Biological markers of risk in nipple aspirate fluid are associated with residual cancer and tumour size

Enhancing Paclitaxel Efficacy with Piperine-Paclitaxel Albumin Nanoparticles in Multidrug-Resistant Triple-Negative Breast Cancer by Inhibiting P-Glycoprotein

Triple-negative breast cancer (TNBC) is a highly aggressive disease with rapid progression and poor prognosis due to multidrug resistance (MDR). Piperine (PIP) shows promise as a P-gp inhibitor, capable of sensitizing chemotherapeutic drugs and exhibiting antitumor properties. This study explores the inhibitory mechanism of PIP on P-glycoprotein (P-gp) and its capacity to enhance the sensitivity of paclitaxel (PTX). We subsequently evaluated the efficacy and safety of albumin nanoparticles that co-encapsulate PTX and PIP (PP@AN). The results demonstrated that PIP enhanced the accumulation of PTX intracellularly, as determined with HPLC/MS/MS analysis. PIP was also found to increase cell sensitivity to PTX. Furthermore, we explored the inhibitory mechanism of PIP on P-gp, utilizing molecular docking simulations, RT-qPCR, and Western blot analysis. PIP appears to compete with the active paclitaxel binding site on P-gp, affecting ATPase activity and downregulating the MDR1 gene and P-gp expression. In summary, PIP could inhibit P-gp and act as a sensitizer in the treatment of TNBC with PTX. Moreover, stable and uniform PP@AN was successfully formulated, resulting in a significant increase in drug accumulation within cells as well as the downregulation of P-gp in tumors at the optimal ratio (PTX:PIP = 1:2). This led to an improvement in the antitumor effect in vivo while also reducing hepatotoxicity and hemototoxicity following chemotherapy. This study comprehensively investigated PIP's inhibitory effect and mechanism on P-gp. We present a new approach for co-delivering PIP and PTX using albumin nanoparticles, which reduced toxicity and improved therapeutic efficacy both in vivo and in vitro.

Diagnostic Accuracy of Nipple Aspirate Fluid Cytology in Asymptomatic Patients: A Meta-analysis and Systematic Review of the Literature

Purpose

To calculate the diagnostic accuracy of nipple aspirate fluid (NAF) cytology.

Background

Evaluation of NAF cytology in asymptomatic patients conceptually offers a non-invasive method for either screening for breast cancer or else predicting or stratifying future cancer risk.

Methods

Studies were identified by performing electronic searches up to August 2019. A meta-analysis was conducted to attain an overall pooled sensitivity and specificity of NAF for breast cancer detection.

Results

A search through 938 studies yielded a total of 19 studies. Overall, 9308 patients were examined, with cytology results from 10,147 breasts [age (years), mean ± SD = 49.73 ± 4.09 years]. Diagnostic accuracy meta-analysis of NAF revealed a pooled specificity of 0.97 (95% CI 0.97–0.98), and sensitivity of 0.64 (95% CI 0.62–0.66).

Conclusions

The diagnostic accuracy of nipple smear cytology is limited by poor sensitivity. If nipple fluid assessment is to be used for diagnosis, then emerging technologies for fluid biomarker analysis must supersede the current diagnostic accuracy of NAF cytology.

Electronic supplementary material

The online version of this article (10.1245/s10434-020-09313-9) contains supplementary material, which is available to authorized users.

Evaluation of nipple aspirate fluid as a diagnostic tool for early detection of breast cancer

There has been tremendous progress in detection of breast cancer in postmenopausal women, resulting in two-thirds of women surviving more than 20 years after treatment. However, breast cancer remains the leading cause of cancer-related deaths in premenopausal women. Breast cancer is increasing in younger women due to changes in life-style as well as those at high risk as carriers of mutations in high-penetrance genes. Premenopausal women with breast cancer are more likely to be diagnosed with aggressive tumours and therefore have a lower survival rate. Mammography plays an important role in detecting breast cancer in postmenopausal women, but is considerably less sensitive in younger women. Imaging techniques, such as contrast-enhanced MRI improve sensitivity, but as with all imaging approaches, cannot differentiate between benign and malignant growths. Hence, current well-established detection methods are falling short of providing adequate safety, convenience, sensitivity and specificity for premenopausal women on a global level, necessitating the exploration of new methods. In order to detect and prevent the disease in high risk women as early as possible, methods that require more frequent monitoring need to be developed. The emergence of "omics" strategies over the last 20 years, enabling the characterisation and understanding of breast cancer at the molecular level, are providing the potential for long term, longitudinal monitoring of the disease. Tissue and serum biomarkers for breast cancer stratification, diagnosis and predictive outcome have emerged, but have not successfully translated into clinical screening for early detection of the disease. The use of breast-specific liquid biopsies, such as nipple aspirate fluid (NAF), a natural secretion produced by breast epithelial cells, can be collected non-invasively for biomarker profiling. As we move towards an age of active surveillance, home-based liquid biopsy collection kits are increasingly being applied and these could provide a paradigm shift where NAF biomarker profiling is used for routine breast health monitoring. The current status of established and newly emerging imaging techniques for early detection of breast cancer and the potential for alternative biomarker screening of liquid biopsies, particularly those applied to high-risk, premenopausal women, will be reviewed.

Bioinformatics analysis of dysregulated microRNAs in the nipple discharge of patients with breast cancer

MicroRNAs (miRNAs/miRs) have been reported to be associated with the tumorigenesis and progression of various types of human cancer; however, the underlying mechanisms of this association remain unclear. The aim of the present study was to explore the potential functions of miRNAs in the development of breast cancer using bioinformatics analysis, based on the miRNA expression profile in nipple discharge. A previous study demonstrated the upregulation of miR-3646 and miR-4484, and the downregulation of miR-4732-5p in the nipple discharge of patients with breast cancer, compared with patients with benign breast lesions. In the present study, the target genes of miR-3646, −4484 and −4732-5p were predicted using TargetScan and the MicroRNA Target Prediction and Functional Study Database. The predicted target genes were further analyzed by Gene Ontology term enrichment analysis, Kyoto Encyclopedia of Genes and Genomes pathway enrichment analysis and protein-protein interaction analysis. Numerous carcinoma-associated genes, including ADIPOQ, CPEB1, DNAJB4, EIF4E, APP and BCLAF1, were revealed to be putative targets of miR-3646, −4484 and −4732-5p. Bioinformatics analysis associated miR-3646 with the Rap1 and TGF-β signaling pathways, miR-4484 with the ErbB, estrogen and focal adhesion signaling pathways, and miR-4732-5p with the proteoglycan signaling pathway. Notably, protein-protein interaction analysis identified that numerous predicted targets of these miRNAs were associated with one other. In addition, the target genes of the miRNAs were identified to be under the regulation of a number of transcription factors (TFs). The predicted target genes of miR-3646, −4484 and −4732-5p were identified to serve a role in cancer-associated signaling pathways and TF-mRNA networks, indicating that they serve a role in breast carcinogenesis and progression. These results provide a comprehensive view of the functions and molecular mechanisms of miR-3646, −4484 and −4732-5p, and will aid in future studies.

