A comparison of ductoscopy-guided and conventional surgical excision in women with spontaneous nipple discharge

A retrospective study of ductoscopy combined with immediate methylene blue staining in nipple discharge diseases

This study investigated the effect of fiberoptic ductoscopy (FDS) combined with methylene blue staining immediately after FDS procedure on pathological nipple discharge diseases. A retrospective analysis of the clinical data of 122 patients with nipple discharge, who underwent FDS and surgical treatment at the Department of Breast and Thyroid Surgery of Tengzhou Central People's Hospital, was conducted. The demographic characteristics and surgical outcomes of all patients were assessed. According to the injection time of methylene blue, the patients were divided into the control and the observational groups. In the observational group, methylene blue was injected immediately after ductoscopy and then surgical treatment was performed 12-24 h later, while in the control group, methylene blue injection was just few minutes before surgery treatment. There was no significant difference in the demographic characteristics between the two groups such as age and disease course, in the observational group, the incision length 2.39 (0.48) cm, the volume of resected tissue 41.93 (40.57) cm3, the intraoperative blood loss 12.19 (2.10) ml and the operation duration 26.95 (4.51) min were significantly lower than those of the traditional group (P < 0.05). The average hospital stay 3.08 (0.62) days, breast shape satisfaction 4.78 (1.63) points and postoperative drainage tube placement [3 (5.08%) days] in the observational group were significantly better than those in the control group (P < 0.05). FDS combined with immediate methylene blue staining, which has the advantages of accurate location of the diseased duct, small surgical incision, less tissue removal, and ease of finding the orifice of discharged mammary duct, and is worthy of widespread clinical application.

Patient-reported outcomes of ductoscopy procedures for pathologic nipple discharge

Background

Pathologic nipple discharge (PND) is a common complaint often associated with breast cancer. However, when ultrasound and mammography are negative, the chances of malignancy are lower than 5%. Currently, major duct excision and microdochectomy are often recommended to alleviate symptoms and definitely rule out malignancy, but can cause infections and breastfeeding problems. Ductoscopy is a minimally invasive endoscopy technique that allows visualization of the mammary ducts and may not only obviate surgery but also detect malignancy. The aim of this study was to determine quality of life (QOL) after ductoscopy in patients with PND.

Materials and methods

All PND patients referred for ductoscopy between 2014 and 2015 to our hospital were included. Ductoscopy procedures were performed under local anaesthesia in the outpatient clinic. Patients were asked to fill out questionnaires (Breast-Q, EQ-5D-5L and SF-36) on the day of ductoscopy, and after 2 weeks, 3 and 6 months. Additionally, we performed reliability analysis to determine if these questionnaires were suitable for PND patients.

Results

Fifty consecutive patients underwent ductoscopy of whom 47 patients participated in this study. One domain of SF-36 (vitality) varied significantly over time. Breast-Q, SF-36 and EQ-5D-5L showed that QOL after ductoscopy for PND was unaffected by ductoscopy. Success of the ductoscopy procedure was a significant predictor for satisfaction with the result domain.

Conclusion

Ductoscopy is a minimally invasive technique that does not seem to impact QoL of PND patients over time. Breast-Q, SF-36 and EQ-5D-5L seem to be suitable existing QOL tests for PND patients undergoing ductoscopy, whereas SF-36 would require modifications.

Detection of breast cancer precursor lesions by autofluorescence ductoscopy

PURPOSE

Autofluorescence is an image enhancement technique used for the detection of cancer precursor lesions in pulmonary and gastrointestinal endoscopy. This study evaluated the feasibility of addition of autofluorescence to ductoscopy for the detection of intraductal breast cancer precursor lesions.

METHODS

An autofluorescence imaging system, producing real-time computed images combining fluorescence intensities, was coupled to a conventional white light ductoscopy system. Prior to surgery, ductoscopy with white light and autofluorescence was evaluated under general anaesthesia in women scheduled for therapeutic or prophylactic mastectomy. Endoscopic findings in both modes were compared, marked and correlated with histology of the surgical specimen.

RESULTS

Four breast cancer patients and five high-risk women, with a median age of 47 years (range 23-62) were included. In autofluorescence mode, two intraductal lesions were seen in two breast cancer patients, which had an increase in the red-to-green fluorescence intensity compared with the surrounding tissue. One lesion had initially been missed by white light ductoscopy but was clearly visible in subsequent autofluorescence mode. One endoscopic finding was classified as suspicious by white light, but was negative in autofluorescence mode and showed normal histology.

CONCLUSIONS

This study demonstrates for the first time the in vivo feasibility of autofluorescence ductoscopy to detect pathologically confirmed breast cancer precursor lesions in both breast cancer patients and high-risk women that were occult under white light.

