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

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Presentation on theme: "Ductoscopy : Future Management of Nipple Discharge Dr Leung Yuen Yee Kwong Wah Hospital."— Presentation transcript:

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

2 Background  Nipple discharge is the 3 rd 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

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

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

17

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 ductal structures, benefit for women of childbearing age 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%) 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)

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 ? Commonest site of neoplasia

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

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

29 Take home messages  Nipple discharge is 3 rd 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

30 References  Mammary ductoscopy in the current management of breast disease Surg endosc review 2010 Sarah SK Tang, Dominique J Twelves Surg endosc review 2010 Sarah SK Tang, Dominique J Twelves  Mammary ductoscopy : current issues and perspectives Breast cancer :93-96 Ken Uchida, Hisaki Fukushima Breast cancer :93-96 Ken Uchida, Hisaki Fukushima  A look into the ductoscope: Its role in pathologic nipple discharge Ann Surg Oncol : C.S. Fisher Ann Surg Oncol : C.S. Fisher  Evaluating nipple discharge CME review article Aneela N CME review article Aneela N  Ductoscopy in the evaluation and management of nipple discharge Ann surg oncol 2010 Sedat kamali 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 Ann surg 2005 Robyn M Moncrief


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