Breast Discharge: Ultrasound and Doppler Evaluation - NCI

Journal of the Egyptian Nat. Cancer Inst., Vol. 20, No. 3, September: 262-270, 2008
Breast Discharge: Ultrasound and Doppler Evaluation
SOHA T. HAMED, M.D.*; MOSTAFA H. ABDO, M.D.** and HOSSAM H. AHMED, M.D.***
The Departments of Radiology*, General Surgery** and Pathology***, Faculty of Medicine, Cairo University.
ABSTRACT
Background: Nipple discharge causes discomfort and
anxiety to many women. Nipple discharge is most commonly
associated with endocrine alterations and/or medications.
These often result in duct ectasia and/or fibrocystic
changes that may lead to discharge from one or several
ducts.
The most common cause of clinically significant
discharge is intraductal growth of the ductal epithelium,
due to hyperplasia, micropapillary proliferation, solitary
papillomas and/or ductal carcinoma (both in situ and
invasive).
The aim of the study was to evaluate the role of the
gray-scale ultrasound and colour Doppler in the diagnosis
of intraductal pathology in patients with nipple discharge.
Patients and Methods: One hundred &seven patients
were included in the study, (age range 23-65years). Standard
mammographic views were taken. Ultrasound evaluation
was performed for all cases; ductography for 20
cases and ductoscopy for 3 cases. US guided fine needle
biopsy was done in 7 cases; microducectomy of affected
duct was done in 20 cases and major duct excision in
5cases. Fibro-optic Ductoscopy is performed for 3 cases.
Results: Revision of biopsy specimens of 17 cases
with intraluminal masses detected by US revealed: Six
cases with intraductal carcinoma, intraductal papilloma
in 7 cases, 1 case of ductal papillomatosis. Three cases
showed atypical cells: Intraductal papilloma with atypia
in 2 cases, proliferative hyperplasia with atypia in one
case. Eighty eight cases had simple duct ectasia (51
bilateral multiple and 37 focal duct ectasia). No dilated
ducts were detected in 2 cases. Fibro-optic Ductoscopy
confirmed the presence of intraductal papilloma in one
case, carcinoma in one case, no intraductal masses in the
third case. A 6 months follow-up was requested for all
cases with no detected intra luminal pathology. Ultrasound
examination is highly sensitive (100%) but less specific
(82.4%) in diagnosis of intraductal pathology. Colour &
power Doppler are sensitive (94%) in detecting flow in
Correspondence: Dr Soha Talaat Hamed, 6 El Shaik Zaid
District 1, sohathamrd@yahoo.com, 010 5309414.
intraductal echogenic masses to differentiate them from
insipissated secretions. Colour and power Doppler raises
specificity and diagnostic accuracy to 100%. Ductography
is an underused procedure that is sensitive (100%) but
less specific (60%) in characterization of intraductal filling
defects.
Conclusion: Ultrasonography is a mandatory complement
to mammography in these cases, US guided fine
needle biopsy is minimally invasive technique in confirming
the diagnosis of suspicious mass. Ultrasound may also
be a guide to fibro-optic ductoscope.
Key Words: Ductography – Nipple discharge – Intraductal
carcinoma – Intraductal papilloma – In
situ ductal carcinoma – Invasive ductal carcinoma
– Duct ectasia – Breast ductoscopy.
INTRODUCTION
Nipple discharge is a symptomatic problem
that causes both discomfort and anxiety to many
women. Tremendous advances have been made
in the management of breast problems, mainly
through advances in diagnostic breast imaging
[1].
The 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
discharge from one or several nipple ducts. The
most common cause of clinically significant
discharge is intraductal growth of the ductal
epithelium, due to 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 1-4cm of the nipple
[2].
262

Breast Discharge: Ultrasound & Doppler Evaluation
Ultrasound is an indispensable complementary
diagnostic tool in the investigation of breast
abnormalities. Ultrasound is not typically used
unless the nipple discharge is accompanied by
a palpable mass or a positive mammographic
finding. Ultrasound may be useful in presurgical
localization if galactography reveals a dilated
duct larger than a few millimeters in width.