Network Meta-analysis for the Diagnostic Approach to Pathologic Nipple Discharge

Pathologic nipple discharge (PND) is one of the most common breast-related complaints for referral because of its supposed association with breast cancer. The aim of this network meta-analysis (NMA) was to compare the diagnostic efficacy of ultrasound, mammogram, cytology, magnetic resonance imaging (MRI), and ductoscopy in patients with PND, as well as to determine the best diagnostic strategy to assess the risk of malignancy as cause for PND. Cochrane Library, PubMed, and Embase were searched to collect relevant literature from the inception of each of the diagnostic methods until January 27, 2020. The search yielded 1472 original citations, of which 36 studies with 3764 patients were finally included for analysis. Direct and indirect comparisons were performed using an NMA approach to evaluate the combined odd ratios and to determine the surface under the cumulative ranking curves (SUCRA) of the diagnostic value of different imaging methods for the detection of breast cancer in patients with PND. Additionally, a subgroup meta-analysis comparing ductoscopy to MRI when conventional imaging was negative was also performed. According to this NMA, sensitivity for detection of malignancy in patients with PND was highest for MRI (83%), followed by ductoscopy (58%), ultrasound (50%), cytology (38%), and mammogram (22%). Specificity was highest for mammogram (93%) followed by ductoscopy (92%), cytology (90%), MRI (76%), and ultrasound (69%). Diagnostic accuracy was the highest for ductoscopy (88%), followed by cytology (82%), MRI (77%), mammogram (76%), and ultrasound (65%). Subgroup meta-analysis (comparing ductoscopy to MRI when ultrasound and mammogram were negative) showed no significant difference in sensitivity, but ductoscopy was statistically significantly better with regard to specificity and diagnostic accuracy. The results from this NMA indicate that although ultrasound and mammogram may remain low-cost useful first choices for the detection of malignancy in patients with PND, ductoscopy outperforms most imaging techniques (especially MRI) and cytology.

Interventional Ductoscopy as an Alternative for Major Duct Excision or Microdochectomy in Women Suffering Pathologic Nipple Discharge: A Single-center Experience

INTRODUCTION

Pathologic nipple discharge (PND) is, after palpable lumps and pain, the most common breast-related reason for referral to the breast surgeon and is associated with breast cancer. However, with negative mammography and ultrasound, the chance of PND being caused by malignancy is between 5% and 8%. Nevertheless, most patients with PND still undergo surgery in order to rule out malignancy. Ductoscopy is a minimally invasive endoscopic technique that enables direct intraductal visualization. The aim of this study was to evaluate (interventional) ductoscopy as an alternative to surgery in patients with negative conventional imaging.

MATERIALS AND METHODS

All patients with PND referred between 2010 and 2017 to our hospital for ductoscopy were retrospectively analyzed. Ductoscopy procedures were performed under local anesthesia in the outpatient clinic. The follow-up period was at least 3 months, and the primary outcome was the number of prevented surgical procedures. Furthermore, we evaluated possible complications after ductoscopy (infection and pain).

RESULTS

A total of 215 consecutive patients undergoing ductoscopy were analyzed. In 151 (70.2%) patients, ductoscopy was successful. In 102 procedures, an underlying cause for PND was visualized, of which 34 patients could be histologically proven and 82 patients treated. Sixty of the 215 patients were eventually operated, 8 owing to suspicious findings during ductoscopy, 42 owing to persistent PND, and 10 because of recurrent PND. In 7 patients, a malignancy was found (5 of them classified as suspicious at dusctoscopy). No serious side effects were seen.

CONCLUSION

Ductoscopy can be safely used as an alternative for surgery in the workup for PND.

Is Ductography Still Warranted in the 21st century?

OBJECTIVE

To determine the utility of ductography in conjunction with mammography and ultrasound in patients with pathologic nipple discharge, and the incremental role of MRI after triple-modality evaluation.

MATERIALS AND METHODS

We retrospectively reviewed the medical records of patients who had presented with pathologic nipple discharge and had undergone mammography and/or ultrasound and ductography between January 1, 2005, and October 31, 2010. We tested the diagnostic sensitivity, specificity and accuracy of combined triple-modality evaluation as well as of MRI performed in addition to these imaging techniques. We used the gold standard of image-guided biopsies, surgical excision, or long-term clinical and imaging follow-up.

RESULTS

Among 94 study patients, benign papillomas were identified in 42 (44.7%), abscess in one (1%), duct ectasia in four (4.3%), and malignancy (invasive ductal carcinoma or ductal carcinoma in situ) or high-risk lesion (atypical ductal hyperplasia) in 10 (10.6%). Forty-six patients (49%) underwent surgical excision; 89.1% of which had presurgical planning with ductography. In 35 (37.2%) with negative imaging, resolution of nipple discharge was confirmed on median clinical and imaging follow-up of 36 months. Two patients with negative imaging were lost to follow-up. Sensitivity, specificity, PPV, and NPV for accurately demonstrating the etiology of pathologic nipple discharge were 13%, 97%, 89%, and 37% respectively for mammography; 73%, 97%, 98%, and 64% respectively for ultrasound; 76%, 72%, 84%, and 61% respectively for ductography; 86%, 70%, 85%, and 72% respectively for combined ultrasound and ductography; and 75%, 100%, 100% and 67% respectively for DCE-MRI.

