Evaluation of robustness in hybrid intensity-modulated radiation therapy plans generated by commercial software for automated breast planning.

This study aimed to evaluate the robustness against geometric uncertainties in the hybrid intensity-modulated radiation therapy (IMRT) plans generated by commercially available software for automated breast planning (ABP). The ABP plans were compared with commonly used forward-planned field-in-field (FIF) technique plans. The planning computed tomography datasets of 20 patients who received left-sided breast-conserving surgery were used for both the ABP and FIF plans. Geometric uncertainties were simulated by shifting beam isocenters by 2, 3, 5, and 10 mm in the six directions: anterior/posterior, left/right, and superior/inferior. A total of 500 plans (20 patients and 25 scenarios, including the original plan) were created for each of the ABP and FIF plans. The homogeneity index of the target volume in the ABP plans was significantly better (p < 0.001) than the value in the FIF plans in the scenarios of shifting beam isocenters by 2, 3, and 5 mm. Mean heart dose and percentage volume of lungs receiving a dose more than 20 Gy were clinically acceptable in all scenarios. The hybrid IMRT plans generated by commercially available ABP software provided better robustness against geometric uncertainties than forward-planned FIF plans.

Epigenetic modifications underlie the differential adipogenic potential of preadipocytes derived from human subcutaneous fat tissue.

Ceiling culture-derived preadipocytes (ccdPAs) and adipose-derived stem cells (ASCs) can be harvested from human subcutaneous fat tissue using the specific gravity method. Both cell types possess a similar spindle shape without lipid droplets. We previously reported that ccdPAs have a higher adipogenic potential than ASCs, even after a 7-wk culture. We performed a genome-wide epigenetic analysis to examine the mechanisms contributing to the adipogenic potential differences between ccdPAs and ASCs. Methylation analysis of cytosines followed by guanine (CpG) using a 450-K BeadChip was performed on human ccdPAs and ASCs isolated from three metabolically healthy females. Chromatin immunoprecipitation sequencing was performed to evaluate trimethylation at lysine 4 of histone 3 (H3K4me3). Unsupervised machine learning using t-distributed stochastic neighbor embedding to interpret 450,000-dimensional methylation assay data showed that the cells were divided into ASC and ccdPA groups. In Kyoto Encyclopedia of Genes and Genomes pathway analysis of 1,543 genes with differential promoter CpG methylation, the peroxisome proliferator-activated receptor (PPAR) and adipocytokine signaling pathways ranked in the top 10 pathways. In the PPARγ gene, H3K4me3 peak levels were higher in ccdPAs than in ASCs, whereas promoter CpG methylation levels were significantly lower in ccdPAs than in ASCs. Similar differences in promoter CpG methylation were also seen in the fatty acid-binding protein 4 and leptin genes. In conclusion, we analyzed the epigenetic status of adipogenesis-related genes as a potential mechanism underlying the differences in adipogenic differentiation capability between ASCs and ccdPAs.

Is Nipple-Sparing Mastectomy Indicated after Previous Breast Surgery? A Series of 387 Institutional Cases.