CA153 in Breast Secretions as a Potential Molecular Marker for Diagnosing Breast Cancer: A Meta Analysis

PURPOSE

Many studies have reported that carbohydrate antigen 153 (CA153) in breast secretions (BS) can discriminate breast cancer (BC) patients from healthy individuals, indicating CA153 in BS as a potential index for BC. This meta-analysis aimed to evaluate the actual diagnostic value of CA153 in BS.

METHODS

Related papers were obtained from Pubmed, Embase, Scopus, Ovid, Sciverse, the Cochrane library, Chinese Biomedical literature Database (CBM), Technology of Chongqing (VIP), Wan Fang Data, and Chinese National Knowledge Infrastructure (CNKI). Pooled sensitivity, specificity, and diagnostic odds ratio (DOR) of CA153 in BS for BC diagnosis were analyzed with the random effect model. SROC and the area under the curve (AUC) were applied to assess overall diagnostic efficiency.

RESULTS

This meta-analysis included five studies with a total of 329 BC patients and 381 healthy subjects. For CA153 in BS, the summary sensitivity, specificity, and DOR to diagnose BC were 0.63 (95% confidence interval (CI): 0.57∼0.68), 0.82 (95% CI: 0.78∼0.86), and 9.18 (95% CI: 4.22∼19.95), respectively. Furthermore, the AUC of BS CA153 in the diagnosis of BC was 0.8614.

CONCLUSIONS

CA153 in BS is a valuable molecular marker in diagnosing BC and should be applied in standard clinical practices of BC screening upon confirmation of our findings in a larger prospective study.

Chronic Inflammation and Breast Pathology: A Theoretical Model

Breast cell pathology results from biochemical and molecular changes that culminate in the cell’s loss of functional responsiveness. The epithelial cell compartment in the breast ductal system is the site of approximately 98% of malignant proliferations, and it is from within these cells that the first biochemical signal of change may be expressed as an inflammatory response. Inflammation may be represented by biomarkers of early pathologic changes in breast cells and be associated with risk for the development of breast cancer. A theoretical model of the inflammatory process is proposed showing predictive linkages among stimuli in the breast microenvironment and the development of breast pathology, in particular, breast cancer. This model fuels intervention concepts that may prevent malignant breast health outcomes.

Identification of microRNAs in Nipple Discharge as Potential Diagnostic Biomarkers for Breast Cancer

BACKGROUND

Intraductal breast cancer is generally difficult to diagnose because of a lack of an efficient method for detection. The purpose of this study was to reveal and validate the differential expression of microRNAs (miRNAs) in nipple discharge from intraductal papilloma patients and identify miRNAs as novel potential biomarkers for primary breast cancer.

METHODS

Nipple discharge samples were collected from three intraductal carcinoma breast cancer patients and three intraductal papilloma patients. The initial screening of miRNA expression was performed with an Axon GenePix 4000B microarray scanner using a novel approach to label miRNAs. The expression levels of the miRNAs selected from the initial screening were further examined by quantitative real-time polymerase chain reaction (qRT-PCR) in 21 validation samples (8 carcinomas and 13 benign tumors). An independent t test was used to detect significant correlations between the miRNA expression levels and breast cancer.

RESULTS

Microarray profiling demonstrated that three miRNAs were markedly up-regulated and three miRNAs were down-regulated in the intraductal carcinoma breast cancer patients compared to the papilloma group. The qRT-PCR analysis further verified that four miRNAs (miR-4484, miR-K12-5-5p, miR-3646, and miR-4732-5p) might serve as potential tumor biomarkers for breast cancer detection.

CONCLUSION

The novel approach of using a microarray scanner is applicable for studying biomarkers in nipple discharge containing small amounts of miRNA. miRNAs could serve as potential tumor biomarkers that can assist in breast cancer screening. Up-regulation of miR-4484, miR-K12-5-5p, and miR-3646 in nipple discharge may be a predictor of malignant breast cancer.

Proliferative epithelial disease identified in nipple aspirate fluid and risk of developing breast cancer: a systematic review

BACKGROUND

Guideline panels recognize the need to increase the accuracy of identifying women at high risk of developing breast cancer who would benefit from prevention strategies. The characterization of proliferative epithelial disease found in nipple aspirate fluid (PED-NAF) may be a relevant risk factor.

OBJECTIVE

To comprehensively review the published literature to characterize and summarize abnormal cytology detected by NAF and the association of PED-NAF with subsequent risk of developing breast cancer.

RESEARCH DESIGN AND METHODS

Literature identified by systematic searches in MEDLINE PubMed and the Cochrane Library was screened for articles containing primary data on NAF cytology based on predefined inclusion and exclusion criteria.

MAIN OUTCOME MEASURES

Study characteristics, cytological group distribution, and incidence of breast cancer.

RESULTS

Thirty articles were included after full-text review, of which 16 were analyzed, containing data on 20,808 unique aspirations from over 17,378 subjects. Seven (44%) of the studies used the King cytological classification system. Among aspirations from women free of breast cancer, 51.5% contained fluid, in which over 27.7% had PED on cytology. In the two prospective studies of 7850 cancer-free women, abnormal cytology by NAF carried a 2.1-fold higher risk (95% CI, 1.6-2.6; p < 0.001) of developing breast cancer, compared with women from whom no fluid could be obtained.

CONCLUSIONS

PED-NAF among women free of breast cancer, compared with no fluid being obtained, has an independent risk of developing breast cancer comparable to the risk of a woman with a positive family history of breast cancer. These findings have implications for augmenting risk prediction and clinical decisions concerning breast cancer surveillance and chemoprevention. As with all reviews, heterogeneity across studies may have influenced the results. The limited literature calls for prospective studies on asymptomatic women with long-term follow-up.

Analysis of nipple aspirate fluid for diagnosis of breast cancer: an alternative to invasive biopsy

Over 40,000 women in the USA will die this year of breast cancer. Current generally accepted techniques to detect breast cancer are limited to breast examination and mammography. Abnormalities found by these techniques require an invasive needle or surgical biopsy to determine if cancer is present. The author's ultimate goal is to determine if a woman has breast cancer without the need for invasive biopsies, and do this before the abnormality is detectable by standard screening techniques. Herein, the technology is reviewed as it was, as it is today, and its future potential is discussed.

