Monday, July 17, 2017

How To Perform A Ductogram / Galactogram

A ductogram is a minimally invasive exam performed by a radiologist for patients with nipple discharge. Also known as a galactogram, a ductogram should be reserved for patients (typically women) with unilateral, spontaneous clear or bloody nipple discharge. That type of discharge is worrisome for malignancy, specifically an intraductal papilloma. 

Indications: 
Women with bilateral nipple discharge should search for central causes first. A common cause would be a pituitary adenoma, which can be assessed with a prolactin level in conjunction with a contrast-enhanced MRI of the brain with sella-specific sequences.

Women with unilateral discharge that is green, yellow, brown or another color most likely have fibrocystic disease, with the discharge representing cystic contents that have been expelled into the ductal system.

Procedure:
Place the patient in a seated position next to the mammography machine. While some texts advocate performing the cannulation supine, the seated position minimizes risk of needle dislodgment when moving the patient.

After cleaning the nipple with an alcohol swap, ask the patient to express the discharge. If they cannot, consider a warm compress or rescheduling the procedure. Once discharge is evident, use a focal light and magnifying glass to attempt to place the needle. A straight or angled 30 gauge needle connected to a 1 cc tuberculin syringe or 3 cc syringe via tubing is utilized. The needle should slide right into the duct if the trajectory is correct. If not, gently re-orient the needle around the clock in 15-30 degree increments. There should not be any resistance or dimpling of the nipple; when the duct is cannulated, the needle will slide right in. This should be relatively painless for the patient.

Once in place, inject 0.3 to 0.5 cc of contrast. Inject S   L   O   W   L   Y, over a minute or more. This is key to preventing extravasation and opacifying the distal ducts.

After injecting, gently affix the needle to skin with Steristrips. Be careful not to affix too forcefully, as this will sidewall the needle. I recommend 1/8th inch strips if available.

Take CC and ML images to document your findings. Once complete, remove the needle and give the patient 2x2 gauze or similar pads to cover the nipple after discharge to capture the contrast that will leak out.

For further details about the procedure and common findings, please see this RadioGraphics article.


References: