Multimodality Imaging of Benign and Malignant Diseases of the Nipple-Areolar Complex.

The nipple-areolar complex (NAC), a unique anatomic structure of the breast, encompasses the terminal intramammary ducts and skin appendages. Several benign and malignant diseases can arise within the NAC. As several conditions have overlapping symptoms and imaging findings, understanding the distinctive nipple anatomy, as well as the clinical and imaging features of each NAC disease process, is essential. A multimodality imaging approach is optimal in the presence or absence of clinical symptoms. The authors review the ductal anatomy and anomalies, including congenital abnormalities and nipple retraction. They then discuss the causes of nipple discharge and highlight best practices for the imaging workup of pathologic nipple discharge, a common condition that can pose a diagnostic challenge and may be the presenting symptom of breast cancer. The imaging modalities used to evaluate and differentiate benign conditions (eg, dermatologic conditions, epidermal inclusion cyst, mammary ductal ectasia, periductal mastitis, and nonpuerperal abscess), benign tumors (eg, papilloma, nipple adenoma, and syringomatous tumor of the nipple), and malignant conditions (eg, breast cancer and Paget disease of the breast) are reviewed. Breast MRI is the current preferred imaging modality used to evaluate for NAC involvement by breast cancer and select suitable candidates for nipple-sparing mastectomy. Different biopsy techniques (US -guided biopsy and stereotactic biopsy) for sampling NAC masses and calcifications are described. This multimodality imaging approach ensures an accurate diagnosis, enabling optimal clinical management and patient outcomes. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.

Combination of 68 Ga-FAPI-04 and Dedicated Breast PET (MAMMI PET) Outperformed Breast MRI and 18 F-FDG PET/CT by Revealing Nipple and Skin Involvement of Breast Cancer.

ABSTRACT: A 41-year-old woman with newly diagnosed breast cancer had suspicious clinical findings of skin involvement on physical examination. The primary tumor had no FDG uptake in 18 F-FDG PET/CT. Nipple and skin had no pathologic enhancement for invasion in breast MRI. Because the T stage was unclear, the patient underwent 68 Ga-FAPI-04 PET/CT for further evaluation. Combination of 68 Ga-FAPI-04 with dedicated breast PET (MAMMI PET) showed nipple and skin involvement of breast cancer with intense FAPI uptake. Consequently, a skin-sparing mastectomy was performed. Histopathological examination confirmed invasive lobular carcinoma infiltration of the deep dermis in the nipple and skin tissue.

Using Laser-Assisted Indocyanine Green Angiography to Assess Nipple-Areolar Complex Survival During Reduction Mammoplasty.

BACKGROUND: In reduction mammoplasty, preserving an appropriate skin flap is crucial to achieve a favorable postoperative appearance and prevent blood supply disorders in the nipple-areolar complex (NAC). Previous studies have indicated that a thinner or narrower flap is more favorable for breast shaping, but also increases the risk of blood supply disorders. Accessing the blood perfusion of the NAC and determining the critical threshold for NAC viability are essential aspects of reduction mammoplasty. OBJECTIVES: The aim of this study was to utilize indocyanine green (ICG) angiography to assess NAC perfusion during reduction mammoplasty. It also sought to identify critical thresholds of various indicators affecting NAC survival and provide guidance for skin flap trimming. METHODS: Thirty-eight patients who underwent reduction mammoplasty were included. Each patient received ICG angiography before and after skin flap trimming. Data on NAC perfusion, skin flap length, width, thickness, and other relevant indicators were collected. RESULTS: Among the patients, 5 experienced NAC blood supply disorders. Multiple linear regression analysis demonstrated that the NAC blood supply had a significant correlation with the tissue thickness at the pedicle base (P < .001) and with the length-to-width ratio across the nipple (P < .05). To optimize NAC survival and achieve favorable breast shaping, cutoff points for the thickness at the pedicle base and the length-to-width ratio across the nipple of 1.15 cm and 1.71, respectively, were established. CONCLUSIONS: ICG angiography provides an effective means to assess NAC blood supply and postoperative survival. The cutoff points established in this study help to predict the survival of the NAC and guide flap trimming.

