Diagnostic value of nipple cytology

Imprint cytology can be a better option for diagnosis of mammary Paget’s disease!!!: A case report with review

Mammary Paget’s disease (MPD) is a rare form of pruritic eczematous skin lesion involving the nipple areola complex usually associated with an underlying in-situ or invasive carcinoma of breast, accounting ≤ 4% of overall breast carcinoma. The patient may present with nipple discharge, eczema, plaque, or nipple destruction with or without a lump which is resistant to common remedies. Diagnosis of MPD is usually accomplished by a punch biopsy, but imprint cytology is found to be an effective modern technique yet less explored. Cytological diagnosis is advantageous over surgical excisional biopsy; advantages being easy practicability, cost-effective, quick non-invasive, and above all can lead the physician for breast-preserving surgeries in selective cases rather than more aggressive standard mastectomies. We report one such case of MPD in a 52-year-old female diagnosed on imprint cytology with the aim to emphasize that imprint cytology can be a better option to improve the treatment protocol.

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.

Accuracy for cytological evaluation in the detection of breast cancer among patients with pathologic nipple discharge: a PRISMA-compliant meta-analysis

Background:

Nipple discharge cytology is a simple non-invasive method that may provide valuable information for detecting underlying malignancy. Several studies have investigated the diagnostic value of cytology in breast cancer patients with pathological nipple discharge, but the results have been highly variable. Herein we presented a systematic review and meta-analysis of published studies pertaining to the diagnostic capacity of nipple discharge cytology in patients with breast cancer.

Methods:

A systematic literature search was performed (Medline/PubMed, Embase, Cochrane Library databases, and Google Scholar) to identify studies that investigated the diagnostic capacity of cytology with regard to breast cancer in patients with pathologic nipple discharge. Two independent researchers identified articles that assessed the sensitivity and specificity of cytological evaluation for breast cancer detection in patients with pathologic nipple discharge published between January 2000 and October 2018. Articles were only included in the meta-analysis if they met predetermined criteria. The characteristics of each study and the data they yielded were summarized. Quality assessment of all articles included was performed using the Methodological Index for Non-randomized Studies Criteria (MINORS) and the Quality Assessment of Diagnostic Accuracy Study 2 (QUADAS-2). Heterogeneity was tested via Cochran Q test and the I² statistic using Stata 12.0 and Meta-DiSc 1.4 software, and meta-analysis was performed.

Results:

A total of 286 articles were identified, of which 12 articles including a total of 1476 patients were deemed eligible for inclusion in the meta-analysis. A random-effects model assessing the capacity of nipple discharge cytology to predict breast cancer yielded pooled sensitivity 63% (95% confidence interval [CI]: 53%–72%), specificity 95% (95% CI: 87%–98%), positive likelihood ratio 12.35 (95% CI: 4.87–31.34), and negative likelihood ratio 0.39 (95% CI: 0.30–0.50). The diagnostic odds ratio was 31.88 (95% CI: 11.30–89.98). The area under the summary receiver operating characteristic curve was 0.79 (95% CI: 0.75–0.82).

Conclusion:

The current meta-analysis suggests that nipple discharge cytology is a useful diagnostic modality for detection of breast cancer in patients with pathological nipple discharge, with moderate sensitivity and high specificity.

Cytological evaluation in males presenting with bloody nipple discharge, with or without breast mass: Report of two cases depicting two poles of the disease spectrum

Nipple discharge (ND) either in the presence or in the absence of underlying mass is a very uncommon presentation in males and its bloody nature is still rarer. ND cytology in males has not been reported much in the literature. Spontaneous and expressed ND, however, can be very useful in establishing the diagnosis. Two males with bloody ND, one, without any palpable mass and another with underlying mass, were evaluated on ND cytology. The presence of loose papillaroid clusters and cell sheets with mild atypia was seen in ND smears itself in case 1. The discharge was more copious in case 2, but the ND smears were paucicellular. The presence of tall columnar cells in ND smears as well as in the FNA from underlying mass with clear features of malignancy was helpful in reaching the diagnosis of papillary carcinoma in case 2. Histopathology in case 1 was a spectrum of ADH to DCIS, whereas in case 2, was tubulopapillary carcinoma. Following two cases highlight the importance of the cytological evaluation of ND smears.

The impact of malignant nipple discharge cytology (NDc) in surgical management of breast cancer patients

Background

The role of nipple discharge cytology (NDc) in the surgical management of breast cancer patients is unclear. We aimed: (i) to evaluate the effect of malignant NDc on the surgical approach to the nipple-areola complex, and (ii) to verify the association between malignant NDc and nipple malignancy.

