Original article / research
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2022 |
Month :
July
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Volume :
11 |
Issue :
3 |
Page :
PO10 - PO16 |
Full Version
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Comparison of Cytological and Histomorphological Findings in Breast Tumours- A Study from a Tertiary Care Hospital in Southern India
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Subhashini Ramamoorthy, Sankappa P Sinhasan, Basavanandaswami C Harthimath
1. Senior Resident, Department of Pathology, JIPMER, Pondicherry, India.
2. Associate Professor and Head, Department of Pathology, Indira Gandhi Medical College and Research Institute, Pondicherry, India.
3. Associate Professor, Department of Surgery, Indira Gandhi Medical College and Research Institute, Pondicherry, India.
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Correspondence
Address :
Subhashini Ramamoorthy, Sankappa P Sinhasan, Basavanandaswami C Harthimath,
Dr. Sankappa P Sinhasan,
Department of Pathology, IGMC and RI Kathirkamam, Pondicherry-605009, India.
E-mail: drspsinhasan@gmail.com
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| | | ABSTRACT |  | : Introduction: Breast cancer is the most commonly diagnosed cancer and the leading cause of cancer death in females. There is increasing awareness and the associated anxiety and stress among women, who perceive every symptom in breast as carcinoma, compels the patients to seek medical advice. Fine Needle Aspiration Cytology (FNAC) is a relatively simple, reliable, atraumatic, economical and complication free technique for the evaluation of mass lesions.
Aim: To study the varied spectrum of breast tumours and to evaluate the diagnostic utility of cytological findings by comparing it with histopathological findings in breast tumours.
Materials and Methods: The present study was a hospital-based cross-sectional study conducted in the Department of Pathology, Indira Gandhi Medical College and Research Institute, Puducherry, India, from November 2017-October 2019. All cases of breast tumours, sent by surgeon, as out-patient or in-patient, who underwent FNAC followed by surgical biopsy, were included in this study. A total of 150 cases were studied. FNAC smears were stained using Haematoxylin and Eosin (H&E) and Papanicolaou (Pap) stains and air-dried smears were stained using May Grunwald Giemsa (MGG) stain. The excised specimen after surgery was subjected to detailed histopathological examination. Representative bits were taken from appropriate sites and stained using H&E stains, special stains and Immunohistochemistry (IHC) were carried out wherever necessary.
Results: Majority of cases were in the age group of 21-30 years. There were 149 cases of female patients and only one case of male patient with breast carcinoma during the study period. Cytology showed, 117 cases of benign tumours and 33 cases were malignant. Histopathology revealed 116 cases of benign tumours and 34 cases of malignant. One case was given as Atypical Ductal Hyperplasia (ADH) in cytology, found to be malignant Infiltrating Ductal Carcinoma (IDC) on histopathological examination. Five cases on cytology which were given as suspicious of carcinoma (C4 category) were found to be IDC on excision biopsy. Benign lesions were common in right breast, whereas malignant lesions were common in left breast. The diagnostic value of FNAC was assessed and showed sensitivity: 97.06%, specificity: 100%, Positive Predictive Value (PPV): 100%, Negative Predictive Value (NPV): 99.15% Accuracy of 99.33%.
Conclusion: The present study was an attempt to compare cytological and histomorphological findings in breast tumours to know the diagnostic accuracy of FNAC and also, studying the spectrum of breast lesions. The high specificity and negative predictive value showed high accuracy of FNAC in diagnosing the malignancy. It is an established method to determine the nature of breast lesions. In the present study, fibroadenoma was the commonest benign tumour and IDC-Not Otherwise Specified (NOS) type was the commonest malignant tumour.
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| Keywords
: Breast lesions, Fibroadenoma, Fine needle aspiration cytology, Histopathology, Infiltrating ductal carcinoma breast |
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| DOI and Others
: DOI: 10.7860/NJLM/2022/53673.2626
Date of Submission: Jan 03, 2022
Date of Peer Review: Feb 08, 2022
Date of Acceptance: Mar 18, 2022
Date of Publishing: Jul 01, 2022
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes
PLAGIARISM CHECKING METH |
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INTRODUCTION |
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The incidence of breast cancer in India has steadily increased and is expected to be the leading cause of cancer in women in the near future (1). Earlier cervical cancer was the most common cancer in Indian woman, but now the incidence of breast cancer has surpassed cervical cancer and is leading cause of cancer death, although cervical cancer still remains the most common in rural India (2). Breast is a site of a broad array of pathological alterations which includes benign and malignant lesions (3). Triple test is the combination of clinical evaluation, mammography, and cytological findings. Triple test when used in parallel leads to improvement of preoperative diagnosis and thus increasing the diagnostic accuracy to 99% (4). FNAC is a relatively simple, reliable, atraumatic, economical and complication free technique for the evaluation of mass lesions (5). FNAC slides were studied and the findings were recorded and classified according to National Health Service Breast Screening Programme (NHSBSP) reporting criteria used for classification of breast tumours and Robinson’s criteria. But, FNAC has some pitfalls in the diagnosis of proliferative breast diseases and histopathology is the gold standard in confirming the diagnosis (6). The present study was conducted with an aim of evaluating the diagnostic reliability of cytological findings by comparing with histopathological observations and studying the spectrum of breast tumours.
