Ductal lavage and ductoscopy: the opportunities and the limitations

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.

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.

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

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

Mammary ductoscopy in the current management of breast disease

BACKGROUND

The majority of benign and malignant lesions of the breast are thought to arise from the epithelium of the terminal duct-lobular unit (TDLU). Although modern mammography, ultrasound, and MRI have improved diagnosis, a final pathological diagnosis currently relies on percutaneous methods of sampling breast lesions. The advantage of mammary ductoscopy (MD) is that it is possible to gain direct access to the ductal system via the nipple. Direct visualization of the duct epithelium allows the operator to precisely locate intraductal lesions, enabling accurate tissue sampling and providing guidance to the surgeon during excision. The intraductal approach may also have a role in screening individuals who are at high risk of breast cancer. Finally, in spontaneous nipple discharge (SND), as biopsy instruments improve and intraductal therapeutics, such as intraductal excision and laser ablation, become a possibility, normal or benign ductoscopic findings may help minimize surgery in selected patients. As MD technology is rapidly advancing, a comprehensive review of current practice will be a valuable guide for clinicians involved in the management of breast disease.

METHODS

This is a review of current ductoscopic practice based on an exhaustive literature search of Pubmed, Google Scholar, and conference proceedings. The search terms "ductoscopy", "duct endoscopy", "mammary", "breast," and "intraductal" were used.

RESULTS/CONCLUSIONS

Duct endoscopes have become smaller in diameter with working channels and improved optical definition. Currently, the role of MD is best defined in the management of SND facilitating targeted surgical excision, potentially avoiding unnecessary surgery, and limiting the extent of surgical resection for benign disease. The role of MD in breast-cancer screening and breast conservation surgery has yet to be fully defined. Few prospective randomized trials exist in the literature, and these would be crucial to validate current opinion, not only in the benign setting but also in breast oncologic surgery.

Breast ductoscopy and the evolution of the intra-ductal approach to breast cancer

Interest in breast endoscopy came from Oriental investigators in the early 1990s where bloody nipple discharge is a more common presentation of breast cancer. The early techniques using a single microfiber scope without ductal distension was successful in navigating only the first 1-3 cm of the ducts and fraught with technical problems such as scope breakage and poor image quality. In spite of these barriers there has been increasing use of this technology in Japan and more widespread acceptance as the technology of scope design improved. Dooley and others tested a new method of obtaining a rich cytologic specimen from the ducts of high-risk women known as ductal lavage recently. The success of this procedure was that it detected severe cytologic and malignant atypia in clinically and radiographically normal breasts. Reproducibly, the same breast duct could be cannulated and severely atypical cytology obtained. The problem arose in identifying the lesion within the breast, which was the source for the atypia. New American multi-fiber microendoscopes were applied to solve this problem in an initial series of patients with abnormal cytology to identify the lesions. Success of that series lead to wider application of the imaging technology and eventual adoption of this imaging modality help to guide during all non-mastectomy breast surgery where fluid could be elicited from the nipple to identify the duct connecting to the lesion for which surgery was being performed. Initial reports have demonstrated the types of operative findings in certain sub-populations early in the use of this technology.

Recent advances and current controversies in the management of DCIS of the breast

