Professional Documents
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Cellularity
Erythropoiesis
Myelopoiesis
Megakaryocytes
M;E ratio
Plasma cells
Abnormal cells
Breast Cancer
Introduction
Types
Aetiopathogenesis
hereditary breast cancer
sporadic breast cancer
Mechanism of carcinogenesis
Classification
carcinoma in situ
o Ductal carcinoma in situ (DCIS; Intraductal carcinoma)
o Lobular carcinoma in situ (LCIS)
invasive (infiltrating) carcinoma
o Invasive (infiltrating) ductal carcinoma
o invasive (infiltrating) lobular carcinoma
o Paget disease of nipple
o Medullary carcinoma
Metastasis
Major Prognostic factors
Minor prognostic factors
Treatment
Introduction
one of the most common malignant tumour of the women
3% of breast cancers are hereditary, constituting 25% of familial cancers
Types
1. Sporadic breast cancer
2. Hereditary breast cancer
Aetiology & Pathogenesis
Sporadic Breast Cancer possibly due to hormonal
Metabolites of estrogen can cause mutations or generate DNA-damaging
free radicals
via its hormonal actions, estrogens drive the proliferation of premalignant
lesions as well as cancers.
Major risk factors:
elderly age (> 50 Yrs)
gender (F>M)
early menarche (<11 Yrs) and late menopause
nulliparous (pregnancy results in terminal differentiation of epithelial cells,
removing them from the potential pool of cancer precursors)
exogenous estrogen administration
postmenopausal obese women - due to synthesis of estrogens in fat depots
overexpression of ER
Radiation Exposure - exposer to therapeutic radiation or atom bomb exposure
have a higher rate of breast cancer (Modern mammographic screening uses
low doses of radiation and is unlikely to have an effect on the risk of breast
cancer)
Geographic Influence - higher in the United States and Europe
Race lower in African-American ancestry, highest rates in Caucasian
increased dietary fat, moderate or heavy alcohol consumption
carcinoma of contra lateral breast
carcinoma of endometrium
atypical hyperplasia in breast biopsies
Lower risk:
Exercise
Breast-Feeding (longer the women breast-feed, the greater is the reduction in
the risk)
Tabacco is not associated
Associated with
BRCA1 and BRCA2 - highly penetrant autosomal dominant genes
multiple affected first-degree relatives
early occurrence i.e., before menopause (20 years younger than sporadic)
multiple cancers (colon, prostate, and pancreas)
male breast cancer(BRCA2)
family members also develop ovarian cancer
high risk of developing ovarian carcinoma (BRCA1)
Features of BRCA1-associated breast cancers
poorly differentiated (syncytial growth pattern with pushing margins & have a
lymphocytic response)
do not express hormone receptors
do not overexpress HER2/neu (an epidermal growth factor receptor that is
commonly overexpressed in breast cancer)
(BRCA2-associated breast carcinomas do not have distinct features)
Other gene mutations
Checkpoint kinase gene (CHEK2)
o important component of the recognition and repair of DNA damage
Li-Fraumeni syndrome (due to a germ-line mutation in the p53 gene)
p53 gene
Cowden syndrome ("multiple hamartoma syndrome" due to a mutation of the
PTEN gene on chromosome 10q)
PTEN gene
Peutz-Jeghers syndrome (mutations in the LKBI gene)
ATM gene (ataxia telangiectasia mutation)
Mechanisms of Carcinogenesis
A general model for carcinogenesis is that a normal cell must achieve seven
new capabilities to become malignant
1. evasion of growth-inhibiting signals
2. evasion of apoptosis
3. self-sufficiency in growth signals
4. genetic instability
5. limitless replicative potential
6. increased angiogenesis
7. ability to invade
Carcinomas
divided in to in situ carcinomas & invasive carcinomas
Carcinoma in situ
a neoplastic population of cells limited to ducts and lobules by the basement
membrane
does not invade into lymphatics and blood vessels
cannot metastasize
classified as ductal carcinoma in situ (DCIS) or lobular carcinoma in situ
