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Jiwa N, Kumar S, Gandhewar R, Chauhan H, Nagarajan V, Wright C, Hadjiminas D, Takats Z, Ashrafian H, Leff DR. Diagnostic Accuracy of Nipple Discharge Fluid Cytology: A Meta-Analysis and Systematic Review of the Literature. Ann Surg Oncol 2021; 29:1774-1786. [PMID: 34839426 PMCID: PMC8627297 DOI: 10.1245/s10434-021-11070-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 10/28/2021] [Indexed: 01/07/2023]
Abstract
Background Nipple discharge is the third most frequent complaint of women attending rapid diagnostic breast clinics. Nipple smear cytology remains the single most used diagnostic method for investigating fluid content. This study aimed to conduct a systematic review and meta-analysis of the diagnostic accuracy of nipple discharge fluid assessment. Methods The study incorporated searches for studies interrogating the diagnostic data of nipple discharge fluid cytology compared with the histopathology gold standard. Data from studies published from 1956 to 2019 were analyzed. The analysis included 8648 cytology samples of women with a presenting complaint of nipple discharge. Both hierarchical and bivariate models for diagnostic meta-analysis were used to attain overall pooled sensitivity and specificity. Results Of 837 studies retrieved, 45 fulfilled the criteria for inclusion. The diagnostic accuracy of the meta-analysis examining nipple discharge fluid had a sensitivity of 75 % (95 % confidence interval [CI], 0.74–0.77) and a specificity of 87 % (95 % CI, 0.86–0.87) for benign breast disease. For breast cancer, it had a sensitivity of 62 % (95 % CI, 0.53–0.71) and a specificity 71 % (95 % CI, 0.57–0.81). Furthermore, patients presenting with blood-stained discharge yielded an overall malignancy rate of 58 % (95 % CI, 0.54–0.60) with a positive predictive value (PPV) of 27 % (95 % CI, 0.17–0.36). Conclusions Pooled data from studies encompassing nipple discharge fluid assessment suggest that nipple smear cytology is of limited diagnostic accuracy. The authors recommend that a tailored approach to diagnosis be required given the variable sensitivities of currently available tests. Supplementary Information The online version contains supplementary material available at 10.1245/s10434-021-11070-2.
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Affiliation(s)
- Natasha Jiwa
- Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, London, UK.
| | | | - Rishikesh Gandhewar
- Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, London, UK
| | - Hemali Chauhan
- Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, London, UK
| | | | - Corrina Wright
- Northwest London Pathology, Imperial College Healthcare Trust, London, UK
| | - Dimitri Hadjiminas
- Department of Breast Surgery, Imperial College Healthcare Trust, London, UK
| | - Zoltan Takats
- Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, London, UK
| | - Hutan Ashrafian
- Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, London, UK
| | - Daniel Richard Leff
- Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, London, UK.,Department of Breast Surgery, Imperial College Healthcare Trust, London, UK
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Lyons D, Wahab RA, Vijapura C, Mahoney MC. The nipple-areolar complex: comprehensive imaging review. Clin Radiol 2020; 76:172-184. [PMID: 33077158 DOI: 10.1016/j.crad.2020.09.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 09/11/2020] [Indexed: 10/23/2022]
Abstract
The nipple-areolar complex can be affected by a variety of benign and malignant entities that can present with non-specific symptoms. Benign pathologies commonly affecting the nipple-areolar complex include nipple calcifications, nipple adenoma, abscess of Montgomery tubercles, ductal ectasia, periductal mastitis, and papilloma. Malignant pathologies that affect the nipple-areolar complex include Paget's disease of the breast, ductal carcinoma in-situ, and invasive ductal carcinoma. Clinical history and examination, imaging, and tissue sampling when appropriate are co-dependent factors that guide the assessment of nipple-areolar pathologies. This article provides a review of the normal anatomy, common anatomical variants, benign and malignant pathologies, and imaging techniques to guide the diagnostic assessment of the nipple-areolar complex.
