Is microductectomy still necessary to diagnose breast cancer: a 10-year study on the effectiveness of duct excision and galactography.

PURPOSE: Patients with spontaneous nipple discharge (SND) who have neither clinically palpable masses nor evidence of disease on imaging with mammogram and/or ultrasound are traditionally investigated with galactogram and duct excision. As breast imaging improves, it has raised the question whether galactography and microductectomy are necessary to diagnose breast cancer. The purpose of this study was to determine the incidence of malignancy in patients presenting with SND who underwent microductectomy and to evaluate the utility of duct excision and galactography in patients whose initial clinical and radiological evaluation were negative. METHODS: A 10-year retrospective study was conducted in British Columbia's largest tertiary breast referral center examining the clinical, radiological and pathological results for all patients who underwent a microductectomy procedure for SND between 2008 and 2017. RESULTS: A total of 231 microductectomies were performed and the overall incidence of malignancy was 13% (n = 32). Following initial work up, 155 patients (67%) had only discharge on exam and no radiologically suspicious findings of malignant disease. Of these patients, 14% (n = 21) were diagnosed with cancer by duct excision. Galactography yielded a sensitivity and specificity of 63% and 36%, respectively (PPV 15% and NPV 85%). Lastly, we found that 3% of patients (n = 8) initially diagnosed with benign disease later developed breast cancer. CONCLUSIONS: Patients with SND should continue to be evaluated with microductectomy to prevent missing a breast cancer. Moreover, we do not recommend performing galactography for diagnosing breast cancer due to poor sensitivity and specificity though it may assist in preoperative planning.

Estrogen modulates mesenchyme-epidermis interactions in the adult nipple.

Maintenance of specialized epidermis requires signals from the underlying mesenchyme; however, the specific pathways involved remain to be identified. By recombining cells from the ventral skin of the K14-PTHrP transgenic mice [which overexpress parathyroid hormone-related protein (PTHrP) in their developing epidermis and mammary glands] with those from wild type, we show that transgenic stroma is sufficient to reprogram wild-type keratinocytes into nipple-like epidermis. To identify candidate nipple-specific signaling factors, we compared gene expression signatures of sorted Pdgfrα-positive ventral K14-PTHrP and wild-type fibroblasts, identifying differentially expressed transcripts that are involved in WNT, HGF, TGFß, IGF, BMP, FGF and estrogen signaling. Considering that some of the growth factor pathways are targets for estrogen regulation, we examined the upstream role of this hormone in maintaining the nipple. Ablation of estrogen signaling through ovariectomy produced nipples with abnormally thin epidermis, and we identified TGFß as a negatively regulated target of estrogen signaling. Estrogen treatment represses Tgfß1 at the transcript and protein levels in K14-PTHrP fibroblasts in vitro, while ovariectomy increases Tgfb1 levels in K14-PTHrP ventral skin. Moreover, ectopic delivery of Tgfß1 protein into nipple connective tissue reduced epidermal proliferation. Taken together, these results show that specialized nipple epidermis is maintained by estrogen-induced repression of TGFß signaling in the local fibroblasts.

The feasibility of nipple aspiration and duct lavage to evaluate the breast duct epithelium of women with increased breast cancer risk.

AIM: Nipple aspiration (NA) and duct lavage (DL) are modalities for obtaining breast duct fluid for biomarker analyses. The aim of this study was to assess the feasibility of obtaining serial NA and DL samples at consecutive patient visits for cytology assessment and the creation of a biobank. METHODS: Seventy eligible subjects were enroled at a single institution in the United Kingdom as part of an international multicentre study. Entry criteria were based on a 5-year Gail model risk of ≥2% or Claus score lifetime risk of ≥26%. Women underwent NA and DL in an outpatient clinic under local anaesthesia. RESULTS: The mean patient age was 48 (range 41-69)years. Sixty seven out of 70 women (96%) attended three consecutive 6 monthly visits and follow-up for 2 years. Three women withdrew due to intolerance of the DL procedure. 56/67 (83%) women produced NA fluid from at least one duct. 204/264 (77%) of ducts declared by NA were cannulated for DL. 170/204 (83%) produced DL samples with adequate cellularity. By the final visit 52/67 (78%) women produced DL, 28/52 (54%) of whom were premenopausal and 24/52 (46%) were postmenopausal. 50/52 women (96%) underwent repeated DL of 81 ducts on 3 consecutive visits. CONCLUSION: NA and DL are well tolerated for repeated assessment to obtain material for cytology and to create a biobank for future biomarker studies in women at high breast cancer risk.

