Diagnosis of Nipple Discharge: Value of Magnetic Resonance Imaging and Ultrasonography in Comparison with Ductoscopy

Advances in fibreoptic ductoscopy for the diagnosis and treatment of pathologic papillary overflow

Fibreoptic mammography is widely recognised as the first screening method for pathologic papillary overflow due to its significant advantages in the diagnosis of ductal dilatation, intraductal papilloma and intraductal carcinoma. The use of fibreoptic ductoscopic excisional biopsy techniques, such as biopsy needles, vacuum negative pressure aspiration, biopsy forceps and grasping baskets, has not been promoted largely due to their existing deficiencies. The imaging effect of fibreoptic ductoscopy compared with electronic ductoscopy is also one of the important factors limiting the progress of microscopic excisional biopsy techniques. Finding a more suitable operating space for electronic fibreoptic ductoscopy and the use of electrosurgical excision biopsy techniques should be the focus of research in view of achieving accurate diagnoses in electronic fibreoptic ductoscopy and microscopic excision biopsy. In this review, the development history, clinical application and existing problems of fibreoptic ductoscopy are reviewed and assessed to provide references for the clinical diagnosis and treatment of pathologic papillary overflow.

Treatment Strategy for Breast Benign Intraductal Papilloma: A Meta-Analysis

Currently, the optimal treatment approach for breast benign intraductal papilloma (IDP) diagnosed via biopsy remains uncertain. There is ongoing debate regarding the feasibility of clinical follow-up and the criteria for selective surgical excision. This study aims to conduct a meta-analysis to determine the rate of upgrade from breast benign IDP and identify predictive factors associated with the conversion of benign IDP to high-risk lesions or carcinoma, which could guide healthcare practitioners in selecting the appropriate clinical treatment strategy. We conducted a comprehensive search across multiple databases (PubMed, Web Of Science, Cochrane Library, and Embase) for studies published between 2012 and 2023 that evaluated upgrade rates and predictive factors of breast benign IDP diagnosed via biopsy. In addition, we included studies that reported on the clinical follow-up of patients with breast benign IDP. In total, 32 studies comprising 7371 cases of biopsy-diagnosed breast benign IDP were included. Among these cases, 720 demonstrated an upgrade to high-risk lesions or carcinoma, resulting in an upgrade rate of 6.94% [95% confidence interval (CI): 3.0-8.0%]. A subgroup of 1713 patients was clinically followed up, demonstrating an average follow-up duration of 30.95 months. Among them, 26 cases experienced an upgrade to high-risk lesions or carcinoma, yielding an upgrade rate of 1.51% (95% CI 0.00-2.00). Furthermore, we identified nine predictive factors associated with the upgrading of breast benign IDP, which included age at diagnosis, personal history of breast cancer, family history of breast cancer, multiple IDPs, lesion size ≥ 10 mm, palpable mass, calcification, and the presence of mass and asymmetry in mammographic findings. Although the conversion rate of breast benign IDP to high-risk lesions or carcinoma is relatively low, timely identification of predictive factors associated with benign IDP upgrades may help selecting the optimal clinical treatment strategy, such as surgery for patients with benign IDP presenting one or more predictive factors, while clinical follow-up for those without specific risk factors.

Deep learning for real-time detection of breast cancer presenting pathological nipple discharge by ductoscopy

Objective

As a common breast cancer-related complaint, pathological nipple discharge (PND) detected by ductoscopy is often missed diagnosed. Deep learning techniques have enabled great advances in clinical imaging but are rarely applied in breast cancer with PND. This study aimed to design and validate an Intelligent Ductoscopy for Breast Cancer Diagnostic System (IDBCS) for breast cancer diagnosis by analyzing real-time imaging data acquired by ductoscopy.

Materials and methods

The present multicenter, case-control trial was carried out in 6 hospitals in China. Images for consecutive patients, aged ≥18 years, with no previous ductoscopy, were obtained from the involved hospitals. All individuals with PND confirmed from breast lesions by ductoscopy were eligible. Images from Beijing Chao-Yang Hospital were randomly assigned (8:2) to the training (IDBCS development) and internal validation (performance evaluation of the IDBCS) datasets. Diagnostic performance was further assessed with internal and prospective validation datasets from Beijing Chao-Yang Hospital; further external validation was carried out with datasets from 5 primary care hospitals. Diagnostic accuracies, sensitivities, specificities, and positive and negative predictive values for IDBCS and endoscopists (expert, competent, or trainee) in the detection of malignant lesions were obtained by the Clopper-Pearson method.

Results

Totally 11305 ductoscopy images in 1072 patients were utilized for developing and testing the IDBCS. Area under the curves (AUCs) in breast cancer detection were 0·975 (95%CI 0·899-0·998) and 0·954 (95%CI 0·925-0·975) in the internal validation and prospective datasets, respectively, and ranged between 0·922 (95%CI 0·866-0·960) and 0·965 (95%CI 0·892-0·994) in the 5 external validation datasets. The IDBCS had superior diagnostic accuracy compared with expert (0.912 [95%CI 0.839-0.959] vs 0.726 [0.672-0.775]; p<0.001), competent (0.699 [95%CI 0.645-0.750], p<0.001), and trainee (0.703 [95%CI 0.648-0.753], p<0.001) endoscopists.

Conclusions

IDBCS outperforms clinical oncologists, achieving high accuracy in diagnosing breast cancer with PND. The novel system could help endoscopists improve their diagnostic efficacy in breast cancer diagnosis.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Ultrasonographic features of ductal carcinoma in situ: analysis of 219 lesions

Background

The purpose of this paper is to clarify the ultrasonographic features and classification of ductal carcinoma in situ (DCIS), and to evaluate the ability of ultrasonography in the prediction of DCIS.

