Nipple discharge: role of ductoscopy in comparison with standard diagnostic tests.

BACKGROUND: This study aims to assess the role of ductoscopy for detecting intraductal anomalies in patients with nipple discharge in comparison to conventional tests and to find an effective combination of both approaches. MATERIALS AND METHODS: Prior to duct excision, ductoscopy was performed in 97 women. Histologic and all other diagnostic results were compared. Sensitivity, specificity, and efficiency were calculated for all methods. These parameters were also calculated for all possible test combinations in 12 patients who had completed all tests. RESULTS: Breast sonography reached the highest sensitivity (64.1%) and efficiency (64%); mammography had the highest specificity (100%). The sensitivity of ductoscopy was 53.2%, its specificity 60%, and its efficiency 55.1%. Among combinations of all methods, the combination ductoscopy + galactography was the most sensitive (80%). Mammography, magnetic resonance imaging, and ductoscopy were each 100% specific. Ductoscopy was the most efficient (75%) single method. CONCLUSION: Ductoscopy is a valuable test for diagnosing intraductal lesions in patients with nipple discharge. It is more efficient than conventional tests in patients undergoing all tests.

Ductoscopy-based descriptors of intraductal lesions and their histopathologic correlates.

BACKGROUND: In order to elucidate criteria for distinguishing benign from malignant lesions, this study correlated the ductoscopy-based macroscopic description of intraductal lesions with histopathologic results. MATERIALS AND METHODS: Aiming to use diagnostic criteria consistent with previous publications, we analyzed the literature and established a uniform set of diagnostic descriptors. Based on these criteria, we subsequently analyzed and catalogued video and photographic material from 68 patients with nipple discharge, who had undergone ductoscopy followed by open surgery. For all breast lesions, the factors lesion type, number of lesions, lesion color, surface characteristics, and presence of blood or atypical vessels were reported. Based on the frequency distribution and the odds ratio, we were able to evaluate the differential diagnostic value of ductoscopic criteria in comparison with the respective histopathologic results. RESULTS: Among the ductoscopic criteria, a fissured surface, hemorrhage or atypical vessels, and a polypoid appearance were important predictors for malignant lesions. In contrast, a smooth surface, the absence of hemorrhage and atypical vessels and a level appearance of the lesions predicted benign lesions. CONCLUSIONS: For predicting the benign versus malignant character of ductoscopic lesions, the following criteria should be used: presence or absence of blood and atypical vessels, surface type, and level versus polypoid appearance.

Correlation of Ductoscopic and Histopathological Findings and Their Relevance as Predictors for Malignancy: A German Multicenter Study.

BACKGROUND/AIM: The study aimed at investigating the correlation between ductoscopic and histopathological findings and clarify whether the former allow for accurate prediction of malignancy. PATIENTS AND METHODS: The prospective national multi-center study covered a sample of 224 patients with pathologic nipple discharge. A total of 214 patients underwent ductoscopy with subsequent extirpation of the mammary duct. The ductoscopic findings were categorized according to shape, number, color and surface structure of lesions and vascularity and compared to the histological results and analyses. RESULTS: Ductoscopy revealed lesions in 134 of 214 patients (62.2%). The criteria "multiple versus solitary lesion" differed significantly between malignant and benign lesions. All other criteria were not statistically significant. Malignant tumors were more frequently presented as multiple lesions, benign lesions or masses as solitary lesions (80% vs. 24.8%; p=0.018). CONCLUSION: The ductoscopic criterion "solitary vs. multiple lesion" appears to have a low diagnostic prediction of malignancy or benignity.

Significance of laboratory studies for ruling out metastases in primary endometrial carcinoma.

