(Radiology. 2001;218:576-579.)
© RSNA, 2001
Benign Intraductal Papilloma: Diagnosis and Removal at Stereotactic Vacuum-assisted Directional Biopsy Guided by Galactography1
Mark A. Guenin, MD
1 From Tristán Associates, 4518 Union Deposit Rd, Harrisburg, PA 17111. Received December 3, 1999; revision requested January 19, 2000; final revision received May 15; accepted June 1. Address correspondence to the author (e-mail: mguenin@tristans.com).
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ABSTRACT
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Galactography was performed in women who had problematic nipple discharge. In five women who had a focal intraductal filling defect, immediate stereotactic vacuum-assisted directional biopsy of the filling defect was performed; results were a benign intraductal papilloma in each, with atypia in one. In the four women who did not have atypia, the procedure was diagnostic and appears to have been therapeutic as well, since nipple discharge ceased after the procedure.
Index terms: Breast, biopsy, 00.1267 • Breast, diseases, 00.312 • Breast, ducts, 00.127, 00.312 • Breast neoplasms, diagnosis, 00.127 • Breast neoplasms, localization, 00.1267 • Breast neoplasms, radiography, 00.1267, 00.127
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INTRODUCTION
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Galactography (ductography) is a useful procedure for evaluating problematic nipple discharge. For unilateral reproducible nipple discharge that is bloody or new and emanates from one duct orifice, galactography can depict the location and extent of intraluminal filling defects and provide mapping of the ductal system to assist in surgical duct exploration, if necessary.
Galactography has had limited acceptance, however. Many surgeons believe that in the setting of a problematic nipple discharge, surgical duct exploration is inevitable, and galactography will not alter the course of diagnosis or therapy; as a result, those surgeons do not request galactography.
During the past decade, surgical exploration of the breast has been supplanted to a large degree by minimally invasive techniques. Furthermore, with the combination of a dedicated prone stereotactic breast biopsy table and vacuum-assisted directional biopsy device, it is now possible to sample smaller targets while harvesting larger volumes of tissue than was previously possible (1). However, performance of stereotactic biopsy requires that a lesion be mammographically visible. Most intraductal lesions causing problematic nipple discharge are invisible at mammography; this limits the applicability of conventional stereotactic biopsy in patients with such lesions. Combining galactography and vacuum-assisted stereotactic biopsy should, in theory, enable minimally invasive biopsy and even removal of such lesions. I have performed five biopsies of this type; the techniques used and the results obtained are presented here.
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Materials and Methods
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During a 16-month period (October 1997 to January 1999), eight patients (mean age, 54 years; age range, 34–67 years) who had a reproducible unilateral nipple discharge that was new or bloody were referred for galactography. Informed consent was obtained from each patient for use of the technique studied, which combines galactography and stereotactic vacuum-assisted directional (Mammotome; Ethicon Endo-Surgery, Cincinnati, Ohio) breast biopsy performed in sequence. These procedures were scheduled at the same 2-hour intervals as for standard stereotactic biopsy.
The ducts were cannulated with the patient in a supine position on the dedicated stereotactic table (DSM; LoRad, Danbury, Conn). By using the technique described by Hou and colleagues (2), a 24-gauge, 19-mm-long pediatric intravenous catheter (Angiocath; Becton-Dickinson, Sandy, Utah) was threaded over 2-0 monofilament suture material (Prolene; Ethicon, Somerville, NJ). On occasion, if there was difficulty in cannulating the duct, a 30-gauge galactogram catheter (Ranfac, Avon, Mass) was used instead. The catheter was taped securely in place, and the patient was carefully turned to the prone position on the stereotactic table. The catheter tends to be easily dislodged, so it was necessary to stabilize the patient’s breast and catheter during the transition from the supine to the prone position so that the catheter was not inadvertently dislodged.
Once the patient was in position on the stereotactic table, with her breast suspended through the hole in the center of the table, compression was applied so that the fenestration of the compression plate was positioned over the subareolar region of the breast. The outline of the fenestration of the compression plate was marked on the skin surface to aid in detecting inadvertent patient movement. A digital scout image (Figure, part a) was obtained during gentle hand injection of water-soluble contrast material (diatrizoate meglumine 52% and diatrizoate sodium 8% [Renografin 60; Bracco Diagnostics, Princeton, NJ]) through the catheter. It was often necessary to reposition the patient to optimally visualize the opacified ductal system when the ductal system coursed off the edge of the image.