Cytology in nipple aspirate fluid during a randomized soy food intervention among premenopausal women

Because soy food consumption may influence breast tissue activity, we examined its effect on the presence of epithelial cells in nipple aspirate fluid (NAF). In a randomized, crossover design, 82 premenopausal women completed a high-soy and a low-soy diet for 6 mo each, separated by a 1-mo washout period. They provided NAF samples at baseline, 6 mo, and 13 mo during the midluteal phase of the menstrual cycle. Papanicolaou-stained cytology slides (for 33 women at baseline, 24 at low-soy, and 36 at high-soy) were evaluated in women with sufficient NAF. Mixed models evaluated the effect of the high-soy diet on epithelial cytology as compared to baseline and the low-soy diet. At the end of the high-soy diet, cytological subclass had decreased in 8 (24%) and increased in 3 (9%) women as compared to baseline, whereas the respective values were 3 (14%) and 6 (29%) for the low-soy diet samples (P = 0.32). Only the change in subclass indicated a trend in lower cytological class (P = 0.06). Contrary to an earlier report, the number of NAF samples with hyperplastic epithelial cells did not increase after a soy intervention in amounts consumed by Asians.

Expression of epidermal growth factor, transforming growth factor-β1 and adiponectin in nipple aspirate fluid and plasma of pre and post-menopausal women

BACKGROUND

Nipple aspirate fluid (NAF) contains large amounts of protein thought to reflect the microenvironment of the breast, and is of interest in breast cancer prevention research. The correlation between specific NAF proteins to plasma concentrations have not been well studied in healthy women. We collected matched NAF and plasma from 43 healthy pre and postmenopausal women participating in an early phase clinical study to compare the levels of putative cancer protein biomarkers. We compared baseline NAF and plasma levels of epidermal growth factor (EGF), transforming growth factor-beta 1 (TGF-β1), and adiponectin and evaluated menopausal status and body mass index (BMI) as potential modifying factors.

FINDINGS

NAF and plasma levels of EGF, TGF-β1 and adiponectin were not correlated. EGF and TGF-β1 levels in NAF of premenopausal women were significantly higher than postmenopausal women (P's < 0.01). These differences by menopausal status were not observed in plasma. Both NAF and plasma adiponectin levels were non-significantly higher in postmenopausal women. NAF biomarker levels were not associated with BMI whereas plasma EGF, TGF-β1 and adiponectin levels in postmenopausal women were all inversely correlated with BMI (P's < 0.05).

CONCLUSIONS

Protein biomarkers differ significantly between NAF and plasma and are affected differently by both BMI and menopausal status. This study demonstrates important differences in biological information gained by characterizing biomarkers in NAF compared to plasma and suggests each sample source may independently inform on breast cancer risk.

Paired ductal carcinoma in situ and invasive breast cancer lesions in the D-loop of the mitochondrial genome indicate a cancerization field effect

Alterations in the mitochondrial genome have been chronicled in most solid tumors, including breast cancer. The intent of this paper is to compare and document somatic mitochondrial D-loop mutations in paired samples of ductal carcinoma in situ (DCIS) and invasive breast cancer (IBC) indicating a potential breast ductal epithelial cancerization field effect. Paired samples of these histopathologies were laser-captured microdissected (LCM) from biopsy, lumpectomy, and mastectomy tissues. Blood samples were collected as germplasm control references. For each patient, hypervariable region 1 (HV1) in the D-loop portion of the mitochondrial genome (mtGenome) was sequenced for all 3 clinical samples. Specific parallel somatic heteroplasmic alterations between these histopathologies, particularly at sites 16189, 16223, 16224, 16270, and 16291, suggest the presence of an epithelial, mitochondrial cancerization field effect. These results indicate that further characterization of the mutational pathway of DCIS and IBC may help establish the invasive potential of DCIS. Moreover, this paper indicates that biofluids with low cellularity, such as nipple aspirate fluid and/or ductal lavage, warrant further investigation as early and minimally invasive detection mediums of a cancerization field effect within breast tissue.

Nipple aspirate fluid and ductoscopy to detect breast cancer

We prospectively performed cytologic assessment and image analysis (IA) on matched nipple aspirate fluid (NAF) and mammary ductoscopy (MD) specimens to determine (1) the accuracy of these methods in cancer detection and (2) whether the two collection methods provide complementary information.NAF and MD specimens were collected from 84 breasts from 75 women (nine bilateral samples) who underwent breast surgery. Cytologic evaluation was performed on all samples. IA was performed on slides with sufficient epithelial cells.Cytologic evaluation proved more accurate in patients without pathologic spontaneous nipple discharge (PND) than those with PND, mainly because of the potential false positive diagnosis in the latter. While the sensitivity of NAF and MD cytology was low (10% and 14%, respectively), both were 100% specific in cancer detection in the non-PND cohort. Combining NAF and MD cytology information improved sensitivity (24%) without sacrificing specificity. Similar to cytology, IA was more accurate in patients without PND having high specificity (100% for aneuploid IA), but relatively low sensitivity (36%). Combining NAF and MD cytology with aneuploid IA improved the sensitivity (45%) while maintaining high specificity (100%). The best predictive model was positive NAF cytology and/or MD cytology combined with IA aneuploidy, which resulted in 55% sensitivity and 100% specificity in breast cancer detection.Cytologic evaluation and IA of NAF and MD specimens are complementary. The presence of atypical cells arising from an intraductal papilloma in ductoscopic specimens is a potential source of false positive diagnosis in patients with nipple discharge.

Intracrinology of breast microenvironment: hormonal status in nipple aspirate fluid and its relationship to breast cancer

Breast cancer, a complex and multifactorial disease, is the most commonly diagnosed malignancy affecting women. Methods currently available for breast cancer detection have well-described limitations; in this respect, the intraductal approaches directly assess the microenvironment of the breast. Nipple aspirate fluid (NAF) can be noninvasively obtained from the breast in most women and represents a promising biological tool to assess metabolic, hormonal and molecular changes occurring in the cells lining the ducts, from which breast cancer arises. The aim of this review is to highlight the application of NAF studies in the field of biomarker discovery, which provide results useful for early detection and prevention of breast cancer risk; in fact, the analysis of NAF (mirroring the ductal-lobular microenvironment) is a reliable method for assessment of metabolic/hormonal pathways within the mammary gland, identifying biomolecular mechanisms of breast cancer initiation and progression. The intracrinology of breast microenvironment (i.e., hormonal status in NAF) may provide independent diagnostic/prognostic factors, highlighting the importance of early altered hormonal metabolism (e.g., aromatase, estrogen sulfotransferase and steroid sulfatase pathway) in relation to breast cancer initiation. The possible application of targeted therapies through the inhibition of intratumoral enzymes involved in steroid metabolism is also discussed. The intraductal approach to hormone analyses may provide a further panel of biomarkers providing clinical benefits and strengthening the armory against breast cancer.

Biologic markers of breast cancer in nipple aspirate fluid and nipple discharge are associated with clinical findings

BACKGROUND

The aim of this prospective study was to assess predictive markers in nipple aspirate fluid (NAF) and pathologic nipple discharge (PND) collected prior to excisional breast biopsy, as well as clinical factors available prior to biopsy, with histopathologic results in women with a radiographically suspicious and/or palpable breast lesion.