BACKGROUND: At the time of initial diagnosis of endometrial cancer, therapeutic decisions depend on the recognition of remote metastases. Tumor markers and hepatic enzymes are frequently used to screen for metastases. This study aimed to assess the clinical value of serum concentrations of tumor markers and liver enzymes. PATIENTS AND METHODS: Laboratory test results from all patients with the initial diagnosis of endometrial cancer treated in our department between 1990 and 2000 were retrospectively reviewed. Hepatic enzyme levels and tumor markers relevant for endometrial cancer were recorded. Analysis of variance and post hoc tests were used to rule out or to confirm systematic differences. Significances were examined by the Mann-Whitney test. RESULTS: A total of 336 women were included in the analysis. Recorded data included serum concentrations of alanine aminotranspherase (ALT) (n = 228), aspartate aminotranspherase (AST) (n = 289), gamma-glutamyltranspherase (Gamma-GT) (n = 176) and alkaline phosphatase (AP) (n = 86). The following tumor markers were analysed: carcinoembryonic antigen (CEA) (n = 182), squamous cell carcinoma antigen (SCC) (n = 40), cancer-associated serum antigen (CASA) (n = 10), CA 15-3 (n = 5), CA 19-9 (n = 21), and CA 125 (n = 28). Only CEA serum levels differed significantly between patients with endometrial cancer and hepatic and pulmonary metastases at the time of initial diagnosis and patients without metastases. CONCLUSION: Our data show that neither the level of the tumor markers CEA, SCC, CA 15-3, CA 125, CA 19-9, CA 72-4 and CASA nor the hepatic enzymes AST, ALT, Gamma-GT and AP in routine evaluation accurately predict the presence of remote metastases.

Breast ductoscopy: technical development from a diagnostic to an interventional procedure and its future perspective.

BACKGROUND: Endoscopy of the female breast, known as ductoscopy, is increasingly gaining acceptance as a diagnostic procedure worldwide. Recent technical development of ductoscopes and micro-instruments is shifting research interest from diagnostic to interventional ductoscopy. We describe novel technical aspects and the resulting possible future perspective of ductoscopy. METHODS: This study comprised the analysis and review of new technical developments from research at the Technical University Munich, Germany, and others, as well as a review of the MEDLINE and COCHRANE databases for the keyword ductoscopy. RESULTS: Diagnostic ductoscopy is performed by many breast physicians worldwide. Interventional ductoscopy, however, depends on an additional working channel and a variety of micro-instruments of 0.4-0.8 mm for procedures inside the breast duct. They are at present not available in the U.S. but are used in Germany and several other countries. Autofluorescence ductoscopy is a new imaging technique used on an experimental base for clinical evaluation to identify intraductal lesions. Laser ductoscopy for removal of intraductal papillomas and 3-dimensional intraductal tracking systems are future projects. CONCLUSION: Technical innovation and further miniaturization of instruments is supporting a change from diagnostic to interventional ductoscopy. A therapeutic intraductal approach as well as autofluorescence endoscopy could potentially eliminate unnecessary biopsies and offer better identification of intraductal lesions.

Ductoscopic detection of intraductal lesions in cases of pathologic nipple discharge in comparison with standard diagnostics: the German multicenter study.

BACKGROUND: According to the literature, ductoscopy is gaining increasing importance in the diagnosis of intraductal anomalies in cases of pathologic nipple discharge. In a multicenter study, the impact of this method was assessed in comparison with that of standard diagnostics. PATIENTS AND METHODS: Between 09/2006 and 05/2009, a total of 214 patients from 7 German breast centers were included. All patients underwent elective ductoscopy and subsequent ductal excision because of pathologic nipple discharge. Ductoscopy was compared with the following standard diagnostics: breast sonography, mammography, magnetic resonance imaging (MRI), galactography, cytologic nipple swab, and ductal lavage cytology. The histological and imaging results were compared and contrasted to the results obtained from the nipple swab and cytologic assessment. RESULTS: Sonography had the highest (82.9%) sensitivity, followed by MRI (82.5%), galactography (81.3%), ductoscopy (71.2%), lavage cytology (57.8%), mammography (57.1%), and nipple swab (22.8%). Nipple swabs had the highest (85.5%) specificity, followed by lavage cytology (85.2%), ductoscopy (49.4%), galactography (44.4%), mammography (33.3%), sonography (17.9%), and MRI (11.8%). CONCLUSION: Currently, ductoscopy provides a direct intraoperative visualization of intraductal lesions. Sensitivity and specificity are similar to those of standard diagnostics. The technique supports selective duct excision, in contrast to the unselective technique according to Urban. Therefore, ductoscopy extends the interventional/diagnostic armamentarium.