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Figure 1a. Images of a 4-mm benign intraductal papilloma in a 46-year-old woman with recent onset of reproducible dark sanguinous discharge from the right nipple. The mammogram and US image (not shown) were unremarkable. (a) Craniocaudal digital galactogram obtained with the patient in a prone position shows a 4-mm rectangular filling defect (arrow) with a smaller round bubble (arrowhead) immediately inferior to it. (b) Paired craniocaudal stereotactic images show the filling defect (arrows) and bubble (arrowheads); targeting was performed by using these paired images. (c) Paired craniocaudal stereotactic prefire images show the 11-gauge Mammotome probe advanced to a position slightly short of and slightly off-axis to the left of the filling defect (arrows); the probe was tilted toward the 3 o’clock position before firing. The off-axis position is preferable when targeting very small objects, since the probe will fire immediately alongside the nodule rather than through it. The main duct (arrowheads) anterior to the defect remains opacified. (d) Paired craniocaudal stereotactic postfire images obtained after the first sample was taken show the 11-gauge Mammotome probe through the region of the filling defect. (e) Paired craniocaudal stereotactic postbiopsy images show a cavity at the biopsy site (curved arrows) and a tissue-marking clip (arrowheads) deployed at the 3 o’clock position in the wall of the cavity.
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Figure 1b. Images of a 4-mm benign intraductal papilloma in a 46-year-old woman with recent onset of reproducible dark sanguinous discharge from the right nipple. The mammogram and US image (not shown) were unremarkable. (a) Craniocaudal digital galactogram obtained with the patient in a prone position shows a 4-mm rectangular filling defect (arrow) with a smaller round bubble (arrowhead) immediately inferior to it. (b) Paired craniocaudal stereotactic images show the filling defect (arrows) and bubble (arrowheads); targeting was performed by using these paired images. (c) Paired craniocaudal stereotactic prefire images show the 11-gauge Mammotome probe advanced to a position slightly short of and slightly off-axis to the left of the filling defect (arrows); the probe was tilted toward the 3 o’clock position before firing. The off-axis position is preferable when targeting very small objects, since the probe will fire immediately alongside the nodule rather than through it. The main duct (arrowheads) anterior to the defect remains opacified. (d) Paired craniocaudal stereotactic postfire images obtained after the first sample was taken show the 11-gauge Mammotome probe through the region of the filling defect. (e) Paired craniocaudal stereotactic postbiopsy images show a cavity at the biopsy site (curved arrows) and a tissue-marking clip (arrowheads) deployed at the 3 o’clock position in the wall of the cavity.
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Figure 1c. Images of a 4-mm benign intraductal papilloma in a 46-year-old woman with recent onset of reproducible dark sanguinous discharge from the right nipple. The mammogram and US image (not shown) were unremarkable. (a) Craniocaudal digital galactogram obtained with the patient in a prone position shows a 4-mm rectangular filling defect (arrow) with a smaller round bubble (arrowhead) immediately inferior to it. (b) Paired craniocaudal stereotactic images show the filling defect (arrows) and bubble (arrowheads); targeting was performed by using these paired images. (c) Paired craniocaudal stereotactic prefire images show the 11-gauge Mammotome probe advanced to a position slightly short of and slightly off-axis to the left of the filling defect (arrows); the probe was tilted toward the 3 o’clock position before firing. The off-axis position is preferable when targeting very small objects, since the probe will fire immediately alongside the nodule rather than through it. The main duct (arrowheads) anterior to the defect remains opacified. (d) Paired craniocaudal stereotactic postfire images obtained after the first sample was taken show the 11-gauge Mammotome probe through the region of the filling defect. (e) Paired craniocaudal stereotactic postbiopsy images show a cavity at the biopsy site (curved arrows) and a tissue-marking clip (arrowheads) deployed at the 3 o’clock position in the wall of the cavity.
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Figure 1d. Images of a 4-mm benign intraductal papilloma in a 46-year-old woman with recent onset of reproducible dark sanguinous discharge from the right nipple. The mammogram and US image (not shown) were unremarkable. (a) Craniocaudal digital galactogram obtained with the patient in a prone position shows a 4-mm rectangular filling defect (arrow) with a smaller round bubble (arrowhead) immediately inferior to it. (b) Paired craniocaudal stereotactic images show the filling defect (arrows) and bubble (arrowheads); targeting was performed by using these paired images. (c) Paired craniocaudal stereotactic prefire images show the 11-gauge Mammotome probe advanced to a position slightly short of and slightly off-axis to the left of the filling defect (arrows); the probe was tilted toward the 3 o’clock position before firing. The off-axis position is preferable when targeting very small objects, since the probe will fire immediately alongside the nodule rather than through it. The main duct (arrowheads) anterior to the defect remains opacified. (d) Paired craniocaudal stereotactic postfire images obtained after the first sample was taken show the 11-gauge Mammotome probe through the region of the filling defect. (e) Paired craniocaudal stereotactic postbiopsy images show a cavity at the biopsy site (curved arrows) and a tissue-marking clip (arrowheads) deployed at the 3 o’clock position in the wall of the cavity.
