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Diagnostic and therapeutic approaches to nipple discharge
Abstracts / Journal of Cellular Immunotherapy 3 (2017) 2e30
DIAGNOSTIC AND THERAPEUTIC APPROACHES TO NIPPLE DISCHARGE Ehsan Shahverdi a, b, *. a Blood Transfusion Research Center, High Institute for Research and Education in Transfusion Medicine, Tehran, Iran; b Student Research Committee, Baqiyatallah University of Medical Sciences, Tehran, Iran * Blood Transfusion Research Center, High Institute for Research and Education in Transfusion Medicine, Tehran, Iran. E-mail address: [email protected]
Extended Abstract The third most common symptom in the breast after pain and palpable mass is nipple discharge. At least 50% of women experience nipple discharge at reproductive age and by increasing awareness of breast cancer, women are increasingly visiting physicians with breast pain symptoms. Many studies are conducting around the world through various methods to diagnose the underlying causes of this disease with proper management of patients. It should be noted that pathological nipple discharge is usually referred to spontaneous unilateral secretion discharged only from one mammary duct. Although the discharge color does not provide specific information about the underlying pathology and serosanguineous, Hemoccult positive or clear and watery discharge are more associated with breast cancer. Nipple discharge in ductal ecstasies is usually multi-channel, bilateral, and colorful, although there are some reports about serosanguineous discharge in this disease. Nipple discharge has rarely been reported in infants and interestingly, nipple discharge can rarely occur in men for breast cancer but as women, the cause of this problem in men is more associated with benign breast disease. Ductoscopy is recently introduced as a method for evaluating and determining the potential sources of abnormal nipple discharge. The primary role of ductoscopy in the diagnosis and treatment of
5
patients with abnormal nipple discharge has been defined. Since the breast ductal epithelium is the primary origin of most breast malignancy, ductoscopy may be used in the future as a screening method for breast cancer. Small brushes to ductoscopes also increase their sensitivity in harvesting cells from mammary ducts epithelium. The sensitivity of obtaining epithelial cells is 87.5% in comparison with 18% of older ducts in irrigation methods. The specificity of cytological examination of cells obtained through ductoscopy for breast cancer diagnosis is very high while the sensitivity is not; Ductoscopy is not only a suitable method for the diagnosis of patients with pathological discharge from the nipple, but it can also help to determine the involved ducts more accurately before their excision. Direct observation and biopsy of breast duct epithelium with duct scope allow early detection of breast cancer at an early stage. Finally, ductoscopy can be used as a guide in determining the exact location of the lesion and the extent of breast cancers and allows breast conservative surgery with negative margins but, the diagnosis must be confirmed by biopsy and pathology. It is noteworthy that cytology has no certainty regarding detection of non-malignant causes of nipple discharge. Many researchers believe that judgment merely by cytology is insufficient to start the treatment, and cytological diagnosis should be consolidated with histological findings. Also, of immunohistochemistry, DNA analysis or electron microscopy may also increase the level of sensitivity of cytology to an acceptable level. Ductography or galactography is an invasive imaging procedure to determine the cause of pathological nipple discharge, Ductography is known as the gold standard method for evaluation of patients with pathological nipple discharge. One of the main advantages of galactography is the localization of abnormalities in mammary ducts, and performing it after surgery helps determine the extent of surgery and avoid extensive excision of the ducts. Ultrasound is a non-invasive, inexpensive and available method which can be used as a diagnostic tool in patients with abnormal nipple discharge and
Fig. 1. Various diagnostic methods. A: Diagnostic galactography image , B: Endoductal mass with a small central vascular pedicle on color Doppler mode representing a small papilloma , C: MR image of a 35-year-old woman with nipple discharge , D: Mammography of woman with several-week history of spontaneous bloody discharge from right nipple.
