Ductal endoscopy of the breast: more painful at the luteal phase?

PURPOSE: To assess the putative predictors that may influence the pain experienced during ductal endoscopy of the breast. METHODS: The pain experienced was evaluated in 19 consecutive premenopausal women with bloody nipple discharge scheduled for ductal endoscopy. The visual analog scale (VAS) was used to estimate the degree of pain. The duration of the procedure, the history of lactation, and the phase of the menstrual cycle were evaluated with respect to pain experienced. Statistical analysis followed. RESULTS: The average reported pain (VAS score, mean +/- standard deviation) was 5.79 +/- 1.51 while the maximum pain was 8.26 +/- 0.99. The average reported pain was marginally associated with the duration of the procedure in contrast to the maximum. Women who were at the luteal phase of their menstrual cycle exhibited a higher average reported pain. The history of breastfeeding was not associated with the average reported pain, but it was associated with less intense maximum pain. CONCLUSIONS: Pain during ductal endoscopy of the breast is influenced by a host of factors: some immutable (such as history of lactation) and others variable (day of menstrual cycle). The latter (ie, avoidance of the luteal phase) may be targeted for the minimization of pain.

Vacuum-assisted breast biopsy in nonpalpable solid breast lesions without microcalcifications: the Greek experience.

PURPOSE: To present the initial Greek experience with vacuumassisted breast biopsy (VABB) in the diagnosis of nonpalpable solid mammographic lesions without microcalcifications. MATERIALS AND METHODS: We performed 83 VABB procedures (using a Fischer table and 11-guage Mammotome probes) in an 18- month period on women with nonpalpable solid breast tumors. We performed VABB procedures on women with breast imaging reporting and data system (BI-RADS) categories 3 and 4. VABB procedures excised more than 24 cores. RESULTS: Eighty-three women with nonpalpable lesions identified on mammography were evaluated; 42.2% were BI-RADS category 3, and 57.8% were BI-RADS 4. Of all solid tumors excised, 83.1% were benign, 3.6% were precursor lesions, and 13.3% of the lesions were malignant. No underestimation occurred. Clinically important hematoma developed in 4.8% of cases. CONCLUSION: VABB is an effective method for the diagnosis of nonpalpable solid lesions because of the lack of underestimation, although it is technically more difficult to focus on lesions without microcalcifications than those with microcalcifications on the Fischer table.

Evaluation of pain experienced during breast ductal endoscopy.

PURPOSE: Ductal endoscopy is valuable for the differential diagnosis of bloody nipple discharge; however, the pain associated with this procedure has not been evaluated. This study aims to assess the pain experienced by patients during ductal endoscopy. METHODS: We studied a consecutive series of women who underwent ductal endoscopy, to investigate the cause of bloody nipple discharge. The procedure was performed using standard local anesthesia (lidocaine 1% 10 ml without epinephrine, involving nipple block and periaureolar administration). Patients were asked to score the level of pain with a visual analog scale, 1, 4, 7, 12, 17, 22, 27, and 32 min after the procedure, and describe their overall and maximum pain. RESULTS: This series comprised 20 women aged from 27 to 68 years old. The overall pain (mean +/- SE) score was equal to 5.8 +/-0.3, and the maximum pain score was 8.3 +/- 0.2. The peak of pain corresponded with when the dilator was inserted through the sphincter. The group in which the dilator was inserted after 4 min experienced more intense maximum and overall pain after 7, 12, 17 and 22 min. CONCLUSIONS: Pain is an important factor in ductal endoscopy, and peaks relatively early. A standard, baseline local lidocaine dose of greater than 10 ml may be necessary at the beginning of the procedure. Late insertion of the dilator seems to be an indicator of the force of the procedure.

Is zero underestimation feasible? Extended Vacuum-Assisted Breast Biopsy in solid lesions - a blind study.

