© 2005 Oxford University Press
CORRESPONDENCE |
RESPONSE: Re: Ductal Lavage Findings in Women With Known Breast Cancer Undergoing Mastectomy
Affiliations of authors: Department of Surgery (SAK), Department of Pathology (RN, EW), School of Medicine, Northwestern University, Chicago, IL; Department of Surgery, Fox Chase Cancer Center, Philadelphia, PA (MM)
Correspondence to: Seema A. Khan, MD, Northwestern University, Feinberg School of Medicine, Department of Surgery, 675 North Saint Clair St., Galter 13-174, Chicago, IL 60611 (e-mail: skhan{at}nmff.org).
The use of ductal lavage for breast cancer surveillance in high-risk women is based on the premises that disease-bearing ducts are more likely to yield fluid than are nondiseased ducts and that, when diseased ducts are lavaged, the histologic abnormalities therein will be reflected in the cytologic sample obtained by lavage. Our findings raise doubt regarding both these premises. The poor diagnostic performance of ductal lavage in our study is not entirely explained by the large invasive cancers present in some of the study breasts, because the associated ductal carcinoma in situ (DCIS) component was larger than 1 cm in diameter in 17 mastectomy specimens. The presence of DCIS in the central ducts close to the nipple, and the size of the DCIS, predicted the presence of atypical cytology in the lavage sample, but most of these atypical cytologic samples displayed only mild atypia, a finding of questionable clinical significance, with statistically significant inter-observer variability of interpretation (1). In 13 breasts where the dye-bearing duct did not correspond to the cancer-bearing duct, 10 contained DCIS either alone or in association with invasive cancer. There were eight study breasts with pure DCIS; in four of these breasts, the disease-bearing duct was lavaged, as evidenced by the presence of dye, and the cytologic finding was mild atypia. These findings do not promote confidence in the idea that early breast cancer will be reliably detected by ductal lavage.
We have subsequently completed a second study focusing on women with mammographically detected microcalcifications (2) who underwent ductal lavage of fluid-yielding ducts before the core biopsy examination. After the lavage procedure, we performed ductography of the lavaged duct to confirm correspondence between the lavaged duct and the area of calcifications. Among the 20 women entered on this study, 10 were diagnosed with DCIS. Four of them produced no nipple fluid; four produced nipple fluid and were lavaged, but the lavaged duct(s) did not overlap with the area of calcifications; one was inevaluable because of dye extravasation; and only one woman with DCIS displayed overlap of the lavaged duct with the mammographic calcifications. Thus, one of 10 women produced nipple fluid from a DCIS-bearing duct. In this single individual, the cytologic finding was benign.
Although these findings do not have direct bearing on the issue of risk assessment, it is important to remember that ductal lavage has not been validated as a risk assessment tool and that its use in this area is based on extrapolation from studies of nipple aspiration fluid (3) and of random fine-needle aspiration (4). In the multicenter trial comparing ductal lavage with nipple aspiration fluid as a method of detecting occult cytologic atypia, the frequency of atypia was higher in ductal lavage samples, but there was imperfect concordance in atypical findings between the two tests (5). Nipple aspiration fluid cytology was benign in 12 samples that were mildly atypical on ductal lavage and in two samples that were markedly atypical on ductal lavage. As long as the long-term implications of these discrepancies remain unknown, ductal lavage should be used with extreme caution for breast cancer risk assessment outside clinical trials.
REFERENCES
(1) Nayar R, Ramakrishnan R, Baird C, DeFrias D, Masood S, Khan SA. Breast ductal lavage (DL): cytologic findings in 114 samples [abstract 76A]. Mod Pathol 2003:16.
(2) Khan SA, Wolfman JA, Segal L, Benjamin S, Nayar R, Wiley EL, et al. Ductal lavage findings in women with mammographic microcalcifications undergoing biopsy. Ann Surg Oncol, in press.
(3) Wrensch MR, Petrakis NL, Miike R, King EB, Chew K, Neuhaus J, et al. Breast cancer risk in women with abnormal cytology in nipple aspirates of breast fluid. J Natl Cancer Inst 2001;93:1791–8.
(4) Fabian CJ, Kimler BF, Zalles CM, Klemp JR, Kamel S, Zeiger S, et al. Short-term breast cancer prediction by random periareolar fine-needle aspiration cytology and the Gail risk model. J Natl Cancer Inst 2000;92:1217–27.
(5) Dooley WC, Ljung B-M, Veronesi U, Ceccarelli C, Elledge RM, O'Shaughnessy J, et al. Ductal lavage for detection of cellular atypia in women at high risk for breast cancer. J Natl Cancer Inst 2001;93:1624–32.
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J Natl Cancer Inst 2005 97: 857.
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