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ORIGINAL ARTICLE
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Cytological study of breast lesions with histopathological correlation


 Department of Pathology, Swami Ramanand Teerth Rural Government Medical College, Ambajogai, Maharashtra, India

Date of Submission01-Aug-2020
Date of Decision25-Jul-2020
Date of Acceptance08-Jan-2021

Correspondence Address:
Sarita Balasaheb Gore,
Department of Pathology, Swami Ramanand Teerth Rural Government Medical College, Ambajogai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjdrdypu.mjdrdypu_410_20

  Abstract 


Introduction: Breast disease is the most common and ranks first among malignant tumors affecting females in many parts of the world. Timely and accurate diagnosis of a breast lump is lifesaving. Fine-needle aspiration cytology (FNAC) is a simple, safe, inexpensive method with wide acceptance and used as a first-line diagnostic procedure for diagnosis of breast lesions. Aim: The aim of the study was to diagnose any palpable lump of the breast in females by cytology and correlate with histopathology wherever possible. Setting and Design: This was a retrospective and prospective descriptive study carried out in the pathology department at our institute. Materials and Methods: This study was done for 2 years. FNAC of breast lesions was done, processed routinely, and stained with Papanicolaou stain. Histopathological correlation was done wherever possible on Tru-cut biopsies, excisional biopsies, and surgical specimens received. Statistical Analysis: The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated. Results: Among 304 cases, 229 were benign and 75 were malignant on cytology. Out of this, 79 cases underwent histopathological examination, in which 32 were benign and 47 were malignant cases. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the present study were 79.16%, 96.77%, 97.73%, 75%, and 86.08% respectively. Conclusion: The FNAC is an important preliminary diagnostic test in palpable breast lumps and the results show a high degree of correlation with a final histopathological report.

Keywords: Benign, fine-needle aspiration cytology, histopathology, malignant



How to cite this URL:
Gore SB, Shivaji D B, Sandhya B N, Dinesh V S. Cytological study of breast lesions with histopathological correlation. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2021 Jun 12]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=316425




  Introduction Top


Breast carcinoma is the most common cancer and leading cause of cancer death in women worldwide.[1],[2] In India, breast carcinoma is the second most common after cervix carcinoma.[2] Breast cancer contributes to 25% of total cancer cases and 15% of all cancer deaths among females throughout the world.[3]

Fine-needle aspiration cytology (FNAC) has become a widely accepted tool for the diagnosis of breast lesions as it is a safe and simple method with high diagnostic accuracy.[4],[5] It is very cost-effective and is used along with clinical and mammography examination in the triple test.[6]

In routine breast pathology, immunohistochemistry is a valuable tool used for both diagnostic and prognostic parameters.[7]


  Materials and Methods Top


In this 2-year study, 304 cases were examined from November 1, 2017, to September 30, 2018, retrospectively and November 1, 2018, to October 31, 2019, prospectively at our institute. The study was commenced after approval of the Institutional Ethics Committee; letter number was 36 approved in October 22, 2018.

It was a retrospective and prospective descriptive study. It included all patients (inpatient department [IPD] and out patient department [OPD]) with breast lesions during the study period according to inclusion and exclusion criteria.

Inclusion criteria

All OPD and IPD cases of breast lesions were included. Histopathological correlation was done wherever possible.

Exclusion criteria

  1. Nonpalpable breast lumps in females
  2. Palpable breast masses in males.


All clinical histories were taken of these 304 cases and complete evaluations were done by doing all routine investigations. After doing local examination, the procedure was explained and consents were obtained. Lesions were localized and aspiration was done with a 22 G needle and 10 ml syringe by piercing the needle into the lesion and moving it in different directions. The material was collected inside the needle and hub. Gross appearance of the material was noted and smears were prepared with coverslip or other slide. The slides were fixed using absolute alcohol in Coplin's jar and stained by Papanicolaou stain. Smears were screened and diagnosis was done.

