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Affiliation(s)
- George Z. Li
- Department of Surgery; Brigham and Women's Hospital; Boston MA USA
| | - Stephanie M. Wong
- Harvard T.H. Chan School of Public Health; Boston MA USA
- Department of Surgery; McGill University Health Centre; Montreal QC Canada
| | - Susan Lester
- Department of Pathology; Brigham and Women's Hospital; Boston MA USA
| | - Faina Nakhlis
- Department of Surgery; Brigham and Women's Hospital; Boston MA USA
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2
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Zhao S, Mei Y, Wang J, Zhang K, Ma R. Different Levels of CEA, CA153 and CA125 in Milk and Benign and Malignant Nipple Discharge. PLoS One 2016; 11:e0157639. [PMID: 27327081 PMCID: PMC4915693 DOI: 10.1371/journal.pone.0157639] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 06/02/2016] [Indexed: 11/18/2022] Open
Abstract
Background The aim of this study was to assess the diagnostic values of three breast tumor markers (i.e., CEA, CA153 and CA125) in milk and nipple discharge in the prediction of different breast diseases diagnoses. Methods Three hundred thirty-six patients (96 breast cancer and 240 benign disease patients) with nipple discharge and a control group of 56 healthy parturient participants were enrolled in the present study. Nipple discharge samples were preoperatively collected from the patients, and milk was collected from the colostrum of the parturient participants. The samples were assayed for the CEA, CA153 and CA125 levels. Cutoff values were determined for the detection of breast diseases using ROC curves. Results The levels of CEA, CA153 and CA125 were significantly different between the nipple discharge and the milk (all ps < 0.001). In the nipple discharge, the CEA and CA153 levels in the breast cancer group were significantly greater than those in the benign group (all ps < 0.001), and cutoff values of 263.3 ng/mL and 1235.3 U/mL, respectively, were established. However, the expression of CA125 did not differ significantly between the breast cancer and benign groups. Conclusion Differences in the apparent expression levels of CEA, CA153 and CA125 in patients with nipple discharge and healthy persons were validated. The present data suggest that CEA and CA153 might potentially be useful in the differential diagnoses of benign tumors and breast cancer. CA125 did not seem to be useful for breast cancer detection.
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Affiliation(s)
- Song Zhao
- Department of Breast Surgery, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Yu Mei
- Department of Breast Surgery, Jinan Maternity and Child Care Hospital, Jinan, Shandong, PR China
| | - Jianli Wang
- Department of Pathophysiology, School of Medicine, Shandong University, Shandong, China
| | - Kai Zhang
- Department of Breast Surgery, Qilu Hospital of Shandong University, Jinan, Shandong, China
- * E-mail: (RM); (KZ)
| | - Rong Ma
- Department of Breast Surgery, Qilu Hospital of Shandong University, Jinan, Shandong, China
- * E-mail: (RM); (KZ)
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Waaijer L, Simons JM, Borel Rinkes IHM, van Diest PJ, Verkooijen HM, Witkamp AJ. Systematic review and meta-analysis of the diagnostic accuracy of ductoscopy in patients with pathological nipple discharge. Br J Surg 2016; 103:632-643. [DOI: 10.1002/bjs.10125] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 11/07/2015] [Accepted: 01/06/2016] [Indexed: 11/06/2022]
Abstract
Abstract
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.
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Affiliation(s)
- L Waaijer
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - J M Simons
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - I H M Borel Rinkes
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - P J van Diest
- Department of Pathology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - H M Verkooijen
- Imaging Division, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - A J Witkamp
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
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4
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Waaijer L, van Diest PJ, Verkooijen HM, Dijkstra NE, van der Pol CC, Borel Rinkes IHM, Witkamp AJ. Interventional ductoscopy in patients with pathological nipple discharge. Br J Surg 2015; 102:1639-48. [PMID: 26447629 DOI: 10.1002/bjs.9950] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2015] [Revised: 06/21/2015] [Accepted: 08/25/2015] [Indexed: 11/12/2022]
Abstract
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.
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Affiliation(s)
- L Waaijer
- Departments of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - P J van Diest
- Departments of Pathology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - H M Verkooijen
- Imaging Division, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - N-E Dijkstra
- Departments of Pathology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - C C van der Pol
- Departments of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - I H M Borel Rinkes
- Departments of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - A J Witkamp
- Departments of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
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5
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Ohlinger R, Stomps A, Paepke S, Blohmer JU, Grunwald S, Hahndorf W, Camara O, Deichert U, Peisker U, Kohlmann T, Buchholz I, Hegenscheid K, Utpatel K, Zygmunt M, Hahn M. Ductoscopic Detection of Intraductal Lesions in Cases of Pathologic Nipple Discharge in Comparison with Standard Diagnostics: The German Multicenter Study. Oncol Res Treat 2014; 37:628-32. [DOI: 10.1159/000368338] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Accepted: 09/03/2014] [Indexed: 11/19/2022]
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Sarica O, Ozturk E, Demirkurek HC, Uluc F. Comparison of ductoscopy, galactography, and imaging modalities for the evaluation of intraductal lesions: a critical review. Breast Care (Basel) 2013; 8:348-54. [PMID: 24415988 PMCID: PMC3862052 DOI: 10.1159/000355833] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Today, in cases of nipple discharge of unclear origin, the abundance of diagnostic procedures - a, diagnostic dilemma' - becomes apparent, because unequivocal indications and a current, standardized examination sequence are presently not available. The diagnostic workup of patients with nipple discharge usually includes the clinical history, physical examination, mammography, ultrasonography, galactography, and nipple discharge cytology, but not ductoscopy. METHODS In this review we analyze and discuss the possible role of ductoscopy in evaluating intraductal pathologies and its combined use with diagnostic imaging modalities. For this purpose, we reviewed and compared the results of the radiological, pathological, and surgical studies independently. CONCLUSIONS Currently, there is no solitary accurate modality to reach our definitive purpose. Being aware of the capability of each diagnostic modality may take us closer to our target. Therefore, adjunct and appropriate use of multiple imaging modalities and ductoscopy is necessary to evaluate patients with nipple discharge.