Methods

We retrospectively analyzed a case series of 139 patients with NDc who underwent breast surgery. The clinical and histological findings, types of surgery with emphasis on nipple-areola complex amputation, immunohistochemical phenotypes of the carcinomas and measurements of the tumor-nipple distance were recorded. Additionally, in patients who showed HER2-positive lesions on definitive surgery, we evaluated the HER2 immunocytochemistry of the NDc smears.

Results

Thirty-two malignant and 107 benign/borderline NDc diagnoses were identified. All 32 malignant-NDc cases were histologically confirmed as malignant. Thirty borderline/benign-NDc cases were histologically diagnosed as malignant (sensitivity 58%). The majority of the patients with malignant NDc were treated with nipple-areola complex amputations in both the mastectomy and conservative surgery groups (P<0.001, χ²51.77). Nipple involvement was strongly associated with HER2-positive ductal carcinoma in-situ (P<0.001, χ²11.98). HER2 immunocytochemistry on the NDc revealed a 100% correlation with the immunocytochemistry performed on the surgical tissues.

Conclusions

Malignant NDc influenced surgical management. The association of malignant NDc with nipple involvement is highly related to ductal carcinoma in-situ with HER2 overexpression. In case of HER2 positive NDc, nipple-areola complex involvement is more likely than in HER2 negative cases.

[How to explore breast skin lesion?: Guidelines]

A change in the shape or appearance of the nipple-areola complex, especially if it is unilateral and recent appearance, is a sign of underlying breast tumor. Breast imaging is then required (grade C). Any erythematous lesion of the nipple or nipple-areola can be a Paget's disease, an adenoma of the nipple or a nipple eczema. Clinical course and pattern can point to a diagnosis without sufficient specificity (LE4). If nipple eczema is suspected, it is recommended to perform a test treatment with topical corticosteroids. In case of failure or if a Paget's disease of the breast is suspected, a biopsy must be done. When indicated, it is not possible to recommend a biopsy modality (scrape cytology, punch biopsy, nipple core biopsy and surgical excision) compared to another. When imaging exploration of the nipple-areola complex is necessary, ultrasound and mammography are recommended as first-line. In the absence of signal, an MRI is recommended as second-line (grade C).

A nomogram based on mammary ductoscopic indicators for evaluating the risk of breast cancer in intraductal neoplasms with nipple discharge

Mammary ductoscopy (MD) is commonly used to detect intraductal lesions associated with nipple discharge. This study investigated the relationships between ductoscopic image-based indicators and breast cancer risk, and developed a nomogram for evaluating breast cancer risk in intraductal neoplasms with nipple discharge. A total of 879 consecutive inpatients (916 breasts) with nipple discharge who underwent selective duct excision for intraductal neoplasms detected by MD from June 2008 to April 2014 were analyzed retrospectively. A nomogram was developed using a multivariate logistic regression model based on data from a training set (687 cases) and validated in an independent validation set (229 cases). A Youden-derived cut-off value was assigned to the nomogram for the diagnosis of breast cancer. Color of discharge, location, appearance, and surface of neoplasm, and morphology of ductal wall were independent predictors for breast cancer in multivariate logistic regression analysis. A nomogram based on these predictors performed well. The P value of the Hosmer-Lemeshow test for the prediction model was 0.36. Area under the curve values of 0.812 (95 % confidence interval (CI) 0.763-0.860) and 0.738 (95 % CI 0.635-0.841) was obtained in the training and validation sets, respectively. The accuracies of the nomogram for breast cancer diagnosis were 71.2 % in the training set and 75.5 % in the validation set. We developed a nomogram for evaluating breast cancer risk in intraductal neoplasms with nipple discharge based on MD image findings. This model may aid individual risk assessment and guide treatment in clinical practice.

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.

Nipple discharge: is its significance as a risk factor for breast cancer fully understood? Observational study including 915 consecutive patients who underwent selective duct excision

Nipple discharge (ND) is a common symptom seen in breast cancer clinics. The primary aim of this study was to identify preoperative risk factors for breast cancer in patients with pathologic ND. The secondary aim was to assess the clinical and pathological effectiveness of physical examination, galactography, cytological examination of the discharge, selective duct excision and ductoscopy. All patients operated on between 1975 and 2008 who presented with ND as their only symptom was analyzed. Discharge's characteristics, cytological data and galactography reports were recorded. The relationship between each individual finding and the risk of breast cancer was calculated. For each diagnostic tool, the sensitivity, specificity and complication rates were calculated and compared. Nine-hundred-fifteen patients underwent selective duct excision. Two-hundred-nineteen patients (23.9%) were found to be affected by carcinoma. In 100/330 (30.3%) patients with bloody discharge and in 42/239 (17.6%) patients with serous secretion cancer was detected (P = 0.004, P = 0.013, respectively). Patients with sero-sanguinous or coloured discharge had the same risk of cancer as the population analyzed (23.9%, P = NS). Galactographic finding of irregular stenosis seemed to be associated with a higher risk of cancer (P = 0.0001). Cytological findings C5 and C4 were associated with cancer (P = 0.001). Selective duct excision showed highest sensitivity and specificity. In conclusion, the well established role of bloody secretion is confirmed. The supposed benign aetiology of serous, coloured or sero-sanguinous discharge is questionable. The high specificity of the cytological exam justifies routine examination of the ND. Selective duct excision can be considered as the diagnostic gold-standard.

