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Ductoscopy: a new technique for ductal exploration
European Journal of Radiology, 12 (1991) 127-129
Elsevier
EURRAD
127
00146
Ductoscopy: a new technique for ductal exploration Juan D. Berna ‘, Vicente Garcia-Medina ‘Departamento
de Radiologia. Hospital General.
’
and Christopher
C. Kuni2
Universidad de Murcia, Spain, and ‘University of Minnesota Hospital, Minneapolis, MN, U.S.A.
(Received
11 September
Key words: Breast, ductography;
1990; accepted
Breast, ductoscopy;
Introduction The technological development of endoscopic equipment has brought about a considerable advance in the diagnosis and treatment of differing pathologies. The aim of this work is to describe a technique for obtaining a direct optical view of the interior of the duct. We describe the ductal endoscopic technique or ‘ductoscopy’ that we carried out for the first time in July 1989. Patients and Methods Ductoscopy was carried out in 12 patients, the average age was 54.6 (age range: 42-70 years), with bloody (9 cases) or serous (3 cases) single-duct nipple discharge, with no mass in the breast on clinical examination and mammography. The cytological examination of the discharge was not suspicious in any of the cases. All patients underwent galactography and in 5 cases we detected intraductal filling defects (Fig. l), 4 cm or less from the base of the nipple, and in all cases the caliber of the main duct was greater than 2 mm (average: 2.4 mm). The endoscopic equipment used was a Neonate Straight Forward Telescope 0” Cystoscope-Urethroscope (Storz, Tuttlingen/F.R.G.) (Fig. 2) with a 1.9 mm diameter. The endoscopic examination of the duct was carried out with the patient either supine or preferably .with Address for reprints: Dr. Juan D. Berna, Departamento de Radiologia, Facultad de Medicina, Universidad de Murcia, 30001. Murcia, Spain. 0720-048X/91/$03.50
0 1991 Elsevier Science Publishers
3 December
1990)
Breast, ultraductal
papilloma
the patient in a sitting position. The first step was to cannulate the secretory orifice, employing a 22-gauge, 32 mm-long Abbocath (Abbot, Sligo, Ireland); the Abbocath was introduced into the duct over a guidewire (0.018 in., 50 cm long) with a 3 cm flexible tip (Cook, Bjaerkov, Denmark) [ 11. Then, we applied a local anaesthetic (Tetracaine) to the nipple and injected a small amount of 1 y0 lidocaine into the duct. Next, for the gradual dilation of the secretory orifice, we used dilators (catheters) size 4 to 9 French and metal lacrimal dilators with a blunt conical tip. Once the optimal dilatation of the orifice was achieved, the endoscope, with its tip lubricated, was introduced into the duct alongside and parallel to the guidewire, with the guidewire serving as a reference as to the introductal progression of the endoscope, in order to avoid any ‘false route’. The endoscope was gently made to progress into the duct, always under visual control or by means of a videocamera (Fig. 3). In order to maintain an appropiate optical field of vision, we used a system of continuous low-pressure irrigation with saline solution through a sheath coupled to the instrument. In every case examined to date, we have achieved an excellent optical view of the interior of the duct. Endoscopic examination showed clearly that the five filling defects observed in ductograms corresponded to intraductal papilloma (Fig. 1). The five patients with bloody discharge underwent microductectomy and histological findings revealed intraductal papilloma in all 5 cases. The remaining patients have not been operated on. The ductoscopic examination has been well tolerated by all patients and no complications have been observed.
B.V. (Biomedical
Division)
Fig. 2. Neonate Cystoscope-Urethroscope
(Storz).
Fig. 3. Endoscope inside the duct. Video-camera coupled to the instrument (long arrow) and irrigation system connected to sheath (short arrow).
Discussion
Fig. 1. (A) Ductogram showing the characteristic image of intraductal papilloma. (B) Endoscopic view of an intraductal papilloma in a 64-year-old patient. The tip of the metal guidewire is seen in the ductal lumen.