Modern high-resolution Ultrasound techniques
are becoming more sensitive for the visualization
of intraductal changes. Tiny solitary papillomas
can sometimes be visualized by using this sophisticated
technology [3].
The aim of the study was to evaluate the
role of the gray-scale ultrasound and colour
Doppler in the diagnosis of intraductal pathology
in patients with nipple discharge.
PATIENTS AND METHODS
One hundred and seven patients were included
in the study, their mean age 42±13
years and their ages ranged between 23 and
65 years. Mammograms were performed for
all cases using "Siemens Mammomat Mammography
Unit". Cranio-caudal, mediolateral
and oblique views were performed for both
breasts. A range of 25-28 KVP and 30-60 MAS
were used. Mammograms were fully inspected
to assess the parenchyma density and pattern,
the presence or absence of associated mass
lesions and calcifications and each was analyzed
individually. The skin thickness, the
condition of nipple areola complex and associated
lymphadenopathy were also reported.
In addition to mammography, Ductography
was performed for 20 cases. The nipple was
inspected to identify the orifice of secretion,
After the nipple is sterilized, a ductography
cannula (i.e., a needle with a blunt end) was
gently inserted into the secreting orifice; Approximately
0.2-0.8mL of water-soluble contrast
material is slowly injected by using a 1-
or 3-mL syringe.
Ultrasound was performed for all patients
with an Ultramark Philips HDI 5000, Siemens
Sonoline Elegra, voluson 730 machines using
a 7-10MHz linear transducer. The region to be
examined extends from the clavicle above to
the infra-mammary fold below and from the
sternum medially to the mid-axillary line laterally.
The axilla and supraclavicular regions
263
were also carefully scanned for lymph node
enlargement. A special technique was applied
to examine the retroareolar region by applying
excessive gel on the nipple with gentle pressure
for better visualization of the retroareolar ducts.
The dilated duct was traced throughout its
whole length. Whenever any intraductal lesion
is seen, we should calculate how far it is from
the nipple. This should be followed by 3D
application which allows better lesion delineation
and Color and power Doppler evaluation
to characterize lesion vascularity Ultrasound
guided fine needle biopsy was performed for
7 cases.
In three cases ductoscopy was performed:
Short term anesthetic was administered, the
nipple was scrubbed and rapped; the breast was
deeply massaged from periphery to the center,
as if expressing milk at lactation. The target
duct (fluid-yielding duct) was identified by
manual compression of the individual lactiferous
sinuses. The duct was dilated using the dilators
of lactiferous duct then the ductoscope was
inserted (Fig. 1).
Criteria of lesion assessment:
• Intraductal papillomas: Are mostly oval in
shape, hypo to isoechoic in echopattern, with
smooth margins. A vascular stalk or minimal
peripheral vascularity is usually identified on
Doppler application.
• Intraductal papilloma with atypia: Showed
higher vascularity than papillomas. The vessels
are arranged in haphazard distribution.
• Malignant intraductal lesions: Appeared less
uniform with corresponding malignant microcalcification
seen on mammography films.
On colour Doppler, malignant lesion showed
higher vascularity, non tapering randomly
dispersed vessels except in small mass lesions.
• Simple duct ectasia: Appeared on mammography
as tubular or diffuse retroareolar increased
density. On ultrasound they appeared
as dilated thin walled ducts (caliber >3mm),
some showed mobile echogenic secretions
that are not adherent to the duct walls, others
revealed inspissated ball like echogenic secretions.
No colour was detected on Doppler
application.

264
RESULTS
One hundred and seven patients, their mean
age 42±13 years and their ages ranged between
23 and 65 years, presenting either by uniorifical
breast discharge (54 cases) or multi orifice
discharge (one of them with bloody or serosanguous
discharge) (53 cases) (Table 1). Duct
ectasia was the predominant pathology, identified
in 88 cases, their ages range 23-53 years,
with mean age 33.8±11.6 years. While intraductal
mass lesions were identified in only 17
cases, their ages ranging between 27-65 years,
with mean age: 45±12 years. Two cases were
normal.