The reporting of FNAC was done using a 5-stage system called as International Academy of Cytology Yokohama System.[8] At an inaugural meeting of the Breast Group members who attended the Yokohama International Congress of Cytology, the use of a 5-stage coding system was discussed. It included:[8]

  • Code 1 – Insufficient material
  • Code 2 – Benign
  • Code 3 – Atypical, probably benign
  • Code 4 – Suspicious, probably in situ or invasive carcinoma
  • Code 5 – Malignant.


Histopathological examination was performed on Tru-cut biopsies, excisional biopsies, and surgical specimens received in the department of pathology. The specimens were fixed in 10% formalin. Tissue sections were processed in an auto processor for the preparation of paraffin blocks. The sections were cut and stained using hematoxylin and eosin stain.

Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated.

Sensitivity = true positive/true positive + false negative × 100

Specificity = true negative/true negative + false positive × 100.


  Observation and Results Top


In this study, a total of 304 cases with breast lesions were examined. Out of 304 cases, 79 cases underwent histopathological examination. Observations of the present study were analyzed and recorded with respect to age, quadrant of involvement, size, laterality, and clinical presentation. In our study, age ranged from 14 to 82 years. Age distribution is shown in [Graph 1]. Majority cases belong to 21–30 years. The most common age group of benign lesions was 21–30 years. The most common age group of malignant breast lesions was 61–70 years. Right breast involvement was more common seen in 147 cases, left breast in 140 cases, and 17 cases bilateral, as shown in [Graph 2].



Maximum lumps were in the upper outer quadrant, seen in 157 (51.64%) cases, lower outer quadrant in 66 (21.71%) cases, upper inner quadrant in 50 (16.45%) cases, lower inner quadrant in 25 (8.22%) cases, and central involvement in 6 (1.98%) cases. Maximum breast lumps were of size 2–5 cm seen in 162 (53.29%) cases, measuring <2 cm seen in 116 (39.16%) cases and measuring more than 5 cm in 26 (8.55%) cases.

The lump was a common complaint seen in 304 cases, 17 presented with lump with pain, 2 with skin involvement, 8 with nipple discharge, and 5 with palpable axillary lymph node.

On cytology, 229 cases were benign and 75 cases were malignant [Figure 1]. The most common benign lesion observed was a fibroadenoma. There were 178 cases of fibroadenoma, 20 cases of fibroadenosis, 6 cases of fibrocystic diseases of the breast, 3 cases of lactational adenoma, 2 cases of galactocele, 1 case of phyllodes tumor, and 4 cases of epithelial hyperplasia. Atypical hyperplasia was seen in 10 cases. One case was diagnosed as suspicious of malignancy. The most common malignant lesion was infiltrating duct carcinoma (no special type [NST]) [Figure 3]. There were 66 cases of infiltrating duct carcinoma (NST), 4 cases of lobular carcinoma, and 1 case each of medullary carcinoma and mucinous carcinoma.
Figure 1: Fibroadenoma (cytology): Microphotograph showing hypercellular smear with bare nuclei arranged in a honeycomb pattern (Papanicolaou stain, x40)

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Figure 3: Invasive duct carcinoma (cytology): Microphotograph showing a loosely cohesive cluster of a malignant cell with pleomorphic nuclei (Papanicolaou stain, x40)

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In the present study out of 304 cases of FNAC, 79 cases underwent histopathology examination. On histopathology, 32 cases were benign and 47 were malignant [Table 2] and [Figure 2]. Fibroadenoma was the most common benign lesion. There were 28 cases of fibroadenoma, 1 case of chronic mastitis, 1 case of lactational adenoma with galactocele, 1 case of phyllodes tumor, and 1 case of ductal hyperplasia [Figure 4]. Infiltrating duct carcinoma (NST) was the most common malignant lesion and it was seen in 42 cases, lobular carcinoma in 2 cases, mucinous carcinoma in 2 cases, and medullary carcinoma in 1 case.
Table 1: Distribution of cytological diagnosis of breast lesions (n=304)

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Table 2: Statistical analysis for fine needle aspiration cytology of breast lesions (n=79)

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Figure 2: Fibroadenoma (histopathology): Microphotograph showing fibroadenoma with intracanalicular pattern. Ducts lined by inner cuboidal and outer myoepithelial cell layer (H and E, x10)

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Figure 4: Invasive duct carcinoma (histopathology): Microphotograph showing invasive duct carcinoma (no special type) showing solid sheets of tumor cells with stromal invasion (H and E, ×40)

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Out of these 79 cases, 68 (86.07%) cases were correlated and 11 (13.92%) cases were not correlated.

