Cyto-histopathological correlation in palpable breast lesions

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1 Interntionl Journl of Reserch in Medicl Sciences Mehr K et l. Int J Res Med Sci Jun;4(6): pissn eissn Reserch Article DOI: Cyto-histopthologicl correltion in plple rest lesions Kuldeep Mehr*, Vnit Kumr, Rjvinder Kur, Neelu Gupt Deprtment of Pthology, Srdr Ptel Medicl College, Bikner, Rjsthn, Indi Received: 13 Mrch 2016 Accepted: 22 April 2016 *Correspondence: Dr. Kuldeep Mehr, E-mil: dr.kuldeepmehr@gmil.com Copyright: the uthor(s), pulisher nd licensee Medip Acdemy. This is n open-ccess rticle distriuted under the terms of the Cretive Commons Attriution Non-Commercil License, which permits unrestricted non-commercil use, distriution, nd reproduction in ny medium, provided the originl work is properly cited. ABSTRACT Bckground: Brest lesions re one of the most commonly encountered lesions in women which require prompt pthologicl confirmtion y fine needle spirtion cytology (FNAC) nd histopthologicl exmintion. Methods: We conducted prospective study from Jnury 2015 to Decemer A totl 98 cses included presenting with plple rest lump in which 80 cses were lso sujected to surgicl iopsy or mstectomy. Results: Out of 98 cses, 34.7% enign cses, 59.2% mlignnt cses, nd 6.1% non-neoplstic cse were dignosed cytologiclly in which 7 (7.1%) cses of mstitis, 2 cses (2%) of grnulomtous mstitis, 22 cses (22.4%) of firodenom, 11 cses (11.2%) of enign rest disese or firocystic disese, 10 (10.2%) cses of dyskryotic chnges, 45 cses (45.9%) crcinom. Men ge ws 46.4±14.2 yers. Mjority of cses 29(29.6%) elonged to yers ge group. Mjority of the msses were situted in the left rest (57.2%) in the upper outer qudrnt (40.8%). In ddition to rest lump, pin in 22 cses, loody dischrge in 5 cses, ulcertion in 8 cses nd nipple retrction in 11 cses were present. Histology ws ville for 80 cses in which 5 (6.3%) cses of non-neoplstic, 27 cses (33.7%) enign nd 48 cses (60%) of mlignnt histology. FNAC proved to e % sensitivity in the dignosis of ll rest lesions in our study. Conclusions: So we concluded tht rest lesions re esily ccessile to FNAC, which is n esy, cost effective nd less time-consuming procedure. FNAC is used to dignose oth enign nd mlignnt lesions. Keywords: Brest, Cyto-histologicl correltion, Ductl crcinom, FNAC Brest INTRODUCTION Brest lesions re one of the most commonly encountered lesions in women. All physicins ccept the necessity of otining prompt pthologicl confirmtion of the nture of ny mss in the rest suspected s enign or mlignnt. Since the most importnt prognostic fctor t the time of presenttion is the extent of the disese, it is impertive tht relile preopertive dignosis is estlished s erly s possile with view to institute proper tretment nd reduce the mortlity rtes. In recent yers, mmmry cytology hs een considered s n effective mens of erly dignosis of rest msses. 1 It is minimlly invsive yet mximlly dignostic method, often oviting n open iopsy. It is simple, fst, nd cn e performed s n OPD procedure, since it requires no specil equipment, cuses miniml moridity, nd hs high ptient cceptnce. It is commonly used s prt of the dignostic trid, which in ddition to the FNA include clinicl rest exmintion nd mmmogrphy. The min purpose of Fine Needle Biopsy of rest lumps is to confirm cncer preopertively nd to void unnecessry surgery in specific enign conditions. 2 The dvntge of these cytologicl procedures lies in the fct tht they re simple to perform, cost-effective, rpidly ccepted y the ptient, nd cosmeticlly lest disfiguring. This more rpid dignostic pproch helps to lly the nxiety cused y delys in scheduling, performing, nd interpreting n open iopsy. So, the purpose of this study is to evlute nd to check the ccurcy of Fine-needle spirtion cytology in the dignosis of plple rest lumps. Interntionl Journl of Reserch in Medicl Sciences June 2016 Vol 4 Issue 6 Pge 1943