CONCLUSION

The combination of mammography, ultrasound and ductography is highly accurate for identifying the etiology of pathologic nipple discharge. DCE-MRI can be used as an alternate to ductography if necessary.

Ex vivo feasibility study of endoscopic intraductal laser ablation of the breast

OBJECTIVE

To determine the feasibility and safety of breast endoscopic thulium laser ablation for treatment of intraductal neoplasia.

STUDY DESIGN

Ductoscopy is a minimally invasive endoscopic approach of the milk ducts of the breast via the nipple. Besides diagnosis in women with pathologic nipple discharge (PND), it allows non-invasive removal of intraductal lesions with a stalk like papillomas. Removal, however, is often incomplete and flat lesions cannot be targeted. We therefore developed laser ductoscopy.

METHODS

Dosimetry of laser ductoscopy was assessed in thirteen mastectomy specimens, applying power settings of 1-5 W with 100-1000 ms pulsed exposure to a 375-μm outer diameter thulium fiber laser. Subsequently histology was obtained from the breast tissue that was treated with the Thulium laser.

RESULTS

Endoscopic view was maintained during ductoscopic laser ablation at 1-3 W. Increasing power to 4-5 W caused impaired vision due to shrinkage of the main duct around the ductoscope tip. Histology revealed localized ablation of the duct wall.

CONCLUSION

We show for the first time that laser ductoscopy is technically feasible. The Thulium laser enables a superficial intraductal ablation and is a useful tool for intraductal interventions. An in vivo prospective study is needed to further demonstrate its potential. Lasers Surg. Med. 50:137-142, 2018. © 2017 Wiley Periodicals, Inc.

Systematic review and meta-analysis of the diagnostic accuracy of ductoscopy in patients with pathological nipple discharge

Background

Invasive surgery remains the standard for diagnosis of pathological nipple discharge (PND). Only a minority of patients with nipple discharge and an unsuspicious finding on conventional breast imaging have cancer. Ductoscopy is a minimally invasive alternative for evaluation of PND. This systematic review and meta-analysis was designed to evaluate the diagnostic accuracy of ductoscopy in patients with PND.

Methods

A systematic search of electronic databases for studies addressing ductoscopy in patients with PND was conducted. Two classification systems were assessed. For DSany, all visualized ductoscopic abnormalities were classified as positive, whereas for DSsusp, only suspicious findings were considered positive. After checking heterogeneity, pooled sensitivity and specificity of DSany and DSsusp were calculated.

Results

The search yielded 4642 original citations, of which 20 studies were included in the review. Malignancy rates varied from 0 to 27 per cent. Twelve studies, including 1994 patients, were eligible for meta-analysis. Pooled sensitivity and specificity of DSany were 94 (95 per cent c.i. 88 to 97) per cent and 47 (44 to 49) per cent respectively. Pooled sensitivity and specificity of DSsusp were 50 (36 to 64) and 83 (81 to 86) per cent respectively. Heterogeneity between studies was moderate to large for sensitivity (DSany: I2 = 17·5 per cent; DSsusp: I2 = 37·9 per cent) and very large for specificity (DSany: I2 = 96·8 per cent; DSsusp: I2 = 92·6 per cent).

Conclusion

Ductoscopy detects about 94 per cent of all underlying malignancies in patients with PND, but does not permit reliable discrimination between malignant and benign findings.

[Management of breast nipple discharge: Recommendations]

OBJECTIVES

To investigate diagnostic value of imaging procedures and management strategies of the patients with nipple discharge (ND) to establish management recommendations.

METHODS

Bibliographical search in French and English languages by consultation of PubMed, Cochrane and Embase databases.

RESULTS

Although, all ND require an systematic evaluation guided by clinical data, bloody ND could be a predictor of breast cancer risk among different colors of discharge particularly in patients of more than 50 years (LE2). The mammography and breast ultrasography are the imaging procedures to realize in first intention (grade C) but they turn out useful only when they detect radiological abnormalities (LE4). Galactography has only a localizing value of possible ductal abnormalities (when standard imaging procedures is not contributive) (LE4). Thus, in the diagnostic investigation of a suspicious ND, galactography it is not recommended in standard practice (grade C). The breast Magnetic Resonance Imaging (MRI) is recommended when breast standard imaging procedures are not contributive (grade C). The ND cytology is useful only if it is positive (i.e. reveal cancer cells). There is no proof on the diagnostic performance of the cytological analysis of the ND to allow a recommendation on its realization or not. In front of a suspicious ND, when breast-imaging procedures reveals an associated radiological lesion, an adapted percutaneous biopsy is recommended by percutaneous way (grade C). Vacuum-assisted breast biopsies is a diagnostic tool but can also be therapeutic allowing to avoid surgery in case of benign lesion but current literature data do not allow recommendations on the therapeutic aspect of vacuum-assisted breast biopsy (LE4). In the absence of associated radiological signal, and in case of reproducible bloody persistent ND, a pyramidectomy is recommended (grade C).