(LCIS) on the basis of the resemblance of the involved spaces to ducts and
lobules
Invasive carcinoma (syn "infiltrating" carcinoma)
has invaded beyond the basement membrane into stroma
can invade into the vasculature
cause regional lymph node metastasis
cause distant sites
types - Invasive ductal carcinoma and Invasive lobular carcinoma
All carcinomas arise from the terminal duct lobular unit, and the terms
"ductal" and "lobular" do not imply a site or cell type of origin
Ductal Carcinoma in Situ (DCIS; Intraductal Carcinoma)
consists of a malignant population of cells limited to ducts by the basement
membrane
myoepithelial cells are preserved
clonal proliferation involving only a single ductal system
cells can spread throughout ducts and lobules and produce extensive lesions
clinically cannot be detected by inspection or palpation
shows calcifications on mammography
progress to invasive carcinoma
proper diagnosis & appropriate therapy is important
associated with recurrence
Risk factors for recurrence
1. high grade
2. larger size
3. ill defined margins
death rate is < 2%
Microscopy
well differentiated, moderately differentiated or poorly differentiated
Well-differentiated tumors
o consist of tubules lined by minimally atypical cells
o express hormone receptors and do not overexpress HER2/neu.
poorly differentiated
o composed of anastomosing sheets of pleomorphic cells
o less likely to express hormone receptors & more likely to overexpress
HER2/neu
most carcinomas induce a marked increase in dense, fibrous desmoplastic
stroma, giving the tumor a hard consistency on palpation and replace fat,
resulting in a mammographic density (scirrhous carcinoma)
Morphology
Gross
firm to hard with an irregular margin
Micro:
hallmark is the pattern of single
infiltrating tumor cells often only one
cell in width (Indian file)
desmoplastic response may be
minimal or absent
cells have the same cytologic
features as LCIS and lack cohesion,
without formation of tubules or
papillae
signet-ring cells are common
cells are arranged in concentric rings
surrounding normal ducts
Metastasis
lymphnode
lungs
bones
liver
adrenals
brain
meninges
Prognostic Factors
Major prognostic factors
o insitu / invasive
o distant metastasis
o lymphnode metastasis
o tumour size
o local invasion
1. Invasive carcinoma or in situ disease
in situ carcinoma cannot metastasize associated with better prognosis.
invasive carcinomas associated with poor prognosis
2. Distant metastases - associated with poor prognosis
3. Lymph node metastases
most important prognostic factor in the absence of distant metastases
o No nodes - 70% to 80% (10 Yrs survival)
o 1 to 3 nodes 35% to 40%
o > 10 nodes 10% to 15%
4. Tumour size
second most important prognostic factor
node-negative carcinomas under 1 cm in diameter have best prognosis
10-year survival is approximately 90%
5. Local invasion
into skin or skeletal muscle are associated with distant disease
6. Inflammatory carcinoma
poor prognosis
Minor Prognostic Factors
o histological subtype
o tumour grade
o ER/PR receptor
o HER2/neu
o lymphovascular invasion
o proliferative rate
o DNA content
STROMAL TUMORS
There are two types of stroma in the breast, intralobular and interlobular.
Biphasic tumors arise in the interlobular stroma
o fibroadenoma
o phyllodes tumor
Fibroadenoma
Intro:
Macroscopy
spherical nodules
well-circumscribed
1 cm to large size
C/S solid, grayish white nodules
and contain slit like spaces
Micro:
stroma is cellular, and often
myxoid, resembling intralobular
stroma
glandular and cystic spaces lined
by epithelium
epithelium may be surrounded by
stroma or compressed and
distorted by it
border is sharply delimited from
the surrounding tissue
Introduction:
term "phyllodes tumor" is preferred, as the majority of these tumors behave
in a relatively benign fashion, and most are not cystic.
