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Mammographic imaging of lactiferous ducts using retrograde introduction of contrast material.
[galacto- + -graphy]
Synonym/acronym: Breast ductoscopy, fiberoptic ductoscopy, galactography.
To visualize and assess the breast ducts for disease and malignancy in women with nipple discharge.
Area of applicationBreast.
ContrastIodine-based contrast medium.
Ductography is an imaging procedure used to visualize the ductal system of the breast and to investigate reasons for production of nipple discharge in the anatomical area of interest. The majority of both benign and malignant breast disease originates from the cells that line the ductal-lobular unit. In ductography, the lactiferous duct is cannulated and a small amount of contrast medium is injected into the duct followed by mammographic images. Ductography is not indicated in patients with bilateral discharge because this is generally caused by hormonal changes. Biopsy and ablation techniques can also be performed during ductoscopy with correlation between visual findings and histopathology.
This procedure is contraindicated for
- Patients who are pregnant or suspected of being pregnant, unless the potential benefits of a procedure using radiation far outweigh the risk of radiation exposure to the fetus and mother.
- Patients younger than age 25 because the density of the breast tissue is such that diagnostic x-rays are of limited value.
- Patients with conditions associated with adverse reactions to contrast medium (e.g., asthma, food allergies, or allergy to contrast medium). Although patients are still asked specifically if they have a known allergy to iodine or shellfish, it has been well established that the reaction is not to iodine, in fact an actual iodine allergy would be very problematic because iodine is required for the production of thyroid hormones. In the case of shellfish the reaction is to a muscle protein called tropomyosin; in the case of iodinated contrast medium the reaction is to the noniodinated part of the contrast molecule. Patients with a known hypersensitivity to the medium may benefit from premedication with corticosteroids and diphenhydramine; the use of nonionic contrast or an alternative noncontrast imaging study, if available, may be considered for patients who have severe asthma or who have experienced moderate to severe reactions to ionic contrast medium.
- Patients with bleeding disorders receiving an arterial or venous puncture because the site may not stop bleeding.
- Breast cancer
- Normal breast examination with high risk of developing breast cancer
- Unilateral nipple discharge, bloody or clear and watery
- Normal breast tissue
Abnormal findings related to
- Ductal thickening
- Papillary lesions
- Ductal carcinoma in situ (DSIS)
- Invasive breast cancer
Factors that may impair clear imaging
- Inability of the patient to cooperate or remain still during the procedure because of age, significant pain, or mental status.
- Metallic objects within the examination field (e.g., jewelry, body rings), which may inhibit organ visualization and can produce unclear images.
- Application of substances such as talcum powder, deodorant, or creams to the skin of breasts or underarms, which may alter test results.
- Previous breast surgery, breast augmentation, or the presence of breast implants, which may decrease the readability of the examination.
- Consultation with an HCP should occur before the procedure for radiation safety concerns regarding younger patients or patients who are lactating. Pediatric & Geriatric Imaging Children and geriatric patients are at risk for receiving a higher radiation dose than necessary if settings are not adjusted for their small size. Pediatric Imaging Information on the Image Gently Campaign can be found at the Alliance for Radiation Safety in Pediatric Imaging (www.pedrad.org/associations/5364/ig/).
- Risks associated with radiologic overexposure can result from frequent x-ray procedures. Personnel in the room with the patient should stand behind a shield or leave the area while the examination is being done. Personnel working in the examination area should wear badges to record their level of radiation exposure.
Nursing Implications and Procedure
- Positively identify the patient using at least two unique identifiers before providing care, treatment, or services.
- Patient Teaching: Inform the patient this procedure can assist in evaluating the breast and mammary ducts for disease.
- Obtain a history of the patient’s complaints or clinical symptoms, including a list of known allergens, especially allergies or sensitivities to latex, anesthetics, contrast medium, or sedatives.
- Obtain a history of the patient’s reproductive system, symptoms, and results of previously performed laboratory tests and diagnostic and surgical procedures.
- Record the date of last menstrual period and determine the possibility of pregnancy in perimenopausal women.
