Limitations and oncological uncertainties of intraductal laser ablation for pathological nipple discharge

We previously investigated the role of mammary ductoscopy (MD) in managing pathological nipple discharge (PND) and concluded that, while it serves as a valuable adjunct for identifying the underlying cause and guiding duct excision, it is not a reliable tool for diagnosing malignancy (1,2). In this context, we read with great interest the recent study by Makineli et al. on intraductal laser ablation during MD (3). While the authors present an innovative approach, several critical limitations warrant further discussion.

First, the study’s small sample size (n=9 for laser ablation) significantly limits the generalizability of its findings. Without a control group, it is difficult to assess whether laser ablation offers a meaningful advantage over standard approaches, particularly given the recurrence rate of 22.2%, which suggests incomplete lesion ablation in some cases.

Second, the study’s short follow-up period (three months) is insufficient to determine the long-term efficacy of laser ablation. Longer follow-up is essential to assess recurrence rates, durability of symptom resolution, and potential oncological implications. The case involving a papilloma with a focus of atypical ductal hyperplasia (ADH) and/or ductal carcinoma in situ (DCIS) is particularly concerning, as complete laser ablation precluded precise tumor localization for subsequent management. The authors suggest imaging-based surveillance, but without histological confirmation of complete lesion removal, this approach remains speculative and potentially risky.

Additionally, while the authors varied laser power settings (1–4 W), they did not systematically determine an optimal power range for effective and safe lesion removal. Standardization of power settings and further evaluation of different laser types (e.g., holmium vs. thulium) would be necessary before broad clinical adoption.

Furthermore, the technical feasibility of laser ablation does not automatically equate to widespread clinical utility. Operator skill level, equipment availability, and cost considerations remain unaddressed. Lastly, the study does not comprehensively tackle malignancy exclusion. MD alone has known limitations in detecting malignancy, and laser ablation may further complicate histological assessment by removing or altering residual tissue, making definitive diagnosis more challenging. Additionally, existing malignancy is often found around papillomas, which could make it more difficult to identify and manage any coexisting cancer (4).

Finally, laser ablation may induce fibrosis, leading to ductal obliteration, which could artificially suppress nipple discharge without addressing the underlying pathology. This raises two key concerns. First, fibrosis that prevents further discharge could delay the detection of residual or recurrent disease, particularly when malignancy has not been fully excluded. Second, ductal obliteration may complicate subsequent procedures, such as repeat MD, biopsy, or surgery, limiting future diagnostic and therapeutic options.

MD presents higher costs due to the need for specialized equipment and the use of disposable instruments. The difficulty in sterilizing these instruments, due to the small diameter of the scope, between procedures makes disposables the preferred option, which adds to the overall expense. Additionally, the challenge of enforcing coverage by private medical insurance complicates access to this diagnostic tool, as many insurers may be reluctant to cover the associated costs, particularly given the lack of evidence supporting the clinical benefits of the procedure. This financial burden can limit its availability and widespread adoption as a diagnostic and therapeutic adjunct (2). In current clinical practice, first-line imaging for the assessment of pathological nipple PND includes ultrasound and mammography. Magnetic resonance imaging (MRI) is recommended when PND persists despite negative findings on conventional imaging. A negative MRI can justify a surveillance approach rather than proceeding to surgery. When MRI is unavailable or contraindicated, contrast-enhanced mammography serves as a suitable alternative (5).

We strongly encourage further research through larger, multi-center randomized controlled trials (RCTs) with extended follow-up. This would be critical to validating the preliminary findings and establishing intraductal laser ablation during MD as a viable alternative to surgical duct excision in the management of PND. Furthermore, the role of MD in local ablation and as a guidance tool for the instillation of drugs, such as anti-human epidermal growth factor receptor 2 (anti-HER2) antibodies and immune checkpoint inhibitors, for the localized treatment of high-risk DCIS warrants further investigation (6).

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was a standard submission to the journal. The article has undergone external peer review.

Peer Review File: Available at https://tcr.amegroups.com/article/view/10.21037/tcr-2025-426/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://tcr.amegroups.com/article/view/10.21037/tcr-2025-426/coif). K.M. receives consulting fees from AMCA. The other author has no conflicts of interest to declare.

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