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Affiliation(s)
- Ozgur Sarica
- Department of Radiology, Taksim Education and Research Hospital, Istanbul, Turkey
| | - Enis Ozturk
- Department of Radiology, Bakirkoy Education and Research Hospital, Istanbul, Turkey
| | - Huseyin C. Demirkurek
- Department of Nuclear Medicine, Taksim Education and Research Hospital, Istanbul, Turkey
| | - Fatih Uluc
- Department of Radiology, Taksim Education and Research Hospital, Istanbul, Turkey
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Albrecht C, Thele F, Grunwald S, Kohlmann T, Hegenscheid K, Utpatel K, Zygmunt M, Ohlinger R. Nipple discharge: role of ductoscopy in comparison with standard diagnostic tests. ACTA ACUST UNITED AC 2013; 36:12-6. [PMID: 23429326 DOI: 10.1159/000346639] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND This study aims to assess the role of ductoscopy for detecting intraductal anomalies in patients with nipple discharge in comparison to conventional tests and to find an effective combination of both approaches. MATERIALS AND METHODS Prior to duct excision, ductoscopy was performed in 97 women. Histologic and all other diagnostic results were compared. Sensitivity, specificity, and efficiency were calculated for all methods. These parameters were also calculated for all possible test combinations in 12 patients who had completed all tests. RESULTS Breast sonography reached the highest sensitivity (64.1%) and efficiency (64%); mammography had the highest specificity (100%). The sensitivity of ductoscopy was 53.2%, its specificity 60%, and its efficiency 55.1%. Among combinations of all methods, the combination ductoscopy + galactography was the most sensitive (80%). Mammography, magnetic resonance imaging, and ductoscopy were each 100% specific. Ductoscopy was the most efficient (75%) single method. CONCLUSION Ductoscopy is a valuable test for diagnosing intraductal lesions in patients with nipple discharge. It is more efficient than conventional tests in patients undergoing all tests.
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Affiliation(s)
- Christine Albrecht
- Klinik und Poliklinik für Frauenheilkunde und Geburtshilfe, Universität, Greifswald, Germany
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8
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Dooley WC. Who wants a blind breast surgeon? Ann Surg Oncol 2011; 18 Suppl 3:S337-8. [PMID: 22238780 DOI: 10.1245/s10434-008-0040-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Foulkes RE, Heard G, Boyce T, Skyrme R, Holland PA, Gateley CA. Duct Excision is Still Necessary to Rule out Breast Cancer in Patients Presenting with Spontaneous Bloodstained Nipple Discharge. Int J Breast Cancer 2011; 2011:495315. [PMID: 22295227 PMCID: PMC3262583 DOI: 10.4061/2011/495315] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2011] [Accepted: 07/05/2011] [Indexed: 01/07/2023] Open
Abstract
Introduction. Spontaneous nipple discharge is the third most common reason for presentation to a symptomatic breast clinic. Benign and malignant causes of spontaneous nipple discharge continue to be difficult to distinguish. We analyse our experience of duct excisions for spontaneous nipple discharge to try to identify features that raise suspicion of breast cancer and to identify features indicative of benign disease that would be suitable for nonoperative management. Methods. Details of one hundred and ninety-four patients who underwent duct excision for spontaneous nipple discharge between 1995 and 2005 were analysed. Results. Malignant disease was identified in 11 (5.7%) patients, 4 invasive and 7 insitu, which was 10.2% of those presenting with bloodstained discharge. All patients with malignant disease had bloodstained discharge. Discharge due to malignant disease was more likely to be bloodstained than that due to benign causes (Fisher's exact test, 2-tailed P value = 0.00134). Conclusion. Our findings do not support a policy of conservative management of spontaneous bloodstained nipple discharge. Cases of demonstrable spontaneous bloodstained nipple discharge should undergo duct excision to prevent malignant lesions being missed.
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Affiliation(s)
- R E Foulkes
- Royal Gwent Hospital, Newport, South Wales, NP20 2UB, UK
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10
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Abstract
OBJECTIVE Mammary ductoscopy allows direct visualization of the ductal system and a method for directed excision and pathologic diagnosis. We reviewed our experience with mammary ductoscopy in the evaluation of pathologic nipple discharge. METHODS We reviewed all patients who underwent ductoscopy for pathologic nipple discharge at our institution from 2006-2010. All procedures were performed by a single surgeon. Data included patient and imaging characteristics, indications, operative findings, and pathologic outcomes. Descriptive statistics were used for data summary. RESULTS During the study period, 121 patients underwent ductoscopy and directed duct excision for pathologic nipple discharge, including 66 (55%) with bloody discharge. Breast imaging [mammography, ultrasound, and/or magnetic resonance imaging (MRI)] revealed BIRADS category I/II/III findings in 112 (93%), BIRADS category IV findings in 6 (5%), and was unknown in 3 (2%) patients. Final pathology revealed papillomas in 64 (53%) patients, duct ectasia and associated benign findings in 48 (40%) patients, ductal carcinoma in situ (DCIS) in 7 (6%) patients, and atypical ductal hyperplasia in 2 (1%) patients. None of the patients with DCIS underwent preductoscopy MRI, but all had BIRADS category I/II/III breast imaging. The extent of DCIS identified by ductoscopy and subsequent surgical excision ranged from <1 cm to 10 cm (median 3 cm). CONCLUSIONS The majority of patients with pathologic nipple discharge have benign nonproliferative findings or benign papillomas. Although atypia and malignancy were diagnosed in only 7% of patients who underwent ductoscopy for pathologic nipple discharge, there were no routine imaging findings indicative of these diagnoses preoperatively.