- Obtain a list of the patient’s current medications, including herbs, nutritional supplements, and nutraceuticals (see Effects of Natural Products on Laboratory Values).
- Review the procedure with the patient. Address concerns about pain and explain that there may be moments of discomfort and some pain experienced during the test. Inform the patient that the procedure is usually performed in a mammography department by an HCP, with support staff, and takes approximately 30 min.
- Sensitivity to social and cultural issues, as well as concern for modesty, is important in providing psychological support before, during, and after the procedure.
- Note that there are no food, fluid, or medication restrictions unless by medical direction.
- Inform the patient not to apply deodorant, body creams, or powders on the day of the procedure.
- Instruct the patient to remove jewelry and other metallic objects in the area to be examined.
- Make sure a written and informed consent has been signed prior to the procedure and before administering any medications.
- Potential complications:
Infection or bleeding
- Observe standard precautions, and follow the general guidelines in Patient Preparation and Specimen Collection. Positively identify the patient.
- Ensure that the patient has removed external metallic objects prior to the procedure.
- Ensure that the patient has removed any deodorant and talcum powder.
- Avoid the use of equipment containing latex if the patient has a history of allergic reaction to latex.
- Have emergency equipment readily available for possible contrast reactions.
- Instruct the patient to change into the gown, robe, and foot coverings provided.
- Instruct the patient to cooperate fully and to follow directions. Instruct the patient to remain still throughout the procedure because movement produces unreliable results.
- Place the patient in the supine position on an examination table.
- Stroke the breast with firm pressure to discharge a small amount of fluid from the duct.
- Cannulate the duct until it passes beyond the sphincter of the orifice.
- Inject a small amount of contrast into the duct, allowing gravity to move it.
- Tape the cannula to the breast and assist the patient to the mammography unit for two mammographic images.
- Remove the cannula and apply a dressing over the nipple.
- Observe/assess the cannula insertion site for bleeding, inflammation, or hematoma formation.
- Inform the patient that a report of the results will be made available to the requesting HCP, who will discuss the results with the patient.
- Observe/assess the cannula insertion site for bleeding, inflammation, or hematoma formation.
- Instruct the patient in the care and assessment of the injection site.
- Recognize anxiety related to test results. Discuss the implications of abnormal test results on the patient’s lifestyle. Provide teaching and information regarding the clinical implications of the test results, as appropriate. Educate the patient regarding access to counseling services.
- Reinforce information given by the patient’s HCP regarding further testing, treatment, or referral to another HCP. Decisions regarding the need for and frequency of breast self-examination, mammography, MRI breast, or other cancer screening procedures should be made after consultation between the patient and HCP. The American Cancer Society (ACS) recommends breast examinations be performed every 3 yr for women between the ages of 20 and 39 yr and annually for women over 40 yr of age; annual mamograms should be performed on women 40 yr and older as long as they are in good health. The ACS also recommends annual MRI testing for women at high risk of developing breast cancer. Genetic testing for inherited mutations (BRCA1 and BRCA2) associated with increased risk of developing breast cancer may be ordered for women at risk. The test is performed on a blood specimen. The most current guidelines for breast cancer screening of the general population as well as individuals with increased risk are available from the ACS (www.cancer.org), the American College of Obstetricians and Gynecologists (ACOG) (www.acog.org), and the American College of Radiology (www.acr.org). Answer any questions or address any concerns voiced by the patient or family.
- Instruct the patient in the use of any ordered medications. Explain the importance of adhering to the therapy regimen. As appropriate, instruct the patient in significant side effects and systemic reactions associated with the prescribed medication. Encourage the patient to review corresponding literature provided by a pharmacist.
- Depending on the results of this procedure, additional testing may be needed to evaluate or monitor progression of the disease process and determine the need for a change in therapy. Evaluate test results in relation to the patient’s symptoms and other tests performed.
- Related tests include biopsy breast, cancer antigens, mammography, MRI breast, stereotactic biopsy breast, and US breast.
- Refer to the Reproductive System table at the end of the book for related tests by body system.