup of physiologic nipple discharge, practitioners in nonacademic settings and those who read breast images during less than 50% of their practice were significantly more likely to recommend DM (with or without US), compared with SM (the standard recommended by the ACR). Those reading breast images less than 50% of the time were also more likely to recommend MRI after conventional imaging revealed negative results. For the workup of pathologic nipple discharge, 91.0% of respondents recommended DM plus US; 8.5%, DM only; and fewer than 1.0%, SM. Nonacademic providers and those who read breast images less than 50% of the time were significantly less likely to recommend DM plus US (the standard recommended by the ACR), compared with DM only.

CONCLUSION

The present study shows variability in imaging modality selection among U.S. radiologists handling the imaging workflow for benign and pathologic nipple discharge. Radiologists do not uniformly follow ACR practice guidelines, which potentially leads to unnecessary workups and extra health care costs.

A survey by the European Society of Breast Imaging on the utilisation of breast MRI in clinical practice

OBJECTIVES

While magnetic resonance imaging (MRI) is considered a helpful diagnostic tool in breast imaging, discussions are ongoing about appropriate protocols and indications. The European Society of Breast Imaging (EUSOBI) launched a survey to evaluate the utilisation of breast MRI in clinical practice.

METHODS

An online survey reviewed by the EUSOBI board and committees was distributed amongst members. The questions encompassed: training and experience; annual breast MRI and MRI-guided-intervention workload; examination protocols; indications; reporting habits and preferences. Data were summarised and subgroups compared using χ² test.

RESULTS

Of 647 EUSOBI members, 177 (27.4%) answered the survey. The majority were radiologists (90.5%), half of them based in academic centres (51.9%). Common indications for MRI included cancer staging, treatment monitoring, high-risk screening and problem-solving, and differed significantly between countries (p≤0.03). Structured reporting and BI-RADS were mostly used. Breast radiologists with ≤10 years of experience preferred inclusion of additional techniques, such as T2/STIR (p=0.03) and DWI (p=0.08) in the scan protocol. MRI-guided interventions were performed by a minority of participants (35.4%).

CONCLUSIONS

The utilisation of breast MRI in clinical practice is generally in line with international recommendations. There are substantial differences between countries. MRI-guided interventions and functional MRI parameters are not widely available.

KEY POINTS

• MRI is commonly used for the detection and characterisation of breast lesions. • Clinical practice standards are generally in line with current recommendations. • Standardised criteria and diagnostic categories (mainly BI-RADS) are widely adopted. • Younger radiologists value additional techniques, such as T2/STIR and DWI. • MRI-guided breast biopsy is not widely available.