Major Duct Excision Research Articles

The role of major duct excision and microdocectomy in the management of nipple discharge: Diagnostic and therapeutic approach

Mammary duct ectasia is considered as a benign condition of the mammary gland. Many theories analyses and summarized the disease regarding the pathogenesis. Firstly, the primary pathological process is due to be involutional and atrophy of the ducts. Other cause of dilation of the ducts, leading to the decrease or absent of secretion, inflammation and duct rupture. Secondly, the causative factor is inflammatory process with periductal inflammation followed by obliteration of ducts, sclerosis of duct and surrounding tissue and duct ectasia. Mostly mammary duct ectasia resolves without any treatment. Applying light warm compresses to nipple and wearing a supportive bra, can help to reduce discomfort of the patient. But If there is evidence of an infection, antibiotics will be prescribed without hesitation. It’s completely prohibited to squeeze the area to increase discharge, as there is increase chance to develop inflammation and infection. If symptoms still persisted than surgery may be done to disconnect the ducts and remove the ducts, Known as Hadfield’s operation. Recently sub-areolar major mammary duct excision – Hadfield’s procedure is very popular and has gained widespread acceptance in management of nipple-areola complex problems like suspicious or troublesome discharge, clinical or sono-mammographic central anomalies and chronic sinus-fistula. Here two cases with nipple discharge managed with two very common surgery with microdocectomy and total duct excision held in Z.H Sikder Women’s Medical College Hospital. Patients were very satisfied with the treatment as they got relief of symptoms and most importantly get rid of the fear of carcinoma.

Patient-reported outcomes of ductoscopy procedures for pathologic nipple discharge

BackgroundPathologic nipple discharge (PND) is a common complaint often associated with breast cancer. However, when ultrasound and mammography are negative, the chances of malignancy are lower than 5%. Currently, major duct excision and microdochectomy are often recommended to alleviate symptoms and definitely rule out malignancy, but can cause infections and breastfeeding problems. Ductoscopy is a minimally invasive endoscopy technique that allows visualization of the mammary ducts and may not only obviate surgery but also detect malignancy. The aim of this study was to determine quality of life (QOL) after ductoscopy in patients with PND.Materials and methodsAll PND patients referred for ductoscopy between 2014 and 2015 to our hospital were included. Ductoscopy procedures were performed under local anaesthesia in the outpatient clinic. Patients were asked to fill out questionnaires (Breast-Q, EQ-5D-5L and SF-36) on the day of ductoscopy, and after 2 weeks, 3 and 6 months. Additionally, we performed reliability analysis to determine if these questionnaires were suitable for PND patients.ResultsFifty consecutive patients underwent ductoscopy of whom 47 patients participated in this study. One domain of SF-36 (vitality) varied significantly over time. Breast-Q, SF-36 and EQ-5D-5L showed that QOL after ductoscopy for PND was unaffected by ductoscopy. Success of the ductoscopy procedure was a significant predictor for satisfaction with the result domain.ConclusionDuctoscopy is a minimally invasive technique that does not seem to impact QoL of PND patients over time. Breast-Q, SF-36 and EQ-5D-5L seem to be suitable existing QOL tests for PND patients undergoing ductoscopy, whereas SF-36 would require modifications.

Management Strategies of Nipple Discharge

Abstract Background: Nipple discharge (ND) is defined as a fluid that flows or is expressed from the mammary ducts. Nipple discharge is classified as benign or pathologic on the basis of its clinical characteristics. Unilateral spontaneous bloody or clear nipple discharge from a single duct may be the first sign of breast carcinoma needing further evaluation. Aim of Study: The aim of this study is to assess manage-ment strategies for patients with nipple discharge (ND). Patients and Methods: This study was carried out on 50 female patients who presented with nipple discharge in the out patient clinics of Shebin El-Kom Teaching Hospital. Lactating females were excluded from the study. Patients were followed up for a minimum of 3 months and a maximum of 18 months on monthly basis. Results: The success rate of conservative management for benign ND was 88%. The discharge immediately stopped in patients managed by microdochectomy but hematoma developed in only one case that got resolved spontaneously. The discharge stopped in all patients managed by major duct excision, Discharge stopped immediately, but recurrence occured in two patients with purulent discharge. They need revision surgery for further debridement. In cases presented with a lump and FNAC showed malignant cells 16% (4 cases) they managed by modified radical mastectomy, the wound disrupted in one case, it occurs at the mammary fold and managed by secondary sutures later on. Conclusion: This study reveals the accuracy of clinical examination, sonomammography & FNAC in evaluating breast lump especially when applied together.

