The value of clinical characteristics and breast-imaging studies in predicting a histopathologic diagnosis of cancer or high-risk lesion in patients with spontaneous nipple discharge

doi:10.1016/j.amjsurg.2005.06.032

The American Journal of Surgery

Volume 190, Issue 4, October 2005, Pages 644-646

Presented at the Sixth Annual Meeting of the American Society of Breast Surgeons, Los Angeles, California, March 16–20, 2005

https://doi.org/10.1016/j.amjsurg.2005.06.032 Get rights and content

Abstract

Background

The purpose of this study was to determine the utility of breast-imaging studies in identifying cancer and high-risk lesions among patients with spontaneous, single-duct, nipple discharge (SSND).

Methods

The medical records of 168 cases with SSND treated with duct excision between June 1998 and May 2004 were reviewed. The sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) of mammogram, ultrasound, and ductogram in predicting high-risk lesions and cancer were calculated.

Results

The sensitivity of mammography was 10%, the specificity 94%, the NPV 88%, and the PPV 18%. Ultrasongraphy had a sensitivity of 36%, specificity of 68%, PPV of 14%, and NPV of 89%. Ductography had a sensitivity of 75%, specificity of 49%, and NPV and PPV of 93% and 18%, respectively.

Conclusions

Conventional imaging studies do not accurately identify cancer or high-risk lesions in patients with SSND.All patients with SSND should be offered duct excision.

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Citation Excerpt :
In one study, the positive predictive value (PPV) was 42%, and the negative predictive value (NPV) was 90% [23]. Malignant and high-risk lesions are identified by mammography with a reported sensitivity of 10% to 26%, specificity of 94% to 95%, PPV of 18%, and NPV of 88% [3,16]. The possible causes of the wide variation in reported sensitivity include differences in imaging technology (digital versus film-screen mammography) and varied breast density among different cohorts of patients.
The type of nipple discharge dictates the appropriate imaging study. Physiologic nipple discharge is common and does not require diagnostic imaging. Pathologic nipple discharge in women, men, and transgender patients necessitates breast imaging. Evidence-based guidelines were used to evaluate breast imaging modalities for appropriateness based on patient age and gender. For an adult female or male 40 years of age or greater, mammography or digital breast tomosynthesis (DBT) is performed initially. Breast ultrasound is usually performed at the same time with rare exception. For males or females 30 to 39 years of age, mammography/DBT or breast ultrasound is performed based on institutional preference and individual patient considerations. For young women less than 30 years of age, ultrasound is performed first with mammography/DBT added if there are suspicious findings or if the patient is at elevated lifetime risk for developing breast cancer. There is a high incidence of breast cancer in males with pathologic discharge. Men 25 years and older should be evaluated using mammography/DBT and ultrasound added when indicted. In transfeminine (male-to-female) patients, mammography/DBT and ultrasound are useful due to the increased incidence of breast cancer. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Galactography is a primary recommendation in the management of nipple discharge (ND), which may be caused by benign or malignant lesions. We aimed to establish a galactogram grading system (GGS) and investigate its role in identifying breast cancer with ND.
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Nipple discharge is a common breast symptom that warrants evaluation. Although most discharges are due to benign conditions, discharge may be due to an underlying malignancy. This chapter reviews the potential etiologies of nipple discharge and the appropriate workup, including the role of ductography, ductoscopy, and magnetic resonance imaging. Algorithms for workup and management of nipple discharge are presented. The technique of duct excision is outlined. This chapter also examines the significance of nipple secretions with respect to breast cancer risk and the technology for obtaining nipple secretions for cytologic examination for risk assessment.

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PresentationThe value of clinical characteristics and breast-imaging studies in predicting a histopathologic diagnosis of cancer or high-risk lesion in patients with spontaneous nipple discharge

Abstract

Background

Methods

Results

Conclusions

Surgery

J Am Coll Surg

Surgery

Eur J Surg Oncol

Presentation
The value of clinical characteristics and breast-imaging studies in predicting a histopathologic diagnosis of cancer or high-risk lesion in patients with spontaneous nipple discharge