CYTOLOGY UNIT updated 2017

1. CYTOLOGY UNIT updated 2017 Soheir Mahfouz-Self Study Series

2. 1 NIPPLE DISORDERS & DISCHARGE BY Soheir Mahfouz Soheir Mahfouz-Self Study Series

3. NIPPLE DISORDERS A) GROSS NIPPLE DISORDERS B) NIPPLE DISCHARGE/Secretions Soheir Mahfouz-Self Study Series

4. A) GROSS NIPPLE DISORDERS • Nipple inversion: commonly with duct ectasia(DE) but cancer has to be excluded • Crustingof nipple: due to DE • Soreness & excoriation: Eczema /Pagets disease & in atheletes due to friction • Accessory/ Extranipple • Areolar cyst: due to a blocked skin gland lies at edge of areola & removed by excision • Peri-areolar or mammary fistula: inflammmatory & managed with antibiotics Soheir Mahfouz-Self Study Series

5. B) NIPPLE DISCHARGE • Homonal disorders • Inflammatory: Acute subacute, chronic mastitis • Fat necrosis & duct ectasia • Fibrocystic changes, duct hyperplasia with papillomatosis • Benign neoplasm: Papilloma • Malignant: DCIS & carcinoma Soheir Mahfouz-Self Study Series

6. Nipple Discharge • Frequency: 1-3% in USA • Mortality / Morbidity: - Morbidity: most patients have medically & surgically reversible disorders & surgery causes minor cosmetic defects - Those with occult malignancies have a mortality = that of others with breast cancer • Sex: F> M ( in young males it usually represents duct ectasia rarely hyperprolacinaemia) • Age: any age • Majority of ND is benign 95% Soheir Mahfouz-Self Study Series

7. Preferred examination • Mammographyis the first investigation in a pt with significant spontaneous unilateral ND • Galactography or ductography if mammography is negative • Fiber-ductoscopy (experimental) • Hemoccult tests to confirm or exclude presence of occult blood (GUIAC test) • Cytology False +ve=2.6% False -ve=17.8% • Sonography if ND + palpable mass • MRI to differentiate between B & M duct abnormalities (experimental) Soheir Mahfouz-Self Study Series

8. DUCTOGRAPHY DUCTOSCOPY CYTOLOGY Soheir Mahfouz-Self Study Series

9. TECHNICAL ASPECTS TYPE OF SAMPLE 1-Nipple discharge/ secretions : spontaneous, pump suction or squeezing (massage) 2-Exudate from ulcer or scrape 3-Wound wash 4- Ductal lavage by instilling saline for high risk patient with no mass and negative mammography Soheir Mahfouz-Self Study Series

10. HOW TO TAKE A SAMPLE • Nipple discharge/secretions a)Spontaneous ·Wipe nipple and areola to avoid contamination with squamous cells ·Discard first few drops since they contain dead or degenerated cells ·Put 1 drop on slide and wipe across ·Immediately immerse slide in fixative b)FNAC (research) c) Breast nipple aspiration fluid (NAF)) / lavage* is used if secretions are minimal or non spontaneous *DL is being assessed now as a new screening method for high risk women • Exudates: Scrape ulcer with a saline soaked cotton bud then spread on slide & fix Soheir Mahfouz-Self Study Series

11. Ductal lavage Indications: 1-High risk women- women with BRCA 1 & 2 mutations, normal mammography & normal breast examination 2- mammographicaly dense breast 3-Women on prolonged CP This will help women guided by ductal lavage to choose a risk reduction drug as tamoxifen or raloxifene (STAR TRIAL) 4-When NAF fails to produce enough cells 1-Aspiration 2-Cannulation 3-Lavage (saline) Soheir Mahfouz-Self Study Series

12. DUCTAL LAVAGE IS A RISK ASSESSMENT TOOL • Ductal lavage is a risk assessment tool: atypical smears would be put on risk reduction drugs • FNAC is a diagnostic tool whereby a diagnosis of malignancy will prompt mastectomy Gail et al. 1989 National Surgical Adjuvant Breast and Bowel Project (NSABP) revised this model in 1992 (model 2) Soheir Mahfouz-Self Study Series

13. WHAT is the basis of cytology for breast cancer risk assessment ? • Women who have atypical intraductal proliferations have a 2X risk of developing invasive cancer Vogel, 2004 diag. Cytopathol : 30: 1151-157 • Presence of atypical hyperplasia increases the RR of cancer development RR=4.9 & +ve family history increases risk even more RR=18.1 Wrensh et al.1992,Am.J.Epidimiol.135:130-141 Soheir Mahfouz-Self Study Series

