Routine operative breast endoscopy for bloody nipple discharge

Background Submillimeter endoscopes are now available and have been described to assist surgeons in the evaluation and management of symptomatic nipple discharge. Methods To evaluate its potential use, a microendoscope (0.9 mm Acueity) was used on all patients in a single surgeon's practice who were undergoing nipple exploration for spontaneous hemoccult positive nipple discharge. This procedure was performed at the surgical resection of the symptomatic retro-areolar duct, and 27 patients underwent the endoscopy during the period from January 2000 to August 2001. Results In 96% (26 of 27) of the patients, the endoscope was successfully introduced into the lactiferous sinus, and the proximal breast ducts were successfully visualized. A lesions accounting for the bleeding was seen in all 26 patients, with 70% (n=19) having multiple intraluminal defects. Cancers were identified in two cases (7.4%), and in both cases, there was a more proximal papilloma in the same ductal system. Similarly, in 33% of the benign cases, both papillomas and usual or atypical ductal hyperplasia were present. Lesions were identified that extended up to 7.5 cm deep to the nipple. The deepest lesions was one of the endoscopically identified cancers in a patient with normal mammogram and breast ultrasound. Surgical resection could be directed by simple transillumination of the skin during endoscopy. Conclusions This series demonstrates the clinical feasibility of routine operative breast endos-copy in the management of bloody nipple discharge. The high incidence of multiple lesion identification suggests that the classic blind resection of a limited distance of duct in the retroareolar space may significantly underestimate the true extent of proliferative disease accounting for pathologic nipple discharge.     

Navigating murky waters: a modern treatment algorithm for nipple discharge

BACKGROUND: Many women with nipple discharge undergo operative duct excision with few actually having carcinoma. METHODS: We reviewed all patients with nipple discharge at our institution from 2001 to 2005. Clinical findings were analyzed to determine an appropriate treatment algorithm. RESULTS: Nipple discharge was present in 204 patients. Carcinoma was identified in 7 patients (3% of all, 9% of those undergoing biopsy). Age > or = 50 years, abnormal mammography, and abnormal sonography were the only significant predictors of carcinoma. Among patients with unilateral, spontaneous, bloody, or serous discharge with a negative mammogram, the carcinoma risk was 3%. Among patients with unilateral, spontaneous, bloody, or serous discharge with a negative mammogram and subareolar ultrasound, the carcinoma risk was 0%. CONCLUSIONS: Patients with nipple discharge can be divided into risk groups by combining clinical and radiologic findings. Low-risk patients can be offered close clinical follow-up rather than operation. A recommended management algorithm is presented.     

纤维乳管镜诊断乳头溢液的临床价值

目的：评价纤维乳管镜在乳头溢液中的诊治价值。方法：1999年3月-2005年6月，对2608例乳头溢液的病例运用了纤维乳管镜检查，直接观察溢液导管内的病变，初步判断其疾病性质并准确定位；将溢液性质、检查结果、手术病理结果进行总结分析。结果：2608例乳头溢液病例中，溢液为乳白色者97例，无色者563例．黄色者l075例，血性者873例。纤维乳管镜拟诊为“导管扩张”361例，慢性炎症596例，乳管内乳头状瘤（病）l609例．乳腺癌42例；并对其中1444例进行了手术。纤维乳管镜对乳管内乳头状瘤（病）的诊断符合率为78．09％，对乳腺癌的诊断符合率为90％。结论：纤维乳管镜具一定的诊断准确性和定位可靠性，对乳头溢液病人是一种安全有效的初步检查方法。对具无色、黄色或血性溢液的病人均应行纤维乳管镜检查。     

Throwing light on nipple discharge

Five percent of the patients presenting to a symptomatic breast clinic have nipple discharge. Conventional surgical management for the nipple discharge includes microdochectomy or total duct excision. Breast duct micro-endoscopy (BDME) is a new technique, which helps evaluate the underlying cause of nipple discharge. We describe a case of nipple discharge with a unique etiology: mammary duct foreign body.     

