Soheir Mahfouz

(1)

CYTOLOGY UNIT

(2)

NIPPLE DISORDERS &

DISCHARGE

NIPPLE DISORDERS &

DISCHARGE

BY

(3)

HOW TO USE

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(4)

NIPPLE DISORDERS

A) GROSS NIPPLE DISORDERS

(5)

A) GROSS NIPPLE

DISORDERS

A) GROSS NIPPLE

DISORDERS



Nipple inversion

: commonly with duct

ectasia(DE) but cancer has to be excluded



Crusting

of nipple

: due to DE



Soreness & excoriation

: Eczema /Pagets

disease & in atheletes due to friction



Accessory/ Extra

nipple



Areolar cyst

: due to a blocked skin gland lies at

edge of areola & removed by excision



Peri-areolar or mammary fistula:

(6)

B) NIPPLE DISCHARGE



Homonal disorders



Inflammatory: Acute subacute, chronic mastitis



Fat necrosis & duct ectasia



Fibrocystic changes, duct hyperplasia with

papillomatosis

(7)

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

(8)

Preferred examination



Mammography

is 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

(9)

DUCTOSCOPY

DUCTOGRAPHY

(10)

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

(11)

HOW TO TAKE A SAMPLE

1. 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

(12)

1 -Aspiration

2 -Cannulation

3 -Lavage (saline)

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

)

(13)

DUCTAL LAVAGE IS A RISK

ASSESSMENT TOOL

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

(14)

WHAT is the basis of

cytology for breast cancer

risk assessment

?

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

(15)

FIXATION

Immediate fixation in

95% ethanol.

(16)

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

(17)

ITEMS TO BE TAKEN INTO

CONSIDERATION

ITEMS TO BE TAKEN INTO

CONSIDERATION

1. Complete clinical data

: age – complaint & its duration ( long duration =

benign) - any recent history of medications -amenorrhea - spontaneity of

discharge

2. 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

(18)

Complete gross description of the discharge



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

(19)

Complete gross description of the

discharge

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}

(20)

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

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

(21)

NORMAL SMEAR

(22)

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

(23)

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

(24)

(25)

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

(26)

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

(27)

Nature of the Foam Cell

(FC)

Nature of the Foam Cell

(FC)



Is it a secretory duct cell ? or

is it a macrophage?

CD 68

CK

(28)

4. INFLAMMATORY

CELLS



PNLs: increase just

after delivery



Lymphocytes:

increase just after

delivery (when present

screen carefully for

(29)

5. SQUAMOUS CELLS

Are mostly aneucleated

squames from lining of

peripheral ducts, skin

(30)

ABNORMAL SMEARS (BENIGN)

Non neoplastic & benign

neoplastic smears

ABNORMAL ND: Is defined as the secretory

production of fluids other than milk & is

due to a pathologic process in the breast

ABNORMAL SMEARS (BENIGN)

Non neoplastic & benign

neoplastic smears

ABNORMAL ND: Is defined as the secretory

production of fluids other than milk & is

(31)

(32)

DISORDERS

:

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-

Benign

papillary hyperplasia , duct papilloma,

6-

Fat necrosis

(rare)

(33)

Galactorrhea:

Milk production

unrelated to pregnancy or lactation

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

(34)

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%

(35)

NIPPLE DISCHARGE THAT MAY

GROSSLY CAUSE CONCERN

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

(36)

MICROSCOPIC



CELL TYPES

1. Foam cells

2. Duct cells:

3. 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

1. Inflammatory cells

2. Giant cells

3. Fat containing cells

1

2

(37)

(38)

DISEASE PATTERNS



1.Endocrine disturbances

:=

Normal Milk

Lipoproteinacious background

with no RBC /

inflammation

Many

Foam cells (FC) + duct cells with or without Giant

(39)

PAP

(40)

Material prepared by



Soheir Mahfouz



Fahima Habib



Zeinab Moheidin



Essam Ayad



Hala Khidr



Hossam Ahmed



Sammar El Sheikh



Ahmed Soliman



Shady Anis



Nada Iskandar



Amira El Zahid



Amany Mamdouh



Abla Sayed