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Research Article | DOI: https://doi.org/10.31579/2640-1053/246
1Head of Marketing and sales Riggs Pharmaceuticals, Karachi; Department of Pharmacy, University of Karachi, Pakistan.
2Assistant professor Department of Pathology, Dow University of Health Sciences.
*Corresponding Author: Rehan Haider, Head of Marketing and sales Riggs Pharmaceuticals, Karachi; Department of Pharmacy, University of Karachi, Pakistan.
Citation: Rehan Haider and Hina Abbas, (2025), Pathology - From Classics to Innovations a Systematic Review of Diagnostic Advances in Breast Cancer, J. Cancer Research and Cellular Therapeutics. 9(5); DOI:10.31579/2640-1053/246
Copyright: © 2025, Rehan Haider. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 04 July 2025 | Accepted: 11 July 2025 | Published: 18 July 2025
Keywords: pathology; artificial intelligence; microscopy; personalized medicine; telepathology
Pathology has undergone a remarkable transformation from its classical roots, characterized by gross anatomical and microscopic examinations, to a highly advanced, technology-driven discipline. The integration of digital imaging, artificial intelligence (AI), and molecular diagnostics has revolutionized the field, enabling unprecedented precision in disease detection and classification. Modern innovations, such as immunohistochemistry, next-generation sequencing, and liquid biopsies, have expanded the diagnostic toolkit, enabling earlier detection and more personalized treatment strategies, particularly in oncology. Digital pathology and AI-powered image analysis tools have enhanced diagnostic accuracy, reduced inter-observer variability, and facilitated remote consultations through telepathology, thereby improving accessibility in underserved regions. Moreover, molecular profiling of tumors has refined our understanding of disease heterogeneity and informed targeted therapies. However, these advancements come with challenges, including the high cost of implementation, the need for specialized training, and evolving regulatory standards. Ethical concerns around data privacy and AI use in clinical settings also warrant attention. Despite these barriers, the continued evolution of pathology promises to enhance diagnostic workflows, streamline clinical decision-making, and ultimately improve patient outcomes. Future research should focus on integrating these innovations into routine clinical practice while ensuring equitable access to emerging technologies across diverse healthcare settings.
Breast malignancy remnants are one of ultimate widespread malignancies worldwide and are a chief cause of tumor-related death in women. Each year, nearly 2.1 heap new cases are diagnosed, accompanying a supposed mortality rate of 15% (300,000 graves occurring) [1,2].
Breast cancer circumscribes an assorted group of diseases accompanying specific biological practices, healing responses, and prognostic associations. The categorization of breast tumors has developed from a purely histological foundation to a microscopic-based approach, including histopathological patterns, oncogene verbalization, and hormonal receptor status, generally judged through immunohistochemistry [3,4].
Recent research has identified novel microscopic gravestones that have refined bosom malignancy classification. The change from a histological system to a microscopic study of a plant-based approach has considerably revised diagnostic veracity, aiding better treatment pick and prognostic amount. These microscopic insights have surpassed the growth of targeted cures supervised at specific historical alterations, considerably improving patient endurance rates [5,6].
Despite advances in microscopic diagnostics, early discovery utilizing traditional clinicopathological categorization debris is the most active design for therapeutic preparation [7]. However, situation options for state-of-the-art-stage tumors, specifically triple-negative conscience tumors, remain restricted. Ongoing research aims to recognize new molecular aims for future dispassionate applications [8-10].
Molecular Subtypes of Breast Cancer
At the beginning of the 21st century, bosom cancer categorization was mainly established histological characteristics. The World Health Organization (WHO) has cultured allure classification of feelings tumors, combining microscopic subtyping to enhance prognostic veracity and situation pick (Table 1).
WHO Classification of Breast Tumors (5th Edition, 2019)
Benign Epithelial Proliferations and Precursors: Usual Ductal Hyperplasia, Columnar Cell Lesions, Atypical Ductal Hyperplasia, etc.
Invasive Breast Carcinoma Subtypes: Infiltrating Ductal Carcinoma (NOS), Lobular Carcinoma, Tubular Carcinoma, Mucinous Carcinoma, etc.
Neuroendocrine Neoplasms: Small Cell Neuroendocrine Carcinoma, Large Cell Neuroendocrine Carcinoma, etc.
The microscopic subtypes of bosom cancer of clinicopathologic significance
At the beginning of the 21st century, conscience tumor was classified for the most part on a histologic base. The WHO's current histologic categorization of breast malignancy is illustrated in Table 1. Photomicrographies of ultimate frequent histologic subtypes of obtrusive breast malignancy are presented in Figure 1. The hormonal rank receptors (estrogen and progesterone) expression for one neoplastic container was just judged by immunohistochemistry on paraffin-embedded samples of the lump (gist annoy biopsy or the surgical extraction example) [6, 7].
