Interventional Procedures

DUCTOGRAPHY

The evaluation and management of patients presenting with nipple discharge is variable among clinicians. Commonly, a prolactin level is checked, and some of the discharge is submitted for cytologic evaluation; if these tests are normal, the patient usually undergoes no further workup unless the discharge is bloody. Patients with bloody nipple discharge are referred to a surgeon and may undergo a subareolar duct excision. Inherent assumptions in these approaches that need to be challenged are outlined in Table 11.1.

Although ductography is not a perfect test, it can help address some of these issues. The presence, location, and extent of a lesion can be demonstrated in many patients with spontaneous nipple discharge. The location of the duct containing the lesion and its distribution in the breast can be established preoperatively. When findings consistent with duct ectasia or fibrocystic changes are diagnosed, surgery may be averted. Finally, if preoperative ductograms are done using a methylene blue-contrast combination (1:1), the contrast allows us to verify that we cannulated the abnormal duct; the methylene blue stains the duct so that it is easy to identify intraoperatively by the surgeon intraoperatively and by the pathologist at the time the specimen is processed. This helps ensure that the lesion is localized, excised, and evaluated histologically.

Clinically, patients with intraductal lesions may present describing nipple discharge. When asked how they notice the discharge, patients invariably provide one of three histories. They notice dark spots on their bra cups or spots on their nightclothes, or after taking a hot bath or shower, they notice that their nipple is dripping. If the discharge is only expressed after vigorous manipulation of the breast and nipple, the likelihood of finding an intraductal lesion is low, and ductography is not indicated.

Ductography is a safe, easy, and simple contrast evaluation of a lactiferous duct (1, 2, 3, 4). The only relative contraindication to ductography is the presence of mastitis, and no significant complications have been described with the water-soluble contrast agents currently in use. Ductography is used to evaluate women presenting with spontaneous nipple discharge, regardless of the character of the discharge (Figure 11.1). Adequate lighting and magnification of the nipple are helpful in identifying the secreting duct opening. Fullstrength iodinated contrast material is drawn into a 3-mL Luer-Lok syringe. A 30-gauge blunt-tip sialography needle with attached tubing is screwed onto the Luer-Lok syringe,
making sure that the connection is tight so that air bubbles are not drawn into the syringe. Contrast material is run through the tubing until all air bubbles are removed from the system. Topical anesthesia and dilators are not needed for this procedure.

Table 11.1: Common Assumptions in Women with Nipple Discharge

Assumption	Fact
1. Negative cytology results reliably exclude pathology.	Negative cytology does not reliably exclude significant pathology.
2. Only bloody nipple discharge is significant.	Ductal carcinoma in situ can present with serous or clear, heme occult-negative nipple discharge.^a
3. The location and extent of a lesion in the duct can be reliably identified intraoperatively so that the dissection is extended as needed to include, but not transect, the lesion.	Not all papillomas are close to the subareolar area and when cancer is present if this is often extensive and not subareolar in location.
4. The pathologist can reliably identify the location of the lesion in the specimen for histologic evaluation.	Staining of the duct with methylene blue facilitates intraoperative identification of the duct for the surgeon and during processing of the specimen for the pathologist.
^aHow a patient notices the discharge is more important than the character of the discharge. Expressed nipple discharge is usually physiologic. Spontaneous nipple discharge needs to be evaluated regardless of its appearance.

The patient is positioned supine with the ipsilateral arm placed above her head. The nipple is inspected for the presence of crusting or a dilated prominent duct opening. Using an alcohol wipe, the nipple is swabbed to remove any keratin plugs that may obstruct the duct opening. Next, the breast is examined. A “trigger point” may be identified in some patients (5). When this trigger point is compressed, nipple discharge is obtained. As you move away from this point, the discharge stops. In some patients with an intraductal lesion, the discharge can be copious and projectile.

Figure 11.1 Spontaneous nipple discharge. A. Spontaneous bloody nipple discharge arising from a single duct opening. B. Spontaneous clear nipple discharge (arrow) arising from a single duct opening. If the patient presents with spontaneous nipple discharge, the character of the discharge does not dissuade us from evaluating the patient with ductography. Breast cancers can present with clear, or serous, heme occult-negative discharge.

Figure 11.2 Duct cannulation. After the duct producing the discharge is identified, the cannula is angled, and the tip is placed in the duct opening. Next, the cannula is gently straightened. In most patients, the cannula falls in the duct to the hub. No pressure is exerted. The patient should experience no pain during cannulation.