Ductal carcinoma in situ (DCIS) is commonly diagnosed today, mainly due to widespread use of screening mammography. Despite a better understanding of its biological behavior, many issues regarding its optimal management remain controversial. The biological behavior of DCIS has been associated with distinct molecular and histological features (such as expression of COX2, Ki67, c-erbB2, p53 mutation, presence or absence of comedonecrosis, nuclear grade, hormone receptor status, etc.). Recent advances in the diagnosis of DCIS include using magnetic resonance imaging, and the use of stereotactic-guided directional vacuum-assisted biopsy (DVAB). Ductoscopy and ductal lavage have a limited role in the management of DCIS. Surgical treatment of DCIS includes simple local excision to various forms of wider excision (segmental resection or quadrantectomy), or even mastectomy (either simple or skin-sparing). Radiotherapy following breast-conserving surgery significantly reduces local recurrence rates. Axillary lymph node dissection is not required for the management of DCIS; however, during the last decade, sentinel lymph node biopsy is increasingly used to exclude the presence of axillary metastases (when invasive disease is present within the DCIS). This approach has many advantages (including the avoidance of a second surgery if invasive disease is diagnosed within the DCIS) and should be considered when there is an increased probability for the presence of invasive breast cancer within the DCIS. The role of other minimally invasive methods (such as the "therapeutic" application of the DVAB technique, radiofrequency ablation, laser therapy, cryotherapy and brachytherapy) in the management of small DCIS remains unproven. Tamoxifen should be considered in the management of selected patients with DCIS, such as patients with hormone receptor positive DCIS, young patients, and patients without risk factors for potential side effects. Additionally, and controversial, there is evidence that aromatase inhibitors may be better than tamoxifen in the management of DCIS.

Reproducibility of ductal lavage cytology and cellularity over a six month interval in high risk women

BACKGROUND

Ductal lavage (DL) allows repeat sampling of breast epithelium for serial observation in a chemoprevention setting; however, the reproducibility of duct cannulation, cell yield and cytology has not been addressed.

METHODS

We conducted a Phase 2 trial, wherein high risk women chose tamoxifen treatment or observation following an entry DL procedure. We present data from the non-intervention arm of our study to assess the reproducibility of cannulation, cell yield, and cytologic diagnosis from DL of the same duct at two time-points. Inter-observer variability was assessed by a blinded review of Papanicoloau-stained slides by two cytopathologists.

RESULTS

Sixty-five women had a successful lavage of 187 ducts at baseline and chose observation; 63/65 (97%) had a successful lavage 6 months later. Successful recannulation of the same duct was accomplished in 63 women (97%) and162 ducts (87%). Total epithelial cell yields >or=100 were obtained from 57/65 women (88%) and 129/187 ducts (69%) at baseline, and 46/63 women (73%) and 80/162 ducts (49%) at both time-points. Cytologic diagnosis was reproducible in 27/63 (43%) women and 77/162 (48%) ducts. Inter-observer variability for cytologic diagnosis between two observers showed good agreement (kappa = 0.62).

CONCLUSIONS

Recannulation and lavage of the same duct after a 6 month interval can be achieved with high frequency; however, reproducibility of cell yield and cytologic findings from the same duct is sub-optimal, leading to significant attrition of evaluable subjects. The utility of DL for the serial monitoring of breast epithelium is therefore limited.

Quantitative multiplex methylation-specific PCR analysis doubles detection of tumor cells in breast ductal fluid

PURPOSE

The challenges of cytology for accurate diagnosis of breast cancer are well recognized. We previously showed that normal and tumor tissue can be distinguished using a technique called quantitative multiplex methylation-specific PCR (QM-MSP). We hypothesized that quantitative analysis of methylated genes will provide enhanced detection of cancer cells present in cytologic specimens.

EXPERIMENTAL DESIGN

QM-MSP was done on ductal lavage cells from a set of 37 ductal lavage samples from women undergoing mastectomy (27 with cancer and 3 without). Duct histology information was available for each lavaged duct. QM-MSP data was assessed by measuring cumulative methylation index and by receiver operating characteristic threshold analysis. To determine the baseline level of methylation for each gene in this population, cells from 60 ducts of women at high risk of developing breast cancer were analyzed.

RESULTS

QM-MSP findings on a panel of nine genes were correlated to duct histology and ductal lavage cytology. Cytology detected cancer in 33% (7 of 21 ducts) with a specificity of 99% (92 of 93). QM-MSP detected cancer as calculated by cumulative methylation index with a sensitivity of 62% (13 of 21) and specificity of 82% (62 of 76) and by receiver operating characteristic threshold analysis with a sensitivity of 71% (15 of 21) and specificity of 83% (63 of 76).