WHO Classification of Epithelial Breast Tumors (5th Edition, 2019)
Benign Epithelial Proliferations and Precursors
Usual Ductal Hyperplasia
Columnar Cell Lesions, containing Flat Epithelial Atypia
Atypical Ductal Hyperplasia
Adenosis and Benign Sclerosing Lesions
Sclerosing Adenoma
Apocrine Adenoma
Microglandular Adenosis
Radial Scar/Complex Sclerosing Lesion
Adenomas
Tubular Adenoma
Lactating Adenoma
Duct Adenoma
Epithelial-Myoepithelial Tumors
Pleomorphic Adenoma
Adenomyoepithelioma (NOS)
Adenomyoepithelioma accompanying Carcinoma
Epithelial-Myoepithelial Carcinoma
Papillary Neoplasms
Intraductal Papilloma
Ductal Carcinoma In Situ, Papillary
Encapsulated Papillary Carcinoma
Encapsulated Papillary Carcinoma Accompanying Invasion
Solid Papillary Carcinoma In Situ
Solid Papillary Carcinoma Accompanying Invasion
Intraductal Papillary Adenocarcinoma Accompanying Invasion
Non-Invasive Lobular Neoplasia
Atypical Lobular Hyperplasia
Lobular Carcinoma In Situ (NOS)
Classic Lobular Carcinoma In Situ
Florid Lobular Carcinoma In Situ
Lobular Carcinoma In Situ, Pleomorphic
Ductal Carcinoma In Situ (DCIS)
Intraductal Carcinoma, Non-Infiltrating (NOS)
DCIS of Low Nuclear Grade
DCIS of Intermediate Nuclear Grade
DCIS of High Nuclear Grade
Invasive Breast Carcinoma
Infiltrating Duct Carcinoma (NOS)
Oncocytic Carcinoma
Lipid-Rich Carcinoma
Glycogen-Rich Carcinoma
Sebaceous Carcinoma
Lobular Carcinoma (NOS)
Tubular Carcinoma
Cribriform Carcinoma (NOS)
Mucinous Adenocarcinoma
Mucinous Cystadenocarcinoma (NOS)
Invasive Micropapillary Carcinoma of the Breast
Apocrine Adenocarcinoma
Metaplastic Carcinoma (NOS)
Rare and Salivary Gland-Type Tumors
Acinar Cell Carcinoma
Adenoid Cystic Carcinoma
Classic Adenoid Cystic Carcinoma
Solid-Basaloid Adenoid Cystic Carcinoma
Adenoid Cystic Carcinoma accompanying High-Grade Transformation
Secretory Carcinoma
Mucoepidermoid Carcinoma
Polymorphous Adenocarcinoma
Tall Cell Carcinoma accompanying Reverse Polarity
Neuroendocrine Neoplasms
Neuroendocrine Tumor (NOS)
Grade 1
Grade 2
Neuroendocrine Carcinoma (NOS)
Small Cell Neuroendocrine Carcinoma
Large Cell Neuroendocrine Carcinoma
Table 1.
Current histologic (morphologic) categorization of epithelial bosom tumors (WHO, 2019, 5th version). This classification considers the tumors histologic patterns of tumors. The lowest histologic conscience tumor subtype is the penetrating duct malignant growth NOS (or obtrusive ductal malignant growth non-distinguished type), which is the reason for 65–80% of all breast cancers. Invasive lobular abnormal growth in animate beings agrees to about 5% of all feelings of malignancies.
Figure 1
Photomicrographs of hematoxylin & eosin (H&E) slides illustrating ultimate frequent histologic subtypes of permeating (invasive) bosom malignancy. (A) Infiltrating duct abnormal growth in animate being (Invasive ductal abnormal growth in animate being NOS) is ultimate frequent histologic subtype of breast malignancy (almost 75–80% of all obtrusive breast malignancy), established of cohesive malignancy containers making infiltrative ductal and ribbons constructions (4×); (B) Lobular obtrusive carcinoma is the second most frequent obtrusive bosom tumor (5–15% of all invasive conscience malignancy), collected of infiltrating malignancy containers with wordy distinct-file pattern (10×). In this subtype, the tumor cells drop the union (e-cadherin, an immunomarker main for cell cling judgment, is negative on immunohistochemistry); (C) Mucinous carcinoma shows nearly 2% of conscience invasive malignancy, the calm of groups of cancer containers outlining ductal forms, implicated in action mucin pools, with sensitive stringy strings containing capillaries (10×); (D) Tubular abnormal growth in animate being shows around 2% of obtrusive conscience malignancy, composed of helter-skelter composition of small well-changed pipe buildings, forming tubules (4×). The added filed obtrusive breast cancers are exceptional, accompanying each histologic subtype mirroring 1% or less (figures derived from [11]).