METHODS

208 NAF samples from 191 women were evaluated for the following candidate predictive proteins and cellular markers: prostate-specific antigen (PSA), human glandular kallikrein 2 (hK2), basic fibroblast growth factor (bFGF), S phase fraction (SPF), DNA index, and cytology. Clinical factors included whether or not the lesion was palpable, menopausal status, history of pregnancy, history of birth control or hormone replacement use, and PND.

RESULTS

Considering all women, bFGF (p=0.005) and SPF (0.031) were associated, and abnormal cytology approached an association (p=0.056) with the presence of breast cancer. Women with PND were less likely to have breast cancer (4 vs. 37%, p<0.001) or palpable lesions (10 vs.43%, p<0.001), were younger, had lower PSA levels (p=0.046), and were more likely to have atypical NAF cytology (p=0.002). Excluding PND, increased age, postmenopause (both p<0.01), high bFGF (p=0.004) and low PSA (p=0.05) were associated with cancer. The best breast cancer predictive model included cytology, bFGF, and age (88% sensitive and 57% specific). When the data were divided by menopausal status, the optimal models to predict breast cancer, which included NAF hK2 or PSA and age, were 100% sensitive and 41% specific in pre- vs. 93% sensitive and 12% specific in postmenopausal women.

CONCLUSION

NAF and clinical biomarkers are sensitive predictors of whether a breast contains cancer, and may ultimately help guide treatment. Future studies to determine the optimal combination of predictive markers are warranted.

Nipple aspirate fluid color is associated with breast cancer

BACKGROUND

Fluid can be non-invasively aspirated from the breast nipple (nipple aspirate fluid, NAF). NAF may have many colors, including clear, white, yellow, green, and red/brown. While bloody spontaneous nipple discharge has been linked with breast cancer, the association of NAF color with cancer is not established. Our hypothesis was that red/brown NAF color was associated with breast cancer. The purpose of this study was to assess (1) if red/brown NAF is associated with the presence and progression of breast cancer, (2) the influence of prior needle or surgical biopsy on NAF color, and (3) if an association between NAF color and breast cancer was found, to develop a cancer predictive model including NAF color and cytology, and clinical information.

METHODS

Specimens were obtained from 848 breasts between 1999 and 2004 after subjects enrolled in an IRB approved protocol to evaluate biologic markers of breast cancer. Cytologic evaluation was performed on Papanicolaou-stained cytospin preparations of NAF.

RESULTS

Red/brown NAF was associated with breast cancer when considering all samples (p<0.001) and samples from women who did not undergo recent surgery (p=0.005). Needle biopsy did not, but surgical biopsy did influence NAF color. For the 327 women with NAF collected from both breasts, there was a significant association between red/brown NAF color and the presence of breast cancer (p=0.005). Red/brown NAF was more common in breasts with ductal carcinoma in situ than atypical hyperplasia (p=0.008). The optimal model, included NAF color, cytology, and age, was 92% sensitive and 61% specific in predicting if a woman had breast cancer.

CONCLUSIONS

NAF color was associated with the presence of breast cancer and the progression from precancer to cancer in a population of women who presented to a breast cancer evaluation clinic. NAF color contributed to a highly predictive breast cancer detection model. Additional studies are warranted to determine the usefulness of NAF color in the assessment of women who present for breast cancer evaluation.

Does mammary ductoscopy have a role in clinical practice?

BACKGROUND

Mammary ductoscopy (MD) is a newly developed endoscopic technique that allows direct visualisation of the mammary ductal epithelium using sub-millimetre fiberoptic microendoscopes inserted through the ductal opening onto the nipple surface. These scopes also provide working channels for insufflation, irrigation, ductal lavage, and possible therapeutic intervention. MD can be performed under local anaesthesia in the office setting. The objective of this study is to assess the technical feasibility of mammary ductoscopy, and examine its role in guiding ductal excision surgery and the early diagnosis of malignancy.

METHODS

Mammary ductoscopy (MD) was performed using a 1 mm fiberoptic microendoscope (Mastascope TM) in 26 patients (age range: 14-73 years): 13 patients undergoing mastectomy (n = 12) or lumpectomy (n = 1) for ductal carcinoma (including 12 cases of DCIS and one case of infiltrating ductal carcinoma) and 13 patients with pathological nipple discharge (PND) and benign breast imaging and simple discharge cytology. Of the latter group: 10 procedures were performed under local anaesthesia (LA) in the office setting and 3 procedures were carried out under general anaesthesia (GA) to guide duct excision surgery. The ductoscopic appearances in this group were graded between 0 and 5 (D0-D5) according to the degree of suspicion.

RESULTS

Intraoperative MD was accomplished in 11 (84.6%) of 13 patients undergoing surgery for DCIS. MD was unsuccessful in 2 cases: one patient (aged 73 years) had sclerosis of the nipple and one patient had preoperative vital blue injection in the subareolar region as part of the sentinel node biopsy thus resulting in inadequate visualisation. Intraductal pathology was visualised in 8 (80%) of the 10 cases undergoing mastectomy but ductoscopic cytology was positive for malignancy in only 2 cases (sensitivity = 16%, specificity = 100%). In the office setting, MD was accomplished in 9 (90%) out of 10 patients with PND and was well tolerated (mean pain score = 3.8 out of 10: range 0-7). Of these 10 patients; MD was inadequate (D0) in one patient due to complete occlusion of lumen by the lesion, showed a papilloma in 3 patients (D3), duct ectasia (D2) in 3 patients, irregular thickening of the lumen suspicious of DCIS (D4) in one patient and non-specific benign findings (D2) in 2 patients. Three women with benign ductoscopy and ductoscopy-assisted cytology were reassured and treated conservatively. The remaining 7 patients had ductoscopy-guided duct excision which revealed DCIS in one, papilloma in 4 and benign breast disease in 2 patients. Adequate cellular yield was obtained in 7 (70%) out of 10 cases (benign cytology). The three patients who had MD under GA during microdochectomy had benign endoscopic appearances and final histology (one papilloma and 2 cases of duct ectasia).

CONCLUSION

MD is technically feasible in most patients and has a potential in the early detection of breast cancer. The procedure can be performed safely in the office setting and should be considered in all patients presenting with a single duct PND. MD has the potential to reduce the number of duct excision procedures and minimise the extent of surgical resection. Ductoscopic cytology is not sufficiently sensitive for the diagnosis of malignancy and the development of a biopsy tool that obtains tissue under direct visualisation is required.