Interventional Ductoscopy as an Alternative for Major Duct Excision or Microdochectomy in Women Suffering Pathologic Nipple Discharge: A Single-center Experience

IntroductionPathologic nipple discharge (PND) is, after palpable lumps and pain, the most common breast-related reason for referral to the breast surgeon and is associated with breast cancer. However, with negative mammography and ultrasound, the chance of PND being caused by malignancy is between 5% and 8%. Nevertheless, most patients with PND still undergo surgery in order to rule out malignancy. Ductoscopy is a minimally invasive endoscopic technique that enables direct intraductal visualization. The aim of this study was to evaluate (interventional) ductoscopy as an alternative to surgery in patients with negative conventional imaging. Materials and MethodsAll patients with PND referred between 2010 and 2017 to our hospital for ductoscopy were retrospectively analyzed. Ductoscopy procedures were performed under local anesthesia in the outpatient clinic. The follow-up period was at least 3 months, and the primary outcome was the number of prevented surgical procedures. Furthermore, we evaluated possible complications after ductoscopy (infection and pain). ResultsA total of 215 consecutive patients undergoing ductoscopy were analyzed. In 151 (70.2%) patients, ductoscopy was successful. In 102 procedures, an underlying cause for PND was visualized, of which 34 patients could be histologically proven and 82 patients treated. Sixty of the 215 patients were eventually operated, 8 owing to suspicious findings during ductoscopy, 42 owing to persistent PND, and 10 because of recurrent PND. In 7 patients, a malignancy was found (5 of them classified as suspicious at dusctoscopy). No serious side effects were seen. ConclusionDuctoscopy can be safely used as an alternative for surgery in the workup for PND.

INTEND II randomized clinical trial of intraoperative duct endoscopy in pathological nipple discharge.

The majority of lesions resulting in pathological nipple discharge are benign. Conventional surgery is undirected and targeting the causative lesion by duct endoscopy may enable more accurate surgery with fewer complications. Patients requiring microdochectomy and/or major duct excision were randomized to duct endoscopy or no duct endoscopy before surgery. Primary endpoints were successful visualization of the pathological lesion in patients randomized to duct endoscopy, and a comparison of the causative pathology between the two groups. The secondary endpoint was to compare the specimen size between groups. A total of 68 breasts were studied in 66 patients; there were 31 breasts in the duct endoscopy group and 37 in the no-endoscopy group. Median age was 49 (range 19-81) years. Follow-up was 5·4 (i.q.r. 3·3-8·9) years in the duct endoscopy group and 5·7 (3·1-9·0) years in no-endoscopy group. Duct endoscopy had a sensitivity of 80 (95 per cent c.i. 52 to 96) per cent, specificity of 71 (44 to 90) per cent, positive predictive value of 71 (44 to 90) per cent and negative predictive value of 80 (52 to 96) per cent in identifying any lesion. There was no difference in causative pathology between the groups. Median volume of the surgical resection specimen did not differ between groups. Diagnostic duct endoscopy is useful for identifying causative lesions of nipple discharge. Duct endoscopy did not influence the pathological yield of benign or malignant diagnoses nor surgical resection volumes. Registered as INTEND II in CancerHelp UK clinical trials database (https://www.cancerresearchuk.org/about-cancer/find-a-clinical-trial/a-study-looking-at-changes-inside-the-breast-ducts-of-women-who-have-nipple-discharge).