Breast tumor is known for allure and miscellaneous behavior [3, 4]. The histologic categorization is acceptable for the malignancy conclusion [6].
However, the dispassionate disconnection based on hormonal rank was defective for the accurate forecast of the forecast and of dispassionate response to healing [5]. Thus, as far as the last ten of something of 20th century, the dispassionate situation of breast malignancy was established as unespecific a destructive agent and hormonal therapy accompanying drugs like tamoxifen, a popular hormonal receptor antagonist [12].
The birth control method of definite bosom cancer is more “changed” than the negative individual, as the tumor cells uphold the epithelial original container feature of hormonal receptor expression and, thus, the hormonal adversary drugs are directed against these tumors [8]. On the other hand, the approach to hormonal negative cancers was changing, because it was forming a kindly assorted group, accompanying various aggressiveness potentials, vague healing answers, and doubtful forecasts [6, 8, 10].
In the first ten of something of the current century, it arose a hopeful categorization of breast malignancy, suggesting a division of the ailment into 3 microscopic subtypes: luminal, HER-2 overexpressed, and “threefold negative” (Table 1). This new classification has explained better equivalence accompanying the breast malignancy demeanor. Thus, it was adopted on the demonstrative routine of conscience tumors. Since this study was published, besides judging the histologic patterns and reporting the pathologic carcinoma stage, the pathologist has been required to decide the microscopic cancer description, which has enhanced indispensable to cure preparation [12, 13].
| Molecular Subtype | Biomarker Profile | Incidence (%) |
|---|---|---|
| Luminal A | ER+ and/or PR+, Ki-67 < 14> | 50–70% |
| Luminal B | ER+ and/or PR+, Ki-67 > 14% | 35–50% |
| Luminal B1 | ER+ and/or PR+, HER-2 negative | 5–15% |
| Luminal B2 | ER+ and/or PR+, HER-2 positive | 5–15% |
| HER-2 Overexpressed | ER- and PR-, HER-2 positive | 10–20% |
| Triple-Negative | ER-, PR-, HER-2 negative | 15–30% |
Table 1: Molecular Subtypes of Breast Cancer and Their Biomarker Profiles
The luminal subtype tumor is the hormonal definite tumor. This somewhat cancer is commonly well or quite changed in the study of animals, made by lower grades of containers, with lower proliferative index, that is judged by antitoxin Ki-67/MIB-1 on immunohistochemistry. Most conscience cancers are classified as this subtype (Figure 2). Eventually, luminal malignancy can overexpress or deepen happening at about the same time the protein named human epithelial tumor determinant receptor 2 (HER-2), codified apiece oncogen ERBB2 [14, 15].
Figure 2: Photomicrographies of the immunohistochemical estimate of obtrusive conscience cancer hormonal verbalization, in an instance of pervading pipe abnormal growth in animate being (Invasive ductal abnormal growth in animate being NOS, WHO 2019), which is the ultimate frequent histologic subtype of bosom malignancy, authorized by ductal and tape structures of malignancy containers pervading the bosom stroma (A). Any somewhat basic positivity of estrogen receptor (B) and progesterone receptor (C) admits to dealing with Cancer as helpful to hormonal receptors on immunohistochemistry, even when excellent cells are definite (C). The hormonal receptors' positivities on immunohistochemistry are judged for force (gentle, moderate, or powerful) and percentages of beneficial cells (0–100%). Examples of gentle readiness (inky missile, C), moderate alacrity (wine arrow, B), and forceful eagerness (green dart, C). Ki-67/ MIB-1 determines the carcinoma proliferative index (D), its zeal is basic and is articulated in percentages of helpful containers (0–100%).
ERBB2 is an oncogene local in chromosome 17, that codifies the HER-2 protein, a type I transmembrane protein accompanying extracellular and intracellular rules, stimulating indicating pathways from extracellular signals. In the last instance, the overexpression/amplification of HER-2 overactivated the intracellular protein kinases, dysregulating the container era, upsetting the container attachment and container polarity, and advancing the obtrusive phenotype [16].
The feelings malignancy top-secret as HER-2 subtype is necessarily negative for hormonal receptors and is promoted by overexpression or elaboration of HER-2. This subtype is repeatedly less changed than the luminal one on study of animal, constituted by extreme grades of tumor containers, accompanying extreme proliferative index. The presence of exalted aggregation of intratumoral lymphocytes (TIL) is not an exceptional verdict in these tumors [17].
This new receptor was individual of the pioneers for goal therapy in a microscopic cycle of bosom tumor nearing, as it was developed a new class of drug, named trastuzumab, accompanying discriminating
operation against the tumor containers overexpressing/amplifying HER-2. Besides the HER-2 subtype tumors, this drug is also urged for the luminal one accompanying certain rank for HER-2 [18, 19].
The rank of HER-2 expression is resolved through immunohistochemistry of paraffin-entrenched samples of the feelings tumor (Figure 3a). The tumor is thought-out negative for HER-2 if it is not described (score anything) or the container sheet is incompletely labeled for the HER-2 microscopic organism (score 1+). The carcinoma is helpful for HER-2 if all the container membrane outlines are powerfully labeled for this agent to negate the effect of an infection or poison (score 3+). Finally, in incomplete cases, the HER-2 often causing illness can label completely the malignancy container membrane, but accompanying depressed force, or can label incompletely the container membrane accompanying extreme force. In these positions, the HER-2 rank is thought-out equivocal (score 2+). The ratification of overexpression/elaboration must be judged through radiance “in seated position” hybridization (FISH) (Figure 3b) [21, 22].
Figure 3: (a) Photomicrography of immunohistochemical amount of HER-2 expression rank by way of tumoral bins in the histologic paraffinized pattern of bosom swelling. Score 0 (horrible): no man's tumoral field is tainted. Grade 1+ (weak): bare promptness following dropped pressure in any of the tumoral boxes. Grade 2+ (unclear): complete enthusiasm following discouraged pressure in adulthood of tumoral boxes. Score three+ (exact): whole skill accompanying powerful pressure in a maximum of tumoral Styrofoam crates. (b) Photomicrographies of illustration of HER-2 deoxyribonucleic acid done by way of brightness in situated function hybridization (FISH) in a HER-2-overexpressed conscience nonconforming progress lifeless act immunohistochemistry (grade 3+, E). HER-2 deoxyribonucleic acid copies are the muskmelon signals (B) and deoxyribonucleic acid 17 centromeres (CEP17) are the unskilled signals (C). The alerts of HER-2 deoxyribonucleic acid and CEP17 are present in tumoral box nuclei (common, A and D). CEP17 is an inside control at the permanent deoxyribonucleic acid to meet beliefs HER-2 signals in the tumoral capsule center. According to the American Society of Healing Oncology/seminary of American Pathologists (ASCO-CAP) information, a HER-2/CEP17 allotment > 2. Nothing delimits a valuable effect for illustration of HER-2 deoxyribonucleic acid. If HER-2/CEP17 portion is < 2> 6.0 alerts/basic delimits an exact result for illustration of HER-2 deoxyribonucleic acid, a middle HER-2 duplication number < 4> 4.0 and < 6>
The “three times as many negative” impressions carcinoma is bad for hormonal receptors and HER-2. It's 5 the much less exchanged lump subtype on the study of animals, fashioned going around wonderful grades cyst bins, following ruler proliferative index, bestowing calamity forecast few of the three tiny subtypes. This lump however is missing a distinguishing remedy, this is wanted as long as the clinicopathological quality. In metastatic disorder, the position focuses on exceptional increase and remedy. In “three times as many negative” tumors, the day of reckoning of BRCA rank is lively [8, 21].
3 Germline mutations of BRCA-1/BRCA-2 genes: raised risk of conscience malignancy happening during the existence
Identified in 1994, BRCA-1/BRCA-2 are tumoral suppressor genes, individually situated in deoxyribonucleic acid 17 and 13. Mutations of these genes have had a connection with inherited conscience tumors, estimated in 5–10% of all conscience malignancies. BRCA-1/BRCA-2 plays a main duty in DNA repair [23, 24]. Mutations of these genes increase the susceptibleness for DNA damage. “Triple negative” subtypes accomplish often mutations of BRCA-1 and mutations of BRCA-2 increase the risk for luminal subtypes of bosom tumor. HER-2 overexpression is inversely compared to BRCA mutations [24, 25].
It was noticed in a few studies that “threefold negative” bosom cancers accompanying BRCA mutations present more chemosensitivity than the ones without BRCA mutations. Chemotherapy accompanying DNA-detrimental drugs, like the alkylating powers and anthracycline, can extend the innocent affliction endurance for tumors of threefold negative phenotypes. This was found proper, because BRCA metamorphosis prejudices the DNA repair and, as a consequence, increases the responsiveness to DNA damage of tumor containers by these drugs. Neither healing response nor innocent ailment continuation of luminal subtypes of conscience malignancy appears expected affected by BRCA mutations [8, 24, 26].
Regarding prognosis, multiple studies present contradictory results. The forecast depends on swelling visage, especially the microscopic subtypes and the clinicopathologic stage. The predicting value depends on the administrated analysis. Thus, the BRCA-1 mutated conscience tumor presents a poor forecast than the BRCA-2 mutated one because BRCA-1 mutated tumors are mainly of “threefold negative” phenotype, accordingly essentially more belligerent than the luminal subtypes hiding BRCA-2 mutations [24, 27].
