Superficial lymphatic drainage of the vulva and its relation to the regional nodes: an experimental study.

BACKGROUND: Sentinel node biopsy in vulvar cancer is associated with much less morbidity than inguinofemoral node dissection. Our study focused on describing the morphology of superficial lymphatic drainage of the vulva and its relationship to regional nodes, which may facilitate orientation during surgery. MATERIALS AND METHODS: In 24 female cadavers, injections of patent blue (at various localisations medially, unilaterally and bilaterally) were used to visualise the lymphatic drainage of the vulva. After dissection of lymphatic vessels and nodes, their course was documented by photograph and then analysed. Subsequently, a map of vulvar superficial lymphatics was created. RESULTS: The cutaneous and subcutaneous tissue of the vulva primarily drained to superficial inguinal nodes. There was no evidence of a solitary lymph node that drained the unilateral vulva. Each area of the vulva drained to its own lymph node, which was variably localised in the subcutaneous groin around the great saphenous vein. Anastomoses between individual inguinal superficial lymph nodes are likely. Right-left symmetry in the course of lymphatic collectors was not detected. Natural drainage of the medial and paramedial areas to contralateral inguinal nodes was also not detected. The drainage pattern to ipsilateral inguinal nodes was consistent in cadavers without evidence of vulvar disease and may be applicable in the early stages of vulvar cancer. CONCLUSIONS: There was no evidence of a solitary node that drained the unilateral vulva. Each part of the vulva may drain to a corresponding lymph node in a different localisation of the groin. The surgeon should take this variability into account.

[Satisfaction and overall quality of life in BRCA positive women after prophylactic surgeries]. / Spokojenost a celková kvalita zivota BRCA pozitivních zen po profylaktických výkonech.

INTRODUCTION: Genetic mutations are responsible for 5-10% of all breast and ovarian carcinomas, while most of them are caused by a mutation of the BRCA gene. Women with this type of mutation have a lifetime risk of breast and ovarian cancer and therefore, they require very intensive medical care, including surgical prevention. Specifically, prophylactic bilateral mastectomy and prophylactic salpingo-oophorectomy are done, which undoubtedly decrease the riskof cancer. The aim of this review article is to inform healthcare professionals and the general public about the satisfaction of BRCA positive women with their decision to undergo these prophylactic surgeries, and also about the impact of these procedures on sexuality, menopausal symptoms, mental health and the overall quality of life. METHODS: Search of original studies and review articles onthe influence of prophylactic surgeries on the life of women with BRCA genemutation. RESULTS: In general, although some changes are observed after the prophylactic surgeries, the overall quality of life does not change. A significant reduction in anxiety and fear of cancer is observed after both prophylactic bilateral mastectomy andprophylactic bilateral salpingo-oophorectomy, providing great psychological relief to the affected women. However, prophylactic bilateral salpingo-oophorectomy causes premature menopause in premenopausal women at the time of surgery and the associated occurrence of menopausal symptoms. Some of the symptoms can be significantly reduced by hormone replacement therapy but will not be eliminated altogether. In postmenopausal women, no or minimal worsening of menopausal symptoms was reported. After prophylactic bilateral mastectomy, particularly appearance-related problems were observed. In both types of surgery, sexual problems were also observed. CONCLUSION: The relief of reducingthe risk of cancerappears to be so great and so important for women that it outweighs the other negative effects of these prophylactic procedures.Key words: BRCA1/2 mutation - breast cancer - ovarian cancer - prophylactic bilateral salpingo-oophorectomy - prophylactic bilateral mastectomy.

[Breast self-examination. Yes or no?] / Samovysetrení prsu. Ano, ci ne?

OBJECTIVE: The rising number of breast cancer is the worldwide problem. The screening mammography is considered as the most effective method to decrease the mortality of the disease. For many years, the breast self-examination has been promoted as the simplest method for breast cancer development in women. In this review article, we provide the results of studies on the effectiveness of breast self-examination. DESIGN: Review article. SETTING: Departmnet of Gynecologic and Obstetrition, General Faculty Hospital and 1st Faculty of Medicine, Charles University Prague. METHODOLOGY: Searching of the original studies and review articles related to brest self-examination. RESULTS: The breast self-examination does not reduce the breast cancer mortality and is not effective to diagnose cancer at an earlier stage of disease. Also, the frequency of the breast self-examination is not related to the stage of the disease in time of diagnosis. The method leads to the higher attendance of women in mammology consulting rooms, to the higher number of diagnostic mammographies and even to the significantly higher number of performed biopsies with negative (benign) results. CONCLUSION: The breast self-examination does not reduce mortality from the breast cancer among the educated women with population risk of developing the disease, despite the practical application of this method on a regular basis. Contrariwise, the breast self-examination rises amount of performed mamography and ultrasound examinations and the number of biopsies with a negative (benign) result.