BACKGROUND: Previous breast surgery does not represent an absolute contraindication for nipple-sparing mastectomy, although it may negatively interfere with surgical outcomes. The aim of the authors' study was to confirm the feasibility of nipple-sparing mastectomy after previous breast surgery, focusing on skin incisions and risk factors, complications, and oncologic outcomes. METHODS: The authors retrospectively identified 368 patients who underwent 387 nipple-sparing mastectomies and reconstruction after previous surgery (quadrantectomy, breast resection, augmentation and reduction mammaplasty, mastopexy) at the European Institute of Oncology from January of 2003 to November of 2017. Patterns of skin incisions (i.e., radial, hemiperiareolar, periareolar, vertical pattern, inframammary fold, Wise-pattern, and round-block) for primary surgery and for mastectomy, type of reconstruction, and radiotherapy have been recorded. The authors collected data regarding early and late complications and further operations (implant change, fat grafting) performed within 2 years to improve cosmetic outcomes. Oncologic follow-up has been reported for in-breast recurrences. RESULTS: Complete and partial nipple-areola complex necrosis occurred, respectively, in 2.8 percent and in 5.4 percent of cases. The authors recorded 5.4 percent failures resulting in implant removal. The analysis of risk factors for complications or for the need for further operations showed no significant association with skin incision for first surgery and mastectomy, use of the same skin incision, previous radiotherapy, or type of primary surgery. Five-year overall survival and disease-free survival were 99.1 and 93.8 percent, respectively. No nipple recurrence was recorded. CONCLUSIONS: The authors' results confirm that nipple-sparing mastectomy can be a safe surgical procedure after previous breast surgery. Surgical planning should be tailored to each patient. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Type of Architecture, Presence of Punctate Necrosis, and Extent of Involvement in Atypical Ductal Hyperplasia Can Predict the Diagnosis of Breast Carcinoma on Excision: A Clinicopathologic Study of 143 Cases.

The literature shows a wide range in the frequencies of finding breast carcinoma in the excised specimens following a biopsy diagnosis of atypical ductal hyperplasia (ADH), likely due to a poor diagnostic reproducibility among different pathologists as well as an inherent heterogeneity in ADH. We evaluated whether histologic subtyping of ADH would help predict the risk of breast carcinoma. Our study consisted of 143 cases of ADH diagnosed by core needle biopsy and followed by excision. Of these, 54 cases (37.8%) showed carcinoma in the excised specimens (47 cases of ductal carcinoma in situ alone, 3 cases of invasive ductal carcinoma alone, and 4 cases of mixed invasive ductal carcinoma and ductal carcinoma in situ). We arbitrarily divided ADH into two subtypes: type A was considered when one or more ducts were completely replaced by low-grade ductal carcinoma in situ type cells but the lesion was <2 mm and type B was considered when one or more ducts were partially involved by low-grade ductal carcinoma in situ type cells regardless of lesion size. Type A was associated with a significantly higher frequency of breast carcinoma (63.6%) than type B (30.0%). ADH containing punctate necrosis showed a higher association of carcinoma (66.7%) compared to those without necrosis (35.1%). Within type B ADH, involvement of 3 or more foci had a higher frequency of carcinoma (50.0%) than involvement of fewer foci (26.6%). These histologic features of ADH may prove useful in predicting the likelihood of breast carcinoma and provide helpful information for patient's management.

Artefactual Epithelial Displacement in a Papilloma with Extensive Usual Duct Hyperplasia Mimics a Solid Papillary Carcinoma with Invasive Growth.

Mammary solid papillary carcinoma and usual duct hyperplasia (UDH) of the breast are morphological look-alikes, characterized by cellular streaming, solid growth, and a lack of high-grade nuclear atypia. Here, we report a challenging papillary lesion in the breast of a 48-year-old woman that presented with a double pitfall. A core needle biopsy showed a solid papillary proliferation of epithelial cells with oval to round overlapping nuclei, surrounded by a sclerotic stroma. This distorted lesion contained peripheral clefts and cellular streaming, without high-grade nuclear atypia. Immunohistochemistry showed diffuse heterogenous immunoreactivity for estrogen receptor and cytokeratin 5, and no immunoreactivity for chromogranin and synaptophysin. The immunohistochemical profile distinguished this sclerosed papilloma with extensive UDH from a solid papillary carcinoma. The lumpectomy specimen revealed a second challenge, where multiple epithelial islets without surrounding myoepithelial cells were observed near the papilloma, mimicking an invasive carcinoma. These islets displayed the same immunohistochemical profile as the sclerosed papilloma and they were surrounded by steatonecrosis and reactive fibroblasts, indicating epithelial displacement within the biopsy needle tract. A sclerosed papilloma with extensive UDH is a morphologically challenging mimic of a solid papillary carcinoma. Immunohistochemistry is helpful to distinguish both entities from one another. Extensive epithelial displacement in the biopsy tract made this case particularly challenging, as the displaced epithelial islets mimicked an invasive carcinoma. Pathologists should be aware of this uncommon double pitfall to prevent misdiagnosis.

