Breast Discharge: Ultrasound and Doppler Evaluation - NCI

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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%)
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Breast Discharge: Ultrasound and Doppler Evaluation - NCI

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