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Material and Methods |
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This was hospital-based cross-sectional study conducted in the Department of Pathology, Indira Gandhi Medical College and Research Institute, Puducherry, India, from November 2017-October 2019 after obtaining permission from Institute Ethical Committee (IEC) (IEC/PP/2017/46).
Inclusion criteria: All adult patients who underwent FNAC followed by surgery (core biopsy/excision) during the present study period were included, after taking informed written consent from the patients.
Exclusion criteria: Patients with non tumourous conditions like suppurative lesions and gynaecomastia and patient underwent only either FNAC or biopsy were excluded from the study.
Sample size calculation: Considering sensitivity for detecting malignant tumour using FNAC as 98% based on previous study (7), ? value as 5%, d (error of margin) as 6% and proportion of having target disorder (breast ca) as 14.6% based on last year hospital data. The sample size is calculated using the formula given below:
So, the estimated sample size is found to be 144.
A total of 150 cases fulfilled the inclusion criteria during the studied period in the present study.
Study Procedure
Aspiration was done using 22-24-gauge needle in a 10 mL syringe. Multiple smears were prepared from the aspirate and those immediately fixed in 95% ethanol was stained using H&E and Pap stains and air-dried smears were stained using MGG stain. All breast lesions were categorised into five categories from C1-C5, as per standard NHSBSP reporting criteria (8).
C1= Inadequate (This category was excluded from the study)
C2= Benign
C3= Atypia probably benign
C4= Suspicious for malignancy
C5= Malignant
Cytological grading of malignancies: Malignant lesions were given cytological grade Robinson’s criteria (9) based on six parameters: cell dissociation, size of nuclei, uniformity of cells, presence of nucleoli, nuclear chromatin and nuclear margins. Each parameter was given a score of 1, 2 or 3. These scores were added for grading breast cancer. Grade I-score between 6-11, Grade II-score between 12-14 and Grade III-score between 15-18.
The excised specimen after surgery was subjected to detailed histopathological examination. The gross and cut section findings were noted. Several bits were taken from appropriate sites and tissues were processed and the blocks were cut at 4-5 μm thickness and stained using H&E stains, special stains and IHC were carried out. Histologic Grade: (Elston and Ellis modification of Bloom & Richardson scoring system) (10).
Tubule and gland formation:
Score 1: >75% of tumour area forming tubular and or glandular structures
Score 2: 10-75% of tumour area forming tubular and or glandular structures
Score 3: <10% of tumour area forming tubular and or glandular structures
Nuclear pleomorphism:
Score 1: small regular uniform cells
Score 2: moderate increase in size and variability
Score 3: marked variation
Mitotic count:
Score 1: 0-5/10 High Power Field (HPF)
Score 2: 6-10/10HPF
Score 3: >10/10HPF
Overall grade:
Grade1 (Well differentiated): 3-5 score
Grade 2 (Moderately differentiated): 6 or 7 score
Grade 3 (Poorly differentiated): 8 or 9 score
STATISTICAL ANALYSIS
Data regarding age and sex of the patient, side (left or right), site of breast lump (which quadrant of breast), cytological diagnosis and histopathological diagnosis and IHC findings were entered. Data entry was done using MS Excel sheet and it was analysed using Statistical Package for the Social Sciences (SPSS) software (version 20.0). Categorical variables were expressed using frequency and percentages. Quantitative variables (age) were expressed using mean and Standard Deviation (SD). Sensitivity, specificity and PPV and NPV of fine needle aspiration as a diagnostic tool was studied and these parameters were calculated using the following formulas:
Sensitivity= True positive/(True positive + false negative)×100
Specificity=True negative/(True negative + false positive)×100
Positive predictive value= True positive/(True positive + false positive)×100
Negative predictive value= True negative/(True negative + false negative)×100
Correlation between grading by cytology and histopathology was assessed by using Spearman correlation. The Spearman's Rank Correlation coefficient (r) was 0.775 which indicates that there is strong correlation between cytological and histopathological grade. The high value coefficient of correlation showed a significant and marked association (p-value <0.001) between the grades of cytology and histopathology. Sensitivity and specificity of Robinson’s cytological grade were calculated for each cytological grade.