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Affiliation(s)
- D Lyons
- Department of Radiology, University of Cincinnati Medical Center, 234 Goodman Street, ML 0772, Cincinnati, OH, 45219-0772, USA.
| | - R A Wahab
- Department of Radiology, University of Cincinnati Medical Center, 234 Goodman Street, ML 0772, Cincinnati, OH, 45219-0772, USA
| | - C Vijapura
- Department of Radiology, University of Cincinnati Medical Center, 234 Goodman Street, ML 0772, Cincinnati, OH, 45219-0772, USA
| | - M C Mahoney
- Department of Radiology, University of Cincinnati Medical Center, 234 Goodman Street, ML 0772, Cincinnati, OH, 45219-0772, USA
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Evaluation and management of pathological nipple discharges without using intraductal imaging methods. Ir J Med Sci 2019; 189:451-460. [PMID: 31631245 DOI: 10.1007/s11845-019-02107-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 09/21/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND The most common cause of pathological nipple discharge (PND) is single papilloma, which is a benign intraductal lesion (BIL). However, underlying malign (MIL) or high-risk intraductal lesions (HIL) should be considered during examination. AIM To reveal the value of conventional imaging methods (CIM), discharge characteristics, and cytology in lack of intraductal imaging methods to detect intraductal lesions (IL) and MIL that cause PND. METHODS We compared the pathological findings with the characteristics of discharge, CIM, and cytology findings of the patients who admitted to our clinic with nipple discharge and underwent duct excision (n = 111). RESULTS IL were detected in 69 (62.2%) patients as BIL (n = 31), HIL (n = 23), and MIL (n = 15). Most of the IL was observed with bloody, serosanguineous, and serous discharges (83.3%, 76.2%, and 69.2%, respectively). The sensitivities of ultrasonography, MRI, and cytology in detecting IL were found to be 50.7%, 42.6%, and 74.1%, while their specificities were found to be 73.8%, 88.2%, and 48.6%, respectively. None of the CIM was sufficient to detect MIL in 5 (33.3%) patients. The appearance of red blood cells detailed in cytology was significantly related to IL (p < 0.01), whereas the presence of inflammatory cells was related to ductal ectasia and periductal mastitis (p < 0.001). CONCLUSIONS Although patients' physical examinations, CIM, and cytology findings were normal, duct excision procedures should be applied to exclude MIL or HIL, which can be a cause of discharge in case of suspicious color. The details in cytology reports have a role in increasing the value of cytology.
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Zacharioudakis K, Kontoulis T, Vella JX, Zhao J, Ramakrishnan R, Cunningham DA, Mufti RA, Leff DR, Thiruchelvam P, Hogben K, Hadjiminas DJ. Can we see what is invisible? The role of MRI in the evaluation and management of patients with pathological nipple discharge. Breast Cancer Res Treat 2019; 178:115-120. [PMID: 31352554 PMCID: PMC6790184 DOI: 10.1007/s10549-019-05321-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 06/11/2019] [Indexed: 01/03/2023]
Abstract
Introduction The aim of this study was to determine the ability of MRI to identify and assess the extent of disease in patients with pathological nipple discharge (PND) with an occult malignancy not evident on standard pre-operative evaluation with mammography and ultrasound. Methods Patients presenting to the breast unit of Imperial College Healthcare NHS Trust between December 2009 and December 2018 with PND and normal imaging were enrolled in the study. Pre-operative bilateral breast MRI was performed in all patients as part of our protocol and all patients were offered diagnostic microdochectomy. Results A total of 82 patients fulfilled our selection criteria and were enrolled in our study. The presence of an intraductal papilloma (IDP) was identified as the cause of PND in 38 patients (46.3%), 14 patients had duct ectasia (DE-17%) and 5 patients had both an IDP and DE. Other benign causes were identified in 11 patients (13.4%). Despite normal mammography and ultrasound a malignancy was identified in 14 patients (17%). Eleven patients had DCIS (13.4%), two had invasive lobular carcinoma and one patient had an invasive ductal carcinoma. The sensitivity of MRI in detecting an occult malignancy was 85.71% and the specificity was 98.53%. The positive predictive value was 92.31% and the negative predictive value was 97.1%. Conclusions Although a negative MRI does not exclude the presence of an occult malignancy the high sensitivity and specificity of this diagnostic modality can guide the surgeon and alter the management of patients with PND.