2 METHODS The study ws crried out in the deprtment of Pthology, Srdr Ptel medicl college nd ssocited group of hospitls, Bikner. This study included 98 cses presenting with plple rest lump from Jnury 2015 to Decemer Comprison etween cytology nd histology ws done ccording to vilility of smples. FNA ws performed on ll the plple lumps without locl nesthesi. FNA ws crried out using 10 ml plstic disposle syringe nd disposle needles of guge on ll of them, stined with H & E nd Giems stin nd the mteril studied in the Deprtment of pthology. Figure1: Distriution of 98 cses ccording to cytologicl dignosis. 80 cses were lso sujected to surgicl iopsy or mstectomy. All iopsy specimens were processed y fixtion, dehydrtion, nd clering followed y impregntion with wx. The wx locks were cut in 5-6 μ sections & stined y hemtoxylin nd eosin stin. The dignoses in ll the cses were mde on histopthologicl exmintion of routinely processed tissue. All cses were reviewed y the uthors nd dignosis ws confirmed. The reltive frequency of tumors nd the distriution of ge, sex nd loction were nlyzed. Figure 2: Distriution Of 80 ccording to Histologicl Dignosis. Inclusion criteri All femles with cliniclly plple rest lumps. Exclusion criteri Autolysed/necrosed tissue specimen, Indequte iopsy were excluded from study. RESULTS In the present study, 98 sujects with rest lesions with lump were studied, out of which 80 cses hd histologicl iopsies lso. Following oservtions nd inferences were rrived t. Figure 3: Distriution of cses ccording to nture of lesions. Cytologiclly, most common dignosis ws Crcinom 45.9% (45 cses) (Figure 10), followed y Firodenom 22.4% (22cses) (Figure 8) long with Firocystic disese 11.2% (11 cses) (Figure 1) (Figure 9). In the present study 80 cses were studied histologiclly. Out of which most common dignosis ws Crcinom 57.5% (46 cses), followed y Firodenom 22.5% (18cses) long with Firocystic disese 11.2% (9 cses). (Figure 2) Figure 4: Distriution of cses ccording to ge group. Interntionl Journl of Reserch in Medicl Sciences June 2016 Vol 4 Issue 6 Pge 1944

3 Totl Histologicl Dignosis Mstitis Grnulomtous Mstitis Firodenom Firocystic disese Dyskryotic chnges Crcinom Hypocellulr Mehr K et l. Int J Res Med Sci Jun;4(6): Non-neoplstic lesions were found in 6 cses (6.1%). Mjor ulk 92 (93.2%) of cses reveled neoplstic in which 34 cses (34.7%) were enign nd 58 cses (59.2%) were mlignnt (Figure 3). Tle 1: Comprision of cses of cytologicl nd histologicl dignosis. Cytologicl Dignosis Totl No. of cses % Mstitis Grnulomtous Mstitis Tuerculr Mstitis Firo-denom Firo-cystic disese IDC Mucinous C SCC No. of cses % In the present study, the ge of ptients rnged from 11 yers to 70 yers nd ove. The men ge ws 46.4 yer with stndrd devition of Mjority of cses 29(29.6%) elonged to yers ge group followed y 19 cses (19.5%) in yers ge group (Figure 4). in 18 spirtes nd lower outer qudrnt in 4 spirtes. Most common loction for mlignnt lesions nd enign lesions ws upper outer qudrnt (38% nd 50% respectively). Inflmmtory lesions were most commonly locted t upper inner qudrnt (50.5%) (Figure 6). Figure 5: Distriution of cses ccording to side of rest involved. In the present study out of 98 cses 56 cses (57.2%) presented with lesion in left rest nd 42 cses (42.8%) presented with lesion in right rest (Figure 5). Most commonly mss ws locted in the upper outer qudrnt in 40 spirtes followed y upper inner qudrnt Figure 6: Antomicl qudrnt distriution of rest lesions. In ddition to lump rest, other presenting symptom ws 22 cses ssocited with pin, 5 cses ssocited with loody dischrge from the nipple nd 8 cses showed evidence of ulcertion djcent to the mss (Figure 7). Interntionl Journl of Reserch in Medicl Sciences June 2016 Vol 4 Issue 6 Pge 1945

