Urgent! Is breast ductography painful? Did you notice anything?

1 Imaging conditions

1.1 Instrument Shanghai Nuclear Instrument Factory mammography target mammography muscle. Special breast cassettes produced in Shanghai and domestic 12.7×17.8cm X-ray films were used. Photography conditions: 30mA, 0.8~2.0 S, 28~35KV, focal length 40cm.

1.2 Instruments: 1 2ml and 5ml syringes each; 2 fine probes; 2 5?1/2? needles shortened to 1.5cm and the needle tips ground flat; 2 tweezers; sterile disinfection supplies Gauze; 1 3-5x magnifying glass.

1.3 Contrast agent: 50% sodium diatrizoate or 50% sodium diatrizoate.

1.4 Iodine allergy test: Take 20ml of 10% potassium iodide orally for 30 minutes and observe no allergic reaction.

1.5 Technical operation: The patient is placed in a supine position, and the affected breasts are routinely disinfected, and nipple secretions are removed until the nipple holes are clearly exposed; the back of the areola is squeezed to squeeze out the overflow, and the contrast nipple holes are determined; the nipple is fixed with one hand and gently Lift it up, take the probe to expand the contrast mammary pore, and slowly insert the contrast needle vertically; first instill a few drops of contrast medium until the needle seat is full (to prevent air injection from affecting the diagnosis), then insert the syringe with the contrast agent into the needle seat, and push After injecting 0.5ml to 2ml of contrast agent, pull out the needle, wipe up the spilled contrast agent, and take axial and lateral radiographs. After completion, ask the patient to squeeze the breast to squeeze out the contrast agent as much as possible.

2 Data and results

The age of the cases was 27 to 76 years old, 3 cases were under 30 years old; 28 cases were between 30 and 39 years old; 17 cases were between 40 and 49 years old; 50 cases The above 11 cases. 42 cases were seen within 1 year; 11 cases were from 1 to 5 years; 3 cases were from 5 to 10 years; 1 case was more than 10 years; and 2 cases had unknown medical history. There were 17 cases of bloody discharge, 6 cases of bloody serous discharge (one of which was bilateral), 30 cases of serous discharge (of which 8 cases were bilateral), 4 cases of acne-like discharge, and 2 cases of no discharge; 5 of them were porous. Discharge (both breasts in 1 case). Clinical examination: 11 cases of breast mass, 1 case of skin scar, 4 cases of nipple retraction, and 2 cases of nipple blackening (including 1 case of nipple erosion). X-ray examination: 26 cases of ductal dilation (of which 5 cases were bilateral), 16 cases of intraductal papilloma, all unilateral, 8 cases of hyperplasia, and another 15 cases of hyperplasia and ductal dilation (of which 9 cases were bilateral hyperplasia) , 2 cases of breast cancer; 2 cases of ductitis; 1 case of intraductal cyst, 3 cases of retroareolar abscess; 59 cases were all confirmed by postoperative pathology, needle biopsy or clinical follow-up treatment.

3 Angiographic manifestations of various breast diseases

3.1 All 16 cases of intraductal papilloma had bloody or bloody serous discharge, and 10 cases occurred in the large retroareolar duct or a , the junction of secondary ducts; 14 cases were single and 2 cases were multiple. The smallest tumor was 1.5mm×2mm and the largest was 5mm×6mm. The angiography usually showed a round shape in the duct, smooth edges, and filling defects. The proximal duct was often dilated and widened. Only one case had a tumor larger than 5 mm, with uneven edges and irregular adjacent duct walls, but the duct was not completely blocked.

3.2 Duct dilatation: All 26 cases had nipple discharge, 16 cases were serous, 6 cases were bloody serous, and 4 cases were acne-like. 15 of the 26 cases were accompanied by varying degrees of hyperplasia. The ages ranged from 27 to 64 years old, with 15 cases under 40 years old and 11 cases over 40 years old. The average age was 40.8 years old, which was consistent with reports in the literature [1]. Patients with hyperplasia often have palpable flat and flaky masses clinically. X-ray shows that the ducts at all levels lose their normal dendritic shape and become segmentally widened or expanded into cystic shapes. In some cases, due to a large amount of secretions in the ducts, in addition to the widening changes in the ducts, continuous irregular density reduction areas can also be seen in the ducts, making the The edges of the catheter appear not to be sharp.

3.3 Breast hyperplasia: 15 of the 23 cases of breast hyperplasia were combined with ductal dilation, and clinical examination showed glandular thickening. 8 cases of simple hyperplasia showed irregular expansion of small ducts below the third level, and the ends of some ducts expanded into cysts. The main duct and the first and second level ducts were normal in shape. One case of giant cystic hyperplasia in this group was clinically palpable as a 10cm × 10cm mass. The ducts at all levels were evenly widened and extended, and were slightly compressed around the mass. Several small cystic dilations were seen at the end of the duct. Fifteen cases with ductal dilation also showed X-ray changes of ductal dilation.

3.4 Breast abscess and mastitis Among the 3 cases of breast abscess, 1 case was bloody discharge and 2 cases were serous. The X-ray showed that the contrast agent directly entered the abscess cavity with irregular shape, the duct behind the areola became thinner, the branches were reduced, and the edge of the duct was blurred. In one case, there was a round-shaped soft tissue mass behind the areola, which was continuous with the areola and the mass was 1.2cm. ×1.5cm, medium density, not very sharp edges. Both cases of ductitis were serous discharge, and angiography showed reduced duct branches and blurred duct edges.

