Skip to main content

Diagnostic accuracy of breast MRI for patients with suspicious nipple discharge and negative mammography and ultrasound: a prospective study

Abstract

Objectives

To evaluate the diagnostic accuracy of breast MRI in identifying lesions requiring excision for patients with suspicious nipple discharge but normal mammograms and ultrasounds.

Methods

Between September 2013 and May 2019, 106 female participants (mean age 57.9 years) were consecutively included in this prospective multicenter study; 102 were retained for analysis. MRI was considered negative in the absence of suspicious enhancement and positive in cases of ipsilateral abnormal enhancement (BI-RADS 3 to 5). Final diagnoses were based on histological findings of surgical or percutaneous biopsies or at 1-year follow-up. We considered all lesions requiring excision found on pathology (papilloma, atypia, nipple adenomatosis, or cancer) as positive results. We considered spontaneous resolution of the discharge at 1 year as a negative result.

Results

MRI showed ipsilateral abnormal enhancement in 54 patients (53%) revealing 46 lesions requiring excision (31 benign papillomas, 5 papillomas with atypia, 2 nipple adenomatosis, and 8 cancers) and 8 benign lesions not requiring excision. No suspicious enhancement was found in the remaining 48 participants (47%). Forty-two were followed up at 1 year with spontaneous resolution of the discharge and six underwent surgery (revealing 2 benign papillomas). MRI diagnostic accuracy for the detection of a lesion requiring excision was as follows: sensitivity 96%, specificity 85%, positive predictive value 85%, and negative predictive value 96%.

Conclusion

In patients with suspicious nipple discharge and normal mammogram and ultrasound, MRI demonstrates excellent performance to identify lesions for which excision is required. Normal MRI indicates it is safe to propose follow-up only management, thus avoiding unnecessary duct excision.

Trial registration

ClinicalTrials.gov NCT02819362

Key Points

• Breast MRI can be useful for the management of patients with suspicious nipple discharge and negative mammogram and ultrasound.

• MRI detected a lesion requiring excision in 46 participants (45%) with unexplained discharge.

• If breast MRI is negative, follow-up is a safe alternative for these patients.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Abbreviations

ACR:

American College of Radiology

DCIS:

Ductal carcinoma in situ

IDC:

Invasive ductal carcinoma

NME:

Non-mass enhancement

NPV:

Negative predictive value

PPV:

Positive predictive value

References

  1. 1.

    Seow J-H, Metcalf C, Wylie E (2011) Nipple discharge in a screening programme: imaging findings with pathological correlation. J Med Imaging Radiat Oncol 55:577–586

    Article  Google Scholar 

  2. 2.

    Li GZ, Wong SM, Lester S, Nakhlis F (2018) Evaluating the risk of underlying malignancy in patients with pathologic nipple discharge. Breast J 24:624–627

    Article  Google Scholar 

  3. 3.

    Adepoju LJ, Chun J, El-Tamer M, Ditkoff B-A, Schnabel F, Joseph K-A (2005) 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. Am J Surg 190:644–646

    Article  Google Scholar 

  4. 4.

    Lorenzon M, Zuiani C, Linda A, Londero V, Girometti R, Bazzocchi M (2011) Magnetic resonance imaging in patients with nipple discharge: should we recommend it? Eur Radiol 21:899–907

    Article  Google Scholar 

  5. 5.

    Lee SJ, Trikha S, Moy L et al (2017) ACR Appropriateness criteria evaluation of nipple discharge. J Am Coll Radiol 14:138–153

    Article  Google Scholar 

  6. 6.

    Ballesio L, Maggi C, Savalli S et al (2008) Role of breast magnetic resonance imaging in patients with unilateral nipple discharge: preliminary study. Radiol Med 113:249–264

    CAS  Article  Google Scholar 

  7. 7.

    Morrogh M, Park A, Elkin EB, King TA (2010) Lessons learned from 416 cases of nipple discharge of the breast. Am J Surg 200:73–80

    Article  Google Scholar 

  8. 8.

    Cardenosa G, Eklund GW (1991) Benign papillary neoplasms of the breast: mammographic findings. Radiology 181:751–755

    CAS  Article  Google Scholar 

  9. 9.

    Vargas HI, Vargas MP, Eldrageely K, Gonzalez KD, Khalkhali I (2006) Outcomes of clinical and surgical assessment of women with pathological nipple discharge. Am Surg 72:124–128

    Article  Google Scholar 

  10. 10.