If you identify a trigger point, use it to express small amounts of discharge. Elicit just enough to moisten and glisten the opening. If a larger amount of discharge is obtained, other openings are flooded, precluding correct identification of the offending duct. With a clear idea of which opening the discharge is coming from, angle the cannula and place the tip on the duct opening (Figure 11.2). After the cannula is engaged in this manner, straighten it so that the cannula falls into the duct to the level of the hub. After cannulation, take a few seconds to observe the tubing. Because the tubing is now in a closed system with the cannulated duct, duct contents can sometimes be seen refluxing back into the tubing (Figure 11.3). If this is not observed, start to inject contrast and look at the nipple. As intraductal fluid is displaced by contrast, some of the fluid may come out to form a drop around the cannula (Figure 11.4). When either of these observations is made, you have some assurance that you cannulated the potentially abnormal duct.

A small amount of contrast (0.2 to 0.4 mL) is injected initially, and the cannula is taped on the nipple (Figure 11.5). Injecting larger amounts of contrast at the onset may obscure small lesions (Figure 11.6) or those that are close to the nipple. Full-paddle magnification views in the craniocaudal (CC) and 90-degree lateral projections are then obtained. After a review of these initial images, additional contrast can be injected as needed, to opacify the duct proximally.

Little is known about the ductographic appearance of normal ducts. There seems to be considerable variation in length, amount of branching, distribution, and caliber (Figure 11.7).
Occasionally, a contained contrast blush is seen, the overall appearance of which suggests the possibility of lobular opacification (Figure 11.8). We use the sialography cannula as an internal measure of duct caliber. Arbitrarily, we define normal duct caliber as up to 3 times the width of the cannula.

Figure 11.3 Reflux of duct contents into tubing. Cannula in the duct to the hub. Immediately after cannulation, observe the tubing for a few seconds before injecting contrast. The tubing is now in a closed system with the cannulated duct such that duct contents can sometimes be seen refluxing into the tubing. If this is seen, it confirms cannulation of the duct producing the discharge. In this patient, the refluxing material is bloody (short, thin arrows). An air bubble (long, thin arrow) separates the refluxing duct contents from the contrast (thick arrow). When the discharge is clear or serous, mixing of the duct contents with the contrast can be seen occurring in the tubing.

Figure 11.4 Duct contents forming droplet around cannula. If duct contents do not reflux into the tubing, duct contents can sometimes be seen forming a droplet (arrow) around the cannula as contrast is injected. The contrast displaces duct contents. When this is seen, it confirms cannulation of the duct producing the discharge.

Solitary papillomas are diagnosed in about half of women presenting with spontaneous nipple discharge (1, 2, 3, 4, 5, 6, 7). Papillomas are most commonly found within dilated ducts in a subareolar location. Although the entire duct may be dilated in these patients, the segment of duct between the lesion and the nipple is most commonly involved. Papillomas, however, can occur anywhere in the duct, and duct dilation is not always present (Figure 11.9). Filling defects (Figure 11.10), obstruction of the main duct (Figure 11.9A) or a branch (Figure 11.11), and, less commonly, wall irregularity (Figure 11.12) are ductographic findings in patients with papillomas. In some patients, contrast can be seen pooling irregularly in the interstices of the lesion. The lesions sometimes appear to expand and disrupt the integrity of the duct; however, when excised, the wall of these ducts is intact (Figure 11.13). In patients with fibrocystic changes, the discharge is often green (7). Ductography findings include connection with one or several cysts (Figure 11.14) or diffuse wall irregularities. Thick, white, pasty discharge may be seen in patients with underlying
duct ectasia as the cause of nipple discharge (7). These ducts are dilated in the subareolar region and often change abruptly in caliber as the duct courses proximally (Figure 11.15).

Figure 11.5 Taping cannula in place. After 0.2 to 0.4 mL of contrast is injected, the cannula is taped onto the nipple using two pieces of paper tape. Leaving the cannula in place permits additional injections of contrast as needed to evaluate the duct. The cannula also helps minimize the amount of contrast that is forced out of the duct when compression is applied.

