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

Synthesis, and In-silico Studies of Indole-chalcone Derivatives Targeting Estrogen Receptor Alpha (ER-α) for Breast Cancer

BACKGROUND

Breast cancer is the prominent reason of death in women worldwide, and the cases are increasing day by day. There are many FDA-approved drugs for treating breast cancer. Due to drug resistance, and problems in selectivity, there is a need to develop more effective agents with few side effects. Indole derivatives have demonstrated significant pharmacological potential as anti-breast cancer agents. Further, chalcone derivatives incorporating heterocyclic scaffolds play a significant role in medicine. Indole-chalcone-based compounds offer the potential for improved biological activity and enhanced drug-like properties. It prompted us to explore the synthesis of Indole-Chalcone derivatives targeting estrogen receptor alpha (ER-α) to discover potent anti-breast cancer agents.

OBJECTIVES

To synthesize indole-chalcone derivatives and study their binding interactions for ER-α protein by molecular docking for breast cancer treatment.

METHODS

In this study, indole-chalcone derivatives have been synthesized using conventional heating. With the help of Schrodinger software, molecular interaction as well as ADME (Adsorption, Distribution, Metabolism, and Excretion) studies of the compounds were conducted.

RESULTS

Among all the synthesized compounds, four compounds (1, 2, 3, and 4) showed better docking scores (-10.24 kcal/mol, -10.15 kcal/mol, -9.40 kcal/mol, -9.29 kcal/mol, respectively) than the standard tamoxifen (-8.43 kcal/mol).

CONCLUSION

From In-silico studies, we can conclude that four compounds from the synthesized series fit into the active site of ER-α. ADME properties of synthesized derivatives were found in the acceptable range. In the future, these compounds can be further explored for biological activity.

Diagnostic Accuracy of Nipple Discharge Fluid Cytology: A Meta-Analysis and Systematic Review of the Literature

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.

Gene-Environment Interaction between Arg72Pro SNP and Selected Environmental Exposures among Brazilian Women Diagnosed with Benign Breast Disease

Background:

Benign breast disease (BBD) is a factor strongly associated with breast cancer worldwide. Arg72Pro SNP association with breast cancer is controversial due to the suggestion that environmental factors are required to modulate such risk. There are no studies evaluating these environmental interactions of the aforementioned SNP within BBD.

Aim:

To determine the frequency of SNP Arg72Pro in a cohort of women diagnosed with BBD; and to investigate gene-environmental interactions with environmental factors.

Results:

The genotype frequency was 44.6% for Arg/Pro, 39.3% for Arg/Arg genotype, and 16.3% for Pro/Pro homozygote. Gene-environment interaction analysis shows that when Arg/Arg is considered as reference, there is an ORinteraction with Arg/Pro and fabric exposure (OR=1.90;95%CI:1.04,3.48), solvents (OR=2.21;95%CI:1.01,4.83) and chlorine, bleaches, disinfectants, and liquid wax exposure (OR=2.52;95%CI:1.07,5.91). Analysis with Pro/Pro genotype as the reference showed an interaction between alcohol consumption and recessive model (OR=1.58;95%CI:1.00,2.51). Gene-environmental interactions were observed too between exposure to hair dyes, straighteners or relaxers and Arg/Arg (OR=3.26;95%CI:1.21,8.82).

Conclusion:

The Arg/Pro genotype was the most frequent in the BBD cohort. When compared with the Arg/Arg genotype, the presence of Arg/Pro genotype and solvents, fabric and cleaning products exposure increased the risk of BBD. When compared with Pro/Pro genotype, there were interactions between recessive model with alcohol consumption and exposure to hair products on the risk of BBD.

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.

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.

Examination of Duct Physiology in the Human Mammary Gland

Background

The human breast comprise several ductal systems, or lobes, which contain a small amount of fluid containing cells, hormones, proteins and metabolites. The complex physiology of these ducts is likely a contributing factor to the development of breast cancer, especially given that the vast majority of breast cancers begin in a single lobular unit.

Methods

We examined the levels of total protein, progesterone, estradiol, estrone sulfate, dehydroepiandrosterone sulfate, and macrophages in ductal fluid samples obtained from 3 ducts each in 78 women, sampled twice over a 6 month period. Samples were processed for both cytological and molecular analysis. Intraclass correlation coefficients and mixed models were utilized to identify significant data.

Results

We found that the levels of these ductal fluid components were generally uncorrelated among ducts within a single breast and over time, suggesting that each lobe within the breast has a distinct physiology. However, we also found that estradiol was more correlated in women who were nulliparous or produced nipple aspirate fluid.

Conclusions

Our results provide evidence that the microenvironment of any given lobular unit is unique to that individual unit, findings that may provide clues about the initiation and development of ductal carcinomas.

Genetic Determinants of Nipple Aspiration Fluid Yield

PURPOSE

Nipple aspiration fluid (NAF) is a non-invasively-acquired biosample that can provide a window into the breast environment, but NAF yield is highly variable. Its determinants must be better understood for studies of breast cancer risk. The wet earwax phenotype was identified as one determinant of NAF yield in the 1970s, and is linked to single nucleotide polymorphisms (SNPs) in the ATP-binding cassette transporter gene ABCC11. We have investigated this, as well as SNPs in the prolactin (PRL) and prolactin receptor (PRLR) genes, in relation to NAF yield.

