ABSTRACT

Corresponding Author:
Dr. Surinder Kumar Atri,
Associate Professor,
House No. 24, Lane 51, Behind Sunny Farms,
Greater Kailash Post Office, Gangyal, Jammu,
Jammu and Kashmir, India.
E-mail: surinderkumaratri@gmail.com

ABSTRACT

BACKGROUND

A cross sectional study for screening of carcinoma breast was done on pregnant women attending gynaecology and surgery OPD at District Hospital Samba, Jammu. All women with sign and symptoms of breast disease who attended the Gynaecology and Surgery OPD from March 2015 to March 2017 were included in the study.

MATERIALS AND METHODS

Clinical examination was done by gynaecologist and surgeon. Fine needle aspiration was done by pathologist and was reported by consultant pathologist. Histopathology reports of these patients where available were also correlated.

RESULTS

The age of the patients ranged from 7 years to 88 years, maximum number of cases were seen in the age group of 21-30 years, followed by of 31-40 years. Clinical presentation of patients was with lump breast, diffuse swelling, nipple discharge, mastalgia, retracted nipple, axillary lymph node, skin manifestation. Fine needle aspiration diagnosis: maximum number of cases were of benign lesions (74.2%) followed by 12.4 % inflammatory cases and 10.06% cases of carcinoma. Among the benign diagnosis, Fibroadenoma (20.06%) was the most common.

CONCLUSION

That means fine needle aspiration can fairly distinguish inflammatory, benign and malignant lesions of breast. Therefore fine needle aspiration can be used for mass screening of population for carcinoma breast.

KEY WORDS

Carcinoma, Breast, FNAC, Cytology, Screening.

BACKGROUND

Carcinoma of the breast is the most common non-skin malignancy in women worldwide. Breast cancer is the most common cancer in women in India and accounts for 27% of all cancers in women.^1,2 According to a 2016 report³ published by the Indian Council of Medical Research, breast cancer is now the most common cancer among urban Indian women, with approximately 1, 44, 000 new cases being reported every year. Carcinoma breast is the second leading cause of cancer mortality after lung cancer. Globally over the last several decades, the incidence of breast cancer has increased and the greatest increase has been seen in Asian countries where breast cancer incidence peaks among women in their forties whereas in the United States and Europe, it peaks among women in their sixties.^4,5,6 India with its multilingual, and multiethnic society has reported breast cancer as the commonest cancer in urban Indian females, and the second commonest in the rural Indian women.³

As per the ICMR HBCR data, breast cancer is the commonest cancer among women in urban registries of Delhi, Chandigarh, Mumbai, Chennai, Guwahati, and Trivandrum where it constitutes 20-30% of all cancers in females.³ Almost all Indian women often do not present for medical care early enough due to various reasons such as illiteracy, lack of awareness, financial constraints, lack of an organized screening programmes and paucity of diagnostic aids. It is hardly surprising that the majority of breast cancer patients in India are still treated at locally advanced and metastatic stages⁷. Detection of it in earlier stages is made possible by a triple assessment which includes clinical examination, radiological imaging and tissue pathology. Triple assessment is a very useful diagnostic tool to evaluate patients with breast lumps and to detect patients with breast cancers with an overall accuracy of 99.3%.⁸

Breast diseases are broadly classified into Inflammatory, benign and malignant diseases. The inflammatory diseases are very rare and accounts for 1% of breast symptoms. Various inflammatory diseases are acute mastitis, periductal mastitis, duct ectasia, fat necrosis, lymphocytic mastopathy and granulomatous mastitis. These diseases present clinically as palpable mass and have to be distinguished from carcinoma breast. Benign epithelial lesions are grouped into three categories according to the subsequent risk of developing breast cancer: (1) Non-proliferative breast changes, (2) Proliferative breast disease without atypia, and (3) Proliferative breast disease with atypia. Several epidemiological studies have established the association of benign epithelial lesions with the later development of invasive cancer. These lesions come to clinical attention as mammographic findings or as incidental findings in surgical specimens. Non-proliferative changes do not increase the risk of cancer. Proliferative breast disease without atypia is associated with a 1.5-2 fold increased risk, while proliferative disease with atypia is associated with 4-5 fold increased risk. The large majority of breast cancers are detected during the reproductive years. The incidence curve starts rising at puberty, increases steeply up to menopausal age, and levels off afterwards. However, breast cancer can develop at any age from childhood to old age. Almost all (>95%) of breast malignancies are adenocarcinomas that first arise in the duct/lobular system as carcinoma in-situ; at the time of clinical detection, majority (at least 70%) have already breached the basement membrane and invaded the stroma. As carcinoma breast is now leading cancer in females in India and there are precursor lesions that progress to invasive carcinoma. We planned this study to assess the accuracy of fine needle aspiration cytology in preoperative diagnosis of carcinoma breast.

