Is a one-step operation for breast cancer patients presenting nipple discharge without palpable mass feasible?

Although spontaneous nipple discharge without mass is a common complaint, only about 5-15% of patients with nipple discharge have cancer. The standard preoperative evaluations, including mammography, physical examination, ultrasonography and squeezing cytology, do not provide enough definite data to make a decision for surgery. We have investigated whether preoperative intraductal aspiration cytology and galactography supply sufficient information about the location and nature of the lesion, and have carried out a one-step operative procedure by adding frozen section diagnosis during surgery. A retrospective review of Kaohsiung Medical University Hospital patients presenting symptoms of nonpalpable mass was conducted from January 1989 to June 2000. The medical charts, pathology and cytology reports, and imaging studies were reviewed. Of 487 patients with spontaneous nipple discharge, 190 with pathologic discharge had complete preoperative galactography and intraductal aspiration cytology, and 176 received surgery. Fourteen cases with negative cytology and normal galactography, who had not had an operation, did not develop cancer during an average 7 years follow-up. The diagnostic accuracy rates of 35 cancer patients using galactography and cytology were 91.4% and 88.6%, respectively, and 97.1% in combination, which is better than those of 141 patients with benign lesions (77.3% and 84.4%, and 90.0% in combination, P<0.05). The results show a 91.5% preoperative diagnostic accuracy rate in all patients with nipple discharge, and can be used to discuss the diagnosis with the patient during the preoperative period. All 35 cases with cancer received the one-step procedure under general anesthesia. Sixteen patients received mastectomies, and the other 19 cases had ductolobular resections, depending on their preoperative evaluations and frozen section in pathology. There were no false positives or false negatives in frozen section when comparing permanent histology and residual cancer in mastectomy specimens. There were no symptoms of recurrence in any of the patients who had undergone the two different procedures during 7 years of follow-up. In patients with spontaneous nipple discharge without palpable mass, the preoperative intraductal cytology and galactography were reliable methods to evaluate intraductal lesions. The one-step procedure will be selected for those patients if the frozen section is added. The ductolobular resection with an adequate surgical margin should be the first choice for those nonpalpable breast cancers with nipple discharge. Due to the limited number of breast cancer cases studied, more cases and a long follow-up period are necessary in future.     

The Role of Breast Ductoscopy in Evaluation of Nipple Discharge: A Chinese Experience of 419 Patients

The aim of this study is to report our experience with ductoscopic evaluation for screening patients with nipple discharge and evaluate any potential indications and benefits of ductoscopy. From January 2010 to December 2012, 419 female patients with nipple discharge were enrolled in this study. All patients involved in this study showed no mass in ultrasound and mammography. Data concerning age, clinical characteristics of nipple discharge, nipple discharge cytology, ductoscopic and postsurgical diagnosis, and complications were statistically analyzed. Ductoscopy examinations were completed in 405 patients (96.66%). For these 405 patients, there were 519 ductoscopic investigations. 112 (27.65%) patients were found to have intraductal papillary lesions of which 62 were operated in our hospital. Postsurgical diagnosis showed 8 (12.9%) malignancy including 6 DCIS and 2 invasive ductal carcinomas. All of the 8 patients meet at least two criteria of pathologic nipple discharge (single duct, spontaneous, bloody nipple discharge). The other patients with nonpapillary lesions are still under surveillance. By univariate analysis, patients with unilateral, single duct, spontaneous and bloody nipple discharge were more likely to have intraductal papillary lesions. By multivariate analysis, unilateral, spontaneous, and bloody nipple discharge showed statistically significant correlations with intraductal papillary lesions revealed by ductoscopy. Ductoscopy is a safe and efficient investigation in preoperative screening of the patients with nipple discharge. Clinical characteristics have predictive value in selection of patients for ductoscopical investigation. Patients with clinical characteristics of unilateral, spontaneous, and bloody nipple discharge were more likely to have intraductal papillary lesions revealed by ductoscopy.     