Statistical analysis

Sensitivity was calculated. It was 79.16%. Specificity was 96.77%. Positive predictive value, negative predictive value, and accuracy were 97.3%, 75%, and 86.07%, respectively.

Sensitivity = true positive/true positive + false negative × 100 = 79.16%

Specificity = true negative/true negative + false positive × 100 = 96.77%

Positive predictive value = true positive/true positive + false positive × 100 = 97.73%

Negative predictive value = true negative/false negative + true negative × 100 = 75%

Accuracy = true positive + true negative/true positive + false positive + false negative + true negative × 100 = 86.07%.


  Discussion Top


In our study, 304 cases were studied and analyzed. We came across different breast lesions benign and malignant.

In this study, age ranged from 14 to 82 years. A maximum number of cases were seen in 21–30 years age group which is also seen in a study done by Shanmugasamy et al.[9] and Gupta.[3] The most common age group was second decades for benign breast lesions and sixth decades for malignant breast lesions.

Right side breast was more commonly involved in the present study which is similar to the study done by Sreedevi.[2] Upper outer quadrant of the breast most commonly involved which is also seen in a study done by Kosthi et al.[10]

In the present study, the most common benign lesion was fibroadenoma and the most common malignant lesion was infiltrating duct carcinoma (NST).

After FNAC examination of 304 cases, 79 cases underwent histopathological examination in which 68 cases were correlated and 11 cases were not correlated. Six cases of atypical ductal hyperplasia, 1 case of benign breast lesion, 1 case of benign cystic lesion, 1 case of mucinous cyst, 1 case of epithelial hyperplasia, and 1 case of hyperplasia with atypia diagnosed on cytology later turned out as infiltrating duct carcinoma and mucinous carcinoma after histopathological examination. The false-negative report may be due to technical failure as normal breast part only may have got aspirated or due to inadequate aspiration.

Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated and compared with previous studies. [Table 3]
Table 3: Statistical analysis for fine needle aspiration cytology of breast lesions

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The sensitivity was 95.24% in a study done by Daramola et al.[11] and specificity and positive predictive value were 88.9% and 99.6% respectively, while in the present study, they were 79.16%, 88.9%, and 97.37%, respectively.

In a study done by Bhadani et al.,[12] sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 98%, 100%, 100%, 92%, and 99.26% respectively, while in our study, they were 79.16%, 96.77%, 97.37%, 75%, and 86.07% respectively.

In a study done by Chauhan and Sarvaiya,[13] sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 98.24%, 98.93%, 96.55%, 99.4%, and 98.77%, respectively, while in the present study, they were 79.16%, 96.77%, 97.37%, 75%, and 86.07% respectively.

In a study done by Banik et al.,[14] sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 87.23%, 100%, 100%, 94.87%, and 96.05, respectively, while in our study, they were 79.16%, 96.77%, 97.37%, 75%, ad 86.07%, respectively.

Normal breast tissue consists of mesenchymal and epithelial components, which includes ductal and acinar (lobular) and myoepithelial components, each cell type having its characteristic immunoprofile. The immunoprofile of breast tumors depends on the origin of neoplastic cells, which can be used for the diagnosis of breast lesions. [Table 4] Mucinous carcinoma of breast is positive for Er and Pr, and negative for Her-2.15. [Figure 5], [Figure 6] and [Figure 7][15]
Table 4: Immunoprofile of breast tumors

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Figure 5: Estrogen receptor positive mucinous breast carcinoma

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Figure 6: Progesterone receptor positive mucinous breast carcinoma

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Figure 7: Her-2 negative mucinous breast carcinoma

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  Conclusion Top


FNAC is simple, cost-effective, least invasive. It should be a part of routine practice in the initial evaluation of breast lumps. The FNAC in a breast lump using histopathology as a gold standard showed sensitivity 79.16%, specificity 96.77%, positive predictive value 97.43%, negative predictive value 75%, and accuracy 86.08%.

