Ductogram - Its Uses, Benefits, Risks and Limitations

What Is a Ductogram?

The breast is composed of three important structures; (1) fat, (2) lobules that produce milk, and (3) ducts that carry the milk from the lobules to the nipples through which it comes out. Nipple discharge can be categorized into normal, physiological, and pathological. A normal milky white nipple discharge from both the breast and multiple pores is seen in lactating mothers. A physiologic nipple discharge (white, green, or yellow) occurs bilaterally with certain medications or hormonal problems. However, a spontaneous pathological nipple discharge is of concern. It usually occurs in a single breast, and the discharge occurs from a single pore. A pathologic nipple discharge could be due to various conditions like an engorged duct or a benign papilloma (similar to a wart), or even a cancerous growth. Hence, it is essential to identify the cause of a spontaneous pathologic nipple discharge.

Ductogram is a diagnostic procedure used to identify the milk ducts and thereby assess the reason for the nipple discharge. It is similar to a mammogram with the additional use of contrast material. Though sonography is preferred for breast examination, ductograms are efficient for viewing the ducts and their associated pathologies. In this procedure, a contrast material is introduced into the milk ducts, which are then examined using a mammogram. This procedure is also known as galactogram.

What Are the Indications of Ductograms?

• A ductogram is indicated in women who have a bloody discharge from the nipple or a clear discharge unilaterally from a single pore whose mammogram reports are normal.

• Ductograms are not indicated if the discharge is milky-white, yellow, or green, or in cases where it is from both breasts through multiple pores as it is considered normal.

• It is used to diagnose the following condition which is associated with pathological nipple discharge such as:

1. Fibrocystic neoplasms of the breast.

2. Ductal ectasia that is clogged and engorged milk ducts.

3. Benign neoplasm such as intraductal papilloma's resembling warts.

4. In case of ductal carcinoma affecting the breast.

• Ductogram can also aid in the surgical removal of the ducts, as in breast cancer surgery.

• Pre-surgery ductogram may also be recommended before the biopsy.

What Are the Patient Preparations Required Before the Ductogram Procedure?

• Ductogram is a simple procedure, not requiring many extensive preparations.

• Patients should avoid any fragrant materials such as deodorant, talcum powder, or lotions in the armpit or near the breast, as these will be visualized as calcified materials on the ductogram.

• Patients should ensure that they do not squeeze the nipple before the procedure, as the discharge is mandatory while the procedure is done.

• Patients should inform the doctor if they have any history of allergy to contrast material, medications, or latex.

• Patients should also inform the doctor of their medical history.

• Ladies who think they could be pregnant should also inform the doctor.

• Patients can wear loose, comfortable clothes and remove all jewelry before the procedure.

How Is a Ductogram Done?

• Ductogram is usually conducted as an outpatient examination, and the procedure will take 30 to 60 minutes.

• The patient will be given a gown to wear and will be made to lie flat on their back on the examination table.

• The breast which has nipple discharge will be uncovered and exposed.

• The nipple will be cleaned, and the breast will be gently squeezed so that the affected duct can be identified.

• Once the duct is traced, a small flexible hollow tube (catheter) will be inserted into the ductal opening. Slight pressure may be felt by the patient.

• Next, a small amount of contrast material (0.2-0.3mL) will be slowly injected through the tube into the affected duct. The patient may feel pressure and a feeling of fullness. A warm compress can help ease the discomfort. An X-ray may be taken immediately to look for the outline of the ducts.

• The patient is then made to stand in front of a mammogram unit. The mammogram machine comprises two plates that compress the breasts, and the images are captured. The patient might be asked to stand still and hold their breath when images are being captured.

• An incomplete filling will usually appear as a black area which is usually suggestive of a soft tissue mass.

• The tube is then removed, and a small dressing is placed over the site.

What Is the Principle Used in Ductogram?

The principle used is the same as in an X-ray. It depends on the varying absorption capacities of the tissue. Dense tissue such as bone absorbs more radiation resulting in a white appearance, whereas soft tissue such as muscle, vessels, and fat absorb less radiation causing gray shades. The air, however, seems black.

What Does the Ductogram Findings Signify?

What Are the Instructions After the Procedure?

• After the procedure is done, patients can return to their normal activities.

• Some soreness may be present. Analgesics may be prescribed for the pain.

• Based on the ductogram findings, the treatment or follow-up can be decided.

• Additional testing or surgical intervention may be required.

What Are the Benefits of the Procedure?

• Ductography is the gold standard in evaluating pathologic nipple discharge.

• Can identify growth at an early stage and better treatment, and positive outcome.

• Minimally invasive.

• Well tolerated by the patients.

What Are the Risks Associated With the Procedure?

• Minimal radiation exposure.

• Duct injury can occur either with the catheter or the material itself. Though it is a self-limiting condition, antibiotics might be required to prevent any infection.

• Rarely there is a possibility of breast infection (mastitis).

• An allergic reaction to contrast material can occur.

What Are the Limitations of This Procedure?

• Discharge needs to be present while conducting this test; if there is no discharge, the procedure may have to be rescheduled.

• It is not of much value to assess the smaller ducts.

• Tumors outside the duct cannot be evaluated using this procedure.

When to Seek Medical Advice?

• High temperature.

• Swelling or reddish discoloration of the breast or nipple.

• Constant pain.

• Bleeding from the nipple.

Conclusion:

Nipple discharge is most frequently associated with benign breast conditions. However, at times there are chances of malignant tumors resulting in abnormal discharge. Ductogram is considered the gold standard in diagnosing abnormal nipple discharge. Though a ductogram is slightly more invasive than a routine mammogram, its diagnostic accuracy is remarkable.