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Technical Innovation |
1 Department of Clinical Radiology, Kuopio University Hospital and Kuopio
University, Puijonlaaksontie 2, FIN-70210 Kuopio, Finland.
2 Department of Pathology, Kuopio University Hospital and Kuopio University,
Kuopio, Finland.
3 Department of Surgery, Kuopio University Hospital and Kuopio University,
Kuopio, Finland.
Received April 26, 2004;
accepted after revision August 26, 2004.
Address correspondence to A. Koskela.
Abstract
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CONCLUSION. Galactography-aided wire or coil localization is a practical localization method for intraductal lesions not detectable on mammography or sonography.
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Lesions that present with nipple discharge are not typically visible on mammography or sonography of the breast and are detected only on galactography [4, 5]. As a consequence, the usual methods of biopsy or preoperative localization of breast lesions (wire placement under sonography or stereotactic guidance) are usually not applicable. Galactography alone may not provide adequate guidance for surgery. Up to 20% of abnormalities identified on galactography remain undetected on surgical pathology [6]. Retromammillary lesions can be detected perioperatively by methylene dye staining of the duct. Distant lesions may be difficult to localize despite perioperative methylene dye staining because the dye quickly diffuses from the ducts into breast tissue, which may lead to excessive resection. Also, it may be impossible to localize the lesion in cases of intermittent nipple discharge in which no discharge is detected during surgery because the secreting duct cannot be identified and cannulated.
Pathologic ducts can be accurately localized using a combination of galactography and wire or coil localization under stereotactic guidance. This may help prevent incomplete or excessive surgery. The aim of our study was to assess the feasibility and diagnostic performance of these techniques in patients with spontaneous unilateral nipple discharge.
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Before surgery, the lesions were localized by cannulating the secreting duct with the patient supine and the ipsilateral arm resting behind the head. First, the nipple and the periareolar area were cleansed with an ethanol swab. The orifice of the secreting duct was localized using slight periareolar pressure to produce discharge. The secreting ducts were cannulated by gently inserting a sterile, blunt, 30-gauge curved or a 20-mm straight metallic cannula (MDTech galactography kit). The cannula was connected to small-volume extension tubing with a 1-mL syringe filled with the water-soluble, nonionic contrast material iohexol (Omnipaque 240 mg I/mL, Amersham Health). The duct was filled with 0.2-2 mL of contrast material by gentle hand injection until resistance was felt, the patient reported discomfort or pain, or there was back-flow of the contrast material at the nipple. The cannula and syringe were fixed securely in place with a bandage to enable administration of additional contrast material, if necessary, and to minimize contrast material leakage. The patient was transferred from the examination table to a mammography unit (Sophie, Planmed). Standard orthogonal film-screen magnification views were obtained from the retroareolar area to verify that the correct duct was cannulated and to further locate the filling defect.
An add-on stereotactic device (Cytoguide, Planmed) was set in place on the mammography unit. The film-screen magnification images just obtained were used to locate the fenestration on the compression plate. Two scout images were first obtained from the target area, and the breast lesion localization needle with the wire (DuaLok, Bard) or a coil (MReye breast lesion needle localization coil, Cook) was targeted to the filling defect under stereotactic guidance. Two more scout images were taken to ensure proper location of the needle tip, which was corrected if needed. When the needle tip was correctly placed within the lesion, a wire or coil was delivered through the location needle and the needle was pulled out. After the procedure, standard craniocaudal and mediolateral mammographic views were obtained so the surgeon could verify the correct location of the wire and lesion. Two of us performed all procedures.
Surgical excision of the diseased duct segment was performed immediately after the localization procedure. A periareolar incision was made to enter the retromammillary area. An excision containing the tip of the wire and 1-2 cm of the surrounding area was created. Retromammillary intraductal lesions are usually small; thus, a perioperative frozen sample examination was not done. The surgical sample was prepared and analyzed using standard histopathologic techniques. Retrospectively, all cases were carefully reviewed in a multidisciplinary meeting with a pathologist, radiologist, and the operating surgeon to confirm that the lesion identified by galactography was in the surgical sample.
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Table 1 shows the patient data and lesion characteristics. The one malignancy (micropapillary DCIS), which was detected in patient 6, was high grade with two foci of microinvasion. The patient had thick, bloody nipple discharge for 6 months. Cytology from the discharge was suggestive of a papillary tumor. On galactography, a duct with multiple branches was visualized and a 3-mm filling defect was noted in the proximal inferomedial branch, 6 cm from the nipple. Surgery was performed under guidewire and methylene dye guidance (Figs. 1A, 1B, 1C). Because of large, high-grade DCIS and unclear resection margins, a subsequent skin-sparing mastectomy with immediate reconstruction was performed.