The management of patients with single-duct nipple discharge without a palpable mass, continues to be a subject of controversy [2,3]. With regard to diagnosis, some suggest that ductography is the most important investigation [ 4-61. Microductectomy is the conventional treatment. Various techniques for microductectomy have been described [7-91. In all the cases in the present study, ductoscopy has permitted us to view the interior of the main duct, its walls, and the aspect of the papillomas. However, with this new ductal exploration we have not been able to visualize the distal ducts and we cannot use this method when the main duct, evaluated by means of ductograms, has a calibre of less than 2 mm. In addition, for the present, there are no instruments capable of obtaining material for cytologic or histologic examination. Further research and perfection of ‘ductoscopy’ will be needed to allow preoperative histology or even endoscopic treatment to be carried out. We hope that an endoscope specifically designed for the galactophorus
129
duct will be manufactured (ductoscope). key to the success of ductoscopy.
This will be the
Acknowledgements We would like to thank Peter Mason for the translation, and Jose L. Leal for technical assistance. References Berna JD, Guirao J, Garcia V. A coaxial technique for performing galactography. AJR 1989; 153: 273-274. Locker AP, Galea MH, Ellis IO, Holliday HW, Elston CW, Blaney RW. Microdochectomy for single-duct discharge from the nipple. Br J Surg, 1988; 75: 700-701. Welch M, Durrans D, Gonzalez J, Daya H, Owen AMWC.
Microdochectomy for discharge from a single lactiferous duct. Br J Surg 1990; 77: 1213-14. Tabar L, Dean PB, Pente KZ. Galactography: the diagnostic procedure of choice for nipple discharge. Radiology 1983; 149: 31-38. Threatt BA, Apelman HD. Mammary duct injection. Radiology 1973. 108: 71-76. Diner WC. Galactography: mammary duct contrast examination. AJR 1981; 137: 853-856. Haagensen CD. Diseases of the breast. 3rd edn. Philadelphia: Saunders, 1986: 136-191. Choudhury A, Wengert PA, Smith JS. A new surgical localization technique for biopsy in patients with nipple discharge. Arch Surg 1989; 124: 874-875. Berna JD, Madrigal M, Guirao J, Arcas I, Gomez S. Microdochectomy: the precise identification of the suspicious duct. Br J Surg 1990; 77: 1217-18.
Elsevier
EURRAD
127
00146
Ductoscopy: a new technique for ductal exploration Juan D. Berna ‘, Vicente Garcia-Medina ‘Departamento
de Radiologia. Hospital General.
’
and Christopher
C. Kuni2
Universidad de Murcia, Spain, and ‘University of Minnesota Hospital, Minneapolis, MN, U.S.A.
(Received
11 September
Key words: Breast, ductography;
1990; accepted
Breast, ductoscopy;
Introduction The technological development of endoscopic equipment has brought about a considerable advance in the diagnosis and treatment of differing pathologies. The aim of this work is to describe a technique for obtaining a direct optical view of the interior of the duct. We describe the ductal endoscopic technique or ‘ductoscopy’ that we carried out for the first time in July 1989. Patients and Methods Ductoscopy was carried out in 12 patients, the average age was 54.6 (age range: 42-70 years), with bloody (9 cases) or serous (3 cases) single-duct nipple discharge, with no mass in the breast on clinical examination and mammography. The cytological examination of the discharge was not suspicious in any of the cases. All patients underwent galactography and in 5 cases we detected intraductal filling defects (Fig. l), 4 cm or less from the base of the nipple, and in all cases the caliber of the main duct was greater than 2 mm (average: 2.4 mm). The endoscopic equipment used was a Neonate Straight Forward Telescope 0” Cystoscope-Urethroscope (Storz, Tuttlingen/F.R.G.) (Fig. 2) with a 1.9 mm diameter. The endoscopic examination of the duct was carried out with the patient either supine or preferably .with Address for reprints: Dr. Juan D. Berna, Departamento de Radiologia, Facultad de Medicina, Universidad de Murcia, 30001. Murcia, Spain. 0720-048X/91/$03.50
0 1991 Elsevier Science Publishers
3 December
1990)
Breast, ultraductal
papilloma