Methods

The clinical data, gray-scale ultrasound images and pathological results of 219 DCIS lesions that detected in 203 consecutive patients who underwent ultrasonography and surgery in our hospital from January 1, 2014 to December 31, 2019 were collected retrospectively. Ultrasonographic features and classification of DCIS were summarized, and the accuracy of ultrasonography in predicting different ultrasonographic findings of DCIS were compared.

Results

Among the 219 DCIS lesions, 91 (41.6%) presented as mass-like lesions and 128 (58.4%) were non-mass-like lesions. For the 91 mass-like DCIS lesions, 79 were hypoechoic solid masses, 12 were cystic-solid structures. For the 128 non-mass-like DCIS lesions, 114 were hypoechoic areas, 10 were ductal dilatation accompanied with intraductal solid components, and 4 were multiple punctate echogenic foci only. The diagnostic accuracy of ultrasound for the 219 DCIS lesions was 81.7% (179/219). The diagnostic accuracy of mass-like DCIS lesions was 90.1% (82/91), which was significantly higher than that in non-mass-like DCIS lesions [75.8% (97/128), P=0.007]. The diagnostic accuracy of hypoechoic solid masses was significantly higher than those of the other ultrasonographic findings (P=0.002). Ducts abnormalities were detected in 45 (20.5%) lesions and punctate echogenic foci in 134 (61.2%) lesions. The diagnostic accuracy of lesions with ducts abnormalities was 93.3% (42/45), which was significantly higher than that in lesions without ducts abnormalities [78.7% (137/174), P=0.024]. The diagnostic accuracy of lesions with punctate echogenic foci was 92.5% (124/134), which was significantly higher than that in lesions without punctate echogenic foci [64.7% (55/85), P=0.000].

Conclusions

DCIS lesions can effectively be recognized as mass-like lesions and non-mass-like lesions by ultrasound. Hypoechoic areas and hypoechoic solid masses were the most common ultrasonographic features of DCIS. Ducts abnormalities and punctate echogenic foci were helpful for the diagnosis of DCIS.

Nipple Ultrasound: A Pictorial Essay

Ultrasound (US) is an attractive diagnostic approach to identify both common and uncommon nipple pathologies, such as duct ectasia, nipple abscess, nipple leiomyoma, nipple adenoma, fibroepithelial polyp, ductal carcinoma in situ (restricted to nipple), invasive carcinoma, and Paget's disease. US is the reliable first-line imaging technique to assess nipple pathologies. It is useful to identify and characterize nipple lesions. Additionally, we have presented the mammography and MRI outcomes correlated with histopathologic features for the relevant cases.

A Nomogram to Predict the Probability of Breast Intraductal Tumors in Patients with Nipple Discharge: A Real-World Study Based on Our 13-Year Clinical Experience

INTRODUCTION

Nipple discharge is a common symptom of breast disease. We aimed to perform a descriptive statistical analysis of the cases we evaluated and establish a model to predict intraductal tumors.

MATERIALS AND METHODS

We conducted a retrospective study of patients from 2007 to 2019. In total, 1333 patients who completed the fiberoptic ductoscopy (FDS) were evaluated. The variables were analyzed by χ 2 test. Logistic regression was used to analyze the relationship between the patient's clinical characteristics and intraductal tumors and establish a predictive model. Receiver operating characteristic (ROC) curve analysis was used to assess the sensitivity and specificity of the predictive ability of the model. Calibration curves and decision curve analysis (DCA) were used to evaluate the model.

RESULTS

Patients with spontaneous, single-duct, bloody discharge and a smooth ductal wall were more likely to be diagnosed with tumors by ductoscopy. A model was established based on five variables: age, side of discharge, spontaneous discharge status, duration of discharge, and color of discharge. The model was subsequently validated in 183 patients with complete data on the variables in the validation cohort. The area under the ROC curve (AUC) was calculated to be 0.716, indicating good predictive ability.

CONCLUSION

Patients with the clinical characteristics of unilateral, bloody, single-duct, spontaneous discharge and a smooth ductal wall were more likely to have intraductal tumors by ductoscopy. Our nomogram can effectively predict intraductal tumors in patients with nipple discharge.

Network Meta-analysis for the Diagnostic Approach to Pathologic Nipple Discharge

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.

MRI for assessment of pathologic nipple discharge: is it mandatory?

Background

Benign breast lesions is the most common cause of nipple discharge; however, a rare but major cause is breast cancer. This study assesses the superadded value of MRI in diagnosing causes of pathologic nipple discharge. Ninety-three patients with pathologic nipple discharge were evaluated by sonomammography and DCE-MRI. Sonomammography and MR imaging features were analyzed and correlated with the histopathology.

Results

Histopathology revealed 69 benign, three high-risk, and 21 malignant lesions. Simply dilated ducts and presence of a mass on US examination as well as non-mass enhancement and STIR signal changes on MRI were of statistically significant probability in differentiation between benign and malignant causes of pathological nipple discharge (p value = 0.017 and 0.001) and (p value ≤ 0.001). Sensitivity and specificity of mammogram and ultrasound in differentiation between benign and malignant causes of pathologic nipple discharge were 71.4% and 54.2% respectively with positive predictive value of 31.2%,negative predictive value of 86.7%, and accuracy of 58.1%. MRI gave higher sensitivity and specificity of 100% and 83.3% with positive predictive value of 63.6%, negative predictive value of 100%, and accuracy of 87.1%.

Conclusion

Magnetic resonance imaging is superior to sonommagraphy in diagnosis of pathologic nipple discharge and we recommend it in special situations.

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.