The tumoral suppressor proteins systematized by BRCA-1/BRCA-2 take action similar to recombination repair of double-stranded DNA breaks. The homologous recombination method covers the uprightness of the genome in multiplying containers. BRCA-1 sees DNA damage and recruits DNA repair proteins. BRCA-2 mediates the conscription of another protein, called RAD51, to double marooned DNA breaks, admitting for similar recombination repair [24, 28].
In BRCA-mutation bosom tumors, the base extraction repair road is the main for cancer container continuation, in answer to alone marooned DNA breaks. Polyadenosine diphosphate-ribose (PARP) is a classification of DNA repair enzymes, that perform a key duty in base excision repair devices. These enzymes are inducted to the spot of DNA damage and adjoin ADP-ribose to aim basic proteins, beginning post-translational modifications and continuing stalled DNA copy. BRCA-mutation conscience tumor presents inadequacy of similar recombination repair, accompanying overactivated PARP, leading the tumor container to prevent apoptosis [24, 26, 28].
The hindrance of PARP cause persistance of alone abandoned break, developing install replication and double string breaks. This device leads to aggregation of DNA damage, inducing container phase arrest and apoptosis. The PARP inhibitors form an arising class of drugs, that have been urged to a destructive agent for BRCA-mutation feelings malignancy and tentatively for metastatic conscience cancer, accompanying hopeful results [24, 25, 28].
Cancer stem-container theory: impact in breast tumor forecast
In the last two decades, exploratory evidences in several studies of neoplastic tissues have told a state of malignancy container with features of self-recurrence, distinction to multiple lineages capability and reduced proliferative index. These characteristics have been deliberate malignancy stem-container like features and assign to a likely tumor stem-cell ancestry present in the cyst most [29, 30].
Cancer stem containers have awakened interest in the context of feelings of malignancy by way of their characteristic variety of organic practices and therapeutic reactions. It has been speculated that cancer stem containers may be an individual of the causes of the extreme variability of organic and prognostic range of feelings cancer. Cancer-stem container power plays a main role in healing fighting and the progress of the disease, moving the overall and innocent affliction continuation [31, 32].
Thus, an important feature that admits attainable cancer stem-container opposition to a destructive agent is its reduced verbalization of surface proteins. Because of allure self-renewal characteristics, tumor stems containers do not depend on signaling from additional containers to originate allure functions in tumoral tissues. Furthermore, for its reduced antigenicity and reduced increase index, there are few options for drug interplays. DNA damage powers are poor directly against these containers perhaps due to a lack of proliferation, also new classes of drugs, like PARP inhibitors, that better take action containers in the proliferative phase [31, 33].
One of the attainable pathways for bosom tumor therapeutic fighting captured ahead the time may be elucidated by communities of cancer stem-containers not removed, picked by diversified chemotherapy eras. Tumoral container's lazy proliferation development is more hitten, growing the bulk of indolent containers accompanying stem-like lineaments in cancer container culture. Through the volume of multilineage differentiation, malignancy stems containers power create new daughter containers accompanying more aggression and chemoresistance [32, 34].
The identification of tumor stem containers is questioned. First, because of its uneven dispersion in selected lump amounts. Second, for description, these containers are commonly scarce in tumor size. In this way, these containers are better recognized through “in vitro” patterns, like natural breedings. However, the main hurt concerning this method is the fact of stem containers properly in various fashion in artificial environments, because the container phenotype verbalization depends on their interplays [32, 35].
Thus, several studies accompanying malignancy stem-containers in different neoplastic tissues have existed consummate accompanying conflicting results. An appealing means to recognize these cells in their original atmosphere is the immunohistochemistry acted on amounts of paraffin-entrenched neoplastic tissues, accompanying the advantages to admit the judgment of phenotype verbalization next to the sensibility and expected surely performed and cost-influence in demonstrative routine [35].
In the last age, some presumed stem-container stones discovered by immunohistochemistry have been proven in paraffinized tissues of bosom malignancy. Multiple studies have demonstrated that verbalization of presumed stem-container markers by tumoral containers appears to bad for the prognosis and endurance in conscience malignancy. The most frequently studied stem-container stones are CD24, CD44, CD133, and EPCAM, accompanying two labeled putative stem-container phenotypes: CD24 depressed/CD44 improved and co-expression of CD133 and EPCAM (Figure 4). Besides the shortage of stem-containers in neoplastic tissues, the conflictous results of these studies may be explained by an essentiality to approximate study of these markers verbalization, particularly for the infrequency of stem-containers [32, 36].