Interventional ductoscopy in patients with pathological nipple discharge

BACKGROUND

Surgery is the intervention of choice for definitive diagnosis and treatment in women with pathological nipple discharge (PND). Ductoscopy has been reported to improve diagnosis, but as an interventional procedure it may also reduce the need for surgery. This study evaluated interventional ductoscopy in patients with PND.

METHODS

A prospective study on ductoscopy was conducted in consecutive patients with PND, but without a suspected malignancy on routine diagnostic evaluation. Intraductal lesions were removed by ductoscopic extraction. Surgery was undertaken if there were suspicious ductoscopic findings or at the patient's request. Therapeutic efficacy was determined by cannulation success, detection and removal rates, symptom resolution and avoided surgery.

RESULTS

Ductoscope introduction was successful in 71 (87 per cent) of 82 patients, with abnormalities visualized in 53 (65 per cent); these were mostly polypoid lesions (29 patients). The lesion was removed in 27 of 34 attempted ductoscopic extractions. Twenty-six (32 per cent) of the 82 patients underwent surgery, whereas surgery was avoided in 56 (68 per cent). After a median follow-up of 17 (range 3-45) months, 40 patients (49 per cent) no longer experienced symptoms of PND, 13 of 34 patients experienced an insufficient therapeutic effect after attempted ductoscopic extraction, and the outcome was unknown in two (2 per cent). Malignancy was diagnosed in four patients (5 per cent); two had been missed at ductoscopy and two at initial surgery after ductoscopy.

CONCLUSION

Interventional ductoscopy is technically feasible and may help to avoid surgery in the majority of patients. As endoscopic removal of intraductal lesions is not always possible and malignancy can be the underlying cause of PND, ductoscopic instruments should be further optimized to allow definitive histological diagnosis.

[Value of galactography for the diagnostic work-up of pathological nipple discharge in multimodal breast diagnostics. Part 2: a systematic review of the literature]

BACKGROUND

The survey results of a previous study showed that galactography is now rarely used in Germany and newer methods are applied. The evidential value of galactography should be established and opposed to the evidential value of ultrasound (US) and magnetic resonance mammography (MRM).

MATERIALS AND METHODS

A search was carried out in PubMed and Cochrane involving studies written in English or German. The level of evidence was measured according to the Oxford Centre for Evidence-based Medicine.

RESULTS

A total of 19 studies were included, 14 with results on galactography, 10 on US and 5 on MRM. Almost all studies were retrospective with an evidence assigned to level 3b or lower. The results on the diagnostic values showed a very wide range. Because of very variable numbers of cases and consideration of various pathologies, the studies are only comparable to a limited extent.

CONCLUSION

Galactography, US and MRM all show a weak level of evidence and no superiority of a particular method can be derived. Therefore, galactography can no longer be considered as a mandatory standard in modern multimodal imaging of the breast. Recommendations for the diagnostic work-up of pathological nipple discharge have to be included in current guidelines and must consider these facts.

Liquid-Based Medium Used to Prepare Cytological Breast Nipple Fluid Improves the Quality of Cellular Samples Automatic Collection

Background

Breast cancer is the second cause of death in women worldwide. The spontaneous breast nipple discharge may contain cells that can be analyzed for malignancy. Halo^® Mamo Cyto Test (HMCT) was recently developed as an automated system indicated to aspirate cells from the breast ducts. The objective of this study was to standardize the methodology of sampling and sample preparation of nipple discharge obtained by the automated method Halo breast test and perform cytological evaluation in samples preserved in liquid medium (SurePath™).

Methods

We analyzed 564 nipple fluid samples, from women between 20 and 85 years old, without history of breast disease and neoplasia, no pregnancy, and without gynecologic medical history, collected by HMCT method and preserved in two different vials with solutions for transport.

Results

From 306 nipple fluid samples from method 1, 199 (65%) were classified as unsatisfactory (class 0), 104 (34%) samples were classified as benign findings (class II), and three (1%) were classified as undetermined to neoplastic cells (class III). From 258 samples analyzed in method 2, 127 (49%) were classified as class 0, 124 (48%) were classified as class II, and seven (2%) were classified as class III.