    Orel SG, Dougherty CS, Reynolds C, Czerniecki BJ, Siegelman ES, Schnall MD (2000) MR imaging in patients with nipple discharge: initial experience. Radiology 216:248–255

    CAS  Article  Google Scholar 

  11. 11.

    Patel B, Falcon S, Drukteinis J (2015) Management of nipple discharge and the associated imaging findings. Am J Med 128:353–360

    Article  Google Scholar 

  12. 12.

    Berger N, Luparia A, Di Leo G et al (2017) Diagnostic performance of MRI versus galactography in women with pathologic nipple discharge: a systematic review and meta-analysis. AJR Am J Roentgenol 209:465–471

    Article  Google Scholar 

  13. 13.

    Sardanelli F, Boetes C, Borisch B et al (2010) Magnetic resonance imaging of the breast : Recommendations from the EUSOMA working group. Eur J Cancer 46:1296–1316

    Article  Google Scholar 

  14. 14.

    Ashfaq A, Senior D, Pockaj BA et al (2014) Validation study of a modern treatment algorithm for nipple discharge. Am J Surg 208:222–227

    Article  Google Scholar 

  15. 15.

    Lavoué V, Fritel X, Antoine M et al (2016) Clinical practice guidelines from the French College of Gynecologists and Obstetricians (CNGOF). Eur J Obstet Gynecol Reprod Biol 200:16–23

    Article  Google Scholar 

  16. 16.

    Sanders LM, Daigle M (2016) The rightful role of MRI after negative conventional imaging in the management of bloody nipple discharge. Breast J 22:209–212

    Article  Google Scholar 

  17. 17.

    Patel BK, Ferraro C, Kosiorek HE et al (2018) Nipple discharge: imaging variability among U.S. Radiologists. AJR Am J Roentgenol 211:920–925

    Article  Google Scholar 

  18. 18.

    Yoon JH, Yoon H, Kim E-K, Moon HJ, Park YV, Kim MJ (2017) Ultrasonographic evaluation of women with pathologic nipple discharge. Ultrasonography 36:310–320

    Article  Google Scholar 

  19. 19.

    Del Riego J, Pitarch M, Codina C et al (2020) Multimodality approach to the nipple-retroareolar complex : a pictorial review and diagnostic algorithm. Insights Imaging. https://doi.org/10.1186/s13244-020-00896-1

  20. 20.

    D’Orsi CJ, Sickles EA, Mendelson EB et al (2013) ACR BI-RADS atlas, breast imaging reporting and data system. American College of Radiology, Reston, pp 56–71

    Google Scholar 

  21. 21.

    Gray RJ, Pockaj BA, Karstaedt PJ (2007) Navigating murky waters: a modern treatment algorithm for nipple discharge. Am J Surg 194:850–855

    Article  Google Scholar 

  22. 22.

    Lippa N, Hurtevent-Labrot G, Ferron S, Boisserie-Lacroix M (2015) Nipple discharge: the role of imaging. Diagn Interv Imaging 96:1017–1032

    CAS  Article  Google Scholar 

  23. 23.

    Rageth CJ, O’Flynn EA, Pinker K et al (2019) Second International Consensus Conference on lesions of uncertain malignant potential in the breast 5B3 lesions). Breast Cancer Res Treat 174:279–296

  24. 24.

    Bahl M, Gadd MA, Lehman CD (2017) Diagnostic utility of MRI after negative or inconclusive mammography for the evaluation of pathologic nipple discharge. AJR Am J Roentgenol 209:1–6

    Article  Google Scholar 

  25. 25.

    Zacharioudakis K, Kontoulis T, Velle JX et al (2019) Can we see what is invisible? The role of MRI in the evaluation and management of patients with pathological discharge. Breast Cancer Res Treat 178:115–120

    CAS  Article  Google Scholar 

  26. 26.

    Van Gelder L, Bisschops RH, Menke-Pluymers MB, Westenend PJ, Plaisier PW (2015) Magnetic resonance imaging in patients with unilateral bloody nipple discharge; useful when conventional diagnostics are negative? Word J Surg 39:184–186

    Article  Google Scholar 

  27. 27.

    Panzironi G, Pediconi F, Sardanelli F (2018) Nipple discharge: the state of the art. BJR Open. https://doi.org/10.1259/bjro.20180016

  28. 28.

    Sauter ER, Schlatter L, Liniger J, Hewett JE (2004) The association of bloody nipple discharge with breast pathology. Surgery 136:780–785

    Article  Google Scholar 

  29. 29.

