In October of this year I traveled to San Francisco, California, for the Clinical Congress of the American College of Surgeons, a yearly event for education, and updates on the most modern advances in surgical care. There are so many lectures going on at the same time that one must choose carefully which to attend. The meeting lasted for four days and I spent as many as 7 ½ hours in lecture per day. Sometimes, it felt like I was “back in school” again.

On one morning I attended a particularly interesting series of lectures on breast ductoscopy. This new technique has promise to alter and improve surgical care
of the breast patient in the very near future. The Nation’s leading experts in
the field spoke. This procedure is only being done in clinical trial settings (not experimental) and the greatest experience anyone had was approximately 100 cases.

First, let me explain a little bit about how this procedure evolved. In the late 1980s, I was fortunate enough to be in on the ground floor of the new surgical specialty called “minimally invasive surgery.” Most of you are familiar with laparoscopy whereby small trocars, or hollow tubes, are placed into the abdominal cavity. One of these trocars is for the lens of a TV camera and the others are for surgical instruments. Removal of the gallbladder (laparoscopic cholecystectomy) is the most common of these operations performed.

Many other specialities saw the promise in these minimally invasive techniques. Neurosurgeons passed a small fiberoptic cable into the brain, allowing them to view the inside surface of the ventricles for diagnosis, or to place drainage shunts very accurately. This fiberoptic device is less than 1 mm (around 3/100 inch) in diameter.

Breast surgeons quickly saw the possible utility of this device in the breast. Six to eight ducts open onto each nipple. Each duct drains a specific portion of the breast. These areas, termed “lobules” generally do not overlap. Injection studies have better defined the internal anatomy of the breast to show that these lobules are grouped in two layers, superficial and deep. There are generally two to four “lobules” in each layer.

For many years we have been performing breast ductography whereby a radio-opaque (visible on x-ray) solution is injected into the duct opening at the nipple to show the location of a growth in the duct. We had also been placing very small tubes (cannulas) into the duct opening and using salt water to wash out cells for diagnosis (ductal lavage).
Under anesthesia, and with very slight dilation of the duct opening at the nipple, a

1 mm fiberoptic scope can be placed into the breast to look for the location of bleeding or the source of abnormal cells which have been detected by lavage. Placement of a ductal lavage cannula (which is only 7/1000 inch in diameter) can be done under local anesthesia without dilation of the duct opening. Breast ductoscopy usually requires a light general anesthetic. Most of the experience has actually been gained in women who are scheduled to undergo a mastectomy for breast cancer. They are completely asleep. They had breast ductoscopy on the affected breast, and occasionally in the opposite, uninvolved, breast.

You can imagine that the visualization through a 1 mm fiberoptic cable is not ideal and some practice is necessary to enable the surgeon to navigate the ducts and to identify lesions which come in and out of focus quite quickly. What can we do once this lesion is seen? Currently there are no good biopsy devices that can be passed through this size scope. One company, from Europe, has a 1.1 mm scope with 3 channels. One channel puts light into the breast, one brings the image out to the camera, and the third is a hollow, multiuse channel. One use is to insert a brush to obtain cells. Another is to inject a solution such as a dye or a medication. Brushing is the most promising technique for obtaining a definitive diagnosis when the surgeon sees abnormal tissue.

Currently, a second method of utilization of breast ductoscopy is to place the end of the cable at the lesion and mark on the breast where the light is most visible. The fiberoptic portion of the scope is sterile. We can actually perform the procedure on a breast which has been prepped sterilely, and then make an incision to excise that small portion of the duct where the lesion is detected.

Another useful procedure is to inject a blue dye at the point where the lesion is detected and then operate by localizing the blue tinted area, and excising it for diagnosis.

Three experimental techniques, are being investigated as to their effectiveness. One is the local administration of chemotherapy directly at the point of the lesion. This is termed intraductal chemotherapy. A second method is to freeze the tissue through a technique called cryoablation (see Women’s I, June 2007). This kills the cells by freezing them. The third approach is to utilize laser energy to kill the tissues within the duct. It is unknown whether any of these three techniques will prove to be effective in the first place, and economical in the second.

How will the Breast Cancer Surgery Center of Maryland utilize ductoscopy in our clinical practice? Once the effectiveness of this technique is proven, we will certainly incorporate it in our list of services. Our Center has always been at the forefront of new technology, and breast ductoscopy may be another one of these “firsts.”

It is exciting to see where scientists from all over the world are observing problems and applying unique techniques to obtain possible solutions. We have certainly made great progress in breast cancer care since the 1950s and even since the 1980s. One wonders where technology will take us in the next 20 years, but I am sure that it will benefit women in keeping this terrible disease from affecting their life so adversely.

As we have noted before, women who get routine mammograms have a 85 - 90% chance of finding a cancer at a curable stage. Women who add the HALO Pap Test (see Women’s I, August 2008) to their breast screening regimen along with mammography have a 98 to 99% chance of finding a cancer when it is curable. We have been very pleased with the acceptance of the HALO Breast Pap Test, but still find many women who have not heard of it and do not recognize its value. The Breast Cancer Surgery Center is the first, and only, facility in Harford County to perform the HALO Breast Pap Test. Please join us as we “create the future of breast cancer surgery to improve women’s lives.”

Article courtesy of Dr. F. W. Walker, M.D., P.A., © 2005 — Director of Breast Cancer Surgery Center of Maryland, 2005 Rock Spring Rd., Suite 5, Forest Hill, MD • 410.836.0909 • BreCanSurCen@aol.com • www.BCSCofMD.com