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Affiliation(s)
- Konstantinos Zacharioudakis
- Breast Unit, Charring Cross Hospital, Imperial College Healthcare NHS Trust, Fulham Palace Rd, Hammersmith, London, W6 8RF, UK. .,Breast Unit, Nightingale Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Southmoor Road, Wythenshawe, Manchester, M23 9LT, UK.
| | - Theodoros Kontoulis
- Breast Unit, Charring Cross Hospital, Imperial College Healthcare NHS Trust, Fulham Palace Rd, Hammersmith, London, W6 8RF, UK
| | - John X Vella
- Breast Unit, Charring Cross Hospital, Imperial College Healthcare NHS Trust, Fulham Palace Rd, Hammersmith, London, W6 8RF, UK
| | - Jade Zhao
- Breast Unit, Charring Cross Hospital, Imperial College Healthcare NHS Trust, Fulham Palace Rd, Hammersmith, London, W6 8RF, UK
| | - Rathi Ramakrishnan
- Breast Unit, Charring Cross Hospital, Imperial College Healthcare NHS Trust, Fulham Palace Rd, Hammersmith, London, W6 8RF, UK
| | - Deborah A Cunningham
- Breast Unit, Charring Cross Hospital, Imperial College Healthcare NHS Trust, Fulham Palace Rd, Hammersmith, London, W6 8RF, UK
| | - Ragheed Al Mufti
- Breast Unit, Charring Cross Hospital, Imperial College Healthcare NHS Trust, Fulham Palace Rd, Hammersmith, London, W6 8RF, UK
| | - Daniel Richard Leff
- Breast Unit, Charring Cross Hospital, Imperial College Healthcare NHS Trust, Fulham Palace Rd, Hammersmith, London, W6 8RF, UK.,Department of Surgery and Cancer Imperial College London, Ayrton Rd, Kensington, London, SW7 5NH, UK
| | - Paul Thiruchelvam
- Breast Unit, Charring Cross Hospital, Imperial College Healthcare NHS Trust, Fulham Palace Rd, Hammersmith, London, W6 8RF, UK
| | - Katy Hogben
- Breast Unit, Charring Cross Hospital, Imperial College Healthcare NHS Trust, Fulham Palace Rd, Hammersmith, London, W6 8RF, UK
| | - Dimitri J Hadjiminas
- Breast Unit, Charring Cross Hospital, Imperial College Healthcare NHS Trust, Fulham Palace Rd, Hammersmith, London, W6 8RF, UK
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Lustig DB, Warburton R, Dingee CK, Kuusk U, Pao JS, McKevitt EC. Is microductectomy still necessary to diagnose breast cancer: a 10-year study on the effectiveness of duct excision and galactography. Breast Cancer Res Treat 2019; 174:703-709. [DOI: 10.1007/s10549-018-05109-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 12/16/2018] [Indexed: 12/27/2022]
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Yılmaz R, Bender Ö, Çelik Yabul F, Dursun M, Tunacı M, Acunas G. Diagnosis of Nipple Discharge: Value of Magnetic Resonance Imaging and Ultrasonography in Comparison with Ductoscopy. Balkan Med J 2018; 34:119-126. [PMID: 28418338 PMCID: PMC5394292 DOI: 10.4274/balkanmedj.2016.0184] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background: Pathologic nipple discharge, which is a common reason for referral to the breast imaging service, refers to spontaneous or bloody nipple discharge that arises from a single duct. The most common cause of nipple discharge is benign breast lesions, such as solitary intraductal papilloma and papillomatosis. Nevertheless, in rare cases, a malignant cause of nipple discharge can be found. Aims: To study the diagnostic value of ultrasonography, magnetic resonance imaging, and ductoscopy in patients with pathologic nipple discharge, compare their efficacy, and investigate the importance of magnetic resonance imaging in the diagnosis of intraductal pathologies. Study Design: Diagnostic accuracy study. Methods: Fifty patients with pathologic nipple discharge were evaluated by ultrasonography and magnetic resonance imaging. Of these, 44 ductoscopic investigations were made. The patients were classified according to magnetic resonance imaging, ultrasonography, and ductoscopy findings. A total of 25 patients, whose findings were reported as intraductal masses, underwent surgery oincluding endoscopic excision for two endoscopic excision. Findings were compared with the pathology results that were accepted as the gold standard in the description of the aetiology of nipple discharge. In addition, magnetic resonance imaging, ultrasonography and ductoscopy findings were analysed comparatively in patients who had no surgery. Results: Intraductal masses were reported in 26 patients, 20 of whom operated and established accurate diagnosis of 18 patients on magnetic resonance imaging. According to the ultrasonography, intraductal masses were identified in 22 patients, 17 of whom underwent surgery. Ultrasonography established accurate diagnoses in 15 patients. Intraductal mass was identified in 22 patients and ductoscopy established accurate diagnoses based on histopathologic results in 16 patients. The sensitivities of methods were 75% in ultrasonography, 90% in magnetic resonance imaging, and 94.6% in ductoscopy. The specificities were 66.7% in ultrasonography, 66.7% in magnetic resonance imaging, and 40% in ductoscopy. Intraductal papillomas were mostly observed as oval nodules with well-circumscribed smooth margins within dilated ducts and persistant in the dynamic analysis. Lesions that protruded into the lumen of the ducts, either solitary or multiple, were characteristic ductoscopy findings of our patients who were diagnosed as having papilloma/papillomatosis. Conclusion: Magnetic resonance imaging and ductoscopy had no statistical superiority over each other, however they were superior to ultrasonography in the diagnosis of pathologic nipple discharge. Magnetic resonance imaging may be highly sensitive for diagnosing nipple discharge with new techniques and sequences and a non-invasive method that more advantageous for showing ductal tree visualization and is able to detect completely obstructed intraductal lesions.
