Eur Radiol (2003) 13:94–99

DOI 10.1007/s00330-002-1401-7 BREAST

M.A. Funovics Galactography: method of choice

M.O. Philipp
B. Lackner in pathologic nipple discharge?
M. Fuchsjaeger
P.T. Funovics
V. Metz

Received: 21 August 2001
Revised: 17 January 2002
Accepted: 4 February 2002
Published online: 16 May 2002
© Springer-Verlag 2002
M.A. Funovics (✉) · B. Lackner
M. Fuchsjaeger · V. Metz
Department of Radiology,
University of Vienna Medical School,
Vienna General Hospital,
Währinger Gürtel 18–20,
1090 Vienna, Austria
e-mail: martin_funovics@yahoo.com
Tel.: +43-1-404007620
Fax: +43-1-404004898
M.O. Philipp
Department of Biomedical Research,
University of Vienna Medical School,
Vienna General Hospital,
Währinger Gürtel 18–20,
1090 Vienna, Austria
P.T. Funovics
Department of Trauma Surgery,
University of Vienna Medical School,
Vienna General Hospital,
Währinger Gürtel 18–20,
1090 Vienna, Austria
Abstract Our objective was to as-
sess the role of galactography in the
diagnostic work-up of patients with
pathological nipple discharge togeth-
er with exfoliative cytology, and in-
vestigation of secretion colour. All
galactographies performed in this
center between 1993 and 1998 were
evaluated retrospectively. In 134
cases, outcomes, defined as either a
postoperative histology or a negative
follow-up over 2 years after galac-
tography, were available. In 96 of
these cases, exfoliative cytology was
performed, and in 65 cases the col-
our of the secretion was determined.
Galactograms, cytological findings
and colour of the secretions were
compared with the outcomes. At
galactography, the radiographic
findings had the following individual
sensitivities/specificities in detecting
carcinomas: filling defect 55.6%/
62.1%; ductectasia 22.2%/94%; and
filling stop 5.6%/77.6%. Normal
galactograms (n=33, 25%) had a
sensitivity of 78% and a specificity
of 93% in predicting absence of dis-
ease. Technically inadequate investi-
gations occurred in 16 (12%) cases.
Cytology showed 69.2%/66.8%
for papillomatous borderline or
malignant cells; 53.8%/75.3% for
borderline or malignant cells; and
7.7%/100% for one case of malig-
nant cells. For the assessment of
pathological secretions, galactogra-
phy is a sensitive but unspecific
method for the detection of papillo-
mas or carcinomas. Filling defects,
ductectasia and ductal distortion car-
ry the highest levels of suspicion for
carcinoma. A normal galactogram is
a specific yet moderately sensitive
indicator of absence of localized dis-
ease. Exfoliative cytology shows low
sensitivity but better specificity for
carcinomas when borderline or ma-
lignant cells are found. In the present
series, the colour of the secretions
does not add significant information
about underlying pathology.
Keywords Breast · Abnormalities ·
Neoplasms · Diagnosis ·
Galactography · Ductography ·
Nipple secretion

Introduction thus, pathological nipple discharge is usually regarded as

While the incidence of breast carcinoma in women who
undergo routine screening mammography ranges around
0.5% [1], the incidence of carcinoma in women with uni-
lateral, single-pore, spontaneous (i.e. pathological) nip-
ple discharge ranges from 4 to 31% [2], with the majori-
ty of studies reporting a rate between 10 and 15% [3, 4];
an indication for surgical removal of the diseased ductal
system.
To avoid incomplete or excessive tissue removal, pre-
operative localisation of the diseased duct and identifica-
tion of intra- or periductal abnormalities is necessary.
Galactography has been advocated as the method of
choice for the evaluation of nipple discharge.
 95

