Can we see what is invisible? The role of MRI in the evaluation and management of patients with pathological nipple discharge

Konstantinos Zacharioudakis,Deborah A Cunningham,Rathi Ramakrishnan,Daniel Richard Leff,Jade Zhao,Paul Thiruchelvam,John X Vella,Katy Hogben,Theodoros Kontoulis,Ragheed Al Mufti,Dimitri J Hadjiminas

doi:10.1007/s10549-019-05321-w

Abstract

IntroductionThe aim of this study was to determine the ability of MRI to identify and assess the extent of disease in patients with pathological nipple discharge (PND) with an occult malignancy not evident on standard pre-operative evaluation with mammography and ultrasound.MethodsPatients presenting to the breast unit of Imperial College Healthcare NHS Trust between December 2009 and December 2018 with PND and normal imaging were enrolled in the study. Pre-operative bilateral breast MRI was performed in all patients as part of our protocol and all patients were offered diagnostic microdochectomy.ResultsA total of 82 patients fulfilled our selection criteria and were enrolled in our study. The presence of an intraductal papilloma (IDP) was identified as the cause of PND in 38 patients (46.3%), 14 patients had duct ectasia (DE-17%) and 5 patients had both an IDP and DE. Other benign causes were identified in 11 patients (13.4%). Despite normal mammography and ultrasound a malignancy was identified in 14 patients (17%). Eleven patients had DCIS (13.4%), two had invasive lobular carcinoma and one patient had an invasive ductal carcinoma. The sensitivity of MRI in detecting an occult malignancy was 85.71% and the specificity was 98.53%. The positive predictive value was 92.31% and the negative predictive value was 97.1%.ConclusionsAlthough a negative MRI does not exclude the presence of an occult malignancy the high sensitivity and specificity of this diagnostic modality can guide the surgeon and alter the management of patients with PND.

Highlights

The aim of this study was to determine the ability of MRI to identify and assess the extent of disease in patients with pathological nipple discharge (PND) with an occult malignancy not evident on standard pre-operative evaluation with mammography and ultrasound
MRI findings were not usually followed by MRIguided biopsies because we have found that these procedures interfere significantly with the success of microdochectomy, which is often rendered impossible after an MRI-guided vacuum-assisted biopsy
Two patients had invasive lobular carcinoma with adjacent ductal carcinoma in situ (DCIS) and one patient had a benign papilloma on microdochectomy but the MRI showed an area with grade 2 invasive ductal carcinoma and low grade DCIS in the ipsilateral breast (Table 1)

Summary

Introduction

The aim of this study was to determine the ability of MRI to identify and assess the extent of disease in patients with pathological nipple discharge (PND) with an occult malignancy not evident on standard pre-operative evaluation with mammography and ultrasound. Conclusions a negative MRI does not exclude the presence of an occult malignancy the high sensitivity and specificity of this diagnostic modality can guide the surgeon and alter the management of patients with PND. The presence of epithelial cells or red blood cells on smear cytology of patients with PND and normal imaging identifies a group of patients with a 10% chance of malignancy and is considered an important diagnostic step in our unit [5]

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