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Mammary Ductoscopy for Evaluation of Nipple Discharge
Mammary Ductoscopy for Evaluation of Nipple Discharge Kapenhas-Valdes E, Feldman SM, Cohen J-M, et al (Beth Israel Med Ctr, NY) Ann Surg Oncol 15:2720-2727, 2008
Background.—Most breast cancers originate in the ductal epithelium with normal cells progressing to atypia and finally to carcinoma. Ductoscopy enables one to visualize and sample the ductal epithelium and therefore identify early changes cytologically. This report describes our experience with mammary ductoscopy as a tool for evaluation of nipple discharge at Beth Israel Medical Center. Methods.—A prospective review of all patients who have undergone ductoscopy for evaluation of persistent nipple discharge was performed. The Acueity ductoscopy system with .9mm scope and a video monitor with 60 magnification were used. Brush biopsy samples and lavage fluid were obtained from some patients and were sent for cytologic analysis. A subset of patients underwent ductoscopically guided duct excision. Results.—Ninety-three patients underwent ductoscopic evaluation of 110 ducts. Of these, 67 patients had abnormal findings and therefore underwent ductoscopically guided duct excision. The remaining 26 patients (28%) had normal ductoscopic examinations. The depth at which intraductal abnormalities were visualized was from 3 to 8 cm with an average of 4.4 cm for cancer cases and from 1 to 10 cm with an average of 4.5 cm for papillomas. Forty-two patients were diagnosed with papilloma/papillomatosis, six patients were diagnosed with atypical papilloma/atypical ductal hyperplasia/atypical lobular hyperplasia,
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and six patients were diagnosed with cancer. Of the six patients diagnosed with cancer, 67% had normal breast imaging, and other than nipple discharge, 67% had normal breast examinations. Conclusion.—Mammary ductoscopy is a useful tool in the evaluation of patients with nipple discharge. Although the most common cause of nipple discharge is an intraductal papilloma, nipple discharge can be the presenting symptom for cancer. Our experience revealed a papilloma rate of 45% (42 of 93), cancer rate of 6.5% (6 of 93), and an atypia rate of 6.5% (6 of 93) among the patients with nipple discharge. Mammary ductoscopy allows for accurate visualization, analysis, and excision of intraductal abnormalities. Many deeper intraductal abnormalities could be missed by blind surgical excision. Although it is most commonly from a benign source, such as an intraductal papilloma, nipple discharge is a relatively rare but very early presentation for image-occult breast cancer. Historically, blind retro-areolar excision of the proximal duct was the diagnostic approach. In this article, Kapenhas-Valdes and colleagues have carefully analyzed their prospectively collected series of cases in which they used breast endoscopy for the work-up and management of nipple discharge. Their review of the literature and discussion of the strengths and weaknesses of prior series provide breast surgical oncologists with a good understanding of how the field has evolved, where we stand currently, and what clinically relevant questions remain to be answered.