A modified technique for a common problem after major duct excision

Objective The present study aims to describe and evaluate a modified major duct excision (MDE) technique as regards its role in minimizing postoperative complications. Patients and methods We included female patients who underwent total duct excision due to the following indications: suspicious nipple discharge, periductal mastitis, and nipple retraction with a history of periductal mastitis. The modified MDE was performed under general anesthesia. All the patients were discharged home on the same day of the procedure and they were followed up for 6 months. In the follow-up, the patients were assessed for any complications to the wound, any retraction or necrosis to the nipple, the nipple sensation compared with the other one, or the nearby skin in bilateral cases. Results In this study, a total of 29 operations were performed on the 25 patients. No seroma or hematomas were observed. On follow-up of the patients, two patients suffered from infection of the wound, three cases developed breakdown that healed by daily dressing, one case presented with nipple necrosis most probably occurred as a result of excessive dissection with diathermy, while the remaining 31 patients recovered by primary intention with no recurrent discharge. Loss of nipple sensation occurred in four patients, impaired sensation occurred in six patients, and normal sensation in the rest of the patients was observed at 6 months of follow-up. Conclusion The modified MDE technique is a safe alternative to the classic technique with low rate of postoperative complications.

Comparative analysis of minimally invasive Microductectomy versus Major Duct Excision in the diagnosis and treatment of patients with pathologic nipple discharge

Comparative analysis of minimally invasive Microductectomy versus Major Duct Excision in the diagnosis and treatment of patients with pathologic nipple discharge

Infiltrating Syringomatous Adenoma of the Nipple: A Case Report

We describe a case of a 46-year-old woman who was treated initially for a presumed non-lactational breast abscess. As symptoms did not subside with conservative management a major duct excision was conducted and histology revealed an infiltrating syringomatous adenoma. She underwent further surgery to achieve clear margins and the tumour is the largest reported to date. These are benign, infiltrating lesions and are rare with less than 40 cases reported in the literature. Patients usually present with a retro-areolar mass and adjacent skin and nipple changes. Radiologically they are difficult to differentiate from breast cancer and diagnosis is largely confirmed through histologic and immunohistochemical analysis. Treatment is with local excision to achieve clear margins as recurrence rates are high with residual tumour.

Infra Mammary Approach for Major Duct Excision in the Management of Multiple Duct Ectasia: Our First Steps

Objective: Worldwide, classical Hadfield’s operation is recognized as the main surgical procedure for MDE. However, this operation can suffer from certain complications such as the loss of nipple sensation and in some cases skin necrosis and skin loss may take place. This study is aiming to evaluate this new technique (infra mammary approach) for major duct excision as regard operative time and postoperative outcome with especial concern to postoperative complications. Patients and method: Inframammary major duct excision was performed on forty five non-lactating female patients suffering from nipple discharge that was either unilateral or bilateral. Results: The postoperative hospital stay was one day. Suction drain was removed after 4 to 10 days of surgery (mean time 6 days). No seroma or hematomas were observed after removal of the drain. Stitches were removed after 10 to 12 days of surgery after complete healing of the wound. Nipple vitality and sensation were intact in all patients and no color change was recorded. No recurrent discharge was noticed during follow up visits. 95% of patients were satisfied by the result of surgery. Conclusion: Although this was a pilot study that should have been supported by larger number of cases as well as by a comparative study, we can still show that the inframammary approach is superior to the classical approach for major duct excision since it can achieve duct excision while preserving the sensory nerve supply as well as the blood supply of the nipple and areola complex with the normal projection of the nipple and is therefore associated with a higher patients satisfaction.