METHODS

DNA was extracted from white blood cells of 557 NAF yielders and 359 non-yielders, and was used to genotype ABCC11 (rs17822931), PRL (rs849870, rs849872, rs849886, rs2244502, rs1341239), and PRLR (rs37364, rs34024951, rs1610218, rs9292575, rs7718468) using Taqman genotyping assay. The association between NAF yield and each single SNP was analyzed using logistic regression adjusting for age, race, and menopausal status.

RESULTS

ABCC11 rs17822931 showed a negative association with NAF yield [odds ratio (OR) 0.66, 95 % confidence interval (CI) 0.49-0.88; p = 0.004]. The PRL rs849870 and the haplotype combination with other SNPs showed a marginal association with NAF yield. In addition, the years since last birth also showed negative association with NAF yielding (OR 0.98, 95 % CI 0.96-0.99; p = 0.001). The combination of the years since last birth with ABCC11 SNP revealed significant interaction between reproductive factor and genetic factor.

CONCLUSIONS

Our results confirmed the association between NAF yield and earwax phenotype through ABCC11 genotype. Combined with the recency of last birth, ABCC11 genotype should be considered in the design of studies utilizing NAF as a biosample.

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.

Breast cancer risk associated with benign breast disease: systematic review and meta-analysis

Benign breast disease (BBD) is a broad category of diagnoses reported to convey a variable degree of increased risk of developing breast cancer. A meta-analysis of the existing literature was performed to quantify the risk estimate associated with BBD. Pubmed, Google Scholar, and EMBASE databases were searched in January 2011. English retrospective and prospective observational studies published from 1972 to 2010 evaluating BBD and the risk of breast cancer were included with data acquisition reported from 1930 to 2007. Eligibility was performed independently following a standardized protocol for full-text publication review by a single reviewer and reviewed by a second author. Of the 3,409 articles retrieved from the literature search, 32 studies met the selection criteria. Reported risk estimates, including relative risk, odds ratio, standardized incidence ratios, rate ratio, hazards ratio, and incidence rate ratio, were the primary outcomes extracted. The most commonly reported pathologies were decided prior to extraction and organized into the following categories for analysis of the extracted risk estimate: non-proliferative disease (NPD), proliferative disease without atypia, benign breast disease not otherwise specified (BBD), and atypical hyperplasia not otherwise specified (AHNOS). The mean age at benign breast biopsy was 46.1 years and the mean age of developing breast cancer was 55.9 years. The mean follow-up length was 12.8 years (range 3.3-20.6). The summary risk estimate of developing breast cancer for NPD was 1.17 (N = 8; 95% CI 0.94-1.47). Proliferative disease without atypia was associated with significantly increased risk of future breast cancer, summary relative risk 1.76 (N = 15; 95% CI 1.58-1.95). The summary risk estimate for AHNOS was 3.93 (N = 13; 95% CI 3.24-4.76). This meta-analysis demonstrates that proliferative benign breast disease with or without atypia is associated with a significant increase in risk of developing breast cancer. These data support management strategies for women with benign breast disease such as additional screening methods or chemoprevention.

Liquid-Based Medium Used to Prepare Cytological Breast Nipple Fluid Improves the Quality of Cellular Samples Automatic Collection

Background

Breast cancer is the second cause of death in women worldwide. The spontaneous breast nipple discharge may contain cells that can be analyzed for malignancy. Halo^® Mamo Cyto Test (HMCT) was recently developed as an automated system indicated to aspirate cells from the breast ducts. The objective of this study was to standardize the methodology of sampling and sample preparation of nipple discharge obtained by the automated method Halo breast test and perform cytological evaluation in samples preserved in liquid medium (SurePath™).

Methods

We analyzed 564 nipple fluid samples, from women between 20 and 85 years old, without history of breast disease and neoplasia, no pregnancy, and without gynecologic medical history, collected by HMCT method and preserved in two different vials with solutions for transport.

Results

From 306 nipple fluid samples from method 1, 199 (65%) were classified as unsatisfactory (class 0), 104 (34%) samples were classified as benign findings (class II), and three (1%) were classified as undetermined to neoplastic cells (class III). From 258 samples analyzed in method 2, 127 (49%) were classified as class 0, 124 (48%) were classified as class II, and seven (2%) were classified as class III.

Conclusion

Our study suggests an improvement in the quality and quantity of cellular samples when the association of the two methodologies is performed, Halo breast test and the method in liquid medium.

Breast cancer risk assessment, prevention, and the future

Today breast cancer remains a major public health problem, although reducing its risk is now an achievable medical objective. Risk-assessment models may be used in estimating a woman's risk for developing breast cancer and to direct suitable candidates for preventive therapy. Researchers are attempting to enhance individualized risk assessment through incorporation of phenotypic biomarkers. Individual selective estrogen receptor modulators have been approved for breast cancer risk reduction, and other drug categories are being studied. It is critical that obstetrician-gynecologists be familiar with the evolving science of the risk assessment of breast cancer as well as interventional and surveillance strategies.

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.