The value of breast ductoscopy in radiologically negative spontaneous/persistent nipple discharge.

Breast ductoscope is a fiberoptic endoscope used for examining the distal breast ducts under direct vision in order to identify the source of pathologic nipple discharge. The purpose of this study was to investigate the reliability of intra-operative breast ductoscopy in patients with pathologic nipple discharge, which could not be identified by radiologic tests. Between April 2002 and March 2007, breast ductoscopy was performed in 34 patients who had pathologic nipple discharge with no radiologic evidence about the source. The procedures were carried out under general anesthesia and ductoscopic findings were as well as the histopathology of the specimens were recorded and documented. In 88%, (30 of 34) of the patients, endoscope was successfully introduced into the external orifice of the ducts at the nipple and proximal breast ducts were successfully visualized. Ductoscopy revealed intraductal lesions (i.e., ductal obstruction, intraductal papilloma, red patches, and erythematoid platter) in 20 patients (66%). Among the 20 patients with visible endoluminal pathology, nine had a papilloma and eight had signs of either acute inflammation (bleeding, erythema) or previous inflammation with healing (adhesions and blocked ducts). In two cases, invasive breast carcinoma was identified, one of which was ductal carcinoma in situ (DCIS) with minimal invasion. In both cases, there had been blocked ducts. In one case DCIS was identified. Breast ductoscopy is a reliable and easy-to-use method to demonstrate the source of pathologic nipple discharge in cases with bleeding and other intraductal lesions.

[Diagnostic image (396). A woman with an eczematous nipple]. / Diagnose in beeld (396). Een vrouw met een eczemateuze tepel.

A 58-year-old woman presented with an eczematous lesion of the right nipple 6 months after a right axillary lymph node dissection that was performed due to a metastatic carcinoma. The nipple scrape smear showed malignant cells compatible with Paget's disease.

Conversion of the nipple to hair-bearing epithelia by lowering bone morphogenetic protein pathway activity at the dermal-epidermal interface.

Epithelial appendages, such as mammary glands and hair, arise as a result of epithelial-mesenchymal interactions. Bone morphogenetic proteins (BMPs) are important for hair follicle morphogenesis and cycling and are known to regulate a wide variety of developmental processes. For example, overexpression of BMPs inhibits hair follicle formation. We hypothesized that the down-regulation of the BMP signaling pathway in the basal epidermis expands regions that are competent to form hair follicles and could alter the fate of the epithelium in the mouse nipple to a hair-covered epidermal phenotype. To test our hypothesis, we used a transgenic mouse model in which keratin 14 (KRT14) promoter-mediated overexpression of Noggin, a BMP antagonist, modulates BMP activity. We observed the conversion of nipple epithelium into pilosebaceous units. During normal mammary gland organogenesis, BMPs are likely used by the nipple epithelium to suppress keratinocyte differentiation, thus preventing the formation of pilosebaceous units. In this report, we characterize the morphology and processes that influence the development of hairs within the nipple of the KRT14-Noggin mouse. We demonstrate that Noggin acts, in part, by reducing the BMP signal in the epithelium. Reduction of the BMP signal in turn leads to a reduction in the levels of parathyroid hormone-related protein. We propose that during evolution of the nipple, the BMP pathway was co-opted to suppress hair follicle formation and create a more functional milk delivery apparatus.

Toker cells of the breast. Morphological and immunohistochemical characterization of 40 cases.

