Surg Endosc (2011) 25:1712–1722 DOI 10.1007/s00464-010-1465-4 REVIEWS Mammary ductoscopy in the current management of breast disease Sarah S. K. Tang • Dominique J. Twelves • Clare M. Isacke • Gerald P. H. Gui Received: 4 May 2010 / Accepted: 5 November 2010 / Published online: 18 December 2010 Ó Springer Science+Business Media, LLC 2010 Abstract terms ‘‘ductoscopy’’, ‘‘duct endoscopy’’, ‘‘mammary’’, Background The majority of benign and malignant ‘‘breast,’’ and ‘‘intraductal’’ were used. lesions of the breast are thought to arise from the epithe- Results/conclusions Duct endoscopes have become lium of the terminal duct-lobular unit (TDLU). Although smaller in diameter with working channels and improved modern mammography, ultrasound, and MRI have optical definition. Currently, the role of MD is best defined improved diagnosis, a final pathological diagnosis cur- in the management of SND facilitating targeted surgical rently relies on percutaneous methods of sampling breast excision, potentially avoiding unnecessary surgery, and lesions. The advantage of mammary ductoscopy (MD) is limiting the extent of surgical resection for benign disease. that it is possible to gain direct access to the ductal system The role of MD in breast-cancer screening and breast via the nipple. Direct visualization of the duct epithelium conservation surgery has yet to be fully defined. Few allows the operator to precisely locate intraductal lesions, prospective randomized trials exist in the literature, and enabling accurate tissue sampling and providing guidance these would be crucial to validate current opinion, not only to the surgeon during excision. The intraductal approach in the benign setting but also in breast oncologic surgery. may also have a role in screening individuals who are at high risk of breast cancer. Finally, in spontaneous nipple Keywords Breast Á Cancer Á Duct endoscopy Á discharge (SND), as biopsy instruments improve and Mammary ductoscopy Á Nipple discharge intraductal therapeutics, such as intraductal excision and laser ablation, become a possibility, normal or benign ductoscopic findings may help minimize surgery in selec- The majority of benign and malignant breast lesions are ted patients. As MD technology is rapidly advancing, a thought to arise from the epithelium of the terminal duct- comprehensive review of current practice will be a valu- lobular unit (TDLU), the biologically active unit of the able guide for clinicians involved in the management of breast. Although modern mammography, ultrasound, and breast disease. magnetic resonance imaging (MRI) have improved diag- Methods This is a review of current ductoscopic practice nosis, a final pathologic diagnosis currently relies on per- based on an exhaustive literature search of Pubmed, Go- cutaneous methods of sampling breast lesions. The ogle Scholar, and conference proceedings. The search advantage of mammary ductoscopy (MD) is that it enables direct access to the ductal system via the nipple. Direct visualization of the duct epithelium allows the operator to locate the intraductal lesion precisely, thereby enabling S. S. K. Tang Á D. J. Twelves Á G. P. H. Gui (&) Academic Breast Unit, Royal Marsden NHS Trust, Fulham accurate tissue sampling. Visualization also aids mapping Road, London SW3 6JJ, UK of the ductal anatomy in relation to the lesion and can e-mail: [email protected] therefore be a guide to the surgeon during excision. The intraductal approach may additionally have a role in C. M. Isacke Breakthrough Breast Cancer Research Centre, Institute of screening individuals at high risk for breast cancer who Cancer Research, London, UK form a unique motivated group of women. Finally, in 123 Surg Endosc (2011) 25:1712–1722 1713 spontaneous nipple discharge (SND), as biopsy instruments and rhomboids) to be passed through the scope for locali- improve and intraductal therapeutics such as intraductal zation and to obtain specimens (microbiopsy forceps and excision and laser ablation become a possibility, normal or cytology brushes). benign ductoscopic findings may help target, locate, and The duct orifices usually are identified by nipple fluid minimize surgery for selected patients. This review inves- expressed through a combination of warming, massage, tigated current ductoscopic practice based on an exhaustive and gentle pressure. The orifice is dilated with a probe or literature search of Pubmed, Google Scholar, and confer- funnel-shaped dilator. A metal introducer, sometimes ence proceedings. The technology and techniques required called a working shaft, is inserted with the aid of a metal to perform ductoscopy and microbiopsy as well as the lumen expander and an in situ plastic obturator. Once in the limitations of MD are examined. The current role of