You are in: eMedicine Specialties > Radiology > BREAST Breast, Nipple Discharge EvaluationArticle Last Updated: May 30, 2007AUTHOR AND EDITOR INFORMATIONSection 1 of 9
  Author: Edward Azavedo, MD, PhD, Director of Clinical Breast Imaging Services, Associate Professor, Department of Radiology, Karolinska University Hospital, Sweden Edward Azavedo is a member of the following medical societies: Swedish Medical Association and Swedish Society of Medicine Editors: John M Lewin, MD, Associate Clinical Professor, Department of Preventative Medicine and Biometrics, Director of Teleradiology, Co-director of Breast Imaging Section, Director of Breast Imaging Research, Department of Radiology, University of Colorado Health Sciences Center; Consulting Radiologist, Diversified Radiology of Colorado; Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand; Edward Azavedo, MD, PhD, Director of Clinical Breast Imaging Services, Associate Professor, Department of Radiology, Karolinska University Hospital, Sweden; Robert M Krasny, MD, Consulting Staff, Department of Radiology, The Angeles Clinic and Research Institute; Eugene C Lin, MD, Consulting Staff, Department of Radiology, Virginia Mason Medical Center Author and Editor Disclosure Synonyms and related keywords: ductography, galactography, nipple discharge, galactorrhea, fiber-ductoscopy, intraductal carcinoma, intraductal papilloma, carcinoma, papilloma, cystic lesion, intraductal growth of the ductal epithelium, hyperplasia, micropapillary proliferation, solitary papillomas, ductal carcinoma, in situ ductal carcinoma, invasive ductal carcinoma, duct ectasia, periductal galactophoritis, galactography, ductography INTRODUCTIONSection 2 of 9
  BackgroundNipple discharge is a symptomatic problem that causes many women both discomfort and anxiety. Tremendous advances have been made in the management of breast problems, mainly through advances in diagnostic breast imaging. PathophysiologyThe causes of nipple discharge are not well understood. However, nipple discharge is most commonly associated with endocrine alterations and/or medications. These often result in duct ectasia and/or fibrocystic changes in the breast. Changes are often bilateral and may lead to bilateral discharge from one or several nipple ducts. An unusual cause of nonmalignant nipple discharge is duct ectasia with periductal galactophoritis, which is inflammation around dilated milk ducts. The most common cause of clinically significant discharge is intraductal growth of the ductal epithelium, resulting from hyperplasia, micropapillary proliferation, solitary papillomas, and/or ductal carcinoma (both in situ and invasive). Most of the intraductal changes that lead to nipple discharge are situated within 1-4 cm of the nipple. FrequencyUnited StatesThe frequency of nipple discharge is 1-3% in patients referred to breast clinics, but frequencies as high as 3-8% have been reported. Mortality/Morbidity
RaceNipple discharge occurs in people of all races. Sex
AgeNipple discharge can occur in patients of all ages, from infants to adults.
Clinical DetailsThe most common types of nipple discharge are bilateral, emanate from several ducts in the same nipple, and vary in color from white to brown. To be clinically significant, nipple discharge must be true, spontaneous, persistent, and nonlactational. Surgically significant discharge is clear (ie, watery), serous (ie, clear yellow), serosanguineous, or sanguineous (ie, bloody). The likelihood of malignancy increases when the discharge is unilateral and arises from a single duct, when it is accompanied by a palpable mass, when it is associated with a positive mammographic or galactographic finding and a positive cytologic result, or when the patient is older than 50 years. Clinically significant nipple discharge most commonly is secondary to intraductal growths, ranging from hyperplasias to malignancies. Researchers have reported that when clinical, cytologic, and breast-imaging findings show no evidence of malignancy, nipple discharge spontaneously resolves in as many as 73% of patients within 5 years.4 Cytologic smears of secreted fluid obtained from women who are taking oral contraceptives can demonstrate dysplastic changes; however, the findings appear to be reversible when the medication is stopped or changed. Preferred ExaminationMammography, although typically unrevealing, is the first examination that should be performed in a patient with clinically significant nipple discharge. Annual screening mammography should be performed in all women aged 40 years or older. Subsequent to negative mammographic findings, galactography or ductography is the procedure of choice. Galactography involves the retrograde injection of water-soluble radiopaque contrast material into a discharging duct, with subsequent mammographic imaging. The nipple is inspected to identify the orifice of secretion, and the direction and path of that duct is ascertained by gently pressing on the breast from different directions toward the nipple. After the nipple is sterilized, a ductography cannula (ie, a needle with a blunt end) is gently inserted into the secreting orifice; both straight and right-angled cannulas are used. Approximately 0.2-0.8 mL of water-soluble contrast material is slowly injected by using a 1- or 3-mL syringe. The injection is discontinued if the patient experiences pain or burning or if resistance is met. Extravasation may occur as a result of the forceful contrast injection or the perforation of the wall as a result of vigorous cannula insertion. If extravasation occurs, it may cause focal burning/pain, or it can be asymptomatic. In such cases, the patient is treated with mild analgesics and the procedure is performed in 1-3 weeks. After the injection of contrast material, craniocaudal and lateral mammograms are obtained. Additional magnification, oblique, and rolled views are acquired as needed to visualize the ductal system. Other tests Hemoccult tests can be used to assess the nipple discharge fluid in