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Abstracts / Journal of Cellular Immunotherapy 3 (2017) 2e30
can be used as a complementary method beside galactography Ultrasound can also be used sometimes to guide ductal excision. The role of CT scan as a diagnostic tool is not well defined in the evaluation of abnormal nipple discharge perhaps, the proof of this requires more detailed research. MRI can image mammary intraductal lesions, but it cannot distinguish malignant lesions from benign ones. However, MRI is a non-invasive method and may replace galactography in certain circumstances where it is required. The recently published study, the highest diagnostic sensitivity belonged to ultrasound followed by MRI, galactography, ductoscopy and fine needle biopsy [FNA]; but regarding specificity, FNA and galactography had the highest level followed by mammography, ductoscopy, ultrasound and MRI. According to the obtained heterogeneous and contradictory results about various diagnostic methods and despite the many advances emerged in imaging. Still, no method with sufficient certainty has been introduced as the preferred and choice method for evaluation of patients with breast discharge. Treatment methods of nipple discharge include two different aspects: first, to rule out malignancy as an uncommon cause of discharge and second, to ignore patients with annoying and persistent nipple discharge. Many scientific resources still believe that the treatment of this disease is to remove mammary ducts through major ductal excision surgically, because due to insufficient sample size removed, the possibility of remaining occult malignancies diminishes. Since the general tendency is towards more non-invasive procedures, nicroductectomy or microductectomy is greatly emphasized today. As a result, open and extensive surgeries for excision of more mammary ducts performed unnecessarily are avoided. Moreover, diagnostic and therapeutic methods have already been
introduced in this regard, but unfortunately, none has an adequate and effective certainty. However, it should be noted that when nipple discharge has not pathological characteristics and is not associated with risk factors, because of low possibility of underlying malignancies, conservative treatment can be selected instead of invasive procedures. Keywords: Nipple discharge, Diagnostic, Therapeutic CENTRAL NERVOUS SYSTEM TOXOPLASMOSIS IN RELAPSED HODGKIN'S LYMPHOMA: A CASE REPORT Ehsan Shahverdi a, b, *. a Blood Transfusion Research Center, High Institute for Research and Education in Transfusion Medicine, Tehran, Iran; b Student Research Committee, Baqiyatallah University of Medical Sciences, Tehran, Iran * Blood Transfusion Research Center, High Institute for Research and Education in Transfusion Medicine, Tehran, Iran. E-mail address: [email protected]
Extended Abstract Patients with Hodgkin's disease seem to be individually threatened because of immunodeficiency associated with the underlying disease and the treatment modalities or both. The difficulty in clinical diagnosis of cerebral toxoplasmosis is related to the lack of pathognomonic clinical or radiological features. CNS toxoplasmosis should be considered in the differential diagnosis of immunosuppressed patients who present with neurological manifestations. A 17- year -old male patient with Hodgkin's lymphoma was admitted to our hospital with anorexia, diplopia, lethargy, and right leg claudication.
Fig. 1. In MRI of the brain: Axial T1W images showed patchy hyperintensity in basal ganglia and cerebral peduncles due to hemorrhage, and axial T2W and FLAIR images showed high signal intensity lesions in the basal ganglia and right cerebral peduncle, and gadolinium enhanced MRI study showed ring- like and nodular enhancing lesions in the basal ganglia and right cerebral peduncle.
DIAGNOSTIC AND THERAPEUTIC APPROACHES TO NIPPLE DISCHARGE Ehsan Shahverdi a, b, *. a Blood Transfusion Research Center, High Institute for Research and Education in Transfusion Medicine, Tehran, Iran; b Student Research Committee, Baqiyatallah University of Medical Sciences, Tehran, Iran * Blood Transfusion Research Center, High Institute for Research and Education in Transfusion Medicine, Tehran, Iran. E-mail address: [email protected]
Extended Abstract The third most common symptom in the breast after pain and palpable mass is nipple discharge. At least 50% of women experience nipple discharge at reproductive age and by increasing awareness of breast cancer, women are increasingly visiting physicians with breast pain symptoms. Many studies are conducting around the world through various methods to diagnose the underlying causes of this disease with proper management of patients. It should be noted that pathological nipple discharge is usually referred to spontaneous unilateral secretion discharged only from one mammary duct. Although the discharge color does not provide specific information about the underlying pathology and serosanguineous, Hemoccult positive or clear and watery discharge are more associated with breast cancer. Nipple discharge in ductal ecstasies is usually multi-channel, bilateral, and colorful, although there are some reports about serosanguineous discharge in this disease. Nipple discharge has rarely been reported in infants and interestingly, nipple discharge can rarely occur in men for breast cancer but as women, the cause of this problem in men is more associated with benign breast disease. Ductoscopy is recently introduced as a method for evaluating and determining the potential sources of abnormal nipple discharge. The primary role of ductoscopy in the diagnosis and treatment of
5
patients with abnormal nipple discharge has been defined. Since the breast ductal epithelium is the primary origin of most breast malignancy, ductoscopy may be used in the future as a screening method for breast cancer. Small brushes to ductoscopes also increase their sensitivity in harvesting cells from mammary ducts epithelium. The sensitivity of obtaining epithelial cells is 87.5% in comparison with 18% of older ducts in irrigation methods. The specificity of cytological examination of cells obtained through ductoscopy for breast cancer diagnosis is very high while the sensitivity is not; Ductoscopy is not only a suitable method for the diagnosis of patients with pathological discharge from the nipple, but it can also help to determine the involved ducts more accurately before their excision. Direct observation and biopsy of breast duct epithelium with duct scope allow early detection of breast cancer at an early stage. Finally, ductoscopy can be used as a guide in determining the exact location of the lesion and the extent of breast cancers and allows breast conservative surgery with negative margins but, the diagnosis must be confirmed by biopsy and pathology. It is noteworthy that cytology has no certainty regarding detection of non-malignant causes of nipple discharge. Many researchers believe that judgment merely by cytology is insufficient to start the treatment, and cytological diagnosis should be consolidated with histological findings. Also, of immunohistochemistry, DNA analysis or electron microscopy may also increase the level of sensitivity of cytology to an acceptable level. Ductography or galactography is an invasive imaging procedure to determine the cause of pathological nipple discharge, Ductography is known as the gold standard method for evaluation of patients with pathological nipple discharge. One of the main advantages of galactography is the localization of abnormalities in mammary ducts, and performing it after surgery helps determine the extent of surgery and avoid extensive excision of the ducts. Ultrasound is a non-invasive, inexpensive and available method which can be used as a diagnostic tool in patients with abnormal nipple discharge and
Fig. 1. Various diagnostic methods. A: Diagnostic galactography image , B: Endoductal mass with a small central vascular pedicle on color Doppler mode representing a small papilloma , C: MR image of a 35-year-old woman with nipple discharge , D: Mammography of woman with several-week history of spontaneous bloody discharge from right nipple.