Predictive factors for the presence of tumor cells in bone marrow and peripheral blood in breast cancer patients.

UNLABELLED: Simultaneous detection of disseminated tumor cells (DTCs) and circulating tumor cells (CTCs) was shown to be associated with an especially poor prognosis and increased incidence of disease-related deaths in non-metastatic breast cancer patients. We analyzed the occurance of DTCs and CTCs in patients with primary breast cancer and evaluated the correlation of their presence with other prognostic markers and investigated the changes in DTCs/CTCs number at different time points during treatment.Blood of 50 patients with primary breast cancer were used for immunomagnetic separation and detection of circulating tumor cells using the commercial available system the AdnaTest Breast Cancer™ (AdnaGen GmbH, Langenhagen, Germany). Bone marrow aspirates from 50 patients were analyzed for DTCs by immunocytochemistry using the pan-cytokeratin antibody conjugated with FITC (Monoclonal Anti-Cytokeratin antibody F3418, Sigma Aldrich).DTCs were identified in 30% (15/50) and CTCs in 22% (11/50) of patients. We found that DTC positivity could point to a significantly high risk of larger primary tumor size (p-value 0.011) and significantly higher risk of lymph node involvement (p-value 0.002). For CTC positivity, no such relationship was proven. DTCs have shown significantly higher prevalence in ER/PR-negative females and in HER2-positive cases. CTCs were equally prevalent in patients with the presence and absence of standard prognostic and predictive markers such as ER, PR and HER2. We found no correlation between CTCs and DTCs findings (r = -0.097, p = 0.504). We used DTCs/CTCs analysis for therapy monitoring in a small group of 29 patients, who underwent neoadjuvant chemotherapy (NACT). We find out no significant correlation between DTCs/CTCs detection and the primary tumor response to NACT. A pathologic complete response (pCR) was achieved by 31% (9/29) of the patients in our study, however, no association was observed between pCR and the detection of DTCs after NACT.These results support the use of DTCs/CTCs analysis in early breast cancer to generate clinically useful prognostic information. The study of these cells apart from the impact on refining prognosis, has the exciting potential of individualising treatment for women with breast cancer. KEYWORDS: breast cancer, disseminated tumor cells, circulating tumor cells, bone marrow aspiration, prognostic/predictive markers, therapy monitoring.

Unusual clinical tumor development in axilla.

This work describes clinical development of a sarcoma in the left axilla of a 36-year-old woman. The macroscopic picture changed from the initial inflammatory reddening to globular resistance of 2.5 cm, suggestive of an enlarged lymph node. Mammography did not reveal any associated breast disease. Colliquation found on the ultrasound images led to a biopsy, the result of which indicated only an inflammation, without any malignancy. Rapid growth of the axillar tumor to 10 cm in size within 8 weeks prompted surgery allowing proper diagnosis of a small mature-to-immature sarcoma. Special examinations performed by a histopathologist (at the Institute for Histopathology) could not establish the precise histogenesis, i.e. the tissue origin. Therefore it was necessary to remove any clinically obscuring tumor for the final proper histological diagnosis and adequate treatment of the patient.

Ultrasound guided cryoablation of fibroadenomas.

PURPOSE: Fibroadenoma (FA) of the breast is the most common disorders in young women. The aim of the study was to evaluate cryoablation (CA) under ultrasound guidance in the office setting for patients with FA. MATERIALS AND METHODS: For this prospective multicenter trial an office-based cryosurgical system was used to treat histological confirmed benign FA with a maximum dimension of 3 cm. 23 CA procedures were performed under ultrasound guidance. The cryoprobe was inserted into the center of the FA guided by real-time ultrasound. A freeze-thaw-freeze treatment cycle was performed according to the size of the FA. During the CA procedure continuous ultrasound monitoring of the ice ball was performed, verifying engulfment of the FA. Patients attended 4 follow-up visits at 1 week, 3 months, 6 months and 1 year and underwent ultrasound and physical examinations. RESULTS: Data was collected from 23 procedures. The ice ball engulfed the treated FA in 91.3 %. A sharp reduction in volume was observed at 6-month follow-up and continued more moderately up to 1 year. No serious but four minor adverse events occurred. At 1 year follow-up, lumps that were assessed pre-treatment as hard were assessed as soft or not palpable. 7 patients complained of pain caused by the lump prior to cryotherapy, while 5 of these patients felt transient pain during the follow up period. It is reasonable to assume that the pain was not related to the CA procedure as it was not consistent. In 96 % of the cases patients and physicians rated the cosmetic results of the procedure as excellent or good. CONCLUSION: The cryodestruction proved functional and safe, while showing reduction in palpability and pain caused by the FA in the treated patients.