Conclusion

Our study suggests an improvement in the quality and quantity of cellular samples when the association of the two methodologies is performed, Halo breast test and the method in liquid medium.

Interventional ductoscopy for pathological nipple discharge

BACKGROUND

Despite the low likelihood of malignancy, it is recommended that patients who have pathologic nipple discharge (PND) undergo duct excision. Intraductal papilloma is well-known most frequent cause of PND. Our goal is to determine whether the ductoscopic retrieval of a solitary papilloma is feasible and/or therapeutic for patients with PND. The accompanying video demonstrates this interventional ductoscopic approach.

METHODS

Consented patients who had been diagnosed with PND were recruited to have ductoscopic exploration. Patients with palpable masses and suspicion of malignancy on ultrasound or mammography were excluded. Under local anesthesia, ductoscopy was performed using LaDuScope-T flex with an outer diameter of 1.1 mm, which allows extraction of a single papilloma with a microbasket (380 μm) via a working channel. Patients with sessile single papilloma or failure on ductoscopic extraction underwent ductoscopically guided microductectomy. Success was determined by recurrence of PND and by standard radiological examinations.

RESULTS

Three patients presented in the video had negative cytology and normal conventional diagnostic imaging. Two patients diagnosed with a nonsessile single papilloma underwent successful ductoscopic extraction. The interventional examination times of those patients were 30 and 35 min. Patient who had a sessile papilloma underwent ductoscopically guided microductectomy. These patients had no recurrence of discharge or suspicious of malignancy after 5 years follow-up.

CONCLUSIONS

Interventional ductoscopy provides an incisionless therapeutic option for patients diagnosed with a papillary nonsessile benign lesion that causes PND.

Office ductoscopy for surgical selection in women with pathologic nipple discharge

BACKGROUND

Pathologic nipple discharge (PND) is diagnosed clinically and managed by diagnostic duct excision (DDE). Mammary ductoscopy in the office setting may change this standard. We performed a prospective study to assess the utility of office ductoscopy for surgical selection in women with nipple discharge.

METHODS

Women with nipple discharge meeting at least 2 of 3 criteria of PND (spontaneous, single duct, bloody or serous) underwent office ductoscopy. Those showing papillomatous lesions underwent DDE in the operating room (surgical group, n = 38); if no lesion was present, women were followed clinically (observation group, n = 21).

RESULTS

A papillomatous lesion was identified in 79% of women with 3-criteria PND and in 21% with 2 criteria (P = .001). DDE yielded a proliferative lesion in 35 of 38 women (92%). Of the 38, 27 (71%) had papillomata, 2 (5%) had florid hyperplasia, and 6 (16%) had ductal carcinoma in situ (DCIS) on final pathology. Also, 11 women with papilloma and 1 with DCIS presented with 2-criteria PND. Ductoscopy findings were a better predictor of the presence of intraductal neoplasia (area under curve [AUC] 0.9, 95% confidence interval [95% CI] 0.8-0.98) compared with 3-criteria PND (AUC 0.7, 95% CI 0.6-0.8). The 21 women in the observation group did not develop signs of malignancy or need biopsy during a 48-month follow-up period.

CONCLUSIONS

Our findings suggest that office ductoscopy provides accurate surgical selection of women with nipple discharge and should be considered for women with 2 criteria of PND, and those with negative ductoscopy can be safely observed. These findings need confirmation in a larger study with longer follow-up.

Breast duct endoscopy: ductoscopy from a diagnostic to an interventional procedure and its future perspective

OBJECTIVE

Breast duct endoscopy is increasingly used for evaluation of intraductal disease. We present a new rigid instrument for ductoscopy that allows intraductal biopsy and the removal of small lesions.

METHODS

Overall, 102 women with breast cancer or pathologic nipple discharge were included in the analysis. All ductoscopies were performed with a rigid gradient index micro-endoscope (phi 0.7 mm) in combination with a special device for intraductal vacuum assisted biopsy. Ductoscopy, ductal lavage and intraductal biopsy were correlated with ductal cytology and histopathology of the resection specimen.

RESULTS

Gradient index ductoscopy provided high resolution images of the breast ducts and identified additional intraductal lesions in 45% of the patients with breast cancer. The accuracy of ductal lavage, ductoscopy and mammography in the detection of an extensive intraductal component was 14%, 65% and 50%, respectively. Intraductal vacuum assisted biopsy yielded diagnostic material in 92% of 38 patients with nipple discharge and papillomatous lesions. Histology of the resection specimen confirmed the diagnosis in all cases including 2 in situ carcinoma and 2 invasive ductal carcinoma.

CONCLUSIONS

Ductoscopy is a useful supplement for the standard radiological workup of breast cancer especially in patients with extensive intraductal carcinoma. Ductoscopic vacuum assisted biopsy is an effective technique for intraductal tissue sampling and allows ablation of small lesions. This technique provides new perspectives for interventional therapy of intraductal tumours.