Regenerative tissue filler for breast conserving surgery and other soft tissue restoration and reconstruction needs.

Complete removal of cancerous tissue and preservation of breast cosmesis with a single breast conserving surgery (BCS) is essential for surgeons. New and better options would allow them to more consistently achieve this goal and expand the number of women that receive this preferred therapy, while minimizing the need for re-excision and revision procedures or more aggressive surgical approaches (i.e., mastectomy). We have developed and evaluated a regenerative tissue filler that is applied as a liquid to defects during BCS prior to transitioning to a fibrillar collagen scaffold with soft tissue consistency. Using a porcine simulated BCS model, the collagen filler was shown to induce a regenerative healing response, characterized by rapid cellularization, vascularization, and progressive breast tissue neogenesis, including adipose tissue and mammary glands and ducts. Unlike conventional biomaterials, no foreign body response or inflammatory-mediated "active" biodegradation was observed. The collagen filler also did not compromise simulated surgical re-excision, radiography, or ultrasonography procedures, features that are important for clinical translation. When post-BCS radiation was applied, the collagen filler and its associated tissue response were largely similar to non-irradiated conditions; however, as expected, healing was modestly slower. This in situ scaffold-forming collagen is easy to apply, conforms to patient-specific defects, and regenerates complex soft tissues in the absence of inflammation. It has significant translational potential as the first regenerative tissue filler for BCS as well as other soft tissue restoration and reconstruction needs.

A Case of Adenomyoepithelioma With a Pleomorphic Adenoma-Like Component of the Male Breast.

Adenomyoepithelioma (AME) of the male breast is a rare tumor characterized by biphasic proliferation of gland epithelial cells and myoepithelial cells. Though pleomorphic adenoma (PA) is also known to be an epithelial-myoepithelial tumor in the breast, and these tumors are considered to exist on the same spectrum by some authors, to the best of our knowledge, there have been no reports of a clear transition from AME to PA in the male breast. Therefore, the case of an 85-year-old man with AME with PA-like components is presented.

Mixed Invasive Apocrine Papillary/Micropapillary Carcinoma of the Breast: Another Brick in the Triple-Negative Wall.

Pure invasive papillary carcinoma (IPC) is a rare subtype of breast carcinoma with good prognosis compared with classical invasive breast carcinoma (IBC) of no special type. The majority of IPC are estrogen receptor and progesterone receptor (ER/PR) positive and HER2 negative (luminal A-like). We report the case of a 72-year-old women who was referred to the Senology Clinic for a routine workup following surgery for an intraductal papilloma. The core needle biopsy (CNB) showed a lesion mainly composed of irregular papillae and micropapillae with apocrine epithelial cells of low-to-intermediate nuclear grade, without a myoepithelial cell layer within the papillae and at the periphery, as demonstrated with multiple immunostains. The diagnosis of apocrine papillary lesion of uncertain malignant potential was made. The subsequent lumpectomy showed an IBC with the same cyto-architectural features as the CNB. In addition, lymphovascular invasion and papillary/micropapillary apocrine in situ lesion were noted. Notably, the tumor was ER/PR and HER2 negative and strongly positive for androgen receptor. A final diagnosis of mixed apocrine papillary/micropapillary carcinoma with triple-negative status was made. To the best of our knowledge, this is the first report of an IBC with these features. Breast pathologists should be aware of this entity when dealing with CNB samples characterized by a complex papillary lesion with apocrine atypia that lacks a myoepithelial cell layer on multiple immunostains. These lesions should be classified at least as of uncertain malignant potential based on the cyto-architectural features prompting a surgery for removal.

Detection of breast cancer precursor lesions by autofluorescence ductoscopy.