"Signet-ring" cell invasive lobular carcinoma of the breast - accidental finding associated with intraductal papilloma: a case report

BACKGROUND

A 57-year old woman had only unilateral milky dischardge of the right breast. Clinical and mammography findings were normal.

CASE PRESENTATION

Cytological diagnosis of intraductal papilloma was established which was galactographically confitmed and patient underwent to surgery. Ductulolobular segmentectomy was made. Histopathologically beside intraductal papilloma numerous single dispread malignant "signet ring" cells in the fibrous retromammilary stroma were found. Imunohistochemically findings were: cytokeratin 8 positive, ER H-score 80, PR H-score 50, HER-2/neu negative. Diagnosis of "signet ring" cell lobular invasive carcinoma was made, followed by mastectomy, axillary limphadectomy and contra lateral breast biopsy.

CONCLUSION

Residual tumor were found only in the breast tissue, while axillary lymph nodes and contra lateral breast biopsy were negative. Patient underwent to oncology therapy.

Evaluating nipple discharge

Nipple discharge is the third most common breast complaint after breast pain and breast mass. It is most often a benign process. Up to 50% women in their reproductive years can express one or more drops of fluid from the breast. Nipple discharge can be of several types, including milky, multicolored and sticky, purulent, clear and watery, yellow or serous, pink or serosanguinous, bloody or sanguinous. The characteristics of the nipple discharge help in the early diagnosis and management of breast disease. The most common cause of pathologic nipple discharge is a benign papilloma followed by ductal ectasia, and the least likely is carcinoma. Most nipple discharges are the result of a clinically insignificant benign process; therefore, less invasive, nonsurgical diagnostic modalities have been explored to reduce the need for surgical intervention. The evaluation and diagnosis of nipple discharge is important for the early detection of carcinoma, when present; and, in the case of benign disease, it is necessary to stop the incommodious discharge.

Comparative analysis of minimally invasive microductectomy versus major duct excision in patients with pathologic nipple discharge

BACKGROUND

Minimally invasive techniques are being used increasingly in patients with benign and malignant breast diseases. The purpose of this study was to compare the diagnostic yield of 2 groups of patients who underwent either minimally invasive microductectomy or major duct excision for pathologic nipple discharge.

METHODS

Two hundred thirty-five patients who underwent nipple exploration and duct excision and were part of an institutional review board-approved database were included in this retrospective analysis. Preoperative imaging, ductal washing cytology, surgical specimen size, and final histopathology were compared among 95 patients who underwent microductectomy by using intraoperative ductoscopy and 140 patients undergoing standard major duct excision.

RESULTS

Mean age of patients undergoing microductectomy was 53 versus 55 years in patients undergoing major duct excision. Preoperative mammogram was negative or benign in 92% and suspicious in 8% of patients in both the microductectomy group and the major duct excision group. A ductal abnormality was identified by preoperative ductography in 43 of 56 (77%) patients in the microductectomy group versus 74 of 92 (80%) patients in the major duct excision group. Ductal cytology was benign in 81% and 80% of patients tested, respectively. Mean specimen size was significantly smaller in patients who underwent microductectomy (9.2 cm3) as compared with major duct excision (12.6 cm3). Although the percentage of patients with atypical ductal hyperplasia or lobular carcinoma in situ was similar among the 2 groups (9% vs 10%), only 3 of 95 (3%) patients within the microductectomy group were found to have carcinoma within the resection specimen as compared with 12 of 140 (9%) within the major duct excision group (P = .03). Mean specimen size of the patients diagnosed with carcinoma was 8.6 cm(3) in the microductectomy group as compared with 15.5 cm3 in the major duct excision group (P = .014).

CONCLUSIONS

These data confirm that patients who present with single duct pathologic nipple discharge usually have benign pathology as the etiology. However, in a small percentage of patients an occult carcinoma might be present. Major duct excision appears to detect a higher percentage of occult carcinoma when compared with minimally invasive microductectomy, which might be related to the larger sample size of the resection specimen.