Fiberoptic ductoscopy for breast cancer patients with nipple discharge

Background: Breast cancer and precancer are thought to originate in the lin ing of the milk duct, but until recently, we have not had direct access to this area other than in tissue removed blindly by core biopsy or fine-needl e aspiration. Fiberoptic ductoscopy (FDS) is an emerging technique that all ows direct visual access of the ductal system of the breast through nipple orifice cannulation and exploration. To date, this technique has been used only in pilot studies. Previously, we have demonstrated that fiberoptic duc toscopy in patients with and without nipple discharge is a safe and effecti ve means of visualizing the intraductal lesion. When combined with cytology , it is a screening technique that has high predictive value. Methods: We applied ductoscopy to 415 women with nipple discharge with the specific intent of detecting those patients with nipple discharge who had i ntraductal carcinoma (DCIS) as the basis of their discharge. Results: In this cohort of patients, ductoscopy was successful in visualizi ng an intraductal lesion in 166 patients (40%). In these cases, ductal lava ge following ductoscopy increased the yield of cytologically interpretable ductal epithelial cells 100-fold compared to discharge fluid alone. In the majority of these patients, FDS examination detected lesions that had the a ppearance of typical papillomas. However, in 10 patients, the intraductal l esion exhibited one of several atypical features, including bleeding, circu mferential obstruction, and gross fungating projections. In eight of these patients, the subsequent histopathology turned out to be DCIS. In two of th ese eight patients, endoscopic biopsy revealed cytologically malignant cell s; in two others, ductal lavage (washings) revealed cytologically malignant cells. In three additional patients, although FDS examination uncovered a typical papilloma that was not biopsied, ductal lavage (washings) revealed cytologically malignant cells. On surgical pathology review of the extirpat ed lesions, all 11 patients were subsequently shown to have DCIS. Of these 11 cases of DCIS that were initially detected with a combination of FDS and ductal lavage cytology, six were completely negative on mammogram and phys ical exam. Conclusion: Although nipple discharge is an unusual presentation for DCIS, in patients with nipple discharge, FDS with ductal lavage cytolo gy is a useful technique for diagnosing DCIS prior to definitive surgery.