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View larger version (81K):
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[Download PPT slide]
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Figure 1e. Images of a 4-mm benign intraductal papilloma in a 46-year-old woman with recent onset of reproducible dark sanguinous discharge from the right nipple. The mammogram and US image (not shown) were unremarkable. (a) Craniocaudal digital galactogram obtained with the patient in a prone position shows a 4-mm rectangular filling defect (arrow) with a smaller round bubble (arrowhead) immediately inferior to it. (b) Paired craniocaudal stereotactic images show the filling defect (arrows) and bubble (arrowheads); targeting was performed by using these paired images. (c) Paired craniocaudal stereotactic prefire images show the 11-gauge Mammotome probe advanced to a position slightly short of and slightly off-axis to the left of the filling defect (arrows); the probe was tilted toward the 3 o’clock position before firing. The off-axis position is preferable when targeting very small objects, since the probe will fire immediately alongside the nodule rather than through it. The main duct (arrowheads) anterior to the defect remains opacified. (d) Paired craniocaudal stereotactic postfire images obtained after the first sample was taken show the 11-gauge Mammotome probe through the region of the filling defect. (e) Paired craniocaudal stereotactic postbiopsy images show a cavity at the biopsy site (curved arrows) and a tissue-marking clip (arrowheads) deployed at the 3 o’clock position in the wall of the cavity.
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In three patients, the visualized ductal system exhibited a normal branching pattern with no filling defect or wall irregularity, and the procedure was terminated—with no target, stereotactic biopsy was not possible. A screen-film mammogram was obtained with the catheter still in place and the contrast material still opacifying the ductal system, for the purposes of documentation and mapping if surgical duct exploration was to be performed. In the remaining five patients, a filling defect or wall irregularity was identified and became the target of stereotactic biopsy. These five patients formed the basis for this report. One patient had a family history of breast carcinoma. All had recent (range, 1 day to 2 months) onset of clear or sanguinous nipple discharge.
A stereotactic pair of images was obtained (Figure, part b), the filling defect was targeted, and stereotactic biopsy was performed with an 11-gauge Mammotome probe by using the filling defect as the target (Figure, parts c and d). During a typical procedure, 18–24 samples were obtained. At the completion of biopsy, a stainless steel tissue-marking clip (MicroMark; Ethicon Endo-Surgery) was deployed to mark the biopsy site (Figure, part e).
The biopsy specimens were prepared and analyzed by using standard histologic techniques. When a benign papilloma was found, mammography was scheduled at 6, 12, and 24 months. I specifically sought any developing nodule or dilated duct at the biopsy site or any recurrent or persistent discharge.
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Results
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In all five patients, a benign intraductal papilloma was diagnosed at histologic examination. In none of the specimens was analysis complicated by a crush artifact. In one patient, atypia was observed within the papilloma, and surgical excision was recommended. At excision, no residual papilloma or atypia was found; there was only moderate ductal hyperplasia without atypia. (The stainless steel tissue-marking clip was present in the surgical specimen, and there was histologic evidence of the recent Mammotome biopsy within the surgical specimen.) In the other four patients, there was no evidence of atypia, and the lesion was thought to have been completely removed; this was judged by comparing the size of the lesion (typically, 4–7 mm) with the size of the cavity (typically, a cylinder 1 cm in diameter x 1.7 cm in length [the length of the sampling notch in the Mammotome probe]). In these four patients, nipple discharge ceased after biopsy. The original mammograms showed no abnormality, and follow-up mammograms have been unchanged (mean follow-up, 27 months; range, 12–36 months) and showed no developing nodule or dilated duct.
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Discussion
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Spontaneous unilateral nipple discharge is most commonly caused by a benign intraductal papilloma.(3) These lesions frequently do not manifest at imaging; as a result, the role of minimally invasive biopsy of such lesions has, until recently, been limited. Sardanelli et al (4) described ultrasonographically (US)-guided fine-needle aspiration after galactography in 36 patients. All patients subsequently underwent excision, and the fine-needle aspiration procedure appeared to influence only the extent of resection, since none of the patients with benign cytologic findings was spared surgical exploration.
With the larger volumes of tissue harvested at vacuum-assisted stereotactic biopsy, it should be possible to render a diagnosis in patients with problematic nipple discharge without resorting to surgical duct exploration. Liberman et al (5) found no carcinomas by using surgical correlation or long-term mammographic stability as a standard among benign papillomas diagnosed at large-core-needle biopsy. Furthermore, Mammotome biopsy has the potential to be therapeutic as well. In a recent article by Dennis and colleagues (6), a technique for performing galactography and immediate Mammotome biopsy under US guidance is described. Although their technique is perhaps more operator-dependent than the technique described in the current study, they reported high diagnostic accuracy and resolution of the problematic discharge in more than 97% (38 of 39) of patients.