PURPOSE: Autofluorescence is an image enhancement technique used for the detection of cancer precursor lesions in pulmonary and gastrointestinal endoscopy. This study evaluated the feasibility of addition of autofluorescence to ductoscopy for the detection of intraductal breast cancer precursor lesions. METHODS: An autofluorescence imaging system, producing real-time computed images combining fluorescence intensities, was coupled to a conventional white light ductoscopy system. Prior to surgery, ductoscopy with white light and autofluorescence was evaluated under general anaesthesia in women scheduled for therapeutic or prophylactic mastectomy. Endoscopic findings in both modes were compared, marked and correlated with histology of the surgical specimen. RESULTS: Four breast cancer patients and five high-risk women, with a median age of 47 years (range 23-62) were included. In autofluorescence mode, two intraductal lesions were seen in two breast cancer patients, which had an increase in the red-to-green fluorescence intensity compared with the surrounding tissue. One lesion had initially been missed by white light ductoscopy but was clearly visible in subsequent autofluorescence mode. One endoscopic finding was classified as suspicious by white light, but was negative in autofluorescence mode and showed normal histology. CONCLUSIONS: This study demonstrates for the first time the in vivo feasibility of autofluorescence ductoscopy to detect pathologically confirmed breast cancer precursor lesions in both breast cancer patients and high-risk women that were occult under white light.

Comma-Shaped Incision for Reduction Mammoplasty and Mastopexy.

OBJECTIVE: Various skin incision methods have been reported for reduction mammoplasty and mastopexy. This report describes a new incision method that may improve on conventional methods, particularly with respect to prevention of hypertrophic scars. METHODS: We developed a comma-shaped incision method that results in fewer scars and less strain on the suture line. We then applied this new method to two cases, namely, one case of breast reduction and one case of breast fixation. RESULTS: In both cases, we achieved good results. There was no scar at the inframammary fold, and no hypertrophic scar formation. All scars were within the breast area and were not in contact with the brassiere wire; hence, there was less pain after the operation. CONCLUSIONS: We developed a new incision method for reduction mammoplasty and mastopexy.

Gene expression profile of normal breast tissue and body mass index.

BACKGROUND: In human breast, adipose tissue represents up to 80% of the total volume and plays a critical role in mammary gland remodeling. Given the emerging role of obesity in breast cancer growth and development, we explored the relationship between body mass index (BMI), as a proxy of woman's obesity status, and the expression in normal breast tissue from healthy women of a selected panel of genes, known to be involved in mammary gland homeostasis. METHODS: Two independent publicly available datasets, composed of 180 specimens of normal breast tissue from reduction mammoplasty were interrogated. Differential gene expression among BMI classes was evaluated by ANOVA, and partial correlation coefficient was used to assay the correlation between genes controlling for BMI. RESULTS: Despite the differences in microarray platforms and analytical procedures, the two datasets shared a core of 9 genes differentially expressed in BMI classes and significantly correlated with BMI. Four (44%) of these genes belong to the functional class of cytokines and cytokine receptors (IL1R1, IL2RA, IL12A, and IL12RB2). The others belong to the functional class of the epigenetic regulation (MEDAG and SETD7), signal transduction (STAT1), cell adhesion (ITGAV), and enzymatic activity (STS). CONCLUSIONS: Although exploratory, present findings are in agreement with the role of inflammation modulators in the homeostasis of normal breast tissue and the believe that an increase in body adipose tissue may have a potentially dangerous local effect, through the increased expression of inflammation-related genes and the establishment of a low-grade chronic inflammation.

Remodelación autóloga mamaria. Importancia de la transferencia grasa y uso de los colgajos dermograsos locales en las grandes pérdidas ponderales / Autologous breast remodeling. Importance of fat transfer and use of local dermal-fat flaps in the massive weigth loss

