Nonsurgical evaluation of pathologic nipple discharge

Outcomes of Clinical and Surgical Assessment of Women with Pathological Nipple Discharge

There is no consensus about the diagnostic approach to pathologic nipple discharge (PND). We hypothesize that lactiferous duct excision (microdochectomy) or image-guided biopsy are safe and effective means of diagnosis of PND. Eighty-two patients with PND underwent history and physical exam followed by breast sonography and mammogram. Image-guided biopsy was done if imaging studies were positive, whereas microdochectomy was done if normal. Discharge was unilateral (96%), bloody (79%), and spontaneous (62%). The sensitivity, specificity, positive and negative predictive values for the detection of neoplasia were 0.07, 1.0, 1.0, and 0.4 for mammography and 0.26, 0.97, 0.91, and 0.48 for sonography, respectively. Tissue diagnosis revealed papillary lesion (57%), mammary duct ectasia (33%), breast cancer (5%), and inflammatory/infectious (5%) causes. Hemorrhagic discharge associated with pregnancy or infections was managed successfully without surgery. After a median follow-up of 18 months, no PND recurrence was seen, but one patient developed cancer in a different location after diagnosis of atypical ductal hyperplasia. In conclusion, imaging studies provide confirmatory information and a biopsy target when positive. Negative imaging does not reliably exclude neoplasia or malignancy. Microdochectomy provides a sensible and effective approach in the workup of patients with PND.

Diagnostic mammography performance and race: outcomes in Black and White women

BACKGROUND

A previous study compared the performance (sensitivity, specificity, positive predictive value, and cancer detection rate) of screening mammography in Black and White women. No study, to the authors' knowledge, has evaluated the difference in the performance of diagnostic mammography between Black and White women.

METHODS

Univariate analysis was used to evaluate differences in characteristics and cancers between Black and White women. Stratified and adjusted logistic regression analyses were used to test the association of Black and White race with performance measures of diagnostic mammography.

RESULTS

The sensitivity of diagnostic mammography was higher (91% vs. 84%) and specificity was lower (86% vs. 90%) among Black women compared with White women. After controlling for age, density, self-reported breast problems, and previous mammography, sensitivity was significantly higher (odds ratio [OR] = 1.82, 95% confidence interval [CI] = 1.22-2.80) and specificity was significantly lower (OR = 0.75, 95% CI = 0.70-0.81) among Black women. The crude cancer detection rate of mammography was higher for Black women (42.6/1000) than for White women (31.0/1000) and Black women had a higher proportion of cancers that were > 2.0 cm (57.4% vs. 46.2%) that were more often poorly differentiated (61.7% vs. 49.3%) and were more often estrogen-receptor and progesterone-receptor negative.

CONCLUSIONS

Black women have lower specificity of diagnostic mammography and, consequently, more unnecessary workups than White women. Black women have higher sensitivity of diagnostic mammography, with cancers that are larger and more advanced than White women. Delay in responding to signs and symptoms would explain the size and later stage. However, more research is needed to understand the biologic differences of breast cancer characteristics between Black and White women.

Ductal carcinoma in situ of the breast in men: a review

Breast carcinoma in men is rare and comprises approximately 1% of all breast cancer cases. In contrast to the increase in the detection rate of ductal carcinoma in situ (DCIS) in women resulting from the wide use of screening mammography programs, the rate of male DCIS is still small and represents approximately 5% of all male breast cancers. Considerable debate exists concerning the nature of this entity, including the clinical course, pathologic findings, treatment, and prognosis. In this review, the relevant literature dealing with male DCIS is summarized in an attempt to more precisely define the features of this disease.

Intraductal Papilloma: Features on MR Ductography Using a Microscopic Coil

OBJECTIVE

The purpose of this study was to describe the features of intraductal papilloma on MR ductography using a microscopic coil.

CONCLUSION

Intraductal papilloma appeared in most cases as a well-circumscribed mass with early enhancement and delayed washout associated with a dilated duct, predominantly showing signal hyperintensity on T1- and T2-weighted imaging.