the patient in a sitting position. The first step was to cannulate the secretory orifice, employing a 22-gauge, 32 mm-long Abbocath (Abbot, Sligo, Ireland); the Abbocath was introduced into the duct over a guidewire (0.018 in., 50 cm long) with a 3 cm flexible tip (Cook, Bjaerkov, Denmark) [ 11. Then, we applied a local anaesthetic (Tetracaine) to the nipple and injected a small amount of 1 y0 lidocaine into the duct. Next, for the gradual dilation of the secretory orifice, we used dilators (catheters) size 4 to 9 French and metal lacrimal dilators with a blunt conical tip. Once the optimal dilatation of the orifice was achieved, the endoscope, with its tip lubricated, was introduced into the duct alongside and parallel to the guidewire, with the guidewire serving as a reference as to the introductal progression of the endoscope, in order to avoid any ‘false route’. The endoscope was gently made to progress into the duct, always under visual control or by means of a videocamera (Fig. 3). In order to maintain an appropiate optical field of vision, we used a system of continuous low-pressure irrigation with saline solution through a sheath coupled to the instrument. In every case examined to date, we have achieved an excellent optical view of the interior of the duct. Endoscopic examination showed clearly that the five filling defects observed in ductograms corresponded to intraductal papilloma (Fig. 1). The five patients with bloody discharge underwent microductectomy and histological findings revealed intraductal papilloma in all 5 cases. The remaining patients have not been operated on. The ductoscopic examination has been well tolerated by all patients and no complications have been observed.
B.V. (Biomedical
Division)
Fig. 2. Neonate Cystoscope-Urethroscope
(Storz).
Fig. 3. Endoscope inside the duct. Video-camera coupled to the instrument (long arrow) and irrigation system connected to sheath (short arrow).
Discussion
Fig. 1. (A) Ductogram showing the characteristic image of intraductal papilloma. (B) Endoscopic view of an intraductal papilloma in a 64-year-old patient. The tip of the metal guidewire is seen in the ductal lumen.
The management of patients with single-duct nipple discharge without a palpable mass, continues to be a subject of controversy [2,3]. With regard to diagnosis, some suggest that ductography is the most important investigation [ 4-61. Microductectomy is the conventional treatment. Various techniques for microductectomy have been described [7-91. In all the cases in the present study, ductoscopy has permitted us to view the interior of the main duct, its walls, and the aspect of the papillomas. However, with this new ductal exploration we have not been able to visualize the distal ducts and we cannot use this method when the main duct, evaluated by means of ductograms, has a calibre of less than 2 mm. In addition, for the present, there are no instruments capable of obtaining material for cytologic or histologic examination. Further research and perfection of ‘ductoscopy’ will be needed to allow preoperative histology or even endoscopic treatment to be carried out. We hope that an endoscope specifically designed for the galactophorus
129
duct will be manufactured (ductoscope). key to the success of ductoscopy.
This will be the
Acknowledgements We would like to thank Peter Mason for the translation, and Jose L. Leal for technical assistance. References Berna JD, Guirao J, Garcia V. A coaxial technique for performing galactography. AJR 1989; 153: 273-274. Locker AP, Galea MH, Ellis IO, Holliday HW, Elston CW, Blaney RW. Microdochectomy for single-duct discharge from the nipple. Br J Surg, 1988; 75: 700-701. Welch M, Durrans D, Gonzalez J, Daya H, Owen AMWC.
Microdochectomy for discharge from a single lactiferous duct. Br J Surg 1990; 77: 1213-14. Tabar L, Dean PB, Pente KZ. Galactography: the diagnostic procedure of choice for nipple discharge. Radiology 1983; 149: 31-38. Threatt BA, Apelman HD. Mammary duct injection. Radiology 1973. 108: 71-76. Diner WC. Galactography: mammary duct contrast examination. AJR 1981; 137: 853-856. Haagensen CD. Diseases of the breast. 3rd edn. Philadelphia: Saunders, 1986: 136-191. Choudhury A, Wengert PA, Smith JS. A new surgical localization technique for biopsy in patients with nipple discharge. Arch Surg 1989; 124: 874-875. Berna JD, Madrigal M, Guirao J, Arcas I, Gomez S. Microdochectomy: the precise identification of the suspicious duct. Br J Surg 1990; 77: 1217-18.