Diagnostic Role of the Presence of Red Blood and Epithelial Cells in Nipple Discharge Cytology

Introduction: Management of nipple discharge (ND) is variable reflecting the lack of a uniformly accepted assessment policy. The aim of this study was to determine the common underlying pathology in patients presenting with ND as well as to evaluate the diagnostic role of red blood cells (RBC) and epithelial cells in the nipple cytology (NC). Methodology: Electronic data base held at Leeds Teaching Hospitals NHS Trust was searched to identify all the patients who underwent Hadfield’s (open diagnostic major duct excision) procedure for ND from January 2004 to December 2009. We included only patients with ND as the primary symptom and excluded those with any underlying palpable or radiological abnormality. Results: Hadfield’s procedure was performed in 120 cases (Median age=49 years; range=20-88). The final histology showed benign changes (duct ectasia/hyperplasia and fibrocystic changes) in most (37.5%), followed by intra-ductal papilloma (32.5%), normal (16.6%), malignant (10.9%) and atypical (2.5%) changes in the rest. The presence of RBC in NC was 87% sensitive to detect any underlying pathology and 69% sensitive to predict malignancy at the expense of specificity. However, epithelial cells were found to be neither sensitive nor specific enough to detect underlying pathology or malignancy. Conclusion: The aetiology remains benign in most patients presenting with ND in the absence of any underlying palpable or radiological abnormality. Even in patients without an underlying radiological abnormality, diagnostic surgery should be offered if RBC is present in the nipple cytology.

Pathologic Nipple Discharge in Patients with Radiologically Invisible Mass: Review of 28 Consecutive Sub-areolar Explorations

The carcinoma frequency of clinically and radiologically negative pathologic nipple discharges (PNDs) and the optimum management strategy of these cases are still unclear. In this study, the frequency of cancer and the situation of the classic surgical intervention in patients with PND and invisible mammographic and ultrasonographic results are reviewed. The data pertaining to the cases of sub-areolar exploration and major duct excision in a surgery clinic of university hospital from December 2002 to June 2007 have been examined in detail. In 28 cases with PND, which did not have any findings during conventional radiologic examinations, 21% of cases had malignant, and 7% of cases had atypical ductal hyperplasia. The frequency of invasive or in situ carcinoma is not low in clinically and radiologically negative PNDs. Sub-areolar exploration and major duct excision seems to be an appropriate and definitive diagnostic and therapeutic option in this special patient group.

The Predictive Value of Ductography and Magnetic Resonance Imaging in the Management of Nipple Discharge

Standard evaluation (physical examination, mammography, sonography) often fails to identify an underlying lesion in patients with suspicious nipple discharge. The aim of this study was to determine the predictive value of ductography (DG) and magnetic resonance imaging (MRI) in this setting. Using ICD-9 codes, we retrospectively identified 376 patients who presented with suspicious nipple discharge (ND) (1995-2005); 306 patients (68%) had negative standard evaluation. Among 306 patients, 186 (61%) underwent further evaluation with DG (n = 163) and/or MRI (n = 52), 35 (11%) underwent major duct excision alone (MDE), and 85 (28%) were followed clinically. Ultimately, 182/306 (59%) patients underwent surgery and/or biopsy. Overall incidence of malignant or high-risk pathology was 15% (46/306). DG was completed in 139/163 (85%) studies and detected 12 cancers and seven high-risk lesions (HRL), but failed to identify four cancers and 2 HRL (PPV 19%, NPV 63%). MRI detected seven cancers and three HRL, but failed to identify one cancer and one HRL (PPV 56%, NPV 87%). MDE alone (n = 35) detected five cancers and three HRL. Of all patients not having surgery, (142/306, 41%), one (0.01%) presented with an invasive cancer at 102 months (median follow-up, 6.3 months; range, 0-124 months). An underlying malignancy was identified in 30/306 (10%) patients with ND and negative standard evaluation. Ductography is a poor predictor of underlying pathology and cannot exclude malignancy. MRI's higher predictive values may allow for improved patient selection and treatment planning; however, MRI should not replace MDE as the gold standard to exclude malignancy in patients with ND and negative standard evaluation.