Clinical Significance of Contrast-Enhanced Ultrasound Galactography in Pre-operative Diagnosis of Patients With Pathologic Nipple Discharge.

OBJECTIVE: The aim of the work described here was to investigate the feasibility and diagnostic value of using contrast-enhanced ultrasound (CEUS) galactography with SonoVue in patients with pathologic nipple discharge (PND). METHODS: Twenty-eight patients who underwent breast surgery for PND from May 2019 to August 2021 were included. Routine ultrasound, ductoscopy and CEUS galactography were performed successively. Lesions were diagnosed and localized. The sensitivity, specificity and pre-operative localization value of each examination method were evaluated on post-operative pathology. RESULTS: CEUS galactography was successfully conducted in all 28 patients and revealed negative ductal ectasia, filling stop and filling defect. Ductoscopy revealed positive nodules in 21 cases and negative nodules in 7 cases. A total of 18 nodules were found by routine ultrasound, and the relationship between all nodules and the discharge duct was confirmed after CEUS galactography. Compared with the other two methods, CEUS galactography had higher sensitivity, positive predictive value and negative predictive value (100%, 81.82% and 100%, respectively), while it has the same specificity as routine ultrasound (both 60%). The pre-operative location of the nipple duct was consistent with the intra-operative findings in 28 patients after CEUS galactography. CONCLUSION: The ultrasound contrast agent SonoVue can be used for CEUS galactography in patients with PND. CEUS galactography can improve the detection of ductal nodules and locate the nipple discharge duct pre-operatively. As the technique does not emit radiation and SonoVue is easily metabolized and safe, CEUS galactography is better than conventional imaging for PND patients.

Evaluation of nipple vascularity using superb microvascular imaging in patients with reduction mammoplasty.

We aimed to investigate the effect of the chosen pedicle on nipple vascularity by evaluating changes in the microvascular circulation of the nipples in patients undergoing reduction mammoplasty through superb microvascular imaging study (SMI). 70 nipples were included in this retrospective study. There were 15 patients (30 nipples) in Group A using the inferior pedicle and 20 patients (40 nipples) in Group B using the superomedial pedicle. The vascular index (VI) of each nipple were evaluated preoperatively and at the third postoperative month using SMI. The mean VI in Group A was 1.25 (0.5-3.6) preoperatively and 1.3 (0.4-3.2) at the third postoperative month (P > .05). The mean VI in Group B was 1.65 (0.7/2.9) preoperatively and 1.15 (0.2/1.9) at the third postoperative month (P < .05). While the VI increased by 11.3% in Group A, it decreased by 30.6% in Group B (P < .001). The changing of the VI was analyzed between comparable groups, and decreasing microvascular circulation of the nipple with use of the superomedial pedicle was detected by quantitative values, which can be useful in at-risk patient groups, the planning of surgical procedures, and early revisions at postoperative month 3.

A Nomogram Based on Conventional and Contrast-Enhanced Ultrasound for Pre-operative Prediction of Nipple-Areola Complex Involvement in Breast Cancer: A Prospective Study.