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Affiliation(s)
- C S Fisher
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
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Mátrai Z, Tóth L, Bidlek M, Szabó É, Farkas E, Sávolt Á, Góbor L, Bartal A, Kásler M. [The role of ductoscopy in the modern diagnostics and therapy of breast diseases]. Orv Hetil 2011; 152:1284-93. [PMID: 21803726 DOI: 10.1556/oh.2011.29163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Mammary ductoscopy is a modern, minimally invasive procedure that enables direct, in vivo observation of the mammary ductal system, primarily by nipple discharge. The rapidly developing device is suitable for aimed biopsy for further cytological or molecular examinations. High-tech equipments facilitate polypectomy or laser vaporization of certain intraluminal lesions, and play an important role in the direct surgical excision of the duct or the so-called terminal duct-lobular unit. The above listed facilitate the early diagnosis of malignancies even before imaging could detect them, and the control of high risk patients. Ductoscopy can foster surgical removal of ductal in situ tumors as anatomical units, thus enabling the optimization of radicality of breast conserving surgeries. Authors give a detailed description of the surgical techniques, and provide a wide review of the literature, for the first time in the Hungarian language. Orv. Hetil., 2011, 152, 1284-1293.
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Affiliation(s)
- Zoltán Mátrai
- Országos Onkológiai Intézet Általános és Mellkassebészeti Osztály, Budapest, Ráth Gy. u. 7-9. 1122.
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12
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Tang SSK, Twelves DJ, Isacke CM, Gui GPH. Mammary ductoscopy in the current management of breast disease. Surg Endosc 2010; 25:1712-22. [PMID: 21170661 DOI: 10.1007/s00464-010-1465-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2010] [Accepted: 11/05/2010] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Sarah S K Tang
- Academic Breast Unit, Royal Marsden NHS Trust, Fulham Road, London, SW3 6JJ, UK
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Dooley WC. The Lobar Distribution of the Lesions in Breast Carcinoma: Ductoscopy and Surgery. Breast Cancer 2010. [DOI: 10.1007/978-1-84996-314-5_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Beechey-Newman N. Current role of breast duct microendoscopy in malignancy. Future Oncol 2009; 5:1523-6. [PMID: 20001790 DOI: 10.2217/fon.09.159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Abstract
BACKGROUND Nipple discharge is a relatively common complaint among patients visiting specialized outpatient clinics for disease of the breast. With advancing technology, it became possible to diagnose and manage nipple discharge using minimally invasive procedures. The aim of this study is to report our experience with ductoscopic evaluation of patients with nipple discharge. MATERIALS AND METHODS Between September 2005 and February 2009, 236 patients with complaint of nipple discharge were admitted prospectively into the study. All patients were evaluated with ductoscopy. Data concerning age, ductoscopic and postsurgical diagnosis, duration, and complications with the procedure were statistically analyzed. RESULTS For 236 patients evaluated, there were 249 ductoscopic investigations. Of these, 39 patients were found to have intraductal solitary papilloma of which 24 were excised ductoscopically. Of the 24 ductoscopically excised solitary papillomas, it was possible to remove 17 completely, but 7 papillomas could be removed partially. For 13 patients with solitary papillomas large enough or unfavorably localized so that they could not be snare-excised and for 14 patients with multiple papillomas, we offered surgical removal of the lesions by limited excision of the ducts with the help of ductoscopic localization and marking. There were 35 patients who had debris within the canalicular system, and the debris was washed out. Ductoscopy revealed atypical ductal hyperplasia in 3 patients, ductal carcinoma in situ in 6 patients, and invasive carcinoma in 3 patients; all patients underwent surgery. CONCLUSIONS We believe that, as the technology quickly improves, ductoscopy will become more widely accepted and applied for breast disorders, not only as a diagnostic tool but also as a privileged therapeutic option for certain pathologies.
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Affiliation(s)
- Sedat Kamali
- General Surgery, Okmeydani Training and Research Hospital, Istanbul, Turkey.
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16
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Abstract
Interest in breast endoscopy came from Oriental investigators in the early 1990s where bloody nipple discharge is a more common presentation of breast cancer. The early techniques using a single microfiber scope without ductal distension was successful in navigating only the first 1-3 cm of the ducts and fraught with technical problems such as scope breakage and poor image quality. In spite of these barriers there has been increasing use of this technology in Japan and more widespread acceptance as the technology of scope design improved. Dooley and others tested a new method of obtaining a rich cytologic specimen from the ducts of high-risk women known as ductal lavage recently. The success of this procedure was that it detected severe cytologic and malignant atypia in clinically and radiographically normal breasts. Reproducibly, the same breast duct could be cannulated and severely atypical cytology obtained. The problem arose in identifying the lesion within the breast, which was the source for the atypia. New American multi-fiber microendoscopes were applied to solve this problem in an initial series of patients with abnormal cytology to identify the lesions. Success of that series lead to wider application of the imaging technology and eventual adoption of this imaging modality help to guide during all non-mastectomy breast surgery where fluid could be elicited from the nipple to identify the duct connecting to the lesion for which surgery was being performed. Initial reports have demonstrated the types of operative findings in certain sub-populations early in the use of this technology.
