What is the role of radiography in nipple discharge evaluation?

Updated: Aug 08, 2018
  • Author: Edward Azavedo, MD, PhD; Chief Editor: Eugene C Lin, MD  more...
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Answer

Mammography is the standard initial step in evaluation of most patients with pathologic nipple discharge. The mammogram needs to include only the symptomatic breast if the patient has undergone recent bilateral screening mammography within the past 6 months. It usually consists of craniocaudal and mediolateral oblique views of the symptomatic breast, with additional views if indicated. [4]

Digital breast tomosynthesis (DBT) is a 3-dimensional technique based on digital mammography (DM) that is known to improve breast cancer detection rates and to reduce recall rates. On DBT, partial 3-D reconstruction of the breast is obtained from a finite number of 2-D projections, which are acquired as the x-ray tube moves along an arc. This reduces the summation of overlapping breast tissues and may increase detection of architectural distortion. [7]  DBT can be useful in improving characterization of noncalcified lesions as compared to conventional mammographic workup and could therefore be useful in the setting of nipple discharge evaluation. [4]

Ductography, also known as galactography, is historically the procedure of choice in identifying and localizing intraductal lesions in patients with pathologic nipple discharge. Repeat ductography can be used to guide preoperative wire localization once a suspicious target lesion is identified. [4]  Ductography has been used in the past to visualize the number, location, and extent of the involved milk ducts in women with pathologic nipple discharge, but it is an invasive imaging method that requires iodinated contrast-medium injection and also has low diagnostic accuracy, because the differential diagnosis of the causative lesion cannot be completed based on ductographic findings alone. [2]

Ductography involves the retrograde injection of contrast medium into a discharging duct, with subsequent mammographic imaging of the breast in at least 2 planes. The contrast agent–filled ducts should decrease in width from the nipple inward. An increase in duct diameter suggests duct ectasia.

A contrast-agent filling defect in an otherwise well-filled duct suggests an intraductal growth. Solitary papillomas are usually seen as single lobulated contrast-agent filling defects within a duct (see the first 4 images below). Occasionally, a continuous filling defect is present; this finding suggests papillomatosis (see the fifth and sixth images below). 

Duct compression due to an extrinsic mass decreases the ductal diameter, which takes on the shape of a cone or funnel.

A 47-year-old woman with serous discharge from her A 47-year-old woman with serous discharge from her right nipple. Ductography reveals a contrast-agent filling defect approximately 3 cm from the nipple. Cytology revealed normal epithelial cells and cell debris. Histopathology after surgery revealed a solitary, lobulated intraductal papilloma.
Close-up view of the immediately preceding image. Close-up view of the immediately preceding image.
A 50-year-old woman with serous discharge from her A 50-year-old woman with serous discharge from her right nipple. Ductography reveals contrast-agent filling defect approximately 4 cm from her nipple. Cytology of the smears from her nipple discharge revealed normal epithelial cells. Histopathology after surgery revealed a solitary intraductal papilloma in a cystic lesion.
Close-up view of the immediately preceding image. Close-up view of the immediately preceding image.
A 48-year-old woman with serous discharge from her A 48-year-old woman with serous discharge from her right nipple. Ductography reveals contrast-agent filling defects approximately 1.5 cm from the nipple, extending to a depth of approximately 2.5 cm. Cytology demonstrated epithelial cells arranged in papillary fragments. Histopathology after surgery revealed extensive involvement of intraductal papillomas.
Close-up view of the immediately preceding image. Close-up view of the immediately preceding image.

In instances in which the passage of radiographic contrast medium stops abruptly, the ductal lumen is totally obstructed and visualization of its proximal portion is precluded. The obstruction could be due to a large papilloma, although malignancy cannot be excluded. Ductal carcinoma in situ is often apparent as irregular duct walls (see the images below), in contrast to the smooth walls associated with normal ducts. Hyperplasia also can appear as continuous, irregular duct walls. A ductogram that reveals irregular duct walls should always be investigated further, because the differential diagnosis includes hyperplastic micropapillary changes and malignancy.

A 42-year-old woman with serous discharge from her A 42-year-old woman with serous discharge from her left nipple. Ductography reveals contrast-agent filling defects approximately 1.5 cm from her nipple. Cytology of smears of secreted fluid revealed malignant epithelial cells. Histopathology after surgery revealed intraductal carcinoma.
Close-up view of the immediately preceding image. Close-up view of the immediately preceding image.

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