Abstract P5-14-09: Ductoscopy and MRI in Patients with Nipple Discharge

Background: Early pre malignant and malignant change originate in mammary ductal epithelium and ductoscopy is reported to be a valuable tool in assessing the ductal tree. Breast MRI is the most sensitive imaging modality for the breast and recent reports indicate that it may be of benefit in the evaluation of patients with nipple discharge. We have combined both these modalities in an ongoing study to determine their utility in the management of patients with nipple discharge. Patients and methods: Between July 2004 and December 2009, 56 women underwent surgery for symptomatic nipple discharge. All were evaluated preoperatively by mammography and breast sonography. A contrast enhanced breast MRI was requested in all patients and the findings discussed with the radiologist. At surgery, a mammary ductoscopy was performed as the preliminary step prior to excision. The ductoscopy findings along with the pre operative MRI assessment were used to direct surgical excision. All specimens were oriented and and carefully evaluated by the pathologist by sectioning at 1 cm interval, from the ductal end to the periphery. Results: Ductoscopy was attempted in 56 patients, successful in 51 patients (91 %) but failed in 5 patients (9%). Ductoscopy displayed a normal ductaltree in 5 patients (8%) and all these patients had normal MRI and benign histological findings. Ductoscopy detected an intra ductal abnormality in 46 patients (82%) viz. intra ductal growth (n=39, 70%), intra ductal bleeding with normal appearing wall (n=3, 5%), and abnormal ductal wall without an intra ductal lesion (n=4, 7%). The overall incidence of malignancy in this series (n=56) was 30%. Of the 39 patients with an intra ductal lesion identified on ductoscopy malignant change was noted in 23%, ADH in 20%, and papilloma in 75% (solitary in 49%; multiple in 26%). Identification of intraductal bleeding with normal duct wall appearance (n=3), and abnormal or irregular appearing ductal walls but without an intra ductal lesion (n=4) correlated with the presence of malignant change within the ductal tree. MRI was requested in all 56 patients but could be performed in 47 patients. It was suggestive of benign change in 28 patients (60%) of which 9 (20%) were malignant on pathology. MRI reported suspicious change in 19 patients (40%). Of these 4 patients (8%) were confirmed to have malignant change while 15 patients (32%) had benign lesions on pathological assessment. In the “ductosocpy failure” group of patients (n=5) MRI appearance was used to guide surgical excision. MRI was deemed suspicious in 4 of these patients while pathology confirmed malignant change in 2. Conclusions: Ductoscopy and MRI together provide a comprehensive “internal and external” assessment of the breast ductal tree. They are complimentary in guiding surgery in patients with nipple discharge. While ductoscopy and MRI help detect early lesions within the ductal tree, a thorough pathological evaluation is essential to diagnose the presence of pre malignant and malignant change. Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P5-14-09.