14. FIXATION Immediate fixation in 95% ethanol. Soheir Mahfouz-Self Study Series

15. STAINING • PAP: spread a minimum of 2 slides and use last drops since they are the most valuable (contain most of the viable cells). • Giemsa (air dried ) • HE • Diff Quick optional for evaluation of adequacy Soheir Mahfouz-Self Study Series

16. ITEMS TO BE TAKEN INTO CONSIDERATION • Complete clinical data: age – complaint & its duration ( long duration = benign) - any recent history of medications -amenorrhea - spontaneity of discharge • Breast examination for: • Mass: fibrocystic disease – duct papillomas – carcinoma – abscess – galactocoele • Pain : F.cystic disease- mastitis • Bilaterality: F.cystic disease/ hormonal • One opening: duct papilloma Multiple: others • Skin: peau d’orange or inflammation • Axilla for lymph nodes NB: If discharge is too dark wipe with cotton to determine if sanguinous Soheir Mahfouz-Self Study Series

17. Watery clear Serous/clear yellow: Colustrum (physiologic – cyst contents – hormonal imbalance) NB Guiac +ve straw coloured sticky unilateral discharge from 1 opening =duct papilloma Milk: Physiologic if lactating or at puberty – galactocoele - hormonal imbalance / galactorrhea Pus: abscess( may be associated with carcinoma)Acute/ subacute mastitis Necrotic material: carcinoma Comedo / pasty discharge usually rich in metaplastic squamous cells/ inspissiated exudate: recurrent subareolar abscess- duct ectasia Complete gross description of the discharge Soheir Mahfouz-Self Study Series

18. Complete gross description of the discharge • Serous pink(serosanguinous): always neoplastic rarely during pregnancy or chemotherapy • Bloody: duct papilloma / carcinoma or chronic mastitis • Yellowish, green or brown: retained cyst contents- cystic mastopathy Soheir Mahfouz-Self Study Series

19. NB: THE RISK OF CANCER IS HIGH IN: Sanguinous, Unilateral discharge particularly from one opening & especially if associated with a mass or the woman is above 40 years Soheir Mahfouz-Self Study Series

20. NORMAL SMEAR Soheir Mahfouz-Self Study Series

21. GROSS 1-Milky: new born (witches milk) & premature telarche – pregnancy/lactation (can remain up to 1 year after stopping of breast feeding) -rarely at puberty, during the menses or premenopausal women who have had many children NB women smokers may have ND 2-Serous: colustrum 3-Serosanguinous: rare during pregnancy NB: Up to 80% of women in their reproductive years can express 1-2 drops of fluid Soheir Mahfouz-Self Study Series

22. MICROSCOPIC Cell types 1.NON SECRETORY DUCT CELLS • Large numbers are present in pregnancy & lactation • Exfoliation: in tight clusters(80%) & single • Cytoplasm: 9-12u cuboidal with little cytoplasm pink or blue Cell cytoplasm moulds but not nuclei • Nucleus: -7u round – oval may be triangular -Fine uniform/condensed chromatin NO large or multiple nucleoli -High N/C ratio Soheir Mahfouz-Self Study Series

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24. 2.SECRETORY DUCT CELLS(foam cells) • Large numbers are present in pregnancy & lactation.They are identical to histiocytes but do not phagocytose • Exfoliation: mostly single or in loose clusters • Cytoplasm: - 30-50u with abundant foamy pink cytoplasm or blue or green -Cell boundaries are well defined • Nucleus: - variable in size, pyknotic usually single but may be multinucleated in pregnancy - round – oval may be eccentric -Fine regular chromatin +/- small nucleoli -Low N/C ratio Soheir Mahfouz-Self Study Series

25. 3.HISTIOCYTES • Exfoliation: mostly single or in loose clusters • Cytoplasm: same as secretory duct cells, unless with phagocytosed material Cell boundaries are ILL defined • Nucleus: - variable in size, bean shaped usually single - round – oval may be eccentric - Fine regular chromatin +/- small nucleoli Soheir Mahfouz-Self Study Series

26. Is it a secretory duct cell ? or is it a macrophage? Nature of the Foam Cell (FC) Krishnamurthy et.al., 2002, Diagnostic Cytopath . 27(5)::261-264 CD 68 CK Soheir Mahfouz-Self Study Series

