Breast duct microendoscopy in nipple discharge: microbrush improves cytology

Systematic review and meta-analysis of the diagnostic accuracy of ductoscopy in patients with pathological nipple discharge

Background

Invasive surgery remains the standard for diagnosis of pathological nipple discharge (PND). Only a minority of patients with nipple discharge and an unsuspicious finding on conventional breast imaging have cancer. Ductoscopy is a minimally invasive alternative for evaluation of PND. This systematic review and meta-analysis was designed to evaluate the diagnostic accuracy of ductoscopy in patients with PND.

Methods

A systematic search of electronic databases for studies addressing ductoscopy in patients with PND was conducted. Two classification systems were assessed. For DSany, all visualized ductoscopic abnormalities were classified as positive, whereas for DSsusp, only suspicious findings were considered positive. After checking heterogeneity, pooled sensitivity and specificity of DSany and DSsusp were calculated.

Results

The search yielded 4642 original citations, of which 20 studies were included in the review. Malignancy rates varied from 0 to 27 per cent. Twelve studies, including 1994 patients, were eligible for meta-analysis. Pooled sensitivity and specificity of DSany were 94 (95 per cent c.i. 88 to 97) per cent and 47 (44 to 49) per cent respectively. Pooled sensitivity and specificity of DSsusp were 50 (36 to 64) and 83 (81 to 86) per cent respectively. Heterogeneity between studies was moderate to large for sensitivity (DSany: I2 = 17·5 per cent; DSsusp: I2 = 37·9 per cent) and very large for specificity (DSany: I2 = 96·8 per cent; DSsusp: I2 = 92·6 per cent).

Conclusion

Ductoscopy detects about 94 per cent of all underlying malignancies in patients with PND, but does not permit reliable discrimination between malignant and benign findings.

Nipple discharge: role of ductoscopy in comparison with standard diagnostic tests

BACKGROUND

This study aims to assess the role of ductoscopy for detecting intraductal anomalies in patients with nipple discharge in comparison to conventional tests and to find an effective combination of both approaches.

MATERIALS AND METHODS

Prior to duct excision, ductoscopy was performed in 97 women. Histologic and all other diagnostic results were compared. Sensitivity, specificity, and efficiency were calculated for all methods. These parameters were also calculated for all possible test combinations in 12 patients who had completed all tests.

RESULTS

Breast sonography reached the highest sensitivity (64.1%) and efficiency (64%); mammography had the highest specificity (100%). The sensitivity of ductoscopy was 53.2%, its specificity 60%, and its efficiency 55.1%. Among combinations of all methods, the combination ductoscopy + galactography was the most sensitive (80%). Mammography, magnetic resonance imaging, and ductoscopy were each 100% specific. Ductoscopy was the most efficient (75%) single method.

CONCLUSION

Ductoscopy is a valuable test for diagnosing intraductal lesions in patients with nipple discharge. It is more efficient than conventional tests in patients undergoing all tests.

Duct Excision is Still Necessary to Rule out Breast Cancer in Patients Presenting with Spontaneous Bloodstained Nipple Discharge

Introduction. Spontaneous nipple discharge is the third most common reason for presentation to a symptomatic breast clinic. Benign and malignant causes of spontaneous nipple discharge continue to be difficult to distinguish. We analyse our experience of duct excisions for spontaneous nipple discharge to try to identify features that raise suspicion of breast cancer and to identify features indicative of benign disease that would be suitable for nonoperative management. Methods. Details of one hundred and ninety-four patients who underwent duct excision for spontaneous nipple discharge between 1995 and 2005 were analysed. Results. Malignant disease was identified in 11 (5.7%) patients, 4 invasive and 7 insitu, which was 10.2% of those presenting with bloodstained discharge. All patients with malignant disease had bloodstained discharge. Discharge due to malignant disease was more likely to be bloodstained than that due to benign causes (Fisher's exact test, 2-tailed P value = 0.00134). Conclusion. Our findings do not support a policy of conservative management of spontaneous bloodstained nipple discharge. Cases of demonstrable spontaneous bloodstained nipple discharge should undergo duct excision to prevent malignant lesions being missed.