[Lymphatic mapping in axilla as possible prevention of lymphedema in breast cancer patients - first results of the anatomical study]. / Mapování lymfatik v axile jako moznost prevence lymfedému u pacientek s karcinomem prsu - první výsledky anatomické studie.

OBJECTIVE: Lymphatic mapping is a method to find and preserve upper extremity lymphatics during axillary surgery (axilla clearance and sentinel node biopsy) in breast cancer patients. This may reduce the incidence of lymphedema. We examined on anatomical model, if the lymphatic drainage of the upper extremity is fully separable from the lymphatic drainage of the breast. We further endeavored to find an explanation as to why lymphedema occurs in the upper extremity after sentinel node biopsy in breast carcinoma. DESIGN: Pilot study. SETTING: Oncogynecologic Center, Department of Obstetrics and Gynecology, First Faculty of Medicine, Charles University in Prague and General University Hospital, Prague. METHODS: Patent blue dye was injected deep and superficially in arm and breast bilaterally in 9 cadavers. After visualization and precise dissection of the lymphatic vessels and nodes, a record of their routes was made. A scheme of arm and breast lymphatics was constructed. RESULTS: The lymph from arm is drained by 2-4 main afferent collectors. As opposed to cranial and medial collectors, caudal collectors diverged from the axillary vein and entered the caudal axilla. In one case the caudal collector entered a node, which was considered to be the sentinel node of the breast. The other important finding is the demonstration of lymphatic anastomoses that take place between imaged nodes in the caudal axilla, which is the most frequent localization of the breast sentinel lymph node. CONCLUSION: The relationship of lymphatic drainage of the arm and breast are closely related and share connections. These connections represent the main problem, which could explain lymphedema following surgery if damaged. Further studies are necessary to improve understanding of this method and to increase the number of observations.

Analysis of direct oil contrast lymphography of upper limb lymphatics traversing the axilla -- a lesson from the past -- contribution to the concept of axillary reverse mapping.

INTRODUCTION: Axillary reverse mapping (ARM) is a method to preserve upper extremity (UE) lymphatics during axillary surgery in breast cancer patients. This may reduce the incidence of lymphedema. Very precise method to demonstrate lymphatic drainage is direct X-ray lymphography. MATERIALS AND METHODS: The evaluation of direct lymphography X-ray images of the axilla and proximal part of the upper extremity was performed in 9 subjects. As contrast was used Lipiodoil injected on the dorsal side of hand. RESULTS: The lymph from UE is drained by 2-4 main afferent collectors, which in 5 of 9 cases entered into one node in the lateral axilla (ARM node). This node was considered to be the sentinel lymph node for the UE. In 4 cases a cranial collector was shown, which led directly to nodes in the upper part of the axilla. This collector had numerous anastomoses with other collectors before entering the axillary nodes. The most important finding is the demonstration of numerous lymphatic anastomoses that take place between all imaged nodes in the axilla including the caudal nodes, which is the most frequent localization of the breast sentinel lymph node. CONCLUSION: The relationship of lymphatic drainage of the UE and breast are closely related and share numerous connections. These connections represent the main problem of the ARM concept because they may pose potencional route for metastatic cancer cells in sentinel node positive breast cancer patients. Further studies are necessary to improve understanding of this method. Axillary reverse mapping - breast cancer - lymphedema - sentinel node biopsy.

[Axillary reverse mapping--chance to prevent lymphedema in breast cancer patients]. / Reverzní mapování lymfatik v axile jako moznost prevence lymfedému u pacientek s karcinomem prsu.