Figure 11.6 Masking of lesion; lobular blushing; papilloma. A. Initial films following injection of 0.2 mL of contrast demonstrate a filling defect (arrow) in a mildly dilated duct. No proximal opacification is noted. Cannula (short thin arrow) is present; tubing with contrast (long thin arrow) should be moved out of the field of view by the technologist. B. After an additional 0.2 mL of contrast, the filling defect (thin arrow) is still seen. Branches of the duct are now filling with contrast, and there is some “blushing” (thick arrows), possibly reflecting contrast in the lobular units. C. An additional 0.2 mL of contrast is injected. The lesion is no longer seen because of the amount of contrast injected. Increased amount of blushing is noted (thick arrows). Small lesions and lesions that are close to the nipple can be obscured if too much contrast is injected initially. A small amount is injected initially. If the cannula is left in place, it is easy to inject additional contrast as needed to evaluate the duct proximally.

Finally, breast cancer can present with spontaneous nipple discharge (1, 2, 3, 4, 5, 6, 7). Most of the patients with underlying cancer as the cause of the nipple discharge have normal mammograms (Figure 11.16). Ductal carcinoma in situ (DCIS) is the most common finding in patients with normal mammograms. These represent about 5% of all patients presenting with spontaneous nipple discharge. A small number of patients present with spontaneous nipple discharge and a finding suggestive of cancer (e.g., malignant-type calcifications, ill-defined or spiculated mass) on their mammograms. In these patients, the discharge is evaluated with a ductogram, and the mammographic finding is evaluated, as needed, based on the finding. Until a relationship is established, these may represent synchronous, yet unrelated, processes (Figure 11.17). The ductographic findings in women with breast cancer overlap with those described for papillomas. Cancer-containing ducts, however, are not usually very dilated, and diffuse wall irregularities with focal areas of dilation and sacculation are more common than discrete filling defects (Figure 11.18). Less common signs of cancer on ductography include contrast extravasation and displacement of the opacified duct (3).

Some potential pitfalls include the masking of small lesions, or those close to the nipple, if too much contrast is injected at the onset (Figure 11.6). Air bubbles may rarely be mistaken for a lesion. Air bubbles, however, are well-defined, round, and lucent, and they change in position between films (Figure 11.19). Rarely, an extensive amount of air outlines portions of the ductal system. This is probably not related to the contrast injection, but the cause is not clear (Figure 11.19). Duct perforation with contrast extravasation is uncommon. It is not easy to perforate a normal duct. It requires a certain amount of force and is painful, and the patient describes a burning sensation as soon as you start injecting contrast. In attempting to distend small ducts, contrast extravasation proximally in side branches of the duct and opacification of lymphatic channels can sometimes be seen (Figure 11.20). These patients tolerate the injection initially but describe a burning sensation after a few drops of contrast have been injected.

Figure 11.7 Normal ducts. A. Using the cannula as an internal measure, this duct is normal in caliber. This duct demonstrates a wide area of drainage with a moderate amount of branching. No focal abnormality is apparent. B. Different patient. Normal caliber duct (cannula at nipple) with a wide area of drainage and more branching than seen in the previous patient. C. Different patient. The subareolar portion of the duct is at the upper limits for what we define as a normal caliber. Significant branching and a wide distribution in the parenchyma. D. Different patient. In contrast to the prior examples, this duct is attenuated with a minimal number of branches and a limited drainage area. In these smaller ducts, proximal extravasation of contrast (arrow) is seen as attempts are made to distend the duct further. E. Different patient. This duct has no detectable branch points, and its distribution is limited in the breast. Normal caliber.

Figure 11.8 Lobular blush; normal duct. In some patients, a contained contrast blush is seen in a lobular-like distribution (arrows) around the duct. This is often seen in normal-caliber ducts such as those seen in this patient. Scattered benign calcifications are seen in the surrounding tissue.

Figure 11.9 Papillomas. A. A lesion is present obstructing the cannulated duct close to the nipple. The irregular interface at the obstructing site reflects contrast pooling in the interstices of the papilloma. The duct between the lesion and the nipple is dilated (compare to cannula). The subareolar location of this lesion, within a distended duct, is a common presentation for papillomas. B. Different patient. The lesion (arrow) is obstructing one of the terminal branches in this duct. The duct is normal in caliber, and there is a significant amount of branching and a wide area of drainage. Despite the magnification technique, some of these lesions can be difficult to identify, and close evaluation of all branches is important. Imagine how limited we would be in trying to detect these small lesions without magnification. C. Photographic coning to area of lesion. Obstructing lesion and two adjacent filling defects (arrows) are evident in this patient. Preoperative ductography is done and then used to direct a wire localization of the lesion.

