- 期刊
Probe-Guided Microdochectomy for Bloody Nipple Discharge with Normal Breast Imaging
鼻淚管通條應用於乳頭血色分泌但乳房影像檢查正常患者之微乳管切片手術
摘要
乳房門診的病人中，有5%的病人主訴乳頭有分泌物。婦女一旦有乳頭分泌物常造成患者的恐慌。雖然大部份的分泌物病人都是良性變化，其中以乳突瘤為主，約佔40%至70%的患者。但是仍有相當比例潛伏乳癌的可能性（約1～23%）。傳統影像檢查（乳房攝影或超音波），卻常無法得到令人放心的診斷。乳管攝影對乳癌偵測敏感性高，但專一性低，施作上有一定難度且常造成病人疼痛。核磁共振影像（MRI）雖然被認為比傳統乳房攝影或超音波都來得準確。但是應用核磁共振於乳頭血色分泌患者仍需克服一些障礙，包括較高假陽性率，高成本而且不易以核磁共振影像導引切片。鼻淚管通條可作為術中可疑乳管內病灶切除的導引切片，使得外科醫師只要在適當的局部麻醉下就能很容易找到乳管內病灶，更準確而有效率取得組織診斷，減少不必要的手術及醫療成本，避免醫療糾紛。乳癌被認為是來自正常乳腺細胞連串的突變，約85%的乳癌起源於乳腺管或乳小葉上皮細胞（TDLU），從正常乳腺上皮細胞經過增生（hyperplasia）、異化增生（atypical hyperplasia）、原位癌（carcinoma in situ）、然後逐漸進展成侵犯性癌（invasive carcinoma）。這種細胞惡性轉型進展常以乳頭血色分泌物表現。身為腫瘤外科醫師，我們總會希望早期診斷及適當的介入，阻止這種細胞惡性轉型的進展。本研究的延伸將可提供安全、準確的乳頭血色分泌病人切片手術模式。
並列摘要
Purpose: Bloody nipple discharge (BND) has been associated with breast cancer in women with normal mammograms. Surgical intervention is the only reliable tool for definitive diagnosis of the cause and treatment of BND. However, in patients with BND with normal imaging and without palpable lesions, an accurate biopsy is challenging to perform. This study evaluated a combination of methylene blue and probe-guided microdochectomy as a means of diagnosing and treating patients with BND, who also had benign or normal imaging results. Materials and Methods: From August 2006 to July 2010, 26 patients with BND and occult breast lesion which were apparent on routine imaging were studied by a single breast surgeon at Mackay Memorial Hospital. All patients in this study underwent microdochectomy under sedation and local anesthesia, assisted by intra-operative use of methylene blue injected intraductally in order to trace the affected duct and its side branches. All patients in our study received nipple aspirate fluid (NAF) and ductal lavage before proceeding to microdochectomy. Results: A total of 27 microdochectomy procedures were performed in 26 patients, with a mean age of 52 years. All the patients presented with BND, with normal or benign mammography and ultrasound findings (BIRADS 1,2) in 26 cases (100%). The histopathological results in the 27 lesions biopsied demonstrated fibrocystic change and nonspecific results in 2 cases, intraductal papilloma with ductal hyperplasia in 9 cases, dilated duct with papillomatosis in 4 cases, papilloma with atypical hyperplasia in 3 cases, intraductal carcinoma in 5 cases, and invasive carcinoma in 4 cases. Clinical signs of BND were resolved in 24 patients (96%), and no complications occurred. Patients were followed for a mean period of 2.5 years. No recurrence was found in the cancer group and no subsequent breast cancer developed in the benign group. Conclusions: Microdochectomy with a combination of probe insertion and methylene blue injection is a safe procedure with high diagnostic and therapeutic value for the management of BND.