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Affiliation(s)
- William C Dooley
- Department of Surgery, The University of Oklahoma, Oklahoma City, Oklahoma 73103, USA.
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Tekin E, Akin M, Kurukahvecioglu O, Tezcaner T, Gulen M, Anadol AZ, Taneri F. The Value of Breast Ductoscopy in Radiologically Negative Spontaneous/Persistent Nipple Discharge. Breast J 2009; 15:329-32. [DOI: 10.1111/j.1524-4741.2009.00735.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Uchida K, Fukushima H, Toriumi Y, Kawase K, Tabei I, Yamashita A, Nogi H. Mammary ductoscopy: current issues and perspectives. Breast Cancer 2009; 16:93-6. [DOI: 10.1007/s12282-008-0083-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2008] [Accepted: 09/30/2008] [Indexed: 11/27/2022]
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Matsunaga T, Misaka T, Hosokawa K, Taira S, Kim K, Serizawa H, Akiyama H, Fujii M. Intraductal approach to the detection of intraductal lesions of the breast. Breast Cancer Res Treat 2009; 118:9-13. [DOI: 10.1007/s10549-008-0203-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2008] [Accepted: 09/19/2008] [Indexed: 10/25/2022]
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Kapenhas-Valdes E, Feldman SM, Boolbol SK. The Role of Mammary Ductoscopy in Breast Cancer: a Review of the Literature. Ann Surg Oncol 2008; 15:3350-60. [DOI: 10.1245/s10434-008-9911-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2007] [Revised: 02/15/2008] [Accepted: 02/17/2008] [Indexed: 11/18/2022]
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Abstract
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.
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Affiliation(s)
- Julie E Lang
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston 77030, USA
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22
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Kapenhas-Valdes E, Feldman SM, Cohen JM, Boolbol SK. Mammary Ductoscopy for Evaluation of Nipple Discharge. Ann Surg Oncol 2008; 15:2720-7. [DOI: 10.1245/s10434-008-0012-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2007] [Revised: 05/19/2008] [Accepted: 05/20/2008] [Indexed: 11/18/2022]
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Rozen WM, Joseph S, Murphy C. The management of papillary breast lesions on core biopsy: the contentious issues. Clin Breast Cancer 2007; 7:644-6. [PMID: 17592679 DOI: 10.3816/cbc.2007.n.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The management of papillary lesions of the breast diagnosed on core needle biopsy is highly contentious. Papillary lesions are epithelial proliferations of breast tissue and are on a continuum of mutations with atypical hyperplastic lesions and in situ carcinoma. With the current literature suggesting that excisional biopsy of papillary lesions might not be required, we discuss a unique case that suggests otherwise. We present a 21-year-old woman with multiple papillary lesions on core biopsy of a breast lesion, and a subsequent excisional biopsy revealing extensive in situ carcinoma of the breast. This finding necessitated total mastectomy. This unique case highlights that core biopsy specimens are unable to effectively exclude adjacent in situ carcinoma and suggests that papillary lesions diagnosed on core needle biopsy require excisional biopsy.
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Affiliation(s)
- Warren M Rozen
- Department of Surgery, Royal Melbourne Hospital, Victoria, Australia.
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Grunwald S, Heyer H, Paepke S, Schwesinger G, Schimming A, Hahn M, Thomas A, Jacobs VR, Ohlinger R. Diagnostic value of ductoscopy in the diagnosis of nipple discharge and intraductal proliferations in comparison to standard methods. Oncol Res Treat 2007; 30:243-8. [PMID: 17460418 DOI: 10.1159/000100848] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Ductoscopy is gaining increased importance in the diagnosis of nipple discharge of unclear origin and intraductal proliferation. For this reason we compared its diagnostic value and feasibility to standard diagnostic methods. MATERIAL AND METHODS Ductoscopy was compared to mammography, galactography, sonography, magnetic resonance imaging (MRI), nipple smear, fine needle aspiration cytology (FNAC), and high-speed core biopsy; feasibility, sensitivity, and specificity were investigated for each method. RESULTS 71 ductoscopies were evaluated, which were followed up by open biopsies. Here, 3 invasive and 8 ductal carcinomas in situ were found, as well as 3 atypical ductal hyperplasias, 44 papillomas/papillomatoses, and 13 benign findings. Feasibility of ductoscopy was in this series 100%. Duct sonography showed the highest sensitivity (67.3%), followed by MRI (65.2%), galactography (56.3%), ductoscopy (55.2%), and FNAC (51.9%). The highest specificity was shown by FNAC, core biopsy, and galactography (each 100.0%), followed by mammography (92.3%), nipple smear (77.8%), ductoscopy, and duct sonography (each 61.5%); the lowest specificity was displayed by MRI (25.0%). CONCLUSION The results confirm that ductoscopy can be performed within the same range of sensitivity and specificity as other techniques. In order to make conclusive statements about ductoscopy, especially in order to precisely define the indications for this method, a prospective multicenter study was initiated.
