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Jiwa N, Kumar S, Gandhewar R, Chauhan H, Nagarajan V, Wright C, Hadjiminas D, Takats Z, Ashrafian H, Leff DR. Diagnostic Accuracy of Nipple Discharge Fluid Cytology: A Meta-Analysis and Systematic Review of the Literature. Ann Surg Oncol 2021; 29:1774-1786. [PMID: 34839426 PMCID: PMC8627297 DOI: 10.1245/s10434-021-11070-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 10/28/2021] [Indexed: 01/07/2023]
Abstract
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.
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Affiliation(s)
- Natasha Jiwa
- Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, London, UK.
| | | | - Rishikesh Gandhewar
- Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, London, UK
| | - Hemali Chauhan
- Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, London, UK
| | | | - Corrina Wright
- Northwest London Pathology, Imperial College Healthcare Trust, London, UK
| | - Dimitri Hadjiminas
- Department of Breast Surgery, Imperial College Healthcare Trust, London, UK
| | - Zoltan Takats
- Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, London, UK
| | - Hutan Ashrafian
- Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, London, UK
| | - Daniel Richard Leff
- Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, London, UK.,Department of Breast Surgery, Imperial College Healthcare Trust, London, UK
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Waaijer L, Filipe MD, Simons J, van der Pol CC, de Boorder T, van Diest PJ, Witkamp AJ. Detection of breast cancer precursor lesions by autofluorescence ductoscopy. Breast Cancer 2020; 28:119-129. [PMID: 32725533 PMCID: PMC7796885 DOI: 10.1007/s12282-020-01136-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 07/16/2020] [Indexed: 12/26/2022]
Abstract
PURPOSE Autofluorescence is an image enhancement technique used for the detection of cancer precursor lesions in pulmonary and gastrointestinal endoscopy. This study evaluated the feasibility of addition of autofluorescence to ductoscopy for the detection of intraductal breast cancer precursor lesions. METHODS An autofluorescence imaging system, producing real-time computed images combining fluorescence intensities, was coupled to a conventional white light ductoscopy system. Prior to surgery, ductoscopy with white light and autofluorescence was evaluated under general anaesthesia in women scheduled for therapeutic or prophylactic mastectomy. Endoscopic findings in both modes were compared, marked and correlated with histology of the surgical specimen. RESULTS Four breast cancer patients and five high-risk women, with a median age of 47 years (range 23-62) were included. In autofluorescence mode, two intraductal lesions were seen in two breast cancer patients, which had an increase in the red-to-green fluorescence intensity compared with the surrounding tissue. One lesion had initially been missed by white light ductoscopy but was clearly visible in subsequent autofluorescence mode. One endoscopic finding was classified as suspicious by white light, but was negative in autofluorescence mode and showed normal histology. CONCLUSIONS This study demonstrates for the first time the in vivo feasibility of autofluorescence ductoscopy to detect pathologically confirmed breast cancer precursor lesions in both breast cancer patients and high-risk women that were occult under white light.
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Affiliation(s)
- Laurien Waaijer
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Mando D Filipe
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Janine Simons
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Carmen C van der Pol
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Tjeerd de Boorder
- Department of Medical Technology and Clinical Physics, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Paul J van Diest
- Department of Pathology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Arjen Joost Witkamp
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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de Boorder T, Waaijer L, van Diest PJ, Witkamp AJ. Ex vivo feasibility study of endoscopic intraductal laser ablation of the breast. Lasers Surg Med 2017; 50:137-142. [PMID: 28990682 DOI: 10.1002/lsm.22745] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2017] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To determine the feasibility and safety of breast endoscopic thulium laser ablation for treatment of intraductal neoplasia. STUDY DESIGN Ductoscopy is a minimally invasive endoscopic approach of the milk ducts of the breast via the nipple. Besides diagnosis in women with pathologic nipple discharge (PND), it allows non-invasive removal of intraductal lesions with a stalk like papillomas. Removal, however, is often incomplete and flat lesions cannot be targeted. We therefore developed laser ductoscopy. METHODS Dosimetry of laser ductoscopy was assessed in thirteen mastectomy specimens, applying power settings of 1-5 W with 100-1000 ms pulsed exposure to a 375-μm outer diameter thulium fiber laser. Subsequently histology was obtained from the breast tissue that was treated with the Thulium laser. RESULTS Endoscopic view was maintained during ductoscopic laser ablation at 1-3 W. Increasing power to 4-5 W caused impaired vision due to shrinkage of the main duct around the ductoscope tip. Histology revealed localized ablation of the duct wall. CONCLUSION We show for the first time that laser ductoscopy is technically feasible. The Thulium laser enables a superficial intraductal ablation and is a useful tool for intraductal interventions. An in vivo prospective study is needed to further demonstrate its potential. Lasers Surg. Med. 50:137-142, 2018. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- Tjeerd de Boorder
- Departments of Medical Technology and Clinical Physics, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Laurien Waaijer
- Departments of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Paul J van Diest
- Departments of Pathology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Arjen J Witkamp
- Departments of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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Waaijer L, Simons JM, Borel Rinkes IHM, van Diest PJ, Verkooijen HM, Witkamp AJ. Systematic review and meta-analysis of the diagnostic accuracy of ductoscopy in patients with pathological nipple discharge. Br J Surg 2016; 103:632-643. [DOI: 10.1002/bjs.10125] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 11/07/2015] [Accepted: 01/06/2016] [Indexed: 11/06/2022]
Abstract
Abstract
Background
Invasive surgery remains the standard for diagnosis of pathological nipple discharge (PND). Only a minority of patients with nipple discharge and an unsuspicious finding on conventional breast imaging have cancer. Ductoscopy is a minimally invasive alternative for evaluation of PND. This systematic review and meta-analysis was designed to evaluate the diagnostic accuracy of ductoscopy in patients with PND.