1–36 Comparative Analysis of Minimally Invasive Microductectomy Versus Major Duct Excision in Patients With Pathologic Nipple Discharge

1–36 Comparative Analysis of Minimally Invasive Microductectomy Versus Major Duct Excision in Patients With Pathologic Nipple Discharge

The role of major duct excision and microdochectomy in the detection of breast carcinoma

BackgroundThe association of nipple discharge with breast carcinoma has resulted in numerous women undergoing exploratory surgery to exclude malignancy. The aim of this study was to determine whether pre-operative factors can identify those patients that are most at risk of carcinoma.MethodsAll patients over a 14-year period (1991–2005) who had a microdochectomy or subareolar exploration for the evaluation of nipple discharge were assessed. Patient characteristics, pre-operative imaging and pathological findings were analysed.ResultsOf the 211 patients included in this study, 116 patients had pathological (unilateral, uniductal serous or bloody) discharge. On excision, 6% (n = 7) of patients with pathological discharge and 2.4% (n = 2) of patients with non-pathological discharge were diagnosed with carcinoma. Overall, major duct excision resulted in the diagnosis of carcinoma in 4.3% (n = 9), ADH/LCIS in 4% (n = 8), papilloma in 39% (n = 83), and duct ectasia or non-specific benign disease in 53% (n = 111) of patients. In the patients determined to have malignancy, 44% (n = 4) were premenopausal. No patient with a non-bloody discharge in the total population analysed (28%; n = 59/211), or in the population with a pathological discharge (21%; n = 24/116) was found to have carcinoma upon excision.ConclusionMicrodochectomy or major duct excision performed for nipple discharge resulted in a low rate of malignancy on excision. Conservative management of non-bloody nipple discharge can be considered in patients with no other clinical or radiological signs of malignancy.

Intraoperative intraductal injection of methylene blue dye to assist in major duct excision

Nipple discharge is not uncommon in women during their reproductive years. The etiology is benign in the majority of cases. Patients presenting with nipple discharge often require major duct excision (MDE) for accurate diagnosis and treatment. MDE is enhanced by the use of intraoperative injection of methylene blue dye into the discharging duct in order to aid visualization. Methylene blue dye–enhanced MDE has several advantages over traditional techniques. Methylene blue dye staining identifies the major discharging duct, as well as its side branches, which allows the surgeon to resect that specific ductal system only. This method allows neighboring major ducts to remain intact, preserving nipple function and permitting future cancer detection. Methylene blue–enhanced MDE allows the surgeon to more accurately determine the precise location and volume of tissue that needs to be excised. Lastly, methylene blue is both safe and inexpensive.

Comparative analysis of minimally invasive microductectomy versus major duct excision in patients with pathologic nipple discharge

Minimally invasive techniques are being used increasingly in patients with benign and malignant breast diseases. The purpose of this study was to compare the diagnostic yield of 2 groups of patients who underwent either minimally invasive microductectomy or major duct excision for pathologic nipple discharge. Two hundred thirty-five patients who underwent nipple exploration and duct excision and were part of an institutional review board-approved database were included in this retrospective analysis. Preoperative imaging, ductal washing cytology, surgical specimen size, and final histopathology were compared among 95 patients who underwent microductectomy by using intraoperative ductoscopy and 140 patients undergoing standard major duct excision. Mean age of patients undergoing microductectomy was 53 versus 55 years in patients undergoing major duct excision. Preoperative mammogram was negative or benign in 92% and suspicious in 8% of patients in both the microductectomy group and the major duct excision group. A ductal abnormality was identified by preoperative ductography in 43 of 56 (77%) patients in the microductectomy group versus 74 of 92 (80%) patients in the major duct excision group. Ductal cytology was benign in 81% and 80% of patients tested, respectively. Mean specimen size was significantly smaller in patients who underwent microductectomy (9.2 cm3) as compared with major duct excision (12.6 cm3). Although the percentage of patients with atypical ductal hyperplasia or lobular carcinoma in situ was similar among the 2 groups (9% vs 10%), only 3 of 95 (3%) patients within the microductectomy group were found to have carcinoma within the resection specimen as compared with 12 of 140 (9%) within the major duct excision group (P = .03). Mean specimen size of the patients diagnosed with carcinoma was 8.6 cm(3) in the microductectomy group as compared with 15.5 cm3 in the major duct excision group (P = .014). These data confirm that patients who present with single duct pathologic nipple discharge usually have benign pathology as the etiology. However, in a small percentage of patients an occult carcinoma might be present. Major duct excision appears to detect a higher percentage of occult carcinoma when compared with minimally invasive microductectomy, which might be related to the larger sample size of the resection specimen.

