1. Ductography 醫事放射師 ： 蕭珮琳

2. What is Ductography? Ductography is an X ray examination that uses mammography, and a contrast material to obtain pictures, of the inside of the breast's milk ducts, also called galactograms. Ductography is an X ray examination that uses mammography, and a contrast material to obtain pictures, of the inside of the breast's milk ducts, also called galactograms.

3. Purpose A ductogram is a mammographic procedure that is performed to help identify an abnormality in the breast duct that may be the source of nipple discharge and is valuable in diagnosing intraductal papillomas and other conditions. Papillomas are wart-like, non- cancerous tumors with branchings or stalks that have grown inside the breast duct; they are the most common cause of nipple discharge. A ductogram is a mammographic procedure that is performed to help identify an abnormality in the breast duct that may be the source of nipple discharge and is valuable in diagnosing intraductal papillomas and other conditions. Papillomas are wart-like, non- cancerous tumors with branchings or stalks that have grown inside the breast duct; they are the most common cause of nipple discharge.

4. Anatomy The breast is composed primarily of three structures: three structures: Fat Fat Lobules (that make the milk) Lobules (that make the milk) Milk ducts (that carry the milk from the lobule to the nipple) Milk ducts (that carry the milk from the lobule to the nipple)

5. Anatomy

6. 正常乳腺 年輕女性乳腺 懷孕女性 脂肪組織 乳腺組織 結締組織

7. 皮膚 皮下脂肪織 Cooper 靭帯 大胸筋 乳頭開口部 乳管洞 乳管 小葉 乳腺後 脂肪織 乳腺内 乳腺的解剖 小葉 5-6 個小葉 :Terminal duct lobular unit

8. Indication unilateral, single-pore spontaneous nipple discharge multicolored/sticky, purulent, clear/watery, yellow/serous, pink/ serosanguineous, bloody /sanguineous

10. Causes of Nipple Discharge Intraductal papilloma Intraductal papilloma Ductectasia Ductectasia Breast Cancer Breast Cancer Pituitary tumor Pituitary tumor Drug Drug

11. Bilateral nipple discharge Drug Drug Pituitary tumor ( >1000mU/L ) Pituitary tumor ( >1000mU/L ) - milkly - milkly

12. Contraindication – Severe allergy to iodinated contrast material – Severe nipple retraction – a history of prior nipple surgery that would completely disconnect the nipple pores from the underlying ducts

13. prepare NPO 4 hours NPO 4 hours The nipple not be squeezed prior to the exam The nipple not be squeezed prior to the exam Do not wear deodorant, talcum powder or lotion under your arms or on your breasts Do not wear deodorant, talcum powder or lotion under your arms or on your breasts

14. material contrast material : water (1:1) Sialography set （ small cathetera plastic hollow tube, blunt-tipped needle ） Sialography set （ small cathetera plastic hollow tube, blunt-tipped needle ）

16. Procedure

18. Slowly administer 0.2–0.3 mL of contrast material

19. normal

21. Normal Ductal System 1.Lactiferous duct 2.Segmental branch 3.Subsegmental branch 4.Peripheral branches 5.Termainal duct unit

22. case

23. Ductal Ectasia Craniocaudal ductogram shows a dilated ductal system. Ductography demonstrates ductal ectasia and no other abnormality

24. Intraductal Papilloma

25. papilloma

26. Multiple microcalcifications

27. Cancer

28. Treatment Preoperative ductography with a 1:1 solution of contrast material and methylene blue allows identification of the abnormal duct for mammography and for the operating surgeon Standard central duct excision results in resectionof a cone of tissue approximately 4–5 cm in length directly posterior to the nipple

29. failure

30. Extravasation Experience focal pain or burning, although the process may be completely asymptomatic Administer too much contrast material, resulting in extravasation in their first few procedures Wall perforation by vigorous cannula insertion Rarely, destruction of ductal integrity by carcinoma leads to extravasation

32. the cannula within a papilloma (arrow). Note the reflux of contrast material to the surface. The cannula may pierce solid intraluminal masses, even without pressure, or slide between a mass and the side wall of the duct Obstruction and Reflux

33. Artifacts Air bubble --from the cannula, syringe, and extension tubing Silicone or saline augmentation implants direct silicone injections

35. Failure or contrast medium extravastion – reschedule it for 7-14 days

37. discussion Nipple discharge can be caused by non- cancerous tumors such as papillomas, or cancer such as ductal carcinoma in situ (DCIS). However, the majority of nipple discharges are due to benign (non-cancerous) causes. 10~15% cancer ( discharge could be only sign) Galactography can find small cancerous and non-cancerous tumors that cannot be identified in any other way so that they may be removed at an early stage.