Ductal Lavage Research Articles

State of the Science and the Intraductal Approach for Breast Cancer: Proceedings Summary of The Sixth International Symposium on the Intraductal Approach To Breast Cancer Santa Monica, California, 19–21 February 2009

Researchers are using the intraductal approach to advance breast cancer risk assessment, prevention, diagnosis, and treatment. Procedures and technologies that can access and interrogate the ductal-alveolar systems include nipple aspiration, ductal lavage and ductoscopy. Ductoscopic papillectomy, ductoscopic margin evaluation, and intraductal therapy are considered promising investigational and innovative treatments. These techniques are used to explore the biology of the normal breast; collect and analyze breast fluid and cells to identify biomarkers that can be used in breast cancer detection and risk assessment; and to identify new ways to find and administer therapeutic and/or preventive agents to the breast tissue. This report summarizes the latest research findings in these areas, presented at The 6th International Symposium on the Intraductal Approach to Breast Cancer in 2009.

A direct comparative study of methylation-specific PCR in ductal lavage fluid, breast cancer tissue, normal breast parenchyma and plasma in women with early breast cancer

Breast duct lavage for analysis by methylation-specific PCR is a novel but established method for detecting the presence of cancer and may contribute additional information about prognosis and response to treatment. The aim of this consecutive series of breast cancer patients was a case-control study to evaluate qualitative methylation of five published tumour suppressor genes1 in breast cancer tissue, adjacent normal breast parenchyma, duct lavage fluid and plasma.

Intraductal micro magnetic resonance imaging and spectroscopy

The majority of breast cancers originate in the mammary ducts. As such many diagnostic techniques introduce mm-diameter devices into the ducts through the nipple. Established intraductal techniques include ductal lavage, and white-light or fluorescence endoscopy. While reported values vary, these techniques typically suffer from low sensitivity and specificity. Similarly, Magnetic Resonance Imaging (MRI) for breast oncology suffers a high rate of false positives. Magnetic resonance (MR) spectroscopy is highly effective in distinguishing between benign and malignant tissue. However, clinical relevance is limited to late-stage of disease due to a required cubic-centimeter volume for diagnosis. Small-volume sensitivity for spectroscopy and imaging is possible through use of a miniature radio-frequency (RF) coil. An intraductal RF microcoil reduces the required volume of diseased tissue to a cubic-millimeter, bringing spectroscopy to early stages of early diagnosis. Micro-scale images from an intraductal microcoil may enable high-precision localization of tumors and tumor margins. The microcoil catheter was designed with an approximate diameter of 1 mm for intraductal use and for possible integration with ductoscopes. Experimental verification of the first-generation coil-design was achieved through ex vivo MR imaging of tissue. As expected, the microcoil provided microscale images. While 3-T (128 MHz) MRI typically provides 1 to 30 voxels per-cubic-mm the MRI microcoil can provide hundreds, and even thousands of voxels in the same volume. The first generation microcoil consisted of a 1-mm-diameter solenoid with 4.5 turns, spaced 0.05 mm apart, leading to 25-mm long parallel leads, with one of the leads passing through the center of the solenoid. A crucial requirement for optimal MR coil design is a homogenous magnetic field generated in the coil. Unfortunately, the central conductor inside the solenoid of the original microcoil greatly disturbed the homogeneity of the magnetic-field. The parallel-leads of the first generation device correspond to a popular catheter-coil geometry, a single-loop coil. The parallel leads therefore collect unwanted signal, in other words noise. The new design overcomes both of these flaws. Turn-spacing of the first microcoil design was intended for optimizing the signal collected from the center of the solenoid. However, since the target tissue is at the tip of the solenoid, the new design is optimized for our target tissue with ten turns separated by the thin insulation of the wire. The turn-spacing of the first generation microcoil was controlled by a thick layer of insulation that also provided a good barrier from the body. Due to the lack of a thick insulator, the second generation-design required a new configuration for isolating the coil from the body to prevent degradation of the performance over time. We analyzed the stability of the new microcoils by soaking 5 microcoils in body temperature saline and measuring the impedance at 128 MHz over time. The impedance of the microcoils remained constant for nearly 2 hours, and increased only slightly after 4 hours. Preliminary heating experiments indicate that little to no heating occurs during use of the microcoil as an MR transceiver. Initial imaging results confirm that the second generation microcoil improves greatly on the first generation coils, with significantly less imaging artifacts despite having twice the lead length. Recent success by Dr. Love with intraductal chemotherapy application intensifies the need for early diagnosis. A microcoil may provide spectroscopic evidence of cancer. Microcoil images may show if the malignancy has breached the ductal lining. The open lumen of the intraductal microcoil enables clinicians to target sub-branches of ducts with chemotherapy.