Toker cells are epithelial cells with clear cytoplasm usually free of cytologic atypia localized within the nipple epidermis. Rarely, they can be so numerous and atypical as to require a careful distinction from malignant cells of Paget's disease. The purpose of this paper was to better define the prevalence of these atypical Toker cells and to investigate phenotypic markers that can be helpful in the differential diagnosis with Paget's disease. Forty cases containing Toker cells were identified in the nipples of 390 patients (10.2%) who underwent complete breast mastectomy. In 24 cases (60%), Toker cells were cytologically bland and benign, disappearing after a few consecutive sections ("normal Toker cells"). In 11 cases (27.5%), Toker cells were more numerous and persistent on serial sections, still retaining bland cytologic features ("hyperplastic Toker cells"). In 5 cases (12.5%), hyperplastic Toker cells also became cytologically atypical ("hyperplastic and atypical Toker cells"). On immunohistochemistry, Toker cells were positive for estrogen (25/25) and progesterone (20/23) receptors, and negative for CD138 (18/19) and p53 (14/14); some hyperplastic and atypical Toker cells (4 cases) and hyperplastic Toker cells (1 case) showed faint immunoreactivity for HER2/NEU. For comparison, Paget's disease were negative for estrogen (6/10) and progesterone (7/10) receptors, and positive for CD138 (7/10), p53 (6/10), and HER2/NEU (9/10). Both Toker cells and Paget's disease stained positive for cytokeratin 7 and epithelial membrane antigen, and negative for p63. In conclusion, Toker cells are detectable in 10% of the nipples and are usually cytologically bland, but in 10% of the cases they can be morphologically atypical. The combined use of CD138/p53 is very helpful in distinguishing these atypical Toker cells from those of Paget's disease.

Pagetoid dyskeratosis of the nipple epidermis: an incidental finding mimicking Paget's disease of the nipple.

Pagetoid dyskeratosis (PD) is considered a selective keratinocytic response in which a small part of the normal population of pale keratinocytes is induced to proliferate. PD has been found incidentally in the squamous epithelium of the skin and mucosas in various locations, but not in the nipple. In cases in which PD cells are conspicuous, there is the danger of overdiagnosis. In a retrospective study, we describe the location and incidence of PD and other pale cells in the nipple epidermis, in 288 mastectomy specimens from women operated on for breast carcinoma, in situ or infiltrating, selected consecutively from our histopathologic files. In addition to the conventional histologic methods an immunohistochemical study was performed in selected cases. PD was found in 184 (63.9%) cases and was a prominent finding in 37 (12.8%) cases. Toker cells (TCs) were identified by standard light microscopy in 24 (8.3%) nipples. Paget carcinoma cells (PCCs) were found in 12 (4.2%) cases, and in 9 (3.1%) they were an incidental finding. The immunohistochemical profile of each type of pale cells was as follows: PD cells, EMA-,LMWCK-,CK7-,HMWCK+, CEA-, HER2/neu protein-, HMB45-, HPV-; TCs, EMA+, LMWCK+, CK7+, HMWCK-, CEA-, HER2/neu protein-, HMB45-, HPV-; PCCs, EMA+, LMWCK+, CK7+, HMWCK-, CEA+, HER2/neu protein+, HMB45-, HPV-. In conclusion, friction may be the stimulus for the appearance of PD cells. PD cells must be distinguished from TCs, PCCs, clear cells of Bowen's disease, pagetoid melanoma cells, cells of clear cell papulosis, koilocytes, artifactual clear cells, and glycogen-rich squamous cells. A combination of immunohistochemical markers is useful for this distinction; however, routine histologic study is usually adequate for recognizing PD. Pathologists should be familiar with the histologic features of PD in the nipple epidermis to avoid misdiagnosis.

Reproducibility of ductal lavage cytology and cellularity over a six month interval in high risk women.