Breast cancer detection using mammary ductoscopy

Mammary ductoscopy (MD) has been used as a tool to evaluate the breast for cancer for over 10 years. MD allows the direct visualization of the duct lumen, providing a more targeted approach to the diagnosis of disease arising in the ductal system, since the lesion can be visualized and samples collected in the area of interest. Initial studies of MD evaluated women with pathologic spontaneous nipple discharge (PND), while more recent reports are also using MD to assess women without PND for the presence of breast cancer. Cytologic assessment of MD is highly specific but less sensitive in the detection of breast cancer. Nonetheless, a MD sample from a breast with PND may rarely undergo cytologic review and be interpreted as consistent with malignancy, only later to undergo surgical resection demonstrating benign pathology. For this reason, PND specimens interpreted as malignant on cytologic review require histopathologic confirmation prior to instituting therapy. Additional sample evaluation using image or molecular analysis may improve the sensitivity and specificity of MD in breast cancer detection.

The clinical applications of mammary ductoscopy

BACKGROUND

Mammary ductoscopy (MD) is a newly developed endoscopic technique that allows direct visualization and biopsy examination of the mammary ductal epithelium where most cancers originate. The procedure can be performed under local anesthesia in the office setting. This article reviews the rationale, current clinical applications, and limitations of MD.

METHODS

A literature search was performed using Pubmed for indexed articles published over the past 30 years using the key words "mammary ductoscopy," "breast ductoscopy," "ductal lavage," and "nipple aspiration." The most important articles were analyzed and discussed.

RESULTS

MD is a useful diagnostic adjunct in patients with pathologic nipple discharge. Furthermore, it can reduce the number and extent of duct excision surgeries for pathologic nipple discharge. There is a clear need to design prospective clinical trials that evaluate the potential role of MD in breast cancer screening, guiding risk-reducing strategies, and as an adjunct to breast-conservation surgery.

CONCLUSIONS

MD is useful in the management of PND, but its potential role in the early detection or management of breast cancer requires further investigation.

Fiberoptic ductoscopy findings in women with and without spontaneous nipple discharge

BACKGROUND

Fiberoptic ductoscopy (FD), which allows direct visualization of the breast ductal lumen, is performed in women with and without spontaneous nipple discharge (SND). Previous reports suggested that cytologic evaluation of SND may be falsely interpreted as containing malignancy. The purpose of the current study, which was performed prospectively, was to determine whether ductoscopic findings were different in women with versus without SND, and to assess the implications of the differences in SND versus non-SND samples regarding the role of FD in assessing whether a woman has breast carcinoma.

METHODS

Data were collected on the distance traveled by the ductoscope, visual observations, pathology, cytology, epithelial and foam cell quantity, and image analysis for ploidy, hypertetraploidy, and S-phase fraction.

RESULTS

Of 100 FD specimens, 60 were from breasts without SND and 40 were from breasts with SND. Intraductal visual observations (P < or = 0.0002), pathologic findings in the resected specimen (P < or = 0.001), and quantity of epithelial cells (P=0.03) were influenced by the presence or absence of SND. Although one specimen from a benign breast was interpreted as cytologically malignant, every breast with both malignant cytology and aneuploidy contained cancer cells. A model incorporating cytology and SND was 92% sensitive and 60% specific in predicting which women had breast carcinoma.

CONCLUSIONS

There were pronounced differences in FD samples from women with and without SND. FD biologic parameters can be chosen to optimize breast carcinoma predictive sensitivity and specificity. SND cytology can present a diagnostic problem, suggesting the need for histologic confirmation before the initiation of therapy.

Ductoscopic cytology and image analysis to detect breast carcinoma

BACKGROUND

The goal of the prospective study was to determine whether 1) image analysis (IA; including DNA index [DI], S-phase fraction, and the presence or absence of aneuploidy or hypertetraploidy [HT]) of fiberoptic ductoscopy (FD) breast specimens was feasible, 2) IA findings from FD specimens predicted histopathologic evidence of disease, and 3) a combination of IA, cytology, and clinical factors provided complementary information in the diagnosis of breast carcinoma.

METHODS

IA and cytologic evaluation were performed on 106 consecutively collected ductoscopic specimens from 88 subjects.

RESULTS

IA was successful in 73 (71%) FD specimens. HT (P = 0.03) was related to intraductal visual observations. The proportion of atypical papillomas with aneuploidy was greater (P = 0.05) than in any other class. The HT index was higher in atypical papilloma (P = 0.02) and in breast carcinoma (P = 0.05) than with other diagnoses. The proportion of papilloma cases with HT was greater (P = 0.04) than benign papillomas. Malignant cytology was associated with a higher DI (P = 0.02) and a higher HT index (P = 0.001) than nonmalignant (benign or atypical) cytology. HT (P = 0.002) was less common with cytology containing few epithelial cells, and the HT index was higher with malignant versus nonmalignant FD cytology (P = 0.001). The percentage of cells containing HT was greater in FD specimens that were suspicious for malignancy (P = 0.006) than in those with benign cytology or mild atypia. Considering all samples and combining IA, cytologic, and visual findings in a stepwise linear discriminant analysis optimized the sensitivity (61%) and specificity (90%) of breast carcinoma prediction. Excluding spontaneous nipple discharge (SND) samples and adding epithelial cell quantity in samples improved the model (sensitivity, 85%; specificity, 80%).

CONCLUSIONS

IA was feasible in FD specimens whenever adequate epithelial cells were present. IA and cytologic findings were associated. Adding IA results to cytology and visual findings and excluding samples with SND improved diagnostic sensitivity.

Prospective evaluation of a novel approach for the use of a quantitative galactose oxidase-Schiff reaction in ductal fluid samples from women with breast carcinoma

BACKGROUND

The galactose oxidase-Schiff reaction (GOS) yields positive findings in a number of malignant solid tumors. The goals of the current study were to develop a novel technique for quantifying GOS reactivity in nipple aspirate fluid (NAF) samples from women with invasive breast carcinoma and to assess the clinical utility of the technique in this setting.

METHODS

Patients with biopsy-proven unilateral invasive breast carcinoma were eligible for study entry. Before definitive surgery, NAF samples were obtained from healthy breast tissue and malignant breast tissue from 23 women with breast carcinoma. Under blind conditions with respect to clinical data, 10 microL NAF samples were applied to a glass fiber membrane and incubated with 100 microL galactose oxidase and 1 mL Schiff reagent. The stain was developed and the color reaction quantitated by measuring hue (shade) and chroma (intensity) using a spectrophotometer.

RESULTS

GOS reactivity was quantitated using two color parameters, hue and chroma. Because chroma varies with concentration, this measurement was adjusted for the concentration of NAF in each sample. After adjustment for NAF concentration, chroma was found to be statistically significantly different in the affected breast tissue sample and the healthy contralateral internal control sample (P = 0.001).

CONCLUSIONS

A quantitative measure of GOS reactivity based on spectrophotometric measurement of intensity of color has been developed and was found to be significantly different in the affected breast compared with the unaffected breast in the current population of patients with breast carcinoma. The preliminary results support further exploration of this novel quantitative test in patients with breast carcinoma.