CONCLUSIONS

Compared with cytology, QM-MSP doubled the sensitivity of detection of cancer. This study provides proof of principle by showing the advantages of using methylation analyses to query cytologic specimens and indicates its potential use in diagnosis and in stratifying risk.

Comparison of Ductal Lavage and Random Periareolar Fine Needle Aspiration as Tissue Acquisition Methods in Early Breast Cancer Prevention Trials

PURPOSE

Short-term phase I and phase II breast cancer prevention trials require tissue acquisition at baseline and after intervention to evaluate modulation of potential biomarkers. Currently used tissue acquisition methods include ductal lavage (DL), random periareolar fine needle aspiration (RPFNA), and core needle biopsy. The optimum method to retrieve adequate samples and the most accepted method by study participants is not known.

EXPERIMENTAL DESIGN

We compared RPFNA and DL as breast tissue acquisition methods for short-term breast cancer prevention trials by evaluating sample adequacy and tolerability in subjects who participated in two prospective phase II breast cancer prevention trials. Eighty-six women at increased risk for breast cancer were included in this study and underwent baseline DL and RPFNA. High risk was defined as having a 5-year Gail score of >1.67% or a history of atypical hyperplasia (AH), lobular carcinoma, or breast cancer.

RESULTS

Median age was 54.5 years (range, 39-75 years); 75% of the women were postmenopausal. About 51% of the women yielded nipple aspiration fluid, and breast fluid samples via DL were retrieved in 73% of these subjects. Of these samples, 71% were adequate samples (greater than 10 epithelial cells). However, when the entire cohort was considered, only 31% of the subjects had adequate samples. RPFNA was also attempted in all subjects, and sample retrieval rate was 100%. Out of these, 96% of the subjects had adequate samples. In DL samples, AH rate was 3.7% was and hyperplasia (H) rate was 11.1%. In RPFNA samples, AH rate was 12.9%, and H rate was 24.7%. Cytology findings in RPFNA samples correlated with age, menopausal status, and breast cancer risk category (previous history of lobular carcinoma in situ). Both procedures were well tolerated, and no complications occurred among participants.

CONCLUSIONS

Considering that the main end point for short-term prevention trials is the modulation of biomarkers, it is important to optimize adequate sample acquisition; therefore, RPFNA is a more practical option for future phase I and II breast cancer prevention trials compared with DL.

Autofluorescence Ductoscopy: A New Imaging Technique for Intraductal Breast Endoscopy

BACKGROUND

Conventional diagnostic imaging techniques of the female breast, eg, ultrasound, mammography, breast magnetic resonance imaging, or ductography, can only give indirect information about the inside of breast ducts. Diagnostic ductoscopy is the first approach for direct visualization of intraductal lesions. Autofluorescence ductoscopy is a new, noninvasive imaging technique that better identifies intraductal lesions under direct vision.

MATERIALS AND METHODS

We describe the technical development of autofluorescence ductoscopy and initial experience with early clinical evaluation at Frauenklinik (OB/GYN) of Technical University Munich, Germany, and its potential future application. In contrast to standard white light breast endoscopy, autofluorescence ductoscopy uses a different light spectrum and, after sophisticated data processing, can mark suspicious intraductal lesions in blue-violet colors. Autofluorescence ductoscopy adds new visual information previously not seen in white-light endoscopy. Technical development is completed and clinical evaluation is under way.

RESULTS

In a small series, the autofluorescence ductoscope was used and confirmed the initial expectations. No complication was expected or occurred. At present time, it is being used on an experimental basis for evaluation of its clinical benefits.

CONCLUSION

The clinical evaluation of autofluorescence ductoscopy is a work in progress at an early stage. This technique is intended to improve visualization and identification of breast duct walls and lesions and possibly allows an instant visual semiquantitative histologic evaluation of nonbenign ductal lesions.