Anatomical association of fluid yielding ducts with location of the breast cancer affected segment in screen detected and symptomatic breast cancer

The concept of the intraductal approach to evaluating the breast microenvironment assumes direct access to the breast cancer containing duct. Previous studies on duct anatomy infusing a dye or contrast found fluid-yielding ducts to be associated with the cancer containing duct in approximately 50% of fluid-yielding breasts with cancer. A concordant anatomical relationship between accessible ductal sytems and the cancer-affected lobe is essential if cytology or other cell markers are to be successfully identified as indicators of cancer or of early cancerous change. The concordant relationship is less important if field change effects are considered to predictors of malignant change. The aim of this study was to determine how often duct lavage effluent drains the breast cancer affected segment.

Tolerability of breast ductal lavage in women from families at high genetic risk of breast cancer.

BackgroundDuctal lavage (DL) has been proposed as a minimally-invasive, well-tolerated tool for obtaining breast epithelial cells for cytological evaluation of breast cancer risk. We report DL tolerability in BRCA1/2 mutation-positive and -negative women from an IRB-approved research study.Methods165 BRCA1/2 mutation-positive, 26 mutation-negative and 3 mutation unknown women underwent mammography, breast MRI and DL. Psychological well-being and perceptions of pain were obtained before and after DL, and compared with pain experienced during other screening procedures.ResultsThe average anticipated and experienced discomfort rating for DL, 47 and 48 (0–100), were significantly higher (p < 0.01) than the anticipated and experienced discomfort of mammogram (38 and 34), MRI (36 and 25) or nipple aspiration (42 and 27). Women with greater pre-existing emotional distress experienced more DL-related discomfort than they anticipated. Women reporting DL-related pain as worse than expected were nearly three times more likely to refuse subsequent DL than those reporting it as the same or better than expected. Twenty-five percent of participants refused repeat DL at first annual follow-up.ConclusionDL was anticipated to be and experienced as more uncomfortable than other procedures used in breast cancer screening. Higher underlying psychological distress was associated with decreased DL tolerability.

Biomarkers for Risk Assessment and Prevention of Breast Cancer

Breast carcinogenesis is a multistep and multipath disease process which occurs in the epithelium lining of the ductal system in the vast majority of cases. Several studies have shown that the relative risk of breast cancer is increased in every step of this progression and many tumour associated antigens or biomarkers appear during each phase of carcinogenesis. However, their ability to predict for a substantial likelihood of developing breast cancer remains unclear. The acquisition of breast tissue samples, representative of an individual's cellular stability and subcellular biochemical and molecular state could lead to definition of surrogates for risk, early detection, pharmacodynamic determination and finally chemopreventive intervention. The intraductal approach includes nipple aspiration fluid (NAF), ductal lavage (DL) and mammary ductoscopy (MD). These techniques together with random periareolar fine needle aspiration (RPFNA) represent the available techniques for the sampling of breast fluid and exfoliated epithelial cells. At the moment, these procedures are not considered a screening procedure for early breast cancer detection but might provide a powerful research tool for studying breast carcinogenesis in vivo. We summarize the current knowledge regarding the vast array of molecules involved at all stages of carcinogenesis, which can be studied by intraductal approach, and the possibility to utilize them as candidate biomarkers to refine risk assessment, and their possible use in prevention strategies.

Ductal Lavage in Women from BRCA1/2 Families: Is There a Future for Ductal Lavage in Women at Increased Genetic Risk of Breast Cancer?