Origin:
tumour arises from intralobular stroma
6th decade
Clinical Features:
palpable masses
Macroscopy:
vary in size (few centimeters to massive lesions involving the entire breast)
C/S shows bulbous protrusions ("leaflike") into the cystic spaces
Microscopy:
Stroma high cellularity, mitotic rate, nuclear pleomorphism
Epithelium covering the stroma and extending into the cystic spaces
Borders infiltrative
Clinical significance:
must be excised with wide margins or by mastectomy
majority are low-grade; recur locally
minority high-grade; recur locally and metastases by haematogenous
o only the stromal component metastasizes
axillary lymph node dissection is not indicated
Casts
Introduction:
Urinary casts are formed in the distal convoluted tubule (DCT) or the collecting duct.
The proximal convoluted tubule (PCT) and loop of Henle are not locations for cast formation.
Hyaline casts are composed primarily of a mucoprotein (Tamm-Horsfall protein) secreted by
tubular cells.
Coombs serum
Broad spectrum Anti IgG + Anti C
Specific
Anti IgG / Anti IgM / Anti C
Types of Coombs Test
Direct Antiglobulin Test (DAT)
to find out whether the patients RBCs are coated with incomplete antibodies
Indirect Antiglobulin Test (IAT)
to find out whether incomplete antibodies are present in the patients serum
Result
Agglutination positive; No agglutination negative
Method:
DAT
add 2 drops of 3% RBC suspension
take 2 drops of Coombs serum
incubate at 37C X 1 min
centrifuge at 250g C 1 min
read the results microscopically
IAT
IAT - applications
1. screening the sera as a means of antibody detection
2. characterising alloantibodies in typing unknown cells
3. as a cross matching procedure
Cytology
Introduction:
Cyto = cell; Logy = study
It is an important diagnostic tool and is a sub specialty of pathology.
Division:
1. Exfoliative cytology
2. Fine Needle Aspiration Cytology (FNAC)
1. Exfoliative cytology
It deals with cells exfoliated from the surface. They are obtained by scraping the surface
or aspirating the fluid
Papsmear cells exfoliated from cervix
Sputum cells exfoliated from bronchopulmonary tree
Gastric lavage Stomach
Pleural, Ascitic, CSF
2. FNAC:
Cells are obtained by aspirating the lesion using a fine needle (23G) and a 10 ml syringe
e.g.,
palpable lesions - breast, thyroid, lymphnode etc.
deep - lung, pancreas, liver, prostate, kidney etc.
Procedure:
Cells are made into smears on the slides
Smears are either air dried or fixed in alcohol
They are stained by papstain or Romanawsky stain and are examined under the
microscope.
Application:
diagnosis of early cancer
female genital tract especially the cervix
respiratory tract especially the lung
genitourinary tract
diagnosis of lumps
palpable lesions - breast, thyroid, lymphnode etc.
deep - lung, pancreas, liver, prostate, kidney etc.
diagnosis of recurrent tumours / metastasis
population screening
Advantages:
outpatient procedure, does not require hospitalisation
does not require anaesthesia
rapid diagnosis
economical
less painful
Limitations:
less sensitive than histopathology
tissue architecture is not preserved
false negative occurs, if the needle did not hit the target.
Erythrocyte indices
(Absolute values or Wintrobes constant)
MCV (Mean corpuscular volume)
means volume of individual RBC
MCV =
PCV in Litre / Litre
RBC count / Litre
Short cut formula =
PCVX10
RBC in millions
Expressed in femtolitres
Normal value is 85 8 fl (77 93fl)
MCV (Mean corpuscular haemoglobin)
MCV=
Hb gm / Litre
RBC count / Litre
Short cut formula =
HbX10
RBC in millions
ESR
Definition:
is a rate at which the erythrocytes are getting sedimented
expressed as mm at first hour
Factors
specific gravity of RBCs
viscosity of plasma
difference between them
verticality of tube
bore of the tube
Specific gravity of RBCs is the most important factor.
directly proportional to rouleux formation
rouleux
fibrinogen
acute phase reactants (e.g., CRP)
immunoglobulin; globulin
rouleux
albumin
poikilocytosis (iron deficiency, sickle cell disease)
spherocytes (spherocytosis; artefact)
Stages of ESR:
1. Stage of rouleux formation (10 min)
2. Stage of settling (40 min)
3. Stage of packing (10 min)
Clinical significance
ESR has prognostic value rather than diagnostic.