OBJECTIVE: Accurately predicting nipple-areola complex (NAC) involvement in breast cancer is essential for identifying eligible patients for a nipple-sparing mastectomy. This study was aimed at developing a pre-operative nomogram for NAC involvement in breast cancer using conventional ultrasound (US) and contrast-enhanced ultrasound (CEUS). METHODS: All patients with primary breast cancer confirmed by pre-operative biopsy underwent US and CEUS examinations. Post-operative pathology was used as the gold standard in assessing NAC involvement. Lasso regression was used to select the predictors most associated with NAC involvement. A nomogram was constructed to calculate the diagnostic efficacy. The data were internally verified with 500 bootstrapped replications, and a calibration curve was generated to validate the predictive capability. RESULTS: Seventy-six patients with primary breast cancer were included in this study, which included 16 patients (21.1%) with NAC involvement and 60 patients (78.9%) without NAC involvement. Among the 23 features of US and CEUS, Lasso regression selected one US feature and two CEUS features, namely, ductal echo extending from the lesion, ductal enhancement extending to the nipple and focal nipple enhancement. A nomogram was constructed, and the results revealed that the area under the curve, sensitivity, specificity and accuracy were 0.891, 81.3%, 86.7% and 85.5%, respectively. The calibration curve exhibited good consistency between the predicted probability and the actual probability. CONCLUSION: The nomogram developed based on US and CEUS had good performance in predicting NAC involvement in breast cancer before surgery, which may facilitate the selection of suitable patients for NAC preservation with greater oncological safety.

The "Trunk sign": A novel X-ray sign in galactography of patients with nipple discharge suggesting malignancy.

The etiology of nipple discharge is often unclear, and there are few studies exploring diagnostic approaches of nipple discharge. Galactography is a common method for clinical diagnosis of patients with nipple discharge. Therefore, this study aimed to evaluate the use of galactography in differentiating between benign and malignant lesions in patients with nipple discharge. A retrospective study of 161 patients with nipple discharges, who were evaluated with galactography and underwent surgery in Qilu Hospital of Shangdong University between January 2018 and December 2019, was conducted. Baseline characteristics were obtained from their electronic records including age, menstruation status, physical examination, galactography, cytology, and pathology. There were 110 cases of benign disease, 12 cases of high-risk disease, and 39 cases of malignant disease. With respect to benign diseases there were 26 (23.6%) patients with hyperplasia and ductal ectasia, and 94 (76.4%) with intraductal papilloma. With respect to high risk diseases, there were 2 (16.7%) patients with atypical intraductal papilloma and 10 (83.4%) with atypical hyperplasia. With respect to malignant lesions, 19 (48.7%) patients had intraductal carcinoma, 4 (10.3%) had solid papillary carcinoma, and 16 (41.0%) had invasive carcinoma. The significant findings of our study are as follows: patients with malignant diseases had a higher proportion of concomitant masses (74.4% vs 41.7% vs 22.7%, P < .001), positive spill cytology (51.3% vs 41.7% vs 2.7%, P < .001), and trunk signs (71.8% vs 33.3% vs 10.9%, P < .001). A forest plot revealed that trunk signs were related to an increased risk of malignant diseases in almost all the subgroups. Galactography is important for the differential diagnosis of benign and malignant lesions in nipple discharge, and the "Trunk sign" is an important radiographic sign of malignant lesions. Combining galactography with other methods is advisable to improve the accuracy of diagnosis in patients with nipple discharge.

Use of Magnetic Resonance Imaging for Evaluating Residual Breast Tissue After Robotic-Assisted Nipple-Sparing Mastectomy in Women With Early Breast Cancer.

OBJECTIVE: Prospective studies on postoperative residual breast tissue (RBT) after robotic-assisted nipple-sparing mastectomy (R-NSM) for breast cancer are limited. RBT presents an unknown risk of local recurrence or the development of new cancer after curative or risk-reducing mastectomies. This study investigated the technical feasibility of using magnetic resonance imaging (MRI) to evaluate RBT after R-NSM in women with breast cancer. MATERIALS AND METHODS: In this prospective pilot study, 105 patients, who underwent R-NSM for breast cancer at Changhua Christian Hospital between March 2017 and May 2022, were subjected to postoperative breast MRI to evaluate the presence and location of RBT. The postoperative MRI scans of 43 patients (age, 47.8 ± 8.5 years), with existing preoperative MRI scans, were evaluated for the presence and location of RBT. In total, 54 R-NSM procedures were performed. In parallel, we reviewed the literature on RBT after nipple-sparing mastectomy, considering its prevalence. RESULTS: RBT was detected in 7 (13.0%) of the 54 mastectomies (6 of the 48 therapeutic mastectomies and 1 of the 6 prophylactic mastectomies). The most common location for RBT was behind the nipple-areolar complex (5 of 7 [71.4%]). Another RBT was found in the upper inner quadrant (2 of 7 [28.6%]). Among the six patients who underwent RBT after therapeutic mastectomies, one patient developed a local recurrence of the skin flap. The other five patients with RBT after therapeutic mastectomies remained disease-free. CONCLUSION: R-NSM, a surgical innovation, does not seem to increase the prevalence of RBT, and breast MRI showed feasibility as a noninvasive imaging tool for evaluating the presence and location of RBT.