    Montroni I, Santini D, Zucchini G et al (2010) Nipple discharge: is its significance as a risk factor for breast cancer fully understood? Observational study including 915 consecutive patients who underwent selective duct excision. Breast Cancer Res Treat 123:895–900

    Article  Google Scholar 

  30. 30.

    Chen L, Zhou W-B, Zhao Y et al (2012) Bloody nipple discharge is a predictor of breast cancer risk: a meta-analysis. Breast Cancer Res Treat 132:9–14

    Article  Google Scholar 

  31. 31.

    Son EJ, Kim EK, Kim JA, Kwak JY, Jeong J (2009) Diagnostic value of 3D fast low-angle shot dynamic MRI of breast papillomas. Yonsei Med J 50:838–844

    Article  Google Scholar 

  32. 32.

    Wang LJ, Wu P, Li XX, Luo R, Wang DB, Guan WB (2018) Magnetic resonance imaging features for differentiating breast papilloma with high-risk or malignant lesions from benign papilloma : a retrospective study on 158 patients. Word J Surg Oncol 16:234–242

    Article  Google Scholar 

  33. 33.

    Francis A, England D, Rowland D, Bradley S (2002) Breast papilloma: mammogram, ultrasound and MRI appearances. Breast 11:394–397

    CAS  Article  Google Scholar 

  34. 34.

    Lubina M, Baker JA, Grenup RA et al (2015) 3.0 Tesla breast resonance imaging in patients with nipple discharge when mammography and ultrasound fail. Eur Radiol 25:1285–1293

    Article  Google Scholar 

  35. 35.

    Mangarano L, D’Ambrosio I, Gigli S et al (2015) Breast MRI in patients with unilateral bloody and serous-bloody nipple discharge: a comparison with galactography. Biomed Res Int. https://doi.org/10.1155/2015/806368

  36. 36.

    Nakahara H, Namba K, Watanabe R et al (2003) A comparison of MR imaging, galactography and ultrasonography in patients with nipple discharge. Breast Cancer 10:320–329

    Article  Google Scholar 

  37. 37.

    Wenkel E, Janka R, Uder M et al (2011) Does direct galactography have the potential to become an alternative diagnostic tool in patients with pathological nipple discharge? Clin Imaging 35:85–93

    Article  Google Scholar 

  38. 38.

    Hirose M, Otsuki N, Hayano D et al (2006) Multi-volume fusion imaging of MR ductography and MR mammography for patients with nipple discharge. Magn Reson Med Sci 5:105–112

    Article  Google Scholar 

  39. 39.

    Nicholson BT, Harvey JA, Patrie JT, Mugler JP (2015) 3D-MR ductography and contrast-enhanced MR mammography in patients with suspicious nipple discharge; a feasibility study. Breast J 21:352–362

    Article  Google Scholar 

Download references

Acknowledgements

The authors thank Pippa McKelvie-Sebileau for medical editing in English.

Funding

This study has received funding from the French Society of Women’s Imaging (SIFEM).

The Funder has no role in the design and conduct of the study: collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript and decision to submit the manuscript for publication.

Author information

Affiliations

Authors

Corresponding author

Correspondence to Martine Boisserie-Lacroix.

Ethics declarations

Guarantor

The scientific guarantor of this publication is Dr M Boisserie-Lacroix

Conflict of interest

The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article.

Statistics and biometry

Professor Simone Mathoulin-Pélissier and Doctor Stéphanie Hoppe (Clinical and Epidemiological Research Unit) kindly provided statistical advice for this manuscript.

One of the authors has significant statistical expertise (Véronique Brouste).

No complex statistical methods were necessary for this paper.

Informed consent

Written informed consent was obtained from all subjects (patients) in this study.

Written informed consent was waived by the Institutional Review Board.

Ethical approval

Approved as National Clinical Trial.

Institutional Review Board approval was obtained.

Methodology

• prospective

• diagnostic/observational

• multicenter study

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Dr. Stéphanie Hoppe is deceased.

Supplementary information

ESM 1

(DOCX 18 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Boisserie-Lacroix, M., Doutriaux-Dumoulin, I., Chopier, J. et al. Diagnostic accuracy of breast MRI for patients with suspicious nipple discharge and negative mammography and ultrasound: a prospective study. Eur Radiol 31, 7783–7791 (2021). https://doi.org/10.1007/s00330-021-07790-4

Download citation

Keywords

  • Nipple discharge
  • Magnetic resonance imaging
  • Breast neoplasms
  • Papilloma