ESR
chronic inflammation (TB, rheumatoid arthritis)
pregnancy
myocardial infarction
anaemia
multiple myeloma
ESR
polycythaemia
congestive cardiac failure
hypofibrinogenaemia
sickle cell disease
spherocytosis
Methods
Westergrens method
Wintrobe method
MicroESR method
Automated method
Frozen Section
Principle:
when tissue is frozen, the water within the tissue turns to ice and in this state the
tissue is firm and the sections can be cut easily.
lesser the temperature, harder the tissue
Application:
on table diagnosis (about 15 min)
confirmation of malignancy, clearance of tumour margin
enzyme histochemistry
acetyl cholinesterase in Hirschprung disease, ATPase in muscle biopsy
non-enzyme histochemistry
lipid, some carbohydrates
immunohistochemistry
immunofluorescent staining
silver staining in neuropathology
Method: (-15C to -20C)
1. Cryostat
2. Freezing microtome
Technique:
Preparation of tissue either unfixed or fixed tissue. Rapid freezing by liquid
nitrogen or CO2 gas or aerosol spray
Cutting the sections require skill
Staining is also rapid, as there is no need for hydrating the sections.
Disadvantages:
expensive equipment
section cutting needs a well experienced technician
interpretation also needs a well experienced pathologist
false negative result
only small sample can be processed.
LE Cell
Introduction:
LE cell means Lupus Erythematosus cell.
LE cell preparation is a test to detect the presence of antinuclear protein antibody in the
patients serum (LE factor)
Positive in
SLE (75% of the cases) and also rarely in
lupoid hepatitis
drug reaction
rheumatoid arthritis
Principle:
LE factor lyses the neutrophil nucleus in vitro.
active neutrophils will phagocytose the lysed nucleus
Essential:
LE factor
nuclear protein material (i.e., traumatised WBC)
complement
actively phagocytic neutrophil
37C
Appearance:
LE cell is a neutrophil containing LE body which is round, structureless, opaque,
homogenous pale blue mass. The nucleus of the neutrophil will be pushed to the
periphery.
Advantages:
cost effective
simple technique.
Limitation:
Less sensitive than the serum estimation of anti nuclear antibodies.
Tart cell will be confused with LE cell.
Leukaemoid reaction
Definition:
It is a non leukaemic condition which microscopically resembles leukaemia
Types:
myeloid leukaemoid reaction, resembles CML
lymphoid leukaemoid reaction, resembles CLL.
Characteristics:
Total WBC count will be markedly elevated.
presence of immature WBCs i.e., metamyelocytes, myelocytes & promyelocytes.
Conditions:
infections
severe bacterial infection, disseminated TB, pertussis, hepatitis
malignancies
Hodgkin lymphoma
gastric, breast, lung cancers
intoxications
Differentiation from leukaemia:
blast will never occur in leukaemoid reaction. blasts will be present in leukaemia
and their number vary depends upon the type.
Neutrophil alkaline phosphatase (NAP) activity Increased in leukaemoid
reaction whereas decreased in leukaemia.
Leukocyte Cytochemistry
Introduction:
Leukocyte cytochemistry encompasses the techniques used to identify diagnostically
useful enzymes or other substances in the cytoplasm of haemopoietic cells.
These techniques are particularly useful for the characterization of immature cells in
the AMLs and the identification of maturation abnormalities in the myelodysplastic
syndromes and myeloproliferative disorders.
The use of cytochemistry to characterise lymphoproliferative disorders has been
largely superseded by immunological techniques
The results of cytochemical tests should always be interpreted in relation to
Romanowsky stains and immunological techniques.