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Patient 2 had intermittent discharge. Cannulation of the duct was successful only on the third galactography attempted because there was no discharge and the duct could not be found in earlier attempts. An ectatic duct with a narrowing and a filling defect suggestive of an intraductal lesion were noted; the area was marked with coils. In addition, a wire was introduced toward the coil under sonography guidance preoperatively (Figs. 2A, 2B, 2C, 2D). During surgery, there was no discharge to guide cannulation and methylene dye staining was not performed. The area with the coils and wire was excised. Benign intraductal papillomatosis was diagnosed on histologic examination.
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Galactography is a method of choice to find intraductal pathology. In the absence of abnormalities at physical examination, mammography, or sonography, the conventional preoperative localizing methods (palpation, sonography, and stereotactic-guided wire localization) usually cannot be used.
Galactography alone may not provide adequate guidance for surgery. Baker et al. [6] report on 30 cases; in six cases, none of the abnormalities revealed on galactography was identified on surgical pathology. The position of the galactographic lesion imaged in the compressed breast may be different in the noncompressed supine breast on the operating table, especially when the lesion is deep.
Traditionally, surgical resection has been performed with perioperative methylene dye marking the secreting duct. Retromammillary tumors usually can be easily found with this technique, but more proximal lesions may be difficult to detect in the operating room. Methylene dye quickly diffuses from the ductal system into breast tissue, potentially leading to excessive excisions. In patients with small breasts or benign findings, overly extensive excisions may not be acceptable because of the possible deformity of the nipple-area complex. Lesions causing intermittent discharge are often difficult to localize. If there is no discharge during surgery, the pathologic duct may remain undetected. Thus, additional techniques to localize intraductal lesions are desirable.
With mammographic wire localization immediately after galactography, the
filling defect can be marked for the surgeon, helping prevent incomplete or
excessive resection. In addition, a wire in the surgical sample may help the
pathologist find the lesion. Chow et al.
[8] describe successful
localization of an intraductal lesion using mammographic guidance with an
-numeric grid after galactography. Mammographic localization using an
-numeric grid is a simple method and can be done without expensive
stereotactic equipment. However, the use of stereotactic guidance is more time
efficient.
Coil localization has proven useful in patients with a lesion causing intermittent discharge. Immediately after successful galactography, the filling defect can be marked with a coil, which can be left in the breast. The coil is easily marked with wire for further surgery. In one of our patients, coil localization was performed 1 week before surgery. On the day of surgery, the coil was localized with a wire under sonography guidance. Coil localization would have also been possible under stereotactic guidance.
Hild et al. [9] report a series of 35 patients with abnormal nipple discharge. Ductal abnormalities were detected by ductal-oriented high-frequency sonography in 26 patients and galactography in 19 patients. If pathology is detected by sonography, primary localization of the lesion should be performed by sonography to avoid unnecessary ionizing radiation. In our study, sonography was performed on five patients, all with normal findings.
Recent studies report promising results using imaging-guided minimally invasive biopsy to diagnose and treat intraductal lesions causing nipple discharge [10-12]. Dennis et al. [11] describe a technique in which a sonography-guided Mammotome (Ethicon Endo-Surgery) biopsy was performed immediately after galactography. The discharge resolved in 97.2% of the 38 patients after the biopsy. Guenin [12] performed a stereotactic vacuum-assisted biopsy immediately after galactography in five patients; the diagnosis was benign papilloma in all cases. In four of the patients, nipple discharge ceased after biopsy; one patient had surgical excision for atypia detected within the papilloma. These new techniques are promising in the diagnosis and treatment of solitary lesions. Multiple lesions, if they are located apart or in many duct branches, as in two of our patients, may require complete removal by surgery. All our patients remained free of nipple discharge after surgery.
New imaging-guided methods are promising in the diagnosis and treatment of solitary intraductal lesions causing nipple discharge. However, surgery may be needed in cases of multiple lesions. Surgery has traditionally been considered the gold standard for confirming a diagnosis and treating the discharge. The pathologic duct can be localized using preoperative diagnostic galactography or perioperatively using methylene dye. With retromammillary lesions, these techniques may be sufficient. However, additional techniques, such as stereotactic wire or coil localization under galactography guidance, may be beneficial in localizing distant and multiple lesions and lesions causing intermittent discharge that are not visible on mammography or sonography.
Acknowledgments
We thank Lea Pulliainen for her valuable comments concerning surgical
treatment of the patients and Tuula Bruun for her invaluable assistance in the
preparation of the manuscript.
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