Panzironi Giovanna, Pediconi Federica, Sardanelli Francesco
Department of Radiological, Oncological and Pathological Sciences, Sapienza, University of Rome, Rome, Italy.
BJR Open. 2018 Nov 7;1(1):20180016. doi: 10.1259/bjro.20180016. eCollection 2019.
Over 80% of females experience nipple discharge during their life. Differently from lactational (milk production) and physiological (white, green, or yellow), which are usually bilateral and involving multiple ducts, pathologic nipple discharge (PND) is a spontaneous commonly single-duct and unilateral, clear, serous, or bloody secretion. Mostly caused by intraductal papilloma(s) or ductal ectasia, in 5-33% of cases is due to an underlying malignancy. After clinical history and physical examination, mammography is the first step after 39, but its sensitivity is low (7-26%). Ultrasound shows higher sensitivity (63-100%). Nipple discharge cytology is limited by a false negative rate over 50%. Galactography is an invasive technique that may cause discomfort and pain; it can be performed only when the duct discharge is demonstrated at the time of the study, with incomplete/failed examination rate up to 15% and a difficult differentiation between malignant and benign lesions. Ductoscopy, performed under local anesthesia in outpatients, provides a direct visualization of intraductal lesions, allowing for directed excision and facilitating a targeted surgery. Its sensitivity reaches 94%; however, it is available in only few centers and most clinicians are unfamiliar with its use. PND has recently emerged as a new indication for contrast-enhanced breast MRI, showing sensitivity superior to galactography, with an overall sensitivity up to 96%, also allowing tailored surgery. Surgery no longer can be considered the standard approach to PND. We propose a state-of-the art flowchart for the management of nipple discharge, including ductoscopy and breast MRI as best options.
超过80%的女性在其一生中会经历乳头溢液。与哺乳期（乳汁分泌）和生理性溢液（白色、绿色或黄色，通常为双侧且涉及多个导管）不同，病理性乳头溢液（PND）是一种自发的、通常为单导管且单侧的、清亮、浆液性或血性分泌物。其主要由导管内乳头状瘤或导管扩张引起，5% - 33%的病例是由潜在的恶性肿瘤导致。在了解临床病史和进行体格检查后，对于39岁以上的患者，乳腺钼靶检查是第一步，但其敏感性较低（7% - 26%）。超声检查显示出更高的敏感性（63% - 100%）。乳头溢液细胞学检查的假阴性率超过50%，存在局限性。乳腺导管造影是一种侵入性技术，可能会引起不适和疼痛；只有在检查时证实有导管溢液时才能进行，检查不完整/失败率高达15%，且难以区分恶性和良性病变。导管镜检查在门诊患者局部麻醉下进行，可直接观察导管内病变，便于进行定向切除并有助于开展有针对性的手术。其敏感性达到94%；然而，只有少数中心能够开展，大多数临床医生对其使用并不熟悉。PND最近已成为对比增强乳腺MRI的一项新适应证，其敏感性优于乳腺导管造影，总体敏感性高达96%，还能实现精准手术。手术不再被认为是PND的标准治疗方法。我们提出了一种用于乳头溢液管理的最新流程图，包括将导管镜检查和乳腺MRI作为最佳选择。