Hormonal determinants of nipple aspirate fluid yield among breast cancer cases and screening controls

BACKGROUND

Nipple aspiration fluid (NAF) use as a biosample is limited by the variable yield across studies. We investigated the endocrine determinants of yield in an ongoing breast cancer case-control study.

METHODS

One-hundred and eighteen women yielding ≥2 μL NAF and 120 non-yielders were included; serum hormones were measured; differences in median hormones were assessed using the Wilcoxon rank-sum test. ORs and 95% confidence intervals (95% CI) for yielder status relative to hormone levels were estimated using logistic regression, adjusting for parity and lactation, and, in premenopausal women, menstrual cycle phase (MCP).

RESULTS

Prolactin concentrations were higher in yielders than non-yielders (premenopausal: 7.6 and 2.5 ng/mL, P < 0.01; postmenopausal 5.3 and 2.2 ng/mL; P < 0.01). Among premenopausal-yielders, estradiol was lower (64.3 vs. 90.5 pg/mL, MCP-adjusted P = 0.02). In separate menopausal status and parity-adjusted models, significant case-control differences persisted in prolactin: case OR 1.93 (95% CI, 1.35-2.77), control OR 1.64 (95% CI, 1.17-2.29). Premenopausal control yielders had higher progesterone (OR, 1.70; 95% CI, 1.18-2.46) and sex-hormone binding-globulin (OR, 2.09; 95% CI, 1.08-4.05) than non-yielders. Among parous women, further adjustment for lactation suggested a stronger positive association of serum prolactin with yield in cases than controls.

CONCLUSION

NAF-yielders show higher prolactin than non-yielders, regardless of menopause and parity; implications of this and other endocrine differences on NAF biomarkers of breast cancer risk deserve further study.

IMPACT

NAF yield is associated with a distinct endocrine environment that must be considered in studies of NAF-based breast cancer risk markers.

Weight loss reduces breast ductal fluid estrogens in obese postmenopausal women: a single arm intervention pilot study

BACKGROUND

Accumulation of excess body fat increases breast cancer risk after menopause. Whether the localized breast is differently influenced by adipose tissue compared to the rest of the body, has not been well studied. Our purpose was to demonstrate feasibility and preliminarily evaluate serum-based and localized breast biomarker changes resulting from a weight loss intervention among obese postmenopausal women.

METHODS

We conducted a 12-week pilot controlled dietary and exercise intervention among healthy obese postmenopausal women, collected serum and breast ductal fluid before and after the intervention, and estimated the association with systemic and localized biomarker changes. We recruited 7 obese (mean body mass index = 33.6 kg/m2) postmenopausal women. We collected samples at baseline and the 12th week for: anthropometry; phlebotomy; dual-energy x-ray absorptiometry (lean and fat mass); exercise fitness (maximum oxygen consumption (VO2Max); 1-repetition strength maximum); and breast ductal lavage.

RESULTS

Changes from baseline occurred in body composition and exercise performance including fat mass loss (14% average drop), VO2Max (+36% increase) and strength improvement (+26%). Breast ductal fluid markers declined from baseline with estradiol showing a 24% reduction and IL-6 a 20% reduction. We also observed serum biomarker reductions from baseline including leptin (36% decline), estrone sulfate (-10%), estradiol (-25%), and Il-6 (-33%).

CONCLUSIONS

Conduct of the diet and exercise intervention, collection of ductal fluid, and measurement of hormones and cytokines contained in the ductal fluid were all feasible. We preliminarily demonstrated estradiol and IL-6 reductions from baseline in both serum and breast ductal fluid among obese postmenopausal women who participated in the 12-week weight loss diet and exercise intervention.

Does ductal lavage assert its role as a noninvasive diagnostic modality to identify women at low risk of breast cancer development?

Objective

Ductal lavage (DL) involves evaluation of the ductal system of the breast for detection of intra-ductal carcinomas and precursor lesions by collecting breast epithelial cells using a small-gauge catheter inserted into a ductal orifice on the nipple. The aim of this survey was to analyze cytologic features of samples obtained from low-risk women with DL and to elucidate the efficacy of this diagnostic modality in evaluating fluid production, cannulating and determining atypical breast epithelial cells.

Methods

Into this prospective study were consecutively registered 80 women between ages 28 to 67. Nipple aspiration was performed to identify all fluid-yielding ducts. According to the grading of specific features the interpretation of the sample included: normal/benign (category, 0), mild atypical (category, I), markedly atypical (category, II) or malignant (category, III) disorders.

Results

Ninety five percent (316/334) of the nipple aspirate fluid samples were classified as category 0, 4.8% (16/334) as category I and 0.2% (2/334) as category II changes. Category III disorders were not detected. Therefore, in 80% of the women examined results were within normal limits while 17.5% of the participants presented mild atypical and 2.5% markedly atypical rates.

Conclusion

DL collection procedure proved to be rapid as well as acceptable by the women studied. It retains the advantage over other methods of nipple aspirate fluid in that it is easy to perform, thereby removing most clinician variability. It also helped low risk women to discriminate those with breast disorders that require additional investigation, further follow-up or administration of preventive medication.