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Affiliation(s)
- Ravza Yılmaz
- Department of Radiology, İstanbul University İstanbul School of Medicine, İstanbul, Turkey
| | - Ömer Bender
- Clinic of General Surgery, Okmeydanı Training and Research Hospital, İstanbul, Turkey
| | - Fatma Çelik Yabul
- Department of Radiology, Bakırkoy Dr. Sadi Konuk Training and Research Hospital, İstanbul, Turkey
| | - Menduh Dursun
- Department of Radiology, İstanbul University İstanbul School of Medicine, İstanbul, Turkey
| | - Mehtap Tunacı
- Department of Radiology, İstanbul University İstanbul School of Medicine, İstanbul, Turkey
| | - Gülden Acunas
- Department of Radiology, İstanbul University İstanbul School of Medicine, İstanbul, Turkey
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Lesetedi C, Rayne S, Kruger D, Benn CA. Indicators of breast cancer in patients undergoing microdochectomy for a pathological nipple discharge in a middle-income country. J Surg Res 2017; 220:336-340. [PMID: 29180200 DOI: 10.1016/j.jss.2017.06.046] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 05/26/2017] [Accepted: 06/16/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND The management of a pathological nipple discharge often involves surgery for the exclusion of a malignant etiology. This study aimed to determine the prevalence of cancer in patients who had microdochectomy for pathological nipple discharge in a population in South Africa and to evaluate patients' demographics and clinical characteristics as indicators of underlying cancer and make recommendations for their management in resource-limited settings. MATERIALS AND METHODS Clinical, radiological, and histological data from 153 patients who underwent a microdochectomy for a pathological nipple discharge at two South African breast clinics was collected. RESULTS Invasive or in situ cancer was found in 12 patients (7.84%), and in all patients, cancer was associated with a bloody nipple discharge. Bloody discharge had a sensitivity of 100% in indicating cancer, specificity of 55.32%, positive predictive value of 16%, and negative predictive value of 100%. Patients with breast cancer were also more likely to be aged 55 y or older (P = 0.04). Preoperative mammogram and ultrasound were poor in detecting cancer (0/12). CONCLUSIONS In our population, a bloody discharge in women aged 55 years or older should mandate a microdochectomy, with selective surgery for younger women and those with nonbloody discharges. Thorough clinical examination to determine the true color and nature of the discharge is vital in the initial assessment of these patients. Preoperative radiology is not helpful in determining the presence of cancer (in an isolated pathological nipple discharge), and microdochectomy still remains the gold standard in diagnosing cancer in these patients.