纤维光导乳管镜用于乳头溢液的诊断

目的　评价纤维光导乳管镜检查对乳头溢液的诊断价值。方法　应用三菱公司FV 2 0 0 0E型半硬性纤维光导乳管镜检查系统 ,对 2 6 9例乳头溢液进行诊断 ,并与术后病理诊断作对比分析。结果　 2 6 9例患者中发现乳管内占位性病变 12 9(48% )例 ,其中单发病变 92 (71 3% )例 ,多发病变2 7(2 0 9% )例 ,弥漫性病变 10 (7 8% )例 ,镜下诊断导管内乳头状瘤 12 5 (96 9% )例 ,恶性病变 4 (3 1% )例。镜下诊断乳头状瘤与病理诊断符合率为 91 9% ,与乳腺癌的诊断符合率为 75 %。另外 14 0(5 2 % )例诊断为非肿瘤性良性疾病 ,主要为乳腺导管扩张症、乳管炎。结论　纤维光导乳管镜检查乳头溢液准确、可靠。     

Breast duct microendoscopy in nipple discharge: microbrush improves cytology

Background Breast duct microendoscopy is a new technique that allows direct visualization of the mammary ductal epithelia and has the potential to provide greater accuracy in the diagnosis of benign and malignant breast conditions. We have already established the feasibility of BDME on mastectomy specimens and in patients both under general and local anesthesia. It was the aim of this study to investigate the use of BDME in patients with pathological nipple discharge and to explore the feasibility of using an endoluminal microbrush to take cytology samples from specific lesions. Materials and methods Breast duct microendoscopy was offered to all patients undergoing surgery for nipple discharge. Surgery included microdochectomy (younger women) and total duct excision (especially in postmenopausal women). The microbrush was used to collect samples whenever an endoluminal papilloma was seen on endoscopy. The results of microbrush cytology samples were compared to ductal lavage samples. Results Fifty consecutive patients undergoing microdochectomy or total duct excision for nipple discharge had breast microendoscopy (28 general, and 22 under local anesthesia). Thirty-one patients had microdochectomy and nineteen had total duct excision. Visualiza- tion of discharging ducts was accomplished in 100% cases. Endoluminal abnormalities were seen in 33 (66%) patients and dilated ducts were seen in 17 patients. Among the 33 patients, 15 had single papilloma, 3 multiple papilloma and 15 inflammation (erythema, fronds, adhesions). Seven out of eight patients with an intraductal papillorna who had microbrush cytology showed papillary cells whereas only 2 out of 11 patients who had ductal lavage were positive for papillary cells. Thus the sensitivity of the brush cytology technique for the diagnosis of papilloma was 87.5% and the sensitivity of ductal lavage 18% (p = 0.0055). Conclusion Breast duct microendoscopy is an effective way of establishing the etiology of nipple discharge. The microbrush increases the sensitivity of cytology significantly.     

乳管镜直视下病灶活检在伴乳头溢液乳管疾病诊断中的应用

目的 研究乳管镜直视下乳管内病灶活检的可行性和意义.方法 2006年5月至2007年4月,共51例有乳管内病灶的患者在复旦大学肿瘤医院接受了53次乳管镜直视下乳管内病灶活检术和随后的开放手术.结果 活检发现29例管内乳头状瘤、15例导管上皮增生、2例上皮重度不典型增生和2例恶性肿瘤.另有5例活检失败.开放手术后病理为12例单发管内乳头状瘤、12例多发性管内乳头状瘤、25例乳腺上皮增生、3例导管内癌、1例浸润性导管癌.结论 乳管镜直视下乳管内病灶活检不仅是微创、安全、方便可行、成功率高的诊断方法,还可部分替代现有开放手术.活检如发现上皮不典型增生或恶性肿瘤,则需进一步手术.     

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目的探讨乳管镜对伴乳头溢液乳腺疾病的诊断价值。方法利用纤维乳管镜系统对乳头溢液病人进行检查,观察溢液导管及其分支的管腔和管壁的结构,发现并确定病灶位置,记录病变导管的形态特征,对可疑病例定位切除送病检确诊,对2000～2004年879例病人资料进行回顾性分析。结果发现占位性病变551例,镜下诊断为乳头状瘤398例,乳头状瘤病86例,乳腺导管癌67例。手术392例。经病理证实对乳腺癌诊断的灵敏度934%,特异度985%。结论乳管镜可以明确引起乳头溢液疾病的病因、确定病变部位,解决了乳腺导管内疾病不易诊断的难题,可提高早期乳腺癌的发现率。     