Influence of diet on nipple aspirate fluid production and estrogen levels

One possible mechanism how nutritional factors may affect breast cancer risk is through an influence on estrogen levels. Nipple aspirate fluid (NAF) is thought to provide a more direct insight into hormonal influences on breast tissue than serum. The ability to produce NAF may be an indicator of breast cancer risk. The current analysis was conducted as part of a soy trial in 92 premenopausal women and evaluated the relation of usual dietary intake with NAF volume and the most predominant steroidal estrogens in NAF and serum at baseline. Estradiol (E(2)) and estrone sulfate (E(1)S) were assessed in NAF and E(2), estrone (E(1)), and E(1)S, in serum using highly sensitive radioimmunoassays. The statistical analysis applied multivariate, log-linear regression models. Intake of saturated fat and cheese (p = 0.06 for both) indicated a positive trend with NAF volume whereas isoflavonoid and soy consumption suggested inverse associations (p = 0.01 and p = 0.08). For estrogens in NAF, total fat and monounsaturated fat intake was positively associated with E(2) (p = 0.05 and p = 0.02) and in serum, alcohol intake was associated with higher E(1)S levels (p = 0.02). These findings suggest a weak influence of dietary composition on NAF production and estrogen levels in serum and NAF.

Temporal changes in the levels of perfluorinated compounds in California women's serum over the past 50 years

Serum samples collected from California women at different time periods: 1960s (n = 40), 1980s (n = 30), and 2009 (n = 35) were examined for the presence of 12 perfluorinated compounds (PFCs) using an online SPE-HPLC-MS/MS method. At each time period, perfluorooctane sulfonate (PFOS) was present at the highest concentration, followed by perfluorooctanoic acid (PFOA, except in the 1960s). We found the highest levels of PFOS (median = 42.1 ng/mL) and perfluorohexane sulfonate (PFHxS, median = 1.56 ng/mL) in the 1960s samples, possibly reflecting widespread use of precursor PFCs. PFOS showed a statistically significant drop from the 1960s to the 1980s (28.8 ng/mL ) and to 2009 (9.0 ng/mL ), the latter being in agreement with national data. For PFOA, there was an approximately 10-fold increase in median concentrations from the 1960s (0.27 ng/mL) to the 1980s (2.71 ng/mL), and a slight drop in the 2009 samples (2.08 ng/mL). For longer chain perfluorocarboxylic acids (PFCAs), there was a continuous build-up in serum from the 1960s to 2009. To our knowledge, this is the first study to investigate temporal changes of PFCs over the past 50 years.

Estrogen levels in nipple aspirate fluid and serum during a randomized soy trial

BACKGROUND

On the basis of hypothesized protective effect, we examined the effect of soy foods on estrogens in nipple aspirate fluid (NAF) and serum, possible indicators of breast cancer risk.

METHODS

In a crossover design, we randomized 96 women who produced 10 μL or more NAF to a high- or low-soy diet for 6 months. During the high-soy diet, participants consumed 2 soy servings of soy milk, tofu, or soy nuts (∼50 mg of isoflavones per day); during the low-soy diet, they maintained their usual diet. Six NAF samples were obtained using a FirstCyte aspirator. Estradiol (E(2)) and estrone sulfate (E(1)S) were assessed in NAF and estrone (E(1)) in serum only, using highly sensitive radioimmunoassays. Mixed-effects regression models accounting for repeated measures and left-censoring limits were applied.

RESULTS

Mean E(2) and E(1)S were lower during the high-soy than the low-soy diet (113 vs. 313 pg/mL and 46 vs. 68 ng/mL, respectively) without reaching significance (P = 0.07); the interaction between group and diet was not significant. There was no effect of the soy treatment on serum levels of E(2) (P = 0.76), E(1) (P = 0.86), or E(1)S (P = 0.56). Within individuals, NAF and serum levels of E(2) (r(s) = 0.37; P < 0.001) but not of E(1)S (r(s) = 0.004; P = 0.97) were correlated. E(2) and E(1)S in NAF and serum were strongly associated (r(s) = 0.78 and r(s) = 0.48; P < 0.001).

CONCLUSION

Soy foods in amounts consumed by Asians did not significantly modify estrogen levels in NAF and serum.

IMPACT

The trend toward lower estrogen levels in NAF during the high-soy diet counters concerns about adverse effects of soy foods on breast cancer risk.

Pilot and feasibility study: prospective proteomic profiling of mammary epithelial cells from high-risk women provides evidence of activation of pro-survival pathways