order to confirm or exclude the presence of occult blood. Cytologic tests of the fluid can be performed; however, false-positive rates and significant false-negative rates have been reported (2.6% and 17.8%, respectively, in Leis' series).5 Sonography is not typically used unless the nipple discharge is accompanied by a palpable mass or a positive mammographic finding. Sonography may be useful in presurgical localization if galactography reveals a dilated duct larger than a few millimeters in width. Modern high-resolution ultrasonographic techniques are becoming more sensitive for the visualization of intraductal changes. Tiny, solitary papillomas can sometimes be visualized by using this sophisticated technology (see Images 9-10). Magnetic resonance imaging (MRI) may play an adjunctive role, aiding in the differentiation of benign ductal abnormalities from malignant ones. However, a prospective study comparing MRI with galactography and sonography will be necessary before MRI's role can be determined. Fiber-ductoscopy is an experimental technique that may eventually play a role in the evaluation of nipple discharge. At this endoscopic examination, a thin, flexible, silica fiber-ductoscope is inserted into the duct through the secreting duct orifice at the surface of the nipple; the intraluminal findings are viewed on a television monitor. The technique is still in its infancy, but progress has been made in the last few years. It is now possible to have not only cytology specimens but also tissue samples for histologic assessment of intraductal lesions visualized through ductoscopy. Limitations of TechniquesGalactography is not indicated unless the nipple discharge is spontaneous, unilateral, and expressed from a single pore. If discharge cannot be expressed at the time of galactography, the affected duct cannot be identified or cannulated. High-resolution ultrasonography is relatively new and expensive. This examination is not available at all breast-imaging centers. In addition, it is operator dependent and requires expertise for the identification of small intraductal structures. MRI and fiber-ductoscopy remain experimental techniques in the evaluation of nipple discharge. Further studies are required before their roles are determined. DIFFERENTIALSSection 3 of 9
Other Problems to Be ConsideredPapillomas
RADIOGRAPHSection 4 of 9
FindingsGalactography 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 Images 3-4). Occasionally, a continuous filling defect is present; this finding suggests papillomatosis (see Images 7-8). 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 Images 1-2), 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. Duct compression due to an extrinsic mass decreases the ductal diameter, which takes on the shape of a cone or funnel. Degree of ConfidenceWhen radiographs show obvious contrast-agent filling defects in the examined ducts that are not due to artifact (eg, air bubbles), the findings always correspond with intraductal growths at pathology. The degree of confidence for other findings is more variable and corresponds to individual experience and the technical quality and success of a ductographic examination. The absence of convincing visible pathologic findings on a ductogram does not exclude local pathophysiologic changes. Therefore, some physicians advocate close interval follow-up; however, others prefer surgical ductal excision. False Positives/NegativesTo the author's knowledge, no large studies have been conducted to define the positive or negative predictive values of galactography. In the author's experience, which encompasses more than 2 decades, with approximately 100 ductograms performed annually, intraductal contrast-agent filling defects at ductography have always corresponded with intraductal epithelial growths at histopathology; therefore, ductography has no false-positive findings. Most defects (98%) represent solitary intraductal papillomas or papillomatosis. Less than 2% of pathologic findings on ductograms are associated with intraductal malignancies at surgery. In the few patients with biopsy-proven intraductal malignancies, galactography demonstrates irregular ducts and never solitary contrast-agent filling defects. In the published data as well as in the author's experience, a negative galactographic finding does not exclude intraductal disease. In patients with clear or sanguineous discharge and negative ductographic findings, abnormalities may still be proven at surgery. In approximately 10% of patients with these findings, histopathology demonstrates micropapillary epithelial proliferations; the corresponding false-negative rate for pathologic findings at galactography is 10%. In less than 1% of cases, histopathology demonstrates atypical ductal hyperplasias or intraductal malignancies; the corresponding false-negative rate for neoplastic changes at galactography is less than 1%. MRISection 5 of 9
FindingsMagnetic resonance (MR) galactography remains under investigation and is not the method of choice in evaluating nipple discharge. ULTRASOUNDSection 6 of 9
FindingsUltrasonography is indispensable as a complementary diagnostic tool in the investigation of breast abnormalities. However, ultrasonography is not commonly indicated for the evaluation of nipple discharge. Ultrasonography is an adjunctive tool for breast evaluation when more specific indications, including an abnormal mammographic finding or a palpable clinical finding, are present. Technological advances in high-resolution ultrasonography mean that in the future this modality may have a role in breast ductal evaluation. INTERVENTIONSection 7 of 9
Spontaneous, unilateral nipple discharge from a single ductal orifice warrants investigation if the secretion is clear and watery or if it is sanguineous or serosanguineous.5 Medical/Legal Pitfalls
MULTIMEDIASection 8 of 9
REFERENCESSection 9 of 9
Breast, Nipple Discharge Evaluation excerpt Article Last Updated: May 30, 2007 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
