What is breast endoscopy?
Endoscopy, a common and proven medical technique for visualising the interior of organs such as the colon, is now being applied to the breast. Breast endoscopy gives your doctor the ability to see inside the tiny milk ducts of your breasts, where most breast cancers originate. During this procedure, a very thin fiberoptic endoscope is inserted into the nipple and threaded through the labyrinth of milk ducts inside your breast. An attached camera and imaging system magnify the video images from within your breast up to 60 times actual size and display the pictures on a computer monitor for both you and your physician to see. With this procedure, very small abnormalities inside the ducts may be found. In fact, early signs of potential breast cancer may be found in one in five high-risk women undergoing breast endoscopy.(1)

I've already had a mammogram. Do I need breast endoscopy too?
While most breast cancers originate in the milk ducts of the breast, these cancers usually grow slowly over a long period. The early growth of breast cancer can sometimes go undetected because the cancer is too small to be found by mammography, MRI or ultrasound. These standard imaging procedures cannot usually detect lesions until they are larger than 5mm. It can take up to ten years for a lesion to grow larger than 5mm and during this time the disease can become more invasive. Mammograms typically find cancers that have been growing for years. Now, through direct visualisation with breast endoscopy, abnormalities so small they can be missed by other imaging technologies may be located. Women whose cancers are caught and treated at an early stage have a better chance of cure and survival than those whose cancers are found at a later stage. Early detection helps preserve normal appearance of the breast.

The importance of nipple fluid
Nipple fluid is a liquid secretion that comes from the nipple of non-breastfeeding women when the breast is massaged and suction is applied to the nipple area. Nipple fluid is associated with an increased incidence of breast cancer (2) and requires further examination. Locating a duct from which there is nipple fluid helps determine which duct should be further investigated with breast endoscopy.

Understanding Your Breast Structure
The breast has four structures: lobules or glands; milk ducts; fat and connective tissue. There are about 15 to 20 lobules in each breast arranged in a circle around the nipple. The lobules empty into the milk ducts and travel to the nipple. At the nipple, they merge into collecting ducts. The collecting ducts enter the base of the nipple and connect with the outside on the surface of the nipple. During breast endoscopy, the breast is entered "backwards" through the nipple and into the breast. The ducts are large at first and as you go deeper in the breast, they branch out like a tree, becoming smaller and smaller. The inside of each milk duct is lined with cells called epithelial cells. Changes in these cells may be associated with an increased risk of breast cancer.

What may be found during breast endoscopy?
During the endoscopic examination of the duct producing nipple fluid several different conditions may be found. Ductal carcinoma in situ, or DCIS, (pronounced "duck-tul car-sin-oma in sigh-two") is an early form of breast cancer that usually cannot be detected by physical examination alone (3). DCIS is a cancerous change that occurs in the cells of the milk duct. If left untreated, over a period of years, DCIS can spread to the tissue around the ducts which means it has become invasive breast cancer. In addition, atypical hyperplasia (pronounced "hyper-play-jah"), which may be a marker for future development of breast cancer, may also be detected. Papillomas (pronounced "pappa-lo-mas") are benign tissue growths within the ducts that may be a pre-cursor to breast cancer as well.(4)

What happens if something is found during breast endoscopy?
If any abnormalities are seen during breast endoscopy, the tissue may be sampled during the procedure using a technique called "intra-ductal biopsy". Intra-ductal biopsy is done from within the duct itself, and does not leave an external scar. The tissue samples retrieved are sent to a laboratory for testing. Your physician will consult with you on the findings and on any recommended follow-up treatment, which may be required.

What should I expect from this procedure?
Your procedure may include both breast endoscopy and intra-ductal biopsy - both of which may be performed as an outpatient procedure. It is relatively painless, requires only local anaesthesia and no incision is made in your breast. Most women report minimal discomfort during intra-ductal procedures and say it is no more uncomfortable than a standard mammogram.(5) Typically, the entire procedure takes about 45 minutes, and is performed on an outpatient basis.

The entire procedure involves 3 simple steps:

• Finding ducts at risk
• Viewing inside ducts
• Collecting tissue samples

Step 1. Finding Ducts at Risk
First, the milk duct producing nipple fluid must be identified. Anaesthetic cream is applied to your nipple area before the procedure. Gentle self-massage of the breast is performed for a few minutes. Using a breast pump, suction is applied to the nipple to draw fluid out to the skin surface. This helps find the opening to the specific duct that will be examined. Once a fluid yielding duct is located, the opening is gently enlarged and a tiny catheter is inserted. Your doctor may administer mild anaesthesia directly into your duct and then inserts a tiny (1.1 mm in diameter, which is about the size of this "o") fiberoptic endoscope.

Step 2. Viewing Inside the Ducts
As the scope moves through the ductal system, your surgeon can see in "real-time" what is happening inside your milk ducts. During the procedure, an imaging system magnifies breast tissue up to 60 times its actual size and displays the pictures onto a computer screen for your doctor to see. A normal duct appears as a shiny white tunnel. DCIS and other lesions have a characteristic appearance that allows them to be distinguished from other tissue. Red patches often correlate with atypical ductal hyperplasia (abnormal breast cells that involve only the lining of the milk duct and have not spread outside the duct into the normal surrounding breast tissue).

Step 3. Collecting Tissue Samples
Intra-ductal biopsy enables your physician to collect cells for analysis from the ducts of your breasts. If a suspicious area is seen, your surgeon will collect additional samples from that area.

What do the cells look like?
Visual features associated with specific lesion types can be seen with the technique. These are examples of the images seen during breast endoscopy. A normal duct appears as a shiny white tunnel. The smooth wall surface features of a normal duct is also seen. Growths in ducts include various grades of papillomas as well as low grade and high grade ductal carcinoma in situ (DCIS). Red patches may often correlate with atypical ductal hyperplasia (abnormal breast cells that involve only the lining of the milk duct. The cells have not spread outside the duct into the normal surrounding breast tissue). DCIS and other lesions have a characteristic appearance.

What are the advantages in undergoing this procedure?
Breast Endoscopy provides a way for your doctor to perform several tasks during one procedure. First, investigation of the causes behind the discharge of nipple fluid may be performed. If a suspicious area is found, your doctor may biopsy it immediately. With this new procedure, lesions found inside the milk ducts may be sampled from inside the duct without having to cut into the breast. If, after laboratory analysis, the intra-ductal biopsy indicates the cells are cancerous, breast endoscopy may help guide your surgeon toward maximum conservation of your breast by identifying the location of abnormal tissue.

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