Intraoperative intraductal injection of methylene blue dye to assist in major duct excision

Advances in fibreoptic ductoscopy for the diagnosis and treatment of pathologic papillary overflow

Fibreoptic mammography is widely recognised as the first screening method for pathologic papillary overflow due to its significant advantages in the diagnosis of ductal dilatation, intraductal papilloma and intraductal carcinoma. The use of fibreoptic ductoscopic excisional biopsy techniques, such as biopsy needles, vacuum negative pressure aspiration, biopsy forceps and grasping baskets, has not been promoted largely due to their existing deficiencies. The imaging effect of fibreoptic ductoscopy compared with electronic ductoscopy is also one of the important factors limiting the progress of microscopic excisional biopsy techniques. Finding a more suitable operating space for electronic fibreoptic ductoscopy and the use of electrosurgical excision biopsy techniques should be the focus of research in view of achieving accurate diagnoses in electronic fibreoptic ductoscopy and microscopic excision biopsy. In this review, the development history, clinical application and existing problems of fibreoptic ductoscopy are reviewed and assessed to provide references for the clinical diagnosis and treatment of pathologic papillary overflow.

Breast ductography: to do or not to do? A pictorial essay

Nipple discharge is a frequent breast disease clinical presentation. Although most cases of nipple discharge are physiologic, pathologic nipple discharge is not uncommon. Eight to 15% of pathological nipple discharge is associated with malignancy, requiring investigation. Some specialists believe that ductography is a challenging procedure that is better to be substituted by other methods, such as MRI. However, an experienced physician can perform ductography quickly and easily and still play an essential role in some clinical scenarios. Conventional imaging, such as mammography and sonography, commonly fails to detect the underlying causes of pathological nipple discharge. MRI has limitations of low specificity, cost, lengthy exam duration, accessibility, and patient factors such as claustrophobia. In addition, we can make a specific diagnosis and appropriate treatment by coupling ductography with other methods, such as ultrasound-guided or stereotactic biopsy. This study aims to present the ductography technique, possible findings, and the clinical settings where ductography is useful.Critical relevance statement Although ductography is currently less used in breast imaging, it still plays an essential role in some clinical scenarios. These clinical scenarios include pathological nipple discharge with negative conventional imaging, contraindicated MRI, unavailable MRI, unremarkable MRI results, and multiple MRI findings.Key points• Conventional imaging commonly fails to detect the underlying causes of pathological nipple discharge.• MRI in the setting of nipple discharge has some limitations.• Ductography still plays an essential role in some clinical scenarios.• Coupling ductography with other methods helps make a specific diagnosis.

Nipple Discharge: When is it Worrisome?

Nipple discharge is the third most common breast related complaint seen in the breast clinics. Although the majority of cases are due to a benign etiology, 5%-12% cases of pathological nipple discharge may be harboring an underlying malignancy. A thorough radiological workup in cases of pathological nipple discharge is thus of utmost importance, with the initial imaging modality depending on the age of the patient. The imaging modalities include mammogram (MG) and ultrasound (US) with addition of breast MRI if the nipple discharge is clinically suspicious and no MG or US correlate is identified. Magnetic Resonance Imaging (MRI) also holds promise in demonstrating the exact extent of a pathology detected on US and thus aids in the planning of further management.

Can we see what is invisible? The role of MRI in the evaluation and management of patients with pathological nipple discharge

Introduction

The aim of this study was to determine the ability of MRI to identify and assess the extent of disease in patients with pathological nipple discharge (PND) with an occult malignancy not evident on standard pre-operative evaluation with mammography and ultrasound.

Methods

Patients presenting to the breast unit of Imperial College Healthcare NHS Trust between December 2009 and December 2018 with PND and normal imaging were enrolled in the study. Pre-operative bilateral breast MRI was performed in all patients as part of our protocol and all patients were offered diagnostic microdochectomy.

Results

A total of 82 patients fulfilled our selection criteria and were enrolled in our study. The presence of an intraductal papilloma (IDP) was identified as the cause of PND in 38 patients (46.3%), 14 patients had duct ectasia (DE-17%) and 5 patients had both an IDP and DE. Other benign causes were identified in 11 patients (13.4%). Despite normal mammography and ultrasound a malignancy was identified in 14 patients (17%). Eleven patients had DCIS (13.4%), two had invasive lobular carcinoma and one patient had an invasive ductal carcinoma. The sensitivity of MRI in detecting an occult malignancy was 85.71% and the specificity was 98.53%. The positive predictive value was 92.31% and the negative predictive value was 97.1%.

Conclusions

Although a negative MRI does not exclude the presence of an occult malignancy the high sensitivity and specificity of this diagnostic modality can guide the surgeon and alter the management of patients with PND.

Microdochectomy assisted by ultrasound-guided indigo carmine staining of intraductal lesions: a case report

Spontaneous bloody nipple discharge from a single duct is a significant clinical problem. When performing preoperative marking of the discharging duct, it is sometimes difficult to identify the duct owing to intermittent discharge. Precise preoperative marking of the discharging duct and intraductal lesions is very important to avoid unnecessary wide excision of breast tissue or failure to remove the cause of nipple discharge. We herein present a case of preoperative ultrasound-guided indigo carmine staining in a patient with no discharge on the day of surgery. When a dilated duct is visualized on ultrasound, the targeted duct can be localized using indigo carmine staining, and it is possible to perform a precise minimal volume microdochectomy.

A randomized controlled study of selective microdochectomy guided by ductoscopic wire marking or methylene blue injection

BACKGROUND

Methylene blue identification of lesions during microdochectomy is often inaccurate, resulting in large dissection and tissue damage. A wire placed via ductoscopy preoperatively into the pathologic duct may aid identification and reduce the amount of dissection required.

METHODS

A total of 53 patients being evaluated for nipple discharge were randomized to receive ductoscopy with either methylene blue or wire marking of the lesion before microdochectomy. Patient clinical characteristics and surgical outcomes were evaluated.

RESULTS

There were 28 patients who received methylene blue marking and 25 who received wire marking of the lesions. There were no differences between the demographic or clinical characteristics of the groups. Wire marking was associated with less surgical time, smaller incisions, and smaller surgical specimens, but the same diagnostic accuracy.

CONCLUSIONS

Wire marking of lesions for microdochectomy is associated with less dissection and tissue damage than methylene blue, yet the same diagnostic accuracy.