A Clinical Analysis of 640 Inpatients With Pathologic Nipple Discharge

Objective To discuss the value of early confirmation of breast cancer in patients with pathologic nipple discharge based on double surgical indications under fiberoptic ductoscopy (FDS) followed by staining with methylene blue. Methods From October 2012 to October 2019, a total of 640 inpatients with pathologic nipple discharge from Wuhan University Zhongnan Hospital underwent fiberoptic ductoscopy, followed by injection of methylene blue into the lesional duct through the discharged hole that would be resected as a segment according to the range of the staining duct on the next day. Based on double surgical indications, different findings by fiberoptic ductoscopy were defined as surgical indications, both with space-occupying intraductal lesions scanned by FDS and without space-occupying intraductal lesions but with dark red bloody fluid or yellow serous fluid spillage at the opening of the terminal mammary duct or extensive erosive duct lesions. We retrospectively analyzed the relations between results from fiberoptic ductoscopy and pathologic diagnosis. Results Inpatients with pathological neoplasm accounted for 87.3%(452/518) of the 518 inpatients with space-occupying intraductal lesions scanned by FDS, but the 122 inpatients without space-occupying intraductal lesions only accounted for 28.7%(35/122) of the patients (P=0.00). However, patients pathologically diagnosed with breast cancer accounted for 11.8% (61/518) of the 518 inpatients with space-occupying lesions and 10.7%(13/122) of the 122 inpatients without space-occupying lesions (P=0.728). Conclusions According to the double standards of surgical indication with or without space-occupying intraductal lesions scanned by fiberoptic ductoscopy, the method of fiberoptic ductoscopy followed by staining of the mammary duct by methylene blue could not only avoid missed diagnosis of breast cancer caused by ductoscopy itself, but also reduce the rate of missed diagnosis on account of inoperative inaccurate resection range, which greatly improved the early diagnosis rate of breast cancer with nipple discharge as the only initial clinical manifestation.

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.

Patient-reported outcomes of ductoscopy procedures for pathologic nipple discharge

Background Pathologic nipple discharge (PND) is a common complaint often associated with breast cancer. However, when ultrasound and mammography are negative, the chances of malignancy are lower than 5%. Currently, major duct excision and microdochectomy are often recommended to alleviate symptoms and definitely rule out malignancy, but can cause infections and breastfeeding problems. Ductoscopy is a minimally invasive endoscopy technique that allows visualization of the mammary ducts and may not only obviate surgery but also detect malignancy. The aim of this study was to determine quality of life (QOL) after ductoscopy in patients with PND. Materials and methods All PND patients referred for ductoscopy between 2014 and 2015 to our hospital were included. Ductoscopy procedures were performed under local anaesthesia in the outpatient clinic. Patients were asked to fill out questionnaires (Breast-Q, EQ-5D-5L and SF-36) on the day of ductoscopy, and after 2 weeks, 3 and 6 months. Additionally, we performed reliability analysis to determine if these questionnaires were suitable for PND patients. Results Fifty consecutive patients underwent ductoscopy of whom 47 patients participated in this study. One domain of SF-36 (vitality) varied significantly over time. Breast-Q, SF-36 and EQ-5D-5L showed that QOL after ductoscopy for PND was unaffected by ductoscopy. Success of the ductoscopy procedure was a significant predictor for satisfaction with the result domain. Conclusion Ductoscopy is a minimally invasive technique that does not seem to impact QoL of PND patients over time. Breast-Q, SF-36 and EQ-5D-5L seem to be suitable existing QOL tests for PND patients undergoing ductoscopy, whereas SF-36 would require modifications.

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.

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.