Ductal carcinoma in situ-associated nipple discharge: A clinical marker for locally extensive disease

Background: This study evaluates the diagnosis and treatment of women with pathologic nipple discharge caused by ductal carcinoma in situ (DCIS). Methods: Women with unilateral spontaneous bloody, serous, or brown nipple discharge who presented between January 1, 1988 and August 1, 1996 were identified by retrospective chart review. Women with nonspontaneous, physiologic discharge were excluded. Results: Two hundred seventy-seven women with a mean age of 59.5 years (range, 24 to 88 years) underwent duct exploration and biopsy for pathologic discharge, with 43 (15.5%) found to have DCIS. The discharge was bloody in 29, clear in eight, and brown in six women. Seven of 12 (58%) women with an associated breast mass were found to have a microinvasive component with the DCIS. Discharge cytology showed malignant cells in only two of 12 (16%) women examined. A ductogram was performed on 20 women, with filling defects seen in 10, ectasia in 3, narrowing in 4, and normal ducts in 3. The DCIS included 17 (40%) specimens with cribriform pattern, 17 (40%) micropapillary, 8 (18%) comedo, and 2 (2%) solid. Twelve microinvasive cancers were found in combination with DCIS. After duct exploration, 37 (86%) patients were found to have extensive or multifocal DCIS to the margin, or both, with 32 (74%) patients requiring mastectomy to achieve free surgical margins. There was residual disease in 27 of 32 (84%) mastectomy specimens after initial biopsy. Breast conservation was possible in only 11 (26%) women. Forty of 43 (93%) are disease-free with a median follow-up of 37 months. Conclusion: Women presenting with pathologic nipple discharge require duct exploration regardless of cytologic or radiologic findings. When discharge is the result of DCIS, extensiveness of disease in relation to central location and intraductal spread may preclude breast conservation in as many as 27 of 43 (63%) cases.     

纤维乳管内视镜在乳头溢液性疾病诊治中的应用

目的 评价纤维乳管内视镜在乳头溢液疾病诊断及介入治疗中的价值.方法 2003年10月-2009年11月3280例乳头溢液患者进行了纤维乳管内视镜检查.对其中1018例乳管镜发现的占位病变患者及2例非占位病变患者进行了手术治疗;其余2260例非占位病变患者进行乳管镜下介入冲洗治疗.结果 血性溢液、单孔溢液、单乳溢液以及病变主要位于总乳管及Ⅰ～Ⅱ级乳管多提示是占位性病变;非血性溢液、多孔溢液、双乳溢液以及病变呈乳管内弥漫性分布多提示是非占位性病变.2260例介入冲洗治疗患者中,总治愈率为59.73％(1350/2260),总有效率为88.72％(2005/2260).结论对血性溢液、单孔溢液、单乳溢液以及病变主要位于总乳管及Ⅰ～Ⅱ级乳管者要考虑到占位性病变可能,利用纤维乳管镜对于非占位病变直接进行局部介入治疗效果明显.     

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目的探讨病人年龄、乳头溢液的性状、乳房肿块等临床因素与乳头溢液性疾病良、恶性的关系。方法对2001年1月至2004年1月收治的265例乳头溢液病例进行回顾性研究。乳腺癌38例,占143%;乳腺良性疾病227例,占857%;采用单因素和多因素分析病人年龄、溢液的性状、乳房肿块等因素与溢液良恶性的关系。结果(1)单因素分析年龄>50岁乳头溢液者患乳腺癌明显高于≤50岁伴乳头溢液者(P<005);血性溢液者患乳腺癌的明显高于其它性状溢液者(P<005);溢液伴乳房肿块者患乳腺癌明显高于不伴乳房肿块者(P<0001)。(2)多因素分析,年龄>50岁、血性溢液、伴有乳房肿块是患乳腺癌的高危因素(z值>6,P<005)。(3)对不伴乳房肿块乳头溢液多因素分析显示年龄>50岁、血性溢液是乳腺癌高危因素(z值>6,P<005)。结论病人年龄和乳头溢液性状对鉴别溢液良、恶性质具有重要临床意义。     

乳管造影在诊断乳头溢液中的价值

目的评价乳管造影的应用价值.方法分析1998年1月至2000年5月间入院的51例乳头溢液患者的乳管造影结果和病理学检查结果.结果乳管造影对乳头溢液有较高的诊断价值,敏感性为84.3%.结论乳管造影可对病变作出定位和定性诊断,特别有利于诊断多发病变和乳腺边缘病变,但不能代替病理学检查.     