The FNAC is an important preliminary diagnostic test in palpable breast lumps, the results show a high degree of correlation with a final histopathological report.

Acknowledgement

We thank Dr. Rupesh Gundawar Sir, Krishna Pathology Lab, Latur for IHC staining.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Pandey V, Verma NK, Sudarshan V, Chandrakar KS, Sharma A. Cyto- histopathological correlation of breast lesions – A rural hospital based study. Indian J Pathol Oncol 2017;4:117-21.  Back to cited text no. 1
    
2.
Sreedevi CH. Correlative study of FNAC and histopathology for breast lesions. Trop J Path Micro 2016;2:206-11.  Back to cited text no. 2
    
3.
Gupta G. Fine needle aspiration cytology with histopathologic correlation in breast lesions. Indian J Pathol Res Pract 2017;6:365-71.  Back to cited text no. 3
    
4.
Raj A, Velu K, Banushree C, Srinivasamurthy JR. Cytological evaluation of benign breast lesions with histopathological correlation. Indian J Pathol Oncol 2016;3:7-10.  Back to cited text no. 4
    
5.
Gardas V. Cytological study of breast lumps with histopathological correlation. Indian J Basic Appl Med Res 2018;7:185-92.  Back to cited text no. 5
    
6.
Agrawal R, Mohan N, Sharan J, Gupta G, Kumar P. Spectrum of breast diseases with Cyto-Histopathological correlation in a tertiary care hospital of Western Uttar Pradesh. Indian J Pathol Onco 2017;4:1-7.  Back to cited text no. 6
    
7.
Liu H. Application of immunohistochemistry in breast pathology: A review and update. Arch Pathol Lab Med 2014;138:1629-42.  Back to cited text no. 7
    
8.
Field AS, Raymond WA, Rickard M, Arnold L, Brachtel EF, Chaiwun B, et al. The International Academy of Cytology Yokohama System for Reporting Breast Fine-Needle Aspiration Biopsy Cytopathology. Acta Cytol 2019;63:257-73.  Back to cited text no. 8
    
9.
Shanmugasamy K, Anandraj K, Bhavani K, Kotasthane DS. Cytolo-histological correlation of breast lump – As a part of internal quality control. Indian J Pathol Oncol 2016;3:328-35.  Back to cited text no. 9
    
10.
Kosthi A, Sulya M, Malik R. Role of fine-needle aspiration cytology in evaluation of breast lumps. Pacifice J 2017;4:143-8.  Back to cited text no. 10
    
11.
Daramola AO, Odubanjo MO, Obiajulu FJ, Ikeri NZ, Banjo AA. Correlation between fine-needle aspiration cytology and histology for palpable breast masses in a nigerian tertiary health institution. Int J Breast Cancer 2015;2015: Article ID 742573.  Back to cited text no. 11
    
12.
Bhadani PP, Smita S, Jamal I, Sinha R, Majumdar S. Reliability of fine needle aspiration cytology in the evaluation of palpable breast lumps – An institutional based study. Arch Cytol Histopathol Res 2017;2:50-4.  Back to cited text no. 12
    
13.
Chauhan SC, Sarvaiya AN. Cytological and histopathological correlation of breast lump: A 3 year study at tertiary care center. Ann Pathol Lab Med 2017;4:A292-6.  Back to cited text no. 13
    
14.
Banik T, Shanmugasamy K, Vaithyanathan A, Kotasthane DS. Cytomorphology of breast lesions with historadiological correlation in a tertiary care centre of Puducherry. IP Arch Cytol Histopathol Res 2018;3:1-6.  Back to cited text no. 14
    
15.
Guski H, Kristiansen G. Immuno Histo-Chemistry in Tumor Diagnostics. Switzerland: Springer; 2018. p. 79-80.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

 
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