Using ductoscopy to detect breast mass at an early stage

AORN Journal,  Nov, 2002  by Carol A. Sparks

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By the time a woman feels a breast mass or a physician finds a mass via mammography, it has been growing in the breast for approximately eight years. When a mass is felt in the breast, it usually is 1 cm in size. By the time it is seen on mammography, it usually is between 0.5 cm and 1 cm. (1) A new procedure for detecting an abnormal breast mass has come to the forefront of medicine. Using this procedure, termed fiberoptic ductoscopy, a surgeon can examine a patient's mammary ducts directly with the aid of a very fine endoscope. With this procedure, surgeons potentially will be able to detect breast masses long before they are felt or visible via mammography.

UNDERSTANDING NEW TECHNOLOGY

The University of Connecticut Health Center (UCHC), Farmington, has been chosen by the only manufacturer of this technology as one of several facilities in the country to conduct research. In addition to conducting breast cancer research, university physicians who specialize in breast surgery will train area physicians in the use of this state-of-the-art technology. The procedure has been approved by the US Food and Drug Administration (FDA), but the manufacturer's engineers, together with breast surgeons, are working constantly to improve the technology.

Eighty-five percent of breast cancers are thought to originate in the epithelial lining of the mammary ducts, and the hope is that this new technology will aid in early breast cancer detection. (2) Ductoscopy cannot be used as a widespread cancer-screening tool--it only can be used in women who present with dilated mammary ducts and nipple discharge because the endoscope will fit only through dilated ducts. The procedure, however, is an effective tool for patients who experience nipple discharge, have had a previous breast cancer diagnosis, or have a significant family history of breast cancer.

Evidence shows that breast cancer may be detected early when there is nipple discharge and no palpable mass. (3) Patients at high risk may have undergone ductal lavage in a surgeon's office. During ductal lavage, the surgeon threads a small filament into the duct and irrigates it with a small amount of saline to try and elicit cells to send for cytological examination. (4) Seventeen percent of women who undergo ductal lavage are found to have atypical hyperplasia, which is a precancerous condition. (5) Further investigation previously has been attempted by fine needle aspiration or by blindly removing tissue. (6) Fiberoptic ductoscopy allows for direct visualization of the ducts and biopsy of the suspect tissue, if needed.

Nipple discharge is a relatively common problem among women and can occur in up to 10% of women. (7) Discharge can be serous, serosanguineous, milky, watery, or bloody. (8) Generally, when a patient presents with nipple discharge, the physician will send the expressed fluid for cytological examination. If cytological examination reveals the need for further treatment, the physician will refer the patient to a surgeon. The surgeon may schedule the patient for a ductogram, in addition to ductal lavage, to radiographically visualize the duct system. If the ductogram is positive for a suspected lesion or if the cells are suspicious, the surgeon can schedule the patient for fiberoptic ductoscopy of the breast. Some surgeons perform this procedure in the office with local anesthetic; however, at UCHC ductoscopy is performed under local anesthesia with monitored anesthesia care in the OR. This is beneficial because, based on the findings, a biopsy can be performed immediately and does not warrant a return trip to the OR.

Thirty-five percent to 48% of cases of nipple discharge are the result of intraductal papilloma or papillomatosis, based on surgical pathology analysis. (9) Papillomatosis is defined as diffuse multicentric hyperplasia involving the ducts. (10) In a recent study of 259 women with nipple discharge, 36% were found to have an intraductal papillary lesion. (11) Ductoscopy, therefore, can be an effective screening tool because if there is no visualized lesion, patients may be spared excisional biopsy.

Ductoscopy, unlike ductography, provides precise localization and mapping of the lesion within the duct. (12) If a lesion is seen, it may dictate the type and extent of surgery. Patients with atypical ductal hyperplasia or focal ductal carcinoma in situ (DCIS) may require more extensive duct excision to achieve negative surgical margins. (13) It has been reported that unsuspected deep lesions were found with ductoscopy that were not visible with ductography and probably would have been missed during routine duct excision. (14)

Direct fiberoptic ductoscopy has been performed in China and Japan for more than 10 years, and initial research was performed in these countries. Ductoscopy was first introduced in the United States in 1997. The first endoscopes used for the procedure were similar to arthroendoscopes in that they were rigid and approximately the size of a wrist or ankle endoscope. New technology has led to the development of a flexible 0.9-mm endoscope with a 0.2-mm working channel. This is the type of endoscope currently being used at UCHC. The endoscope is approximately the size of a pencil lead (Figure 1).