Ductoscopic Cytology to Detect Breast Cancer

PURPOSE

Fiberoptic ductoscopy allows direct visualization of the breast ductal lumen, providing a targeted approach to the diagnosis of intraductal disease. The purpose of this prospective study was to determine whether (1) endoscopic evaluation of the breast could be reliably performed, and (2) ductoscopic data (intraductal distance traveled, visual observations, epithelial and foam cell quantity, cytology) predict whether a woman has breast cancer.

PATIENTS AND METHODS

Ductoscopic information was collected on intraductal distance traveled, visual observations, epithelial and foam cell quantity, and cytology.

RESULTS

Ductoscopic samples were successfully collected in 106/108 attempts. The first six specimens collected were acellular. Of the 100 remaining ductoscopic specimens, 37 were from breasts with ductal carcinoma in situ or invasive breast cancer, 10 from breasts with precancerous lesions, 37 duct hyperplasia/papilloma, 11 histologically normal specimens, and five specimens from breasts that did not undergo subsequent surgical excision. The ability to travel intraductally > or = 10 cm was greater in women with hyperplasia and papilloma (with and without atypia) lesions. Intraductal lesions that were visually considered tumors were more often hyperplasia/papilloma and malignant than other lesions. Extrinsic duct occlusion was observed only in malignant lesions. Excluding learning curve samples, 67/100 (45% of normal, 68% of hyperplastic, 90% of precancerous, 82% of ductal carcinoma in situ, and 70% of invasive) fiberoptic ductoscopy specimens had adequate epithelial cells, and all duct cannulation attempts except two were successful. There was one false-positive cytologic result in a woman found to have a papilloma. Foam cell quantity was significantly related to epithelial cell quantity.

CONCLUSION

Fiberoptic ductoscopy is feasible in the vast majority of subjects. Fiberoptic ductoscopy is a specific but not sufficiently sensitive method to be used alone to diagnose breast cancer. The presence of highly atypical epithelial cells in specimens from breasts containing papillomas is a pitfall of this method. Caution must be exercised to avoid a false-positive diagnosis in patients with spontaneous nipple discharge.

Prostate-specific antigen expression in nipple aspirate fluid is associated with advanced breast cancer

We previously demonstrated that prostate-specific antigen (PSA) is present in breast nipple aspirate fluid (NAF) and its expression is inversely associated with the presence of breast cancer. The purpose of this study was to determine if PSA levels in NAF decrease with disease progression from DCIS to metastatic breast cancer. One hundred and forty-nine women underwent nipple aspiration before or in conjunction with surgery to treat their breast cancer. PSA levels decreased with more advanced disease stage (P = 0.016), larger tumor size (P = 0.031), and nodal involvement (P = 0.041). PSA levels were lower in women with than without distant disease spread (P = 0.049). We also evaluated the association of PSA with these clinical parameters based on menopausal status. In general, PSA predicted disease involvement better in pre- than in post-menopausal women. There was no association between PSA and race. Spearman's rank analysis demonstrated that PSA was inversely related to tumor size (P = 0.009), nodal status (P = 0.005), disease stage (P = 0.004), and distant metastases (P = 0.04). NAF PSA provides useful prognostic information which may assist with breast cancer treatment.

Mammogram synthesis using a three-dimensional simulation. III. Modeling and evaluation of the breast ductal network

A method is proposed for realistic simulation of the breast ductal network as part of a computer three-dimensional (3-D) breast phantom. The ductal network is simulated using tree models. Synthetic trees are generated based upon a description of ductal branching by ramification matrices (R matrices), whose elements represent the probabilities of branching at various levels of a tree. We simulated the ductal network of the breast, consisting of multiple lobes, by random binary trees (RBT). Each lobe extends from the ampulla and consists of branching ductal segments of decreasing size, and the associated terminal ductal-lobular units. The lobes follow curved paths that project from the nipple toward the chest wall. We have evaluated the RBT model by comparing manually-traced ductal networks from 25 projections of ductal lobes in clinical galactograms and manually-traced networks from 23 projections of synthetic RBTs. A root-mean-square (rms) fractional error of 41%, between the R-matrix elements corresponding to clinical and synthetic images, was computed. This difference was influenced by projection and segmentation artifacts and by the limited number of available images. In addition, we analyzed 23 synthetic trees generated using R matrices computed from clinical images. A comparison of these synthetic and clinical images yielded a rms fractional error of 11%, suggesting the possibility that a more appropriate model of the ductal branching morphology may be developed. Rejection of the RBT model also suggests the existence of a relationship between ductal branching morphology and the state of mammary developmentand pathology.

Nipple aspirate fluid cytology in breast carcinoma

BACKGROUND

Nipple aspirate fluid (NAF) cytology is a simple noninvasive method to study cells exfoliated into the ductal system of the breast. In the current study, the significance of cytologic findings in NAF was determined by correlating them with histopathologic findings from corresponding breast tissue. Cytologic-histologic correlations of NAF were performed in only a few studies.

METHODS

Nipple aspirate fluid was collected by breast massaging and by using a breast aspiration device from 74 women with biopsy confirmed intraductal or invasive carcinoma with or without a history of preoperative neoadjuvant chemotherapy. Cytospin preparations were Pap stained. The number of epithelial cells was quantitated and foamy macrophages were semiquantitatively scored. Cytologic findings were categorized as insufficient for diagnosis (less than 10 epithelial cells), benign, mild atypia, marked atypia or suspicious, and malignant. Finally, they were correlated with tissue findings.

RESULTS

Nipple aspirate fluid was obtained from 74 women, including 24 who had received preoperative neoadjuvant chemotherapy. The median age of patients was 54 years. A mean volume of 57 microL NAF and a mean of 149 epithelial cells were obtained. Foamy macrophages were present in 51 (70%) of the specimens. There was a significant correlation between the presence of epithelial cells and foamy macrophages (P < 0.001). Patients treated with chemotherapy had fewer epithelial cells in their NAF compared with patients who were not treated with chemotherapy. Thirty specimens (41%) were inadequate for diagnosis, 34 were (46%) benign, 5 (7%) were mildly atypical, 1 (1%) was markedly atypical, and 4 (5%) were malignant. Of the five cases with mildly atypical cytology, three were intraductal papilloma, one was low-grade papillary intraductal carcinoma, and one was low-grade intracystic papillary carcinoma with invasion in the corresponding tissue specimen. The single case with markedly atypical NAF cytology had extensive ductal carcinoma in situ (DCIS). Of the four cases with malignant NAF cytology, two were extensive DCIS and two had invasive carcinoma with extensive DCIS in the breast specimen. Overall, 3 (27%) of 11 cases of DCIS were detected in NAF and only 2 (4%) of 52 invasive carcinomas including the only two cases with extensive DCIS were detected in NAF.