27. 4.INFLAMMATORY CELLS • PNLs: increase just after delivery • Lymphocytes: increase just after delivery (when present screen carefully for malignancy) Soheir Mahfouz-Self Study Series

28. 5.SQUAMOUS CELLS Are mostly aneucleated squames from lining of peripheral ducts, skin surface, areola, nipple or as a contaminant from fingers Soheir Mahfouz-Self Study Series

29. ABNORMAL SMEARS (BENIGN)Non neoplastic & benign neoplastic smearsABNORMAL ND: Is defined as the secretory production of fluids other than milk & is due to a pathologic process in the breast Soheir Mahfouz-Self Study Series

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31. DISORDERS: 1- Endocrine disturbances: oral contraceptive & other medications– Chiari Frommel syndrome – Del Castillo syndrome NB: galactorrhea ( milk or serous or yellow green fluid not related to pregnancy or lactation) 2- Acute & subacute mastitis 3- Chronic mastitis & Fibrocystic disease: ·        Duct dilatation & stasis (duct ectasia & periductal mastitis) ·        Retention cyst (Fibrocystic disease) 4- Benignpapillary hyperplasia , duct papilloma, 6- Fat necrosis (rare) Soheir Mahfouz-Self Study Series

32. Galactorrhea: Milk production unrelated to pregnancy or lactation • Hyperprolactinemia- pituitary adenoma/ medications as some steroid hormones , mostly oral CP-tranquilizers some sedatives-drugs that inhibit dopamine (phenothiazines/methyl dopa) and CRF,hypothyroidism ND is usually white or clear but may be yellow or green • Chronic breast stimulation e.g. badly fitting bra/ clothing • Post thoracotomy syndrome: healing of chest wound simulates a suckling infant Soheir Mahfouz-Self Study Series

33. GROSS 1) Milk ( endocrine disturbances): cloudy, white or almost clear, thin & non sticky 2) Purulent: Acute & subacute mastitis 3) Sanguinous/ serosanguinous: papilloma, duct papillomatosis – chronic mastitis 4) Greenish or brown: retained cyst contents 5) Serous: rest 90% NB: Pink watery discharge always consider neoplastic Soheir Mahfouz-Self Study Series

34. NIPPLE DISCHARGE THAT MAY GROSSLY CAUSE CONCERN • Bloody or brown black • Watery or serous with a red, pink or brown colour • Sticky and clear • Appears spontaneously without squeezing • Persistent • Unilateral • One opening Soheir Mahfouz-Self Study Series

35. 1 MICROSCOPIC • CELL TYPES • Foam cells • Duct cells: • Apocrine metaplastic cells: -Pattern: clusters / sheets -Cytoplasm: large amounts of deep pink cytoplasm +/- brown granules of glycogen sometimes fine vacuolation & appear similar to FC -Nucleus: loose chromatin and prominent nucleolus/ dense irregular nuclei -Multinucleation is common • Inflammatory cells • Giant cells • Fat containing cells 2 3 Soheir Mahfouz-Self Study Series 4

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37. DISEASE PATTERNS • 1.Endocrine disturbances:= Normal Milk Lipoproteinacious background with no RBC / inflammation Many Foam cells (FC) + duct cells with or without Giant cells Soheir Mahfouz-Self Study Series

38. PAP PAP HE PAP Soheir Mahfouz-Self Study Series

39. DISEASE PATTERNS 2-Acute & subacute mastitis: purulent ·Debris + Bacteria ·Acute= PNLs > mononuclears .Sub acute: mononuclears> PNL 3-Chronic mastitis & FC: Serous- sanguinous- cheesy–green sticky ·Debris & inspissiated material + RBCs ·Acute + chronic inflammatory cells+/-GC ·Foam cells + duct cells + Apocrine cells • Plasma cell mastitis & duct ectasia: Cheesy with many lymphoplasmacytic cells • Fat necrosis: Infl. Cells +Giant cells Fat globules+ cholesterol crystals Soheir Mahfouz-Self Study Series

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46. DISEASE PATTERNS • Papillary duct hyperplasia & duct papilloma:papillae of ductal cells forming well defined cohesive groups with nuclear moulding and small prominent nucleolus IN Not more than 10% of cells (if more recommend biopsy Soheir Mahfouz-Self Study Series

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