INTRODUCCIÓN Y OBJETIVO: El aumento de la cirugía bariátrica como alternativa al tratamiento tanto del síndrome metabólico como de la obesidad y el sobrepeso, conlleva múltiples deformidades corporales, entre las que unas de las más complejas son las alteraciones mamarias. Su tratamiento quirúrgico depende de un diagnóstico y técnica adecuados, capaces de remodelar la estética mamaria. El objetivo de esta investigación es definir la importancia del injerto de grasa como procedimiento previo a la mamoplastia en pacientes que han sufrido grandes pérdidas ponderales. MATERIAL Y MÉTODO: Realizamos un estudio retrospectivo, lineal, en 124 pacientes sometidas a 158 procedimientos quirúrgicos consecutivos entre enero de 2009 y diciembre de 2019, con rango de edad entre 18 y 72 años. Evaluamos los procedimientos para la corrección de las diversas deformidades mamarias tales como, hipotrofia o atrofia mamaria, ptosis, asimetrías, posicionamiento lateralizado del complejo areola pezón, pérdida de la proyección del polo superior, flacidez cutánea asociada a lipodistrofia corporal persistente, cirugías previas de contorno corporal, así como la edad y el índice de masa corporal (IMC). RESULTADOS: El mayor porcentaje de procedimientos correspondió a la triple interposición de colgajos (28%, 44 procedimientos), seguida del injerto de grasa mamaria (27%, 42 procedimientos) y la triple interposición de colgajos con implante de silicona (19%, 30 procedimientos). Se realizó injerto graso mamario en un 40.50% de los procedimientos realizados, con una media de volumen graso infiltrado de 450.60 ml. CONCLUSIONES: Recomendamos la realización de injertos de grasa en todas las pacientes sometidas a cirugía de remodelación mamaria secundaria a pérdida masiva de peso con el fin de recomponer volumétricamente la mama y reconstruir estructuras cutáneas, parenquimatosas y musculares, siendo la transferencia de grasa mamaria la única forma de relleno definitiva del polo superior. Los colgajos locales representan no solo una forma de aumento volumétrico de la mama sino también una posibilidad de mejorar el contorno mamario y el segmento superior del cuerpo

BACKGRAUND AND OBJECTIVE: The increase in bariatric surgery as an alternative to the treatment of both the metabolic syndrome and obesity and overweight leads to multiple bodily deformities, among these one of the most complex are mammary alterations. The surgical treatment of these alterations depends on an adequate diagnosis and a suitable technique able to reshape the mammary aesthetics. The objective of this research is to define the importance of fat grafting as a procedure prior to breast-plasty in patients with post-weight loss. METHODS: A retrospective and linear study was performed in 124 patients, who underwent 158 consecutive procedures between January 2009 and December 2019, age range between 18 and 72 years. The evaluated procedures allowed correction of different breast deformities such as hypotrophy or breast atrophy, ptosis, asymmetries, lateral positioning of the nipple areola complex, loss of the upper pole projection, skin flaccidity associated with persistent body lipodystrophy, previous body contour surgeries, and patient's age and body mass index (BMI). RESULTS: A total of 158 procedures were performed which the highest percentage was of triple flap interposition (28%, 44 procedures), followed by breast fat grafting (27%, 42 procedures) and triple flap interposition with silicone implants (19%, 30 procedures). The fat graft to breast was performed in 40.50% of the total procedures performed, with a mean infiltrated fat volume corresponded to 450.60 ml. CONCLUSIONS: We recommend performing fat grafts in all patients undergoing breast remodeling procedures after massive weight loss in order to volumetrically recompose the breast and rebuild skin, parenchymal and muscular structures, with breast fat transfer being the only way definitive filling of the upper pole. In addition, local flaps represent not only a form of volumetric augmentation of the breast but also a possibility of improving the breast contour and upper body segment

Intracystic papillary carcinoma: clinical presentation, patterns of practice, and oncological outcomes.