4 80 cses out of 98 FNAC hd corresponding histologicl dignosis. Out of 80 iopsies done, the discrepncies t cytology were s follows: Three cses of enign prolifertive rest disese in histology were reported s mstitis t cytology (flse negtive dignosis in disese) One cse of Tuerculr mstitis ws wrongly reported s Grnulomtous mstitis t cytology (flse negtive dignosis in disese) (Figure 11) Three cses reported s intrductl crcinom in histology were reported s enign prolifertive rest disese in cytology (flse negtive dignosis in disese). One cse reported s intrductl crcinom disese in histology ws reported s Hypocellulr in cytology (flse negtive dignosis in disese) (Tle 1). Figure 9: Firocystic disese; () cytologicl smer (H & E 400 x); () corresponding histologicl section (H&E 100X). Figure 7: Distriution of cses ccording to clinicl fetures. Figure 10: Intrductl crcinom; () Cytologicl smer; () Corresponding histologicl section (H & E 400 x). 80 cses out of 98 FNAC hd corresponding histologicl dignosis. With this confirmtion n overll sensitivity, predictive vlue of positive result nd percentge of flse negtive indices were clculted. Therefore in 7 out of 80 cses, the dignosis in cytology ws not in keeping with histology. The FNAC proved to e % sensitivity in the dignosis of ll rest lesions in our study. Overll flse negtive percentge ws 9.5 (Tle 2). Figure 11: Tuerculr mstitis; () cytologicl smer () corresponding histologicl section (H & E 400 x). Sttisticl Anlysis of mlignnt lesions Figure 8: Firodenom; () cytologicl smer; () corresponding histologicl section (H & E 400 x). Out of 80 cses iopsied, 36 cses clerly show mlignncy; in cytology 9 cses show dyskryotic chnges proved to e mlignnt in histology lso. 2 cses flsely reported s enign prolifertive rest disese, nd one cse ws hypocellulr. All enign cses reported in cytology were proved s enign in histology lso.therefore, the FNAC proved to e 93.8 % sensitive nd 100 specific in the dignosis of mlignnt lesions in our study (Tle 3). Interntionl Journl of Reserch in Medicl Sciences June 2016 Vol 4 Issue 6 Pge 1946

5 Tle 2: Overll sttisticl nlysis. Vlue Formul Percentge Sensitivity TP(73)/TP(73)+FN(7)x Positive predictive vlue TP(73)/TP(73)+FP(0)x Flse negtive percentge FN(7)/TP(73)+FN(0)x Tle 3: Sttisticl dt in mlignnt lesions. Vlue Formul % Sensitivity TP(45)/TP(45)+FN(3)x Specificity TN (32)/FP(0)+TN(32) 100 Positive predictive vlue TP(45)/TP(45)+FP(0)x Negtive predictive vlue TN(32)/FN(3)+TN(32) 91.4 Accurcy TP(45)+TN(32)/TP(45)+TN(32) +FN(3) +FP(0)x DISCUSSION In our study, out of 98 cses, 58 (59.2%) cses were showing mlignncy nd 40cses (40.8%) were showing enign nd non-neoplstic nture of lesions. Pttri SK et l. studied 71 histologiclly confirmed cses nd documented infiltrting ductl crcinom s the most common lesion (24/71). 3 Unlike our study, Jyrm G et l. in their study of 543 cses of FNAC found firocystic disese (39.8%) s the most common lesion. 4 Khnn R et l showed 61.3% enign nd non-neoplstic nture of lesions nd 38.7% mlignncy. 5 Mlignnt lesions were much higher in our study s cses were tken minly from cncer l. Oservtions mde in our study differ from other studies proly ecuse of difference in smple collection from cncer l, smple size nd durtion of study. Most common nture of lesions were mlignnt 58 (59.2% confirmed cses) which includes Intrductl crcinom (96.6%), Mucinous crcinom 1 (1.7%), Squmous cell crcinom 1 (1.7%). Benign lesions were 34 (34.7%) which include minly firodenom (64.7%) nd firocystic disese 12 (35.3%). Non-neoplstic lesions were 6 (6.1%) including mstitis 4 cses nd grnulomtous mstitis 2 cses. The ge of the sujects in the present study rnged from 18 yers to 85 yers. Mjority elonged to yers ge group (29.6%) with the men ge of 46.4 yers. Averge ge ws slightly lower thn the study undertken y Bhrgv V et l. who found the men ge t yers. 6 In the study undertken y Doussl VL et l. the medin ge ws higher nd found to e t 57 yers. 7 Gnit O et l. reported mximum numer of ptients with mlignnt lesions in the fourth to seventh decde of life. 8 In the present study, ll the 98 sujects (100%) presented with rest lump. Out of these, 63 cses (64%) presented with lump s the min presenting symptom while 22 (22.44%) with lump nd pin, 11 (11.22%) with lump ssocited with