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MESH Headings
- Adult
- Aged
- Biopsy
- Breast Diseases/diagnosis
- Breast Diseases/pathology
- Breast Neoplasms/diagnosis
- Breast Neoplasms/pathology
- Carcinoma, Ductal, Breast/diagnosis
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Intraductal, Noninfiltrating
- Cell Division/physiology
- Diagnosis, Differential
- Diagnostic Imaging
- Endoscopy
- Female
- Galactorrhea/etiology
- Galactorrhea/pathology
- Humans
- Mammary Glands, Human/pathology
- Middle Aged
- Nipples/pathology
- Papilloma, Intraductal/diagnosis
- Papilloma, Intraductal/pathology
- Precancerous Conditions/diagnosis
- Precancerous Conditions/pathology
- Retrospective Studies
- Sensitivity and Specificity
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Affiliation(s)
- Susanne Grunwald
- Department of Obstetrics and Gynecology, Ernst Moritz Arndt University, Greifswald, Germany
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Grunwald S, Bojahr B, Schwesinger G, Schimming A, Kohler G, Schulz K, Ohlinger R. Mammary ductoscopy for the evaluation of nipple discharge and comparison with standard diagnostic techniques. J Minim Invasive Gynecol 2007; 13:418-23. [PMID: 16962525 DOI: 10.1016/j.jmig.2006.05.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2005] [Revised: 05/08/2006] [Accepted: 05/08/2006] [Indexed: 11/25/2022]
Abstract
STUDY OBJECTIVE To describe performance of breast duct endoscopy and compare the method with conventional diagnostic techniques. DESIGN Canadian Task Force classification III. SETTING Interdisciplinary Breast Unit of a university hospital. PATIENTS Consecutive and unselected series of 15 female patients including 20 breasts with nipple discharge. INTERVENTIONS Prospective data assessment on all patients with ductoscopy for nipple discharge between April 2003 to April 2004. All preoperative (mammography, ultrasonography, nipple smear) and minimally invasive (galactography, fine needle aspiration cytologic study) diagnostics were evaluated and compared with ductoscopy. MEASUREMENTS AND MAIN RESULTS Mammography on 20 breasts showed BI-RADS-I (5%), BI-RADS-II (50%), and BI-RADS-III (45%). Breast ultrasound scanning showed abnormalities, classified as BI-RADS-III equivalent lesions in all cases. Nipple smear showed in 69.2% a normal cytology and in most cases revealed a papilloma later (n=8/9). Unilateral galactography was performed in 46.7% who had spontaneous nipple discharge. Two galactography results were unremarkable, and open biopsy demonstrated 1 atypical ductal hyperplasia and papilloma. On 20 breasts of 15 women, 19 ductoscopies were successfully performed (95%). In 17 cases open biopsy followed ductoscopy, and 1 ductal carcinoma in situ (DCIS), 3 atypical ductal hyperplasia (ADH), 1 ductal hyperplasia without atypias, and 12 ductal papillomas were found. CONCLUSION Compared to nipple smear, the diagnostic value of ductoscopy in this study is superior but marginally inferior to galactography and highly specialized breast ultrasound scanning. Therefore ductoscopy needs to be evaluated on a larger scale, preferably in multicenter trials to further determine its potential and indications.
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Affiliation(s)
- Susanne Grunwald
- Department of Gynecology and Obstetrics, Ernst-Moritz-Arndt-University, Greifswald, and Clinic of Minimally Invasive Surgery, Evangelic Hospital Hubertus, Berlin, Germany.
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Valdes EK, Boolbol SK, Cohen JM, Balassanian R, Feldman SM. Clinical Experience With Mammary Ductoscopy. Ann Surg Oncol 2006; 23:9015-9019. [PMID: 16897273 DOI: 10.1245/aso.2006.08.025] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2005] [Accepted: 12/28/2005] [Indexed: 11/18/2022]
Abstract
BACKGROUND Most breast cancers begin in the ductal epithelium with normal cells and progress to atypia and finally to carcinoma. Mammary ductoscopy enables one to directly visualize and sample the ductal epithelium and, therefore, identify early changes cytologically. This article describes our initial experience with mammary ductoscopy at Beth Israel Medical Center. METHODS A prospective review of all patients who underwent ductoscopy at Beth Israel Medical Center from November 2001 to February 2004 was performed. The indications for ductoscopy were a persistent nipple discharge, high-risk status, or intraoperative margin assessment in patients undergoing lumpectomy. RESULTS Seventy-four patients underwent ductoscopic evaluation of 88 ducts. Of the 32 patients who underwent office ductoscopy, 15 were high risk, and 17 had spontaneous nipple discharge. Spontaneous nipple discharge was the indication for ductoscopy in 40 of 42 intraoperative procedures. The remaining two patients underwent ductoscopy for margin assessment during breast conservation, and final pathologic analysis revealed negative margins. Thirty-eight of the 40 patients who had spontaneous nipple discharge had abnormal findings during ductoscopy and therefore underwent ductoscopically guided duct excision. Carcinoma was the final diagnosis in 5 (8.8%) of the 57 patients who were scoped for nipple discharge. CONCLUSIONS Mammary ductoscopy is a potentially useful tool in the evaluation of patients with spontaneous nipple discharge. This is a well-tolerated office procedure with minimal risks and complications. Mammary ductoscopy may have a role in the assessment of high-risk women. Further research is necessary to confirm these potential applications.