溢液乳腺疾病乳腺导管造影表现与病理(附105例分析)

目的分析溢液乳腺疾病的乳腺导管造影表现,并分析其病理基础,以提高诊断水平。方法对临床表现为乳头溢液并经手术、病理证实的溢液乳腺疾病105例,包括乳腺癌12例、导管内乳头状瘤38例、乳腺导管扩张症43例及12例乳腺囊性增生病,回顾性分析其乳腺导管造影的影像表现及病理特征。结果本组乳腺导管造影正确诊断乳腺癌11例,导管内乳头状瘤35例,乳腺导管扩张症41例,乳腺囊性增生病12例。乳腺癌主要造影表现：导管内充盈缺损,管壁浸润;＂潭湖征＂;导管结构紊乱;管壁不规则伴微钙化灶;乳头状瘤病伴导管壁毛糙破坏,提示恶变。单发导管内乳头状瘤造影表现为大导管内边缘光滑的充盈缺损,导管边缘光整;多发者表现为小分支导管内多发边缘光滑之充盈缺损。乳腺导管扩张症造影表现：大、中、小导管同时不同程度地扩张,或伴有管壁毛糙,分支导管萎缩变形等炎症表现。乳腺囊性增生病中囊肿表现为小导管高度扩张形成囊袋状改变,盲管腺病表现为小导管或末梢导管呈多发小囊袋状改变。结论乳腺导管造影对溢液性乳腺疾病是一项安全而有效的检查方法,对乳腺导管内占位性病变的定性、定位诊断具有高度价值,对导管扩张症、乳腺囊性增生病等疾病亦能作出较准确的诊断。     

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。     

Chromogalactography preceding ductal-lobular unit excision for nipple discharge--with special reference to diagnostic galactography and histology

Between 1981-88, 223 surgical interventions were performed in cases of pathologic breast secretion after exclusion of extra-mammary aetiology. The milk duct was identified by pre-operative chromogalactography, followed by a selective excision of the ductal-lobular unit. In 36 cases (16.1%), however, neither spontaneous nor provocable secretion remained after diagnostic galactography, so that a segment resection was required. In all tissue specimens, the cause of the pathologic secretion was found histologically; most often, it was fibrocystic disease or solitary intraductal papilloma (21.5% each). In 32.3% of the specimens, findings with a prospective significance (papillomatosis, carcinoma in situ or invasive carcinoma) were discovered and further operative treatment was initiated. The colour of the discharge allowed no prediction of the histological findings. In 28.6% (8/28) of the carcinomas, secretion was bilateral. In 46.4% of the specimens containing carcinoma, papillomatosis was also detected; vice versa, papillomatosis was associated with carcinoma in 22.8%. The recurrence rate of 1.6% indicates the efficiency of this method in removing the pathology. The diagnostic value of galactography for the prediction of findings with a prospective significance was considerably reduced by a rate of 37.5% false-negatives; therefore, we have decided to omit diagnostic galactography in our patients. Now, provided extra-mammary causes of the nipple discharge have been excluded and mammography has been inconspicuous, a selective excision of the ductal-lobular unit is performed after preoperative chromogalactography.     

Pathologic Nipple Discharge: Surgery Is Imperative in Postmenopausal Women

Background A total of 10% to 15% of pathologic nipple discharge in women is due to malignant lesions of the breast. The purpose of this study was to discover the rate of breast cancer in women who present with this symptom and undergo ductal excision, to evaluate the different diagnostic methods used before surgery, and to discover whether there are specific factors with regard to dignity.Methods We analyzed 118 ductal excisions in 116 patients performed at the women’s hospital of the University of Rostock, Germany, between 1995 and 2002. The discharging duct was identified by preoperative galactography.Results The rate of cancer in these patients was 9.3% (n = 11). The most frequent benign lesion was intraductal papillomatous proliferation (36.4%; n = 43). Solitary papillomas were shown in 21.2% (n = 25), and other specific benign histologic findings were shown in 27.1% (n = 32). Women with malignancies were significantly older (P = .009) and were more often postmenopausal (P = .095) compared with patients with benign histology. Galactography was the method that reached the highest sensitivity (73%), and clinical examination showed the highest specificity (85%) in distinguishing between benign and malignant lesions.Conclusions Because 94.1% of all cases presented with specific histological findings causing pathologic nipple discharge, ductal excision combined with preoperative galactography was proven to be a sufficient method for diagnosis and therapy. This procedure should be performed in all postmenopausal women with this symptom because of a cancer rate of 12.7% among this age group and the unsatisfactory quality of other diagnostic methods.     