Figure 4.
Photomicrographies of double-marked plain stained presumptive CSC antibodies (400×, original praise, immunoperoxidase, and DAB). (A) CD133: cytoplasm positivity (immunoperoxidase); (B) EPCAM: sheath positiveness (DAB); (B) CD133+/EPCAM+: CSC profile (hopeless projectile: membrane alacrity to DAB and cytoplasm eagerness to immunoperoxidase at the same container); (C) CD24: cytoplasm alacrity (immunoperoxidase); (D) CD24−/CD44+: CSC profile (inky missile: membrane readiness only to DAB)
In a few studies, identification of a stem-container-like phenotype CD24 depressed/CD44 enriched has biased the innocent disease endurance, exceptionally in cases of early stages of feelings tumor, with more incidents of faraway metastasis and malignancy frequency after surgical and secondary situations. The presence of malignancy containers with eagerness for tumor stem-cell phenotype CD133/EPCAM has had a connection with poor overall endurance in bosom cancer, accompanying secondary therapeutic abandon [32].
For the moment, these presumptive stem-cell phenotypes appear expected independent prognostic determinants in feeling cancer. “Triple negative” feelings tumor and BRCA-1 mutant feelings tumor have existed associated with stem-container-like phenotype CD24 depressed/CD44
enriched. These presumptive stem-container markers can enhance possible future aims for new drugs from now on [30, 32].
5 Immunologic facets had a connection with Breast Cancer
In the circumstances of the tumor, the immune arrangement can restrain the lump growth apiece demolition of malignancy cells or hindrance of their consequence. On the other hand, the immune arrangement can imitate Cancer progression for one collection of swelling cells that are used to bear in an immunocompetent host or modify the lump atmosphere to facilitate the Cancer outgrowth [37].
Elevated levels of CD4+ supervisory T lymphocytes (Tregs) in the direction of many cancers are joined to poor prognosis. Tregs form an encouraging immunosuppressive microenvironment for the projection and progression of the cyst. On this habit, FOXP3 is articulated by the Tregs and may be discovered by immunohistochemistry. FOXP3 arranges induction and support of fortitude to self-antigens in normal containers, also this immunotolerance may be performed for one Tregs accompanying malignancy cell antigens [37, 38].
Another model of tumor container escape mechanism from the invulnerable arrangement is caspase-8 mutations present in “threefold negative” breast cancers and different stable diseased tumors. These mutations abolish the obliteration persuaded by cytotoxic lymphocytes CD8+ in tumoral containers [37, 39].
The activation of T lymphocytes by overseas antigens happens by contributing to major histocompatibility complex (MHC) irritant performance and co-verbalization of T-cell receptor (TCR). At the same time, kin of T-container transmembrane proteins CD28/B7, named “immune checkpoints”, produce co-inhibitory or co-stimulatory signals. The invulnerable checkpoints organize the T-cell immunotolerance to care for the tissues from unacceptable damage. Cancer containers may produce signals to restrict T-container operation, through cytotoxic T-lymphocyte associated irritant-4 (CTLA-4), prioritize container death-1 (PD-1), and allure ligands (PDL-1) [37, 40].
PD-1 is an inhibitory “invulnerable checkpoint” articulated on the surface of T-containers, B-containers, and NK-containers. When T-cells have mobilized by their TCR, the containers express at the same time PD-1, which is feasibility for the assaulted cell to escape from the invulnerable backlash (Figure 5). Cancer containers express the ligand PDL-1 on their surfaces, activating PD-1 of T-containers, emerging from the attack [37, 40].
Figure 5
Simplified diagrammatic drawing of PD-1/PDL-1 interactions in invulnerable reactions against cancer container. Tumoral antigens (Ag) are bestowed via T-container by the big histocompatibility complex (MHC) of dendritic containers. T-container perceives tumoral Ag via TCR (T-container receptor). Interaction Ag-TCR induces a helpful immune reaction against tumoral Ag. Though, skilled is a scape machine of malignancy cell from the T-container attack: interplay of set up death container ligands (PDL-1/2) articulated by cancer container accompanying PD-1 expressed by T-container prevent the T-cell operation. This view mechanism of malignancy container mimics the rule action to prevent invulnerable responses of T-containers against self-antigens. The law of immune analysis is the hindrance of PD-1/PDL-1 (extracted from [40]).
PD-L1 verbalization has happened guide large lump proportion, high grade, extreme increase, estrogen receptor (ER)-negative status, and human epidermal development determinant receptor-2 (HER2)-positive rank in feelings malignancy. Survival in breast malignancy is with the order reversed related to PD-1/PDL-1 levels. PDL-1 verbalization increases cyst aggressiveness, exciting tumorigenesis, invasiveness, and skill to escape from cytotoxic T CD8+ lymphocyte attacks [39, 41]. The immunohistochemical evaluation of PDL-1 is proved in Figure 6.