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MESH Headings
- Breast Neoplasms/diagnostic imaging
- Breast Neoplasms/surgery
- Carcinoma, Ductal, Breast/diagnostic imaging
- Carcinoma, Ductal, Breast/surgery
- Carcinoma, Intraductal, Noninfiltrating/diagnostic imaging
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Endoscopy
- Female
- Humans
- Mammary Glands, Human/diagnostic imaging
- Margins of Excision
- Mastectomy, Segmental
- Neoplasm, Residual
- Nipple Discharge/diagnostic imaging
- Patient Selection
- Prospective Studies
- Risk Factors
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Affiliation(s)
- Edna K Valdes
- Department of Surgery, Louis Venet, MD, Comprehensive Breast Service, Beth Israel Medical Center, 10 East Union Square, Suite 4E, New York, New York, 10003.
| | - Susan K Boolbol
- Department of Surgery, Louis Venet, MD, Comprehensive Breast Service, Beth Israel Medical Center, 10 East Union Square, Suite 4E, New York, New York, 10003
| | - Jean-Marc Cohen
- Department of Pathology, Beth Israel Medical Center, 10 East Union Square, New York, New York, 10003
| | - Ronald Balassanian
- Department of Pathology, Beth Israel Medical Center, 10 East Union Square, New York, New York, 10003
| | - Sheldon M Feldman
- Department of Surgery, Louis Venet, MD, Comprehensive Breast Service, Beth Israel Medical Center, 10 East Union Square, Suite 4E, New York, New York, 10003
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Hünerbein M, Raubach M, Gebauer B, Schneider W, Schlag PM. Ductoscopy and intraductal vacuum assisted biopsy in women with pathologic nipple discharge. Breast Cancer Res Treat 2006; 99:301-7. [PMID: 16752074 DOI: 10.1007/s10549-006-9209-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2005] [Accepted: 02/18/2006] [Indexed: 10/25/2022]
Abstract
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.
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MESH Headings
- Adult
- Aged
- Biopsy, Needle/instrumentation
- Biopsy, Needle/methods
- Breast Neoplasms/diagnosis
- Breast Neoplasms/pathology
- Carcinoma, Ductal, Breast/diagnosis
- Carcinoma, Intraductal, Noninfiltrating/diagnosis
- Diagnosis, Differential
- Endoscopy
- Evaluation Studies as Topic
- Female
- Fiber Optic Technology
- Humans
- Mammary Glands, Human/pathology
- Mammography/methods
- Middle Aged
- Nipples/metabolism
- Papilloma, Intraductal/diagnosis
- Predictive Value of Tests
- Prospective Studies
- Sensitivity and Specificity
- Suction
- Ultrasonography, Mammary
- Vacuum
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Affiliation(s)
- Michael Hünerbein
- Department of Surgery and Surgical Oncology, Charité Universitätsmedizin Berlin, Campus Berlin Buch and Helios Hospital, Buch, Berlin, Germany.
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Sharma N, Huston TL, Simmons RM. Intraoperative intraductal injection of methylene blue dye to assist in major duct excision. Am J Surg 2006; 191:553-4. [PMID: 16531154 DOI: 10.1016/j.amjsurg.2005.07.032] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2005] [Revised: 07/26/2005] [Accepted: 07/26/2005] [Indexed: 11/17/2022]
Abstract
Nipple discharge is not uncommon in women during their reproductive years. The etiology is benign in the majority of cases. Patients presenting with nipple discharge often require major duct excision (MDE) for accurate diagnosis and treatment. MDE is enhanced by the use of intraoperative injection of methylene blue dye into the discharging duct in order to aid visualization. Methylene blue dye-enhanced MDE has several advantages over traditional techniques. Methylene blue dye staining identifies the major discharging duct, as well as its side branches, which allows the surgeon to resect that specific ductal system only. This method allows neighboring major ducts to remain intact, preserving nipple function and permitting future cancer detection. Methylene blue-enhanced MDE allows the surgeon to more accurately determine the precise location and volume of tissue that needs to be excised. Lastly, methylene blue is both safe and inexpensive.
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Affiliation(s)
- Neha Sharma
- Department of Surgery, The Weill Medical College of Cornell University, The New York-Presbyterian Hospital, New York, NY, USA.
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Abstract
There is no consensus about the diagnostic approach to pathologic nipple discharge (PND). We hypothesize that lactiferous duct excision (microdochectomy) or image-guided biopsy are safe and effective means of diagnosis of PND. Eighty-two patients with PND underwent history and physical exam followed by breast sonography and mammogram. Image-guided biopsy was done if imaging studies were positive, whereas microdochectomy was done if normal. Discharge was unilateral (96%), bloody (79%), and spontaneous (62%). The sensitivity, specificity, positive and negative predictive values for the detection of neoplasia were 0.07, 1.0, 1.0, and 0.4 for mammography and 0.26, 0.97, 0.91, and 0.48 for sonography, respectively. Tissue diagnosis revealed papillary lesion (57%), mammary duct ectasia (33%), breast cancer (5%), and inflammatory/infectious (5%) causes. Hemorrhagic discharge associated with pregnancy or infections was managed successfully without surgery. After a median follow-up of 18 months, no PND recurrence was seen, but one patient developed cancer in a different location after diagnosis of atypical ductal hyperplasia. In conclusion, imaging studies provide confirmatory information and a biopsy target when positive. Negative imaging does not reliably exclude neoplasia or malignancy. Microdochectomy provides a sensible and effective approach in the workup of patients with PND.