Methods
A systematic search of electronic databases for studies addressing ductoscopy in patients with PND was conducted. Two classification systems were assessed. For DSany, all visualized ductoscopic abnormalities were classified as positive, whereas for DSsusp, only suspicious findings were considered positive. After checking heterogeneity, pooled sensitivity and specificity of DSany and DSsusp were calculated.
Results
The search yielded 4642 original citations, of which 20 studies were included in the review. Malignancy rates varied from 0 to 27 per cent. Twelve studies, including 1994 patients, were eligible for meta-analysis. Pooled sensitivity and specificity of DSany were 94 (95 per cent c.i. 88 to 97) per cent and 47 (44 to 49) per cent respectively. Pooled sensitivity and specificity of DSsusp were 50 (36 to 64) and 83 (81 to 86) per cent respectively. Heterogeneity between studies was moderate to large for sensitivity (DSany: I2 = 17·5 per cent; DSsusp: I2 = 37·9 per cent) and very large for specificity (DSany: I2 = 96·8 per cent; DSsusp: I2 = 92·6 per cent).
Conclusion
Ductoscopy detects about 94 per cent of all underlying malignancies in patients with PND, but does not permit reliable discrimination between malignant and benign findings.
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Affiliation(s)
- L Waaijer
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - J M Simons
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - I H M Borel Rinkes
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - P J van Diest
- Department of Pathology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - H M Verkooijen
- Imaging Division, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - A J Witkamp
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
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Wu Y, Liu Y, Dong Y, Vadgama J. Diabetes-associated dysregulated cytokines and cancer. INTEGRATIVE CANCER SCIENCE AND THERAPEUTICS 2016; 3:370-378. [PMID: 29930868 PMCID: PMC6007890 DOI: 10.15761/icst.1000173] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Epidemiological data demonstrate that patients with diabetes have an augmented risk of developing various types of cancers, accompanied by higher mortality. A number of mechanisms for this connection have been hypothesized, such as insulin resistance, hyperinsulinemia, hyperglycemia, and increased inflammatory processes. Apart from these potential mechanisms, several diabetes-associated dysregulated cytokines might be implicated in the link between diabetes and cancer. In fact, some inflammatory cytokines, e.g. TNF-α, IL-6 and leptin, have been revealed to play important roles in both initiation and progression of tumor. Here, we depict the role of these cytokines in key events of carcinogenesis and cancer development, including their capability to induce oxidative stress, inflammation, their participation in epithelial mesenchymal transition (EMT), angiogenesis, and metastasis. Finally, we will also highlight the existing knowledge in terms of the involvement of these cytokines in different cancer types and comment on potential significances for future clinical applications.