Combined breast ductal lavage and ductal endoscopy for the evaluation of the high-risk breast: a feasibility study

BACKGROUND AND OBJECTIVES

Evaluation of the ductal epithelium of the breast at increased risk for breast cancer is needed to define the carcinogenic pathway, for risk assessment, and to improve selection of women for chemoprevention therapy. We studied the feasibility of combining breast ductal endoscopy with ductal lavage in the high-risk contralateral breast of women with ipsilateral breast cancer for the evaluation of high-risk ducts and acquisition of ductal epithelial cells for analysis.

METHODS

Breast ducts were studied by ductal lavage and ductal endoscopy, and epithelial cell content studied cytologically and quantitatively.

RESULTS

Twenty-five subjects and 44 ducts, including 22 (50.0%) which did not produce nipple aspirate fluid (NAF), were studied. Cellular atypia was present in five subjects. Ductal endoscopy was performed on 1 or more ducts in 24 subjects. Structural changes were noted in 63.6% of the ducts, most commonly fibrous stranding or bridging. Ductal sampling with endoscopic brush and coil sampling devices provided additional cellular samples of relatively pure ductal epithelial content (> or = 91% purity) in 8/11 subjects.

CONCLUSIONS

Breast ductal endoscopy combined with ductal lavage represents a feasible approach for characterizing the ducts and ductal epithelium of the high-risk breast, especially in a research setting.

Endocrine biomarkers in ductal lavage samples from women at high risk for breast cancer

BACKGROUND

Ductal lavage is a method of minimal epithelial sampling of the breast, with potential utility for repeat sampling and biomarker analysis in chemoprevention studies. We report here the baseline findings from a study designed to assess the utility of ductal lavage in this setting.

METHODS

Tamoxifen-eligible, high-risk women underwent ductal lavage; epithelial cell number (ECN) and morphology were assessed on Papanicolaou-stained slides. Additional slides were immunostained for estrogen receptor (ER) alpha, Ki-67, and cyclooxygenase-2, and the labeling index (LI) was established by counting negative and positive cells. The ductal lavage supernatant (DLS) was assayed for estradiol, several of its precursors, progesterone, cathepsin D, interleukin-6, and epidermal growth factor (EGF).

RESULTS

One hundred sixty-eight women have entered the study (mean age, 51 years; mean 5-year Gail score, 2.8). Ductal lavage was accomplished in 145 (86.3%) women. Data were analyzed by duct and by woman (averaging data across all ducts). Mild atypia was seen in 43 of 145 (29.6%), whereas severe atypia was seen in 2 (1.4%) of women. We observed significant positive correlations between ECN and cytologic atypia, ER LI, cyclooxygenase-2 LI, and Ki-67 LI. EGF levels in supernatant were significantly associated with estrogenic precursors, ER LI and ECN. A factor representing the DLS hormone and protein variables explained 36% of the variance; total ECN was highest when factor score and ER LI were high and was lowest when both were low (P for interaction = 0.001).

CONCLUSIONS

Biomarker analyses in epithelial cells and DLS are feasible. The significant associations of EGF with other markers suggest a possible role in increasing epithelial cell mass.

The future prospect: ductoscopy-directed brushing and biopsy

The intraductal approach to breast cancer and premalignant lesions has now developed to yield substantial cytologic samples of exfoliated cells. Standard cytology is still inadequate in sensitivity and specificity to accurately interpret the majority of samples. As techniques evolve using ductoscopic biopsy and molecular marker panels to increase accuracy of cytologic interpretation, these tools will be able to unravel the breast carcinogenesis pathways. They will also offer considerable benefit in screening for premalignant changes and developing effective chemoprevention strategies.

Nipple Fluid Cytology

With increasing emphasis on public awareness of breast cancer and screening mammography, more women seek consultation for breast symptoms, including nipple discharge. The presence of nipple discharge is distressing for the patient; however, its origin is fortunately most often benign. Nipple discharge associated with a recognizable mass requires sampling and surgical excision. Currently, clinical breast examination, cytology, ductography, mammogram, and ultrasound are commonly used to evaluate patients who have nipple discharge. Ductal lavage and ductoscopy, in association with emerging new technology, may be of help in increasing the sensitivity of nipple fluid cytology. In addition, nipple fluid cytology may offer a new way to study the spectrum of premalignant breast lesions, and to identify women at risk for breast cancer.