OBJECTIVE: The axillary reverse mapping (ARM) technique has been developed to map and preserve arm lymphatic drainage during axillary lymph node dissection (ALND) and/or sentinel lymph node (SLN) biopsy, thereby minimizing arm lymphedema. However, several problems remain to be resolved in the practical application of this technique. This article presents a review of current knowledge regarding ARM and discusses the practical applicability and relevance of this technique. TYPE OF STUDY: Review. SETTING: Oncogynecologic center, Gynecology-Obstetrics Clinic, 1st Medical Faculty and General Teaching Hospital, Prague. CONCLUSIONS: The axillary reverse mapping (ARM) procedure is based on the hypothesis that the lymphatic drainage from the upper arm is different from that of the breast and offers the opportunity to prevent lymphedema in breast cancer patients. However, the oncologic safety of the procedure has not yet been determined.

Comparative analysis of loss of heterozygosity and expression profile in normal tissue, DCIS and invasive breast cancer

INTRODUCTION: Ductal carcinoma in situ (DCIS) is considered to be related to the development of invasive breast cancer. The aim of molecular biological research of preinvasive breast lesion characteristics and comparison with normal tissues and tissue of invasive tumours is to identify patients at high risk of developing invasive tumour on the basis of already established preinvasive lesions, and thus influence clinical decision-making. The aim of our study was to analyse several key molecules involved in different cellular pathways important for cancer development and progression in different types of breast tissue and to describe similarities and differences between premalignant and malignant lesions. MATERIAL AND METHODS: Genetic material isolated from both the tumour and healthy tissue was examined by loss of heterozygosity (LOH) analysis and real-time PCR using collagen 2A as a house-keeping gene. RESULTS: We analysed 65 samples of healthy mammary gland, 25 DCIS and 42 invasive ductal breast cancer samples. We analysed the LOH in three genes: BRCA1, BRCA2 and p53; and the gene expression of the VEGF gene and Bcl-2 gene. LOH in the BRCA1 gene was present in 44.74% of invasive samples and in 8.69% of DCIS (p=0.026); LOH in the BRCA2 gene in 45.0% of invasive samples and in 9.52% of DCIS (p=0.036); LOH in the p53 gene in 32.5% of invasive samples and in 31.82% of DCIS (p=0.97). No LOH was observed in normal tissue samples. VEGF was overexpressed in 14.3% of invasive cancers and in 12.0% of DCIS. Overexpression of Bcl-2 was observed in 11.9% of invasive cancers and in 8.0% of DCIS. CONCLUSION: We have confirmed that some of the molecular characteristics of DCIS are identical to those of invasive carcinoma. This approach could lead to the identification of molecular markers as indicators for the potential development of DCIS into invasive carcinoma or identification of DCIS subgroups with latent invasion (AU)

Late morbidity following nerve-sparing radical hysterectomy.

OBJECTIVES: Nerve-sparing (NS) modification of radical hysterectomy (RH) has been developed with the main purpose of improving the quality of life after radical surgical treatment of early-stage cervical cancer. Although the procedure has been discussed for almost 30 years, there are only limited data available on late morbidity. The aim of the study was to prospectively evaluate the morbidity of patients before and 6 months after NS RH and compare that with the morbidity in patients following different types of parametrectomy without nerve sparing. METHODS: Multiple parameters were assessed prospectively using 20-item self-reported questionnaire, focusing on three main areas of morbidity: bladder, sexual, and anorectal functions. Excluded were patients treated with adjuvant radiotherapy. RESULTS: Enrolled were women following NS RH (N=32), type C RH (N=19), and type D RH (N=21). Nine parameters significantly deteriorate in the whole group after the treatment: defecation straining (p=0.03), defecation regularity (p=0.0006), defecation frequency (p=0.02), need to use laxatives (p<0.001), flatulence incontinence (p<0.001), urinary incontinence (p<0.001), nocturia (p=0.002), loss of bladder sensation (p=0.04), and straining to void (p<0.001). There were significant differences (p<0.05) between groups following NS and type C or D RH in changes of following parameters: defecation regularity, receptivity to sexual activity, urinary incontinence, nocturia, and straining to void, while no differences were found between type C and D RH. Minimal changes were observed in any of 10 parameters of sexual functions. CONCLUSIONS: Our results confirmed a significant negative impact of RH on bladder and anorectal functions. Autonomic nerve preservation significantly improved morbidity 6 months after treatment.

Sentinel node (SLN) biopsy in the management of locally advanced cervical cancer.