Diagnostic Accuracy of Magnetic Resonance Imaging Features and Tumor-to-Nipple Distance for the Nipple-Areolar Complex Involvement of Breast Cancer: A Systematic Review and Meta-Analysis.

OBJECTIVE: This systematic review and meta-analysis evaluated the accuracy of preoperative breast magnetic resonance imaging (MRI) features and tumor-to-nipple distance (TND) for diagnosing occult nipple-areolar complex (NAC) involvement in breast cancer. MATERIALS AND METHODS: The MEDLINE, Embase, and Cochrane databases were searched for articles published until March 20, 2022, excluding studies of patients with clinically evident NAC involvement or those treated with neoadjuvant chemotherapy. Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Two reviewers independently evaluated studies that reported the diagnostic performance of MRI imaging features such as continuity to the NAC, unilateral NAC enhancement, non-mass enhancement (NME) type, mass size (> 20 mm), and TND. Summary estimates of the sensitivity and specificity curves and the summary receiver operating characteristic (SROC) curve of the MRI features for NAC involvement were calculated using random-effects models. We also calculated the TND cutoffs required to achieve predetermined specificity values. RESULTS: Fifteen studies (n = 4002 breast lesions) were analyzed. The pooled sensitivity and specificity (with 95% confidence intervals) for NAC involvement diagnosis were 71% (58-81) and 94% (91-96), respectively, for continuity to the NAC; 58% (45-70) and 97% (95-99), respectively, for unilateral NAC enhancement; 55% (46-64) and 83% (75-88), respectively, for NME type; and 88% (68-96) and 58% (40-75), respectively, for mass size (> 20 mm). TND had an area under the SROC curve of 0.799 for NAC involvement. A TND of 11.5 mm achieved a predetermined specificity of 85% with a sensitivity of 64%, and a TND of 12.3 mm yielded a predetermined specificity of 83% with a sensitivity of 65%. CONCLUSION: Continuity to the NAC and unilateral NAC enhancement may help predict occult NAC involvement in breast cancer. To achieve the desired diagnostic performance with TND, a suitable cutoff value should be considered.

Development of Three-Dimensional Breast Scan and Measurement Application Using Laser Imaging Detection and Ranging Sensor on iPhone.

SUMMARY: Laser imaging detection and ranging (LiDAR) is a modern three-dimensional (3D) technology that uses a time-of-flight method based on the round-trip time of an infrared laser beam to detect the presence and features of objects. The iPhone 12 Pro is the first smart mobile device with built-in LiDAR sensors. The authors' team developed a software application based on iOS devices with built-in LiDAR sensors for 3D breast scanning and automatically analyzing the breast's geometric measurement. Breast geometry, including midclavicle-to-nipple distance, sternal notch-to-nipple distance, nipple-to-inframammary fold (IMF) distance, distance between nipples, and body circumference on nipple and IMF level were measured using the software application and tapeline. The relative technical error of measurement (rTEM) value was used to calculate the error ratios between the measurements acquired by the software application and those of the tapeline. Good rTEM values ranging from 2.99% to 5.19% were found in the midclavicle-to-nipple distance, sternal notch-to-nipple distance, distance between nipples, nipple-level circumference, and IMF-level circumference. However, there was a poor rTEM value greater than 10% in the nipple-to-IMF distance. The proposed software application using current iOS devices with built-in LiDAR sensors can provide an ideal 3D scanning system that has a low cost burden, good accuracy, portability, and ease of use.

