:::: FOR OUR REFERRING PHYSICIANS : NEWSLETTER :.

Ductography

Dear Colleagues:

The workup and management of nipple discharge and the role of ductography in evaluating nipple discharge has generated a number of questions from our referring community. We are strong advocates for the use of ductography in identifying lesions responsible for spontaneous, unilateral nipple discharge. We have prepared a brief discussion of nipple discharge and the role of ductography in the evaluation of women presenting with spontaneous discharge and the pre-operative localization of intraductal lesions. 

We hope you will find this information useful and interesting. Should you have any questions pertaining to ductography or other breast-related concerns, please feel free to call me or my associates, Dr. Paul Meunier or Dr. Jane Bedell.

Sincerely,

G.W. Eklund, M.D., FACR

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THE WORKUP AND MANAGEMENT OF
SPONTANEOUS, UNILATERAL NIPPLE DISCHARGE

G.W. Eklund, M.D., FACR

Nipple discharge is a common presenting complaint of women seeking medical attention. The challenge for the clinician is to differentiate physiological from pathological discharge and to initiate appropriate management or referral.

Physiological nipple discharge:  Physiological nipple discharge is almost always bilateral and comes from multiple ducts. It may be milky, clear or serous and may be Hemoccult positive. It may be associated with medications or hormonal effects and is usually managed conservatively.

Pathological nipple discharge:  The characteristics of typical pathological nipple discharge are:

• Spontaneous
• Coming from one nipple
• Usually coming from a single ductal orifice
• Usually clear, serous, bloody or with a green or brown color
• Almost never milky

What is the character of nipple discharge associated with DCIS or invasive breast cancer?  Clear, serous and bloody discharges have an equal association with breast cancer. It is a mistake to believe that only bloody discharge is associated with underlying malignancy.

What is the role of cytological assessment of nipple discharge?  Although cytological evaluation of nipple discharge is a common practice, it has been our experience and that of many other investigators that cytological examination of ductal secretions is unreliable, frequently misleading and not cost effective. Atypical cells are commonly seen and may lead to unnecessary surgery and unwarranted anxiety. Negative results can be seen with breast cancers and positive results with benign lesions. 1, 3-5

What is the role of ductography in the workup of nipple discharge?  Ductography is a contrast study of a major duct and its tributaries and the only method available to characterize intraductal pathology in patients with nipple discharge1-4.  The appropriate indication for ductography is a SPONTANEOUS, UNILATERAL discharge.  Bilateral discharge and/or discharge which is seen only with manual expression is rarely associated with significant intraductal lesions.5   The character of the discharge most often associated with lesions requiring surgery is bloody, clear or serous.  We have not seen an intraductal lesion associated with milky discharge.  The most common source of brown or greenish discharge has been single or multiple communicating cysts.

Ductography is a reliable method for identifying intraductal lesions that require surgical excision. Pre-operative ductographic localization is a reliable method for directing the surgeon to the offending lesion and enabling a conservative tissue-sparing excision. 1-4 Ductography may reveal benign causes of spontaneous discharge, thus avoiding unnecessary surgery. Examples include duct ectasia or communicating cysts.

What are the most common causes of pathological nipple discharge? 1-4, 6.  

• Benign papilloma or multiple papillomas >70%
• Duct ectasia
• Communicating cysts
• Ductal hyperplasia
• DCIS or invasive breast cancer ~ 10%

What is involved in performing a ductogram? Ductography is a simple, quick and usually painless procedure that involves the identification of the offending duct, cannulation with a fine (30-guage) cannula and injection of a small amount of iodinated contrast. Magnified mammographic images are obtained to show the opacified ducts and to identify intraductal abnormalities. The procedure takes between 10 and 30 minutes and has no significant adverse effects to the patient.

REFERENCES

• Tabar L, Dean PB, Zoltan P. Galactography: the diagnostic procedure of choice for nipple discharge. Radiology 1983; 149:31-38
• Cardenosa G, Eklund GW. Benign papillary neoplasms of the breast: mammographic findings. Radiology 1991; 181:751-755
• Cardenosa G and Eklund GW. Ductography. Applied Radiology, September 1992
• Cardenosa G, Doudna C, Eklund GW: Ductography: technique and findings: A pictorial essay.  AJR 1994; 162:1081-1087
• Leis HP, Cammarata A, Laraja RD. Nipple discharge: significance and treatment. Breast 11: 6-12
• Bjorn-Hansen R. Contrast-mammography. Brit J Radiol 1965; 38:947-951

Additional information may be found on our Website – www.PacificBreastCenter.com