Diagnostic value of ductoscopy in the diagnosis of nipple discharge and intraductal proliferations in comparison to standard methods.

BACKGROUND: Ductoscopy is gaining increased importance in the diagnosis of nipple discharge of unclear origin and intraductal proliferation. For this reason we compared its diagnostic value and feasibility to standard diagnostic methods. MATERIAL AND METHODS: Ductoscopy was compared to mammography, galactography, sonography, magnetic resonance imaging (MRI), nipple smear, fine needle aspiration cytology (FNAC), and high-speed core biopsy; feasibility, sensitivity, and specificity were investigated for each method. RESULTS: 71 ductoscopies were evaluated, which were followed up by open biopsies. Here, 3 invasive and 8 ductal carcinomas in situ were found, as well as 3 atypical ductal hyperplasias, 44 papillomas/papillomatoses, and 13 benign findings. Feasibility of ductoscopy was in this series 100%. Duct sonography showed the highest sensitivity (67.3%), followed by MRI (65.2%), galactography (56.3%), ductoscopy (55.2%), and FNAC (51.9%). The highest specificity was shown by FNAC, core biopsy, and galactography (each 100.0%), followed by mammography (92.3%), nipple smear (77.8%), ductoscopy, and duct sonography (each 61.5%); the lowest specificity was displayed by MRI (25.0%). CONCLUSION: The results confirm that ductoscopy can be performed within the same range of sensitivity and specificity as other techniques. In order to make conclusive statements about ductoscopy, especially in order to precisely define the indications for this method, a prospective multicenter study was initiated.

Mammary ductoscopy for the evaluation of nipple discharge and comparison with standard diagnostic techniques.

STUDY OBJECTIVE: To describe performance of breast duct endoscopy and compare the method with conventional diagnostic techniques. DESIGN: Canadian Task Force classification III. SETTING: Interdisciplinary Breast Unit of a university hospital. PATIENTS: Consecutive and unselected series of 15 female patients including 20 breasts with nipple discharge. INTERVENTIONS: Prospective data assessment on all patients with ductoscopy for nipple discharge between April 2003 to April 2004. All preoperative (mammography, ultrasonography, nipple smear) and minimally invasive (galactography, fine needle aspiration cytologic study) diagnostics were evaluated and compared with ductoscopy. MEASUREMENTS AND MAIN RESULTS: Mammography on 20 breasts showed BI-RADS-I (5%), BI-RADS-II (50%), and BI-RADS-III (45%). Breast ultrasound scanning showed abnormalities, classified as BI-RADS-III equivalent lesions in all cases. Nipple smear showed in 69.2% a normal cytology and in most cases revealed a papilloma later (n=8/9). Unilateral galactography was performed in 46.7% who had spontaneous nipple discharge. Two galactography results were unremarkable, and open biopsy demonstrated 1 atypical ductal hyperplasia and papilloma. On 20 breasts of 15 women, 19 ductoscopies were successfully performed (95%). In 17 cases open biopsy followed ductoscopy, and 1 ductal carcinoma in situ (DCIS), 3 atypical ductal hyperplasia (ADH), 1 ductal hyperplasia without atypias, and 12 ductal papillomas were found. CONCLUSION: Compared to nipple smear, the diagnostic value of ductoscopy in this study is superior but marginally inferior to galactography and highly specialized breast ultrasound scanning. Therefore ductoscopy needs to be evaluated on a larger scale, preferably in multicenter trials to further determine its potential and indications.