To date, studies have demonstrated the association be- water-soluble, non-ionic contrast material (Iopamidol) as far as the
tween abnormal galactograms and presence of intraduc- patient could tolerate, up to a maximum of 1 ml per duct. No pro-
cedure-related complications were observed, and the contrast ma-
tal pathologies in general, and even with distinct histo- terial was completely resorbed on subsequent investigations, in
pathological entities [3], but no attempt has been made contrast to previous experiences with Lipiodol [5]. After removal
to calculate the sensitivities and specificities of specific of the cannula, plain-film mammography was performed in the
radiographic patterns in predicting the presence of carci- craniocaudal and oblique planes on a Philips Mammovision unit
(Philips Medical Systems, Hamburg, Germany).
noma in subsequent excisional biopsy. Furthermore, the The radiographic findings on the galactograms were classified
negative predictive value of a normal galactogram is un- according to a modified scheme of Gregl [6] into the following
known. Traditionally, galactography is often performed groups:
together with exfoliative cytology of the secrete, al- 1. Technically inadequate investigation
though the value of this investigation remains controver- 2. Normal findings
sial. 3. Ductectasia (i.e. duct over 2 mm width)
In this study we present the results of a large series of 4. Filling defects
5. Filling stops
galactograms performed at our centre which have been 6. Distorted ducts
reevaluated for the presence of specific radiographic
findings with verification of the findings by either histol- In all cases of papilloma or carcinoma, plain-film mammography,
which was performed immediately before galactography, was
ogy or a negative follow-up over 2 years and including a evaluated for the presence of lesions suggestive for malignancy.
group of normal galactograms. In addition, the results of For 94 of the patients undergoing galactography (70.1%), exfo-
exfoliative cytology are compared with the histological liative cytology performed at the same time of galactography was
findings. available. The cytological findings were classified according to
previous studies into five groups [7, 8]:
Group 0: insufficient material
Group 1a: benign cytology without papillomatous formations
Materials and methods Group 1b: benign with papillomatous formations
Group 2: borderline
A retrospective study was performed in which the medical reports Group 3: malignant cytology
and files of all patients who underwent galactography at this cen-
ter were reviewed. Between 1993 and 1998, a total of 316 galac- The colour of the secretion could be determined in 65 of the pa-
tographies were performed in 285 patients who were referred to tients undergoing galactography (48.5%) and was differentiated
the radiology department because of nipple discharge. Patients en- into:
tered the study if they had unilateral, spontaneous secretion from 1. Haemorrhagic
one to four ducts and if either surgery was performed within 2. Clear
2 weeks of the galactography, or if a record of 2 years of negative 3. Yellow/green
follow-up of the secreting breast was available. 4. White/milky
Surgery performed after galactography included ductectomy or
segmentectomy under guidance of the galactography films, but For each group and combination of groups, the sensitivity, speci-
without placement of a hook wire or dye staining of the ducts. The ficity and significance in predicting presence of carcinoma were
negative follow-up over 2 years was defined as follows: determined.
Outcomes were classified as:
1. Negative gynecological screening investigation on a yearly ba-
sis including palpation of the breasts 1. Benign by follow-up
2. Negative mammography screening on a yearly basis for pa- 2. Benign by histology
tients who were over 50 years of age 3. Papilloma
3. No subjective complaints such as masses, abnormal pain, in- 4. Carcinoma
flammation or ongoing secretions
These groups were correlated with the radiographic findings as
For those patients who were not followed-up at this centre, the well as with the exfoliative cytology results and the colour of the
above criteria were verified by telephone interview. secretions using crosstables. Sensitivity and specificity for each
A total of 134 galactographies entered the study. All patients radiographic abnormality in the detection of carcinoma were cal-
reported spontaneous secretion over at least 6 weeks. In 125 cases culated. The correlation of the radiographic finding, filling defect
a single duct was secreting, in 9 cases two to four ducts. or filling stop, with the histological finding, papilloma or carcino-
In 33 cases a negative follow-up was available, and in 101 ma, was tested using the χ2 test. A receiver-operating characteris-
cases surgery was performed. In 96 of the 134 cases, exfoliative tics (ROC) curve was drawn for overall sensitivity versus specific-
cytology was performed additionally, and in 65 cases the colour of ity of galactography in the detection of carcinoma by means of
the secretions was available. Cytology and the colour of the secre- stepwise inclusion of the radiographic abnormalities in the order
tions were correlated with the outcomes in the same way as the ra- of their respective individual sensitivities (Fig. 1). The area under
diographic findings. the curve (Az) was calculated by triangulation and the significance
Galactography was performed with the patient in supine posi- by χ2 analysis using dedicated statistics software (SPSS, Chicago,
tion and the ipsilateral arm resting behind the head. By examining Ill.).
a small drop of secretion, the orifice of the secreting duct was lo-
calized. The ducts were cannulized by insertion of blunt sterile
steel cannula, measuring 25 mm in length and 0.6 mm in diameter
(42-G end-port sialography cannula). Once the tip entered the ori-
fice, the cannula easily descended into the duct. A 1-ml tuberculin
syringe was attached to the cannula and the duct was filled with
96