Preoperative galactography increases the diagnostic yield of major duct excision for nipple discharge

Although most nipple discharge is due to a benign etiology, approximately 10-15% is due to breast carcinoma. The standard management of nipple discharge includes major duct excision, and although this procedure may eliminate future nipple discharge, a specific etiology is not always found. This study investigates the utility of preoperative galactography in targeting the causative lesion.During 1994-1996, 46 cases of major duct excision were identified from operating room records. All patients presented with spontaneous nipple discharge from a single duct. In 16 patients both a diagnostic galactogram and a preoperative galactogram with methylene blue were performed to localize the causative lesion and to enable intraoperative identification. Data were obtained by retrospective chart review. Statistical significance was determined by Fisher's exact test.Preoperative galactography was obtained in 7 of 31 patients (23%) with bloody nipple discharge and 9 of 15 patients (60%) with guaiac negative discharge. All patients undergoing preoperative galactography were found to have either a filling defect and/or duct cutoff (n = 13) or duct ectasia (n = 3). All patients with a filling defect and/or duct cutoff on galactogram were found to have a carcinoma or papilloma at surgery. In the three patients with duct ectasia observed on galactogram, the diagnosis was confirmed at surgery. All patients who underwent preoperative galactography were found to have specific pathology that accounted for the nipple discharge versus 20 of 30 patients (67%) who did not undergo preoperative galactography (P = 0.009).Although major duct excision for nipple discharge may eliminate the presenting symptomatology, a pathologic correlate is not always found. The data from the current study show that localizing the causative lesion by preoperative galactography increases the likelihood that specific pathology will be found at surgery, and suggests that preoperative galactography may be helpful in the evaluation and management of patients presenting with spontaneous nipple discharge. Cancer 1998;82:1874-80. 1998 American Cancer Society.

Preoperative galactography increases the diagnostic yield of major duct excision for nipple discharge.

Although most nipple discharge is due to a benign etiology, approximately 10-15% is due to breast carcinoma. The standard management of nipple discharge includes major duct excision, and although this procedure may eliminate future nipple discharge, a specific etiology is not always found. This study investigates the utility of preoperative galactography in targeting the causative lesion. During 1994-1996, 46 cases of major duct excision were identified from operating room records. All patients presented with spontaneous nipple discharge from a single duct. In 16 patients both a diagnostic galactogram and a preoperative galactogram with methylene blue were performed to localize the causative lesion and to enable intraoperative identification. Data were obtained by retrospective chart review. Statistical significance was determined by Fisher's exact test. Preoperative galactography was obtained in 7 of 31 patients (23%) with bloody nipple discharge and 9 of 15 patients (60%) with guaiac negative discharge. All patients undergoing preoperative galactography were found to have either a filling defect and/or duct cutoff (n = 13) or duct ectasia (n = 3). All patients with a filling defect and/or duct cutoff on galactogram were found to have a carcinoma or papilloma at surgery. In the three patients with duct ectasia observed on galactogram, the diagnosis was confirmed at surgery. All patients who underwent preoperative galactography were found to have specific pathology that accounted for the nipple discharge versus 20 of 30 patients (67%) who did not undergo preoperative galactography (P = 0.009). Although major duct excision for nipple discharge may eliminate the presenting symptomatology, a pathologic correlate is not always found. The data from the current study show that localizing the causative lesion by preoperative galactography increases the likelihood that specific pathology will be found at surgery, and suggests that preoperative galactography may be helpful in the evaluation and management of patients presenting with spontaneous nipple discharge. Cancer 1998;82:1874-80. 1998 American Cancer Society.