3.5 Breast cancer Two of the 46 cases of breast cancer underwent duct angiography, and the changes in X-ray angiography were different.

3.5.1 Invasive ductal carcinoma, clinical examination shows that the nipple turns black and is slightly eroded, with serous discharge, and a hard mass can be touched behind the areola; mammography shows that the mass is irregular, medium density and It was uneven. Piles of silt-like calcifications were seen in and around the mass. The duct was interrupted in front of the mass on angiography. The stump duct was irregularly damaged and stiff, but the duct was not thickened.

3.5.2 Clinical palpation of a hard, fixed mass accompanied by bloody discharge; mammography showed uneven density of the mass, irregular edges, and thick and twisted drainage vessels around it; angiography showed the posterior canal of the main tube The wall is irregularly damaged, the wall is stiff, and the distal small ducts are slender and messy, distributed in a coil shape, and concentrated on one side of the mass.

4 Discussion

4.1 Selection of contrast agent and iodine allergy test

4.1.1 Contrast agent 50% sodium diatrizoate and 50% sodium diatrizoate. The catheter display contrast was ideal. According to Ouyang Yong's report [2], other water-soluble iodine contrast agents were also satisfactory. We have tried low-concentration sodium diatrizoate reagent as a control. The ducts were weakly visualized and easily obscured by higher-density glands. Therefore, we believe that low-concentration water-soluble contrast agents should not be used.

4.1.2 Iodine allergy test There are many methods for X-ray contrast iodine allergy test [3]. We use potassium iodide powder diluted with water to 10%. The patient takes 20ml orally at one time, and the results can be observed after 30 minutes. This method is simple, easy and reliable. No allergic reaction occurred in this group after angiography.

4.2 Contrast imaging technology Careful search and determination of contrast emulsification before imaging is the key to obtaining positive imaging results and avoiding missed or misdiagnosed. Regarding the method of determining breast pores by duct angiography, Su Lifu's method [4] has been introduced in detail. Our approach is now introduced as follows.

4.2.1 To confirm the nipple pores, gently squeeze the affected breast before inserting the needle to squeeze out the overflow to confirm the breast pores; for those with multiple holes and discharge, you should choose bloody holes or those with a large amount of discharge. Contrast agent can be injected into multiple holes at the same time to avoid missed diagnosis.

4.2.2 Clear breast pore secretions If there is a lot of discharge, especially acne-like secretions, try to squeeze them out to avoid clogging the needle or diluting the contrast medium. However, excessive squeezing should be avoided, causing papilledema and affecting needle insertion.

4.2.3 Improved breast ductography method Generally, it is not difficult to insert a needle into a breast hole with obvious discharge. However, it is more difficult for patients with nipple inflammation and inflammatory edema of the nipple pores. It is also difficult for patients without nipple discharge due to long-term atresia of the nipple pores. It has been reported in the literature [5] that the application of soft catheters to improve breast duct angiography can achieve a success rate of 100%.

4.2.4 Contrast dose The injected contrast dose varies from person to person, ranging from 0.5ml to 2ml. It is advisable to stop the injection when the operator feels the pressure increases and the patient feels swelling and pain. Excessive pressure that causes the contrast agent to enter the acini and cause pain to the patient should be avoided.

4.2.5 Taking X-rays After the contrast agent is injected, take axial and lateral breast X-rays. There is no need to close the breast pores in the standing position, but care should be taken not to pressurize too much to avoid overflow of the contrast agent. Generally, the lateral position is taken first and then the axial position is taken to prevent the contrast agent from overflowing and contaminating parts and cassettes during the first position. The selection of photography conditions should also be greater than that of plain films in order to better display the catheter image.

4.3 Diagnostic value of breast ductography

4.3.1 Breast ductography is simple and easy to operate. There are many kinds of breast diseases, especially those with nipple discharge. Ordinary mammography is often used. The diagnosis cannot be made clearly, but angiography examination is the most ideal for diagnosis and often has typical X-ray manifestations [6]. In this group of cases, except for 1 case of intraductal cyst diagnosed as papilloma before surgery; 1 case of large intraductal papilloma due to irregular duct wall and large tumor body was considered intraductal cancer, the remaining cases were consistent with the diagnosis. Therefore, we believe that breast ductography is the preferred examination method for patients with nipple discharge.

4.3.2 Ductal ectasia and cystic hyperplasia The terms ductal ectasia and cystic hyperplasia are very inconsistent. Literature [2] reported that the basis for X-ray diagnosis of both is: Any manifestation of large duct or both Those with dilation of small and medium-sized ducts of varying thickness are classified as duct ectasia; if large ducts do not dilate, the main manifestations are mild dilation of small ducts and the formation of small cysts at their ends, especially when multiple cysts are seen in their lumens at the same time. Those with small filling defects are diagnosed as cystic hyperplasia. We believe that there is something wrong with this diagnostic basis. The pathological basis of the two is different, and the clinical manifestations are different. Patients often have symptoms and signs of both, and the treatment methods are also different. Among the 25 dilation cases in our hospital, 15 cases were also accompanied by hyperplasia. The symptoms improved after symptomatic treatment. There was a case of giant cystic hyperplasia in this group. In addition to the manifestations of cystic hyperplasia, the ducts at all levels showed dilatation and widening in angiographic examination. Therefore, we believe that the two cannot be forcibly distinguished or merged simply based on the location of ductal dilation. Clinical examination and patient signs should be combined to not rule out the possibility of both coexisting.