BREAST CYTOLOGY

AMA AFRAH

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ANATOMY OF FEMALE BREAST

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 INTRODUCTION

• Normal Breast Cytology

• The most important role of diagnostic cytology

in the assessment of breast lesions is in making
the decision between benign and malignant.

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 INTRODUCTION

• Malignant breast epithelium exhibits the nuclear

enlargement, anisonucleosis and chromatin
derangements.
• They are the hallmarks of malignancy in breast in a
way that is often more subtle than in malignancies in
other site.
• The major difficulty is the imperceptibility in the
gradation between the lesions that all
histopathologists would regard as benign and those
that are obviously malignant.
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 INTRODUCTION

• further difficulties arise because the adjacent

soft tissues and overlying skin and adnexae
may be the host to lesions.

• These are mistaken clinically and cytologically

for breast disease.

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 DEVELOPMENT AND HORMONAL
RESPONSIVENESS OF BREAST

• Mature resting
functional units of the
breast occurs
throughout reproductive
life with accentuation in
pregnancy.

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 DEVELOPMENT AND HORMONAL
RESPONSIVENESS OF BREAST

• Under the influence of

oestrogen , and then
following menarche,
progesterone, and in
complex hormonal milieu of
growth hormone, thyroxine
and insulin, the breast
parenchyma (epithelium)
grows by the process of duct
elongation and branching.
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 DEVELOPMENT AND HORMONAL
RESPONSIVENESS OF BREAST

• Before puberty, the

progenitors of the adult
breast are concentrated in a
small volume of tissue.

• Therefore, damage to the

vestigial organ can result in
post-pubertal disfigurement

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 DEVELOPMENT AND HORMONAL
RESPONSIVENESS OF BREAST

• Pubertal hyperplasia occurs in both males

and females and can be temporarily
unbalanced or unilateral , but should not be
mistaken for a pathological process when
seen in appropriate stage of development of
the child.

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 DEVELOPMENT AND HORMONAL
RESPONSIVENESS OF BREAST

• The parenchyma (ducts and loules) of human

breast becomes fully developed at puberty
and is then subjected to the waxing and
waning due to stimuli of the menstrual cycle.

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 DEVELOPMENT AND HORMONAL
RESPONSIVENESS OF BREAST

• Following ovulation, rising

levels of progesterone
cause hyperplasia and
dilation of terminal
ductules.

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 DEVELOPMENT AND HORMONAL
RESPONSIVENESS OF BREAST
• Mitotic activity appears
in the lobular
epithelium as does
vacuolation

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 DEVELOPMENT AND HORMONAL
RESPONSIVENESS OF BREAST

• In the secretory phase of

the menstrual cycle the
stroma becomes
oedematous , giving the
woman the sensation
fullness of the breasts

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 DEVELOPMENT AND HORMONAL
RESPONSIVENESS OF BREAST

• Late in the secretory and menstrual phase

apoptotic activity occurs with some shedding
of epithelial cell debris into the ductal
lumina.

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 DEVELOPMENT AND HORMONAL
RESPONSIVENESS OF BREAST
• The effect of ageing on breast tissues have
been the focus of subjective as well as more
morphometric scrutiny .

• Generalized involution of stroma and epithelial

elements is the usual morphological finding in
normal postmenopausal women, but its
predominant in premenopausal women.
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 BREAST DISEASES

• Cysts
• Fat necrosis
• Sclerosing adenosis
• Generalized breast lumpiness
• Breast tenderness.

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 BREAST LUMP

• Hard lump
• Breast cancer is very rare in adolescents.
However, if you find a lump with any of the
following qualities, visit the clinic:
• hard
• not movable
• feels like it’s attached to the chest wall
• combined with dimpling or puckering of the
breast

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 BREAST LUMP
• Fibroadenomas are solid, smooth, firm, benign lumps.
They are most commonly found in women in their late
teens and early twenties, but can occur in women of
any age.

• Fibroadenomas occur twice as often in African-

American women as in other American women.

• Fibroadenomas are painless lumps that feel rubbery

and move around freely. They vary in size and can grow
anywhere in the breast tissue.
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 Breast Cysts/FIBROCYSTIC CHANGE

• A cyst is a fluid-filled sac that develops in the breast tissue.

They typically occur in older women, but are sometimes
found in teens. Cysts often enlarge and become tender and
painful just before the menstrual period and may seem to
appear overnight.

• Cysts can feel either soft or hard. When close to the surface
of the breast, cysts can feel like a large blister, smooth on
the outside, but fluid-filled on the inside. However, when
they are deeply embedded in breast tissue, a cyst will feel
like a hard lump because it is covered with tissue
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GYNAECOMASTIA

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 WHEN IS NIPPLE DISCHARGE ABNORMAL

• Spontaneous nipple discharge unrelated to pregnancy or

breast feeding is considered abnormal.