BACKGROUND: Intracystic/encapsulated papillary carcinoma remains a poorly understood disease of the breast with a little amount of reports that describe it. It shares features with DCIS and IDC and predominantly affects postmenopausal women. This study aims to evaluate the clinical presentation, treatment, and outcomes in IPC patients managed at our institution. METHODS: We retrospectively pooled twenty-eight IPC patients' medical records at our institution. Descriptive analysis of clinicopathological characteristics, approach, and outcomes was done along with a quantitative statistical analysis. RESULTS: Cases were divided into three groups: isolated IPC, IPC associated with DCIS, and IPC associated with Invasive Carcinoma. Treatment modalities varied according to the IPC type and its associated components. All patients presented with a palpable mass. Immunohistochemical staining revealed that all isolated IPCs were ER and PR positive and HER2 negative. Lymph node dissection proved necessary only in IPC associated invasive carcinoma. Irregular borders and lobulations, among others, were found on non-invasive core biopsies that turned out to be associated with invasion on surgical pathology. All patients were alive after a median follow-up time of 23 months when the study was over with no reports of recurrence. CONCLUSION: IPC cases and treatment approaches at our institution appear similar to the available literature and confirm the excellent prognosis among IPC. Even more, further studies into the key features such as BMI, family history, and radiological findings are necessary for a potential algorithm that could assess for risk of finding invasion in surgical pathology and subsequently the need for axillary/sentinel lymph node biopsy.

Efficacy and safety of topical nitroglycerin in the prevention of mastectomy flap necrosis: a systematic review and meta-analysis.

Flap necrosis is a common complication after mastectomy, and nitroglycerin (NTG) ointment has been used successfully to treat it. However, it is not clear whether topical NTG can completely prevent the occurrence of flap necrosis after breast cancer surgery, and it is also unclear whether this treatment may cause side effects. Three randomized controlled trials (RCTs) and two retrospective cohort studies (RCSs) were included in our investigation. This meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We found that NTG significantly reduced the rates of mastectomy flap necrosis, full-thickness flap necrosis, and debridement as well as the rate of early complications other than flap necrosis. However, there was no significant difference in drug-related adverse reactions, explantation, superficial flap necrosis, infection, hematoma or seroma between the NTG and placebo groups.

Langerhans cell histiocytosis of an intra-mammary lymph node in an 18-year-old woman.

We describe an 18-year-old woman with several month's history of a 12 x 7 mm palpable mammary nodule, that was hypoechoic, with regular margins and vascularization areas by ultrasound. A fibroadenoma was hypothesized (American College of Radiology BI-RADS 3). A 14 G needle biopsy was performed, showing a LC proliferation suspected for LCH of a lymph node, with florid dermatopathic lymphadenopathy in differential diagnosis. The multidisciplinary team of the breast clinic decided to perform a lumpectomy and a diagnosis of LCH involving an intra-mammary lymph node was made. Langerhans cells (LC) are dendritic cells characterized by grooved nuclei, irregular nuclear contours, and abundant cytoplasm, that normally reside in the skin and mucosal surfaces. They were positive for CD1a, langerin/CD207, and S100 by immunohistochemistry. Langerhans cell histiocytosis (LCH) is a clonal proliferation of histiocytes that is thought to be neoplastic in most cases. Reactive LC can be distinguished from LCH by cyclin D1 immunostaining, which is positive only in LCH. About 50% of cases have BRAF V600E mutations. The revised classification of histiocytes divides LCH in subtypes: LCH SS (single system), LCH lung positive, LCH Multiple System/Risk Organ negative and LCH Multiple System/Risk Organ positive. Localized disease can progress to multisystem involvement. The diagnosis of LCH is based on clinical and radiological findings in combination with histopathological, immunophenotypic or ultrastructural analyses identifying tissue infiltration by LC. It is recommended that biopsy confirmation of suspected LCH be performed in all cases. Lymph nodes may be the only site of disease or a part of multisystem involvement by LCH. The histologic differential diagnosis is discussed.

Interventional Ductoscopy as an Alternative for Major Duct Excision or Microdochectomy in Women Suffering Pathologic Nipple Discharge: A Single-center Experience.