Breast ductoscopy with a 0.55-mm mini-endoscope for direct visualization of intraductal lesions

Standard radiologic examinations of breast duct lesions can give only indirect information. Mini-endoscopy with a breast ductoscope of only 0.55 mm offers direct visualization of the lesion and helps in the decision to perform or avoid exploratory breast tissue resection. We used a LaDuScope (PolyDiagnost, Pfaffenhofen, Germany) with a 0.55- or 0.95-mm outer diameter and a 75-mm working length from October 2003 through July 2004 on 11 women (average age of 48.3 years [range 36-69 years]) with suspicious nipple discharge. The optics have zero-degree direct view, 70-degree field vision, and 3000 or 6000 pixel resolution. Breast ducts and walls could be easily inspected; and irrigation of breast ducts, aspiration, and use of cytology brush were possible under visual control. We had no intraoperative or postoperative complications. The new procedure of mini-ductoscopy is feasible, safe, and helpful as an additional ambulatory diagnostic method for visual inspection of breast ducts. This instrument demonstrates the latest advances of technology and a trend toward less-invasive diagnostics for breast duct lesions.

A comparison of ductoscopy-guided and conventional surgical excision in women with spontaneous nipple discharge

INTRODUCTION

Radiologic imaging is routinely used to evaluate women with spontaneous nipple discharge (SND), but definitive diagnosis is usually only achieved by surgical terminal duct excision (TDE). Ductoscopy has been reported to result in improved localization of intraductal lesions and may avoid surgery in women with endoscopically normal ducts.

MATERIALS AND METHODS

We conducted a retrospective review of the records of 117 consecutive women who underwent ductoscopy to guide ductal excision (scope-DE) or received conventional TDE without ductoscopy. Two women had atypical ductal lavage cytology and the remainder presented with SND from 1 or more duct. Preoperative evaluation included radiologic imaging as clinically indicated.

RESULTS

Fifty-nine women underwent scope-DE, and 58 underwent conventional TDE. There were no significant differences in age, race, discharge characteristics, or radiologic findings. The proportion of women with intraductal neoplasia was slightly greater in the group undergoing scope-DE (88% vs. 81%, P = 0.2). In the conventional TDE group, 8.5% were found to have atypical hyperplasia or duct carcinoma in situ compared with 18.6% in the scope-DE group. In the ductoscopy group, 22 of 59 (37.3%) had lesions >5 cm from the nipple, compared with 1 of 17 women for whom distance of the lesion from the nipple was known in the conventional group (P = 0.02). Of the ductoscopy-detected cancers, 5 of 6 had no symptoms other than SND, whereas 1 of the 4 malignancies in the conventional group presented as SND alone.

DISCUSSIONS

Ductoscopy identifies intraductal lesions in a high proportion of women with SND, and it may contribute to more accurate resection of these. A prospective study is required to obtain an unbiased assessment of these possible advantages.

Failure of high risk women to produce nipple aspirate fluid does not exclude detection of cytologic atypia in random periareolar fine needle aspiration specimens

INTRODUCTION

Evidence of hyperplasia with atypia found both on random periareolar fine needle aspiration (RPFNA) and in nipple aspirate fluid (NAF) fluid are associated with an increased risk for breast cancer.

AIM

In this study, we report the correlation of NAF production with cytological assessment of ductal cells obtained by RPFNA.

METHODS

113 women at high risk for development of breast cancer attending the Breast Cancer Prevention Clinic at the University of Kansas Medical Center underwent a single NAF collection attempt and RPFNA.