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Results |
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The age group ranged from 18-76 years with a mean age of 21.4 years. Among the gender distribution, females comprised predominantly of about 149 (99.3%) and male patient comprised of 1 case (0.7%). Out of 150 cases, the benign tumours were seen in 21-30 years group which comprised of 43 (28.9%) cases. The malignancies were commonly seen in 41-50 years which comprised 13 (8.6%) cases (Table/Fig 1). The youngest patient with breast carcinoma was of 30 years in the present study and the eldest age was 76 years. Benign lesions were noted predominantly on right side of breast constituting 60 cases (40%), whereas malignancies of breast were found mainly on left side of breast in 22 cases (14.6%). Bilateral breast lesions constituted 9 cases (6%) (Table/Fig 2). The lumps were located in upper outer quadrants (UOQ) of breast in 118 (78.7%) cases (Table/Fig 3). The cytology of these 150 cases was categorised into five categories from C1 to C5 according to NHSBSP criteria (Table/Fig 4). The present study doesn’t include C1 category, which indicates inadequate sampling. The majority of cases were in C2 category (Table/Fig 5) (benign lesions) constituting 116 (77.3%). The most common entity encountered was C2 category, fibroadenoma which accounted for 77 (51.3%) of the total cases and then, one case in C3 category (Atypia probably benign) (Table/Fig 6), five cases in C4 category (Table/Fig 7), (suspicious of malignancy) and 28 cases in C5 category (definitive of malignancy) (Table/Fig 8). Reaspiration was carried out in cases where initial aspiration was not adequate. Ultrasound guided FNAC was done in cases where material was not adequate even after reaspiration to ensure adequacy.
In 150 cases, the histopathological diagnosis of benign tumours includes 116 (77.3%) cases accounts for majority (Table/Fig 9) and the malignant cases include 34 (22.7%) cases which include 33 cases of IDC (Table/Fig 10), (Table/Fig 11), (Table/Fig 12), (Table/Fig 13), (Table/Fig 14), (Table/Fig 15), (Table/Fig 16) and one case of malignant phyllodes tumour (Table/Fig 17), (Table/Fig 18), (Table/Fig 19).
Cytological and histopathological comparison: On cytology, 21 cases were diagnosed as Benign Proliferative Breast Disease (BPBD), when classical findings of fibroadenoma were not seen (e.g., due to less cellularity), but these cases revealed benign ductal epithelial component, they have been diagnosed as BPBD as a broad way of cytological diagnosis and grouped under C2 category. In all these cases, histopathological examination was advised to confirm the diagnosis further. On histopathology, 18 cases were fibroadenomas, two cases diagnosed as fibrocystic disease and one case as fibroadenosis. Among the benign entities, this diagnostic difficulty on cytology could be due to poor cellularity or deep location of tumours.
A total of 77 cases were diagnosed as fibroadenoma on cytology, out of which 68 cases were fibroadenoma, seven cases were benign Phyllodes and each case of tubular adenoma, duct ectasia and Pseudo Angiomatous Stromal Hyperplasia (PASH) on histopathological examination. This discordance could be due to low cellular yield by the lesion on aspiration or failure to sample the representative areas while aspirating.
Four cases of benign Phyllodes on cytology were observed, but histopathology confirmed three cases as benign Phyllodes and one case was reported as fibroadenoma with benign Phyllodes like features. This variation could be due to aspiration done at a site showing Phyllodes like areas in a fibroadenoma.
Present study encountered 14 cases of fibrocystic disease on cytology. Histopathology showed only four cases as fibrocystic disease of breast, seven cases as fibroadenoma with focal cystic changes and each case of benign Phyllodes, fibroadenosis and complex sclerosing adenosis. This discordance could be due to deep location of tumour, or fibroadenoma with hyalinisation, cystic changes with presence of cyst macrophages or low yield of the aspirate. Ultrasound guided aspiration would have probably reduced the discordance.
Present study encountered five cases which were diagnosed as suspicious of carcinoma on cytology (C4 category). All these five cases were turned out to be IDC on histopathology.
The authors encountered 27 cases which were diagnosed as malignant on cytology (C5 category) and all cases were confirmed as IDC on histopathology. One case of malignant Phyllodes diagnosed on cytology was confirmed further on histopathology.
One case was diagnosed as ADH diagnosed on cytology (C4 category), and it was diagnosed as IDC breast on Tru-cut needle biopsy. This was followed by radical mastectomy and histopathological examination proved as IDC-NOS type. The pitfall in diagnosis on cytology in the present case was due to poor cellularity which was in-turn due to extensive desmoplastic response by the tumour.
Out of 150 cases, 117 cases were benign and 33 cases were malignant on FNA, but histopathology revealed 116 as benign and 34 cases were malignant. The comparison between cytology and histopathology is shown in (Table/Fig 20). The sensitivity, specificity, PPV, NPV and also diagnostic accuracy were calculated as follows (Table/Fig 21).