Figure 11.10 Papilloma, filling defect. A. Opacified duct is moderately dilated. Do you see the lesion? Despite the magnification technique, some of these lesions can be difficult to identify, and close evaluation of all branches is important. Imagine how limited we would be in trying to detect these lesions without magnification. B. Photographic coning to the area of the lesion demonstrates a filling defect (arrows) in the opacified duct. The edges of the lesion are irregular, consistent with contrast pooling in the interstices of the papilloma. Notice the distance from the nipple to the lesion. Although papillomas are often in a subareolar location, not all of them are. Without knowing the location of this lesion preoperatively, do you think the surgeon would extend the dissection to this point? Even if the dissection was extended to this point, can we be sure the pathologist would know where to look for the lesion for complete histological evaluation?

Figure 11.11 Papilloma obstructing side branch; air bubbles. Craniocaudal (A) and 90-degree lateral (B) views demonstrating a lesion (thin arrows) obstructing one of the branches of the opacified duct. The duct is dilated. Air bubbles (thick arrows) are well circumscribed and lucent. They are not seen on the craniocaudal view in this patient.

Figure 11.12 Papilloma, wall irregularity. Normal-caliber duct with apparent narrowing and irregularity involving a side branch of the duct (arrow). Ductographic findings for ductal carcinoma in situ and papillomas often overlap, hence the need to recommend biopsy.

Figure 11.13 Papilloma, expanding and distorting the duct. This lesion (thick, black arrow) is obstructing the duct. Contrast (thick, black arrow) is seen seemingly outside the confines of the duct, but this is actually contrast in the interstices of the lesion, and the duct itself is normal. The duct is dilated compared with the cannula (white arrow).

Figure 11.14 Fibrocystic changes, connection to cysts. Normal-caliber duct with contrast opacifying multiple cysts (black arrows). A portion of the contrast-containing tubing (thin, white arrow) used for the ductogram is seen superimposed on the breast. Ideally, the technologist moves the tubing away from the field of view. Portion of cannula (thick, white arrow) is seen.

Figure 11.15 Duct ectasia. A. Thick, white discharge is seen commonly in women with duct ectasia. B. Different patient; dilated duct in its subareolar distribution. The more proximal branches assume a normal caliber. No focal finding is identified.

Figure 11.16 Ductal carcinoma in situ (DCIS). A. Intraductal lesion with interstices outlined by contrast. The duct is dilated between the lesion and the nipple. A papilloma with associated and adjacent DCIS (low to intermediate nuclear grade with no central necrosis) is diagnosed histologically. B. Different patient; focal area of narrowing (arrow) in opacified duct. The duct is minimally dilated. DCIS is diagnosed histologically.

Figure 11.17 Invasive ductal carcinoma, not otherwise specified. Patient has a spiculated mass on her mammogram and spontaneous nipple discharge. The opacified duct is borderline dilated. A side branch of the duct is obstructed (black arrow), with a meniscus noted at the obstruction site. This corresponds to the area of the spiculated mass (white arrows) on orthogonal views (only one view is shown) consistent with an invasive ductal carcinoma presenting with nipple discharge and a mass seen on the mammogram.

Figure 11.18 Ductal carcinoma in situ (DCIS). A. Craniocaudal magnified (1.8×) view of the anterior aspect of the left breast. Diffusely abnormal duct in a 42-year-old patient with spontaneous nipple discharge and a normal mammogram. This duct extends proximally in the upper central portion of the left breast. Multiple areas of narrowing and sacculation are identified, as are abrupt, rounded terminations of the duct. B. Mediolateral oblique magnified view posteriorly. Focal areas of sacculation are seen terminating several of the duct branches (thick arrows). Clusters of calcifications (thin arrows) are also noted on the magnification views, although not very striking on the routine views, however, with magnification, concern in increased. DCIS diffusely involving the opacified duct and surrounding tissue is diagnosed histologically. C. Different patient; diffusely abnormal duct with areas of sacculation and narrowing.

Rarely, pseudolesions may be seen on ductography. Diffuse wall abnormalities may be seen on the initial ductogram, yet at the time of the preoperative ductogram, the findings are not confirmed (Figure 11.21). Nonspecific fibrocystic changes are diagnosed in these patients. It is unclear why this is seen, but it may represent debris in the lumen of the duct. Finally, false-negative ductography secondary to the cannulation of the wrong duct occurs in about 15% of patients. Duct openings are closely apposed on the surface of the nipple; hence, identifying the one with the discharge can be a challenge. If a patient presents with a classic history (e.g., dark spots on the bra cup) and physical examination suggestive of an intraductal lesion (focal crusting on the nipple, identifiable trigger point with copious discharge), a normal ductogram is not accepted. The patient is asked to return for a repeat study, and ultrasound is used in an attempt to localize the lesion.