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Affiliation(s)
- Chiapo Lesetedi
- Department of Surgery, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sarah Rayne
- Department of Surgery, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Helen Joseph Breast Care Clinic, Helen Joseph Hospital, Johannesburg, South Africa.
| | - Deirdre Kruger
- Department of Surgery, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Carol-Ann Benn
- Department of Surgery, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Helen Joseph Breast Care Clinic, Helen Joseph Hospital, Johannesburg, South Africa; Netcare Breast Care Centre, Milpark Hospital, Johannesburg, South Africa
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Wong Chung JERE, Jeuriens-van de Ven SAH, van Helmond N, Wauters CAP, Duijm LEM, Strobbe LJA. Does Nipple Discharge Color Predict (pre-) Malignant Breast Pathology? Breast J 2016; 22:202-8. [PMID: 26799061 DOI: 10.1111/tbj.12544] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Unilateral single-duct nipple discharge is associated with an increased risk for underlying breast malignancy. There is no consensus whether color of nipple discharge independently indicates the risk of malignancy. We sought to assess the relationship between the color of discharge and the risk of malignancy. Patients with unilateral single-duct nipple discharge without abnormalities on clinical and radiologic examination were included. Prior to diagnostic microdochectomy nipple discharge characteristics were registered. Multiple logistic regressions were performed to assess the relationship between color of nipple discharge and malignancy, corrected for age. During a mean follow-up period of 7.1 years we determined complication rate and false-negative rate of microdochectomy. A total of 184 patients were included (median age 53 years, range 19-84). Histologic examination revealed (in situ or invasive) breast carcinoma in 10.9% (20) of patients and high-risk lesions in 11.4% (21). Malignancy or high-risk lesions were found in 25% (OR: 1.37; 95% CI: 0.62-3.00) of patients with bloody discharge. Risk of underlying malignancy increased in patients >60 years (OR: 2.35; 95% CI: 1.14-4.83). Complication rate of microdochectomy was 2.7%. Single-duct, unilateral nipple discharge is a sign of underlying malignancy in a substantial proportion of cases. The majority of patients with unilateral single-duct nipple discharge, diagnosed with breast cancer, present with bloody discharge. However, the association between bloody nipple discharge and malignancy is not strong enough to distinguish high-risk patients. Therefore, invasive diagnostic procedures like microdochectomy should be offered to all patients with unilateral uniductal nipple discharge to search for underlying malignancy.
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Affiliation(s)
| | | | - Noud van Helmond
- Faculty of Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Carla A P Wauters
- Department of Clinical Pathology, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Lucien E M Duijm
- Department of Radiology, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Luc J A Strobbe
- Department of Surgery, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
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Aljarrah A, Malik KA, Jamil H, Jaffer Z, Sawhney S, Lakhtakia R. Diagnostic dilemmas in Intraductal papillomas of the breast - Experience at Sultan Qaboos University Hospital in the Sultanate of Oman. Pak J Med Sci 2015; 31:431-4. [PMID: 26101505 PMCID: PMC4476356 DOI: 10.12669/pjms.312.6476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Accepted: 01/15/2015] [Indexed: 01/09/2023] Open
Abstract
Objectives: The aim of this retrospective study was to correlate the significance and accuracy of the colour of nipple discharge and breast ultrasound imaging in the diagnosis of intraductal papilloma. Methods: This is a retrospective study of 34 patients who underwent 36 microdochectomies in Sultan Qaboos University Hospital (SQUH) in the Sultanate of Oman, over a 4 year period of January 2009 till December 2012. The confounders considered were patient age, physical examination findings, nipple discharge cytology result, ultrasound results and biopsy report following microdochectomy. Comparisons analysis, charts and graphs were made using the SPSS software (version 20). Results: The mean age of the patients was 44(27-73) years old. Twenty-seven out 36 (75%) patients had presented with nipple discharge, 14 out 27 (52%) had blood stained nipple discharge and 13(48%) with coloured discharge (yellow, brown and green), 9 patients had no discharge. The final histopathology showed intraductal papilloma 13 (36%), duct ectasia 18(50%), DCIS 1 (2.7%), fibrocystic disease 3(8.3%) and LCIS 1(2.7%). Thirteen out of 36 had intraductal papilloma on final histopathology. The correlation between blood stained discharge and final histopathology of intraductal papilloma was insignificant (p=0.44). Conclusion: Nipple discharge is irrelevant to the diagnosis of intraductal papilloma. Spontaneous nipple discharge regardless of color is to be referred to breast surgeon and to be assessed with triple assessment. Surgery remains the mainstay of treatment.