Ductal lavage has been used for risk stratification and biomarker development and to identify intermediate endpoints for risk-reducing intervention trials. Little is known about patient characteristics associated with obtaining nipple aspirate fluid (NAF) and adequate cell counts (> or =10 cells) in ductal lavage specimens from BRCA mutation carriers. We evaluated patient characteristics associated with obtaining NAF and adequate cell counts in ductal lavage specimens from the largest cohort of women from BRCA families yet studied (BRCA1/2 = 146, mutation-negative = 23, untested = 2). Fisher's exact test was used to evaluate categorical variables; Wilcoxon nonparametric test was used to evaluate continuous variables associated with NAF or ductal lavage cell count adequacy. Logistic regression was used to identify independent correlates of NAF and ductal lavage cell count adequacy. From 171 women, 45 (26%) women had NAF and 70 (41%) women had ductal lavage samples with > or =10 cells. Postmenopausal women with intact ovaries compared with premenopausal women [odds ratio (OR), 4.8; P = 0.03] and women without a prior breast cancer history (OR, 5.2; P = 0.04) had an increased likelihood of yielding NAF. Having breast-fed (OR, 3.4; P = 0.001), the presence of NAF before ductal lavage (OR, 3.2; P = 0.003), and being premenopausal (OR, 3.0; P = 0.003) increased the likelihood of ductal lavage cell count adequacy. In known BRCA1/2 mutation carriers, only breast-feeding (OR, 2.5; P = 0.01) and the presence of NAF (OR, 3.0; P = 0.01) were independent correlates of ductal lavage cell count adequacy. Ductal lavage is unlikely to be useful in breast cancer screening among BRCA1/2 mutation carriers because the procedure fails to yield adequate specimens sufficient for reliable cytologic diagnosis or to support translational research activities.

Ductal Lavage Is an Inefficient Method of Biomarker Measurement in High-Risk Women

Effective methods of serial epithelial sampling to measure breast-specific biomarkers will aid the rapid evaluation of new preventive interventions. We report here a proof-of-principle phase 2 study to assess the utility of ductal lavage (DL) to measure biomarkers of tamoxifen action. We enrolled women with a 5-year breast cancer risk estimate >1.6% or the unaffected breast of women with T1a or T1b breast cancer. After entry DL, participants chose tamoxifen or observation and underwent repeat DL 6 months later. Samples were processed for cytology and immunohistochemistry for estrogen receptor alpha, Ki-67, and cyclooxygenase-2. Of 182 women recruited, 115 (63%) underwent entry and repeat DL; 85 (47%) had sufficient cells for analysis from > or =1 duct at both time points; in 78 (43%), cells were sufficient from > or =1 matched ducts. Forty-six women chose observation and 39 chose tamoxifen. We observed greater reductions in the tamoxifen group than in the observation group for Ki-67 (adjusted P = 0.03) and estrogen receptor alpha (adjusted P = 0.07), but not in cyclooxygenase-2 (adjusted P = 0.4) labeling. Cytologic findings showed a trend toward improvement in the tamoxifen group compared with the observation group. Interobserver variability for cytologic diagnosis between two observers showed good agreement (kappa = 0.44). Using DL, we observed the expected changes in tamoxifen-related biomarkers; however, poor reproducibility of biomarkers in the observation group, the 53% attrition rate of subjects from recruitment to biomarker analyses, and the expense of DL are significant barriers to the use of this procedure for biomarker assessment over time.

Mammary ductoscopy: current issues and perspectives

Until recently, the mammary duct had not been directly observed in vivo. Starting with the success of Teboul et al., studies of mammary ductoscopy (MD) for nipple discharge have been performed in Japan and other East Asian countries. Ductal lavage screening trials for breast cancer started in the 2000s. Concurrently, the number of English-language articles about MD increased. Sixty-nine English-language and 74 Japanese-language papers published in the last 19 years were reviewed. Important reports and studies were analyzed. MD has undergone significant technological development, and studies of MD have taken place in many countries. As a result, endoscopic images of the mammary duct have developed, and the endoscopic diagnosis for nipple discharge has become possible. MD-guided biopsy and surgery have been studied. Findings of MD are useful for diagnosing intraductal lesions with nipple discharge. As a result, MD has reduced the number and extent of microdochectomies. MD is also helpful in guiding breast-conserving surgery. Many pioneers have tried direct biopsy or interventions under MD, but further developments are necessary for its practical use.

Abstract B65: Atypia in ductal lavage: A reproducible marker of risk?

