Annals of Surgical Oncology 9:920-923 (2002)
© 2002 Society of Surgical Oncology
Routine Operative Breast Endoscopy for Bloody Nipple Discharge
William C. Dooley, MD
From the OU Breast Institute, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma.
Correspondence: Address correspondence and reprint requests to: William C. Dooley, MD, OU Breast Institute, 825 NE 10th St., Suite 3500, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104; Fax: 405-271-3495; E-mail: wcdooley{at}cox.net
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ABSTRACT
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Background: Submillimeter endoscopes are now available and have been described to assist surgeons in the evaluation and management of symptomatic nipple discharge.
Methods: To evaluate its potential use, a microendoscope (0.9 mm Acueity) was used on all patients in a single surgeon’s practice who were undergoing nipple exploration for spontaneous hemoccult positive nipple discharge. This procedure was performed at the surgical resection of the symptomatic retro-areolar duct, and 27 patients underwent the endoscopy during the period from January 2000 to August 2001.
Results: In 96% (26 of 27) of the patients, the endoscope was successfully introduced into the lactiferous sinus, and the proximal breast ducts were successfully visualized. A lesion accounting for the bleeding was seen in all 26 patients, with 70% (n = 19) having multiple intraluminal defects. Cancers were identified in two cases (7.4%), and in both cases, there was a more proximal papilloma in the same ductal system. Similarly, in 33% of the benign cases, both papillomas and usual or atypical ductal hyperplasia were present. Lesions were identified that extended up to 7.5 cm deep to the nipple. The deepest lesion was one of the endoscopically identified cancers in a patient with normal mammogram and breast ultrasound. Surgical resection could be directed by simple transillumination of the skin during endoscopy.
Conclusions: This series demonstrates the clinical feasibility of routine operative breast endoscopy in the management of bloody nipple discharge. The high incidence of multiple lesion identification suggests that the classic blind resection of a limited distance of duct in the retroareolar space may significantly underestimate the true extent of proliferative disease accounting for pathologic nipple discharge.
Key Words: Breast carcinoma • Breast ductoscopy • Breast endoscopy • Nipple discharge
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INTRODUCTION
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Bloody nipple discharge has been associated with breast cancer in women with normal mammograms.1–8 The presence of single duct hemoccult positive nipple discharge remains an indication for surgical biopsy. Most series show an incidence of breast cancer of less than 10% with the most common cause identified being a large papilloma in the lactiferous sinus in the immediate retroareolar region. Most surgeons have chosen to perform duct excision by cannulating the offending duct with lachrymal duct dilators and removing the first 2 to 3 cm of retropapillary duct. Some have chosen to get preoperative galactogram, but because the most proximal obstructing lesion is often retroareolar, this has not been universally embraced.9–13
Breast ductoscopy has become increasingly popular in the Orient since its introduction in the early 1990s for the evaluation of patients presenting with spontaneous bloody nipple discharge.10–20 As the outside diameter of the scopes and the price of the scopes has fallen, it is now practical to use microendoscopes during the operative management of such patients.
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METHODS
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After an initial study demonstrating the feasibility and safety of routine operative breast endoscopy, all patients who underwent microductectomy, performed by the author (W.C.D.), from January 2000 to August 2002 for the management of spontaneous bloody nipple discharge were considered candidates for routine operative breast endoscopy. Before being prepared and draped in the operating room, the nipple of each patient was cleansed using a facial abrasive exfoliant. A skin moisturizing cream was then applied to the breast, and the breast was deeply massaged from periphery to the center, as if expressing milk at lactation. The target duct producing hemoccult positive fluid in the operative breast was identified by manual compression of the individual lactiferous sinuses and/or by use of a standard nipple aspirator. The duct was cannulated with a 2-0 prolene suture. The duct was then dilated using the Seldinger technique over the indwelling 2-0 prolene using 26G, 24G, and 22G angiocaths. When dilated with the last angiocath, 5 to 10 cc of local anesthetic were injected into the ductal system. After 2 to 3 minutes, an Acueity 0.9-mm ductoscope (Acueity, Inc, Palo Alto, CA) was then advanced into the lactiferous sinus. The ductal system was distended using saline or more local anesthetic. The duct was then explored, with priority to the largest ductal branches, until every duct larger than the scope had been explored.