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Affiliation(s)
- Yong Wu
- Division of Cancer Research and Training, Charles R. Drew University of Medicine and Science, Los Angeles, USA
- David Geffen School of Medicine, University of California, Los Angeles, USA
| | - Yanjun Liu
- Division of Endocrinology, Charles R. Drew University of Medicine & Sciences, UCLA School of Medicine, Los Angeles, USA
| | - Yunzhou Dong
- Vascular Biology Program BCH3137, Boston Children's Hospital, Harvard Medical School, Boston, USA
| | - Jay Vadgama
- Division of Cancer Research and Training, Charles R. Drew University of Medicine and Science, Los Angeles, USA
- David Geffen School of Medicine, University of California, Los Angeles, USA
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Ohlinger R, Stomps A, Paepke S, Blohmer JU, Grunwald S, Hahndorf W, Camara O, Deichert U, Peisker U, Kohlmann T, Buchholz I, Hegenscheid K, Utpatel K, Zygmunt M, Hahn M. Ductoscopic Detection of Intraductal Lesions in Cases of Pathologic Nipple Discharge in Comparison with Standard Diagnostics: The German Multicenter Study. Oncol Res Treat 2014; 37:628-32. [DOI: 10.1159/000368338] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Accepted: 09/03/2014] [Indexed: 11/19/2022]
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Yang X, Li H, Gou J, Tan Q, Wang L, Lin X, Feng X, Jiang Y, Zhang S, Lv Q. The Role of Breast Ductoscopy in Evaluation of Nipple Discharge: A Chinese Experience of 419 Patients. Breast J 2014; 20:388-93. [PMID: 24985528 DOI: 10.1111/tbj.12275] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2013] [Revised: 08/29/2013] [Accepted: 08/30/2013] [Indexed: 02/05/2023]
Affiliation(s)
- Xiaoqin Yang
- Department of Thyroid and Breast Surgery; West China Hospital; Sichuan University; Chengdu 610041 China
| | - Hongjiang Li
- Department of Thyroid and Breast Surgery; West China Hospital; Sichuan University; Chengdu 610041 China
| | - Juxiang Gou
- Department of Thyroid and Breast Surgery; West China Hospital; Sichuan University; Chengdu 610041 China
| | - Qiuwen Tan
- Department of Thyroid and Breast Surgery; West China Hospital; Sichuan University; Chengdu 610041 China
| | - Liping Wang
- Department of Thyroid and Breast Surgery; West China Hospital; Sichuan University; Chengdu 610041 China
| | - Xiaoyan Lin
- Department of Thyroid and Breast Surgery; West China Hospital; Sichuan University; Chengdu 610041 China
| | - Xiaojuan Feng
- Department of Thyroid and Breast Surgery; West China Hospital; Sichuan University; Chengdu 610041 China
| | - Yixue Jiang
- Department of Thyroid and Breast Surgery; West China Hospital; Sichuan University; Chengdu 610041 China
| | - Shu Zhang
- Department of Thyroid and Breast Surgery; West China Hospital; Sichuan University; Chengdu 610041 China
| | - Qing Lv
- Department of Thyroid and Breast Surgery; West China Hospital; Sichuan University; Chengdu 610041 China
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Sarica O, Ozturk E, Demirkurek HC, Uluc F. Comparison of ductoscopy, galactography, and imaging modalities for the evaluation of intraductal lesions: a critical review. Breast Care (Basel) 2013; 8:348-54. [PMID: 24415988 PMCID: PMC3862052 DOI: 10.1159/000355833] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Today, in cases of nipple discharge of unclear origin, the abundance of diagnostic procedures - a, diagnostic dilemma' - becomes apparent, because unequivocal indications and a current, standardized examination sequence are presently not available. The diagnostic workup of patients with nipple discharge usually includes the clinical history, physical examination, mammography, ultrasonography, galactography, and nipple discharge cytology, but not ductoscopy. METHODS In this review we analyze and discuss the possible role of ductoscopy in evaluating intraductal pathologies and its combined use with diagnostic imaging modalities. For this purpose, we reviewed and compared the results of the radiological, pathological, and surgical studies independently. CONCLUSIONS Currently, there is no solitary accurate modality to reach our definitive purpose. Being aware of the capability of each diagnostic modality may take us closer to our target. Therefore, adjunct and appropriate use of multiple imaging modalities and ductoscopy is necessary to evaluate patients with nipple discharge.
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Affiliation(s)
- Ozgur Sarica
- Department of Radiology, Taksim Education and Research Hospital, Istanbul, Turkey
| | - Enis Ozturk
- Department of Radiology, Bakirkoy Education and Research Hospital, Istanbul, Turkey
| | - Huseyin C. Demirkurek
- Department of Nuclear Medicine, Taksim Education and Research Hospital, Istanbul, Turkey
| | - Fatih Uluc
- Department of Radiology, Taksim Education and Research Hospital, Istanbul, Turkey
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The anatomy of fluid-yielding ducts in breast cancer. Breast Cancer Res Treat 2011; 132:555-64. [DOI: 10.1007/s10549-011-1623-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2011] [Accepted: 05/31/2011] [Indexed: 10/25/2022]
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