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Table of Contents
REVIEW ARTICLE
Year : 2021  |  Volume : 26  |  Issue : 2  |  Page : 77-83

Exploring the resourcefulness of an underutilized modality: Conventional ductography


Department of Radiation Medicine, Faculty of Medical Sciences, College of Medicine, University of Nigeria, Ituku-Ozalla, Enugu, Nigeria

Date of Submission27-Mar-2020
Date of Decision24-Aug-2020
Date of Acceptance05-Oct-2020
Date of Web Publication29-Jan-2021

Correspondence Address:
Nneka Ifeyinwa Iloanusi
Department of Radiation Medicine, Faculty of Medical Sciences, College of Medicine, University of Nigeria, Ituku-Ozalla, Enugu.
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmh.IJMH_15_20

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  Abstract 

Ductography (DG), also called galactography, is an important imaging diagnostic tool for evaluating patients with suspicious nipple discharge (SND). It is practical and cost-effective yet it is heavily underutilized in resource-constrained countries. The aim of this review was to explore the use of conventional DG as a diagnostic tool in the management of patients with pathologic or SND. This is a review of available literature on DG and SND over the past 36 years. In patients with SND, conventional DG is still a valuable, simple, and cost-effective imaging tool for the accurate localization of causal intra-ductal lesions including breast cancer. In resource-challenged environments, therefore, promoting ductographic diagnosis is cost-effective and attractive because it also affords curative targeted duct excisions.

Keywords: Breast cancer, duct, ductography, galactography, pathological or suspicious nipple discharge excision


How to cite this article:
Ezeofor SN, Iloanusi NI, Okere PC. Exploring the resourcefulness of an underutilized modality: Conventional ductography. Int J Med Health Dev 2021;26:77-83

How to cite this URL:
Ezeofor SN, Iloanusi NI, Okere PC. Exploring the resourcefulness of an underutilized modality: Conventional ductography. Int J Med Health Dev [serial online] 2021 [cited 2022 Aug 12];26:77-83. Available from: https://www.ijmhdev.com/text.asp?2021/26/2/77/308246




  Introduction Top


Nipple discharge is a frequent breast complaint making up about 3%–10% of all complaints among women with breast pathology.[1] Most discharges are milky, multiduct, and bilateral and therefore physiological. Pathological nipple discharges are usually bloody, serous, or clear and arise spontaneously from a single duct.[2] Aside from benign causes such as intraductal papillomas, malignancy is a known cause in 10%–15% of cases.[3] These cancers and other causal intraductal lesions may be nonpalpable and are typically not readily visualized on mammography or breast ultrasound but are detected by ductography (DG).[3],[4],[5] This aside, other more sophisticated diagnostic modalities like MR-DG are frequently inaccessible in resource-challenged environments due to unavailability and high cost. In this regard conventional DG (also called galactography––GL) offers hope. It is a valuable imaging tool in patients with suspicious/pathological nipple discharge (SND/PND).[6] It is procedurally, simple, and its cost-effectiveness compliments its accuracy in the detection, localization, and characterization of the cause of duct abnormalities as well as the determination of the extent of intraductal lesions.[7],[8],[9] Furthermore, preoperative DG enables evaluation of the extent of the disease, identification of the central and peripheral lesions thereby enabling accurate guidance of surgical excision.[10]

Despite all its inherent advantages especially in resource-poor environments with high incidence of breast-related morbidities like cancer, this important diagnostic procedure is grossly underutilized, as can be attested for by the paucity of published literature in Africa. It may also be attributable to under-reporting.


  Materials and Methods Top


Review of available literature on DG and pathological nipple discharge in the past 36 years.


  Literature Review Top


MEDLINE, PubMed, and the Web of Knowledge electronic data bases were searched for identification of review papers, original articles, and case reports using the following keywords: pathological, suspicious nipple discharge (SND), DG, GL, duct excision, breast cancer. Only publications in English language were selected.