BACKGROUND: Ductal lavage (DL) allows repeat sampling of breast epithelium for serial observation in a chemoprevention setting; however, the reproducibility of duct cannulation, cell yield and cytology has not been addressed. METHODS: We conducted a Phase 2 trial, wherein high risk women chose tamoxifen treatment or observation following an entry DL procedure. We present data from the non-intervention arm of our study to assess the reproducibility of cannulation, cell yield, and cytologic diagnosis from DL of the same duct at two time-points. Inter-observer variability was assessed by a blinded review of Papanicoloau-stained slides by two cytopathologists. RESULTS: Sixty-five women had a successful lavage of 187 ducts at baseline and chose observation; 63/65 (97%) had a successful lavage 6 months later. Successful recannulation of the same duct was accomplished in 63 women (97%) and162 ducts (87%). Total epithelial cell yields >or=100 were obtained from 57/65 women (88%) and 129/187 ducts (69%) at baseline, and 46/63 women (73%) and 80/162 ducts (49%) at both time-points. Cytologic diagnosis was reproducible in 27/63 (43%) women and 77/162 (48%) ducts. Inter-observer variability for cytologic diagnosis between two observers showed good agreement (kappa = 0.62). CONCLUSIONS: Recannulation and lavage of the same duct after a 6 month interval can be achieved with high frequency; however, reproducibility of cell yield and cytologic findings from the same duct is sub-optimal, leading to significant attrition of evaluable subjects. The utility of DL for the serial monitoring of breast epithelium is therefore limited.

Correlation of nipple aspiration and ductal lavage cytology with histopathologic findings for patients before scheduled breast biopsy examination.

BACKGROUND: The use of ductal lavage to obtain cells from within the breast ducts has been described for patients at high risk for breast cancer. The purpose of this study was to correlate ductal lavage cytologic findings with the corresponding histology. METHODS: Twenty-two patients were evaluated and 20 patients underwent ductal lavage followed by breast biopsy examination as a result of positive nipple aspiration fluid. Ductal lavage samples were classified by a cytopathologist as negative, mild atypia, marked atypia, or malignant. A different pathologist interpreted the histologic findings of the biopsy examination. RESULTS: Adequate specimens for cellularity were obtained in 12 of 22 (53%) patients: 6 of the 12 (50%) had both benign cytology and histology, 2 (16.7%) had benign cytology with atypical ductal hyperplasia or atypical lobular hyperplasia on histology, 2 (16.7%) had marked atypia on cytology and benign histology, and 2 (16.7%) had malignant cytology and benign histology. The specificity of the procedure was 83.4%. CONCLUSIONS: Ductal lavage yielding an adequate sample for analysis was successful in only 52% of patients. Of those, the cytologic-histologic correlation was discordant in 50%. The role of ductal lavage in accurately predicting lesions present on subsequent breast histologic evaluation of planned biopsy examinations requires further investigation.

Cytologic findings and protein expression profiles associated with ductal carcinoma of the breast in ductal lavage specimens using surface-enhanced laser desorption and ionization-time of flight mass spectrometry.

BACKGROUND: Early detection of breast carcinoma enhances the chances for patient survival. The authors' work focused on an innovative technique that couples breast ductal lavage (DL) with surface-enhanced laser desorption and ionization-time of flight mass spectrometry (SELDI-TOF MS) to yield a highly sensitive and specific method of breast carcinoma detection. METHODS: The study group included 16 women who had unilateral, biopsy-proven breast carcinoma. Studying paired DL specimens from each woman (the breast with and the breast without carcinoma), a cytologic investigation was performed on the cells present in the DL samples, and the protein content of the DL fluid was analyzed with the SELDI-TOF MS technique using the strong anionic exchange chip surface. RESULTS: Only 5 of 16 DL specimens (31%) from breasts with biopsy-proven carcinoma contained malignant cells, whereas the remaining samples contained only histiocytes and clusters of benign ductal epithelium. In contrast, 12 of 16 DL specimens (75%) from breasts that contained carcinoma had a different protein peak pattern compared with the paired DL specimen from the same patient's contralateral, uninvolved breast. This finding was independent of the presence of neoplastic cells in the lavage fluid. In addition, specific protein peaks, which may represent potential biomarkers, were identified in the DL fluids from breasts with carcinoma. Some of these peaks were conserved between different patients. CONCLUSIONS: The combination of breast DL with SELDI-TOF MS offers a unique and powerful technique for the detection and monitoring of breast carcinoma. This method has the potential to enhance the diagnostic utility of conventional DL cytology.

Nipple-areolar pigmentation: histology and potential for reconstitution in breast reconstruction.