Abstract B65 Background The majority of breast cancers originate in the ductal epithelium of the breast. Ductal lavage provides a minimally invasive tool for assessing epithelial cells and their microenvironment. Previous studies of pathological atypical hyperplasia on biopsy, and cytological aypia in nipple aspirate fluid (NAF) and random fine needle aspiration (FNA) have suggested that these cells are precancerous because of the subsequent increased risk of cancer. It has therefore been hypothesized that serial ductal lavage could be used to identify atypia and monitor the effects of chemoprevention over time. This report is part of a larger study examining the differences in hormone levels and cytology between ducts and their reproducibility. This report presents a cohort of women unselected for risk who voluntarily underwent ductal lavage of the same ducts on two occasions six months apart. Samples were analyzed for epithelial cells and macrophages. Methods A total of 107 women were recruited in this IRB-approved prospective study to undergo ductal lavage of three fluid or non-fluid-yielding ducts within a breast. Women were unselected for risk: the average Gail score was 1.67 and ten women had a history of contralateral breast cancer. The average age was 51 years. Fifty-four women were premenopausal, 4 were perimenopausal and 49 were postmenopausal. Samples were submitted in a blinded fashion to a central laboratory and were analyzed by duct for both macrophage and epithelial cell number on Papanicolaou-stained slides. If adequate epithelial cells were present (&amp;gt;10), a diagnosis of each duct (benign, mild atypia, or marked aytpia) was made by an experienced cytopathologist. Results Of the 107 women, 317 (99%) ducts were successfully cannulated without regard to nipple aspirate fluid (NAF) production. Thirty ducts in 23 women were diagnosed with mild or marked atypia on either of the two visits. Of these ducts, 16 were diagnosed at the initial visit and 13 at the second visit. Only one duct was diagnosed with mild atypia on both visits, in a woman with a Gail score of 1.4. Cellular atypia in ductal lavage was not reproducible at a six month interval (p=0.45). This absence of reproducibility was seen in women at all risk levels. Macrophage and epithelial cell numbers also showed a lack of reproducibility at the six month interval (p=0.31 and p=0.22, respectively). Conclusion Atypia on cytology in ductal lavage in women unselected for risk was not reproducible at a six month interval, suggesting that a single diagnosis of atypia on lavage should not be used as a marker for the identification of women at risk. Further studies are necessary to indicate whether persistent atypia over an extended interval could represent an elevated risk for breast cancer. In addition, ongoing studies are being performed to identify better cellular markers of premalignancy and subsequent risk. Citation Information: Cancer Prev Res 2008;1(7 Suppl):B65.

Intraductal approach to the detection of intraductal lesions of the breast

Bloody nipple discharge is a clue in the detection of ductal carcinoma of the breast that do not display a mass. Since sensitivity of discharge cytology is not sufficiently high and mammary ductendoscopy (MS) contributes to the diagnosis of intraductal lesions. We set out to determine whether the intraductal approach is effective for detection of ductal carcinoma. We performed 445 MS procedure in 323 patients who had nipple discharge but no overt mass. The diagnostic accuracy rates of discharge cytology and intraductal breast biopsy (IDBB) were studied in detecting malignancy. The therapeutic value of IDBB for intraductal papillomas was studied in 73 patients. Out of 323 patients, 80 had breast cancer and 155 had intraductal papilloma. MS detected intraductal tumors in 47 cases (58.8%). IDBB was performed in 35 of these 47 cases. The sensitivity was 37.1% by touch cytology, 68.6% by IDBB, and 82.8% by directed ductal lavage cytology. Of the 73 intraductal papilloma patients who were followed for more than 3 years, the therapeutic effectiveness of IDBB was recognized in 57 (78.1%). Directed ductal lavage cytology was the most sensitive method in detecting malignancy. MS and IDBB were benefit in the treatment of intraductal papilloma.

The feasibility of nipple aspiration and ductal lavage as a screening tool in healthy women with increased breast cancer risk

The feasibility of nipple aspiration and ductal lavage as a screening tool in healthy women with increased breast cancer risk

The Role and Limitations of Mammary Ductoscope in Management of Pathologic Nipple Discharge

Mammary ductoscope allows visualization of the breast ductal wall and sampling of the abnormal area for diagnostic purposes. We are reporting our center experience in application of mammary ductoscope in detecting the underlying etiology of pathologic nipple discharge. Between November 2005 and December 2006 a total of 54 women, with spontaneous persistent nonlactational unilateral uniductal nipple discharge of no palpable lesions and negative breast sono-mammography, were included in the study for morphologic assessment of ductal epithelium, ductal lavage and ductoscopically guided procedures as punch biopsy and ductoscopically guided microdochectomy. Forty-one patients (76%) with nipple discharge were positive ductoscopically. Thirteen patients (24%) appeared normal. Ductoscopic lavage has a much more cellular yield than ordinary squeezing cytology. Ductal thickening by the ductoscope (11 cases) revealed to be hyperplasia on pathology (five cases), papilloma (two cases), atypical ductal hyperplasia (two cases), ductal carcinoma in situ (one case), and invasive breast carcinoma (one case). There was a significant association between intraductal visual observations and histopathologic diagnosis. Mammary Ductoscope is a promising tool in management of pathologic nipple discharge. Biopsy and ablation techniques can be performed during ductoscopy with correlation between visual findings and histopathology, but there are still some limitations of in clinical practice.