Figure 11.19 Air bubbles. A. Well-circumscribed, round, lucent filling defects. These change in position between views. B. Different patient. Craniocaudal (CC) and 90-degree lateral (C) views. Photographic cone down, CC projection (D). Air bubbles (black arrows) are present in the opacified duct, and there is air (white arrows) outlining proximal branches of the duct. The source of the air is not clear. Although there is dense tissue, the air is not apparent on the preductogram films, and yet no air was present in the syringe or cannula at the time of the injection.

Figure 11.20 Opacified lymphatic channels. A. Contrast opacifies channels (black arrows) in a nonanatomic distribution for ducts. B. Different patient; proximal extravasation (thin arrows) resulting from an attempt to opacify the cannulated duct. Burning is described by the patient when the extravasation occurs. Contrast opacifies a channel (thick arrows) in a nonanatomic distribution for a duct. Opacification of lymphatics is seen in some patients with proximal contrast extravasation, as in this patient.

Figure 11.21 Pseudolesions. A. Diagnostic ductogram demonstrates a diffusely irregular duct with filling defects and wall irregularities (white arrows). Excision is recommended. B. Preoperative ductogram demonstrates a normal duct. Previously noted abnormalities are not reproduced. Nonspecific fibrocystic changes are reported histologically. C. Different patient; tubular-like filling defects are noted in different portions of this duct (arrows demonstrate extent of filling defects). It is unclear whether these represent duct contents.

Figure 11.22 Papilloma. A. Diagnostic ductogram demonstrating a filling defect (arrow) in a side branch of an arborized duct. B. On the day of surgery, the ductogram is repeated and used to guide a wire localization. Midportion of reinforced wire segment is just posterior to the intraductal lesion.

If an intraductal lesion is identified on ductography, excision is usually recommended. A preoperative ductogram with a methylene blue-contrast combination (1:1) can be helpful to the surgeon intraoperatively and ensures that the pathologist will process and evaluate the lesion. Occasionally, in women with lesions that are a distance from the nipple or proximal to multiple branch points in the duct, a wire localization of the lesion is done using the ductogram as a guide (Figure 11.22). In these patients, the ductogram is done with undiluted contrast material (e.g., no methylene blue is injected).

After the study is completed, the cannula is removed, and the nipple is covered with gauze or a nursing pad. This prevents contrast material from leaking out onto the patient’s clothes. Many patients describe a significant reduction or complete cessation of the discharge for several weeks after the ductogram. It is unclear why this occurs, but it is usually not a problem for the preoperative ductogram because discharge is still obtained when the nipple is compressed.

CYST ASPIRATION AND PNEUMOCYSTOGRAPHY

Aspiration of cysts is undertaken in three situations: when there are associated significant symptoms (e.g., tenderness, burning), when there are atypical features on ultrasound, or at the patient’s request. As cysts enlarge and tension on the wall and surrounding tissue increases, patients may describe significant discomfort and tenderness. Some investigators have suggested that as cysts enlarge, some of the fluid escapes into the surrounding breast parenchyma, eliciting an aseptic inflammatory response. Aspiration under these circumstances often relieves the symptoms (2,8,9).

We consider aspiration when the ultrasound findings are not diagnostic of a cyst (Figure 11.23). Pneumocystography is sometimes undertaken in patients in whom an intracystic or mural abnormality is suspected. Palpation, ultrasound, or mammography can be used to guide the aspiration. Even with palpable cysts, our preference is to aspirate them using ultrasound guidance. Direct observation with ultrasound expedites needle movements and is helpful in determining the amount of pressure needed to puncture cyst walls that are sometimes thickened and inflamed. After the aspiration, no residual abnormality should be seen ultrasonographically (Figure 11.24). If a persistent abnormality is seen, a core biopsy or short-term follow-up ultrasound (6 to 8 weeks) is undertaken (Figure 11.25). When pneumocystography is done, half the amount of aspirated fluid is replaced with air. Spot compression magnification views of the cyst are obtained in orthogonal projections (CC and 90-degree lateral views) to evaluate the cyst wall.

