To the Editor:
We read with great interest the article by Moncrief et al reporting a comparative study on the management of women with nipple discharge with or without ductoscopy-guided excision.1 Ductoscopy improved the localization of intraductal lesions and the proportion of women with intraductal neoplasia was greater in the group undergoing ductoscopy-guided excisions (88% vs. 81%). Visualization of a luminal lesion correlated significantly with proliferative disease, but reliable distinction between benign and malignant lesions was not possible based on the endoscopic appearance. Of the 49 papillomatous lesions visualized, 36 (73%) were indeed papilloma, 5 (10%) were cancer, 3 were atypical hyperplasia (6%), and 3 were hyperplasia of usual type. Although cytology results were not reported, it is well known from other studies that the specificity of ductoscopic cytology is limited.2 The authors conclude that new methods such as optical spectroscopy will be required to improve the in situ diagnosis of intraductal lesions.
A method for intraductal tissue sampling would significantly improve the diagnostic potential of ductoscopy and could help to define the appropriate surgical procedure in patients with ductal lesions. However, it has been difficult to establish ductoscopic biopsy techniques, mainly because of the small dimensions of ductoscopes (diameter <1 mm).
We have developed a simple ductoscopic biopsy technique that allows precise tissue sampling from intraductal breast lesions under visual control.3 The biopsy device consists of a special biopsy needle with an outer diameter of 0.9 mm and a rigid gradient index ductoscope with a diameter of 0.7 mm. The needle has a lateral oval opening located 3 mm from the distal tip. The surface of the opening is designed as a blade to cut off tissue samples from lesions that protrude into the lumen. Usually, the tip of the ductoscope is ending at the tip of the cannula, thus sealing the biopsy chamber. When a neoplastic lesion is found, the ductoscope is withdrawn 4 mm to open the biopsy chamber. Under visual control, the lesion can now be maneuvered into the lumen of the biopsy needle. Then vacuum is applied while the instrument is withdrawn from the duct. Multiple tissue samples can be obtained, and substantial parts of smaller lesions may be removed by repeated biopsies. The size of the biopsy samples is approximately 1 mm and the diagnostic quality is generally good.
With the biopsy device, ductoscopy was performed in 30 patients who presented with pathologic nipple discharge. The examinations were carried out preoperatively using topical anesthesia with an anesthetic cream. The study was approved by the institutional review board and informed consent was obtained from all patients. Papillary tumors or obstructing lesions were identified in 21 patients (70%). The biopsy procedure was technically successful in all cases. On average, 3 tissue specimens (range, 1–5) were sampled from any suspicious lesion. Biopsy specimens in diagnostic quality were obtained in all but 1 patient. Histopathology revealed papilloma in 17 patients (80%), ductal carcinoma in situ in 2 patients (10%), and invasive ductal carcinoma in 1 patient. Histopathologic analysis of the resection specimen confirmed the diagnosis made by ductoscopic biopsy in all cases. The rate of 14% cancerous lesions diagnosed by ductoscopic biopsy in patients with nipple discharge compares favorably to the data of Moncrief et al1 and others.4
Ductoscopic vacuum-assisted biopsy is a simple and efficient technique that allows targeted tissue sampling of intraductal lesions in women with nipple discharge. This new technique allows differentiation of benign papillary tumors from cancerous lesions and could help to define the indication for surgery and the extent of surgery in women with nipple discharge. In the future, ductoscopic biopsy may provide the basis for minimally invasive therapy for benign intraductal lesions.
Michael Hünerbein, MD
Peter M. Schlag, MD, PhD, FSSO
Department of Surgery and
Surgical Oncology
Charité Campus Buch and
Helios Hospital Berlin
Berlin, Germany
schlag@rrk.charite-buch.de
REFERENCES
- 1.Moncrief RM, Nayar R, Diaz LK, et al. A comparison of ductoscopy-guided and conventional surgical excision in women with spontaneous nipple discharge. Ann Surg. 2005;241:575–581. [DOI] [PMC free article] [PubMed] [Google Scholar]
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