[TAG:2]Technique of Ductography[5],[11][/TAG:2]

DG is a simple contrast procedure done by a radiologist with good illumination and a magnifier. Prior to this, the patient’s medical records are reviewed, the procedure and possible complications are explained to the patient and informed consent is obtained.[12]

Ductography cannulas

There are two types of cannulas for DG: the straight and the right-angled cannulas. The straight enhances flexible in-depth placement. It is better in patients with inverted nipples or those with fissures and crevices. An example is the 30-gauge end-port sterile sialography infusion cannula initially designed for sialography. The right-angled tip cannula, also called Jabczenski cannula is actually designed for easier taping of the device in place after successful cannulation. The cannula is evenly connected to a small-volume extension tubing and then to a 1–3mL syringe filled with contrast medium, for example, iopamidol.

Contents of a DG procedure tray

The procedure tray should contain the following: DG cannula set, contrast medium, gauze pad, sterile alcohol swabs, 3-mL syringe, gloves, nursing pad, test strips, magnifying glass preferably headset, high-intensity light source, plaster/paper tape, and xylocaine gel.

Technique of ductography

A precontrast/preliminary view is taken in a craniocaudal subareolar magnification view to assess the breast for suspicious calcifications or mass. On the examination table, with the patient lying in the oblique supine position [Figure 1] with the ipsilateral arm raised and the hand placed behind the back of head, the nipple is examined with a high-intensity lamp. Local xylocaine spray may be used prior to cannulation. After wearing sterile gloves, the nipple is gently cleansed and sterilized with an alcohol swab or povidone-iodine swab also to clean off dried secretions. The discharging nipple is identified by gentle periareolar pressure thereby localizing the “trigger point” which is the part around the breast that reliably and reproducibly produces ND when compressed. A test strip, for example, Hemastix, if available, could be used to check for the presence of blood in the ND. After carefully expelling all gas in the DG device, a sialography needle, or blunt-tipped cannula is placed in the discharging orifice with the aid of a magnifying lens, then gentle downward pressure is applied with stabilization of the nipple between the thumb and the forefinger. In addition, the nipple can be gently raised and straightened on cannulation; it can be rotated or gently angulated as the cannula is guided into the pore. This is because the duct openings may be at varying locations within the external channel of the pore. Local anesthetic gel, for example, 2% xylocaine gel or warm moist compress with a wash cloth can be applied to the nipple and areola to relax the surface and adjoining muscle fibres thereby aiding easier cannulation.
Figure 1: Image showing the insertion of the ductography needle and injection of contrast

Click here to view


On getting into the duct orifice, 0.2–0.3mL of contrast medium is administered. In the case of ductal ectasia, a larger volume may need to be instilled. In our practice, we discontinue the contrast instillation as soon as the patient begins to feel some discomfort. The cannula is then taped in place and the syringe strapped to the skin. A single digital spot magnification craniocaudal view is obtained with the breast in compression. Thereafter, a 90° mediolateral magnification view of the subareolar breast is obtained. At the end of the procedure, the tape is removed and a nursing pad put over the nipple to avert fluid staining the patient’s clothing.


  Normal DG Appearance Top


Normal ductographic features in lactating women are that of arborization and tortuosity, which may have variations in duct caliber giving an apparent “beaded” appearance but with no duct dilatation.[5] The lactiferous sinus is a dilated, fusiform segment adjacent and posterior to the nipple. The diameter of the cannula is comparative to the diameter of other parts of the duct. The demonstration of the ducts (which can proceed in unexpected directions as they emanated from the nipple) is vital information for the operating surgeons.[11]

Another possible normal finding is the lobular blush which is due to contrast medium filling the lobular portion of the terminal ductal lobular unit, indicating that the volume pressure in that ductal system has reached its maximum.[12]


  Limitations/Contraindications/Complications Top


The limitation of DG is that in patients with intermittent ND or nipple retraction, it may be difficult to cannulate the duct and at surgery may prove impossible to localize the lesion.[3] Extravasation of the contrast medium and reflux are possible side effects of the procedure. Presence of artifacts can also give an erroneous assessment. The presence of an air bubble can mimic a ductal filling defect. This is seen as a rounded, well- defined, filling defect within the duct which typically shifts in position between images.