Normal mammary gland homeostasis requires the coordinated regulation of protein signaling networks. However, we have little prospective information on whether activation of protein signaling occurs in premalignant mammary epithelial cells, as represented by cells with cytological atypia from women who are at high risk for breast cancer. This information is critical for understanding the role of deregulated signaling pathways in the initiation of breast cancer and for developing targeted prevention and/or treatment strategies for breast cancer in the future. In this pilot and feasibility study, we examined the expression of 52 phosphorylated, total, and cleaved proteins in 31 microdissected Random Periareolar Fine Needle Aspiration (RPFNA) samples by high-throughput Reverse Phase Protein Microarray. Unsupervised hierarchical clustering analysis indicated the presence of four clusters of proteins that represent the following signaling pathways: (1) receptor tyrosine kinase/Akt/mammalian target of rapamycin (RTK/Akt/mTOR), (2) RTK/Akt/extracellular signal-regulated kinase (RTK/Akt/ERK), (3) mitochondrial apoptosis, and (4) indeterminate. Clusters 1 through 3 comprised moderately to highly expressed proteins, while Cluster 4 comprised proteins that are lowly expressed in a majority of RPFNA samples. Our exploratory study showed that the interlinked components of mitochondrial apoptosis pathway are highly expressed in all mammary epithelial cells obtained from high-risk women. In particular, the expression levels of anti-apoptotic Bcl-xL and pro-apoptotic Bad are positively correlated in both non-atypical and atypical samples (unadjusted P < 0.0001), suggesting a delicate balance between the pro-apoptotic and anti-apoptotic regulation of cell proliferation during the early steps of mammary carcinogenesis. Our feasibility study suggests that the activation of key proteins along the RTK/Akt pathway may tip this balance to cell survival. Taken together, our results demonstrate the feasibility of mapping proteomic signaling networks in limited RPFNA samples obtained from high-risk women and the promise of developing rational drug targets or preventative strategies for breast cancer in future proteomic studies with a larger cohort of high-risk women.

The volume of nipple aspirate fluid is not affected by 6 months of treatment with soy foods in premenopausal women

Based on the hypothesis that soy food consumption may influence breast tissue activity, we examined its effect on the production of nipple aspirate fluid (NAF), a possible indicator of breast cancer risk. Of 310 premenopausal women screened, 112 (36%) produced at least 10 μL of NAF, the minimum for study participation. In a crossover design, we randomized 96 women to 2 groups who, in reverse order, consumed a high-soy diet with 2 soy servings/d (1 serving = 177 mL soy milk, 126 g tofu, or 23 g soy nuts) and a low-soy diet with <3 servings/wk of soy for 6 mo each separated by a 1-mo washout period. During each diet period, 3 NAF samples were obtained (baseline and 3 and 6 mo) using a FirstCyte Aspirator and 4 urine samples (baseline and 1, 3, and 6 mo) were analyzed for isoflavonoids by liquid chromatography tandem MS. Adherence to the study protocol according to 24-h dietary recalls and urinary isoflavonoid excretion was high. The drop-out rate was 15% (n = 14); 82 women completed the intervention. The 2 groups produced similar mean NAF volumes at baseline (P = 0.95) but differed in age and previous soy intake and in their response to the intervention (P = 0.03). In both groups, NAF volume decreased during the first 3 mo of the high-soy diet period and returned to baseline at 6 mo, but there was no effect of the high-soy diet on NAF volume (P = 0.50 for diet; P-interaction = 0.21 for diet with time). Contrary to an earlier report, soy foods in amounts consumed by Asians did not increase breast tissue activity as assessed by NAF volume.

HER2/neu protein expression and fine needle breast aspiration from Argentinean patients with non-palpable breast lesions

The objective of this pilot project was to investigate whether the breast fine needle aspiration (FNA) technique is a useful tool for determining the increased risk of breast cancer in patients with non-palpable breast lesions. FNA is a minimally invasive technique that isolates mammary epithelial cells from breast cells in the suspicious region. In this study, two FNA samples were collected from 12 patients. The level of HER2/neu expression at the mRNA level (in serum) was measured in each patient. As gene amplification is characteristic of cancer cells and may assist in diagnosis and prognostic assessment, it is crucial that gene amplification of HER2/neu in patients with non-palpable breast lesions is compared to breast biopsy results. In serum, the level of HER2/neu was determined by ELISA assay. Gene amplification was determined by PCR and confirmed by IHC employing monoclonal ERRB2 in the FNA sample. The results indicate that FNA has a good correlation with breast biopsy. FNA combined with mammographic imaging is a strong tool for determining favorable treatment options for patients.

Cellular and hormonal content of breast nipple aspirate fluid in relation to the risk of breast cancer

In research settings, the measurement of serum and urine hormone concentrations has shown modest positive relationships with breast cancer risk in postmenopausal women. However, the local production of sex steroids in the breast is a significant contributor to the hormonal environment of the breast. Nipple aspiration fluid provides a window into this environment and allows the measurement of hormone and protein content which may show stronger relations to breast cancer risk, and therefore enable both more accurate risk assessment, and the use of preventive measures directed to the lowering of local breast hormonal exposure.

Status of Intraductal Therapy for Ductal Carcinoma in Situ

The intraductal approach is particularly appealing in the setting of ductal carcinoma in situ (DCIS), a preinvasive breast neoplasm that is thought to be entirely intraductal in its extent. Based on an emerging understanding of the anatomy of the ductal system as well as novel techniques to leverage the access accorded by the intraductal approach, researchers are actively exploring how ductal lavage, ductoscopy, and intraductal infusion of therapeutic agents may enhance breast cancer treatment. Both cytologic and molecular diagnostics continue to improve, and work is ongoing to identify the most effective diagnostic biomarkers for DCIS and cancer, although optimal targeting of the diseased duct remains an important consideration. Ductoscopy holds potential in detection of occult intraductal lesions, and ductoscopically guided lumpectomy could increase the likelihood of a more comprehensive surgical excision. Exciting pilot studies are in progress to determine the safety and feasibility of intraductal chemotherapy infusion. These studies are an important starting point for future investigations of intraductal ablative therapy for DCIS, because as our knowledge and techniques evolve, it is likely that DCIS may be the target most amenable to treatment by intraductal therapy. If such studies are successful, these approaches will allow an important and meaningful transformation in treatment options for women diagnosed with DCIS.