Breast duct microendoscopy in nipple discharge: microbrush improves cytology

BACKGROUND

Breast duct microendoscopy is a new technique that allows direct visualization of the mammary ductal epithelia and has the potential to provide greater accuracy in the diagnosis of benign and malignant breast conditions. We have already established the feasibility of BDME on mastectomy specimens and in patients both under general and local anesthesia. It was the aim of this study to investigate the use of BDME in patients with pathological nipple discharge and to explore the feasibility of using an endoluminal microbrush to take cytology samples from specific lesions.

MATERIALS AND METHODS

Breast duct microendoscopy was offered to all patients undergoing surgery for nipple discharge. Surgery included microdochectomy (younger women) and total duct excision (especially in postmenopausal women). The microbrush was used to collect samples whenever an endoluminal papilloma was seen on endoscopy. The results of microbrush cytology samples were compared to ductal lavage samples.

RESULTS

Fifty consecutive patients undergoing microdochectomy or total duct excision for nipple discharge had breast microendoscopy (28 general, and 22 under local anesthesia). Thirty-one patients had microdochectomy and nineteen had total duct excision. Visualiza- tion of discharging ducts was accomplished in 100% cases. Endoluminal abnormalities were seen in 33 (66%) patients and dilated ducts were seen in 17 patients. Among the 33 patients, 15 had single papilloma, 3 multiple papilloma and 15 inflammation (erythema, fronds, adhesions). Seven out of eight patients with an intraductal papillorna who had microbrush cytology showed papillary cells whereas only 2 out of 11 patients who had ductal lavage were positive for papillary cells. Thus the sensitivity of the brush cytology technique for the diagnosis of papilloma was 87.5% and the sensitivity of ductal lavage 18% (p = 0.0055).

CONCLUSION

Breast duct microendoscopy is an effective way of establishing the etiology of nipple discharge. The microbrush increases the sensitivity of cytology significantly.

The value of clinical characteristics and breast-imaging studies in predicting a histopathologic diagnosis of cancer or high-risk lesion in patients with spontaneous nipple discharge

BACKGROUND

The purpose of this study was to determine the utility of breast-imaging studies in identifying cancer and high-risk lesions among patients with spontaneous, single-duct, nipple discharge (SSND).

METHODS

The medical records of 168 cases with SSND treated with duct excision between June 1998 and May 2004 were reviewed. The sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) of mammogram, ultrasound, and ductogram in predicting high-risk lesions and cancer were calculated.

RESULTS

The sensitivity of mammography was 10%, the specificity 94%, the NPV 88%, and the PPV 18%. Ultrasonography had a sensitivity of 36%, specificity of 68%, PPV of 14%, and NPV of 89%. Ductography had a sensitivity of 75%, specificity of 49%, and NPV and PPV of 93% and 18%, respectively.

CONCLUSIONS

Conventional imaging studies do not accurately identify cancer or high-risk lesions in patients with SSND. All patients with SSND should be offered duct excision.

Diagnostic value of nipple cytology

BACKGROUND

Nipple discharge/scraping cytology is a simple, noninvasive method that complements patient assessment. Despite low reported sensitivities for detecting malignancy, the authors predicted that this method would provide important diagnostic information when applied to patients with nonphysiologic nipple discharge or eczematous nipple lesion.

METHODS

From 1995-2002, 466 case specimens from 395 patients were evaluated by nipple discharge or scraping cytology. Of the 98 patients with abnormal cytologic findings, histologic follow-up was available for 45 cases (39 patients). After review, each case was categorized as negative or positive for malignancy. Cytologic findings were compared with the findings of subsequent biopsy or excision of the affected duct or nipple lesion.

RESULTS

Of the 13 cases of in situ or invasive carcinoma diagnosed by histology, 11 had positive cytology (sensitivity, 85%). Two malignant cases were not represented by preceding cytology and one case with positive cytology failed to demonstrate malignancy after a subsequent biopsy was performed (specificity, 97%). Clinically, all but one case of malignancy was associated with a serosanguinous discharge or eczematous nipple lesion. The cytology of all malignant cases showed dyshesive epithelial cell groups and single cells with prominent nucleoli in a bloody background. The positive predictive value for cytology was 92% and the negative predictive value was 94%.

CONCLUSIONS

Cytologic examination of nipple discharge and nipple lesion scrapings is highly specific and sensitive in the detection of carcinoma when applied to patients with unilateral serosanguinous nipple discharge or an eczematous nipple lesion.