There are no absolute contraindications to DG.[13] The relative contraindications are mastitis or breast abscess. In these cases, the contrast injection may worsen the inflammation.[13],[14] Patients with allergy to contrast medium and those with non-severe reactions, for example, itching, erythema or hives, pre-treatment with antihistamines and corticosteroids is recommended. In addition, a low-osmolar contrast medium is preferred.[11]

The complications of DG are duct perforation with resultant intense pain and subsequent mastitis. If too much volume or pressure is used during the contrast injection, it can result in duct perforation and peripheral extravasation of contrast and lymphatic opacification.[5],[14] Duct perforation is evidenced by dense subareolar blush and a sharp, severe burning pain experienced by the patient.[15] Also, excessive injection of contrast can obscure small lesions It is therefore advisable to start the technique carefully with very small amounts of contrast. This will make all the above-mentioned complications a rare occurrence.[5]


  Ductography Classifications Top


DG findings can be classified following any of two schemes, namely the Gregl scheme and the Galactogram Imaging Classification System (GICS).

The Gregl scheme[16] grade findings are as follows: (1) technically inadequate investigation, (2) normal findings, (3) duct ectasia (i.e., duct > 2 mm), (4) filling defects, (5) filling stops, and (6) ductal distortions. A report has shown that DG has a 100% specificity and 100% positive predictive value in the detection of ductal pathologies.[17] The same study by Manganaro et al.[17] also noted that at DG there is a statistical association between filling stop (G5) and DCIS and between ductal distortion (G6) and papillary cancer.



The Galactogram Imaging Classification System (GICS)[18] developed by Berna-Serna et al.[6] classified galactographically detectable findings into different categories.

Ductographic appearances in common breast pathologies[11]

Ductal ectasia

A condition in which there is a dilated ductal system without filling defects, duct wall irregularity, obstruction, extravasation, or architectural distortion [Figure 2].
Figure 2: Ductal ectasia: the right craniocaudal (RCC) and mediolateral oblique (RMLO) views of a ductogram showing a dilated tortuous ductal system in a 40-year-old woman with 3 months history of solitary, unilateral, and brownish-red nipple discharge. Note that there are no filling defects and no irregularity in the outline of the duct

Click here to view


Fibrocystic change

The appearance is that of normal ducts communicating with cysts.

Papillomas

These are the most common of all the causes of suspicious ND. Papillomas are benign tumors of the ductal epithelium. DG features include smooth intraluminal filling defect if small, or an irregular outline if large. Ducts proximal to the papilloma are often not dilated. However, a papilloma may secrete fluid filling up the proximal and distal aspects of the duct [Figure 3]. There may also be focal ductal narrowing at the point of the filling defect. Another feature is that of the “amputated duct,” which signifies complete obstruction of the column of contrast at the location of the papilloma.
Figure 3: A 48-year-old postmenopausal woman with a history of brownish, unilateral, solitary ND from the left breast. LMLO and LCC images show a consistent, well-defined, differential density (black arrow) at the ampullary aspect of the left offending duct suggestive of intraductal papilloma. Note that there is associated focal ductal dilatation

Click here to view


Carcinoma

Ductographic features of intraductal malignancy include a precontrast view shows casting and pleomorphic calcification within the ducts. With contrast introduction, there are intraductal filling defects near the nipple, with dilatation of the duct distally. Other features include irregularity of the ductal wall. Curiously, some features may sometimes resemble those of intraductal papilloma.

Ductal ectasia, papilloma, and ductal carcinoma may be seen in combination in the same patient.

The differential diagnosis of some findings on DG

Diffuse irregularities of the ductal wall can also be seen in cases with pseudo-lesions which can also present as solitary, multiple, or extensive filling defects. Its findings are not reproducible on preoperative DG. Pseudolesions have an unknown etiology but the proposed explanations are blood clots, inspissated duct secretions, or less likely muscle contractions. The differential diagnosis of an abrupt “cut-off” of a column of contrast in the duct is postmajor subareolar duct excision in which there is an abrupt termination at the site of surgical ligation.[5]

DG in breast cancer diagnosis

Researchers have reported a good correlation between GICS category 5 and cancer.[6] They further noted that the retro- and periareolar region is where most solitary intraductal papillomas are seen but centrally and/or peripherally is where cancers are located more frequently. Studies by Hou et al.[19] revealed that patients with ND caused by cancer had their lesions located >2 cm from the nipple.