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Escobar PF, Crowe JP, Matsunaga T, Mokbel K. The clinical applications of mammary ductoscopy. Am J Surg 2006; 191:211-5. [PMID: 16442948 DOI: 10.1016/j.amjsurg.2005.04.020] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2004] [Revised: 04/29/2005] [Accepted: 04/29/2005] [Indexed: 01/02/2023]
Abstract
BACKGROUND Mammary ductoscopy (MD) is a newly developed endoscopic technique that allows direct visualization and biopsy examination of the mammary ductal epithelium where most cancers originate. The procedure can be performed under local anesthesia in the office setting. This article reviews the rationale, current clinical applications, and limitations of MD. METHODS A literature search was performed using Pubmed for indexed articles published over the past 30 years using the key words "mammary ductoscopy," "breast ductoscopy," "ductal lavage," and "nipple aspiration." The most important articles were analyzed and discussed. RESULTS MD is a useful diagnostic adjunct in patients with pathologic nipple discharge. Furthermore, it can reduce the number and extent of duct excision surgeries for pathologic nipple discharge. There is a clear need to design prospective clinical trials that evaluate the potential role of MD in breast cancer screening, guiding risk-reducing strategies, and as an adjunct to breast-conservation surgery. CONCLUSIONS MD is useful in the management of PND, but its potential role in the early detection or management of breast cancer requires further investigation.
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Abstract
The intraductal approach to breast cancer and premalignant lesions has now developed to yield substantial cytologic samples of exfoliated cells. Standard cytology is still inadequate in sensitivity and specificity to accurately interpret the majority of samples. As techniques evolve using ductoscopic biopsy and molecular marker panels to increase accuracy of cytologic interpretation, these tools will be able to unravel the breast carcinogenesis pathways. They will also offer considerable benefit in screening for premalignant changes and developing effective chemoprevention strategies.
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Sharma R, Dietz J, Wright H, Crowe J, DiNunzio A, Woletz J, Kim J. Comparative analysis of minimally invasive microductectomy versus major duct excision in patients with pathologic nipple discharge. Surgery 2005; 138:591-6; discussion 596-7. [PMID: 16269286 DOI: 10.1016/j.surg.2005.07.015] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2005] [Revised: 07/28/2005] [Accepted: 07/30/2005] [Indexed: 11/21/2022]
Abstract
BACKGROUND Minimally invasive techniques are being used increasingly in patients with benign and malignant breast diseases. The purpose of this study was to compare the diagnostic yield of 2 groups of patients who underwent either minimally invasive microductectomy or major duct excision for pathologic nipple discharge. METHODS Two hundred thirty-five patients who underwent nipple exploration and duct excision and were part of an institutional review board-approved database were included in this retrospective analysis. Preoperative imaging, ductal washing cytology, surgical specimen size, and final histopathology were compared among 95 patients who underwent microductectomy by using intraoperative ductoscopy and 140 patients undergoing standard major duct excision. RESULTS Mean age of patients undergoing microductectomy was 53 versus 55 years in patients undergoing major duct excision. Preoperative mammogram was negative or benign in 92% and suspicious in 8% of patients in both the microductectomy group and the major duct excision group. A ductal abnormality was identified by preoperative ductography in 43 of 56 (77%) patients in the microductectomy group versus 74 of 92 (80%) patients in the major duct excision group. Ductal cytology was benign in 81% and 80% of patients tested, respectively. Mean specimen size was significantly smaller in patients who underwent microductectomy (9.2 cm3) as compared with major duct excision (12.6 cm3). Although the percentage of patients with atypical ductal hyperplasia or lobular carcinoma in situ was similar among the 2 groups (9% vs 10%), only 3 of 95 (3%) patients within the microductectomy group were found to have carcinoma within the resection specimen as compared with 12 of 140 (9%) within the major duct excision group (P = .03). Mean specimen size of the patients diagnosed with carcinoma was 8.6 cm(3) in the microductectomy group as compared with 15.5 cm3 in the major duct excision group (P = .014). CONCLUSIONS These data confirm that patients who present with single duct pathologic nipple discharge usually have benign pathology as the etiology. However, in a small percentage of patients an occult carcinoma might be present. Major duct excision appears to detect a higher percentage of occult carcinoma when compared with minimally invasive microductectomy, which might be related to the larger sample size of the resection specimen.
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Affiliation(s)
- Ranjna Sharma
- Department of General Surgery, Cleveland Clinic Foundation, Ohio 44195, USA
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Abstract
BACKGROUND Mammary ductoscopy (MD) allows direct visualisation of the mammary ducts using sub-millimetre fiberoptic microendoscopes inserted through the ductal opening onto the nipple surface. The sharp clear magnified images are viewed on a video monitor. Such scopes have working channels that allow irrigation and ductal lavage for cytological analysis. MD can be performed under local anaesthesia in the office setting. This article reviews the evolving role of MD in the diagnosis and treatment of intraductal breast disease. METHODS A literature search was carried out from Pubmed for indexed articles published over the last 30 years using the keywords 'mammary ductoscopy' and 'breast ductoscopy'. RESULTS The search yielded 27 indexed published articles and reports. Important major reports and studies were reviewed, screened and tracked for other relevant publications. The most important articles were analysed and discussed. The review also includes our published and unpublished original work in the field of MD. CONCLUSIONS MD is a useful diagnostic adjunct in patients with pathological nipple discharge (PND). Furthermore, it can reduce the number and extent of duct excision operations for PND. However, its potential use in the early detection of breast cancer, guiding breast conserving surgery (BCS) for cancer, therapeutic ablation of intraductal disease, and guiding risk-reducing strategies among high risk women requires further research and evaluation. Future developments include the development of a biopsy kit, combining MD with molecular diagnostic markers and real-time optical biopsy system for the diagnosis of pre-malignant and early malignant disease and radiofrequency for curative ablation of intraductal lesions.
