Fiberoptic ductoscopy for patients with nipple discharge

BACKGROUND. Breast carcinoma and precancer are thought to start in the lini ng of the milk duct or lobule, yet until recently, we have not had direct a ccess to this area other than by blindly removing tissue by core biopsy or fine-needle aspiration. Fiberoptic ductoscopy (FDS) is an emerging techniqu e allowing direct visual access to the ductal system of the breast through nipple orifice exploration. METHODS. We applied ductoscopy to 259 women who had nipple discharge, and w e analyzed the visual findings, the cytological washings, and the subsequen t histopathology. RESULTS. In 92 (36%) of these women, fiberoptic ductoscopy was successful i n detecting an intraductal papillary lesion. Of these observed lesions, 68 (74%] were single papilloma, 21 (23%) were multiple discrete papillomas, an d 3 (3%) were diffuse intraductal thickening which corresponded to diffuse papillomatosis on histopathological analysis. The overall positive predicti ve value of FDS screening was 83%. Of the lesions observed, 29.8% were loca ted in the main [segmental) duct, 43.9% lesions in the first branch, 17.5% lesions in the second branch, 7.9% in the third branch, and 0.9% in the fou rth branch. These lesions had an overall average distance of 2.7 cm from th e nipple orifice. Ductal washings performed at the time of ductoscopy were effective at obtaining representative exfoliated ductal cells which could b e evaluated for the presence of clumps (> 50 cells), clumps with atypia or single ductal cells. The presence of clumps with positive FDS increased the positive predictive value to 86%. CONCLUSIONS, Fiberoptic ductoscopy currently offers a safe alternative to d uctography in guiding subsequent breast surgery in the treatment of nipple discharge. Cancer 2000;89:1512-9, (C) 2000 American Cancer Society.