Ductoscopy, lavage combo promising

OB/GYN News,  Feb 15, 2002  by Bruce Jancin

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SAN ANTONIO -- Mammary ductoscopy may provide the missing link that renders ductal lavage more clinically relevant, Dr. Seema A. Khan said at the annual breast cancer symposium sponsored by the San Antonio Cancer Institute.

The finding of cytologic atypia on lavage indicates that something abnormal is going on but provides no information about precisely where within the sampled duct the abnormality is located, or even if a definable lesion is present. That's where ductoscopy shows great promise, said Dr. Khan, a surgeon at Northwestern University in Chicago.

To perform ductoscopy, the physician inserts a rigid endoscope into the duct and directly visualizes the duct lining. The idea is that the operator will often be able to tell whether a lesion, if present, is worrisome and warrants surgical excision. If so, ductoscopy can delineate the extent of disease and direct surgery such that the entire affected area can be removed with a smaller specimen than would otherwise be taken, often preserving duct function. And if no pathology is seen on ductoscopy, perhaps the patient may safely avoid surgery altogether.

There are as yet no published data on the use of lavage in combination with ductoscopy although this is under active study at a number of institutions. In one recent success story, a 62-year-old woman at Northwestern who was at high risk for breast cancer underwent ductal lavage, which yielded cellular atypia. Next came ductoscopy, which showed the precise location of a white nodular lesion of ductal carcinoma in situ. Excision of the duct yielded a 9-mm grade 3 carcinoma in situ.

"We have one other patient like this, and many other institutions have anecdotes along the same lines. But to define this further; it will most likely need a multicenter study," said Dr. Khan, who is on the advisory board of Acueity Inc., the industry leader in ductoscopy.

Ductoscopy is also being used to investigate spontaneous nipple discharge, although in Dr. Khan's view the technique isn't yet ready to be used without surgical confirmation when lesions are identified. There is also intense interest in potential therapeutic applications for ductoscopy.

The state-of-the-art instrument used in ductoscopy is a rigid endoscope 0.9 mm in diameter. Seen through the ductoscope, a normal duct looks like a shiny white tunnel. Red patches usually correlate with duct hyperplasia. Ectasias, papillomas, ductal carcinoma in situ, and other lesions also have a characteristic appearance.

Dr. Khan said that although she gets lots of inquiries about ductal lavage from patients and physicians, she and her Northwestern colleagues are "relatively conservative" about recommending the procedure, largely reserving it for high-risk women who want a further assessment before deciding on a risk-lowering strategy such as tamoxifen.

Key questions about ductal lavage remain unanswered. Payers are reluctant to reimburse for it because of the lack of long-term data. It's unclear how often non-fluid-yielding ducts contain significant pathology. The reliability and reproducibility of lavage findings aren't known. And most importantly, the surgeon continued, the histologic correlates of cytologic atypia detected by lavage are unclear.

Dr. Khan knows of at least one cautionary tale involving a patient who underwent mastectomy because her ductal lavage yielded malignant cells, yet the specimen contained no cancer. This is exactly the sort of patient who might have benefited from ductoscopy.

COPYRIGHT 2002 International Medical News Group
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