BACKGROUND: Vacuum-Assisted Breast Biopsy (VABB) is effective for the preoperative diagnosis of non-palpable mammographic solid lesions. The main disadvantage is underestimation, which might render the management of atypical ductal hyperplasia (ADH), and ductal carcinoma in situ (DCIS) difficult. This study aims to develop and assess a modified way of performing VABB. PATIENTS AND METHODS: A total of 107 women with non-palpable mammographic breast solid tumors BI-RADS 3 and 4 underwent VABB with 11G, on the stereotactic Fischer's table. 54 women were allocated to the recommended protocol and 24 cores were obtained according to the consensus meeting in Nordesterdt (1 offset-main target in the middle of the lesion and one offset inside). 53 women were randomly allocated to the extended protocol and 96 cores were excised (one offset-main target in the middle of the lesion and 7 peripheral offsets). A preoperative diagnosis was established. Women with a preoperative diagnosis of precursor/preinvasive/invasive lesion underwent open surgery. A second pathologist, blind to the preoperative results and to the protocol made the postoperative diagnosis. The percentage of the surface excised via VABB was retrospectively calculated on the mammogram. The discrepancy between preoperative and postoperative diagnoses along with the protocol adopted and the volume removed were evaluated by Fisher's exact test and Mann-Whitney-Wilcoxon test, respectively. RESULTS: Irrespectively of the protocol adopted, 82.2% of the lesions were benign. 14.0% of the lesions were malignancies (5.1% of BI-RADS 3, 5.3% of BI-RADS 4A, 25% of BI-RADS 4B, and 83.3% of BI-RADS 4C lesions). 3.7% of the biopsies were precursor lesions. There was no evidence of underestimation in either protocols. In the standard protocol, the preoperative/postoperative diagnoses were identical. In the extended protocol, the postoperative diagnosis was less severe than the preoperative in 55.5% of cases (55.5% vs. 0%, p = 0.029), and preoperative ADH was totally removed. The phenomenon of discrepancy between diagnoses was associated with larger volume removed (8.20 +/- 1.10 vs. 3.32 +/- 3.50 cm3, p = 0.037) and higher removed percentage of the lesion (97.83 +/- 4.86% vs. 74.34 +/- 23.43%, p = 0.024) CONCLUSION: The extended protocol seems to totally excise precursor lesions, with minimal underestimation. This might possibly point to a modified management of ADH lesions.

Imprint cytology on microcalcifications excised by vacuum-assisted breast biopsy: a rapid preliminary diagnosis.

BACKGROUND: To evaluate imprint cytology in the context of specimens with microcalcifications derived from Vacuum-Assisted Breast Biopsy (VABB). PATIENTS AND METHODS: A total of 93 women with microcalcifications BI-RADS 3 and 4 underwent VABB and imprint samples were examined. VABB was performed on Fischer's table using 11-gauge Mammotome vacuum probes. A mammogram of the cores after the procedure confirmed the excision of microcalcifications. For the application of imprint cytology, the cores with microcalcifications confirmed by mammogram were gently rolled against glass microscope slides and thus imprint smears were made. For rapid preliminary diagnosis Diff-Quick stain, modified Papanicolaou stain and May Grunwald Giemsa were used. Afterwards, the core was dipped into a CytoRich Red Collection fluid for a few seconds in order to obtain samples with the use of the specimen wash. After the completion of cytological procedures, the core was prepared for routine histological study. The pathologist was blind to the preliminary cytological results. The cytological and pathological diagnoses were comparatively evaluated. RESULTS: According to the pathological examination, 73 lesions were benign, 15 lesions were carcinomas (12 ductal carcinomas in situ, 3 invasive ductal carcinomas), and 5 lesions were precursor: 3 cases of atypical ductal hyperplasia (ADH) and 2 cases of lobular neoplasia (LN). The observed sensitivity and specificity of the cytological imprints for cancer were 100% (one-sided, 97.5% CI: 78.2%-100%). Only one case of ADH could be detected by imprint cytology. Neither of the two LN cases was detected by the imprints. The imprints were uninformative in 11 out of 93 cases (11.8%). There was no uninformative case among women with malignancy. CONCLUSION: Imprint cytology provides a rapid, accurate preliminary diagnosis in a few minutes. This method might contribute to the diagnosis of early breast cancer and possibly attenuates patients' anxiety.