Fig. 1 Receiver-operating characteristics curve for ductal patholo-
gies at galactography (filling defects, ductectasias, distorted ducts,
filling stops included in the order of their individual sensitivities)
for the detection of carcinoma
Results
Of the 134 galactographies available for study, Table 1
shows outcomes correlated with the radiographic find-
ings. The galactograms showed filling defects (Fig. 2) in
54 cases (40.3%), filling stops (Fig. 3) in 27 (20.1%),
duct distortion in 3 (2.2%) and ductectasias in 11 (8.2%)
cases. Sixteen cases (11.9%) did not show properly filled
ducts and were considered technically inadequate (col-
umn 1 in Table 1). In 6 of these cases the patient could
not tolerate cannulation of all secreting ducts. In 8 of the
cases the duct could not be cannulated properly, and in
the 2 remaining cases there was paravasation of contrast
material that did not allow for proper delineation of the
ducts.
Normal galactographic findings correlated in 18 cases
with a negative follow-up over 2 years; thus, normal
findings at galactography showed a sensitivity of 78.3%
in detecting absence of intraductal pathology, with a
specificity of 92.6% (p<0.001; χ2 test). The galacto-
graphic correlation of intraductal processes (i.e. filling
defects or filling stops) in 51 cases showed a sensitivity
of 86.4% and a specificity of 49.2% in predicting papil-
loma or carcinoma (p<0.001; χ2 test). The low specifici-
ty is largely due to a high rate of 22 false-positive find-
ings that were identified as periductal fibrocystic chang-
es on subsequent surgery. Seventy-three percent of all

Table 1 The radiographic find-

ings at galactography (col- Technically Normal Duct- Filling Filling Distor- Total
umns) vs the histological out- inadequate ectasia defect stop tion
come (rows) for 134 patients
with pathological secretion. Benign by follow-up 7 18 4 2 2 33
The last two rows represent the Benign by histology 2 3 3 16 10 35
sensitivities and specificities of Papilloma 6 1 26 14 1 48
the respective radiographic Carcinoma 1 1 4 10 1 1 18
findings in the detection of car- Total 16 23 11 54 27 3 134
cinomas
Sensitivity (%) 5.6 22.2 55.6 5.6 5.6
Specificity (%) 81.0 94.0 62.1 77.6 98.3

Table 2 Results of exfoliative

cytology (columns) vs the his- 0 1a 1b 2 3 Total
tological outcome (rows) for Insufficient Benign Papillomatous Borderline Malignant
96 patients with pathological material
secretions. The sensitivities and
specificities of cytology results Benign by follow-up 12 1 13
1b or higher, 2 or higher, and Benign by histology 16 3 9 28
3 in predicting carcinoma on Papilloma 9 17 3 11 40
subsequent surgery are given in Carcinoma 4 2 6 1 13
the lower rows Total 9 49 9 26 1 94
Sensitivity |.......................... 69.2% ...........................|
|............. 53.8% ............|
|... 7.7% ...|
Specificity |.......................... 66.6% ...........................|
|............. 75.3% ............|
|...100% ...|
 97

Fig. 2 Galactogram in the cra-

niocaudal plane in a 62-year-
old patient with pathological
nipple discharge. In the ectatic
duct, there is a lobulated
mass. Histology after lumpec-
tomy showed an intraductal
papilloma