Resolution of Nonmass Enhancement Extension to the Nipple at Breast MRI after Neoadjuvant Chemotherapy: Pathologic Response and Feasibility for Nipple-sparing Mastectomy.

Background Nipple-sparing mastectomy (NSM) is usually contraindicated in patients with nonmass enhancement (NME) extension to the nipple at breast MRI. However, little is known about the feasibility of NSM when NME extension to the nipple resolves after neoadjuvant chemotherapy (NAC). Purpose To evaluate whether NSM is an appropriate surgical procedure for patients in whom NME extension to the nipple resolves after NAC. Materials and Methods This retrospective study included 383 women with NME at baseline MRI who underwent NAC followed by mastectomy between January 2007 and March 2022 at a single institution. NME extension to the nipple was assessed using breast MRI before NAC (hereafter, pre-NAC) and after NAC (hereafter, post-NAC). In 326 women who underwent mastectomy with removal of the nipple-areolar complex, the rate of pathologic analysis-confirmed tumor invasion of the nipple compared with NME extension to the nipple at post-NAC breast MRI was evaluated. Tumor involvement of the nipple was also assessed in those with complete pathologic response at posttreatment MRI. Furthermore, the outcomes in 57 women undergoing NSM were investigated, particularly in patients with NME extension to the nipple at initial diagnosis. Results Of the 326 women who underwent mastectomy with removal of the nipple-areolar complex (mean age, 49 years ± 9.4 [SD]), 217 patients (67%) showed NME extension to the nipple on pre-NAC MRI scans. Among the 153 women (70%) in whom the NME extension to the nipple resolved after NAC, the rate of pathologic analysis-confirmed tumor invasion of the nipple was 2.6% (four of 153 women; 95% CI: 0, 6.5). No pathologic analysis-confirmed tumor invasion of the nipple was detected in 31 women with complete response at MRI. Of the 57 women who underwent NSM, 12 (21%) with resolution of NME extension to the nipple after NAC had no relapse during the median follow-up of 31 months (range, 11-80 months). Conclusion Pathologic analysis-confirmed tumor invasion of the nipple was rare in women with resolution of nonmass enhancement extension to the nipple after neoadjuvant chemotherapy (NAC). Therefore, nipple-sparing mastectomy could be feasible in this population, especially in those with complete MRI response to NAC. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Lee in this issue.

Improving Decision-making in Prepectoral Direct-to-implant Reconstruction After Nipple Sparing Mastectomy: The Key Role of Flap Thickness Ratio.

We report our experience in direct-to-implant breast reconstruction with prepectoral polyurethane implants, with a focus on intraoperative mastectomy flap thickness compared to preoperative data (flap thickness ratio) as a reliable predictive variable of ischemic complications and reconstructive outcomes (satisfaction with breast). BACKGROUND: The optimization of nipple sparing mastectomy and implant-based reconstruction techniques led to an increase in the popularity of prepectoral reconstruction. The aim of this study is to explore the ratio between the intraoperative and preoperative breast tissue coverage assessment as reliable tool in order to predict the risk of ischemic complications in prepectoral reconstruction. METHODS: We analyzed 124 preoperative digital mammograms of 100 patients who underwent prepectoral implant-based reconstruction. We applied a Rancati modified score for breast tissue coverage classification, adding 4 measurements on the craniocaudal view. The intraoperative mastectomy flap thickness was measured using an intraoperative ultrasound assessment. We investigated the differences between the groups with and without ischemic complications related to the preoperative, intraoperative, and flap thickness ratio data. RESULTS: The flap thickness ratio was lower in ischemic complication group compared to no ischemic complication group (0.4 vs. 0.8) with statistically significant differences for all ischemic complication subgroups: major mastectomy flap necrosis (P = .000), minor mastectomy flap necrosis (P = .005), partial nipple areola complex necrosis (P = .007), and implant exposure (P = .001).