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Affiliation(s)
- Adil Aljarrah
- Adil Aljarrah, Breast Unit, Department of Surgery, Sultan Qaboos University Hospital, Muscat, Sultanate of Oman
| | - Kamran Ahmad Malik
- Kamran Ahmad Malik, Breast Unit, Department of Surgery, Sultan Qaboos University Hospital, Muscat, Sultanate of Oman
| | - Husam Jamil
- Husam Jamil, Breast Unit, Department of Surgery, Sultan Qaboos University Hospital, Muscat, Sultanate of Oman
| | - Zoheb Jaffer
- Zoheb Jaffer, Breast Unit, Department of Surgery, Sultan Qaboos University Hospital, Muscat, Sultanate of Oman
| | - Sukhpal Sawhney
- Sukhpal Sawhney, Breast Unit, Department of Radiology, Sultan Qaboos University Hospital, Muscat, Sultanate of Oman
| | - Ritu Lakhtakia
- Ritu Lakhtakia, Breast Unit, Department of Pathology, COM&HS, Sultan Qaboos University Hospital, Muscat, Sultanate of Oman
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Ohlinger R, Stomps A, Paepke S, Blohmer JU, Grunwald S, Hahndorf W, Camara O, Deichert U, Peisker U, Kohlmann T, Buchholz I, Hegenscheid K, Utpatel K, Zygmunt M, Hahn M. Ductoscopic Detection of Intraductal Lesions in Cases of Pathologic Nipple Discharge in Comparison with Standard Diagnostics: The German Multicenter Study. Oncol Res Treat 2014; 37:628-32. [DOI: 10.1159/000368338] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Accepted: 09/03/2014] [Indexed: 11/19/2022]
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11
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Ohno T, Inoue K, Nagayoshi S, Fukuda T, Irie J. A novel duct-lobular segmentectomy for breast tumors with nipple discharge using near-infrared indocyanine green fluorescence imaging. Asian J Surg 2013; 36:170-3. [PMID: 24054757 DOI: 10.1016/j.asjsur.2012.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2012] [Revised: 08/17/2012] [Accepted: 08/21/2012] [Indexed: 10/27/2022] Open
Abstract
A 44-year-old woman was referred to our hospital with pathological nipple discharge from her left breast. Ultrasonography revealed a solid tumor beneath her left areola that measured 17 mm in diameter with a dilated mammary duct. Contrast-enhanced magnetic resonance imaging showed an early-enhanced cystic tumor and a dilated mammary duct. We performed a duct-lobular segmentectomy using near-infrared indocyanine green (ICG)-fluorescence imaging. Under general anesthesia, a silicone tube was inserted into an orifice of a fluid-discharging mammary duct, and 1 mL dye-fluorescence liquid containing ICG and indigo carmine was injected into the mammary duct. A periareolar incision was made, and the fluorescence image of the demarcated mammary duct segment was obtained. The mammary duct segment was dissected, along with the demarcation line. The cystic lesion and dilated mammary duct were fully resected, and the pathological diagnosis was intraductal papilloma of the breast. We report that near-infrared ICG fluorescence could be applied for imaging of the mammary duct segment, and the fluorescence image allowed for easier duct-lobular segmentectomy for nipple discharge.
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Affiliation(s)
- Tsuyoshi Ohno
- Department of Surgery, Nagasaki Municipal Hospital, Nagasaki, Japan.
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12
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Chen L, Zhou WB, Zhao Y, Liu XA, Ding Q, Zha XM, Wang S. Bloody nipple discharge is a predictor of breast cancer risk: a meta-analysis. Breast Cancer Res Treat 2011; 132:9-14. [PMID: 21947751 DOI: 10.1007/s10549-011-1787-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2011] [Accepted: 09/15/2011] [Indexed: 10/17/2022]
Abstract
Nipple discharge is a common complaint of patients with breast disease. The color of nipple discharge is always the first alarming symptom for patients. It is controversial whether the discharge color is an indicator of an underlying malignancy. The electronic database PubMed was searched for relevant articles. A meta-analysis about the association between the color of nipple discharge and breast cancer risk was conducted. Eight studies, including 3,110 patients, were eligible for this meta-analysis. Compared with patients in non-bloody nipple discharge group (179/1,478), patients in bloody nipple discharge group (404/1,632) had a markedly higher breast cancer risk (OR: 2.27, 95% CI: 1.32-3.89, P < 0.001 for heterogeneity). Compared with patients in clear/serous group (71/575), patients in bloody nipple discharge group (326/1,271) also had a higher risk (OR: 2.49, 95% CI: 1.25-4.93, P = 0.011 for heterogeneity). Furthermore, compared with patients in the colored group (55/448), patients in bloody nipple discharge group (296/1,124) (OR: 2.00, 95% CI: 0.74-5.45, P = 0.009 for heterogeneity) had no significant difference. Besides, there was no significant difference between patients in colored group (55/448) and clear/serous group (61/470) (OR: 1.35, 95% CI: 0.83-2.18, P = 0.707 for heterogeneity). Therefore, bloody nipple discharge could be a predictor of breast cancer risk among different colors of discharges. The symptom of bloody nipple discharge is helpful to the stratification of preoperative patients.