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.

State of the Science and the Intraductal Approach for Breast Cancer: Proceedings Summary of The Sixth International Symposium on the Intraductal Approach To Breast Cancer Santa Monica, California, 19–21 February 2009

Researchers are using the intraductal approach to advance breast cancer risk assessment, prevention, diagnosis, and treatment. Procedures and technologies that can access and interrogate the ductal-alveolar systems include nipple aspiration, ductal lavage and ductoscopy. Ductoscopic papillectomy, ductoscopic margin evaluation, and intraductal therapy are considered promising investigational and innovative treatments. These techniques are used to explore the biology of the normal breast; collect and analyze breast fluid and cells to identify biomarkers that can be used in breast cancer detection and risk assessment; and to identify new ways to find and administer therapeutic and/or preventive agents to the breast tissue. This report summarizes the latest research findings in these areas, presented at The 6^th International Symposium on the Intraductal Approach to Breast Cancer in 2009.

Does the new automated "HALO" nipple aspiration fluid system really deliver as promised? The answer is "No, but...": A literature review of the role of breast fluid cytology in cancer risk assessment

The HALO breast Pap test is a new automated nipple aspiration fluid (NAF) system that was recently introduced into the market. In an extensive marketing campaign directed principally toward OB/GYN practices, including endorsements from few local news media, HALO has been promoted as the "new Pap screening test for breast." Physicians are encouraged to perform this test on all women, as part of their annual examination, with claims that HALO will detect breast cancers as early as 10 years before mammography. These arguments are made more appealing to physician's offices by highlighting the potential positive financial impact on their practices, without consuming physician time, as medical assistants or technicians can perform this test. As a result of this directed campaign, cytology laboratories are increasingly confronted with implementing the HALO system and clinicians are increasingly soliciting pathologist's input regarding its validity. Yet, there is no data available regarding this new system, outside rare reports sponsored by the manufacturer. In this discussion, I examine the pros and cons of this new NAF system, including literature review of breast fluid cytology, and how it relates to breast cancer risk assessment.

Phosphorylation of the SRC epithelial substrate Trask is tightly regulated in normal epithelia but widespread in many human epithelial cancers

PURPOSE

The frequently elevated activities of the c-src and c-yes products in human epithelial tumors suggest that these activated tyrosine kinases have tumorigenic functions analogous to the v-src and v-yes oncogene products. Studies of v-src-transformed fibroblasts have identified many of the effectors of this potent oncogene; however, because c-src and c-yes lack the mutational and promiscuous activities of their retroviral oncogene homologues, their presumptive tumorigenic functions in human epithelial tumors are more subtle, less well-defined, and await identification of possible effectors more directly relevant to epithelial cells.

EXPERIMENTAL DESIGN

We recently identified a transmembrane glycoprotein named Trask that is expressed in epithelial tissues but not fibroblasts and is phosphorylated by SRC kinases in mitotic epithelial cells. In this study, we have surveyed the expression and phosphorylation of Trask in many human epithelial cancer cell lines and surgical tissues and tumors.

RESULTS

Trask is widely expressed in human epithelial tissues, but its phosphorylation is tightly regulated and restricted to detached mitotic cells or cells undergoing physiologic shedding. However, abberant Trask phosphorylation is seen in many epithelial tumors from all stages including preinvasive, invasive, and metastatic tumors. Trask phosphorylation requires SRC kinases, and is also aberrantly hyperphosphorylated in the SRC-activated PyMT mouse epithelial tumors and dephosphorylated by the SRC inhibitor treatment of these tumors.

CONCLUSIONS

The widespread phosphorylation of Trask in many human epithlelial cancers identifies a new potential effector of SRC kinases in human epithelial tumorigenesis.

Ductal Carcinoma in Situ: State of the Science and Roadmap to Advance the Field

Purpose

Ductal carcinoma in situ (DCIS) is the fourth leading cancer for women in the United States. Understanding of the biology and clinical behavior of DCIS is imperfect. This article highlights the current knowledge base and the scientific roadmap needed to advance the field.

Methods

This article is based on work done by and consultations obtained from leading experts in the field over a 6-month period that culminated in a full-day symposium designed to systematically review the most pertinent MEDLINE published reports and develop a roadmap to elucidate the molecular steps of carcinogenesis, reduce the extent or prevent the need for therapies, eliminate recurrences, and reduce morbidity.

Results

Expression profiling of pure DCIS will help elucidate the molecular characteristics that distinguish high-risk lesions from clinically irrelevant lesions. The development of new methods of extracting RNA from processed tissues may provide opportunities for research. Mammography often underestimates the pathologic extent of DCIS; other imaging methods need to be investigated for detection and monitoring of disease stability or progression. Novel biologic agents are being delivered in neoadjuvant clinical trials, and alternative methods for breast irradiation are being studied. Future trials of treatment versus no treatment for biologically selected cases of DCIS should be developed.

Conclusion

There is a critical need for a concerted international effort among patients with DCIS, clinicians, and basic scientists to conduct the research necessary to improve fundamental understanding of the biology and clinical behavior of DCIS and prevent development of invasive breast cancer.