Lessons learned from 416 cases of nipple discharge of the breast

Background

For patients with nipple discharge (ND), surgical duct excision is often required to exclude underlying malignancy. Our objective was to define clinical predictors of malignancy and examine the utility of common preoperative studies.

Study design

We retrospectively identified 475 patients presenting with a chief complaint of ND from 1995 to 2005; 416 (88%) were eligible for review.

Results

Following standard evaluation (clinical breast examiation/mammogram/ultrasound), 129 of 416 (31%) were considered to have physiological ND and were managed expectantly, whereas 287 of 416 (69%) underwent further evaluation (cytology/ductography/magnetic resonance imaging) followed by biopsy ± surgery. Clinical features associated with pathological ND included bloody ND (adjusted odds ratio 3.7) and spontaneous ND (adjusted OR 3.2). Biopsy/surgery identified a causative lesion in 259 of 287 (90%), of which 37% were either malignant (n = 65) or high-risk (n = 30) lesions. The sole clinical predictor of malignant/high-risk lesion was a palpable mass (adjusted odds ratio 4.3). Preoperative evaluation identified 76 of 95 (80%) malignant/high-risk lesions, whereas 19 of 95 (20%) were identified by duct excision alone.

Conclusions

Although clinical stratification alone reliably identified patients with pathological ND, neither the clinical characteristics nor preoperative studies can reliably distinguish between benign and malignant pathology. Surgical duct excision remains the gold standard to exclude underlying malignancy.     

乳管内视镜与选择性乳管造影对乳头溢液诊断价值的比较

目的：比较乳管内视镜检查和选择性乳管造影对乳头溢液的诊断价值。方法：对1997年到1999年115例行乳管镜检查及48例行乳管造影的病例进行临床对照研究。结果：乳管内视镜对乳管内隆起性病变的诊断敏感性、特异性、阳性预测值及阴性预测值分别为95．6％，80．0％，97．7％，66．7％；乳管造影对乳管肿瘤的诊断敏感性、特异性、阳性预测值及阴性预测值分别为82．6％，56．0％，63．3％，77．8％，乳管内视镜和乳管造影对乳管内隆起性病变诊断的准确性分别为92．5％和54．1％。结论：乳管内视镜对乳头溢液的病因诊断明显优于选择性乳管造影，可以取代乳管造影。     

89例乳头溢液的外科治疗

目的探讨89例乳头溢液患者的外科治疗效果。方法对我院于2004年1月至2009年9月收治89例乳头溢液患者,分别采用乳腺区段切除,单纯乳房切除或者改良根治术进行回顾性分析。结果术后病理类型：乳腺导管内乳头状瘤57例,乳腺增生21例,导管扩张5例．导管癌4例,浸润性导管癌2例。结论乳头溢液最常见的原因是乳管内乳头状瘤,其次是乳腺增生。乳腺导管扩张及导管癌。乳头溢液以手术治疗为主,术式应根据病理决定。行术中冰冻切片病理活检可以确定病理类型。     

乳管内窥镜在合并甲状腺功能低下或垂体瘤的双侧乳头溢液中的应用

目的 探讨合并甲状腺功能低下或垂体瘤的双侧乳头溢液与乳腺导管内病变的关系.方法 对222例临床确诊的甲状腺功能低下(94例)和垂体瘤(128例)患者行乳管镜检查.结果 222例患者中有64例乳管镜诊断为乳腺导管内乳头状瘤,158例诊断为导管扩张炎症.64例均行手术治疗,术后病理证实59例为导管内乳头状瘤,5例为导管扩张性炎症,病理符合率为92.18%(59/64),未见乳腺癌.合并甲状腺功能低下或垂体瘤的双侧乳头溢液患者各民族之间分布差异无统计学意义(P>0.05);绝经前的合并垂体瘤的患者发生导管病变的概率高于甲状腺功能低下患者,而绝经后甲状腺功能低下患者发生导管病变的概率高于垂体瘤患者(P<0.05);合并垂体瘤的乳头溢液多为乳汁样,而合并甲状腺功能低下的乳头溢液多为清水样.本组乳管内乳头状瘤约71.19%发生在主导管以下的分支导管.结论 合并甲状腺功能低下或垂体瘤的双侧乳头溢液患者要考虑到发生导管内病变的可能.乳管镜是较为适宜的检查方法.     