retrcted nipple nd 8 (8.10%) with lump ssocited with ulcer. In 3(3%) with lump were ssocited with nipple dischrge. In concurrence with this study, rest lump ws the min presenting symptom in the study y Rin V et l. 9 In our study, mjority of the msses were situted in the left rest (57.2%) in the upper outer qudrnt (40.8%). Mjority of non-neoplstic cses were situted in the right rest (66.8%) in the Upper inner Qudrnt (50.2%), enign cses were situted in the left rest (64.7%) in the upper outer qudrnt (50%) nd mlignnt cses were situted in the left rest (55.2%) in the upper outer qudrnt (38%). Out of 122 cses, 60 cses (49.18%) were in left rest, 54 cses (44.26%) were in right rest, nd 8 cses (6.55%) presented ilterlly. 10 Hussin MT et l. reported left rest involvement in 27 ptients (54%) nd right rest involvement in 23 cses (46%) nd concluded similrly tht left rest ws involved more commonly thn right. 11 In the present study, mjority of the tumors (40) were in the upper outer qudrnt (40.8%) followed y upper inner qudrnt 18(18.6%). Meen SP et l. lso found mjority of the tumors in the upper outer qudrnt (54%). 12 In our study, the totl numer of cses dignosed cytologiclly s firodenom ws 22. All were femle ptients ged yers. The min fetures of stghorn clusters nd single re ipolr nuclei were seen in ll the cses. Frgments of firomyxoid strom were seen in 21 cses (95.5%) nd Monolyered sheets were seen in 19 cses (86.4%). Cellulr dissocition, nucler pleomorphism, multinucleted gint cells were not seen. Interntionl Journl of Reserch in Medicl Sciences June 2016 Vol 4 Issue 6 Pge 1947

6 All iopsied firodenoms (18 cses) correlted with the FNA dignosis, giving sensitivity of 100%. The sensitivity of FNAC in dignosing firodenom in our study ws comprle to study y Kollur et l, which gives sensitivity of 100%. 13 In our study, eleven cses were dignosed t cytology s enign prolifertive rest disese. The ge of the ptients ws from 24 to 70 yers. These presented with ill-defined to well-formed msses nd the smers were poorly to modertely cellulr showing few enign clusters of epithelil cells nd myoepithelil cells rrnged minly in sheets. Nucler pleomorphism ws seen in 3 cses in the form of nucleomegly nd prominent nucleoli in some clusters. Bre nuclei were seen ll 11 cses. Few cyst mcrophges were seen in some cses. In 2 cses were lso showed metplstic pocrine cells nd cyst mcrophges with ductl epithelil. Tle 4: Dignostic ccurcy of FNAC in the dignosis of plple rest Lesions. Authors Sensitivity Specificity PPV NPV Accurcy Sheikhetl et l Plominietl et l Sneigeetl et l Oneiletl et l Qureshi N et l Kimetl et l Mnsoor et l Choi et l Tiwri et l Qureshi H et l Present study Mlik et l studied 271 cses of rest cncer, which comprised of 269 femles nd two mles. Infiltrting ductl crcinom ws documented in 199 (71%) cses. The men ge for presenttion of rest crcinom ws 44.1 yers. 14 Our study documented 59.2% incidence of Brest crcinoms, mong which Infiltrting ductl crcinom ws 96.6 % in the ge group yers. Mucinous crcinom of rest is reltively rre, pure form ccounting for 2% of ll rest cncers. The common ge is post-menopusl ge. Shrm et l reported 30 yer old femle, dignosed y fine needle spirtion cytology s mucinous crcinom of the rest with lymph node metstsis nd susequently confirmed y histopthology. 15 In our study, we hd one cse of mucinous crcinom dignosed histologiclly in 61 yer old womn. One cse of squmous cell crcinom dignosed histologiclly in 55 yer old womn cytologicl findings did not mtch with squmous cell crcinom. Only mild pleomorphism nd hyperchromtism were seen in oth cses. In the literture, the sensitivity rnges from 80-98% nd the specificity my e up to 100%. Results of our study were comprle to ove studies. High degree of sensitivity nd sensitivity in this study my permit surgicl mngement on pre-opertive cytologicl dignosis (Tle 4). CONCLUSION Considering histologicl dignosis s the gold stndrd, we concluded tht rest lesions re esily ccessile to FNAC, which is n esy, cost effective nd less timeconsuming procedure. FNAC is used to dignose oth enign nd mlignnt lesions. It is more sensitive nd specific in dignosing mlignnt lesions, showing 93.8 % sensitivity nd 100% specificity. Funding: No funding sources Conflict of interest: None declred Ethicl pprovl: Not Required REFERENCES 1. Cngirell J, Simsir A. Brest. In: Orell SR, Sterrett GF, Whitker D, editors. Fine Needle Aspirtion Cytology. 