Breast cancer screening and biomarkers

Annual screening mammograms have been shown to be cost-effective and are credited for the decline in mortality of breast cancer. New technologies including breast magnetic resonance imaging (MRI) may further improve early breast cancer detection in asymptomatic women. Serum tumor markers such as CA 15-3, carcinoembyonic antigen (CEA), and CA 27-29 are ordered in the clinic mainly for disease surveillance, and not useful for detection of localized cancer. This review will discuss blood-based markers and breast-based markers, such as nipple/ductal fluid, with an emphasis on biomarkers for early detection of breast cancer. In the future, it is likely that a combination approach to simultaneously measure multiple markers would be most successful in detecting early breast cancer. Ideally, such a biomarker panel should be able to detect breast cancer in asymptomatic patients, even in the setting of normal mammogram and physical examination results.

Breast ductal secretions: clinical features, potential uses, and possible applications

BACKGROUND

Nipple discharge accounts for approximately 5% of visits to a breast specialist surgical practice and may be encountered as the chief complaint by many other types of physicians. The vast majority of breast cancers originate in the ductal system, which prompted interest in the evaluation of the intraductal approach to breast cancer. Ductoscopy, nipple aspiration, and ductal lavage have emerged as innovative fields of study that may have clinical applications.

METHODS

We performed a literature search of published manuscripts using the keywords nipple discharge, breast ductal secretions, and intraductal approach. We also report our single-institution experience in managing nipple discharge.

RESULTS

We present our institutional algorithm for the management of nipple discharge. The possible etiologies of nipple discharge and the appropriate workup are reviewed. Three evolving minimally invasive techniques for the evaluation of high-risk patients include ductoscopy, nipple aspiration, and ductal lavage. Nipple aspiration and ductal lavage fluid may be assayed for cytology, genomic, gene expression, and proteomic studies. Several different translational approaches are being undertaken to investigate the local microenvironment associated with the development and progression of breast carcinoma.

CONCLUSIONS

Nipple aspiration fluid and ductal lavage offer the opportunity to study the local microenvironment of the ductal system, which is where most breast cancers originate. These powerful approaches to biomarker analysis could be applied to the prevention and treatment of breast cancer.

Facile whole mitochondrial genome resequencing from nipple aspirate fluid using MitoChip v2.0

Background

Mutations in the mitochondrial genome (mtgenome) have been associated with many disorders, including breast cancer. Nipple aspirate fluid (NAF) from symptomatic women could potentially serve as a minimally invasive sample for breast cancer screening by detecting somatic mutations in this biofluid. This study is aimed at 1) demonstrating the feasibility of NAF recovery from symptomatic women, 2) examining the feasibility of sequencing the entire mitochondrial genome from NAF samples, 3) cross validation of the Human mitochondrial resequencing array 2.0 (MCv2), and 4) assessing the somatic mtDNA mutation rate in benign breast diseases as a potential tool for monitoring early somatic mutations associated with breast cancer.

Methods

NAF and blood were obtained from women with symptomatic benign breast conditions, and we successfully assessed the mutation load in the entire mitochondrial genome of 19 of these women. DNA extracts from NAF were sequenced using the mitochondrial resequencing array MCv2 and by capillary electrophoresis (CE) methods as a quality comparison. Sequencing was performed independently at two institutions and the results compared. The germline mtDNA sequence determined using DNA isolated from the patient's blood (control) was compared to the mutations present in cellular mtDNA recovered from patient's NAF.

Results

From the cohort of 28 women recruited for this study, NAF was successfully recovered from 23 participants (82%). Twenty two (96%) of the women produced fluids from both breasts. Twenty NAF samples and corresponding blood were chosen for this study. Except for one NAF sample, the whole mtgenome was successfully amplified using a single primer pair, or three pairs of overlapping primers. Comparison of MCv2 data from the two institutions demonstrates 99.200% concordance. Moreover, MCv2 data was 99.999% identical to CE sequencing, indicating that MCv2 is a reliable method to rapidly sequence the entire mtgenome. Four NAF samples contained somatic mutations.

Conclusion

We have demonstrated that NAF is a suitable material for mtDNA sequence analysis using the rapid and reliable MCv2. Somatic mtDNA mutations present in NAF of women with benign breast diseases could potentially be used as risk factors for progression to breast cancer, but this will require a much larger study with clinical follow up.

Epithelial cells in nipple aspirate fluid and subsequent breast cancer risk: a historic prospective study

Background

Past studies have shown that women with abnormal cytology or epithelial cells in nipple aspirate fluid (NAF) have an increased relative risk (RR) of breast cancer when compared to women from whom NAF was attempted but not obtained (non-yielders). This study analyzed NAF results from a group of women seen in a breast clinic between 1970–1991 (N = 2480). Our analysis presented here is an aggregate of two sub-groups: women with questionnaire data (n = 712) and those with NAF visits beginning in 1988 (n = 238), the year in which cancer case information was uniformly collected in California.