[The role of ductoscopy in the modern diagnostics and therapy of breast diseases]

Mammary ductoscopy is a modern, minimally invasive procedure that enables direct, in vivo observation of the mammary ductal system, primarily by nipple discharge. The rapidly developing device is suitable for aimed biopsy for further cytological or molecular examinations. High-tech equipments facilitate polypectomy or laser vaporization of certain intraluminal lesions, and play an important role in the direct surgical excision of the duct or the so-called terminal duct-lobular unit. The above listed facilitate the early diagnosis of malignancies even before imaging could detect them, and the control of high risk patients. Ductoscopy can foster surgical removal of ductal in situ tumors as anatomical units, thus enabling the optimization of radicality of breast conserving surgeries. Authors give a detailed description of the surgical techniques, and provide a wide review of the literature, for the first time in the Hungarian language. Orv. Hetil., 2011, 152, 1284-1293.

Selective microdochectomy after ductoscopic wire marking in women with pathological nipple discharge

Background

To investigate the diagnostic reliability of selective microdochectomy after direct ductoscopic wire marking of suspect lesions in patients with pathological nipple discharge.

Methods

Selective microdochectomy due to pathological discharge was performed in 33 patients with mean age of 51.7 years. Ductoscopes of 0.9 and 1.1 mm in diameter with a channel for wire marking were used. Only patients without sonographic or mammographic correlation for the discharge were included. The pathologic mammary duct was wire marked and extirpated under direct visual guidance via the ductoscope. The histological results were compared with cytology, galactography and ductoscopy.

Results

In 24 out of 33 cases (72%) an intraductal, epithelial proliferation was found histologically. The following sensitivities for intraductal, epithelial proliferations could be determined: cytology 4%, galactography 74%, and ductoscopy 78%.

Conclusion

The method allows selective microdochectomy of the pathological duct and the intraductal proliferation under visual guidance. The resection volume can be reduced in contrast to the unselective ductectomy after injection of methylene blue.

Depressive symptoms and proinflammatory cytokine levels in chronic renal failure patients

BACKGROUND/AIMS

Cytokine secretion is known to play an important role in the pathophysiology of depression, and levels of proinflammatory cytokines are increased in chronic renal failure (CRF) patients. The objective of this study was to examine the correlation between levels of proinflammatory cytokines in CRF patients and degree of depression.

METHODS

31 patients on hemodialysis, 31 patients on continuous ambulatory peritoneal dialysis, and 31 conservatively managed chronic kidney disease (CKD) patients were enrolled in this study. Depressive symptoms were measured with the Beck Depression Inventory (BDI), and 'elevated symptoms of depression' were defined as a BDI score > or =17. IL-6 and TNFalpha cytokine levels were measured by ELISA.

RESULTS

'Elevated symptoms of depression' occurred in 37 of 93 patients (40%). IL-6 and TNFalpha levels were not significantly different among CRF patients with and without elevated depressive symptoms (p = 0.937 and p = 0.414, respectively). When analyzed by treatment subgroup, proinflammatory cytokine levels were not significantly different in patients with and without elevated symptoms of depression.

CONCLUSION

In patients with CRF, elevated symptoms of depression were not associated with increased cytokine levels.

Evaluating nipple discharge

Nipple discharge is the third most common breast complaint after breast pain and breast mass. It is most often a benign process. Up to 50% women in their reproductive years can express one or more drops of fluid from the breast. Nipple discharge can be of several types, including milky, multicolored and sticky, purulent, clear and watery, yellow or serous, pink or serosanguinous, bloody or sanguinous. The characteristics of the nipple discharge help in the early diagnosis and management of breast disease. The most common cause of pathologic nipple discharge is a benign papilloma followed by ductal ectasia, and the least likely is carcinoma. Most nipple discharges are the result of a clinically insignificant benign process; therefore, less invasive, nonsurgical diagnostic modalities have been explored to reduce the need for surgical intervention. The evaluation and diagnosis of nipple discharge is important for the early detection of carcinoma, when present; and, in the case of benign disease, it is necessary to stop the incommodious discharge.