Principal uses of cytochemistry:
1. Myeloperoxidase (MPO) Positive in AML with maturation; Negative in more
primitive myeloblast. (Brown)
2. Sudan Black same as MPO. (Black)
3. PAS Block positivity in ALL, AML M6 (Erythroblasts in erythroleukaemia) (Red)
4. Esterases ANAE (-Naphthyl Acetate Esterase) and ANBE (-Naphtyl Butyrate
Esterase) Monocytic series (Brown)
5. Neutrophilic alkaline phosphatase (NAP) scores is low in chronic phase of CML;
high in leukaemoid reaction (Blue)
6. Pearls reaction - demonstration of ring sideroblasts in MDS (Blue)
7. Tartrate-Resistant Acid Phosphatase (TRAP) positive in hairy cell leukaemia
(Brown)
Reticulocyte Count
Introduction:
Reticulocytes are juvenile red cells
they contain remnants of the ribosomal ribonucleic acid (RNA)
Principle:
RNA reacts with basic dye, brilliant cresyl blue, or New methylene blue to form a
blue or purple precipitate of granules or filaments.
This reaction takes place only in vitally stained unfixed preparations
Procedure:
Equal mixture of 1% dye mixed with blood and incubated at 37C for 15 minutes
Then smears are made
Observed under oil immersion.
Count 1000 consecutive RBC and express the reticulocyte in percentage.
Appearance:
Reticulocyte appears bigger than the mature RBC and contains blue precipitates in the
form of reticulum (net work) or granules.
Normal count:
0.2 to 2 %
Corrected Reticulocyte count:
= Observed Retic count X
Measured PCV or Hb
Appropriate Normal PCV or Hb
Significance:
The number of reticulocytes in the peripheral blood is a fairly accurate reflection of
erythropoietic activity.
Increased Haemolytic anaemia, Nutritional
anaemia responding to the treatment.
Decreased or Absent Aplastic anaemia,
Aplastic crisis in haemolytic anaemias.
Tumour Markers
Introduction:
A tumour marker is a substance found in the blood, urine, or body tissues that may be
elevated in cancer.
They are used in oncology to help detect the presence of cancer.
Production:
Tumour markers can be produced directly by the tumour or by non-tumour cells as a
response to the presence of a tumour.
Classification
Tumour markers can be classified in two groups: Cancer-specific markers and tissuespecific markers.
Cancer-specific markers
Cancer-specific markers are related to the presence of certain cancerous tissue. Because
there is a large overlap between the many different tumour tissue types and the markers
produced, these markers might not be specific in making a diagnosis. They can, however,
be useful in the follow-up of treated patients to describe progress of the disease or
response to treatment.
CEA, or carcinoembryonic antigen
first noted to be produced by tumours of the gastrointestinal system
it was also produced by the occasional lung and breast cancer
an elevated level does not necessarily mean a bowel cancer. However, in a patient
with a history of a treated bowel cancer, a rising CEA level can be an early sign of
recurring bowel cancer.
Tissue-specific markers
related to specific tissues which have developed cancer
not specifically related to the tumour, and may be present at elevated levels when no
cancer is present
unlike the previous group, elevated levels point to a specific tissue being at fault.
o elevated PSA Ca prostate, hyperplasia or trauma to prostate
o elevated beta-HCG choriocarcinoma, hydatidiform mole, pregnancy
o elevated AFP liver cancer
Application:
* Screening for common cancers on a population basis
e.g., elevated prostate specific antigen suggests prostate cancer.
* Monitoring of cancer survivors after treatment
e.g., elevated AFP in a previously treated for endodermal sinus tumour suggests relapse.
* Diagnosis of specific tumour types, particularly in certain brain tumours and other
instances where biopsy is not feasible.
Limitations:
An elevated level of a tumour marker can indicate cancer; however, there can also be
other causes of the elevation. Hence, tissue diagnosis (biopsy & histopathological
examination) is required for confirmation.
Method of detection:
1. Biochemical method to detect the tumour markers in the blood and body fluids
2. Immunohistochemitry method to detect the tumour markers in the tissue.