The makeup of nipple-areolar skin, in terms of its melanin and melanocyte content has not previously been established. This histological information is required if pigmentation of the reconstructed nipple-areola is to be successful in post-mastectomy breast reconstruction. We describe examination of 200 parallel sections of nipple-areolar skin of 20 women using histochemical (Masson-Fontana) and immunohistochemical (Mel-5) techniques, evaluated using quantitative image analysis. The amount of melanin present per length of basement membrane was 2.14 times higher in areolar skin than breast skin. The ratio of melanocytes to keratinocytes was 1:9.7 in areolar skin vs. 1:14.7 in breast skin. We also describe a cell culture and skin construct method using autologous human serum without toxic growth promoting additives, which could be used in the clinical setting of nipple-areolar reconstruction.

Reproducibility of cytologic atypia in repeat nipple duct lavage.

BACKGROUND: It is believed that atypical cells identified by nipple duct lavage (NDL) indicate an increased risk for breast carcinoma similar to atypical ductal hyperplasia diagnosed by tissue biopsy, but many basic performance characteristics of NDL currently are undefined. METHODS: NDL was performed in 108 patients unselected for breast carcinoma risk and then was repeated after 2-14 months (median, 8 months) if the initial lavage was classified as atypical. Breast magnetic resonance images (MRIs) were obtained from a subset of patients who had atypical lavage results. RESULTS: Marked atypia was diagnosed in 22% of 36 breasts with an incident carcinoma compared with 7% of 172 unaffected breasts (P = 0.01). After excluding breasts with an incident carcinoma, there were 32 patients (30%) with either mild or marked atypia. The lavage was repeated in 23 of these women, and the second lavage was classified as atypical in 48%. Neither marked atypia on the initial lavage nor a 5-year Gail risk > or = 1.7% predicted atypia on repeat lavage, but there was a trend for improved reproducibility when the atypia initially was diagnosed in a fluid-producing duct. MRIs were abnormal in 13% of 24 breasts with an atypical lavage, and ductal carcinoma in situ was diagnosed subsequently in 1 breast. CONCLUSIONS: Atypia frequently is diagnosed by NDL, but the reproducibility of repeat lavage is low. Lavage atypia may be physiologic or artifactual rather than pathologic in many instances. Marked atypia occasionally may represent mammographically occult ductal carcinoma in situ.

Feasibility of breast duct lavage performed by a physician extender.

BACKGROUND: The safety and feasibility of ductal lavage (DL), a risk-assessment tool utilizing a minimally invasive technique that permits sampling of breast duct epithelium, performed primarily by a nurse practitioner (NP), was studied prospectively. METHODS: Women at high risk for breast cancer with a normal clinical breast exam and mammogram were enrolled. Nipple aspirate fluid (NAF)-yielding ducts were identified, cannulated, and lavaged primarily by an NP in collaboration with a breast surgeon. Samples with sufficient cellularity were categorized as benign, mild atypia, marked atypia, or malignant. Pain and adverse events were recorded. RESULTS: Thirty-seven women, with a mean age of 51.7 years, were enrolled. Thirty-one (83.8%) women yielded NAF and, of those, 28 (90.3%) had one or more ducts successfully cannulated. Of 65 lavaged ducts in these 28 women, cellularity was adequate for diagnosis in 44 (67.7%) samples. Cytologic findings were as follows: 24 benign, 15 mild atypia, 4 marked atypia, and 1 malignant. The procedure was well tolerated with a mean pain score of 3.2 (SD +/- 1.81). The most frequent adverse event was breast fullness, reported by 44.8% of the women. Two women with marked atypia were evaluated further and found to have intraductal papillomata. The woman with malignant cytology had ductal carcinoma in situ. CONCLUSION: DL is a safe, generally well-tolerated procedure that can be performed successfully by a trained NP.

Anatomy of the nipple and breast ducts revisited.

BACKGROUND: Increasing interest in the intraductal approach to the breast has necessitated revisiting the anatomy of the breast. METHODS: Using six different complementary in vivo and in vitro approaches, the authors determined the number, distribution, and anatomic properties of the ductal systems of the breast, which extend from the nipple orifices to the terminal duct lobular units. RESULTS: More than 90% of all nipples examined contained 5-9 ductal orifices, generally arranged as a central group and a peripheral group. Each nipple orifice communicated with a separate, nonanastomosing ductal system, which extended to the terminal duct lobular unit. CONCLUSIONS: Increased knowledge of the ductal anatomy of the breast and the ability to access the nipple ductal orifices will provide a foundation for the intraductal approach to the breast.

