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The Value of Breast Ductoscopy in Radiologically Negative Spontaneous⁄Persistent Nipple Discharge

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The Value of Breast Ductoscopy in Radiologically Negative Spontaneous⁄Persistent Nipple Discharge ORIGINAL ARTICLE The Value of Breast Ductoscopy in Radiologically Negative Spontaneous⁄Persistent Nipple Discharge Ercument Tekin, MD, Murat Akin, MD, Osman Kurukahvecioglu, MD, Tugan Tezcaner, MD, Merter Gulen, MD, Ahmet Ziya Anadol, MD, FACS and Ferit Taneri, MD Department of General Surgery, Gazi University School of Medicine, Ankara, Turkey n Abstract: Breast ductoscope is a fiberoptic endoscope used for examining the distal breast ducts under direct vision in order to identify the source of pathologic nipple discharge. The purpose of this study was to investigate the reliability of intra-operative breast ductoscopy in patients with pathologic nipple discharge, which could not be identified by radiologic tests. Between April 2002 and March 2007, breast ductoscopy was performed in 34 patients who had pathologic nipple discharge with no radiologic evidence about the source. The procedures were carried out under general anesthesia and ductoscopic findings were as well as the histopathology of the specimens were recorded and documented. In 88%, (30 of 34) of the patients, endoscope was successfully introduced into the external orifice of the ducts at the nipple and proximal breast ducts were successfully visualized. Ductoscopy revealed intraductal lesions (i.e., ductal obstruction, intraductal papilloma, red patches, and erythematoid platter) in 20 patients (66%). Among the 20 patients with visible endoluminal pathology, nine had a papilloma and eight had signs of either acute inflammation (bleeding, erythema) or previous inflammation with healing (adhesions and blocked ducts). In two cases, invasive breast carcinoma was identified, one of which was ductal carcinoma in situ (DCIS) with minimal invasion. In both cases, there had been blocked ducts. In one case DCIS was identified. Breast ductoscopy is a reliable and easy-to-use method to demonstrate the source of pathologic nipple discharge in cases with bleeding and other intraductal lesions. n Key Words: breast cancer, breast ductoscopy, spontaneous nipple discharge reast ductoscopy (BD) allows direct visualization PATIENTS AND METHODS Bof the breast ducts using fiberoptic microendo- Thirty-four patients with PND were included in this scopes inserted through the ductal opening at the nip- study. Nipple discharge that was spontaneous, bloody, ple surface. It has first been applied in the clinical serous, and persisting more than 2 months was setting for the detection of intraductal lesions (1). BD defined as PND. Radiologic examinations (mammo- has been evolving over the past 15 years. The earlier graphy, breast ultrasonography, and ⁄ or magnetic reso- attempts were constrained by limited optics, large cali- nance imaging) were also used for patients with PND, ber scopes, and lack of working channels for insuffla- preoperatively. All patients who were included this tion and biopsy examination under direct visualization study had no pathologic findings in these radiologic (2,3). An important potential clinical application of tests. Although the procedure was described for either BD is pathologic nipple discharge (PND). PND is general or local anesthesia (topical local anesthetic found in 3–10% of all women with a symptomatic cream plus intradermal local anesthetic injection at breast disorder. Approximately, 2–15% of women the areolar margin), we performed the ductoscopy and who undergo surgery for significant PND will be the biopsy under general anesthesia. The nipple, are- found to have an underlying breast carcinoma as the ola, and the breast were cleaned by povidone–iodine cause of the PND (4). The purpose of this study is to solution. The discharging duct was cannulated with a investigate the ability of intraoperative BD to identify 2 ⁄ 0 prolene suture as the first step and the duct was intraductal lesions in women with PND. then dilated using the Seldinger technique over the Address correspondence and reprint requests to: Murat Akin, MD, Ayten indwelling 2 ⁄ 0 prolene using 26G or 24G angiocath Sok. 12 ⁄ 14 Mebusevler, Tandogan, Ankara, Turkey, or e-mail: makin @gazi.edu.tr. (Mediflon Eastern Medikit Ltd, Delhi, India). After adequate dilatation, the ductoscope (Karl Storz, DOI: 10.1111/j.1524-4741.2009.00735.x Tuttlingen, Germany) was inserted through the ductal Ó 2009 Wiley Periodicals, Inc., 1075-122X/09 The Breast Journal, Volume 15 Number 4, 2009 329–332 opening on the nipple surface after dilating the duct 330 • tekin et al. with a suitable probe (e.g., Bowmann’s lachrymal mal duct cavities had appearances ranging from dilators or angiocaths). Saline solution was injected lustrous pale yellow to pink and were observed to into the duct through the working channel in order to exhibit ring folds on the duct walls (Fig. 1a). The widen it and facilitate the passage of the endoscope appearance of intraductal papillary lesions under BD for clear visualization of the intraductal space. The examination was