June Challenge: Can you diagnose this breast lesion?

November 2, 2007
Surgical Rounds®, June 2007, Volume 0, Issue 0

Can you diagnose this breast lesion?

June Challenge: Can you diagnose

this breast lesion?

Maria Flynn, MD

GU Imaging Chief

Radiology Intern

Program Director

Department of Radiology

Naval Medical Center Portsmouth

Portsmouth, VA

Each month, Dr. Maria Flynn issues a Radiology Challenge, presenting images from one of a variety of imaging modalities and a case report. Can you diagnose the condition? Follow the link to find out whether your answer was correct, what was really wrong with the patient, and how the patient was treated. Then, come back next month to test your radiographic reading skills on a new case!

Dr. Maria Flynn is Chief of Genitourinary Imaging and Radiology Intern Program Director at the Naval Medical Center Portsmouth, as well as a Lieutenant Commander in the US Navy Medical Corps. She received her medical degree from Tulane Medical School in 1994 and completed her radiology residency at the National Capital Consortium in 2003. She is certified by the American Board of Radiology and has been appointed Adjunct Assistant Professor of Radiology and Radiological Sciences at the F. Edward Hébert School of Medicine.

Case report

A 45-year-old woman presented to the hospital with spontaneous unilateral nipple discharge occurring for approximately 2 years. She noted the discharge to be intermittently bloody. Physical examination revealed clear discharge from the 10 o'clock position of the left nipple. No masses were palpated and no skin changes were identified. A mammogram (Figures 1 and 2) and a magnified galactography (Figures 3 and 4) were performed.

Challenge: Given the patient's history and radiology findings, the most likely cause of the nipple discharge is:

  1. Invasive carcinoma
  2. Ductal carcinoma in situ
  3. Intraductal papilloma
  4. Hamartoma

Answer: c) Intraductal papilloma

Although the most likely cause of unilateral nipple discharge is benign intraductal papilloma, 10% to 15% of spontaneous nipple discharge is due to breast carcinoma; therefore, surgical excision of the identified lesion is warranted.1,2 The color of the discharge is not a significant consideration in making a diagnosis because any unilateral discharge should be investigated histologically.3 Generally, bilateral nipple discharge is due to an endocrine related disorder, such as a pituitary adenoma.

Figure 5

Lesions causing unilateral nipple discharge should be investigated with galactography because they are usually not seen on mammography or ultrasonography.4 In a study of 826 women who underwent surgical excision of galactographic abnormalities, more than 40% had a solitary papilloma, 13.4 % had invasive carcinoma or carcinoma in situ, and 13.7% had extensive intraductal solid papillary or adenomatous epithelial proliferation.3

In this case, surgical resection was performed in conjunction with wire localization from a steriotactic galactogram (Figure 5). Wire localization following galactography has been proven to increase the pathologic correlation and decrease incomplete or excessive surgeries. As many as 20% of abnormalities identified on galactography (without wire localization) are missed during excision and are absent during surgical pathology review.1 Some reasons for this include nipple discharge that is intermittent and not detected during surgery, rapid periopertative methylene blue diffusion into lesions distal from the retroareolar region, and tortuous or diving ducts that are difficult to follow during surgical excision.

References

  1. Koskela A, Berg M, Pietilainen T, et al. Breast lesions causing nipple discharge: preoperative galactography-aided stereotactic wire localization. AJR Am J Roentgenol. 2005;184(6):1795-1798.
  2. Van Zee KJ, Ortega Perez G, Minnard E, et al. Preoperative galactography increases the diagnostic yield of major duct excision for nipple discharge. Cancer. 1998;82(10):1874-1880.
  3. Paterok EM, Rosenthal H, Sabel M. Nipple discharge and abnormal galactogram. Results of a long-term study (1964-1990). Eur J Obstet Gynecol Reprod Biol. 1993;50(3):227-234.
  4. Woods ER, Helvie MA, Ikeda DM, et al. Solitary breast papilloma: comparison of mammographic, galactographic, and pathologic findings. AJR Am J Roentgenol. 1992;159(3):487-491.

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