Ductoscopy : Future Management of Nipple Discharge Dr Leung Yuen Yee Kwong Wah Hospital

Background Nipple discharge is the 3rd most common breast complaint after breast pain and breast mass Account 3-8% breast symptoms Mostly benign

Aetiology Intraductal papilloma Ductal ectasia Breast cancer Fibrocystic changes Breast abscess/ Infection Hyperprolactinaemia/ Thyroid disease

Aetiology Intraductal papilloma Most frequent cause of nipple discharge in non-pregnant / non-lactating women Account for ~35-48% Characterized by bloody/serosanguinous nipple discharge from single duct

Aetiology Ductal ectasia Account for 15-20% Incidence increases with age, peak >50yo Benign dilatation and shortening of terminal ducts within 3cm of nipple Asymptomatic / breast mass / pain / retracted nipple / creamy and cheesy discharge

Aetiology Breast cancer (less likely) DCIS ~10 % unilateral single duct nipple discharge Usually present together with a mass

Investigations MMG/ USG/ MRI no direct visualization of ductal system

Mammary Ductoscopy First introduced in Japan 1980s direct visualization of ductal system Diagnostic to localize intraductal lesions ductal anatomy mapping to guide excision allows tissue sampling / cytology Therapeutic intraductal excision / laser ablation

Ductoscopy

Ductoscopy Fibreoptic improve the optical resolution Magnification up to 60X Smaller calibre (flexible/rigid, diameter range from 0.55mm to 1.2mm) Working channels admit brush / basket / biopsy forceps

Ductoscopy General anesthesia when performed with standard surgical procedure Local anesthesia with topical gel to nipple / periareolar infiltration / infusion down the cannulated duct

Ductoscopy Duct orifice identified by site of nipple fluid expressed Orifice dilated with a probe Learning curve required. Series study show at least 10-15 performance required . In addition surgeon need knowledge to comment on the images (ann surg oncol 2010 17:778-783)

Ductoscopy Markers using dye / clip / thread / wires help precise identification of lesion and ensure excision at open surgery and accurate pathological assessment

Ductoscopy

Ductoscopy

Ductoscopy Malignant lesions usually display hemorrhagic characteristic Yet, papilloma can be friable and bleed Final diagnosis cannot be based on visual appearance alone

Problems of Conventional Surgery in Spontaneous Nipple Discharge (SND) Conventional surgery for spontaneous nipple discharge Major duct excision Microdochectomy ---Relatively blind Major duct excision is undirectional procedure Disc of retroareolar tissue excised which may include normal tissue Microdochectomy use probe which target distal offending duct but doesn’t guide proximal lesion chance of leaving cause of discharge untreated

Role of Ductoscopy in SND 68 patients with ductoscopy guided duct excision -64 intraductal papilloma, 4 DCIS All lesions completely excised , no extended extra resection required None have post operative breast distortion Conventional surgery group -96 intraductal papilloma, 6 DCIS, 4 adenosis 22.6 % need extended resection 26 patients have deformed breast A comparison of localization by ductoscopy-guided wire and conventional methods in terminal duct excision for women with pathological nipple discharge Wu XZ at el 2008

Role of Ductoscopy in SND Visualize and spare the central, normal appearing portion of duct in disease begins at 3 or 4cm from ductal orifice minimize disruption of adjacent normal ductal structures, benefit for women of childbearing age

Role of Ductoscopy in SND Better localization Less surgical complications e.g.altered sensation / hemoseroma / poor cosmesis / nipple ischaemia if less tissue excised

Role of Ductoscopy in SND Matsunaga et al. 107/295 patient with SND found to have papilloma Intraductal biopsy performed 54/70 patient with SND ceased (therapeutic rate 77.6%) Matsunsga et al -36/70 ceased, another 13 stopped aftre 2nd intraductal procedure Matsunaga T 2004 Intraductal biopsy for diagnosis and treatment of intraductal lesions of the breast

Role of Ductoscopy in SND Bender et al 22 endoscopic papillomectomies among SND 21/22 patients have no more discharge in mean follow up period of 11.5 months Therapeutic efficacy 95.4% Bender O 2009 scarless endoscopic papillectomy of the breast

Complications Uncommon Pain / inflammation / infection Failure due to perforation of ducts (pass into breast parenchyma / adipose tissue) Acute angulation predispose to perforation of ducts Perforation of ducts no long lasting effect, mainly post op pain

Limitations Failure to perform Breast ductal system with variable anatomy Ductoscopy usually examine 1-2 ducts only, though the main central ducts draining 75 % of breast vol are accessible ? Commonest site of neoplasia Study usu have detailed visualization of one or two ducts per breast, may miss other significant ducts

Limitations Length and outer diameter may limit access to terminal duct-lobular unit which miss more distal lesion Lesions farther than 6cm from nipple are beyond reach of ductoscope yet even major duct excision/ microdochectomy also likely to miss these lesions as only proximal ducts closer than 3cm are removed TDLU (terminal ductal lobular unit) In some study –patient with blood stained discharge have deeper lesion DCIS yet papillomas more proximally in the same ductal system

Ductoscopy Learning curve required ~ 10-15 ductoscopy required for reasonable performance Require experience for analyzing images Cost and time needed No scoring system for communication Ductoscopy in the evaluation and management of nipple discharge 2010 Ann Surg Oncol

Ductoscopy Overall diagnostic sensitivity ~85% False –ve rate should fall with improvement of ductoscopes Some case positive MD but no papilloma found in histology -1) papilloma fragile,exfoliated 2) lesion too small and missed by pathologists

Take home messages Nipple discharge is 3rd most common breast complaint Careful evaluation required though cause of cancer less likely Ductoscopy can facilitate target surgical excision/ limit extent of surgical resection for benign disease Ductoscopy has potential for intraductal therapeutic endoluminal procedures The future role of ductoscopy on breast cancer screening and breast conservation surgery for CA breast has yet to be defined In our centre, indication of MD Usu MD alone / MD + standard microdochectomy results

References Surg endosc review 2010 Sarah SK Tang, Dominique J Twelves Mammary ductoscopy in the current management of breast disease Surg endosc review 2010 Sarah SK Tang, Dominique J Twelves Mammary ductoscopy : current issues and perspectives Breast cancer 2009 16:93-96 Ken Uchida, Hisaki Fukushima A look into the ductoscope: Its role in pathologic nipple discharge Ann Surg Oncol 2011 18:3187-3191 C.S. Fisher Evaluating nipple discharge CME review article Aneela N Ductoscopy in the evaluation and management of nipple discharge Ann surg oncol 2010 Sedat kamali A comparison of ductoscopy –guided and conventional surgical excision in women with spontaneous nipple discharge Ann surg 2005 Robyn M Moncrief