red, yellow, or ash gray. The direct outer diameter of fiber endoscope was 1 mm with a photographs of intraductal papilloma and DCIS are working length of 10 cm, and the examination sheet shown in Fig. 1b,c. DCIS and epithelial hyperplasia diameter was 1.3 mm with a working length of were seen as erythematoid platters. Erythematoid plat- 7.5 cm. The average time required for the procedure ters were found to be associated with epithelial hyper- was 20–25 minutes. plasia (moderate or severe) and DCIS (Fig. 1c). Endoluminal abnormalities were seen in 20 patients (66, 6%) whereas dilated ectatic ducts were only seen RESULTS in 10 (33, 3%) patients. Among the 20 patients with Between April 2002 and March 2007, BD was per- visible endoluminal pathology, nine (30%) had a formed in 34 patients who had PND. The patients’ papilloma and eight (26, 6%) had signs of either acute mean age was 45.3 ± 12.4 (17–71 years) and the aver- inflammation (bleeding, erythema) or previous inflam- age duration of PND was 6 months (1–12 months). mation with healing (adhesions and blocked ducts). In Cytologic examination was performed for all patients two cases, invasive breast carcinoma was identified, with PND. Three of thirty patients had suspected one with DCIS with minimal invasion. In both cases, malignant lesions according to cytologic evaluation, there were blocked ducts. In one case, DCIS was but only two out of these three had malignancy. One identified which was greater than 7 cm in depth. of the patients with negative cytology was diagnosed In patients with invasive ductal carcinoma (two as ductal carcinoma in situ (DCIS). The sensitivity and patients), the ductoscope was inserted from the exter- specificity of cytologic examination of the nipple dis- nal orifice of the discharging duct. There were adhe- charge were 66.6% and 96.2%, respectively. sions and blocked duct where the tumors were In 88% (30 of 34) of the patients, the endoscope detected (Fig. 1d). One patient had DCIS with micro- was successfully introduced into the lactiferous sinus invasion. In addition, one patient had intraductal pap- and the proximal breast ducts were visualized. All in- illoma with erythematoid platters on the surface of traluminal lesions seen in the ductal system were the duct. This part of the duct was excised with the included within the duct excision. The excision was guide (transillumination) of scope and DCIS was diag- guided by the transillumination from the scope. Nor- nosed. (a) (b) (c) (d) Figure 1. Ductoscopic appearances of (a) normal ducts, (b) intraductal papilloma, (c) ductal carcinoma insitu, and (d) invaziv duc- tal carcinoma (blocked duct). Breast Ductoscopy • 331 DISCUSSION Dooley used a 9-mm fiberendoscope in 27 patients Breast ductoscopy is an evolving technology that has who were undergoing nipple exploration for PND (5). been used primarily and historically in conjunction with In 26 of 27 patients, the fiberendoscope was intro- open surgical procedures. BD allows intraductal biopsy duced successfully into breast ducts and the ducts and its application in the clinical setting is for diagnos- were visualized successfully. A bleeding lesion was tic evaluations of the breast (5). An important potential seen in 26 patients while DCIS was identified in two clinical application of BD is PND where current imag- patients. In three cases, both papilloma and atypical ing techniques and ⁄ or cytologic examination of PND hyperplasia were present. Most lesions were located fluid failed to demonstrate the underlying pathology within 3 cm from the nipple. In our study, one patient (3). Approximately 5% of patients referred to breast with DCIS, 20 patients with visible endoluminal clinics have PND. Following mastalgia and breast pathology, and nine patients with papilloma were masses, PND is the most frequent condition that brings detected. In two cases, invasive breast carcinoma was women to breast clinics. Papilloma is the most common seen one of which was DCIS with microinvasion. The pathologic finding in women with PND accounting for nearest lesion was the microinvasive carcinoma and it 40–70% of cases followed by adenomatous or papillary was 2-cm deep from the nipple surface. In another epithelial proliferations (14%). The incidence of malig- case, a DCIS was found 7-cm deep from the nipple nancy as a cause of PND varies between 1% and 23% surface. depending upon the series studied (3,6). Dooley et al. (12) performed BD routinely in Breast ductoscopy is a new technique that allows patients undergoing surgical lumpectomy with a pre- direct visualization of the breast duct epithelia and has operative diagnosis of atypical ductal hyperplasia, in the potential to provide a more accurate diagnosis of situ, and ⁄ or invasive cancer. BD identified intraductal benign and malignant breast lesions (7). In 1991, abnormalities outside of the lumpectomy resection Makita et al. (8) established the use of blind intraduc- specimen in 41% of patients and additional informa- tal biopsy of the breast for the pathologic diagnosis of tion would have decreased the positive margin rate PND through a rigid endoscope with a 1.25 mm outer from 23% to 5%.
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