A Comparison of Ductoscopy-Guided and Conventional Surgical Excision in Women With Spontaneous Nipple Discharge

Moncrief, Robyn M.; Nayar, Ritu; Diaz, Leslie K.; Staradub, Valerie L.; Morrow, Monica; Khan, Seema A.

doi:10.1097/01.sla.0000157371.10776.d8

Cited by 51 publications

(43 citation statements)

References 18 publications

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“…These ducts could be targeted for more careful surveillance. To test this concept, we did a prospective study to evaluate whether quantitative assessment of gene promoter hypermethylation could enhance the utility of office ductoscopy in women with PND and those with atypical cytology on ductal lavage (5). In this article, we compare methylation levels of a panel of 11 genes in cells obtained from ductoscopy washings derived from ducts with minimal or no ductoscopy findings versus ducts with clinically significant findings.…”

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confidence: 99%

“…The most frequent causes of PND in these cases are intraductal papilloma in 36% to 66% (2-7), duct carcinoma in situ (DCIS) in 3% to 20% (2)(3)(4)(5)(6)8), and other benign causes in up to 23% (3,4). The evaluation of women with PND usually involves mammography, ultrasonography, and frequently, ductography (galactography).…”

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confidence: 99%

“…Each of these procedures has low sensitivity for detection of cancer, and often low specificity (3,10,11). Mammary endoscopy (ductoscopy) was first introduced in Japan in 1988 for the evaluation of patients with PND, and is currently being used to improve localization of lesions in patients with PND; it also allows retrieval of intraductal cells for diagnostic purposes (5,(12)(13)(14)(15)(16)(17). Although useful for lesion localization, ductoscopy does not distinguish benign from malignant growth (6,7,18).…”

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confidence: 99%

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Hypermethylated Genes as Biomarkers of Cancer in Women with Pathologic Nipple Discharge

Fackler¹,

Rivers²,

Teo³

et al. 2009

Clinical Cancer Research

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Purpose: In a pilot study of women with pathologic nipple discharge (PND) undergoing ductoscopy, we tested quantitative assessment of gene promoter hypermethylation using quantitative multiplex methylation-specific PCR (QM-MSP) to enhance detection of duct carcinoma in situ (DCIS). Experimental Design: Women with PND underwent ductoscopy; ducts with significant lesions were surgically resected (36 ducts in 33 women) and those with minimal findings were not (28 ducts in 16 women). QM-MSP was done on ductoscopy cell samples. Results were compared with cytology and tissue histology. Results: Cells from ducts with significant lesions on ductoscopy had significantly higher levels of methylation than those with minimal findings. Furthermore, cells from ducts with DCIS displayed higher levels of methylation than those with benign lesions such as papilloma (P = 0.006); or ducts with minimal findings on ductoscopy (P = 0.0001). Cumulative RASSF1A, TWIST1, and HIN1 gene methylation accurately distinguished ducts with cancerous versus benign lesions (100% sensitivity, 72% specificity, and area under the curve of 0.91 according to receiving operating characteristic analyses). QM-MSP analysis was more informative than cytology (100% versus 29% sensitivity, respectively), for detecting DCIS. In a validation set of paraffin-embedded DCIS and papilloma samples from women presenting with PND, QM-MSP was significantly higher in DNA from DCIS than papilloma sections (P = 0.002). Conclusion:The positive predictive value of ductoscopy was more than doubled (19% versus 47%) with the addition of QM-MSP, demonstrating the benefit of targeting ducts having both high methylation and significant abnormalities on ductoscopy for surgical excision. Future large-scale studies to validate this approach are needed.