the duct, the obturator and lumen expander are removed, intraductal approach, MD and ductal lavage (DL) in leaving the introducer in place to secure the duct for pas- screening, nipple discharge, and breast cancer is discussed. sage of the endoscope. When associated with a standard surgical procedure, MD often is performed with the patient under general Technology and technique anesthesia. Mammary ductoscopy also can precede stan- dard minor procedures performed with the aid of intrave- Intraluminal microendoscopic technology has improved nous sedation in addition to local anesthesia. In addition, over the past 20 years, and earlier limitations of poor MD can be performed easily as an office or out-patient optical resolution and access restriction of large-caliber diagnostic procedure with application of a local anesthetic scopes have been overcome. The technology of entering (commonly lidocaine or xylocaine) by topical gel to the large orifices such as the respiratory, gastrointestinal, and nipple or by periareolar infiltration or infusion down the urinary tracts has now evolved to entering smaller-diameter cannulated nipple duct. Instillation of a local anesthetic ducts such as the salivary gland and the breast. The into the nipple ducts after cannulation facilitates relaxation development of working channels within microendoscopes of the major duct muscle sphincters [1–3]. makes it possible to biopsy lesions and perform therapeutic An understanding of the breast’s three-dimensional procedures. anatomy is important to prevent loss of orientation and to Earlier techniques of air insufflation have been super- ensure that all possible ducts are explored and once seded by saline infusion for distension of mammary ducts explored, not reexplored. Markers using color dyes, to obtain a superior picture quality. Current scopes can be marking wires, or clips may be helpful for precise identi- flexible or rigid, with diameters ranging from 0.7 to fication of lesions during MD to ensure excision at open 1.2 mm (Fig. 1). Microendoscopes magnify tissues up to surgery and for accurate pathologic assessment [4]. More 60 times normal size to produce high-quality images. The crude ways to localize the cannulated duct can be achieved presence of a working channel allows accessories (hooks using transillumination [5] or by simply inserting a Fig. 1 The dissembled components of a 0.9-mm LaDuscope (PolyDiagnost GmbH, Pfaffenhofen, Germany) comprising a A fiberoptic scope, B disposable two-port cannula, C cannula sheath, D shifter, and E protective metal sheath for the fiberoptic to be used during sterilization 123 1714 Surg Endosc (2011) 25:1712–1722 lacrimal probe into the recently endoscoped lesion-con- secondary or long-lasting effects of breast duct perforation taining duct. When disposable scopes are used, the sheath have been reported, although this may be a transient cause of the MD may be sutured in place and if not dislodged, of postprocedure discomfort. will enable the pathologist to identify accurately the lesion of interest to the endoscopist [3]. It also is possible to inject methylene blue dye through the endoscope to mark the Intraduct appearances target duct for surgical excision. Potential complications of MD are uncommon and General consensus exists concerning the intraductal include pain, inflammation, and infection. Occasionally, appearances of common lesions, with studies providing MD fails as a result of lumen occlusion from scarring and histologic correlation (Table 1, Fig. 2). Malignant lesions sclerosis. Access to peripheral lesions may be limited by are more likely to display hemorrhagic characteristics than the scope length (6 cm). Perforation of the duct by the benign lesions [9, 10], although papillomas can be friable scope creates a false passage into the breast parenchyma and seen to bleed at endoscopy. and usually can be recognized by transition of the visual Despite ductoscopic characteristics, it is not always image of ducts from a white shiny smooth surface to a gray possible to make a final diagnosis based on visual ragged surface (fibrous parenchyma) or to a yellow cav- appearances alone. A number of studies have evaluated ernous honeycomb (adipose tissue). Acute angulation of endoscopic clinical features compared with histologic ductal branches may predispose to duct perforation. No outcomes that give an indication of diagnostic accuracy Table 1 Published articles describing typical intraductal appearances correlated with final histologic diagnosis Ductoscopic appearance Histologic diagnosis Japanese Association of Mammary Polypoid Solitary or multiple Benign papillary lesions Ductoscopy and Makita et al. [6] Superficial Continuous luminal irregularity with no obvious Carcinoma Combinedelevations Carcinoma