Ultrasound proved to have 100% and 82.4%
sensitivity and specificity in differentiating
intraductal mass from non mass lesions, namely
inspissated secretions and in identifying the
benign or malignant nature of these masses.
Colour and power Doppler raises specificity
and diagnostic accuracy to 100%.
The mean size of papillomas was (8.7±
4.3mm). They lied within 3.2±2.1cm from the
nipple. They all fulfilled the above described
criteria with the exception of two papillomas
with rather irregular outline (Fig. 2). A vascular
stalk could be identified in 4 cases and minimal
peripheral vascularity in 3 cases (Fig. 3), Ductoscopy,
performed for 1 case, confirmed the
site and size of the ultrasound detected papilloma
(Fig. 4). 3D US was performed confirming the
intraductal location of a lesion (Fig. 5).
The intraductal papillomas showing atypia
measured 5 and 11mm, being located between
12 and 27mm from the nipple respectively. They
showed higher vascularity than papillomas, the
vessels are arranged in haphazard distribution
(Fig. 6). The case proved to be ductal hyperplasia
with atypia, was discovered during annual
follow-up for fibrocystic breast changes, an
intraductal mass 5mm is seen 27mm from the
nipple (Fig. 7).
Ultrasound was complementary to mammography
in identifying malignant intraductal lesions,
one case proved to be invasive ductal
carcinoma, on mammography it was reported
as BIRADS 3, on ultrasound an intraductal mass
with wall irregularity was seen, microcalcification
are seen within the mass but obscured on
Soha T. Hamed, et al.
mammogram by lobulated dilated duct (Fig. 8).
Other masses were ranging in size 4-14mm, no
definite ductal dilatation was seen in two of
them. On colour Doppler, malignant lesion
showed higher vascularity, non tapering randomly
dispersed vessels except in small 4mm
mass.
Simple duct ectasia was identified in 88
cases according to the above described criteria.
Mammography showed tubular retroareolar
density in 8 cases, in the rest of cases, there
was just an increase in retroareolar density; By
US In 51 cases, bilateral dilated thin walled
ducts are ranging in caliber from 3-8mm, some
of the ducts showed Intra-ductal mobile, non
adherent movable echogenic secretions were
sometimes identified. In two cases, echogenic
ball like lesions were identified resembling
intraductal pappilomas, yet, they were non
adherent to the wall and no colour flow could
be detected on Doppler application (Fig. 9).
The ducts were completely normal on both
ultrasound and galactography in two cases.
Ductography was requested in 20 cases, in
five cases, intraductal filling defects were seen
three cases proved to be intraductal mass lesions,
other two cases were inssipisated secretions
with no malignancy. Ductography showed 100%
sensitivity and 60% specificity in diagnosing
intraductal filling defect.
Table (1): Pathological diagnosis of uni-orificial discha.
Pathological diagnosis
Intraductal carcinoma
Intraductal papilloma
(including intraductal
papillomatosis, one case)
Intra ductal papilloma/
hyperplasia with atypia
Localized duct ectasia
Bilateral diffuse duct ectasia
Normal
Total
No. of cases %
6 (5.6%)
8 (7.5%)
3 (2.8%)
37 (35%)
51 (47.7%)
2 (1.8%)
107 (100%)

Breast Discharge: Ultrasound & Doppler Evaluation
265
(A)
Fig. (1): Technique of ductoscope. A- Dilatation of the duct. B- Insertion of the ductoscope.
(B)
(A)
Fig. (2): 54 year - old female presenting with bilateral breast discharge & left uniorificial bleeding. A. US revealed bilateral
duct ectasia with an exceptionally dilated duct (9mm in caliber) located at 9 o’clock in the right retroareolar
region. Two irregular masses isoechoic to breast parenchyma, the largest (6x3mm) are seen about 1.2cm away
from the nipple (arrows). B. Power Doppler application showed a central vascular stalk in the larger lesion.