4th ed. New Delhi, Indi: Elsevier Puliction. 2005; Orell SR, Sterrett GF, Whitker D. In Orell SR, Sterrett GF, Whitker D. Fine Needle Aspirtion Cytology. 4th Ed. New Delhi. Elsevier Puliction; 2005; Pttri SK, Dey P, Gupt SK, Joshi K. Myoepithelil cells: Any role in spirtion cytology smers of rest tumours? Cytojournl. 2008;5:9. 4. Jyrm G, Alhdy SF, Yip CH. Cytologicl nlysis of rest lesions: A review of 780 cses. Mlysin J Pthol. 1996;18:81-7. Interntionl Journl of Reserch in Medicl Sciences June 2016 Vol 4 Issue 6 Pge 1948

7 5. Khnn R, Khnn S, Chturvedi S, Ary NC. Spectrum of rest disese in young femles; retrospective study of 1315 ptients. Indin J Pthol Microiol. 1998;41(4): Bhrgv V, Jin M, Agrwl K, Thoms S, Singh S. Criticl pprisl of cytologicl nucler grding in crcinom of the rest nd its correltion with ER/PR expression. Journl of Cytology 2008;25(2): Doussl VL, Tuin-Hulin M, Friedmn S, Hcene K, Spyrtos F, Brunet M. Prognostic vlue of histologicl grde nucler components of Scrff Bloom Richrdson (SBR). An improved score modifiction sed on multivrite nlysis of 1262 invsive ductl crcinom. Cncer 1989;64: Gnit O, Omoniyi-Esn G, Ossn S, Titiloye N, Olsode B. Cytopthologicl review of rest lesions in Ile-Ife Nigeri. The Internet J. of Third World Med. 2008;8: Rin V, Bhutni M, Bedi R, Shrm A, Deo SVS, Shukl NK, et l. Clinicl fetures nd prognostic fctors of erly cncer t mjor cncer centre in North Indi. Ind J Cncer. 2005;42: Rthi M, Khlid M, Budni SK, Mittl A, Verm N. A clinicopthologic study of vrious rest lesions with cytohistologicl correltion. Muller J Med Sci Res. 2015;6: Hussin MT. Comprison of fi ne needle spirtion cytology with excision iopsy of rest lump. J Coll Physicins Surg Pk. 2005;15: Meen SP, Hemrjni DK, Joshi N. A comprtive nd evlutive study of cytologicl nd histologicl grding system profile in mlignnt neoplsm of the rest n importnt prognostic fctor. Indin J Pthol Microiol. 2006;49: Kollur SM, El hg IA. FNA of rest firodenom:oserver vriility nd review of cytomorphology with cytohistologicl correltion. Cytopthol. 2006;17(5): Mlik R, Bhrdwj VK. Brest lesions in young femles 20 yer study for significnce of erly recognition. Indin J Pthol Microiol 2003;46(4): Crter BA, Pge DL, O Mlley FP. Usul epithelil hyperplsi nd typicl ductl hyperplsi. Chpter 14. In : O mlley FP, pinder SE. Brest pthology : volume in the series foundtions in dignostic pthology. Goldlum JR, editor. Phildelphi: Elsevier. 2006; Hshemzdeh SH, Kumr PV, Mlekpour N, Hshemi Z, Ftthi F, Mlekpour F. Dignostic ccurcy of fine needle spirtion cytology : comprison of results in Triz imm Khomeini hospitl nd shirz university of medicl sciences. IJCP. 2009;3: Plomini L, Fulciniti F, Vetrni A, Ros G, Benedetto G, Zepp P. Fine needle spirtion iopsies of rest msses criticl nlysis of 1956 cses in 8 yers ( ). Cncer. 1988:61; Qureshi H, Amnullh A, Khn KM, Dee F. Efficcy of fine needle spirtion cytology in the dignosis of rest lumps. JPMI 2007;21(4): Pinder SE, Mullign AM, O Mlly FP. Firoepithelil lesions including firodenom nd phyllodes tumour. Chpter 10. In : O mlley FP, pinder SE. Brest pthology : volume in the series foundtions in dignostic pthology. Goldlum JR, editor.phildelphi : Elsevier. 2006; Tiwri M. Role of fine needle spirtion cytology in dignosis of rest lumps. Kthmndu university medicl journl. 2007;5(18): Cite this rticle s: Mehr K, Kumr V, Kur R, Gupt N. Cyto-histopthologicl correltion in plple rest lesions. Int J Res Med Sci 2016;4: Interntionl Journl of Reserch in Medicl Sciences June 2016 Vol 4 Issue 6 Pge 1949