Nipple-areolar complex (NAC) or skin flap ischemia necrosis post nipple-sparing mastectomy (NSM)-analysis of clinicopathologic factors and breast magnetic resonance imaging (MRI) features.

BACKGROUND: The purpose of this study is to identify clinicopathologic factors and/or preoperative MRI vascular patterns in the prediction of ischemia necrosis of the nipple-areola complex (NAC) or skin flap post nipple-sparing mastectomy (NSM). METHODS: We performed a retrospective analysis of 441 NSM procedures from January 2011 to September 2021 from the breast cancer database at our institution. The ischemia necrosis of NAC or skin flap was evaluated in correlation with clinicopathologic factors and types of skin incision. Patients who received NSM with preoperative MRI evaluation were further evaluated for the relationship between vascular pattern and the impact on ischemia necrosis of NAC or skin flap. RESULTS: A total of 441 cases with NSM were enrolled in the current study, and the mean age of the cases was 49.1 ± 9.8 years old. A total of 41 (9.3%) NSM procedures were found to have NAC ischemia/necrosis. Risk factors were evaluated of which old age, large mastectomy specimen weight (> 450 g), and peri-areola incision were identified as predictors of NAC necrosis. Two-hundred seventy NSM procedures also received preoperative MRI, and the blood supply pattern was 18% single-vessel type and 82% double-vessel pattern. There were no correlations between MRI blood supply patterns or types of skin flap incisions with ischemia necrosis of NAC. There were also no correlations between blood loss and the pattern or size of the blood vessel. CONCLUSION: Factors such as the type of skin incision, age, and size of mastectomy weight played an important role in determining ischemia necrosis of NAC; however, MRI vascular (single or dual vessel supply) pattern was not a significant predictive factor.

Utility of Nipple Markers in the Era of Digital Imaging.

PURPOSE: Nipple markers maybe used to decrease the recall of patients undergoing chest radiography by aiding in distinguishing between a nipple shadow and lung nodule. We evaluated the use of digital chest radiographs in clinical practice including accuracy of placement and markers that do not contribute to interpretation (ie, projected outside the lung fields). We also evaluated the recall rate for additional imaging in patients who received nipple markers compared to those who did not. MATERIAL AND METHODS: In this Institutional Review Board approved retrospective study, 1000 consecutive outpatient frontal and lateral chest radiographs performed in 2018 for which nipple markers were provided to patients formed the study group. Three cardiothoracic radiologists evaluated the images for the presence of markers and accuracy of placement. The recall rate was calculated over a 3-year period from March 21, 2016 and March 21, 2019. RESULTS: One or both markers were missing without an explanation (such as mastectomy), misplaced or outside the lung fields in 57.8% (578/1000) of studies. The 3-year recall rate for all chest radiographs was very low (0.03%; 42/135,792) and was lower for patients provided nipple markers (0.007%; 5/62,587) than those who were not (0.05%; 37/73,205) ( P <0.001). CONCLUSIONS: The low overall recall rate and high prevalence of inaccurate marker placement or markers that do not contribute to interpretation (ie, outside the lung fields) does not justify the routine use of nipple markers for chest radiography.

The nipple-areolar complex: anatomy, methods and pathologic findings, between senologist and dermatologist.

The purpose of this presentation is to show the ultrasonography findings of normal variants and benign and malignant diseases that affect the nipple-areolar complex. Many of which have unspecific clinical and radiological presentations that can present a challenge for medical specialists. Experienced specialists need to know the different imaging modalities used to study the nipple-areolar complex and the aspect not exactly senology, as well as dermatologist who approach the ultrasound must know the anatomy of this complex area. We will show you a combined clinical and radiological approach to evaluate the nipple-areolar complex, the findings for the normal morphology and the most common benign and malignant diseases that can affect this region. We discuss the characteristics of the different ultrasonography findings and provide guidance on how to avoid artifacts and pitfalls.

