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Advances in Breast Surgery: Intraductal Papillomectomy

Division of Breast Surgery to offer scarless, endoscopic procedure to detect intraductal papillomas

Patients at NewYork-Presbyterian Hospital/Columbia University Medical Center will soon benefit from yet another in a long string of advances: intraductal diagnosis, and eventually, treatment of breast papillomas. Intraductal papillomas are benign lesions within the milk ducts that account for 40% of cases of pathologic nipple discharge in women aged 20-40.

The development of intraductal approaches to diagnosis and treatment represents one of the most important advances in breast disease treatment in the past decade. Intraductal techniques allow surgeons to perform evaluations through the nipple using very fine micro-endoscopes without surgery and without general anesthesia. This minimally invasive approach has been proven highly successful in the detection of papillomas. Sheldon M. Feldman, MD, Chief, Breast Surgery Section, is considered the most experienced breast endoscopist in the U.S., having researched and used minimally invasive techniques for ten years.

Now, NYP/Columbia is poised to become the only facility in the U.S. to offer scarless endoscopic papillomectomy for diagnosis of pathologic nipple discharge. This unprecedented advance will be made possible in large part by the presence of Fatih Levent Balci, MD, a postdoctoral research scientist who also has extensive expertise in endoscopic ductoscopy. In his native Turkey, Dr. Balci and colleagues determined that the intraductal approach could be successfully used not only for the diagnosis of intraductal lesions, but also to remove single papillomas. In his 2009 paper published in Onkologie, "Scarless Endoscopic Papillomectomy of the Breast," Dr. Balci's team found that the technique had 95% therapeutic efficacy in patients with pathologic nipple discharge due to papillomas. "Using this procedure, we can remove single papillomas in an office with a local anesthetic cream," Dr. Balci says despite its value in treating papillomas, endoscopic papillomectomy is currently restricted to diagnostic purposes in the U.S., as the super-fine micro-endoscope needed for removal of papillomas has not yet received FDA approval in this country. That technology is currently available in Turkey, permitting endoscopic removal of papillomas in patients there. Dr. Balci and Dr. Feldman have submitted applications for approval of the necessary catheter so that NYP/Columbia can begin using intraductal ductoscopy for both detection and removal of breast papillomas at this hospital. That process is likely to take several months, according to Dr. Balci.

In addition to its role in detecting and removing papillomas, Dr. Balci points to yet another potentially groundbreaking role of intraductal endoscopy: Detection of ductal carcinoma in situ (DCIS), a non-invasive form of breast cancer in the milk ducts. Although studies have yet to confirm his group's early findings, Dr. Balci's team has been able to detect DCIS using intraductal endoscopy during its research in Okmeydani Teaching and Research Hospital, Istanbul, Turkey, from 2004 to 2009. "DCIS does not always appear on conventional imaging such as MRI or mammography, but early results of our study indicate that DCIS can be detected during ductoscopy. The ability to detect breast cancer before our conventional imaging models find it would be an enormously valuable advance." Moreover, Dr. Balci explains it would be possible to easily extract just the isolated duct using ductoscopy and microductectomy. "Extracting just the isolated duct should give women the best cosmetic result, with no deformity of the breast," he says.

Dr. Feldman concludes, "By assembling a robust team with expertise in mammary ductoscopy and ductscopic minimally invasive procedures, we are well poised to advance diagnosis and treatment of breast cancer."

To learn more, visit: breastmd.org

http://www.columbiasurgery.org/news/healthpoints/2012_fall/p3.html