RESULTS

NAF was successfully collected in 51% of women. There was no significant difference in age, 5-year Gail risk assessment, menopausal status, hormone use, family history of breast cancer, history of prior atypical hyperplasia/LCIS or history of contralateral DCIS/invasive breast cancer between women who produced NAF and those that did not. The only significant difference between the two groups was in history of prior lactation (p = 0.018). Twenty-seven of the 113 subjects were found to have hyperplasia with atypia by RPFNA was 31% in women who produced NAF versus 16% in those who did not (p = 0.07).

CONCLUSION

Although prevalence of RPFNA atypia was numerically higher in NAF producers than non-producers the difference did not reach statistical significance. Failure to produce NAF does not exclude the presence of hyperplasia with atypia by random periareolar fine needle aspiration.

Ductal lavage findings in women with known breast cancer undergoing mastectomy

BACKGROUND

Ductal lavage has the potential to detect cancer by sampling breast epithelium in asymptomatic high-risk women. To assess the utility of ductal lavage as a cancer diagnostic test, we investigated the association between ductal lavage cytologic findings and histologic findings in women with known breast cancer undergoing mastectomy.

METHODS

Ductal lavage was performed in the operating room before mastectomy on 44 breasts from 32 women with known cancer and on eight breasts from seven women undergoing prophylactic mastectomy, two with occult malignancy. If the ductal lavage sample from one or more ducts contained enough epithelial cells for a cytologic diagnosis, lavaged ducts were injected with a mixture of colored dye, gelatin, and a radiographic contrast compound after mastectomy, and breast tissue was radiographed and sectioned. Histologic findings in ducts with and without dye were recorded. Associations between cytologic results and histologic results were examined by univariate and multivariable analyses.

RESULTS

At least one duct was lavaged in 36 breasts (mean = 1.4 ducts per breast); all histologic and cytologic procedures were completed in 28 breasts and in 39 ducts. Markedly atypical or malignant cytology was found in five cancer-containing breasts. In 39 ducts with complete cytologic and histologic data and when marked atypia or malignant cells defined a positive cytologic test, sensitivity was 43% (95% confidence interval [CI] = 23% to 72%), specificity was 96% (95% CI = 86% to 100%), and accuracy was 77% (95% CI = 63% to 89%). When mild or marked atypia or malignant cells defined a positive cytologic test, sensitivity was 79% (95% CI = 57% to 96%), specificity was 64% (95% CI = 46% to 83%), and accuracy was 69% (95% CI = 55% to 83%). When all 31 cytologically evaluable breasts were analyzed, sensitivity was 17% (95% CI = 7% to 35%), specificity was 100% (95% CI = 5% to 100%), and accuracy was 19% (95% CI = 9% to 38%).

CONCLUSION

In breasts with cancer, ductal lavage appears to have low sensitivity and high specificity for cancer detection, possibly because cancer-containing ducts fail to yield fluid or have benign or mildly atypical cytology.

Office-based breast ductoscopy for diagnosis

OBJECTIVE

Ductoscopy is an evolving technology that has been used primarily and historically in conjunction with open surgical procedures. New technical improvements allow intraductal biopsy and therefore its application in the clinical setting for diagnostic evaluations of the breast. This study looks at the initial use of intraductal biopsy in a variety of settings from an academic university practice to a private single-surgeon office.

METHODS

This is a multicenter retrospective series of 88 patients undergoing ductoscopy of > or =1 duct for the diagnostic workup of common breast problems. The procedures were done with the patient under local anesthesia, and intraductal biopsy specimens were taken and analyzed as breast cytology samples.

RESULTS

Of the 88 patients undergoing office ductoscopy, nipple discharge was the most common indication (n = 83 patients; 94% to 66% spontaneous and 34% elicited). Fifty-five percent were high risk for breast cancer by history. The majority of patients had normal previous mammograms: 48 Breast Imaging-Reporting and Data System (BIRADS) 1, 24 BIRADS 2, and 7 BIRADS 3 to 5. The most common finding was papilloma present in 29 (32%) patients by endoscopy. Only 31% of patients had a history of brown or bloody nipple discharge. A wide variety of other endoscopic abnormalities were seen and biopsied. The average number of biopsies per patient was 2 with 18 (20.5%) having severe or malignant atypia. Further follow-up and management of these more concerning abnormalities is currently ongoing.