Gradient index ductoscopy and intraductal biopsy of intraductal breast lesions

OBJECTIVE: Breast duct endoscopy is increasingly used for evaluation of intraductal disease. We have investigated a new rigid instrument for ductoscopy and intraductal biopsy of pathologic lesions. METHODS: From 2002 to 2006, ductoscopy was performed in 111 women with breast cancer or pathologic nipple discharge. A rigid gradient index microendoscope (diameter .7 mm) was used for all examinations in combination with a specially developed needle for intraductal vacuum-assisted biopsy. Ductoscopy and intraductal biopsy were correlated with ductal cytology and histopathology of the resection specimen. RESULTS: Ductoscopy identified intraductal lesions in 41% of the patients with breast cancer presenting as red patches, microcalcifications, or ductal obstruction. Compared with patients with a normal ductoscopy, patients with pathologic ductoscopy had a significantly higher risk of extensive intraductal carcinoma (71% versus 16%, P < .05). Ductal cytology showed only a few cases with severe cytologic atypia or malignant cells in cases with ductoscopic abnormalities. Intraductal vacuum-assisted biopsy yielded diagnostic material in 89% of 36 patients with nipple discharge and papillomatous lesions. Histology of the resection specimen confirmed the diagnosis in all cases (26 papillomas, 2 in situ carcinomas, and 2 invasive ductal carcinomas). In contrast, ductal cytology showed only moderate correlation with histopathology. CONCLUSIONS: Ductoscopy is a useful supplement for the standard radiological workup of breast cancer especially in patients with extensive intraductal carcinoma. Ductoscopic vacuum-assisted biopsy is a new and effective technique for intraductal biopsy under visual control.     

Fiberoptic ductoscopy for breast cancer patients with nipple discharge

Background: Breast cancer and precancer are thought to originate in the lining 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-needle aspiration. Fiberoptic ductoscopy (FDS) is an emerging technique that allows 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 ductoscopy in patients with and without nipple discharge is a safe and effective 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 intraductal carcinoma (DCIS) as the basis of their discharge. Results: In this cohort of patients, ductoscopy was successful in visualizing an intraductal lesion in 166 patients (40%). In these cases, ductal lavage 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 appearance of typical papillomas. However, in 10 patients, the intraductal lesion exhibited one of several atypical features, including bleeding, circumferential obstruction, and gross fungating projections. In eight of these patients, the subsequent histopathology turned out to be DCIS. In two of these eight patients, endoscopic biopsy revealed cytologically malignant cells; 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 extirpated 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 physical exam. Conclusion: Although nipple discharge is an unusual presentation for DCIS, in patients with nipple discharge, FDS with ductal lavage cytology is a useful technique for diagnosing DCIS prior to definitive surgery.     

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.     

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.     

乳管内窥镜对乳腺导管内病变的诊断和治疗价值

目的评价乳管内窥镜(FDS)对乳腺导管内疾病的诊断和治疗价值。方法回顾性分析近2年来FDS检查的548例乳头溢液患者的临床资料。结果548例乳头溢液病例中,FDS下诊断为乳管炎59例(10.8%),乳腺导管扩张症117例(21.4%),乳腺导管扩张合并乳管炎185例(33.4%),乳管内乳头状瘤159例(29.0%),乳管内乳头状瘤病12例(2.2%),乳腺癌16例(2.9%)。135例在我院接受手术治疗,其中91例在FDS定位下行肿瘤切除或区段切除手术(甲组),44例按常规经溢液乳管内注射染料美蓝后再行选择性区段切除(乙组)。甲组术后FDS诊断符合率97.8%(89/91)明显高于乙组的86.4%(38/44)(χ2=6.96,P=0.008)。结论FDS不仅是诊断乳腺导管内病变的可靠方法,而且可以帮助手术中定位切除乳腺导管内新生物。FDS定位下手术能够避免盲目性,为病灶的切除提供可靠的帮助。     

乳管内乳头状病变的临床分析：附1?211例报告

目的：探讨乳管内乳头状病变的临床病理特征及诊断方法。 方法：采用回顾性方法,对1?211例不同类型乳管内乳头状病变的年龄分布、乳头溢液与乳房肿块情况、病理及影像学检查结果进行分析。 结果：1?211例患者中,乳头状瘤874例,乳头状瘤病231例,乳头状癌106例;恶性病变患者平均年龄大于良性病变患者（P<0.01）,31~50岁为乳头状瘤及乳头状瘤病的高发年龄;16.0%患者有乳腺疾病手术史,乳头状瘤病患者中先后多次手术及同时双侧手术者明显多于乳头状瘤与乳头状癌患者（P<0.05）;67.8%患者有不同性质的乳头溢液,乳头状癌患者中溢液病例少于良性病变患者,但血性溢液明显多于良性病变患者（P<0.05）;约80%的良性病变术中可见肿块,恶性者术中均可见肿块,乳头状瘤病患者中伴有中-重不典型增生者明显多于乳头状瘤（P<0.05）,肿块>1.0 cm时常伴有中-重不典型增生,乳头状癌患者肿块平均最大径（1.93±0.78）cm;导管造影及导管镜检查对良性病变诊断的准确率高于彩色B超和钼靶（P<0.05）。 结论：不同类型乳管内乳头状病变有一些共同表现,也有各自特征,掌握这些特征有利于临床正确诊断及合理的治疗。     