Figure 11.23 Cysts. A. Right mediolateral oblique view. A mass with obscured margins (arrow) is imaged corresponding to a palpable area. B. With the patient in a supine position, ultrasound demonstrates a macrolobulated mass with posterior acoustic enhancement and internal echoes (arrows) in the dependent portion of the cyst. C. Decubitus position. Internal echoes have now shifted into what is now the dependant portion of the cyst (arrows). This shift in the echoes confirms that the finding is a cyst. When we can establish the diagnosis of a cyst, we do not routinely undertake aspiration unless the patient is symptomatic or requests it. D. Different patient. A mass with obscured margins (arrows) is imaged corresponding to a tender lump. E. A cystic lesion with posterior acoustic enhancement is imaged corresponding to the area of concern to the patient. Internal echoes and apparent septations are noted (arrows). The wall is not sharply defined. Aspiration and pneumocystography are undertaken for diagnostic purposes. F. Needle with tip in the center of the cyst. The aspiration is monitored with real time ultrasound, and many of the echoes are seen being aspirated into the needle. The wall of the cyst is not sharp. This is often seen with tender, possibly “aseptically inflamed,” cysts. After the contents are aspirated, 50% of the volume of fluid aspirated is replaced with air. Craniocaudal (G) and 90-degree lateral (H) double spot compression magnification (1.8×) views following the injection of air. A smooth-walled cyst cavity is seen with no intracystic component. There is wall thickening, and the surrounding tissue is normal.

Figure 11.23 (continued)

When using ultrasound guidance, we select an approach that enables us to introduce the needle parallel to the chest wall and transducer (see Needle Biopsy section for a more detailed description). The skin is cleaned with povidone-iodine (Betadine) and alcohol. One or 2 mL of lidocaine (2%) is used to slowly raise a skin wheal. Under ultrasound guidance, the anesthesia needle is advanced up to the cyst, and lidocaine is infiltrated along the expected course of the needle. A few minutes are allowed to elapse after the administration of the lidocaine. Using ultrasound guidance, a 20-gauge spinal needle is used to puncture the cyst. With real-time scanning, it is easy to appreciate how much pressure to apply in traversing the cyst wall. With the tip of the needle in the center of the cyst, the inner stylet is removed, and the needle is connected to a 10-mL syringe. Under direct ultrasound visualization, suction is applied until all of the contents are evacuated. There should be no residual abnormality after the aspiration. In patients with cysts having thick contents, an 18-gauge spinal needle may be needed to evacuate the cyst completely. The aspirated fluid is not submitted for cytologic evaluation, unless the aspirate is bloody (or the patient makes the request).

Figure 11.24 Cyst. A. Nearly anechoic cyst with posterior acoustic enhancement and internal echoes. The distribution of the echoes is such that they may not represent reverberation artifact. B. After puncturing the cyst with a 20-gauge spinal needle (arrows), the aspiration is monitored with real time ultrasound. C. No abnormality should be seen at the completion of the aspiration. No area of hypoechogenicity is seen surrounding the tip of the needle (arrows).

Figure 11.25 Poorly differentiated invasive ductal carcinoma, not otherwise specified. A. Spot tangential view in a 36-year-old patient who presents with a tender lump. A round mass with microlobulated and ill-defined margins is seen. B. Complex cystic mass with internal echoes and posterior acoustic enhancement. Closely evaluate the margins and note irregular microlobulations. Aspiration is undertaken. C. Residual irregular abnormality is seen after aspiration. The fluid is submitted for cytology. Necrosis, inflammatory cells, and viable cells with atypia are reported. A trial of antibiotics is recommended with a follow-up ultrasound in 4 weeks. D. Five weeks later, a round mass with a heterogeneous echotexture and posterior acoustic enhancement is imaged at the prior aspiration site. Ultrasound-guided core biopsy is done to establish the diagnosis.

Air can be injected into the cyst cavity. Some investigators have suggested that injecting air may have a therapeutic benefit by reducing the likelihood of cyst recurrence (2,8,9). In these patients, no mammographic images are obtained after the air is injected. Alternatively, a pneumocystogram (2,8,9) can be done, for diagnostic purposes, to evaluate potential intracystic (Figure 11.26) or mural lesions (Figure 11.27). After the cyst is drained, the needle is stabilized, and the fluid-filled syringe is replaced with a syringe containing air. Fifty percent of the aspirated fluid is replaced with air. The needle and syringe are then removed. Ultrasonographically, an irregular echogenic line is seen after air is injected (Figure 11.28). Spot compression magnification views of the cyst are obtained to
evaluate the wall of the cyst and the appearance of the surrounding tissue (Figures 11.26 and 11.27).

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