Feasibility and utility of using chromosomal aneusomy to further define the cytologic categories in nipple aspirate fluid specimens: a preliminary study.

BACKGROUND: There is renewed interest in using the cytologic changes in the epithelial cells obtained from specimens such as nipple aspiration fluid (NAF) and ductal lavage for risk stratification of women at increased risk for developing breast carcinoma. METHODS: Molecular tests such as fluorescence in situ hybridization (FISH) have the potential to be used as adjuncts to conventional cytology for more accurately categorizing cells in these types of specimens. The current study investigated the feasibility and utility of FISH analysis of aneusomy in chromosomes 1, 8, 11 and 17 as an adjunct to conventional cytology in the classification of NAF specimens. RESULTS: The authors found chromosomal aneusomy for at least one chromosome in all three malignant and both markedly atypical cases. Of the five cases classified as being mildy atypical on cytology, four were disomic, and only one showed aneusomy in chromosomes 8 and 11. CONCLUSIONS: The current study established the possibilities, limitations, and feasibility of using FISH in conjunction with routine cytology for a more accurate classification of ductal epithelial cells in NAF specimens. FISH-based detection of chromosomal aneusomy helped to define mild atypia, thereby aiding in the selection of the truly atypical cases for appropriate therapeutic intervention. In addition, FISH-based detection of chromosomal aneusomy can also be a valuable adjunct to conventional cytology in selected cases for confirming a benign, suspicious, or malignant diagnosis.

Detection of LOH and mitochondrial DNA alterations in ductal lavage and nipple aspirate fluids from hngh-risk patients.

We describe a method for the isolation of free DNA from ductal lavage (DL) and nipple aspirate fluid (NAF), and its evaluation for the presence of LOH at the BRCA1 and FHIT genes and for mitochondrial DNA (mtDNA) mutations at the D310 marker, to improve early detection of breast cancer. We evaluated 26 DL and six NAF samples from 14 women of known BRCA1 status, who have no clinical evidence of breast tumors: nine mutation carriers and five non-carriers. LOH studies at the BRCA1 locus were possible in 19/26 DL samples, and at the FHIT locus in 16/26 samples. In 4/9 mutation carriers we found LOH at the BRCA1 allele, and in two of these we also found LOH at the FHIT allele. In one of the mutation carriers with BRCA1 LOH, invasive breast cancer was subsequently detected, and the tumor showed the same LOH as the DL. In one of the true negatives, BRCA1 and FHIT LOH were detected. The mitochondrial studies were possible in all 26 DL samples and a somatic mutation was found in 3/9 carriers, two of whom also had LOH at the BRCA1 locus, and in none of the non-carriers. mtDNA mutation evaluation was possible in 4/6 NAF samples. The NAF and DL results were concordant. One NAF sample from a BRCA1 patient showed a mtDNA mutation. Our data demonstrates the feasibility of performing molecular studies using the free DNA present in the ductal fluid, while the intact cells can be used for cytologic studies.

Cytology of ductal lavage fluid of the breast.

The cytologic evaluation of nipple aspirate fluids has been shown to identify women at increased risk for developing breast cancer. One limitation of this assay is the often scant cellularity of the specimen. An improved technique, ductal lavage, utilizes a microcatheter inserted into individual breast ducts to collect large numbers of cells for cytologic evaluation. Epithelial cells in ductal lavage fluids can be categorized as benign, malignant, or showing mildly or markedly atypical changes. The cell characteristics which were most helpful in identifying abnormal cells were related to cell arrangement, cell size, nuclear size, and size variation, nuclear membrane irregularity, chromatin granularity, and the presence of large nucleoli. Cell size, nuclear size variation, and large nucleoli were the most robust features, as determined by agreement between two pathologists. Moderate cell enlargement and the presence of large nucleoli were the features selected by structured tree analysis for classifying the specimens into the diagnostic groups. The similarity of the cytology of ductal lavage fluid to nipple aspirate fluid strongly suggests that these specimens will also be useful for predicting breast cancer risk.