The Role of Galactography in Patients with Postoperative Nipple Discharge

Abstract: Spontaneous nipple discharge presenting temporally after breast surgery may be due to ductal communication with the biopsy site or to a second abnormality in the breast. Galactography is useful in excluding an intraductal lesion and documenting a communication between the discharging duct and the biopsy site, in cases where the discharge persists for more than a few weeks after surgery. In this clinical setting, galactography averted a second surgical procedure.     

Nipple discharge from the breast

Abnormal nipple discharge is rare, constituting only 3-5% of mammary consultation. In the present paper 267 patients with primary nipple discharge operated on at Institut Gustave-Roussay (IGR) in Villejuif, France, between January 1, 1960 and December, 1974 were evaluated. In all cases, the nipple discharge was symptomatic, spontaneous, and represented the primary reason for the patient's consultation. During the same period 1,145 cases of nipple discharge were treated at IGR. Of the 1,145 cases with symptomatic nipple discharge, 267 patients (23%) required surgical intervention. Among these, fibrocystic disease and duct ectasia were the leading causes of nipple discharge occurring in 42% of surgical specimens. Twenty one per cent of the patients had carcinoma and 35% were found to have intraductal papilloma. The overall incidence of malignancy, however, was 4.8% among the 1,145 women with nipple discharge. On the average, patients with nipple discharge due to malignancy were ten years older than those with benign lesions (Table 2). Approximately 25% of patients with malignant discharge and 5% with benign discharge have associated tumor. Over 60% of the patients with both discharge and a mass had malignancy.     

Management of nipple discharge

In a series of 8,703 breast operations, nipple discharge was the presenting symptom in 7.4% of cases. It is even more common in the office and clinic since many discharges can be treated medically. To be significant, a discharge should be true, spontaneous, persistent, and nonlactational. Of the 7 basic types, i.e., milky, multicolored and sticky, purulent, clear (watery), yellow (serous), pink (serosanguineous), and bloody (sanguineous), the last 4 are the surgically significant ones. Of the 586 patients operated on for one of these types of discharge, the majority had a benign etiology, i.e., intraductal papillomata (48.1%) and fibrocystie changes (32.9%), but 14.3% were due to cancer and another 7.3% to precancerous mastopathy. In the 84 patients with cancers, the false-negative rate for mammography was 9.5% and was 17.8% for cytology. There was no palpable mass in 13.1% of patients. There was an increasing likelihood of the discharge being due to cancer when the discharge was, in order of increasing frequency, yellow, pink, bloody, or watery, when it was accompanied by a lump, when it was unilateral and from a single duct, when the mammogram or galactogram and the cytology were positive, and when the patient was over 50 years of age.Milky discharges are usually treated medically unless they are due to a pituitary adenoma. If the cause cannot be found and eradicated, bromocriptine is the drug of choice. Multicolored sticky discharges are also treated medically, chiefly by nipple hygiene, except when advanced. Purulent discharges are treated with appropriate antibiotics but abscesses need drainage and a biopsy of the wall. Except in women under 35 years of age or in those anxious to have children, surgically significant discharges are treated by central duct excision. Good cosmetic results can be obtained with careful technique and the danger of a recurrent discharge is eliminated.     

纤维乳腺导管内镜辅助诊治乳头溢液632例报告

目的探讨纤维乳腺导管内镜对Tis期乳腺癌的临床诊断价值。方法 2001年5月～2010年5月,对632例乳头溢液进行乳腺导管内镜检查702次,并对其中310例隆起性病变行乳腺导管内镜辅助定位手术。结果 475例诊断为隆起性病变,包括乳管内乳头状瘤388例（61.4%）,乳管内乳头状瘤病79例（12.5%）,导管内癌8例（1.3%）;157例为非隆起性病变,包括导管扩张症82例（13.0%）,慢性乳管炎73例（11.6%）和导管内癌2例（0.3%）。310例行乳腺导管内镜辅助定位手术,内镜诊断对导管内癌的阳性预测值为83.3%（10/12）。结论 纤维乳腺导管内镜检查弥补了伴有乳头溢液的Tis期乳腺癌诊断的空白,对乳腺癌的早期诊断有积极的意义。     