• In most cases it has a non-cancerous (benign) cause.

• Spontaneous nipple discharge that is caused by disease

(pathology) in the breast is more likely to be from one breast
only (unilateral), confined to a single duct, and clear or
blood-stained in appearance.

• Nipple discharge that is associated with other symptoms

such as a lump in the breast or ulceration or inversion of
the nipple needs prompt investigation, even if it is not
spontaneous or blood-stained.
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 CAUSES OF NIPPLE DISCHARGE

• Duct papilloma

• Nipple eczema

• Breast cancer

• Drugs and medication: oral contraceptive,

hormone replacement therapy
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 NIPPLE DISCHARGE
• Due mostly to duct ectasia: an
anomaly of duct development
that results from “pleats” of
obstructing epithelium in the
lumen of the duct. This
obstruction can lead to bacterial
overgrowth and formation of an
abscess, most commonly with S.
aureus.

• Infants with mammary duct ectasia

typically present with a bloody
discharge.

• Cytology may show foamy

macrophages
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Nipple-areolar:cancer:nipple
discharge:gynaecomastia(M):

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 How are breast disorders diagnosed?

• The first step in diagnosing any type of breast

disorder is a physical exam.

• Depending on the findings, your doctor may

order other tests to help make a diagnosis.
These tests may include: 
• ultrasound 
• mammogram
• fine-needle aspiration (FNA)
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 CLINICAL EXAMINATION OF BREAST

FNA and Direct smears preparation

• The first stage of the procedure is

for the cytologist to examine both
breasts and the axillae should be
fully examined clinically.

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TECHNICAL EXAMINATION OF BREAST

• In examining of the lesion, the cytologist

should confirm the presence or absence of
tethering to skin or chest wall or
in-drawing/retraction of the nipple
• Retracted nipple Peau d’erange

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 CLINICAL AND TECHNICAL METHODS

• Quadrant
• It is important that cytologist
records his description of
the lesion including size,
location, tissue plane, and
whether it is well or poorly
defined, hard or soft.

• It is also good to record the

sensation obtained when
the needle enters the lesion.

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 CLINICAL AND TECHNICAL METHODS

• The following can be described and correlated

in the following way according to NHSBSP
GUIDELINES
• When lump feels:
I. Soft-fibroadenoma, mucoid carcinoma,
medullary carcinoma

II. Rubbery – fibrocystic change, lobular

carcinoma, fibroadenoma
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 CLINICAL AND TECHNICAL METHODS

iii. Variable resistance with popping sensation-

fibrocystic change
iv. Leathery – dense fibrous change, ancient
fibroadenoma
v. Gritty – carcinoma, partial calcification, a few
fibroadenomas
vi. Solid- completely calcified ancient
firboadenomas
vii. No resistance – fatty tissue
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 CLINICAL AND TECHNICAL METHODS

• There has been debate as to the most

appropriate guage of needle to use for breast
aspiration.

• A very large needle will produce too much

pain and haemorrhage, whereas, a needle
that is too small will not permit an adequate
sample to be taken

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 CLINICAL AND TECHNICAL METHODS
• Women with symptomatic breast lumps
randomly allocated with 21 - 23 gauge needles.

• In an earlier in vitro study, it was shown that the

amount of epithelium obtained may be greater
with the larger needle

• From observing the patients reaction, it is clear

that the 23 – gauge needle causes less
discomfort 32
FNA PREPERADNESS

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 CLINICAL AND TECHNICAL METHODS
• When the aspirate is taken and interpreted by
different individuals, it has been shown that
sensitivity can be optimized within the
limitations of practicality by taking three or four
aspirations routinely from each lesion

• Another modification of the technique is the

use of a needle without a syringe or the
application of suction.
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 OBTAINING THE ASPIRATE

 The patient should lie on a couch with the head

raised.

 Right-handed aspirators should approach from the

patients right, even for aspiration of a lesion in the
left breast. If necessary the patient is asked to roll
towards the aspirator

A 10ml syringe should be inserted in the pistol grip if

one is available. A needle , 21G(green) or 23G(blue)
should be used 35
 NEEDLE GUAGE
• GREEN : 21 GUAGE
• BLUE:23

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 OBTAINING THE ASPIRATE

The syringe is primed with 1-2 ml of air to aid the expulsion

of the sample

The assembled syringe is laid within reach or handed to an

assistant with an opened antiseptic swab.

An ethylene chloride spray is laid within reach

The lump is identified and grasped between the thumb and

forefinger of the left hand. some time should be spent
manipulating the lump so that it is gripped firmly
particularly for deep breasts lumps in obese patients
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 OBTAINING THE ASPIRATE
Breast lumps shouldn’t be fixed against the
chest wall but to manipulate them forward
between the finger and thumb to reduce the
risk of pneumothorax (collapse of lung).