Diagnosis of intraductal papilloma was confirmed by both FNAB and post duct excision revision of the pathology
specimen.
(B)
(A)
Fig. (3): Two different cases of intraductal papillomas presenting by uni orificial bloody nipple discharge. Both lesions
appeared isoechoic. A. Mass was seen 2.8cm from the nipple. B. A central vascular stalk was identified on Power
Doppler. Diagnosis was confirmed after FNAB.
(B)

266
Soha T. Hamed, et al.
(A)
(B)
Fig. (4): 50 years old female, with single uniorificial bleeding. A- Gray scale US to the left showed hypoechoic intraductal
mass with cresentic hypoechoic outline in the periphery insuring intraductal site (curved arrow), to right of image
colour Doppler showed vascularity inside maintaining benign characters. B- The intraductal papilloma seen on
ductoscopy image.
(A)
Fig. (5): 40 years old female presenting by bleeding per nipple. A- An intraductal mass with rather microlobulated outline
is seen sagging from anterior upper wall of the duct. B- Surface rendering 3D US of intraductal mass.
(B)
(A)
Fig. (6): 35 years old female presenting by right uniorificial bleeding. A- US examination showed an isoechoic mass with
lobulated outline. B- Colour Doppler showed high vascularity with irregular distribution. Pathological diagnosis
was intraductal papilloma with atypia.
(B)

Breast Discharge: Ultrasound & Doppler Evaluation
267
(A)
(B)
Fig. (7): 35 years old female with long history of breast discharge &developed uniorificial bleeding. A- A small mass with
ill defined outline is seen with proximal ductal dilatation. B- On colour Doppler a small vascular stalk is seen.
Pathology was florid ductal hyperplasia with focal atypia.
(A)
(B)
(C)
(D)
Fig. (8): Forty years old female with right uniorficial sero-sanginous discharge. A- Mammogram mediolateral view
revealed retroarelar rather well circumscribed macro-lobulated mass(arrow). B- Radial US image showed an
irregular intraductal mass (arrows) & microcalcifications (arrow head). C- On colour Doppler non tapering
vascular stalk is seen. D- Ductoscopy image showed irregular intraductal mass.

268
Soha T. Hamed, et al.
(A)
(B)
Fig. (9): Forty years old female with uniorificial discharge. A- Galactography revealed two small intraductal filling
defects (arrow). B- US revealed multiple echogenic rounded lesions separable from the wall, no flow inside.
DISCUSSION
Nipple discharge disorders is a field in which
there has been both increasing awareness on
the part of patients and advances in management
[4].
In this study in five cases the only finding
seen in galactography was intraductal filling
defects. In dedicated study done by cho and his
colleagues ,they stated that in order to thoroughly
and accurately evaluate patients exhibiting
pathologic nipple discharges, it is important to
perform ductography and not to miss the subtle
but suspicious ductographic findings associated
with breast cancer. Diffusely spreading intraductal
cancers, with or without focal invasions,
are often found to be negative by mammography
(especially in absence of microcalcifications)
and sonography. In such cases, ductography
constitutes the best imaging method, as it has
proven effective in the determination of the
nature and extent of such lesions and can facilitate
appropriate surgical management [5].
We agree with other radiologists who maintain
that ductography is prohibitively timeconsuming
and that it can be replaced, at least
in part, by sonography. Intraductal papillary
lesions are sometimes visualized as isoechoic
or hyperechoic masses in dilated ducts on sonography
and can often be biopsied under sonographic-guidance
[6-8].
The quality of breast US is closely related
to the performance of the equipment used for
the examination and the skill of the examiner.
