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

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

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

4. 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

5. 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

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

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

8. 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

9. Ductoscopy

10. 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

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

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

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

14. Ductoscopy

15. Ductoscopy

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

18. 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

19. 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

20. 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

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

22. 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

23. 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

24. 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

25. 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

26. 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

27. Ductoscopy Learning curve required
~ 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

28. 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

29. 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

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