Technical Enhancements to Breast Ductal Lavage

Ductal lavage is a technique that samples the contents of breast ducts for research into the biology of breast cancer. Enthusiasm for this method has declined because of technical challenges associated with the procedure. These include: difficulty in duct cannulation, high levels of subject discomfort, and an inability to confirm perforation. As part of a larger institutional review board (IRB)-approved study, consenting healthy women underwent ductal lavage of 3-4 ducts in one breast. Intranipple lidocaine was administered before duct cannulation. Ductoscopy was performed prior to catheterization and high-definition ultrasound was used for imaging during the lavage procedure. Pain scores were recorded at 24 hours and 2 weeks. Subjects were asked to return in 6 months for a repeat of the procedure. Ductoscopy was performed prior to lavage under real-time ultrasound 308 times in 107 subjects. There were 280 confirmed ducts (90.9%) and 21 perforations (6.8%), while seven (2.3%) were indeterminate. Subjects reported minimal discomfort, and 91% reported a 0 (0-10 range) pain score 2 weeks after the procedure. The retention rate was 90% at 6 months. The injection of lidocaine directly into the nipple greatly increases the feasibility of duct cannulation and improves subject comfort. Confirmation of duct cannulation and lavage can be documented with ductoscopy and ultrasound imaging. These procedures can be added to ductal lavage to facilitate its use as a research tool.

Analysis of the presence of cutaneous and mucosal papillomavirus types in ductal lavage fluid, milk and colostrum to evaluate its role in breast carcinogenesis

Several independent studies have presented evidence for the involvement of human papillomaviruses (HPV) in the aetiology of human breast cancer, while others have reported the opposite findings. Here, we have analysed by a high sensitive multiplex PCR-based method the prevalence of alpha mucosal and beta cutaneous HPV DNA in 90 ductal lavages, colostrum and milk. Ten of the 70 DLs analyzed (14%) contained a single or multiple beta HPV types, while DNA from mucosal high-risk HPV types was detected in only one sample (1/70). A strong reduction of HPV positivity in DL fluids was observed in 45 specimens collected after removal of the superficial layers of the nipple epidermis. All DLs were negative for the mucosal low-risk HPV types 6 and 11. Finally, HPV positivity was low in colostrum and milk. Our data show that DNA of alpha mucosa and beta cutaneous HPV types are rarely present in the breast fluids and suggest that a direct role of HPV in breast carcinogenesis is unlikely.

Ductal lavage: a new perspective for the early diagnosis of breast cancer

Within the last ten years, the development of innovative minimally invasive breast biopsy technologies has made a significant impact on the diagnostic evaluation of impalpable breast lesions. The Mammotome minimally invasive biopsy system is a diagnostic tool used under stereotactic or ultrasound guidance. The minimally invasive biopsies for 143 impalpable breast lesions in 86 patients were performed using the B-ultrasound-guided 8-gauge vacuum-assisted Mammotome system at Jinan Military General Hospital. One hundred and forty-three breast lesions in 86 patients were excised completely using this method. The average biopsy procedure time was 17 min (range, 3–45 min). Clinically, suspicious lesions were satisfactorily confirmed by this system. One hundred and twenty-one lesions were diagnosed as fibroadenoma, nineteen lesions as breast adenosis, one lesion as invasive breast cancer, and two lesions as ductal carcinoma in situ. Skin ecchymosis was found in two patients. One hundred and thirty-two impalpable lesions were completely excised, as demonstrated by the follow-up ultrasound examination. The results suggest that the B-ultrasound-guided Mammotome system may be an efficient tool for the diagnosis and treatment of impalpable breast lesions.