Fig. 3 Galactogram in the cra-

niocaudal plane in a 77-year-
old patient with secretions and
pain, negative mammography
and no palpable mass. There is
a filling stop of the ectatic duct
after 4 cm due to a convex
mass protruding into the lumen.
Histology after segmentectomy
showed an invasive ductal
carcinoma

false-positive findings could be attributed to fibrocystic
changes, whereas the proportion of fibrocystic changes
among all histological groups other than papilloma or
carcinoma was only 39.7%.
There were 18 cases of carcinomas, corresponding to
a percentage of 13.4% in the study population. Of these
18 cases, 11 showed filling defects or filling stops at ga-
lactography. In 1 case galactography was technically in-
adequate, and of the remaining 6 cases, galactography
was normal in only 1 case. In this case the carcinoma
was detected at mammography. This was the only case
of carcinoma, where mammography, which was per-
formed together with galactography in all patients, re-
vealed a suspicious lesion. The last two lines of Table 1
show the respective sensitivities and specificities of each
single radiographic abnormality in the detection of carci-
noma. If the radiographic abnormalities are stepwise in-
cluded in the diagnosis of carcinoma in the order of their
individual sensitivities, an ROC curve is obtained which
is shown in Fig. 1. The area under the curve (Az) is
0.652 (p=0.038).
Table 2 shows the 94 cases in which cytology was ob-
tained and correlated with the histological diagnosis. In
the 13 cases of carcinoma, normal benign cytology had
been reported in 4 cases, benign cytology with papillo-
matous formations in 2 cases, borderline cytology in
6 cases and malignant cytology in only 1 case. In 9 cases
there was not enough material for diagnosis. All of these
9 cases were papillomas at histology. Sensitivity and
specificity for detection of carcinoma were 69.2 and
66.6%, respectively, for types 1b, 2 or 3 cytology, 53.8
and 75.3%, respectively, for types 2 or 3 cytology, and
7.7 and 100%, respectively, for 1 case of type-3 cytolo-
gy.
In 65 cases the colour of the secretions was noted.
There was no significant correlation between any colour
98
group or any combination of groups and carcinoma or
papilloma. Haemorrhagic secretion showed a sensitivity
of 66.7% and a specificity of 43.4% (p=0.523), and clear
secretion showed a sensitivity of 8.3% and a specificity
of 86.8% (p=0.643). The fact that most secretions for car-
cinomas and papillomas were of the haemorrhagic type is
due to the high proportion (58%) of haemorrhagic secre-
tions in the entire study group. The incidence of carcino-
ma in patients with haemorrhagic secretions was 21.1%,
and in those with secretions of other colours, 14.8%.
Discussion
Nipple discharge is relatively common and occurs in
3–8% of the patients who consult a doctor for a disease
of the breast [9, 10]. Usually, the underlying cause is be-
nign. Approximately 50% of the secretions are physio-
logical or secondary secretions with an underlying sys-
temic cause, and the other half are pathologic secretions
caused by a lesion in the breast [11, 12].
The results of this study suggest that in the assess-
ment of pathologic nipple secretions, normal findings at
galactography do carry a high specificity and a moderate
sensitivity in predicting the absence of intraductal dis-
ease, whereas filling defects and filling stops are a sensi-
tive yet unspecific indicator for intraductal papilloma or
carcinoma.
In this study the most important limitation of galac-
tography was the high number of false-positive results in
predicting intraductal processes, with most misinterpre-
tations in the fibrosis group (including mastopathy, peri-
ductal fibrosis and sclerosing adenosis). At our centre
surgical excision of diseased ducts is performed with
guidance of the galactograms alone and usually without
the aid of placing a hook wire or dye staining of the
duct; thus, a certain proportion of intraductal pathology
shown on the galactograms may have been missed at
surgery [13]. In addition, galactography alone cannot
distinguish between intrinsic and extrinsic obliteration of
a duct, and some fibrotic processes in the breast have
been shown to produce distortion, calibre irregularities
and extrinsic occlusions of ducts. This explains the over-
lap between the fibrosis group and the group of intraduc-
tal pathologies.
There were 14.5% of patients evaluated for pathologi-
cal nipple discharge who had in situ or invasive ductal
carcinomas, a rate consistent with the literature [14, 15].
The most frequent cause for discharge (38.7%) was pap-