A comparative analysis of diagnostic values of high-frequency ultrasound and fiberoptic ductoscopy for pathologic nipple discharge.

BACKGROUND: This study aimed to compare the diagnostic accuracy of high-frequency ultrasound (HFUS) and fiberoptic ductoscopy (FDS) for pathologic nipple discharge (PND). METHODS: HFUS and FDS were conducted in 210 patients with PND (248 lesions) treated at our hospital. The diagnostic accuracy of these two methods was compared using pathological diagnosis as the standard. RESULTS: Among 248 lesions, 16 and 15 of 16 malignant lesions were accurately diagnosed by HFUS and FDS, respectively. Of 232 benign lesions, 183 and 196 cases were accurately diagnosed by HFUS and FDS, respectively. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of HFUS in diagnosis of intraductal lesions were 84.36% (95% CI 79.26-88.39%), 60% (95% CI 23.07-92.89%), 96.03% (95% CI 96.55-99.83%), and 7.31% (95% CI 2.52-19.4%) respectively. The sensitivity, specificity, PPV, and NPV of FDS in diagnosis of intraductal lesions were 86.83% (95% CI 82.00-90.52%), 100% (95% CI 56.55-100%), 100% (95% CI 98.21-100%), and 13.51% (95% CI 5.91-27.98%) respectively. Diagnostic accuracy rates of HFUS and FDS were 83.87% (208/248) and 85.08% (211/248), respectively, exhibiting no statistically differences (χ2 = 0.80, P > 0.05). The accuracy of HFUS combined with FDS was 93.14% (231/248), showing statistically differences (χ2 = 10.91, P < 0.05). CONCLUSIONS: Both HFUS and FDS demonstrated high diagnostic values for PND. HFUS has the advantage of non-invasive for nipple discharge with duct ectasia, exhibited good qualitative and localization diagnostic values. It is the preferred evaluation method for patients with nipple discharge. When HFUS cannot identify the cause of PND, FDS can be considered.

The Value of Adding Ductography to Ultrasonography for the Evaluation of Pathologic Nipple Discharge in Women with Negative Mammography.

OBJECTIVE: The optimal imaging approach for evaluating pathological nipple discharge remains unclear. We investigated the value of adding ductography to ultrasound (US) for evaluating pathologic nipple discharge in patients with negative mammography findings. MATERIALS AND METHODS: From July 2003 to December 2018, 101 women (mean age, 46.3 ± 12.2 years; range, 23-75 years) with pathologic nipple discharge were evaluated using pre-ductography (initial) US, ductography, and post-ductography US. The imaging findings were reviewed retrospectively. The standard reference was surgery (70 patients) or > 2 years of follow-up with US (31 patients). The diagnostic performances of initial US, ductography, and post-ductography US for detecting malignancy were compared using the McNemar's test or a generalized estimating equation. RESULTS: In total, 47 papillomas, 30 other benign lesions, seven high-risk lesions, and 17 malignant lesions were identified as underlying causes of pathologic nipple discharge. Only eight of the 17 malignancies were detected on the initial US, while the remaining nine malignancies were detected by ductography. Among the nine malignancies detected by ductography, eight were detected on post-ductography US and could be localized for US-guided intervention. The sensitivities of ductography (94.1% [16/17]) and post-ductography US (94.1% [16/17]) were significantly higher than those of initial US (47.1% [8/17]; p = 0.027 and 0.013, respectively). The negative predictive value of post-ductography US (96.9% [31/32]) was significantly higher than that of the initial US (83.3% [45/54]; p = 0.006). Specificity was significantly higher for initial US than for ductography and post-ductography US (p = 0.001 for all). CONCLUSION: The combined use of ductography and US has a high sensitivity for detecting malignancy in patients with pathologic nipple discharge and negative mammography. Ductography findings enable lesion localization on second-look post-ductography US, thus facilitating the selection of optimal treatment plans.