Ductal Lavage for Breast Cancer Risk Assessment

Lisa A. Newman, MD, MPH, FACS, Cassann Blake, MD

Disclosures

Cancer Control. 2002;9(6) 

In This Article

Ductal Lavage vs Aspiration

Sporadic nipple discharge (usually studied as nipple aspirates following manual breast massage) has been reported to be a risk factor for breast cancer for several decades.[2,3,4] Nonlactational secretory activity in the breast may actually be a surrogate marker for proliferative changes in the ductal tissue. These proliferative changes may in turn indicate an increased risk for breast carcinogenesis. However, the yield of cellular material from a direct nipple aspirate is generally too low to permit a meaningful cytologic analysis. A major benefit of ductal lavage is the substantially improved yield of fluid characterized by a significant cellular content.

Dooley et al[5] conclusively demonstrated the increased cytology yield resulting from ductal lavage compared to nipple aspirates in a multicenter study involving more than 500 women who were identified as being at high-risk for breast cancer on the basis of family history, prior personal history of breast cancer, and/or other features, resulting in a 5-year Gail model risk estimate of at least 1.7%. Ductal lavage was 3.5 times more successful at producing cytologically evaluable fluid compared to nipple aspirates (72% vs 21%, respectively; P<.001) and the median yield with ductal lavage was 13,500 epithelial cells compared to 120 cells for the subset of nipple aspirates that were evaluable.

The ductal lavage procedure involves the application of a topical anesthetic cream to the skin of the nipple and removal of keratin formation. Following breast massage, a suction apparatus is applied to the nipple, and any fluid-yielding ducts are candidates for lavage. An attempt is made to cannulate these ducts with a specially designed catheter that is attached to two separate ports, one for infusion and the other for aspiration. A selected duct is catheterized, approximately 5 to 10 mL of saline is infused into the cannulated ductal system, and the fluid is aspirated and sent for cytologic analysis. The procedure is repeated in a stepwise fashion for any additional fluid-yielding ducts, using a separate catheter for each. The sites for each cannulated duct should be recorded on a grid or map representing the nipple to use for comparisons with any future attempts at ductal lavage. Alternatively, a segment of suture material can be left partially inserted into each cannulated ductal orifice, and a photo is taken to document these sites. The cytology report is standardized to stratify results as follows: (1) inadequate cellular material for diagnosis (fewer than 10 epithelial cells), (2) benign cells, (3) mild-ly atypical cells, (4) markedly atypical cells, or (5) malignant cells. An example of a lavage specimen characterized by atypical cells is shown in Fig 1.

Example of a lavage specimen characterized by atypical cells.

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