Figure 6
Examples of PDL-1 verbalization in conscience cancer utilizing 3 various antibodies: Dako 22C3 (D, E, and F), Ventana SP263 (G, H, and I), and BioCare RbM CAL10 (A, B, and C). PDL-1 cut is divided into 3 groups: nothing staining is negative, 1–49% of certain containers are considered “depressed PDL-1 verbalization” and 50% of more helpful cells are deliberate “extreme PDL-1 verbalization”. Examples of negative, low, and extreme PDL-1 verbalization are presented on A, B, and C for BioCare antibodies (culled from [42]).
Immune healings accompanying anti-CTLA-4 and antagonistic-PD1/antagonistic-PDL-1 powers have been hopeful for medicating various cancers. In breast malignancy, few researchers stated positive results in about 20% of bosom tumors in situations with these powers, for the most part, the “threefold negative” and HER-2 subtypes, for their higher antigenicity. In general, bosom tumors present lower immunogenicity than different cancers and breast malignancy containers commonly create an immunosuppressor carcinoma microenvironment by indicating [37, 43].
The demeanor of tumor permeating lymphocytes (TIL) in a few feeling cancers has had a connection with a friendly forecast, especially in “threefold negative” and HER-2 subtypes. TIL are made principally by T-cells CD3+/CD56 negative, that are either CD4+ or CD8+. A youth component of B-containers CD20+ and NK-cells concede possibility show. The attractiveness of TIL by cancer containers has had a connection with their expression of a few chemokines, like CXCL9 and CXCL13 [37, 44].
In “threefold negative” and HER-2 subtypes of conscience cancer, the demeanor of TIL is had connection with a better answer to neoadjuvant therapy, also neoadjuvant situation grant permission modify the swelling microenvironment to engage TIL to carcinoma site. Furthermore, when the TIL are not brought a suggestion of correction neoadjuvance, it is exhibitive for bad forecast [44].
6. Advanced stage bosom malignancy: considerations undercurrent approach and future outlooks
Metastatic feelings cancer is deliberately unchangeable at this time with no remedies. Therapy of metastatic affliction aims to guarantee quality of existence, relief of symptoms, and extension of the patient continuation. Advanced stage affliction is becoming more and more never-ending, conditional sequential therapies, accompanying made-to-order approach than the inception of breast malignancy [8].
Systemic analysis is repeatedly the first choice of metastatic affliction. Before the new healing resolution, it is necessary to believe the former situations. If possible, it is recommended to reconsider the histologic facial characteristics and microscopic subtype status of the metastatic wound through a new medical checkup, accompanying a new immunohistochemical study for hormonal receptor and HER-2 status. Some studies stated just before 40% of discrepancies of metastatic lesion histologic appearance and microscopic subtype rank versus basic cyst histologic and immunohistochemical facets [45].
The metastatic disease healing selections follow positive aims to hit the neoplastic containers. Thereby, the expression of hormonal receptors for one metastatic wound is important for endocrine therapy. Endocrine drugs involve tamoxifen, aromatase inhibitors, fulvestrant and progestins. The use of these drugs in often major accompanying hormone receptor definite rank has illustrated an increase of free of ailment continuation in various studies [8, 45].
Furthermore, generation after baby boom of drugs that restrict the cyclin-dependant kinase (CDK) has been profitable in the extension of innocent ailment survival in luminal subtype HER-2 negative metastatic ailment. CDK4/6 is a holoenzyme being the reason for various extracellular indicating pathways to cell era changes. CDK4/6 fosforilates and inactivates retinoblastoma cyst suppressor protein (Rb). Extracellular signals organize the expression of cyclins and CDK inhibitors, like p16INK4a [46].
In human malignancy, this track is dysregulated by either the overexpression of cyclin D1, the misfortune of p16Ink4a, the metamorphosis of CDK4 to an Ink4-refractory state, or the misfortune of Rb itself. The basic goal of CDK4 is the Rb protein, though this holoenzyme either can phosphorylate determinants involved in container distinction moving their transcriptional endeavor, apoptotic factors moving their project, and additional determinants that can directly influence mitochondrial function [8, 46, 47].
Therefore, CDK inhibitors act in carcinoma microenvironment, obstructing Rb phosphorilation and superior to cell era exit. Moreover, CDK have kinase venture towards SPOP, an ubiquitin protein that communicates accompanying PDL-1. CDK inhibitors lead to restriction of SPOP phosphorilation accompanying barrier of PDL-1 and provocation to PD-1 expression by T-containers, appealing to T-container combination to the tumor. In this way, the linked use of CDK inhibitors and PDL-1/PD-1 inhibitors can be hopeful, needing more future studies [46, 47, 48].