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Affiliation(s)
- Ling Chen
- Department of Breast Surgery, The First Affiliated Hospital with Nanjing Medical University, 300 Guangzhou Road, Nanjing 210029, China
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13
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Zhu X, Xing C, Jin T, Cai L, Li J, Chen Q. A randomized controlled study of selective microdochectomy guided by ductoscopic wire marking or methylene blue injection. Am J Surg 2010; 201:221-5. [PMID: 20870205 DOI: 10.1016/j.amjsurg.2010.03.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2009] [Revised: 03/15/2010] [Accepted: 03/15/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND Methylene blue identification of lesions during microdochectomy is often inaccurate, resulting in large dissection and tissue damage. A wire placed via ductoscopy preoperatively into the pathologic duct may aid identification and reduce the amount of dissection required. METHODS A total of 53 patients being evaluated for nipple discharge were randomized to receive ductoscopy with either methylene blue or wire marking of the lesion before microdochectomy. Patient clinical characteristics and surgical outcomes were evaluated. RESULTS There were 28 patients who received methylene blue marking and 25 who received wire marking of the lesions. There were no differences between the demographic or clinical characteristics of the groups. Wire marking was associated with less surgical time, smaller incisions, and smaller surgical specimens, but the same diagnostic accuracy. CONCLUSIONS Wire marking of lesions for microdochectomy is associated with less dissection and tissue damage than methylene blue, yet the same diagnostic accuracy.
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Affiliation(s)
- Xun Zhu
- Department of General Surgery, The Second Affiliated Hospital of Soochow University, Jiangsu, People's Republic of China.
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14
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Dolan RT, Butler JS, Kell MR, Gorey TF, Stokes MA. Nipple discharge and the efficacy of duct cytology in evaluating breast cancer risk. Surgeon 2010; 8:252-8. [PMID: 20709281 DOI: 10.1016/j.surge.2010.03.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2010] [Revised: 02/28/2010] [Accepted: 03/29/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND Nipple discharge accounts for up to 5% of referrals to breast surgical services. With the vast majority of breast carcinomas originating in the ductal system, symptomatic dysfunction of this system often raises disproportionate clinical concern. The aim of this study is firstly, to evaluate the clinical importance of nipple discharge as an indicator of underlying malignancy and secondly, to assess the diagnostic application of duct cytology in patients presenting with nipple discharge. STUDY DESIGN We performed a retrospective analysis of all patients presenting with nipple discharge as their primary symptom to the symptomatic breast unit at a tertiary referral center over a 30-month period (n = 313). The Hospital Inpatient Enquiry (HIPE) System and BreastHealth database were used to identify our study cohort. Parameters evaluated included patient demographics, clinical presentation, clinical evaluation, radiological assessment and histological/cytological analysis. RESULTS Three-hundred and thirteen patients presented with nipple discharge as their primary complaint. Invasive breast carcinoma was diagnosed by Triple Assessment in 5% of patients. 24% of patients presenting with nipple discharge underwent nipple aspiration and cytological analysis. Duct cytology was diagnostic of the underlying breast carcinoma in 50% of triple assessment diagnosed carcinoma. Four risk factors were identified as having a significant association with breast carcinoma, these included (a) age >50 years (p < 0.0001), (b) bloody nipple discharge (p < 0.008), (c) presence of a breast lump (p < 0.0001) and (d) single duct discharge (p < 0.006). CONCLUSIONS Nipple discharge is a poor indicator of an underlying malignancy. Use of nipple aspiration and duct cytology for the assessment of nipple discharge is of limited diagnostic benefit. However, by utilizing the systematic, gold standard approach of Triple Assessment (clinical, radiological and cytological evaluation), the risk of underlying carcinoma can be accurately defined.