Mammary ductoscopy in the current management of breast disease

BACKGROUND

The majority of benign and malignant lesions of the breast are thought to arise from the epithelium of the terminal duct-lobular unit (TDLU). Although modern mammography, ultrasound, and MRI have improved diagnosis, a final pathological diagnosis currently relies on percutaneous methods of sampling breast lesions. The advantage of mammary ductoscopy (MD) is that it is possible to gain direct access to the ductal system via the nipple. Direct visualization of the duct epithelium allows the operator to precisely locate intraductal lesions, enabling accurate tissue sampling and providing guidance to the surgeon during excision. The intraductal approach may also have a role in screening individuals who are at high risk of breast cancer. Finally, in spontaneous nipple discharge (SND), as biopsy instruments improve and intraductal therapeutics, such as intraductal excision and laser ablation, become a possibility, normal or benign ductoscopic findings may help minimize surgery in selected patients. As MD technology is rapidly advancing, a comprehensive review of current practice will be a valuable guide for clinicians involved in the management of breast disease.

METHODS

This is a review of current ductoscopic practice based on an exhaustive literature search of Pubmed, Google Scholar, and conference proceedings. The search terms "ductoscopy", "duct endoscopy", "mammary", "breast," and "intraductal" were used.

RESULTS/CONCLUSIONS

Duct endoscopes have become smaller in diameter with working channels and improved optical definition. Currently, the role of MD is best defined in the management of SND facilitating targeted surgical excision, potentially avoiding unnecessary surgery, and limiting the extent of surgical resection for benign disease. The role of MD in breast-cancer screening and breast conservation surgery has yet to be fully defined. Few prospective randomized trials exist in the literature, and these would be crucial to validate current opinion, not only in the benign setting but also in breast oncologic surgery.

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.

Nipple discharge and the efficacy of duct cytology in evaluating breast cancer risk

BACKGROUND

Nipple discharge accounts for up to 5% of referrals to breast surgical services. With the vast majority of breast carcinomas originating in the ductal system, symptomatic dysfunction of this system often raises disproportionate clinical concern. The aim of this study is firstly, to evaluate the clinical importance of nipple discharge as an indicator of underlying malignancy and secondly, to assess the diagnostic application of duct cytology in patients presenting with nipple discharge.

STUDY DESIGN

We performed a retrospective analysis of all patients presenting with nipple discharge as their primary symptom to the symptomatic breast unit at a tertiary referral center over a 30-month period (n = 313). The Hospital Inpatient Enquiry (HIPE) System and BreastHealth database were used to identify our study cohort. Parameters evaluated included patient demographics, clinical presentation, clinical evaluation, radiological assessment and histological/cytological analysis.

RESULTS

Three-hundred and thirteen patients presented with nipple discharge as their primary complaint. Invasive breast carcinoma was diagnosed by Triple Assessment in 5% of patients. 24% of patients presenting with nipple discharge underwent nipple aspiration and cytological analysis. Duct cytology was diagnostic of the underlying breast carcinoma in 50% of triple assessment diagnosed carcinoma. Four risk factors were identified as having a significant association with breast carcinoma, these included (a) age >50 years (p < 0.0001), (b) bloody nipple discharge (p < 0.008), (c) presence of a breast lump (p < 0.0001) and (d) single duct discharge (p < 0.006).

CONCLUSIONS

Nipple discharge is a poor indicator of an underlying malignancy. Use of nipple aspiration and duct cytology for the assessment of nipple discharge is of limited diagnostic benefit. However, by utilizing the systematic, gold standard approach of Triple Assessment (clinical, radiological and cytological evaluation), the risk of underlying carcinoma can be accurately defined.

Mammary ductoscopy in the evaluation and treatment of pathologic nipple discharge: a Canadian experience

BACKGROUND

Mammary ductoscopy allows direct visualization of ductal epithelium using a fibreoptic microendoscope. As the first centre in Canada to apply ductoscopy to surgical practice, we report our experience with this technology.

METHODS

Between 2004 and 2008, 65 women with pathologic nipple discharge underwent ductoscopy before surgical duct excision under general anesthetic. Prospective data collection included cannulation and complication rates, procedure length and lesion visualization rate compared with preoperative ductography, if performed. In addition, we classified the endoscopic appearance according to Makita and colleagues and correlated it with surgical pathology.

RESULTS

It took longer than 6 months to overcome technical problems before the routine use of ductoscopy in the operating room. The ductoscope was easy to use: we achieved cannulation in 63 of 66 breast ducts (95%) and we visualized a lesion in 52 of 63 breast ducts (83%). The mean procedure length was 5.1 minutes, with no complications. Lesions seen on ductography were seen endoscopically 30 of 33 (91%) times. All 3 malignancies were seen: invasive carcinoma in 1 of 62 (1.6%) and in situ disease in 2 of 62 (3.2%) patients. Surgeons found ductoscopy helpful in defining the extent of duct excision. Except for the "polypoid solitary" class, which accurately predicted a papilloma (23/23), we found poor correlation between Makita and colleague's endoscopic classification and final pathology.

