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In the management of breast discharge within non-lactating women, ductography often plays a key role in deciding on the necessity for surgical biopsy or assisting in the localization of the area to be removed.

Ductography services are available at St. Mary’s Hospital (258-6933) through Madison Radiologists. Identification of ductal ectasia and/or cysts only at ductography, in the absence of bloody discharge may allow conservative follow up. However, identification of focal intraductal mass at ductography, or persistent bloody discharge is a usual indicator for surgical biopsy.

Opinions vary on which types of breast discharge require work-up and potential ductography. The presence of bloody discharge is more concerning since the incidence of cancer in this situation is 7-28%. The algorithm for the evaluation of non-bloody discharge is more controversial since in the vast majority of circumstances, cancer is not present. However, some cancers can present with serous or watery discharge. Factors such as the number of draining orifices (more = less suspicious), unilaterality (bilateral = less suspicious), age, presence or absence of a lump, cytology and the appearance of the mammogram will influence management in these circumstances.

Because of the complexities involved in deciding appropriate management, most cases of breast discharge should undergo surgical consultation. Then, the breast surgeon can decide whether ductography will contribute.

If surgery in inevitable because of proven persistent bloody discharge, then we recommend a localization and biopsy be scheduled at the same time as the diagnostic ductogram. This will spare the patient a return appointment for a second ductogram and localization.

The Procedure

Because there are multiple small orifices at the nipple, successful procedure requires the ability to reproduce the discharge at the time of ductography so the proper duct can be cannulated. The radiologist will attempt to elicit the discharge by squeezing the breast. Sometimes, the patient will be asked to assist with this.

In a small percentage of cases, the discharge may not be reproduced. In this circumstance, the procedure must be rescheduled for a second attempt on another day.

After the discharge is elicited, a small catheter (cannula) is inserted into the draining orifice. This usually produces mild discomfort, often described by patients as less than they would expect. However, if the cannulation is difficult, an uncomfortable irritation can be experienced.

Small amounts of contrast are then injected and mammograms are performed.

If a biopsy has been scheduled for the same day, then an additional localization procedure may be performed with a needle through the skin, or a small wire placed into the draining orifice.

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Intraductal papilloma (benign). Craniocaudad magnified ductogram in patient with bloody discharge demonstrates irregular filling defect (arrowhead) of papilloma, medial peri-areolar breast

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Intraductal papilloma (benign). Medial-lateral magnified ductogram in same patient demonstrates irregular filling defect (arrowhead) of papilloma.

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