OBJECTIVES: Sentinel lymph node (SLN) biopsy can significantly contribute to the management of locally advanced cervical cancers with high risk of lymph node (LN) positivity. However, low detection rate and sensitivity were reported in larger tumors, albeit on a small number of cases. It was the aim of our study to verify the SLN reliability in large tumors, with modified dye application technique and a careful identification of side-specific lymphatic drainage. METHODS: The study involved 44 patients with tumors 3 cm in diameter or larger, stages IB1 to IIA, or selected IIB. In cases where SLN could not be detected, systematic pelvic lymphadenectomy was performed on the respective side. Systematic pelvic lymphadenectomy was performed during the second step radical procedure if not already done. RESULTS: Detection rate in the whole cohort reached 77% per patient and 59% bilaterally. No significant difference was found whether a blue dye or a combined method was used (75% vs 80%, and 55% vs 67%). Systematic pelvic lymphadenectomy was performed in cases with undetected SLN unilaterally in 8 and bilaterally in 10 women. A systematic pelvic lymphadenectomy was included in the second step radical procedure in 19 cases and no positive LN were found. There was no case of false-negative SLN result in patients who underwent surgical treatment. CONCLUSION: Detection rate in locally advanced cervical cancer could be improved by a careful dye application technique. Low false-negative SLN rate could be achieved if pelvic lymphatic drainage is evaluated on a side-specific principle by performing systematic lymphadenectomy if SLN is not detected.

[Analyses of LOH and expression in healthy gland, DCIS and invasive breast cancer gland]. / Srovnávaci analýza ztráty heterozygozity (LOH) a profilu exprese v normální tkáni, DCIS a v tkáni invazivního karcinomu prsu.

OBJECTIVE: To characterize molecular pattern differences (LOH and expression) between DCIS and invasive breast cancer. DESIGN: Original paper. SETTING: Oncogynecologic center, Clinic of Obstetrics and gynecology, First Faculty of Medicine, Charles University in Prague and General Teaching Hospital, Prague. MATERIAL AND METHODS: We analyzed LOH in 3 genes (BRCA1, BRCA2 and p53) and expression of 2 genes (VEGF and Bcl-2) in fresh frozen tissue samples of DCIS and invasive breast cancer. Each sample was evaluated by pathologist before sampling and analysis. RESULTS: Molecular pattern analysis was performed in three types of tissue: healthy breast gland (65 samples), DCIS (25 samples) and invasive breast cancer (42 samples). LOH in BRCA1 was detected in 22.3% of invasive cancer samples and in 13.4% of DCIS; BRCA2 LOH in 32.1% of invasive cancer samples and in 14.1% of DCIS; p53 LOH in 35.6% of invasive cancer samples and in 33.2% of DCIS. VEGF was overexpressed in 15.3% of invasive cancer samples and in 8.3% of DCIS. Overexpression of Bcl-2 was detected in 13.2% of invasive breast cancer samples and in 7.1% of DCIS. CONCLUSION: We confirmed that substantial part of DCIS has molecular pattern similar to invasive cancer. These molecular changes could serve as potential markers of DCIS progression to invasive cancer or they could identify subgroup of DCIS with latent invasion.

Reconstruction of defect after radical vulvectomy by the use of four-flap local transfer--a case report.

Malignant vulvar tumors must be treated by radical removal of the tumor as well as a sufficient amount of surrounding healthy tissue. The resulting defects can be resolved by skin transplants, local transfers, skin flaps, muscle flaps or free tissue transfers. We describe the case history of a patient who underwent radical vulvectomy for a malignant tumor with immediate reconstruction by local flaps from the area of inner thighs and mons pubis. The advantages and disadvantages of this method are compared to other reconstructive surgery methods.

[Molecular characterization of epithelial ovarian borderline tumors with respect to clinical management and prognosis]. / Molekulární charakteristiky borderline ovariálních tumoru ve vztahu k biologickému chování nádoru.

OBJECTIVE: To analyze up-to-data knowledge in the field of molecular characterization of epithelial ovarian borderline tumors with respect to clinical management and prognosis. DESIGN: Review. SETTING: Oncogynecological Center, Department of Obstetrics and Gynecology, Charles University in Prague, First Faculty of Medicine, and General Faculty Hospital, Prague. METHODS: Based on literature search and own experimental data in the field of molecular biology of ovarian cancer and borderline tumors of ovary, we summarize up-to-date knowledge of molecular differences and specific features of BTO with respect to implementation of these knowledge into the clinical management. RESULTS AND CONCLUSION: We suppose that spectrum of genomic changes (i.e. genetic and epigenetic) causing tumor transformation is limited and these changes take place in stem or progenitor cell. Analysis of genomic changes can help to define certain subtypes of BTO and, correlated to clinical characteristics, to identify subtypes with different biological behavior. Such molecular typing of BTO allows to individualize treatment.