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confidence: 99%

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Hypermethylated Genes as Biomarkers of Cancer in Women with Pathologic Nipple Discharge

Fackler¹,

Rivers²,

Teo³

et al. 2009

Clinical Cancer Research

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“…From their study and others, it is not a giant leap to conclude that intraluminal abnormalities in the ductal system have just as much need to undergo biopsy as the average palpable lump or radiographical (mammographic, ultrasound, or magnetic resonance imaging) lesion. 4,6,[8][9][10][11][12][13] But this relatively narrow view misses the greatest power of this new technology.We do not have mammogram and magnetic resonance imaging machines in our operating rooms to direct our surgical procedures. The best we can do is preoperative needle localization and postexcision specimen imaging.…”

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confidence: 99%

“…Improving our intraoperative mapping of the suspicious lesions-especially if these are potentially ductal carcinoma-in-situ-can only further enhance our success at getting truly clear margins. [4][5][6][7][8][9][10][11][12][13][14][15][16][17][18] We understand that many cancers are years in evolution. We should not be waiting to treat them until they are invasive and have the potential to spread from the breast.…”

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Who Wants a Blind Breast Surgeon?

Dooley

2008

Ann Surg Oncol

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Mammary ductoscopy was introduced by Japanese surgeons in the early 1990s for the direct visualization of the source of bloody nipple discharge.1 As techniques and equipment have evolved in the last 15 years, we now have several relatively simple submillimeter endoscopes that can be used to look within saline-distended larger ductal segments within the breast.2-6 Valdes et al. 7 demonstrate in their early experience with ductoscopy the ability to find and visualize intraductal lesions for excision. As with prior studies, they were impressed with the ability to identify histologically significant lesions that were relatively distant from the nipple, such as an 8-cmdeep ductal carcinoma-in-situ. They clearly have increased the number of breast cancers identified before traditional radiographical imaging or clinical examination alone. From their study and others, it is not a giant leap to conclude that intraluminal abnormalities in the ductal system have just as much need to undergo biopsy as the average palpable lump or radiographical (mammographic, ultrasound, or magnetic resonance imaging) lesion. 4,6,[8][9][10][11][12][13] But this relatively narrow view misses the greatest power of this new technology.We do not have mammogram and magnetic resonance imaging machines in our operating rooms to direct our surgical procedures. The best we can do is preoperative needle localization and postexcision specimen imaging. Despite this, most breast surgery operations today are performed with the same intraoperative imaging tool that Halsted used: the surgeon's palpation alone. The last decade has seen a rapid increase in intraoperative ultrasonography use by dedicated breast surgeons to assist in better and more accurate excisions of small invasive cancers. Improving our intraoperative mapping of the suspicious lesions-especially if these are potentially ductal carcinoma-in-situ-can only further enhance our success at getting truly clear margins. [4][5][6][7][8][9][10][11][12][13][14][15][16][17][18] We understand that many cancers are years in evolution. We should not be waiting to treat them until they are invasive and have the potential to spread from the breast. Finding cancers earlier and intervening sooner has been the mantra that has led to the dramatic decreases in breast cancer death rates in the last several years.Over the last decade, we have learned the importance of ellictable fluid from the nipple, especially in high-risk individuals. If we know someone is high risk and she is having breast surgery, should we not be certain that any intraductal lesions, related or unrelated to the target of the surgical procedure, are also adequately sampled? Can we perform a more accurate lumpectomy by actually mapping out the extent of the involved ductal system and either excising it all or excising the lesion and all associated intraluminal defects? When vascular surgeons are sewing on small blood vessels, is there any argument about putting on loops to make a better and smoother suture line closure? Although there are ma...

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Systematic review and meta-analysis of the diagnostic accuracy of ductoscopy in patients with pathological nipple discharge

Waaijer

Simons

Rinkes

et al. 2016

British Journal of Surgery

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A Comparison of Ductoscopy-Guided and Conventional Surgical Excision in Women With Spontaneous Nipple Discharge

Abstract: Ductoscopy identifies intraductal lesions in a high proportion of women with SND, and it may contribute to more accurate resection of these. A prospective study is required to obtain an unbiased assessment of these possible advantages.

Cited by 51 publications

References 18 publications

Hypermethylated Genes as Biomarkers of Cancer in Women with Pathologic Nipple Discharge

Hypermethylated Genes as Biomarkers of Cancer in Women with Pathologic Nipple Discharge

Who Wants a Blind Breast Surgeon?

Systematic review and meta-analysis of the diagnostic accuracy of ductoscopy in patients with pathological nipple discharge

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