illoma. Mammography which was performed together
with galactography in all of these cases revealed in only
1 case a suspicious mass. This low sensitivity may be
due to the typically small size of the malignant lesions
that were detected at galactography.
Generally, solitary papillomas are regarded as benign
lesions, whereas papillomatosis has been found to re-
present a precanceromatous condition [16, 17]; however,
the frequency of carcinomas in patients with pathologi-
cal nipple discharge is high enough to mandate excision-
al biopsy of the diseased region, typically performed af-
ter galactography to locate intraductal lesions. In addi-
tion, nipple discharge together with a palpable mass, are
symptoms that are normally discovered and easily ob-
served by the patient herself. In such cases the indication
for further diagnosis and biopsy/surgery is broader, be-
cause even if the symptom itself has a benign cause, an
eventual incidental carcinoma could occur, and in such a
case it would be difficult to justify a conservative work-
up.
Traditionally, haemorrhagic nipple discharge has been
associated with carcinoma or with localized intraductal
disease. The incidence of haemorrhagic secretion ranges
between 22 and 55% for all patients, and up to 51% for
patients with carcinoma [12, 13, 18, 19]. Watery and se-
rous secretion has been found in 2–33% of cases [20].
Furthermore, up to 11% of the patients with physiologi-
cal secretions have been reported to produce haemor-
rhagic secretions [11, 19].
In the present study the overall incidence of haemor-
rhagic secretion was 58%, and the haemorrhagic secre-
tions in the carcinoma group were 67%. There was no
statistically significant correlation between the colour of
the secretions and any histological diagnosis; however,
in this relatively small cohort of 65 cases, the absence of
statistically significant differences between two groups
has to be regarded very carefully and cannot be interpret-
ed as equality. With this number of cases, the beta error
is still >0.2, i.e. a difference of over 20% between the
groups in carcinoma incidence would go unnoticed.
Some previous studies also found a trend to higher inci-
dence of carcinoma in patients with haemorrhagic secre-
tions [21], but these correlations have not been tested for
significance.
The results of exfoliative cytology showed only 1
case of malignant cytology, whereas 4 of the 13 carcino-
mas had benign cytology. These results correspond well
with several other studies where exfoliative cytology and
galactography were correlated with histological diagno-
sis [22]. One reason may be the proportion of well-dif-
ferentiated ductal carcinomas, of which only 30–40%
have been shown to be associated with malignant cytolo-
gy [10]. In a large series of exfoliative cytology investi-
gations comprising 225 cases, only 2 definitive malig-
nant cytologies were found [13]. In contrast to galactog-
raphy, borderline or malignant exfoliative cytology has a
low sensitivity but high specificity in detecting carcino-
mas, and therefore has the potential to increase the likeli-
hood of malignant disease if it occurs together with in-
traductal pathologies at galactography.
 99

Conclusion intraductal pathology at galactography does not allow for

In conclusion, galactography should be the method of
choice in the work-up of pathological nipple secretions.
If galactograms are negative, a close follow-up with
mammography and repetitive galactographies seems jus-
tified. In the case of pathological findings at galactogra-
phy, especially filling defects or filling stops, one should
be aware that these findings are an unspecific yet sensi-
tive indicator for the presence of papilloma or carcino-
ma, even if mammography is negative. The presence of
borderline or malignant cytology for such cases further
increases likelihood of malignant disease. Presence of
a reliable differentiation between benign and malignant
lesions by radiographic features. The role of galactogra-
phy is therefore a topographic one. For these cases initial
results with MR galactography have shown a high speci-
ficity in exclusion of malignant disease and thus the po-
tential to reduce unnecessary surgery [23]; however, if
MR galactography is not available, the high prevalence
of carcinomas in patients with ductal pathologies justi-
fies excisional biopsy, eventually after placement of a
hook wire or dye staining of the diseased ducts, since
this has been shown to reduce the volume of the resec-
tion necessary for reliable inclusion of the pathology [2].

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