Breast Diseases: A Year BookÒ Quarterly Vol 20 No 2 2009
Breast endoscopy can identify lesions earlier than any other imaging technique. Therefore, we need to collectively try to broaden the practical applications of this technique to include patients who are not so lucky as to have nipple discharge as their first breast cancer symptom. If we find these ‘‘cancers’’ when they are substantially smaller than 5 mm, we can begin to address refining our breast cancer therapies and limiting their morbidity. We already know that most invasive cancers larger than 10 mm—found with radiographic imaging—will require chemotherapy, radiation therapy, and larger surgical procedures, at major personal and societal costs. And we know that as the size of tumors at diagnosis decreases to below 1 cm, lessintensive therapy still gives better results. Ductoscopy is a tool that we as surgeons can use to directly begin to address these issues. Ductoscopes have evolved to less than 1 mm in diameter, with images that rival laparoscopy, and a rapidly increasing array of biopsy tools for these tiny scopes is being developed around the world. Five and 10 years ago, this looked like a field for a few dedicated researchers. Now we have a practical and reliable use for ductoscopy: nipple discharge work-up. Soon this tool may help improve our understanding of in vivo breast cancer development and, thereby, direct us to a new era, one of prediction and prevention and minimal-access early breast cancer treatment. W. C. Dooley, MD
Background.—Most breast cancers originate in the ductal epithelium with normal cells progressing to atypia and finally to carcinoma. Ductoscopy enables one to visualize and sample the ductal epithelium and therefore identify early changes cytologically. This report describes our experience with mammary ductoscopy as a tool for evaluation of nipple discharge at Beth Israel Medical Center. Methods.—A prospective review of all patients who have undergone ductoscopy for evaluation of persistent nipple discharge was performed. The Acueity ductoscopy system with .9mm scope and a video monitor with 60 magnification were used. Brush biopsy samples and lavage fluid were obtained from some patients and were sent for cytologic analysis. A subset of patients underwent ductoscopically guided duct excision. Results.—Ninety-three patients underwent ductoscopic evaluation of 110 ducts. Of these, 67 patients had abnormal findings and therefore underwent ductoscopically guided duct excision. The remaining 26 patients (28%) had normal ductoscopic examinations. The depth at which intraductal abnormalities were visualized was from 3 to 8 cm with an average of 4.4 cm for cancer cases and from 1 to 10 cm with an average of 4.5 cm for papillomas. Forty-two patients were diagnosed with papilloma/papillomatosis, six patients were diagnosed with atypical papilloma/atypical ductal hyperplasia/atypical lobular hyperplasia,
180
and six patients were diagnosed with cancer. Of the six patients diagnosed with cancer, 67% had normal breast imaging, and other than nipple discharge, 67% had normal breast examinations. Conclusion.—Mammary ductoscopy is a useful tool in the evaluation of patients with nipple discharge. Although the most common cause of nipple discharge is an intraductal papilloma, nipple discharge can be the presenting symptom for cancer. Our experience revealed a papilloma rate of 45% (42 of 93), cancer rate of 6.5% (6 of 93), and an atypia rate of 6.5% (6 of 93) among the patients with nipple discharge. Mammary ductoscopy allows for accurate visualization, analysis, and excision of intraductal abnormalities. Many deeper intraductal abnormalities could be missed by blind surgical excision. Although it is most commonly from a benign source, such as an intraductal papilloma, nipple discharge is a relatively rare but very early presentation for image-occult breast cancer. Historically, blind retro-areolar excision of the proximal duct was the diagnostic approach. In this article, Kapenhas-Valdes and colleagues have carefully analyzed their prospectively collected series of cases in which they used breast endoscopy for the work-up and management of nipple discharge. Their review of the literature and discussion of the strengths and weaknesses of prior series provide breast surgical oncologists with a good understanding of how the field has evolved, where we stand currently, and what clinically relevant questions remain to be answered.
Breast Diseases: A Year BookÒ Quarterly Vol 20 No 2 2009
Breast endoscopy can identify lesions earlier than any other imaging technique. Therefore, we need to collectively try to broaden the practical applications of this technique to include patients who are not so lucky as to have nipple discharge as their first breast cancer symptom. If we find these ‘‘cancers’’ when they are substantially smaller than 5 mm, we can begin to address refining our breast cancer therapies and limiting their morbidity. We already know that most invasive cancers larger than 10 mm—found with radiographic imaging—will require chemotherapy, radiation therapy, and larger surgical procedures, at major personal and societal costs. And we know that as the size of tumors at diagnosis decreases to below 1 cm, lessintensive therapy still gives better results. Ductoscopy is a tool that we as surgeons can use to directly begin to address these issues. Ductoscopes have evolved to less than 1 mm in diameter, with images that rival laparoscopy, and a rapidly increasing array of biopsy tools for these tiny scopes is being developed around the world. Five and 10 years ago, this looked like a field for a few dedicated researchers. Now we have a practical and reliable use for ductoscopy: nipple discharge work-up. Soon this tool may help improve our understanding of in vivo breast cancer development and, thereby, direct us to a new era, one of prediction and prevention and minimal-access early breast cancer treatment. W. C. Dooley, MD