This year-long series on breast health from the Breast Cancer Surgery Center started with breast cancer risk assessment, continued with risk reduction, and most recently covered genetic testing. This issue's article deals with the promising new technique entitled nipple aspiration and ductal lavage (NADL). This new, but not experimental, technique shows promise for further characterizing women's risks so that selective screening can become even more precise.

      As most women know, most abnormalities that are palpated (felt) in a breast, or seen on a mammographic study, are not cancer. Frequently, these lesions require removal. In the study of the cells under the microscope, other cells are sometimes seen which can be correlated with the patient's known riskfactors. One of the incidental benign findings which has shown a high association with the future development of breast cancer is termed atypical ductal hyperplasia.

      Most (but not all) breast cancers arise in the tubes which carry milk from the glands to the nipple (6 - 8 ducts per nipple). These tubes are lined with tissue termed ductal epithelium which is usually one cell layer thick. Frequently, a portion of this ductal lining becomes much more cellular.This is termed benign ductal hyperplasia. Under influences which we are only now beginning to understand, these hyperplastic areas can then develop pre-cancerous cells. This is termed dysplasia. Dysplastic cells are just one step away from being cancerous.

      Since these changes do not create images on your mammogram or lumps in your breast, they are usually found only incidental to a second pathological process which led to a biopsy whereby these cells are identified under the microscope. Studies have shown, quite consistently, that women who have atypical ductal hyperplasia carry a significantly elevated risk (over 15% in some studies)of developing breast cancer within the next five years.

      Even when a woman is not lactating and nursing, small amounts of watery fluid are continuously produced in the breast. This fluid evaporates at the nipple just like sweat and is not noticeable. When hyperplasia, or other pathologic entities, create a narrowing, but not a total blockage, of the duct, this fluid collects or "pools" in the duct behind the blockage. Using a very gentle suction cup, pooled fluid can be brought to the surface identifying that duct's opening in the nipple. This is called nipple aspiration and the fluid is called nipple aspiration fluid (NAF).

      Early attempts to obtain these cells for diagnosis were performed by blindly aspirating tissue from the four quadrants of the breast. As you can surmise, this was not very often fruitful. Since the duct is accessible to the outside world through its natural opening in the nipple, technology has enabled surgeons to place a small (0.007 in.) catheter through the natural duct opening in the anesthetized nipple (a nearly pain-free procedure). Sterile saline (saltwater) is gently washed through the duct obtaining thousands of cells for microscopic examination.

      The accuracy of this test is significantly better than the examination of fluid which simply presents at the nipple surface. Smears of this fluid from the nipple generally provide 10 to 30 cells for microscopic exam (cytology). Ductal lavage specimens routinely retrieve 800 to 1000 cells for examination. This gives a nearly 100% accuracy in identifying the cell types present.

      Women who by standard criteria are considered high risk are candidates for ductal lavage. This includes (1) women who have had a cancer in the opposite breast, (2) women with a strong family history of breast cancer, (3) women who have a high Gail Model risk, and (4) women whose genetic testing has shown them to have a deleterious mutation. When these women are shown, by NADL, to have atypical ductalhyperplasia, additional risk reduction methods can be employed to either reduce the chance of developing cancer, or increase the chance of finding it at its earliest possible (curable) stage.

      Ductal lavage can, on occasion, diagnose breast cancer cells themselves. This is usually two to three years before any changes become apparent on the mammogram. Women who are found to have cancer at this stage are usually 100% curable. Furthermore, they frequently do not need either chemotherapy or radiation therapy to achieve this excellent outcome.

      The latest studies on ductal lavage show additional information which may become useful. Surgeons have studied the types and amounts of protein in the ductal lavage fluid. Over 1500 separate proteins have been identified in ductal fluid. Studies have shown that women who have a cancer in one breast do not have significantly different ductal proteins in the opposite breast.

      However, women who have had a cancer in either breast have a significantly different protein composition from those women who do not have cancer. This may, in the very near future, provide another tool for identifying women who are likely to develop cancer within the next 6 to 18 months and enable them to employ additional therapy plans to achieve the results outlined several paragraphs above (prevention or cure!)

      Approximately 200 surgeons across the United States have been credentialed to perform nipple aspiration and ductal lavage. Since most insurance companies do not cover this procedure, it has not been as widely employed as we would like. Further research studies are needed to prove the usefulness of this information before the insurance carriers will pay for the testing.

      We have been performing ductal lavage at the Breast Cancer Surgery Center for more than five years. Most patients have found it to be painless, or about the same as having blood drawn. Several patients are now taking tamoxifen to reduce their risk of developing breast cancer as a result of the findings obtained from performing Nipple Aspiration and Ductal Lavage.

      In the next issue of Women's I, we will discuss one of the newest treatment innovations improving lives of our cancer survivors. It is a method of delivering radiation therapy to thebreast tissue in women who have a partial mastectomy. This technique, termed partial breast irradiation, causes less damage to normal structures near the breast. A further benefit is that is completed in 5 rather than 30 days! See you next issue. As always, you can contact the Breast Cancer Surgery Center at BreCanSurCen@aol.com.