Linear-array, broad-bandwidth transducers with
maximum frequencies of 10-13MHz and a center
frequency of at least 7 or 7.5MHz are required
to depict Ductal carcinoma in situ
(DCIS). The adjustment of focal zones, system
gain and time gain compensation setting is also
important. US should be performed in radial
and anti-radial planes as well as longitudinal
and transverse planes. In patients with DCIS,
radial US is particularly useful for depicting
intraductal masses and evaluating the ductal
extent of disease, whereas anti-radial US is
more helpful for evaluating the surface characteristics
of the mass [9]. We add to perfect US
technique for assessment of retroareolar area,
excessive gel and gentle pressure to see mass
inside the duct.
Cancer risk from nipple discharge is reported
to be anywhere from 1.3% to 47% [10]. The
incidence of malignancy in this study was 5.6%
in addition to 2.8% precancerous condition
likely hyperplasia and atypia.
In this study, masses of intraductal carcinoma
are relatively hypoechoic compared to benign
cases, this coincides with those who reported
that ultrasound appearance of non-screening
detected intraductal carcinoma is relatively
isoechoic in comparison with invasive carcinoma
[10], regarding shape; oval shaped masses
proved in this study to be papillomas but assessment
of margins, was not a point of differentiation,
as in two cases of atypia which showed
macro-lobulated outline and in two cases of

Breast Discharge: Ultrasound & Doppler Evaluation
papilloma irregular outline was encountered.
Other authors reported that An oval or lobulated
shape was found more frequently in intraductal
carcinoma than in invasive carcinomas [11].
In malignant cases diagnosed in this study,
no microcalcification could be seen in mammography
even in the case of invasive duct
carcinoma. The microcalcifications were obscured
by dilated duct proximal to mass. Mammographic
detection of DCIS lesions without
microcalcifications may be quite difficult, especially
in dense breasts. At US, most DCIS
lesions without calcifications manifest as single
or multiple hypoechoic masses without a
pseudocapsule. Ductal extension is sometimes
seen. It is easier to visualize noncalcified DCIS
lesions than calcified DCIS lesions at US because
of their hypoechogenicity, but they can
also be misinterpreted as benign nodules due
to their roundness and well-circumscribed margins.
Posterior acoustic enhancement may be
seen in large masses. DCIS lesions without
calcifications may manifest as a solid or cystic
mass with solid component [12]. Diagnosis of
non-calcified DCIS by mammography is not an
easy task due to the lack of typical malignant
calcifications or masses. High resolution ultrasound
can be useful for detecting non-calcified
DCIS [13].
In the study of Yang and TSI in 2004, Color
power Doppler sonography revealed a positive
signal in 22 (69%) of 32 patients in whom it
was performed, so they concluded that it is not
discriminating feature [14]. In the contrary, in
our study all cases with intraductal masses
showed different pattern of vascularity. So it
was highly sensitive and specific (100%) in
discriminating between solid masses and inspissated
secretions. Vessel arrangement helped in
differentiating benign from malignant masses.
In this study, ultrasound guided ductoscopy
in three cases facilitated lesion delineation. The
size of the mass and its distance from the nipple
was comparable. Mammary endoscopy (ductoscopy)
is a recently introduced technique, which
may allow more precise identification and delineation
of intraductal disease but is not currently
a standard practice among most surgeons.
Ductoscopy has been reported to result in improved
localization of intraductal lesions [15].
269
We concluded that ultrasound examination
is highly sensitive(100%) but less specific
(82.4%) in diagnosis of intraductal pathology.
Colour & power Doppler are sensitive (94%)
in detecting flow in intraductal echogenic masses
to differentiate them from insipissated secretions.
Colour & power Doppler raises specificity
and diagnostic accuracy to 100%. Ultrasonography
is a mandatory complement to mammography
in these cases. US guided fine needle
biopsy is minimally invasive technique in confirming
the diagnosis of suspicious mass. Ultrasound
may also be a guide to fibro-optic ductoscope.
Ductography is an underused procedure
that is sensitive (100%) but less specific (60%)
in characterization of intraductal filling defects.
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