乳管镜诊断乳头溢液性疾病的后续治疗

目的探讨乳头溢液性疾病乳管镜诊断后的治疗措施。方法采用乳管镜对51例乳头溢液的病变导管进行观察、评估，并根据乳管镜下的不同表现特征实施治疗。乳头溢液性疾病的乳管镜下病变表现特征可分为隆起性病变和非隆起性病变，隆起性病变又分为结节状隆起和不规则隆起。本组结节状隆起29例，采取病灶局部切除23例，单纯乳腺切除6例；不规则隆起1例，病灶切除活检证实为乳腺癌后按恶性肿瘤的原则治疗；非隆起性病变21例，行乳管镜下冲洗治疗18例，3例有血性病变导管及其所属小叶切除术后石蜡切片病理诊断乳腺癌后按恶性肿瘤治疗。结果51例随访6～21个月，平均14个月，B超及胸片未见复发转移。结论乳管镜下的病变表现特征是乳头溢液性疾病制定治疗措施的重要依据。     

新疆3154例乳腺乳头溢液与导管内病变关系的临床分析

目的 探讨新疆地区汉族、维吾尔族、哈萨克族及其他民族的妇女乳腺乳头溢液与乳腺导管内病变的关系.方法 收集2004-2010年3154例经病理组织证实,纤维乳管镜检查、手术治疗的导管内病变患者临床资料并进行统计分析.结果 3154例导管内病变包括导管内上皮普通型增生(usual ductal hyperplasia,UDH) 335例(10.62％),导管上皮非典型增生(atypical ductal hyperplasia,ADH)312例(9.89％),导管原位癌(ductal carcinoma in situ,DCIS)57例(1.81％)、导管内乳头状瘤(intraductal papilloma,IDP) 2223例(70.48％)、浸润性导管癌(infiltrating ductal carcinoma,IDC) 227例(7.20％).发病年龄在30 ～50岁占71.99％,各民族之间差异无统计学意义(P＞0.05).导管内病变ADH汉族多见(11.42％),UDH维吾尔族多见(19.73％),IDC哈萨克族多见(15.74％)(均P ＜0.05);IDP和DCIS的发病率在各民族之间差异无统计学意义(P＞0.05);溢液性质与导管内病变关系比较结果:UDH、ADH、DCIS及IDP以浆液性溢液为主,分别为64.78％(217/335),59.94％(187/312),45.61％ (26/57),46.92％ (1043/2223),血性溢液主要见于IDC、DCIS,分别为84.14％(191/227)、42.11％(24/57)(均P＜0.05).结论 乳头溢液可能是导管内病变的早期表现,不同民族导管内不同病变构成比有差异.     

乳管镜在乳头溢液疾病中的临床应用

目的探讨纤维乳管镜在乳头溢液疾病中诊断和治疗的应用价值。方法对2006年3月至2007年3月在我院行纤维乳管镜检查及冲洗的27例患者的临床资料进行回顾性分析。结果27例患者中,乳管镜诊断为乳管内乳头状瘤12例（其中1例为导管原位癌）,乳头状瘤病5例,乳管扩张及乳管炎共8例,未见明显异常2例。乳管内乳头状瘤和乳头状瘤病的镜下诊断与病理诊断符合率分别为91．7％（11／12）和80．0％（4／5）。结论纤维乳管镜可在直视下对乳头溢液疾病进行检查和冲洗,诊断准确率较高,是临床上对乳头溢液疾病进行诊断和治疗的可靠方法。     

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目的 总结单纯性乳头溢液的诊断和治疗经验。方法 回顾性分析了对３２例单纯性乳头溢液病人行双功能超声、相靶摄片、乳管造影的检查结果。结果 双功能超声和乳管造影对本病均有较高的诊断价值，敏感性分别为６６．７％和６８．４％（Ｐ〉０．０５）。相靶摄片对诊断无帮助。病变乳管内置管灵兰注射有助于病灶的探查和切除。结论 影像学检查只可做出病灶的定位诊断，术中冰冻切片才是定性诊断的唯一方法。病变区乳腺的区段切除应