Office-based breast ductoscopy for diagnosis

OBJECTIVE: Ductoscopy is an evolving technology that has been used primarily and historically in conjunction with open surgical procedures. New technical improvements allow intraductal biopsy and therefore its application in the clinical setting for diagnostic evaluations of the breast. This study looks at the initial use of intraductal biopsy in a variety of settings from an academic university practice to a private single-surgeon office. METHODS: This is a multicenter retrospective series of 88 patients undergoing ductoscopy of > or =1 duct for the diagnostic workup of common breast problems. The procedures were done with the patient under local anesthesia, and intraductal biopsy specimens were taken and analyzed as breast cytology samples. RESULTS: Of the 88 patients undergoing office ductoscopy, nipple discharge was the most common indication (n = 83 patients; 94% to 66% spontaneous and 34% elicited). Fifty-five percent were high risk for breast cancer by history. The majority of patients had normal previous mammograms: 48 Breast Imaging-Reporting and Data System (BIRADS) 1, 24 BIRADS 2, and 7 BIRADS 3 to 5. The most common finding was papilloma present in 29 (32%) patients by endoscopy. Only 31% of patients had a history of brown or bloody nipple discharge. A wide variety of other endoscopic abnormalities were seen and biopsied. The average number of biopsies per patient was 2 with 18 (20.5%) having severe or malignant atypia. Further follow-up and management of these more concerning abnormalities is currently ongoing. CONCLUSIONS: These results indicate that office ductoscopy with biopsy is both feasible and does identify suspicious or malignant atypia in patients with expressed or spontaneous nipple fluid.     

The role and limitations of mammary ductoscope in management of pathologic nipple discharge

Mammary ductoscope allows visualization of the breast ductal wall and sampling of the abnormal area for diagnostic purposes. We are reporting our center experience in application of mammary ductoscope in detecting the underlying etiology of pathologic nipple discharge. Between November 2005 and December 2006 a total of 54 women, with spontaneous persistent nonlactational unilateral uniductal nipple discharge of no palpable lesions and negative breast sono-mammography, were included in the study for morphologic assessment of ductal epithelium, ductal lavage and ductoscopically guided procedures as punch biopsy and ductoscopically guided microdochectomy. Forty-one patients (76%) with nipple discharge were positive ductoscopically. Thirteen patients (24%) appeared normal. Ductoscopic lavage has a much more cellular yield than ordinary squeezing cytology. Ductal thickening by the ductoscope (11 cases) revealed to be hyperplasia on pathology (five cases), papilloma (two cases), atypical ductal hyperplasia (two cases), ductal carcinoma in situ (one case), and invasive breast carcinoma (one case). There was a significant association between intraductal visual observations and histopathologic diagnosis. Mammary Ductoscope is a promising tool in management of pathologic nipple discharge. Biopsy and ablation techniques can be performed during ductoscopy with correlation between visual findings and histopathology, but there are still some limitations of in clinical practice.     

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。     

Nipple discharge: personal experience with 2,818 cases

After mastodynia, nipple discharge is the second most frequent condition that brings women to the attention of breast clinics. Seven types of nipple discharge exist: milky, multicolored, purulent, clear-watery, serous, pink or serosanguineous, brown or reddish-brown. From January 1982 to January 2003 we observed 2818 patients with nipple discharge (range: 16-83 years). Amongst these, 805 patients with nipple discharge were submitted to cytological examination of the secretions. One hundred and seventy-six had bilateral discharge, and 629 unilateral discharge. All patients with positive C3, C4 or C5 cytology and with unilateral discharge (227) were referred for surgical treatment. In 92 of these 227 cases (41%) the secretion was serous, in 59 cases (26%) bloody, in 45 cases (20%) purulent and in 31 cases (13%) multicolored. We performed duct galactophorectomy in 89 cases (39%), resection with reconstruction of the nipple-areola complex in 48 cases (21%), microdochectomy in 42 cases (18.5%), segmentectomy or quadrantectomy in 41 cases (18%), and mastectomy in 6 cases (3%); we also removed a papilloma from the ductal orifice in 1 case (0.44%). Histological specimens showed papilloma in 98 cases (43%), breast cancer in 39 cases (17%), galactophoritis in 36 cases (16%), fibrocystic disease in 46 cases (20%), including 31 (14%) with florid adenosis, and papillomatosis in 8 cases (4%). An increased probability of cancer is therefore associated with serous, bloody, reddish brown and watery secretions. This is particularly true when the secretion is unilateral and originates from a single duct, when there are cytological alterations, whether mammographic or galactographic, and when the patient is aged over 50 years.