CONCLUSION

Ductoscopy is feasible, safe and practical. Our surgeons routinely use it to identify the location and extent of duct excision without ordering preoperative ductography. Identifying pathology based on the endoscopic appearance is unreliable unless the lesion is solitary and polypoid.

Minimally invasive technology in the management of breast disease

Minimally invasive surgery is gaining popularity around the world because it achieves the same or even superior results when compared to standard surgery but with less morbidity. Minimally invasive breast surgery is a broad concept encompassing new developments in the field of breast surgery that work on this minimally invasive principle. In this regard, breast-conserving surgery and sentinel lymph node biopsy are good illustrations of this concept. There are three major areas of progress in the minimally invasive management of breast disease. First, percutaneous excisional devices are now available that can replace the surgical excision of breast mass lesions. Second, various ablative treatments are capable of destroying breast cancers in situ instead of surgical excision. Third, mammary ductoscopy provides a new approach to the investigation of mammary duct pathology. Clinical experience and potential applications of these new technologies are reviewed.

Breast ductal secretions: clinical features, potential uses, and possible applications

BACKGROUND

Nipple discharge accounts for approximately 5% of visits to a breast specialist surgical practice and may be encountered as the chief complaint by many other types of physicians. The vast majority of breast cancers originate in the ductal system, which prompted interest in the evaluation of the intraductal approach to breast cancer. Ductoscopy, nipple aspiration, and ductal lavage have emerged as innovative fields of study that may have clinical applications.

METHODS

We performed a literature search of published manuscripts using the keywords nipple discharge, breast ductal secretions, and intraductal approach. We also report our single-institution experience in managing nipple discharge.

RESULTS

We present our institutional algorithm for the management of nipple discharge. The possible etiologies of nipple discharge and the appropriate workup are reviewed. Three evolving minimally invasive techniques for the evaluation of high-risk patients include ductoscopy, nipple aspiration, and ductal lavage. Nipple aspiration and ductal lavage fluid may be assayed for cytology, genomic, gene expression, and proteomic studies. Several different translational approaches are being undertaken to investigate the local microenvironment associated with the development and progression of breast carcinoma.

CONCLUSIONS

Nipple aspiration fluid and ductal lavage offer the opportunity to study the local microenvironment of the ductal system, which is where most breast cancers originate. These powerful approaches to biomarker analysis could be applied to the prevention and treatment of breast cancer.

Breast MR for the Evaluation of Occult Nipple Discharge

Pathologic nipple discharge often presents a diagnostic and therapeutic dilemma for clinicians. We present two patients with pathologic nipple discharge in whom breast MR facilitated preoperative identification of and management of otherwise occult index lesions. Breast MR should be considered in the toolbox for evaluation of occult nipple discharge when other available strategies have failed to demonstrate an underlying etiology for the pathologic discharge. The use of breast MR in this setting may permit directed evaluation and management of potentially malignant lesions.

Gradient index ductoscopy and intraductal biopsy of intraductal breast lesions

OBJECTIVE

Breast duct endoscopy is increasingly used for evaluation of intraductal disease. We have investigated a new rigid instrument for ductoscopy and intraductal biopsy of pathologic lesions.

METHODS

From 2002 to 2006, ductoscopy was performed in 111 women with breast cancer or pathologic nipple discharge. A rigid gradient index microendoscope (diameter .7 mm) was used for all examinations in combination with a specially developed needle for intraductal vacuum-assisted biopsy. Ductoscopy and intraductal biopsy were correlated with ductal cytology and histopathology of the resection specimen.

RESULTS

Ductoscopy identified intraductal lesions in 41% of the patients with breast cancer presenting as red patches, microcalcifications, or ductal obstruction. Compared with patients with a normal ductoscopy, patients with pathologic ductoscopy had a significantly higher risk of extensive intraductal carcinoma (71% versus 16%, P < .05). Ductal cytology showed only a few cases with severe cytologic atypia or malignant cells in cases with ductoscopic abnormalities. Intraductal vacuum-assisted biopsy yielded diagnostic material in 89% of 36 patients with nipple discharge and papillomatous lesions. Histology of the resection specimen confirmed the diagnosis in all cases (26 papillomas, 2 in situ carcinomas, and 2 invasive ductal carcinomas). In contrast, ductal cytology showed only moderate correlation with histopathology.

CONCLUSIONS

Ductoscopy is a useful supplement for the standard radiological workup of breast cancer especially in patients with extensive intraductal carcinoma. Ductoscopic vacuum-assisted biopsy is a new and effective technique for intraductal biopsy under visual control.