Such was the case in four of the five patients in the current study, in whom a specific benign diagnosis of intraductal papilloma without atypia was made. At the same time, the procedure was therapeutic, because the nipple discharge stopped completely. At the time this article was published, follow-up mammographic findings had been stable for a mean of 27 months.
Several considerations, many related to the visibility of the lesion during the procedure, make the stereotactic biopsy procedure performed in the current study different from conventional stereotactic biopsy of an abnormality visible on a standard mammogram (eg, microcalcifications). First, time is of the essence, because the injected contrast material can become diluted. During the course of biopsy, the ductal system is, by definition, disrupted, which permits dissipation of the remaining contrast material into the surrounding breast tissue. For these reasons, the pre- or postfire stereotactic image is frequently the last on which the filling defect will be visible as a discrete target.
Second, when performing conventional stereotactic biopsy of a target such as a small nodule, I often use the removal of all imaging evidence of the lesion as an end point for determining the completion of sampling. At galactogram-directed stereotactic biopsy, however, it is not possible to use such an end point, because the lesion virtually always becomes difficult or impossible to see after just one sample is obtained. Therefore, I typically obtain 18–24 samples at the site. Ambient air, blood, or a combination of the two always fills the resultant cavity, and the adequacy of sampling is judged by comparing the size of the cavity on the postprocedure images with that of the filling defect on the preprocedure galactogram. Not being able to see the lesion directly once biopsy is underway is not as problematic as one might imagine. In the majority of instances, there is objective evidence that the patient has not moved during the procedure, with use of marks on the patient’s skin surface, nearby fibrous bands, or other mammographic landmarks to verify lack of breast movement. It is natural that, when the filling defect identified on the galactogram has a corresponding nodule that is visible without the use of contrast material, standard stereotactic biopsy can be performed without such considerations.
Third, deployment of a tissue-marking clip is critical. Because, by definition, these lesions are not visible at conventional mammography and the ductal system becomes disrupted, a tissue-marking clip would be the only means to identify the site for needle localization should wide local excision become necessary.
Fourth, these lesions are often in the subareolar region, which presents theoretic challenges related to the adequacy of breast compression, innervation, and local blood vessels. I have not had a practical problem with these issues, however. In my experience, none of these challenges have proved insurmountable, and biopsy was completed successfully in all patients with a focal intraductal filling defect.
Finally, the range of histologic findings that may adequately explain symptomatic nipple discharge is limited, so meticulous attention must be paid to radiologic and histologic correlation. If (a) the lesion is well seen on the galactogram and is small, circumscribed, and easily targeted; (b) an adequate volume of tissue is removed; and (c) a benign intraductal papilloma is found at histologic examination, then biopsy findings can be considered concordant. On the other hand, if histologic analysis yields a nonspecific finding, then the biopsy result should be considered discordant, and surgical duct exploration should be considered.
If multiple filling defects are visible on the galactogram, it might be unwise to proceed with stereotactic biopsy for several reasons. First, given the potential for histologic heterogeneity of extensive or multifocal lesions (7), a Mammotome biopsy targeting one such defect and yielding a benign intraductal papilloma might not be representative, perhaps missing another focus that contains ductal carcinoma in situ. Second, when carcinoma or atypia is found at Mammotome biopsy, the duct is, by definition, disrupted, which potentially makes therapeutic surgical duct exploration more difficult. (This is of less concern when a single filling defect identified during galactography-stereotactic biopsy is proved to be carcinoma or atypia, since a more conventional excision targeting the clip can be performed.) Third, if extensive benign intraductal papilloma is merely sampled and left alone, the potential exists for subsequent accumulation of large amounts of fluid within the ducts, since the route of egress has been disrupted. All of these concerns are theoretic and might bear further testing.
In summary, stereotactic Mammotome biopsy of a small circumscribed filling defect depicted at galactography is a useful diagnostic procedure and appears to have been therapeutic in this series of patients who had benign papillomas. This technique poses several technical challenges but may potentially eliminate the need for surgical duct exploration in select individuals.
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FOOTNOTES
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Author contribution: Guarantor of integrity of entire study, M.A.G.
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REFERENCES
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Hou MF, Huang TJ, Huang YS, Hsieh JS. A simple method of duct cannulation and localization for galactography before excision in patients with nipple discharge. Radiology 1995; 195:568-569.[Abstract/Free Full Text]
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Sardanelli F, Imperiale A, Zandrino F, et al. Breast intraductal masses: US-guided fine needle aspiration after galactography. Radiology 1997; 204:143-148.[Abstract/Free Full Text]
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Liberman L, Bracero N. Vuolo MA, et al. Percutaneous large-core biopsy of papillary breast lesions. AJR Am J Roentgenol 1999; 172:331-337.[Abstract/Free Full Text]
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ABSTRACT
INTRODUCTION