Sensitivity: TP/ (TP+FN) x 100 = 97.06%
Specificity: TN/ (TN+FP) x100 = 100%
PPV: TP/ (TP+FP) x100 = 100%
NPV: TN/ (TN+FN) x 100 = 99.15%
Accuracy: TP+TN/ (TP+FP+TN+FN) x 100 = 99.33%
Immunohistochemical status: IHC was done for all malignant cases diagnosed on histopathology. This was done not only to confirm the diagnosis but also to know the prognosis of the malignancies, as Triple negative tumours will have worst prognosis. The IHC status of malignant tumours were studied which includes Oestrogen Receptor (ER), Progesterone Receptor (PR) and Human Epidermal Growth Factor Receptor 2 (HER2) was positive in 47.1% and triple negative was observed in 20.5% and HER2/neu positive was observed in 5.9% cases (Table/Fig 22).
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Discussion |
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The FNAC is widely used in the diagnosis of breast tumours because it is safe and cost-effective diagnostic procedure. It is an established method to determine the nature of breast lesions (6). In the present study, 150 patients presented with breast lumps underwent both the FNAC and biopsy. The age ranged from 18-76 years with mean age of 21.4 years. Benign lesions were common in 21-30 years, whereas the malignancy was common in 41-50 years which was similar to age group found in a study done by Thakral A and Daveshwar M, among the gender distribution 149 were females and one male (11). In this study, 71 (47.4%) cases showed right breast lump, whereas the left breast shows lump in 70 (46.6%) cases and 9 (6%) cases show bilaterality and the most common site of tumour was UOQ in 118 (78.7%) cases. The most common benign lesion is fibroadenoma accounted for 51.3% (77) cases. There was only one case (0.7%) of ADH of C3 category in the present study. This 1 case of ADH later diagnosed as IDC on histopathological examination. In the present study, 5 (3.3%) cases of suspicious for malignancy (C4 category) were finally diagnosed as IDC on histopathology.
In comparative analysis of FNAC and histopathological association, the present study found one case of cytologically interpreted error which was a false negative case. This false negative case was diagnosed as atypia probably benign of C3 category in cytology, but histopathology showed IDC. This discordance could occur due to low cellularity, tumours with extensive hyalinisation or with cystic change. Among 34 cases of malignancy, IDC (NOS) category constitutes the most common subtype, which was seen in 22 (66.67%) cases. The present study encountered various subtypes of breast cancer including invasive papillary breast carcinoma, mucinous breast carcinoma, medullary breast carcinoma, IDC with medullary like features and also, metaplastic carcinoma and malignant Phyllodes tumour.
The present study was undertaken to assess the value of FNAC for the primary diagnosis of breast tumours. Various parameters to know the efficacy of FNAC such as sensitivity, specificity, PPV, NPV were almost at par with the reported literature. The comparative analyses is depicted in (Table/Fig 23) (4),(6),(12),(13),(14),(15),(16),(17).
Expression of both ER, PR was specifically nuclear positive, while HER2 expression was continuous membrane immunoreaction. In present study, the total cases positive for ER, PR and HER2 was 73.5%, 73.5% and 53%. whereas these results were comparable with previous study by Thakral A and Daveshwar M, Ali EM et al., and Doval DC et al., (11),(18),(19).
In the present study, the triple negative group comprises of 20.5% of the total breast malignancies studied. Expression of both ER, PR was specifically nuclear positive, while HER2 expression was continuous membrane immunoreaction. In present study, the total cases positive for ER, PR & HER2 was 73.5%, 73.5% and 53%. whereas these results were comparable with previous study by Thakral A and Daveshwar M, Ali EM et al., and Doval DC et al., (11),(18),(19) (Table/Fig 24). Although this comparison was not the aim of the present study, however, in the growing world of IHC, marker studies play an incredible aid in confirming the diagnosis where H&E alone may not be sufficient to interpret. IHC is also useful to predict the prognosis of breast cancers as the further course of treatment after surgery depends on their results.
Limitation(s)
Although FNA has helped a lot in diagnosing the breast lesions within a short span of time, it has certain diagnostic limitations particularly in C3 and C4 category. Therefore, the accurate classification of disease on cytology may be difficult sometimes, despite the adequate sampling; cytologist should guide the clinician to a repeat FNA under USG guidance or better to proceed with Core Needle Biopsy (CNB).
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Conclusion |
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The FNAC is an effective tool for initial investigation and screening of breast lump. It is easy, safe, simple, valuable and cost-effective. It helps the clinician to decide, further management of patients as FNA is sensitive and specific. Uncertain diagnosis in cytology should always be followed by CNB. Although few centres have totally replaced FNA by CNB, the authors still propose diagnostic role of FNA considering its easy accessibility. Histopathology, still remains the gold standard for final diagnosis.
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| TABLES AND FIGURES | |
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