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A Prospective Study about Abnormal Ductal Dilatations without Associated Masses on Breast US

Posted Feb 29, 2012 Updated Apr 10, 2023
By Sung Eun Song MD , Ann Yie MD , Bo Kyoung Seo MD PhD , Seung Hwa Lee MD PhD , Kyu Ran Cho MD PhD , Ok Hee Woo MD PhD , Ki Yeol Lee MD PhD , Young Sik Kim MD PhD
8 min read

Rationale and Objectives

Ductal changes are described as a finding of surrounding tissues in breast masses according to the Breast Imaging Reporting and Data System – Ultrasound. However, ductal changes are often found as an isolated finding without a mass on ultrasound. The purpose of this study was to investigate the clinical significance of abnormal ductal dilatations without masses on breast ultrasound.

Materials and Methods

From August 2006 to August 2008, 75 pathologically verified pure ductal dilatations without associated masses on breast ultrasound were collected. Ultrasound findings including the diameter and length of the duct, the presence of ductal wall thickening and intraluminal content, the echo pattern of intraluminal content, and distribution were evaluated. The ultrasound findings were correlated with clinical and pathologic features, and radiologic differences between benign and malignant lesions were assessed using Fisher’s exact tests.

Results

Of the 75 cases with abnormal ductal dilatations, seven (9%) were malignant, and four (5%) were atypical ductal hyperplasia. Ductal dilatations were longer in malignancies than in benign lesions ( P < .05). Ductal wall thickening was more frequent in malignancies (100%) and atypical ductal hyperplasia (50%) than in other benign lesions (3%) ( P < .05). Hypoechoic intraluminal content was more common in malignancies (86%) and atypical ductal hyperplasia (50%) than in other benign lesions (8%) ( P < .05). Furthermore, a segmental distribution was more frequent in malignancies (43%) than in benign lesions (1%). Clinical symptoms were also frequent in malignancies (86%) than in benign lesions (4%) ( P < .05).

Conclusions

Abnormal ductal dilatations without masses have a 9% malignancy rate, and these would be recommended to undergo biopsy as suspicious abnormalities according to Breast Imaging Reporting and Data System – Ultrasound. Ultrasound has an essential role in the assessment of abnormal ducts for distinguishing benign and malignant ductal changes.

In the first edition of the Breast Imaging Reporting and Data System (BI-RADS) – Ultrasound, ductal changes are defined as abnormal caliber and/or arborization and belong to findings of surrounding tissues for breast masses . The significance and clinical management of ultrasound-detected ductal dilatations and the positive predictive value for malignancies or high-risk lesions have been less commonly reported in the past . Also, BI-RADS – Ultrasound does not provide detailed explanations about how to assess abnormal ducts, and it does not provide recommended clinical guidelines. The clinical significance of abnormal ductal dilatations on mammography or magnetic resonance imaging is known, and ductal dilatations have a wide spectrum of pathologic diagnoses, from benign lesions including fibrocystic changes, intraductal papilloma, or ductal hyperplasia to carcinomas . Recently, Hsu et al performed a retrospective study of dilated ducts on breast ultrasound and demonstrated that the positive predictive value for malignancy ranged from 9% to 43% according to the presence of associated masses, multiplicity, or intraductal content.

Pure ductal dilatations without associated masses of the breast are frequently found on breast ultrasound examinations, because ultrasound has been widely used as a screening modality or an adjuvant tool following mammography . Physicians often hesitate to decide on the possibility of malignancy when they encounter pure ductal dilatations on breast ultrasound because of the lack of previous studies and experience.

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Materials and methods

Study Population

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Image Analysis

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Pathologic Examinations

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Statistical Analysis

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Results

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Table 1

Correlation of Clinical Symptoms with Pathologic Findings in 75 Ductal Lesions

Clinical Symptom Malignancy

( n = 7) Proliferative Lesion with Atypia ( n = 4) Proliferative Lesion without Atypia ( n = 11) Nonproliferative Lesion

( n = 53) Palpable lump 2 (29%) 0 (0%) 0 (0%) 0 (0%) Nipple discharge 4 (57%) 1 (25%) 0 (0%) 1 (2%) Pain 0 (0%) 0 (0%) 0 (0%) 1 (2%) None 1 (14%) 3 (75%) 11 (100%) 51 (96%)

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Table 2

Correlation of Mammographic and Pathologic Findings in 60 Ductal Lesions

Mammographic Finding Malignancy

( n = 7) Proliferative Lesion with Atypia ( n = 4) Proliferative Lesion without Atypia ( n = 9) Nonproliferative Lesion

( n = 40) Mass 0 (0%) 0 (0%) 1 (11%) 1 (2%) Asymmetric density 2 (29%) 1 (25%) 1 (11%) 2 (5%) Calcifications 1 (14%) 0 (0%) 0 (0%) 0 (0%) None 4 (57%) 3 (75%) 7 (78%) 37 (93%)

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Table 3

Correlation of Ultrasound Findings with Pathologic Diagnoses in 75 Ductal Lesions

Pathologic Diagnosis Mean Diameter of the Duct (mm) Length of the Duct (mm) Presence of Ductal Wall Thickening Presence of Intraluminal Content Hypoechoic Intraluminal Content Segmental Distribution Malignancy ( n = 7) 3.1 32.4 7 (100%) 7 (100%) 6 (86%) 3 (43%) Proliferative lesion with atypia ( n = 4) 2.6 27.5 2 (50%) 4 (100%) 2 (50%) 1 (25%) Proliferative lesion without atypia ( n = 11) 2.9 18.9 2 (18%) 9 (82%) 2 (18%) 0 (0%) Nonproliferative lesion ( n = 53) 2.5 18.3 0 (0%) 36 (68%) 3 (8%) 0 (0%)

Figure 1, A 38-year-old woman with bloody nipple discharge. (a) Ultrasound image demonstrates focal ductal dilatations ( arrows ) in the right subareolar region. The ducts have indistinct margins due to wall thickening and hypoechoic intraluminal contents. (b) Intraductal spread of uniform tumor cells is demonstrated, with cribriform ( black arrows ) and solid ( white arrows ) subtypes of ductal carcinoma in situ on pathologic examination (hematoxylin and eosin, 100×).

Figure 2, A 58-year-old woman with no clinical symptoms. (a) Right breast ultrasound image demonstrates that the ducts ( arrows ) have wall thickening and isoechoic intraluminal contents ( arrowheads ). (b) Atypical cells proliferate and form irregular lumens ( arrows ) on pathologic examination (hematoxylin and eosin, 40×). The pathologic diagnosis was atypical ductal hyperplasia.

Figure 3, A 40-year-old woman with no clinical symptoms. (a) Ultrasound image shows focal duct ectasia ( arrows ) in the left breast. The ducts show isoechoic intraductal content and no ductal wall thickening. (b) Ductal epithelial cells have papillary growth ( arrows ) and vascular cores evident on pathologic examination (hematoxylin and eosin, 40×). This was pathologically verified as an intraductal papilloma with moderate ductal hyperplasia.

Figure 4, A 55-year-old woman with no clinical symptoms. (a) Ultrasound image shows focal duct ectasia ( arrows ) in the right central region. The duct shows no wall thickening and no intraluminal content. (b) Two cell layers of ductal epithelial and myoepithelial cells ( arrows ) are preserved and the surrounding fibrosis is demonstrated on pathologic examination (hematoxylin and eosin, 40×). The cell layers were pathologically confirmed as nonproliferative fibrocystic change.

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Discussion

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Conclusions

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Academic Radiology, Volume 19, Issue 3
Journals General Radiology
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