[Inactivation of BRCA1, BRCA2 and p53 genes in sporadic ovarian cancer]. / Inaktivace genu BRCA1, BRCA2 a p53 u sporadického karcinomu vajecníku.

OBJECTIVE: To analyze loss of heterozygosity (LOH), loss of expression and somatic mutations of BRCA1, BRCA2 and p53 genes in sporadic epithelial ovarian cancer samples. DESIGN: Original paper. SETTING: Oncogynecologic center, Clinic of Obstetrics and gynecology, First Faculty of Medicine, Charles University in Prague and General Teaching Hospital, Prague. MATERIAL AND METHODS: We used genomic DNA and total RNA from peripheral blood and fresh frozen tumor as a template for LOH, loss-of-expression and mutation analyses. RESULTS: LOH in at least one region was found in 60% of tumors. Majority of these alterations occurred not solely, but in conjunction with other region deletions. CONCLUSION: Our study confirms high frequency of somatic alteration of BRCA1, BRCA2 and p53 genes in sporadic epithelial ovarian cancer.

[Detection of HPV DNA in lymph nodes in early stages cervical cancers]. / Stanovení DNA HPV v lymfatických uzlinách u casných stadií karcinomu delozního hrdla.

OBJECTIVE: Review recent knowledge concerning significance of detection of DNA HPV in regional lymph nodes in cervical cancer patients. TYPE OF THE STUDY: Literature review. SETTING: Department of Obstetrics and Gyneacology, 1st Faculty of Medicine, Charles University and General Teaching Hospital, Prague. RESULTS: Metastatic involvement of pelvic lymph nodes is the most important prognostic parameter in early stages cervical cancer. Still, almost 20% of patients with negative pelvic nodes experience recurrence. Detection of HPV DNA in lymph nodes might be a marker of occult metastatic involvement. However, published data are limited, mostly due to inconsistent methodology. Only 3 prospective studies evaluating HPV from fresh or frozen tissue were published till now, all other retrospective studies extracted HPV DNA from paraffin embedded samples. A few papers showed correlation between HPV DNA and metastatic involvement of pelvic lymph nodes. DNA HPV identification in histopatology-negative nodes was considered as a risk factor for recurrence. Presence of DNA HPV 18 in histopathology-negative pelvic nodes was described as a poor prognostic factor; however prognostic significance of individual genotype is still unclear. CONCLUSION: Detection of high risk HPV DNA in regional lymph nodes is a good candidate for prognostic parameter in early stages cervical cancers. The group of women with both absence of metastatic involvement and negative HPV DNA evaluation of regional lymph node should represent a cohort of patients with particularly good prognosis.

[Molecular biology of preinvasive and invasive breast tumors]. / Molekulární biologie preinvazivních a invazivních nádoru prsu.

OBJECTIVE: To present an overview of molecular characteristics and differences of and between preinvasive and invasive breast tumors. DESIGN: Review. SETTING: Oncogynecologic center, Clinic of Obstetrics and Gynecology, First Faculty of Medicine, Charles University in Prague and General Teaching Hospital, Prague. MATERIAL AND METHODS: Review of literature. CONCLUSION: Identification of genetic and epigenetic changes in preinvasive and invasive breast tumors can help to better classify these lesions and improve and tailor their clinical management. Due to completely different biological behavior of morphologically identical lesions, it is clear that the matter of classification and clarification of their clinical behavior is hidden inside the entire genome or proteome.

[Ductal approaches in mammary diagnostics]. / Intraduktální prístupy v mamární diagnostice.

OBJECTIVE: Information about new possibilities of early diagnostics in mammary lesions. TYPE OF STUDY: Review. SETTING: Gynecology-Obstetrics Clinic, 1st Medical Faculty and General Teaching Hospital, Prague. SUBJECT AND METHODS: Most malignant tumors of the breast originate from ductal epithelium. A direct examination of the ductal system, could significantly improve diagnostics of breast cancer as well as its preinvasive stages (DCIS) and to influence mortality. The concept of ductal approaches includes several techniques and ductal lavage and duscoscopy. CONCLUSIONS: Ductal approaches represent an attractive area for minimal load upon the patients. Specificity and sensitivity of these methods have some limits, which will be subject to change in relation to understanding of carcinogenesis and in a close relation to the knowledge of biomarkers, genomics and proteomics. Ductoscopy appears to be the ideal method for the future due to possibilities of direct visualization of epithelium in combination with biopsy and ductal lavage. It other advantages include minimal invasiveness, minimal risk and the origin of possible complications for the patient.