It has been reported that ND is a very significant symptom in males and is more frequently associated with malignancy than in females.[20],[21] Researchers have noted that any ND in a male should be regarded as malignant until proven otherwise.[22] Furthermore, in clinical practice, ND is observed to cause anxiety to women. Most pathological NDs present without a detectable lump and undefined mammographic and ultrasound findings.[4],[23] DG has the advantage of a higher diagnostic yield than mammography and ultrasonography. In previous years, patients with ND who underwent complete subareolar excision without prior DG imaging developed complications such as nipple inversion and numbness and postoperative seroma formation.[24]

Several reports have described findings on DG that suggest malignancy,[19],[25],[26] while others have argued that DG may not differentiate benign from malignant lesions.[16],[27]

Other authorities declare that its predictive role in the non-operative setting is limited.[12] Morrogh et al.[12] and Adepoju et al.[28] in their studies of 306 and 168 cases, respectively, with suspicious ND concluded that the absence of a lesion on DG may not totally exclude malignancy. However, since DG identifies the abnormal ductal system, avoidance of incomplete or excessive removal of breast tissue is achieved.[11],[15] It increases the diagnostic yield of major duct excision by allowing selective duct excision to be done.[12]

Preoperative DG

Studies have shown that DG aids in the pre-operative assessment and further management of patients with suspicious ND.[20],[29] Localization of the causative lesion improves detection of the specific pathology at surgery.[20] The injection of methylene blue post DG maps the offending duct and aids accurate surgical excision.[13],[30],[31]It also facilitates recognition of lesions on histological examination; an advantage underscored by the fact that on histological examination, up to 20% of major duct excision specimens do not include the lesion found in a previously obtained conventional DG.[32] Duct excision postmethylene blue injection should be quick to prevent dye diffusion leading to possible excessive breast tissue excision and scarring.[3]

Other techniques such as ductographic-aided stereotactic wire or coil localization, and use of the alpha-numeric grid also help prevent excessive breast tissue excision.[20],[31],[33],[34]


  MR Ductography Top


Although magnetic resonance imaging MRI has been reported to have a higher sensitivity in detection of ductal diseases compared to conventional DG,[17] it is very expensive and not readily available in resource-poor settings. The same goes for other novel tools used to evaluate SND such as MR DG using microscopic coil[35],[36] and DG with tomosynthesis (galactosynthesis).[37]


  Comparative Costs Top


With all the advantages of conventional DG, it is surprising that in a resource-constrained environment like ours where the cost of a conventional DG is less than 20 USD and about 400 USD for MR-DG, this very simple yet potentially useful technique is not widely used as a tool in the early detection of intraductal lesions which may potentially prove to be cancers. Conventional DG is therefore more than 60 times cheaper than the nearest specific axial alternative.

Although researchers have shown that DG is an investigation that is rarely carried out in radiological practice leading to ill-experience of the procedure among most resident doctors and radiologists,[38],[39],[40] for an unclear reason, recent reports noted that the utility of DG cannot be overemphasized in cases of SND; therefore, it should still be included.[41],[42],[43]

Despite its cost-effectiveness, there isa paucity of data in the literature on local experiences with DG techniques. Therefore, there is a need for training and retraining on the use of this resourceful procedure to further enhance the management of patients with SND, especially in developing countries.


  Conclusion Top


Conventional DG is a simple imaging and interventional procedure used not only in the localization and preoperative assessment of patients with SND, but also it is invaluable in the accurate histological sampling of the excised specimen.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Morrogh M, Morris EA, Liberman L, Borgen PI, King TA The predictive value of ductography and magnetic resonance imaging in the management of nipple discharge. Ann Surg Oncol 2007;14:3369-77.  Back to cited text no. 12
    
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Piccoli CW, Feig SA, Vala MA Breast imaging case of the day. Benign intraductal papilloma with focal atypical papillomatous hyperplasia. Radiographics 1998;18:783-6.  Back to cited text no. 15
    
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Manganaro L, D’ Ambrosio I, Gigli S, Di Pastena F, Giraldi G, Tardioli S, et al. Breast MRI in patients with unilateral bloody and serous-bloody nipple discharge: A comparison with galactography. Biomed Res Int 2015;2015:1-9.  Back to cited text no. 17
    
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  In this article
Abstract
Introduction
Materials and Me...
Literature Review
Technique of Duc...
Normal DG Appearance
Limitations/Cont...
Ductography Clas...
MR Ductography
Comparative Costs
Conclusion
References
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