CONCLUSION

The probability of detecting malignant cells in NAF is dependent on the extent of DCIS and nipple involvement by DCIS. Nipple aspirate fluid is not a sensitive test for detecting invasive carcinoma of the breast. Atypical cytology in NAF is associated with papillary lesions in the underlying breast.

Classification of galactograms with ramification matrices: preliminary results

RATIONALE AND OBJECTIVES

The poor specificity of galactography, the imaging modality generally indicated in cases of nipple discharge, has led to a large number of biopsies with negative results. A quantitative scheme for classifying galactographic findings might help reduce the number of such biopsies in the future. As a first step toward that goal, the authors have studied one quantitative method for describing the branching of ducts by using ramification matrices (R matrices), and the correlation of the values of the matrix elements with clinical findings.

MATERIALS AND METHODS

The ductal trees were manually segmented for 25 galactographic views from 15 patients, and corresponding R matrices were calculated. Patients were divided into two groups: those with no reported galactographic findings (NF) and those with reported findings (RF) of ductal ectasia, cysts, or papilloma. In a leave-one-out fashion, the authors evaluated a classification scheme that was based on R-matrix coefficients and used a Bayesian decision rule. The effects of segmentation were tested by successively removing each of the terminal ducts and computing the corresponding matrices of the pruned trees.

RESULTS

With use of a single R-matrix element, 92% and 62% of NF and RF cases were correctly classified, respectively (P = .007). With use of two elements, 83% and 77% of NF and RF cases were correctly classified, but this result was not statistically significant (P = .108). In a test of robustness, an analysis of pruned trees yielded an average root-mean-square fractional difference of 9.7% between the elements of the original and the R matrix averaged over all pruned trees.

CONCLUSION

The preliminary analysis indicates that it may be possible to identify cases with reported galactographic findings by using R matrices.

Prostate-specific antigen and insulin-like growth factor binding protein-3 in nipple aspirate fluid are associated with breast cancer

Insulin-like growth factor-1 (IGF-1) is an important growth factor for breast cancer cells and insulin-like growth factor binding protein-3 (IGFBP-3) its most prevalent binding protein. Prostate-specific antigen (PSA) enzymatically cleaves IGFBP-3 into fragments (BP3-FR). Our purpose was to determine the association of these markers in nipple aspirate fluid (NAF) and serum with the presence of breast cancer. NAF from 175 and serum from 215 subjects were collected from women with or without breast cancer. In unadjusted analysis low NAFPSA (P < 0.001) and high NAFIGFBP-3 (P = 0.023) were associated with breast cancer. Low serum PSA was associated with postmenopausal breast cancer (P = 0.034). In separate multivariate analyses, controlling for age, menopausal status, and age at menarche, NAF PSA and IGFBP-3 were each associated with breast cancer. The association was significant for NAF IGFBP-3 in all women (P = 0.031), but for NAF PSA only in premenopausal women (P < 0.001). When considered jointly, only NAF PSA was significant. Therefore, NAF PSA, and to a lesser extent NAF IGFBP-3 and serum PSA, seem to be important predictors of breast cancer.

Lipocalin-type and hematopoietic prostaglandin D synthases as a novel example of functional convergence

Prostaglandin (PG) D2 is a major PG produced in the central nervous system and is involved in the regulation of sleep and pain responses through DP receptors. It is also actively produced by mast cells, basophils, and Th2 cells, acting as an allergic mediator through DP and CRTH2 receptors. PGD2 is further dehydrated to produce PGJ2, delta12-PGJ2, and 15-deoxy-delta(12,14)-PGJ2, the last being a ligand for the nuclear receptor PPARgamma. PGD synthase (PGDS) catalyzes the isomerization of PGH2 to PGD2 in the presence of sulfhydryl compounds. Two distinct types of PGDS have been identified: one is the lipocalin-type PGDS (L-PGDS); and the other, the hematopoietic PGDS (H-PGDS). We isolated the human and mouse cDNAs and genes for L-PGDS and H-PGDS, determined their X-ray crystallographic structures, examined their tissue distribution profiles and cellular localization, and generated gene-knockout mice and human enzyme-overexpressing transgenic mice. L-PGDS and H-PGDS are quite different from each other, in terms of their amino acid sequence, tertiary structure, evolutional origin, chromosomal and cellular localization, tissue distribution, and also functional relevance. Therefore, L-PGDS and H-PGDS are considered to be a novel example of functional convergence.

Circulating testosterone and prostate-specific antigen in nipple aspirate fluid and tissue are associated with breast cancer

Preliminary evidence has associated testosterone and prostate-specific antigen (PSA) with breast cancer. Our objective was to determine whether a) testosterone levels in nipple aspirate fluid (NAF), serum, or breast tissue are associated with breast cancer; b) testosterone levels in serum are associated with levels in NAF; c) PSA in NAF, serum, or breast tissue is associated with breast cancer; and d) serum PSA is associated with NAF PSA levels. We obtained 342 NAF specimens from 171 women by means of a modified breast pump. Additionally, we collected 201 blood samples from 99 women and 51 tissue samples from 41 subjects who underwent surgical resection for suspected disease. Women currently using birth control pills or hormone replacement therapy were excluded from the study. Controlling for age and menopausal status, serum testosterone was significantly increased in women with breast cancer (p = 0.002). NAF and serum testosterone levels were not associated. Neither NAF nor tissue testosterone was associated with breast cancer. Controlling for menopausal status and age, NAF PSA was significantly decreased in women with breast cancer (p < 0.001). We did not find serum PSA to be associated with breast cancer, although we found an indication that, in postmenopausal women, its levels were lower in women with cancer. Serum PSA was associated with NAF PSA in postmenopausal women (p < 0.001). PSA levels in cancerous tissue were significantly lower than in benign breast specimens from subjects without cancer (p = 0.011), whereas levels of PSA in histologically benign specimens from subjects with cancer were intermediate. Our results suggest that serum testosterone is increased and NAF PSA is decreased in women with breast cancer, with PSA expression being higher in normal than in cancerous breast tissues. NAF and serum PSA levels in postmenopausal women are correlated, suggesting that as laboratory assessment of PSA becomes more sensitive, serum PSA may become useful in identifying women with breast cancer.

Breast cancer risk in women with abnormal cytology in nipple aspirates of breast fluid

BACKGROUND

We previously showed that women with abnormal cytology in breast fluid obtained by nipple aspiration had an increased relative risk (RR) of breast cancer compared with women from whom fluid was not obtained and with women whose fluid had normal cytology. This study extends the follow-up in the original study group (n = 4046) and presents the first follow-up for a second group of women (n = 3627).

METHODS

We collected nipple aspirate fluid from women in the San Francisco Bay Area during the period from 1972 through 1991, classified the women according to the most severe epithelial cytology observed in fluid specimens, and determined breast cancer incidence through March 1999. We estimated RRs for breast cancer using Cox regressions, adjusting for age and year of study entry. All statistical tests were two-sided.