For the moment, hormonal receptors and HER-2 rank are the few substantiated microscopic marks of dispassionate importance on metastatic conscience malignancy nearing through a destructive agent and endocrine therapy. For HER-2 certain metastatic afflictions, antagonistic-HER-2 situation with trastuzumab is traditional and is urged as shortly as likely. Immune therapy is not patterned for metastatic conscience malignancy, because metastatic breast ailment is well various. Though it is a hopeful therapy for the future, it also aims for microscopic analyses, which enhance more direct accompanying findings of novel pathways and mutations by new studies to be grown [8].
A take up of main biomarkers of clinicopathologic significance for feelings cancer administration is proved in Table 2 and a suggestion of a treasure for clinicopathologic evaluation of bosom malignancy is bestowed in Table 3.
| Biomarker | Detection Technique | Nature | Clinicopathologic Importance |
|---|---|---|---|
| Hormonal Receptors / HER2 | IHC / FISH | Biomarkers of molecular subtypes of breast cancer | Targets for endocrine and anti-HER2 therapies; prognostic predictors |
| BRCA1 / BRCA2 | PCR sequencing | Biomarker of hereditary breast cancer | Target for PARP inhibitors; indication for screening of other malignancies |
| CD24, CD44, CD133, EPCAM | IHC | Putative stem-cell biomarkers | Prediction of poor prognosis, tumor progression risk, and survival reduction |
| PD-1 / PDL-1 | IHC | Biomarker of possible inhibited immune response of T-cells against cancer cells | Target for immunotherapy using PD-1/PDL-1 antagonists |
| TILs (Tumor-Infiltrating Lymphocytes) | Histologic assessment and IHC | Marker of better cellular-mediated immune response against cancer cells | Predicts better therapeutic response, especially to neoadjuvant therapies |
1HC = Immunohistochemistry.
2TILs = Tumoral permeating lymphocytes.
Table 2: Summary of Main Biomarkers of Clinicopathologic Importance for Breast Cancer Management
| Step | Evaluation Criteria | Tests/Methods | Clinical Significance |
|---|---|---|---|
| 1. Patient History & Physical Exam | Family history, risk factors, symptoms (lump, pain, nipple discharge, etc.) | Clinical breast exam (CBE) | Identifies high-risk patients and symptomatic cases |
| 2. Imaging Studies | Suspicious findings in clinical exam | Mammography, ultrasound, MRI | Differentiates benign vs. malignant lesions, detects non-palpable tumors |
| 3. Biopsy & Pathologic Diagnosis | Suspicious imaging findings | Core needle biopsy, fine-needle aspiration, excisional biopsy | Confirms malignancy and histologic subtype |
| 4. Histopathologic Evaluation | Tumor type, grade, lymphovascular invasion | H&E staining, Nottingham grading system | Determines tumor aggressiveness and prognosis |
| 5. Immunohistochemistry (IHC) & Biomarker Analysis | Hormone receptor (ER, PR), HER2 status, Ki-67 proliferation index | IHC, FISH (for HER2) | Guides targeted therapy (hormonal, HER2-directed) |
| 6. Molecular Testing (if indicated) | High-risk or triple-negative cases | Oncotype DX, Mammaprint, BRCA mutation testing | Predicts recurrence risk, eligibility for chemotherapy or genetic counseling |
| 7. Staging & Metastatic Workup | Tumor size, nodal involvement, distant metastases | TNM classification, CT, PET-CT, bone scan | Determines stage and treatment plan |
| 8. Multidisciplinary Tumor Board Review | Integrative case discussion | Oncology, surgery, radiology, pathology review | Optimizes treatment strategy based on case-specific factors |
| 9. Treatment Planning | Surgery, radiation, systemic therapy | Breast-conserving surgery (BCS), mastectomy, neoadjuvant/adjuvant therapy | Individualized treatment approach for best outcomes |
| 10. Follow-up & Surveillance | Recurrence risk, long-term monitoring | Regular clinical exams, imaging, tumor markers | Ensures early detection of recurrence or new malignancies |
Table 3: Proposal of an Algorithm for Clinicopathologic Evaluation of Breast Cancer
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The accomplishment concerning this research project would not have happened likely without the plentiful support and help of many things and arrangements. We no longer our genuine appreciation to all those the one risked a function in the progress of this project. I herewith acknowledge that:
I have no economic or added individual interests, straightforwardly or obliquely, in some matter that conceivably influence or bias my trustworthiness as a journalist concerning this Manuscript
The authors declare that they have no conflicts of interest.
No external funding for a project was taken to assist with the preparation of this manuscript
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