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Endoscopic Visualization of Breast Tumors
To the Editor: A number of ductal cytologic sampling techniques have been proposed as possible screening techniques for breast cancer.1 We attempted to assess the feasibility of direct intraoperative breast endoscopy in women undergoing partial mastectomy for diagnostic and therapeutic purposes using new endoscopes measuring 1.2 and 0.9 mm in external diameter (DOFI Technologies, Los Angeles, Calif). Until recently, direct visualization techniques have been subject to the technical limitations of endoscopic technology and the excessive cost of the smallest instruments (<5 mm in diameter).2-3
Method
We attempted to examine 55 women with ductal hyperplasia, ductal carcinoma in situ, or invasive breast cancer identified by current breast screening practices. All lesions were confirmed preoperatively by pathologic analysis of a histologic specimen (core biopsy or incisional surgical breast biopsy). At the time of surgical lumpectomy, the target ductal orifice was identified by the presence of discharge after massage in the quadrant containing the target lesion. The orifice was then successfully cannulated and dilated in all but 8 patients. An endoscope was passed into the lactiferous sinus while using local anesthetic and saline distension. The endoscope was advanced into all ductal segments that could be distended. All endoscopic lesions identified were catalogued and, using surgical excision of the lesion at the endoscope tip, were included within the lumpectomy specimen for histologic correlation.
Results
No lesion could be identified endoscopically in 6 of the 47 remaining patients who underwent endoscopy. Of the 41 remaining patients (75% of original sample), the target lesion could be identified by direct cannulation of the suspected ductal orifice on the nipple papilla and navigation of the ducts under saline distention. In 21 patients (38% of original sample), endoscopy revealed more extensive intraluminal disease that required a wider breast resection than previously anticipated. Although limited to examination of the ducts on only the nipple side of the cancer or premalignant lesion, endoscopy reduced need for reexcision by guiding appropriately extensive excisions on the side of the specimen where the ducts were visualized. Following endoscopic guidance, microscopic assessment did not reveal any positive margins within 5 mm in the nippleward boundary of the excised tissue in of any of these patients. Figure 1 shows the spectrum of endoscopic findings in this initial series.
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Figure. Findings in Direct Intraoperative Breast Endoscopy
DCIS indicates ductal carcinoma in situ; ADH, atypical ductal hyperplasia.
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Comment
The ability to identify malignant and premalignant breast diseases endoscopically may allow better direction of surgical therapeutic and diagnostic procedures and also development of new ductal-based screening procedures in women at high risk of breast cancer.
William C. Dooley, MD
Department of Surgery
The Johns Hopkins University School of Medicine
Baltimore, Md
1. Okazaki A, Hirata K, Okazaki M, Svane G, Azavedo E. Nipple discharge disorders: current diagnostic management and the role of fiber-ductoscopy. Eur Radiol. 1999;9:583-590.
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2. Okazaki A, Okazaki M, Asaishi K, et al. Fiberoptic ductoscopy of the breast: a new diagnostic procedure for nipple discharge. Jpn J Clin Oncol. 1991;2:188-193.
3. Love SM, Barsky SH. Breast-duct endoscopy to study stages of cancerous breast disease. Lancet. 1996;348:997-999.
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Letters Section Editors: Stephen J. Lurie, MD, PhD, Senior Editor; Phil B. Fontanarosa, MD, Executive Deputy Editor.
JAMA. 2000;284:1518.
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ABSTRACT
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