All intraluminal lesions seen in the ductal system were included within the duct excision. The excision was guided by transillumination from the scope with an attempt to get margins of several millimeters around all intraluminal defects. The number, type, and extent of intraluminal disease was recorded and compared with the final pathology report. When suspicion of ductal carcinoma-in-situ (DCIS) was identified, the surgeon also inked the specimen intraoperatively for margin assessment.
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RESULTS
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During the time period from January 2000 to August 2001, the author (W.C.D.) explored 27 patients for spontaneous bloody nipple discharge for the purpose of microductectomy for diagnosis. The patients ranged in age from 18 to 84 years. To become a candidate for exploration, each patient had to demonstrate, on two separate occasions, hemoccult positive fluid on breast exam from the same ductal orifice. All patients in this series had normal mammography in the 3 months before the surgical procedure. All patients with additional clinical symptoms, physical exam finding, or radiographic lesions were excluded. Of the patients, 16 had also undergone an attempt at galactogram before surgical referral. Two of these were technically unsuccessful, five had no clearly visualized lesions, and the remaining nine had ductal obstruction in the first 3 cm of duct. In each case, the duct was cannulated, and, before resection, endoscopy was performed using a 0.9-mm Acueity microendoscope. In one patient, the ductal lining could not be extensively explored because of scarring in the base of the nipple papilla, so the endoscopy added no additional information to traditional approaches. In the remaining 96% of cases, a lesion with irritation accounting for bleeding was identified. In 19 patients (70%), multiple lesions were present, and the bleeding was most often from lesions deeper than the first 2 cm of duct retroareolar. In two cases, extensive DCIS was identified. In both cases, there had been a large retroareolar papilloma, and the DCIS was present at greater than 5-cm depth. Atypical ductal hyperplasia (ADH) was a common finding as the source for bleeding (33%), and in all cases it coexisted with papillomas. Surgical resection was guided by transillumination, and the lesions were removed entirely with clear microscopic margins.
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CONCLUSIONS
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Breast endoscopy to evaluate and plan treatment intraoperatively for patients with bloody nipple discharge is now feasible.21,22 Ducts, which produce fluid freely, are easily cannulated for galactogram or with an endoscope about the same diameter as a galactogram catheter. The past difficulties with breast endoscopy have been related to either large scope sizes of greater than 1.5 mm or with distension of the ducts for navigation. The Oriental use of air to insufflate the duct leads to glare from refraction at the interface of air and fluid in the ductal system. The approach used here of saline distension after relaxation of the ductal smooth muscle with topical local anesthetic avoids those air/fluid interfaces and maximizes the distension without disruption of the ductal system. Navigation is accomplished by distracting the nipple papilla and advancing the scope while moving breast tissue back and forth in front of the scope to direct it down specific branches. Clearly, extremes in breast size can interfere with this crude steering approach.
Lesion identification is obvious because the normal ductal lining is white and smooth. Bleeding lesions are usually red and injected with clot adherent. Papillomas are typically large yellow spongiform masses and different in character from ADH and DCIS as seen in Figs. 1, 2, 3, and 4. This technique adds only 5 to 15 minutes to a traditional blind lachrymal probe directed excision of the proximal duct. The scope is reusable and comes with a disposable sheath introducer. The prorated cost of a disposable scope is approximately $150 to $200 per case, which is in the same range as a localization needle or a galactogram catheter and dye, so it is competitive with other imaging/localization methods.
The much higher incidence of multiple lesion identification suggests that the classic blind resection of the first 2 to 3 cm of duct retroareolar may underestimate the true causes of bleeding from deeper DCIS or ADH. In the DCIS cases, the identified bleeding cancerous change was 2 to 4 cm deep to benign retroareolar papillomas. This similar finding of multiple lesions is more common in some ductography guided surgical series. A large clinical trial of combining breast endoscopy with surgical duct excision for bloody nipple discharge is needed to see if the use of this new technique increases the rate of diagnosis of cancerous and precancerous conditions in this rare group of patients presenting with symptomatic hemoccult positive nipple discharge. Endoscopic snares and biopsy devices must be developed before endoscopic excision of these small lesions can replace traditional open surgical excision.
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Footnotes
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Routine operative breast endoscopy is applied to women with bloody nipple discharge and demonstrates utility in identification of the source of bleeding and detecting radiographically occult breast cancer.
Received for publication March 22, 2002.
Accepted for publication July 21, 2002.
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ABSTRACT
INTRODUCTION
