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How is Ductography Performed?
The ductography procedure takes between 30 minutes to an hour. Patients referred for
ductography most always have nipple discharge at the time of the study. Before performing
the procedure, the nipple is usually cleaned and sterilized with an alcohol swab or other
material to remove any dried discharge. The radiologist then applies manual pressure to
the breast to elicit a fluid discharge. In patients who experience nipple discharge, there
is often a "trigger" spot that causes discharge from the nipple when pressure is
applied to it. After identifying the discharging duct, the radiologist feeds a small
hollow needle (called a blunt-tipped cannula) into this area of the nipple while
stabilizing the nipple between his or her thumb and forefinger. Usually, no force, only
downward guidance, is needed to insert the cannula into the patient’s breast duct.
Once the cannula has been gently fed down the duct, a small amount of radiopaque
substance (contrast media) is injected into the breast through a syringe that is connected
to the cannula. The breast is then imaged with mammography;
the radiopaque contrast helps enhance the duct anatomy on the resulting images. After the
procedure is completed, a bandage is typically placed over the nipple to prevent fluid or
dye from staining the patient’s clothes.
The radiopaque contrast media is a pharmaceutical liquid made up of substances that
weaken (attenuate) x-rays as they pass through the organ containing the contrast (in this
case, the breast duct). The breast duct filled with contrast is then seen more clearly on
the resulting mammogram image and allows the radiologist to better visualize intraductal
papillomas or other abnormalities that may be present. The abnormality in the breast
appears as a black nodule in the middle of the white duct.
If the radiologist has difficulty feeding the cannula into the breast duct, a local
anesthetic gel or warm compress or washcloth is often used before re-attempting the
procedure. Some physicians coat the tip of the cannula with anesthetic gel and also dab it
on the surface of the nipple. If the cannula is still unable to be thread into the breast
duct after three attempts, the procedure is typically canceled and rescheduled for one to
two weeks later.
Is Ductography Painful?
A ductogram procedure can be mildly uncomfortable but is not usually painful. A
ductogram is likely to be more uncomfortable when there is not a significant quantity of
nipple discharge, making it difficult for the physician to find the opening of the
discharging duct. This may require "probing" to find the right duct. If there is
significant fluid discharge, the needle (cannula) insertion into the breast duct is
usually much easier to perform and less uncomfortable for the patient.
The syringe is used to slowly instill the contrast material through the needle
(cannula) into the breast duct. This is not painful but may cause a "full"
sensation similar to when the breast fills with milk during lactation
(breast-feeding). If the patient feels fullness or pain during the injection of contrast,
she should tell the radiologist. The goal is to completely fill the duct with contrast to
get the best image possible. A sensation of pressure or "fullness" is a good
sign that the duct is full and distended (enlarged). However, care should be taken to
avoid overfilling because this can hide abnormalities.
In some cases, extravasation may occur during ductography. Extravasation is the flow of
contrast media from the breast duct out into the surrounding breast tissue. If
extravasation occurs, the cannula is removed from the breast and the patients may be
treated with a pain reliever (such as ibuprofen) if necessary. The procedure is usually
rescheduled for a later date, typically one to two weeks later. To help minimize the
occurrence of extravasation, ductography should be performed by radiologists with
significant experience with the procedure.
What Treatment May Follow Ductography?
The ductogram (also called galactogram) may or may not identify the cause of the nipple
discharge. The majority of patients who undergo ductography ultimately need surgery to
treat the discharge. Surgery may involve removing a papilloma or other nodule in the
breast duct. In some cases, removal of the entire ductal system may be required. For
example, some patients with duct ectasia (widening and
hardening of the duct) may need surgery to
remove the affected duct if other treatments, such as heat compresses, do not help.
Even if the cause of discharge remains unknown after ductography, the ductogram can
still help the surgeon find the affected duct so that only that duct needs to be removed.
This is accomplished by mixing blue dye with the radiographic contrast so the surgeon can
see the abnormal duct as blue.
Some surgeons feel that ductography is unnecessary since the patient will likely need
surgery anyway. However, identifying the type of abnormality, the number of abnormalities,
and their extent in the breast can be very helpful in aiding the surgeon in either
removing as little tissue as necessary or in making sure to remove all of the involved
tissue associated with extensive abnormalities.
Visit the page on nipple discharge to learn more about duct
excision surgery.
Additional Resources and References
- Lois F. O'Grady, MD, et al., A
Practical Approach to Breast Disease, Boston: Little, Brown and Company, 1995.
- The report, "Ductography: How to and What If?," by S. Horatio Slawson, MD, and
Bradley A. Johnson, MD of the Susan G. Komen Breast Center is published in Volume 21, 2001
issue of Radiographics
- To learn more about nipple discharge, please visit http://www.imaginis.com/breasthealth/nipple.asp
Updated: September 12, 2007
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