INTRODUCTION: Pathologic nipple discharge (PND) is, after palpable lumps and pain, the most common breast-related reason for referral to the breast surgeon and is associated with breast cancer. However, with negative mammography and ultrasound, the chance of PND being caused by malignancy is between 5% and 8%. Nevertheless, most patients with PND still undergo surgery in order to rule out malignancy. Ductoscopy is a minimally invasive endoscopic technique that enables direct intraductal visualization. The aim of this study was to evaluate (interventional) ductoscopy as an alternative to surgery in patients with negative conventional imaging. MATERIALS AND METHODS: All patients with PND referred between 2010 and 2017 to our hospital for ductoscopy were retrospectively analyzed. Ductoscopy procedures were performed under local anesthesia in the outpatient clinic. The follow-up period was at least 3 months, and the primary outcome was the number of prevented surgical procedures. Furthermore, we evaluated possible complications after ductoscopy (infection and pain). RESULTS: A total of 215 consecutive patients undergoing ductoscopy were analyzed. In 151 (70.2%) patients, ductoscopy was successful. In 102 procedures, an underlying cause for PND was visualized, of which 34 patients could be histologically proven and 82 patients treated. Sixty of the 215 patients were eventually operated, 8 owing to suspicious findings during ductoscopy, 42 owing to persistent PND, and 10 because of recurrent PND. In 7 patients, a malignancy was found (5 of them classified as suspicious at dusctoscopy). No serious side effects were seen. CONCLUSION: Ductoscopy can be safely used as an alternative for surgery in the workup for PND.

Could ductoscopy alleviate the need of microdochectomy in pathological nipple discharge?

BACKGROUND: Microdochectomy is the gold-standard for definitive diagnosis for pathological nipple discharge (PND); however, problem of over-treating exists since majority of PND are self-limiting and due to benign causes. Ductoscopy may assist diagnosis, and triage patients for intervention or expectant management. This study aimed to evaluate if ductoscopy could reduce unnecessary microdochectomy but not compromising the diagnosis of malignancy. METHOD: A multicenter, retrospective study was conducted in consecutive patients of PND without a suspected malignancy on routine diagnostic evaluation. Ductoscopy was performed with attempts to remove intraductal lesions if they were found. Microdochectomy was carried out if there were positive intraductal lesions, but failed endoscopic extraction, or failed ductoscopy and persistent PND. Efficacy of ductoscopy was determined by cannulation success rate, number of avoided surgery and number of missed malignancy. RESULTS: In a 3-year period between 2016 and 2018, a total of 223 ductoscopy were performed and 94.2% had successful cannulation. Within such, 59.5% (N = 125) had intraductal mass identified, and 82 microdochectomy were carried out. The final histology showed 15 malignancy, making the overall malignancy rate 6.7%. Ductoscopy successful and negative patients (N = 85, 37.8%) were triaged for surveillance and the malignancy rate is 0% in a median follow-up of 2 years; hence, microdochectomy was avoided. CONCLUSION: PND with non-suspicious conventional imaging and negative ductoscopy have rare malignancy rate which makes subsequent microdochectomy unnecessary. However, intraductal mass in ductoscopy is a predictor for malignancy so definitive histology diagnosis is mandatory.

Galactogram Grading System for Identifying Breast Cancer With Nipple Discharge.

BACKGROUND: Galactography is a primary recommendation in the management of nipple discharge (ND), which may be caused by benign or malignant lesions. We aimed to establish a galactogram grading system (GGS) and investigate its role in identifying breast cancer with ND. PATIENTS AND METHODS: A total of 350 patients were included in our study. All patients received preoperative mammographic galactography successfully and underwent surgery at Qilu Hospital of Shandong University between January 2011 and August 2015. We first performed a retrospective study in a consecutive series of 250 patients with ND to establish a GGS. Then the subsequent consecutive series of 100 patients was analyzed to validate the grading system. RESULTS: Our data showed that the GGS can well assess the risk of a galactogram's being malignant. Galactograms classified into grade I have a lower risk of being malignant, while those classified into grade III have a higher risk of being malignant. Thus, our GGS was useful for distinguishing malignant from benign lesions. CONCLUSION: We established a scoring system for breast disease with ND. This GGS may be a novel approach for identifying breast cancer with ND.