CONCLUSIONS

These results indicate that office ductoscopy with biopsy is both feasible and does identify suspicious or malignant atypia in patients with expressed or spontaneous nipple fluid.

Ductal lavage and its histopathologic basis: A cautionary tale

Ductal lavage has been touted as a possible screening tool for patients with a high risk for the development of breast cancer. This article examines the fundamental concepts underlying the procedure and critically evaluates its possible utility in light of the known molecular and surgical pathologic data. It highlights the fact that risk assessment in breast cancer is far from an exact science, since most women who develop breast cancers are not identified as high-risk by the Gail model. The utility of ductal lavage has as yet not been proven, and even if it were useful, it is likely to benefit only a subset of all breast cancer patients. Further studies, preferably controlled clinical trials, are necessary before routine use of the procedure can be recommended.

The diagnosis and management of pre-invasive breast disease: the role of new diagnostic techniques

In recent years we have seen significantly increased use of minimally invasive diagnostic techniques in the management of breast disease. There is wide recognition of fine needle aspiration and core biopsy as the principal diagnostic methods. However, concerns exist regarding their reliability. This article provides a brief overview of the major diagnostic issues related to use of fine needle aspiration, core biopsy and ductal lavage. It summarizes areas of use for each technique, outlines the main diagnostic pitfalls and their causes, and provides a perspective on future developments in the field.

Use of exfoliated cells from target tissues to predict responses to bioactive food components

A host of bioactive food components have been proposed to promote health and reduce the risk of disease states. It is clear that not all individuals respond identically to these essential and nonessential food components. Genetic polymorphisms may influence absorption, metabolism and accumulation of bioactive food components, thereby influencing their actions in target tissues. Unfortunately, serum concentrations of bioactive food components may not correlate with tissue concentrations and may therefore under- or overestimate the response in target tissues. Exfoliated cells may be useful to assess the actions of nutrients in specific tissues. Although not extensively examined, evidence already suggests the usefulness of these cells in predicting changes in gene expression, DNA methylation, DNA damage, protein expression and accumulation of dietary components. Although there are limitations on the collection of exfoliated cells, the inaccessibility of tissues they can represent raises intriguing possibilities for their ability to predict the outcome of nutritional intervention studies.

Novel agents for chemoprevention, screening methods, and sampling issues

An aggressive approach to breast cancer control based on preventing the disease must complement efforts at effective treatment. To date clinical trials testing new chemopreventative agents have not generally met with the kind of success expected. A wide range of new breast cancer chemopreventative agents are poised to be tested in clinical trials. We review these novel agents and approaches, including those for which clinical trials have been initiated and those that are promising in the preclinical arena. Further progress in this area requires not only new agents, but novel methods for screening for risk assessment, sampling and development of intermediate biomarkers. We review these novel potential surrogate endpoints, including new imaging-techniques, breast sampling approaches, and methods to assess biomarkers in breast epithelium. Factors that could contribute to a meaningful choice of the chemopreventive agents and the design of clinical trials are discussed.

The diagnosis and management of pre-invasive breast disease: pathological diagnosis--problems with existing classifications

In this review, we comment on the reasons for disagreement in the concepts, diagnosis and classifications of pre-invasive intraductal proliferations. In view of these disagreements, our proposal is to distinguish epithelial hyperplasia, lobular carcinoma in situ and ductal carcinoma in situ, and to abandon the use of poorly reproducible categories, such as atypical ductal hyperplasia or ductal intraepithelial neoplasia, followed by a number to indicate the degree of proliferation and atypia, as these are not practical for clinical decision making, nor for studies aimed at improving the understanding of breast cancer development. If there is doubt about the classification of an intraductal proliferation, a differential diagnosis and the reason for and degree of uncertainty should be given, rather than categorizing a proliferation as atypical.