 The gripping of the lump should also put

tension on the skin to aid needle penetration.

When the lump is securely gripped the alcohol

swab is used to wipe the area. 38
 OBTAINING THE ASPIRATE

Ethyl chloride spray(prevent pain) is then

sprayed onto the area until a white frost appears.

The needle tip is then pushed into the centre of

the lump and negative pressure applied to the
syringe

The tip of the needle is gently moved backwards

and forwards in the same direction through the
lesions as this may cause bleeding. 39
FNAC PRECEDURE

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 FNAC PRECEDURE

It is important to wait until a “sample” appears in the

hub of the needle.
The ideal aspirate is invisible and resides within the
shaft of the needle.

The negative pressure is then released fully before

the tip of the needle is withdrawn from the lesion

Immediately, the contents of the needle are expelled

onto a single slide to form a few millimeters from
the frosted end. 41
 FNAC PRECEDURE
Dispose needle and syringe in a safe disposal container

Immediately spread the aspirate with a second slide

held at right angles with a gentle, even pressure on 2
labelled slides.

Allow 1 smear to air dry, fix in methanol, stain

Rowmanosky.
One smear should be fixed in 95% ethanol immediately
(wet-fixed )stain with Papanicoloau stain.
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 COMPLICATIONS OF FNA OF THE
BREAST

• The common problem encountered clinically is

the formation of haematoma

• This can obscure the lesion

• Pneumothorax is another very rare

complication
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 CYTOLOGICAL FINDINGS IN
BREAST ASPIRATES
• Normal epithelial and myoepithelial cells -
mixture of epithelial and myoepithelial cell
nuclei can give a spurious appearance of
anisonucleosis.

• Bipolar cell nuclei(stripped, bare, naked or

stromal nuclei) – small ovoid or elongated
naked nuclei are seen in the background of
benign breast aspirates
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 FIBROADENOMA

• Blue arrow: naked bipolar nuclei, black:

myoepithelial cell, yellow arrow: tight cluster
of ductal epithelial cells

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 FIBROCYSTIC CHANGE/BREAST
CYST
• Yellow arrow: APOCRINE METAPLASTIC CELLS

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 FAT NECROSIS: (DEATH).

• Injury to fatty tissues resulting in cell death of

adipose tissue. Fat replaced by oil(because of
necrosis, there is no nuclei)

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 MASTITIS
• INFLAMMATION: ACUTE/CHRONIC

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 MALIGNANT BREAST
• Malignant breast epithelium exhibits the
nuclear enlargement, anisonucleosis and
chromatin derangements.

• They are the hallmarks of malignancy in breast

in a way that is often more subtle than in
malignancies in other site.

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 MALIGNANT BREAST
• The major difficulty is the imperceptibility in
the gradation between the lesions that all
histopathologists would regard as benign and
those that are obviously malignant.

• Criteria for malignancy: loose clusters of

ductal cells, single ductal cells, nuclear
pleomorphism, hyperchromasia in Pap
stained smear, polychromasia etc
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 DUCTAL CARCINOMA
FEMALE BREAST MALE BREAST

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 DUCTAL CARCINOMA
• Criteria: Loose • CYTOLOGY
clusters of
ductal cells,
• hyperchromasia
in Pap stained
smear

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INVASIVE DUCTAL CARCINOMA
• IDC: Tumour has
• \
crossed basement
membrane
• CRITERIA: Loose
cluster of ductal
cells
• Presence of
prominent
nucleoli
• Tumour diathesis

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 OTHERS CELLS THAT CAN BE
PRESENT IN BREAST ASPIRATES
• Adipose tissue - this is the only frequent component
of breast aspirates commonly found in both benign
and malignant aspirates. Fatty aspirates contain
balloon-like fats cells in clusters of variable sizes.

• Red blood cells

• Platelets

• Skeletal muscle fibres – they appear as distinctive

elongated cylinders with basophilic cytoplasm with
cross striations and peripherally-located nuclei 54
 LYMPHOID CELLS IN BREAST
ASPIRATES
• Lymphoid cells – lymph nodes are often seen
as well-defined impalpable masses on
mammograms

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REPORTING PROTOCOLS
• The UK NHS BSP recommends a 5- tier
reporting scheme . They are;
1. C1: inadequate/non-diagnostic
2. C2 : Benign
3. C3: Atypical, probably benign
4. C4: Suspicious, probably malignant
5. C5: Malignant

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 DIAGNOSTIC PITFALLS IN
BREAST CYTODIAGNOSIS
• Lobular carcinoma cells • Lobular carcinoma :Invasive lobular
carcinoma
are relatively small and
their malignant nature
may be overlooked

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THANK YOU

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