Methods

Cytological classification was determined for a group of 946 women using the most abnormal epithelial cytology observed in fluid specimens. Breast cancer incidence and mortality status was determined through June 2006 using data from the California Cancer Registry, California Vital Statistics and self-report. We estimated odd ratios (ORs) for breast cancer using logistic regression analysis, adjusting for age. We analyzed breast cancer risk related to abnormality of NAF cytology using non-yielders as the referent group and breast cancer risk related to the presence or absence of epithelial cells in NAF, using non-yielders/fluid without epithelial cells as the referent group.

Results

Overall, 10% (93) of the 946 women developed breast cancer during the follow-up period. Age-adjusted ORs and 95% confidence intervals (C.I.) compared to non-yielders were 1.4 (0.3 to 6.4), 1.7 (0.9 to 3.5), and 2.0 (1.1 to 3.6) for women with fluid without epithelial cells, normal epithelial cells and hyperplasia/atypia, respectively. Comparing the presence or absence of epithelial cells in NAF, women with epithelial cells present in NAF were more likely to develop breast cancer than non-yielders or women with fluid without epithelial cells (RR = 1.9, 1.2 to 3.1).

Conclusion

These results support previous findings that 1) women with abnormal epithelial cells in NAF have an increased risk of breast cancer when compared to non-yielders or women with normal epithelial cells in NAF and 2) women with epithelial cells present in NAF have an increased risk of breast cancer when compared to non-yielders or women who had NAF without epithelial cells present.

The reliability of nipple aspirate and ductal lavage in women at increased risk for breast cancer--a potential tool for breast cancer risk assessment and biomarker evaluation

PURPOSE

Ductal lavage, a technique used to sample epithelial cells from breast ducts, has potential use in risk assessment and biomarker evaluation among women at increased risk for breast cancer. However, little is known about the reliability of the procedure.

METHODS

We evaluated the reliability of nipple aspirate (NAF) and ductal lavage at two time points 6 months apart in women at increased risk for breast cancer. Eligible women had a 5-year Gail risk >or=1.66% or lifetime risk of >20%, and/or a family history or personal history of breast cancer. All ducts that produced NAF were cannulated. The kappa statistic was used to evaluate reliability of NAF production, cellular yield, and cytologic diagnosis.

RESULTS

Sixty-nine women (mean age, 47 years) were enrolled over 35 months. Forty-seven returned for a second visit. At baseline, 65% of premenopausal and 41% of postmenopausal women produced NAF (P = 0.05), of which 72% underwent successful lavage of at least one duct. Samples of inadequate cellular material for diagnosis were significantly more likely in postmenopausal women than in premenopausal women (P = 0.04). Of the women who returned for a second visit, 18 of 24 who produced NAF had at least one duct successfully cannulated. Twenty-four ducts in 14 women were lavaged twice. Among these ducts, cellular yield for the two time points was inconsistent (kappa = 0.33 +/- 0.13), and only fair cytologic agreement was observed (kappa = 0.32 +/- 0.15). Ductal lavage was associated with moderate discomfort.

CONCLUSION

Currently, the use of ductal lavage is limited by technical challenges in duct cannulation, inconsistent NAF production, a high rate of inadequate cellular material for diagnosis, fair cytologic reproducibility, and low participant return rates.

C-reactive protein in nipple aspirate fluid associated with Gail model factors

BACKGROUND

The majority of breast cancers originate in the epithelial lining of the breast ductal system. Premalignant cell damage in this lining may produce biochemical signals that deliver inflammatory proteins to the site. The presence of C-reactive protein (CRP) in nipple aspirate fluid (NAF) may reflect an inflammatory state indicative of a premalignant breast microenvironment. This study ascertained CRP's presence in NAF and evaluated if risk factors, as identified by the Gail model, were associated with NAF CRP levels among healthy women.

DESIGN

NAF CRP levels were assayed in 59 women.

RESULTS

CRP was present in NAF and significantly (p = .04) and positively related to breast cancer risk as predicted by the Gail model.

CONCLUSION

CRP is differentially present in NAF and varies by Gail model risk factors. CRP in NAF holds promise as a noninvasive biomarker that detects a precarcinogenic breast ductal microenvironment and may contribute to the diagnosis of breast cancer early in the course of the disease when prognosis is most favorable.

Prospective multicenter trial to determine the feasibility of collection and predictive ability of breast fluid analysis in postmenopausal women receiving SERMs

We conducted a prospective ancillary study to the study of tamoxifen and raloxifene (STAR) trial involving 4 institutions to determine: (1) our ability to collect nipple aspirate fluid (NAF) in postmenopausal women taking medication to decrease breast proliferation and (2) NAF biomarkers associated with breast cancer. NAF was collected before and 6 months after starting treatment. Three biomarkers, cytology, fluid volume, and prostate-specific antigen (PSA), were analyzed. NAF was collected from 26 of 33 (79%) enrolled subjects at baseline. We were able to collect fluid in 84% of the subjects who produced NAF at baseline and returned for second aspiration after 6 months of treatment. In these women, cytology was unchanged in 85%, improved in 11%, and worsened in 4% of breasts. Median PSA increased from 37.5 to 112 ng/L after treatment. NAF volume did not significantly change. In conclusion, after treatment with tamoxifen or raloxifene, changes in both NAF cytology and PSA were generally favorable, consistent with their expected antiproliferative effective effect on the breast. Multiinstitutional clinical trials in postmenopausal women using NAF biomarkers as the primary endpoints are feasible.