Pancreatic Duct Lavage Cytology for the Diagnosis of Branch Duct-Type Intraductal Papillary Mucinous Neoplasm of the Pancreas

Sai, Jin Kan MD; Suyama, Masafumi MD; Kubokawa, Yoshihiro MD; Watanabe, Sumio MD Author Information

Reproducibility of ductal lavage cytology and cellularity over a six month interval in high risk women

Ductal lavage (DL) allows repeat sampling of breast epithelium for serial observation in a chemoprevention setting; however, the reproducibility of duct cannulation, cell yield and cytology has not been addressed. We conducted a Phase 2 trial, wherein high risk women chose tamoxifen treatment or observation following an entry DL procedure. We present data from the non-intervention arm of our study to assess the reproducibility of cannulation, cell yield, and cytologic diagnosis from DL of the same duct at two time-points. Inter-observer variability was assessed by a blinded review of Papanicoloau-stained slides by two cytopathologists. Sixty-five women had a successful lavage of 187 ducts at baseline and chose observation; 63/65 (97%) had a successful lavage 6 months later. Successful recannulation of the same duct was accomplished in 63 women (97%) and162 ducts (87%). Total epithelial cell yields >or=100 were obtained from 57/65 women (88%) and 129/187 ducts (69%) at baseline, and 46/63 women (73%) and 80/162 ducts (49%) at both time-points. Cytologic diagnosis was reproducible in 27/63 (43%) women and 77/162 (48%) ducts. Inter-observer variability for cytologic diagnosis between two observers showed good agreement (kappa = 0.62). Recannulation and lavage of the same duct after a 6 month interval can be achieved with high frequency; however, reproducibility of cell yield and cytologic findings from the same duct is sub-optimal, leading to significant attrition of evaluable subjects. The utility of DL for the serial monitoring of breast epithelium is therefore limited.

Development of a high sensitivity, nested Q-PCR assay for mouse and human aromatase

Measurement of breast tissue estradiol levels could provide a powerful method to predict the risk of developing breast cancer but obtaining sufficient amounts of tissue from women is difficult from a practical standpoint. Assessment of aromatase in ductal lavage fluid or fine needle aspirates from breast might provide a surrogate marker for tissue estrogen levels but highly sensitive methods would be required. These considerations prompted us to develop an ultra-sensitive, "nested" PCR assay for aromatase which is up to one million fold more sensitive than standard PCR methods. We initially validated this assay using multiple tissues from the aromatase transgenic mouse and found that coefficients of variation for measurement of replicate samples averaged less than 5%. We demonstrated a 60-fold enhancement in aromatase message in the transgenic versus the wild type mouse breast but surprisingly, levels in the transgenic animals were highly variable, ranging from 0.4 to 27 relative units. The variability of aromatase expression in the transgenic breast did not correlate with the degree of breast development and did not appear to relate to hormonal manipulation of the MMTV promoter but probably related to lack of exhaustive inbreeding and mixed zygocity of transgenic animals. Extensive validation in mouse tissues provided confidence regarding the assay in human tissues, since nearly identical methods were used. The human assay was sufficiently sensitive to detect aromatase in a single human JAR (choriocarcinoma) cell, in all breast biopsies measured, and in 7/23 ductal lavage fluids.

Breast Ductal Secretions: Clinical Features, Potential Uses, and Possible Applications

Nipple discharge accounts for approximately 5% of visits to a breast specialist surgical practice and may be encountered as the chief complaint by many other types of physicians. The vast majority of breast cancers originate in the ductal system, which prompted interest in the evaluation of the intraductal approach to breast cancer. Ductoscopy, nipple aspiration, and ductal lavage have emerged as innovative fields of study that may have clinical applications. We performed a literature search of published manuscripts using the keywords nipple discharge, breast ductal secretions, and intraductal approach. We also report our single-institution experience in managing nipple discharge. We present our institutional algorithm for the management of nipple discharge. The possible etiologies of nipple discharge and the appropriate workup are reviewed. Three evolving minimally invasive techniques for the evaluation of high-risk patients include ductoscopy, nipple aspiration, and ductal lavage. Nipple aspiration and ductal lavage fluid may be assayed for cytology, genomic, gene expression, and proteomic studies. Several different translational approaches are being undertaken to investigate the local microenvironment associated with the development and progression of breast carcinoma. Nipple aspiration fluid and ductal lavage offer the opportunity to study the local microenvironment of the ductal system, which is where most breast cancers originate. These powerful approaches to biomarker analysis could be applied to the prevention and treatment of breast cancer.