Breast sonography in localizing the cause of nipple discharge: comparison with galactography in 52 patients

OBJECTIVE

The purpose of this study was to evaluate breast sonography in localizing abnormalities in the discharging duct in patients with spontaneous nipple discharge.

METHODS

Fifty-two patients with unilateral bloody or serous nipple discharge and normal findings on palpation and mammography underwent breast sonography before surgical duct excision. The results of sonography were compared with the findings of galactography and histologic examination of the surgical specimen.

RESULTS

The final diagnosis was benign in 47 cases (90%) and malignant in 5 cases (10%). Sonography visualized an echogenic intraductal tumor in 36 (69%) of 52 cases, dilated duct(s) without an intraductal tumor in 6 cases (12%), and no abnormality in 10 cases (19%). Eighty percent of papillomatous lesions, 58% of other benign lesions, and 20% of malignant lesions were sonographically positive. The abnormal duct was surgically removed after methylene blue staining in 38 cases, after sonographically guided wire localization in 11 cases, after both wire localization and methylene blue staining in 1 case, and with review of the diagnostic galactographic images in 2 cases.

CONCLUSIONS

Sonography was found to be a valuable method for localizing intraductal abnormalities, especially papillomatous lesions, in patients with nipple discharge with no other clinical or radiologic findings. Preoperative sonographically guided wire localization can be used successfully instead of conventional methylene blue staining in cases with problems in cannulation of the discharging duct. Galactography remains the primary diagnostic method, especially in depicting malignant causes of nipple discharge, which may be seen only as duct dilatation on sonography.

The role of major duct excision and microdochectomy in the detection of breast carcinoma

BACKGROUND

The association of nipple discharge with breast carcinoma has resulted in numerous women undergoing exploratory surgery to exclude malignancy. The aim of this study was to determine whether pre-operative factors can identify those patients that are most at risk of carcinoma.

METHODS

All patients over a 14-year period (1991-2005) who had a microdochectomy or subareolar exploration for the evaluation of nipple discharge were assessed. Patient characteristics, pre-operative imaging and pathological findings were analysed.

RESULTS

Of the 211 patients included in this study, 116 patients had pathological (unilateral, uniductal serous or bloody) discharge. On excision, 6% (n = 7) of patients with pathological discharge and 2.4% (n = 2) of patients with non-pathological discharge were diagnosed with carcinoma. Overall, major duct excision resulted in the diagnosis of carcinoma in 4.3% (n = 9), ADH/LCIS in 4% (n = 8), papilloma in 39% (n = 83), and duct ectasia or non-specific benign disease in 53% (n = 111) of patients. In the patients determined to have malignancy, 44% (n = 4) were premenopausal. No patient with a non-bloody discharge in the total population analysed (28%; n = 59/211), or in the population with a pathological discharge (21%; n = 24/116) was found to have carcinoma upon excision.

CONCLUSION

Microdochectomy or major duct excision performed for nipple discharge resulted in a low rate of malignancy on excision. Conservative management of non-bloody nipple discharge can be considered in patients with no other clinical or radiological signs of malignancy.

Ductoscopy and intraductal vacuum assisted biopsy in women with pathologic nipple discharge

BACKGROUND

Fiberoptic ductoscopy is increasingly used to evaluate pathologic nipple discharge. A major limitation of this technique is the inability to obtain tissue samples from suspicious intraductal lesions. We present a novel technique for ductoscopic biopsy of intraluminal tumors.

METHODS

From 2002 to 2005 ductoscopy was performed in 38 women with nipple discharge using a rigid gradient index microendoscope (diameter 0.7 mm) and a special needle for intraductal vacuum assisted biopsy. Results of preoperative biopsy were correlated with the histology of the resection specimen

RESULTS

Cannulation of the discharging duct was successful in 37 of 38 patients (97%). Intraductal lesions were diagnosed in 29 women (78%). The sensitivity of ductoscopy and galactography in the detection of intraductal lesion was comparable (96% vs. 89%). Ductoscopic biopsy of intraductal lesions was technically successful in all but one case. Generally, the quality of the biopsy samples was good. Diagnostic biopsy samples were obtained in 26 of 28 patients (93%). Two samples contained necrosis and were considered to be non-representative. Histological analysis of the biopsy specimens showed 22 papilloma, 2 in situ carcinoma and 2 invasive carcinoma. Histology of the resection specimens confirmed the diagnosis in all cases, but there was one case with additional carcinoma lobulare in situ.

CONCLUSIONS

Ductoscopic vacuum assisted biopsy is a new technique for tissue sampling of intraductal breast lesions. This method may improve preoperative evaluation of pathologic nipple discharge in selected patients, but it should not be considered as a method for screening of early breast cancer.