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Affiliation(s)
- Roisin T Dolan
- Department of Breast & Endocrine Surgery, Mater Misericordiae University Hospital, Dublin, Ireland.
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15
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Microdochectomy in the management of pathologic nipple discharge. Arch Gynecol Obstet 2010; 283:851-4. [PMID: 20458490 DOI: 10.1007/s00404-010-1481-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2010] [Accepted: 04/12/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND There is a debate in the literature whether a pathologic nipple discharge is a distinct sign of breast carcinoma. Our own results obtained by the use of microdochectomy as a minimally invasive operative procedure in 184 patients with pathologic nipple discharge were analysed. The aim of this retrospective 20-year study was to assess the efficacy of microdochectomy in detecting early stages of intraductal breast carcinoma. PATIENTS AND METHODS The study included data on 184 patients aged 24-77 years (median 46.6) divided into two groups of premenopausal (n = 123) and postmenopausal (n = 61) women. There were 139 patients with unilateral single-duct sanguinolent discharge and 45 patients with other types of nipple discharge. The operative procedure consisted of the discharging duct excision by use of a guide probe, preceded by cytology and ductography studies. RESULTS Histopathology of the excised ducts revealed only three carcinomas in premenopausal women and ten carcinomas in postmenopausal women. In a total of 13 carcinomas, there were 4 ductal carcinomas in situ, detected in patients aged 41-72 (median 66) years. Twelve carcinomas were associated with sanguinolent nipple discharge. Papilloma was the most common histology finding (56.5%). CONCLUSION Results of the study suggested mainly the association of sanguinolent single-duct nipple discharge and papilloma, whereas the rate of malignancies detected (7.0%) was consistent with literature reports. Microdochectomy proved to be a highly efficient operative method free from any impairment of the breast integrity. Conservative treatment with close clinical monitoring of the patient with cytology and ultrasonographic assessment might be possible in selected cases.
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16
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Jain A, Crawford S, Larkin A, Quinlan R, Rahman RL. Management of nipple discharge: technology chasing application. Breast J 2010; 16:451-2. [PMID: 20443787 DOI: 10.1111/j.1524-4741.2010.00933.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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17
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Zervoudis S, latrakis G, Economides P, Polyzos D, Navrozoglou I. Nipple Discharge Screening. WOMENS HEALTH 2010; 6:135-51. [DOI: 10.2217/whe.09.81] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Stefanos Zervoudis
- Stefanos Zervoudis, Lito Hospital, Department of Mastology, Athens, Greece
- Technological Educational Institution of Athens, Athens, Greece
- Universiry of Ioannina, Department of Obstetrics/Gynecology, Breast Unit, Ioannina, Greece, Tel.: +69 44 308 777, Fax: +210 898 1178,
| | - Georgos latrakis
- Georgos Iatrakis, Lito Hospital, Department of Mastology, Athens, Greece
- Technological Educational Institution of Athens, Athens, Greece, Tel.: +210 661 1178, Fax: +210 661 3986,
| | - Panagiotis Economides
- Panagiotis Economides, Lito Hospital, Department of Mastology, Athens, Greece, Tel.: +69 36 121 158, Fax: +210 690 2417,
| | - Demetrios Polyzos
- Demetrios Polyzos, Lito Hospital, Department of Mastology, Athens, Greece, Tel.: +69 44 81 2923, Fax: +210 690 2417,
| | - Iordanis Navrozoglou
- Iordanis Navrozoglou, Universiry of Ioannina, Department of Obstetrics/Gynecology, Breast Unit, Ioannina, Greece, Tel.: +69 44 308 777, Fax: +210 898 1178,
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Hahn M, Fehm T, Solomayer EF, Siegmann KC, Hengstmann AS, Wallwiener D, Ohlinger R. Selective microdochectomy after ductoscopic wire marking in women with pathological nipple discharge. BMC Cancer 2009; 9:151. [PMID: 19445720 PMCID: PMC2689244 DOI: 10.1186/1471-2407-9-151] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2009] [Accepted: 05/17/2009] [Indexed: 12/05/2022] Open
Abstract
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.
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Affiliation(s)
- M Hahn
- Department of Obstetrics and Gynaecology, University Hospital Tuebingen, Tuebingen, Germany.
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