6
Abstracts / Journal of Cellular Immunotherapy 3 (2017) 2e30
can be used as a complementary method beside galactography Ultrasound can also be used sometimes to guide ductal excision. The role of CT scan as a diagnostic tool is not well defined in the evaluation of abnormal nipple discharge perhaps, the proof of this requires more detailed research. MRI can image mammary intraductal lesions, but it cannot distinguish malignant lesions from benign ones. However, MRI is a non-invasive method and may replace galactography in certain circumstances where it is required. The recently published study, the highest diagnostic sensitivity belonged to ultrasound followed by MRI, galactography, ductoscopy and fine needle biopsy [FNA]; but regarding specificity, FNA and galactography had the highest level followed by mammography, ductoscopy, ultrasound and MRI. According to the obtained heterogeneous and contradictory results about various diagnostic methods and despite the many advances emerged in imaging. Still, no method with sufficient certainty has been introduced as the preferred and choice method for evaluation of patients with breast discharge. Treatment methods of nipple discharge include two different aspects: first, to rule out malignancy as an uncommon cause of discharge and second, to ignore patients with annoying and persistent nipple discharge. Many scientific resources still believe that the treatment of this disease is to remove mammary ducts through major ductal excision surgically, because due to insufficient sample size removed, the possibility of remaining occult malignancies diminishes. Since the general tendency is towards more non-invasive procedures, nicroductectomy or microductectomy is greatly emphasized today. As a result, open and extensive surgeries for excision of more mammary ducts performed unnecessarily are avoided. Moreover, diagnostic and therapeutic methods have already been
introduced in this regard, but unfortunately, none has an adequate and effective certainty. However, it should be noted that when nipple discharge has not pathological characteristics and is not associated with risk factors, because of low possibility of underlying malignancies, conservative treatment can be selected instead of invasive procedures. Keywords: Nipple discharge, Diagnostic, Therapeutic CENTRAL NERVOUS SYSTEM TOXOPLASMOSIS IN RELAPSED HODGKIN'S LYMPHOMA: A CASE REPORT Ehsan Shahverdi a, b, *. a Blood Transfusion Research Center, High Institute for Research and Education in Transfusion Medicine, Tehran, Iran; b Student Research Committee, Baqiyatallah University of Medical Sciences, Tehran, Iran * Blood Transfusion Research Center, High Institute for Research and Education in Transfusion Medicine, Tehran, Iran. E-mail address: [email protected]
Extended Abstract Patients with Hodgkin's disease seem to be individually threatened because of immunodeficiency associated with the underlying disease and the treatment modalities or both. The difficulty in clinical diagnosis of cerebral toxoplasmosis is related to the lack of pathognomonic clinical or radiological features. CNS toxoplasmosis should be considered in the differential diagnosis of immunosuppressed patients who present with neurological manifestations. A 17- year -old male patient with Hodgkin's lymphoma was admitted to our hospital with anorexia, diplopia, lethargy, and right leg claudication.
Fig. 1. In MRI of the brain: Axial T1W images showed patchy hyperintensity in basal ganglia and cerebral peduncles due to hemorrhage, and axial T2W and FLAIR images showed high signal intensity lesions in the basal ganglia and right cerebral peduncle, and gadolinium enhanced MRI study showed ring- like and nodular enhancing lesions in the basal ganglia and right cerebral peduncle.