RESULTS

For women in the first and second study groups, the median years of follow-up were 21 years and 9 years, respectively, and breast cancer incidences were 7.8% (285 cases in the 3633 women for whom breast cancer status could be determined) and 3.5% (115 of 3271), respectively. Compared with women from whom no fluid was obtained, whose incidences of breast cancer were 4.7% (39 of 825) and 3.3% (65 of 1950) for those in group 1 and group 2, respectively, incidences and adjusted RRs were 8.1% (34 of 422), with RR = 1.4 (95% confidence interval [CI] = 0.9 to 2.3), and 0% (0 of 31), respectively, for those with unsatisfactory aspirate specimens and 8.2% (148 of 1816), with RR = 1.6 (95% CI = 1.1 to 2.3), and 3.1% (25 of 811), with RR = 1.2 (95% CI = 0.8 to 2.0), respectively, for those with normal cytology in aspirates. Compared with women from whom no fluid was obtained, incidences and adjusted RRs for women in group 1 with epithelial hyperplasia and atypical hyperplasia in aspirates were 10.8% (52 of 483), with RR = 2.4 (95% CI = 1.6 to 3.7), and 13.8% (12 of 87), with RR = 2.8 (95% CI = 1.5 to 5.5), respectively, while those for women in group 2 were 5.5% (25 of 457) and 0% (0 of 22), respectively, with a combined RR = 2.0 (95% CI = 1.3 to 3.3).

CONCLUSION

The results obtained with the newly followed women independently confirmed previous findings that women with abnormal cytology in nipple aspirates of breast fluid have an increased risk of breast cancer.

Nipple aspirate cytology and pathologic parameters predict residual cancer and nodal involvement after excisional breast biopsy

We previously demonstrated that abnormal nipple aspirate fluid (NAF) cytology predicted residual breast cancer (RC) and tumour size after excisional biopsy (EB), although normal NAF cytology did not exclude RC. Tumour size correlates with the risk of lymph node (LN) metastases. LN metastases provide prognostic information allowing medical and radiation oncologists to determine the need for adjuvant therapy. We hypothesized that pathologic factors known after EB, combined with NAF cytology, would predict with a high degree of accuracy the presence of RC and LN spread. NAF cytology and pathologic parameters: tumour distance from biopsy margins, multifocal and multicentric disease, sub-type of ductal carcinoma in situ (DCIS) or invasive cancer (IC), grade of DCIS or IC, tumour and specimen size, tumour and biopsy cavity location, presence or absence of extensive DCIS, and biopsy scar distance from the nipple were evaluated bivariately and then by logistic regression (LR) for their association with RC and involved LN (> or = 1 (+) LN, useful to determine chemotherapy need, and > or = 4 (+) LN, useful to determine radiation need to the chest and axilla). Data were analysed using NAF cytology alone, pathologic parameters alone, and NAF cytology and pathologic parameters combined. The combined LR model was superior in predicting residual cancer (94%) to LR models using NAF cytology (36%) or pathologic parameters (75%) alone. When only subjects with normal NAF cytology were evaluated by LR, the model was 92% sensitive in predicting RC. Tumour size and NAF cytology predicted which patients had > or = 1 (+) LN, whereas tumour and specimen size predicted which patients had > or = 4 (+) LN. We propose an algorithm which, if confirmed in a larger study, may allow clinicians to be more selective in their recommendations of re-excision breast biopsy or mastectomy.

Nipple aspiration in diagnosis of breast cancer

It has been shown that early detection of breast cancer saves lives. Mammography and physical examination are currently the most commonly utilized screening methods for breast cancer. Research is being carried out to optimize these screening methods, as well as to develop new techniques. This review summarizes the findings of the research focusing on the diagnostic techniques involving the breast ductal system to date. These tests include nipple fluid cytology, nipple fluid tumor markers, ductogram, and ductoscopy.

Biochemical and ultrastructural features of human milk and nipple aspirate fluids

Breast duct epithelium produces, secretes, and metabolises several biologically important compounds, which are found in breast secretions obtained in physiologic and pathologic conditions (milk and nipple aspirate fluids, respectively). In order to preliminarily evaluate the ultrastructural morphology of the cells found in Type II nipple aspirate fluids (NAF) and correlate it with the biochemical profile of the extracellular fluid present in these breast secretions and in human milk, we analyzed 72 NAFs from nonlactating premenopausal women affected by various breast diseases and 10 normal milk samples. Although several constitutive proteins were detected in all samples examined, the preliminary biochemical analyses and electrophoretic profiles revealed characteristic behaviours for several biologic constituents, suggesting a possible basic mechanism of production by breast epithelial cells during both physiologic and pathologic conditions. The ultrastructural analysis of milk cellular components give preliminary evidence of the apocrine secretion mechanism peculiar of breast gland, whereas Type II NAF cells appeared as biosynthetically active cells, showing a possible modified secretion mechanism. Our multidisciplinary approach seems to support the hypothesis that cellular and biochemical behaviour of Type II NAF may be an useful tool to identify aberrated breast epithelial cells in nonlactating women that might be prone to premalignant transformation.

Nipple fluid carcinoembryonic antigen and prostate-specific antigen in cancer-bearing and tumor-free breasts

PURPOSE

Mammograms and breast examinations are established methods for early breast cancer detection. Routine mammography screening reduces breast cancer mortality among women ages > or = 50 years, but additional screening methods are needed. We and others have found high levels of carcinoembryonic antigen (CEA) and prostate-specific antigen (PSA) in nipple aspirate fluids (NAFs), but the usefulness for these bio-markers for early breast cancer detection is unknown.

PATIENTS AND METHODS

NAFs from one or both breasts of 388 women were analyzed for CEA, PSA, and albumin levels. The study included 44 women with newly diagnosed invasive breast cancers, 67 women with proliferative breast lesions (ductal and lobular carcinoma in situ and atypical ductal hyperplasia), and 277 controls without these breast lesions. Analyses were conducted using the log(10)-transformed CEA and PSA levels to normalize the distributions of these tumor markers.

RESULTS

Nipple fluid CEAs are significantly higher for cancerous breasts than tumor-free breasts (median 1,830 and 1,400 ng/mL, respectively; P <.01). However, at 90% specificity of the assay (CEA = 11,750 ng/mL), the corresponding sensitivity for cancer detection is 32%. CEA levels are not significantly different for breasts with proliferative lesions compared with tumor-free breasts. Nipple fluid PSAs do not differ by tumor status. Analyses of NAF albumin-standardized CEAs and PSAs yield similar results. Nipple fluid CEA and PSA titers are correlated in the affected and unaffected breast of women with unilateral lesions.

CONCLUSION

Nipple fluid CEAs are higher for breasts with untreated invasive cancers, but the test sensitivity is low. Nipple fluid PSA titers do not seem to be useful for breast cancer detection.