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Affiliation(s)
- Kefah Mokbel
- St George's Hospital, Blackshaw Road, London SW17 0QT, UK.
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Abstract
OBJECTIVE Ductoscopy is an evolving technology that has been used primarily and historically in conjunction with open surgical procedures. New technical improvements allow intraductal biopsy and therefore its application in the clinical setting for diagnostic evaluations of the breast. This study looks at the initial use of intraductal biopsy in a variety of settings from an academic university practice to a private single-surgeon office. METHODS This is a multicenter retrospective series of 88 patients undergoing ductoscopy of > or =1 duct for the diagnostic workup of common breast problems. The procedures were done with the patient under local anesthesia, and intraductal biopsy specimens were taken and analyzed as breast cytology samples. RESULTS Of the 88 patients undergoing office ductoscopy, nipple discharge was the most common indication (n = 83 patients; 94% to 66% spontaneous and 34% elicited). Fifty-five percent were high risk for breast cancer by history. The majority of patients had normal previous mammograms: 48 Breast Imaging-Reporting and Data System (BIRADS) 1, 24 BIRADS 2, and 7 BIRADS 3 to 5. The most common finding was papilloma present in 29 (32%) patients by endoscopy. Only 31% of patients had a history of brown or bloody nipple discharge. A wide variety of other endoscopic abnormalities were seen and biopsied. The average number of biopsies per patient was 2 with 18 (20.5%) having severe or malignant atypia. Further follow-up and management of these more concerning abnormalities is currently ongoing. CONCLUSIONS These results indicate that office ductoscopy with biopsy is both feasible and does identify suspicious or malignant atypia in patients with expressed or spontaneous nipple fluid.
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Affiliation(s)
- William C Dooley
- The University of Oklahoma Breast Institute, 925 Stanton L. Young Blvd., Room 2290, Oklahoma City, OK 73103, USA.
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Singletary SE, Dowlatshahi K, Dooley W, Hollenbeck ST, Kern K, Kuerer H, Newman LA, Simmons R, Whitworth P. Minimally invasive operation for breast cancer. Curr Probl Surg 2004; 41:394-447. [PMID: 15114298 DOI: 10.1016/j.cpsurg.2003.12.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Abstract
BACKGROUND Bloody nipple discharge is a significant clue in the detection of ductal carcinoma of the breast. In the past, pathologic diagnoses were obtained exclusively via excision, but recently developed mammoscopic techniques have been found to yield valuable information relating to the diagnosis of intraductal lesions. METHODS Mammary duct endoscopy (i.e., mammoscopy) was performed a combined total of 407 times for 295 patients who experienced nipple discharge. Intraductal breast biopsy (IDBB) under mammoscopic observation was performed in 193 intraductal papillomas (from a total of 107 patients) and 30 ductal carcinomas (from a total of 27 patients); IDBB was performed a combined total of 36 times in the 27 patients who had breast carcinoma and yielded 21 diagnostic specimens (58.3%). In addition, the therapeutic value of IDBB was assessed in 70 patients with intraductal papilloma who had undergone more than 3 years of follow-up; these 70 patients harbored a combined total of 75 intraductal papillomas. RESULTS IDBB correctly identified the presence of carcinoma in 9 of 27 patients (33.3%); 7 other lesions (25.9%) were placed in the suspected carcinoma (i.e., atypical papillary lesion) category, and 5 (18.5%) were identified as intraductal papillomas. Using IDBB, it was difficult to collect diagnostic specimens from patients with breast carcinoma, because of the location and weak tissue cohesiveness of these lesions compared with intraductal papillomas. The 193 intraductal biopsies performed on intraductal papillomas yielded only 20 specimens that were insufficient for diagnosis. IDBB exhibited therapeutic efficacy in 54 of 70 patients with intraductal papilloma (77.6%) who had more than 3 years of clinical follow-up. Therapeutic results tended to be less favorable for patients who had intraductal lesions in multiple duct lobular units. CONCLUSIONS Mammoscopy can contribute not only to the diagnosis of cases of nipple discharge but also to the treatment of intraductal papilloma.
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Dooley WC. Breast cancer-have we been chasing the wrong target? J Surg Oncol 2003; 83:57-60. [PMID: 12772194 DOI: 10.1002/jso.10252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Abstract
An aggressive approach to breast cancer control based on preventing the disease must complement efforts at effective treatment. To date clinical trials testing new chemopreventative agents have not generally met with the kind of success expected. A wide range of new breast cancer chemopreventative agents are poised to be tested in clinical trials. We review these novel agents and approaches, including those for which clinical trials have been initiated and those that are promising in the preclinical arena. Further progress in this area requires not only new agents, but novel methods for screening for risk assessment, sampling and development of intermediate biomarkers. We review these novel potential surrogate endpoints, including new imaging-techniques, breast sampling approaches, and methods to assess biomarkers in breast epithelium. Factors that could contribute to a meaningful choice of the chemopreventive agents and the design of clinical trials are discussed.
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Affiliation(s)
- Mary Jo Fackler
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland 21231-1000, USA
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