CORRESPONDENCE

Re: Ductal Lavage Findings in Women With Known Breast Cancer Undergoing Mastectomy

Susan M. Love

Correspondence to: Susan M. Love, MD, Dr. Susan Love Research Foundation, PO Box 846, Pacific Palisades, CA 90272 (e-mail: slove{at}earthlink.net).

Khan et al. (1) have done an excellent study of the clinical correlation of cytologic findings in fluid-producing ducts and cancer in the same breasts. This work suggests that the current hypothesis that the ducts yielding fluid on nipple aspiration are the ones likeliest to contain malignant disease may not be correct. Cancer was as likely to be in a non-fluid-yielding duct as in a fluid-yielding duct. This is similar to the independent findings of Hartman et al. (2) and Maddux et al. (3), in which atypia was as likely to be found in non-fluid-yielding ducts as in fluid-yielding ducts.

When limited to the ducts containing cancer, Khan's work also corroborates the findings of Sartorius et al. (4), who were unable to detect cancers of more than 8 mm in diameter by lavage. Their explanation for this finding was that destruction of the integrity of the ductal system by the cancer allowed the fluid to leak into the stroma of the breast rather than travel through the ductal system.

In addition, the findings of Khan et al. suggest that the ductal systems are independent and that, rather than being a field defect, breast cancer occurs in one ductal system, as suggested by Holland et al. (5). The likelihood of finding abnormal cells if you lavage the wrong duct is low. Finally, the limitations of using results of cytologic abnormalities as the marker for cancer were demonstrated. As Khan et al. pointed out, both aneusomy (6) and DNA methylation (7) have been shown to more accurately detect cancer in lavage samples than does cytologic evaluation.

Khan validly concludes that ductal lavage, as currently practiced, should not be used to detect cancer. However, it would be a shame to dismiss this new technology on the basis of this study. Ductal lavage and nipple aspirate fluid collection have been shown to be valid tools for risk assessment. In addition, ductal lavage allows us, for the first time, to study the cells and microenvironment where breast cancer begins. This tool will surely give us the insights needed to finally understand this disease.

REFERENCES

(1) Khan S, Wiley EL, Rodriguez N, Baird C, Ramakrishman R, Nayar R, et al. Ductal lavage findings in women with known breast cancer undergoing mastectomy. J Natl Cancer Inst 2004;96:1510–7.[Abstract/Free Full Text]

(2) Hartman A, Daniel BL, Kurian AW, Mills MA, Nowels KW, Dirbas FM, et al. Breast magnetic resonance image screening and ductal lavage in women at high genetic risk for breast carcinoma. Cancer 2004;100:479–89.[CrossRef][ISI][Medline]

(3) Maddux AJ, Ashfaq R, Naftalis E, Keutch AM, Hoover S, Euhus D. Patient and duct selection for nipple duct lavage. Am J Surg 2004;188:390–4.[CrossRef][ISI][Medline]

(4) Sartorius OW, Smith HS, Morris P, Benedict D, Friesen L. Cytologic evaluation of breast fluid in the detection of breast disease. J Natl Cancer Inst 1977;59:1073–80.[ISI][Medline]

(5) Holland R, Hendriks J, Verbeek AL, Mravunnac M, Schuurmans Stekhoven JH. Extent, distribution and mammographic/histological correlations of breast ductal carcinoma in situ. Lancet 1990;335:519–22.[CrossRef][ISI][Medline]

(6) King BL, Tsai SC, Gryga ME, D'Aquila TG, Seelig SA, Morrison LE, et al. Detection of chromosomal instability in paired breast surgery and ductal lavage specimens by interphase fluorescence in situ hybridization. Clin Cancer Res 2003;9:1509–16.[Abstract/Free Full Text]

(7) Evron E, Dooley WC, Umbricht CB, Rosenthal D, Sacchi N, Gabrielson E, et al. Detection of breast cancer cells in ductal lavage fluid by methylation specific PCR. Lancet 2001;357:1335–6.[CrossRef][ISI][Medline]



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