MATERIALS AND METHODS

A cross sectional study was conducted on women attending gynaecology and Surgery OPD with sign and symptoms suspicious of disease of breast at District hospital Samba, Jammu; Jammu and Kashmir from March 2015 to March 2017. The women who presented with symptoms like lump breast, diffuse swelling breast, nipple discharge, mastalgia, retracted nipple, axillary lymph node, ulceration of skin, peau d’ orange appearance of skin were included in the study. In each case personal information and clinical history like age, size of swelling, duration of swelling, location of swelling, history of any discharge from the nipple, pain, adherence to adjacent structures, detailed history, general physical examination and local examination of breast was carried out. Fine needle aspiration cytology of all these patients and their histology where available were retrieved from cytopathology and histopathology forms of department of Pathology, Medical College, Jammu. Statistical analysis was performed using SPSS 10.0 for Windows student version (SPSS Inc., 233 South Wacker Drive, 11^th Floor, Chicago, IL 60606-6412). Standard variables of specificity, sensitivity and predictive value were also applied.

RESULTS

In a two-year period from March 2015 to March 2017, 132 women had FNA cytology of the breast performed. Of these 132 women, histology was available of only 39 women.

Analysis of Result of FNA Cytology

The age of the patients ranged from 7 years to 88 years with mean age of 36 year. Maximum number of cases were seen in the age group of 21-30 years i.e. 47 cases (30.6%) followed by 41 cases (26.5%) in the age group of 31-40 years, 26 cases (16.6%) in the age group of 41-50 years and 17 cases (14.01%) in the age group of 11-20 years. Left breast (54.1%) was more commonly involved than right breast (44.6%). Upper outer quadrant of breast was the most common quadrant involved followed by upper inner quadrant. Out of 132 patients, 100 cases (75.7%) presented with breast lump while the swelling was diffuse in 5 cases (3.4%). Nipple discharge was seen in 3 cases (2.6%) and mastalgia in 4 cases (2.6%). Axillary lymph node was involved in 5 cases (3.8%), 4 cases (2.6%) presented with retracted nipple, 3 patients (1.9%) had peau d’ orange appearance of the overlying skin while 1 patient (0.7%) presented with ulcerated lesion. There was history of trauma in 2 cases (1.1%). 5 patients (3.8%) were lactating in our study.

Fine needle aspiration cytology diagnosis revealed there were 18 cases (13.63%) of Inflammatory lesions, 98 (74.24%) cases of benign lesions and 16 cases (12.12) of carcinoma breast. Among the benign lesions maximum number of cases i.e. 46 cases (34.84%) were reported as Fibroadenoma, 27 (20.45 %) cases as Fibroadenomatosis, and 22 cases (16.66%) cases as fibrocystic change. Two cases (2.04%) of Ductal papilloma and 1 case (1.082) of phyllodes tumour were also reported. Among the inflammatory lesions most commonly seen were acute mastitis and Breast abscess with 06 cases (33.33%) each. Granulomatous mastitis was seen in 03 cases (16.66%), chronic mastitis in 02 cases (11.11%) and Fat necrosis in 1 case (5.55 %). 16 cases (12.12%) were categorised as malignant on FNAC.

44.7 % of cases with benign breast disease had duration of breast lump ranging from 1 to 6 months, 30.3% had duration of less than 1 month as and 13.08% cases with benign breast disease had duration of breast disease more the 12 months. Most of the patients with malignant breast lesion i.e. 10 cases had duration of the breast lump ranging from 1 to 6 months, 2 cases had duration of 6 to 12 months. 2 cases (9.3 %) with malignant breast lesion had duration of breast lump less than 1 month and 2 cases (9.3%) had duration more than 12 months. 74.6% of cases with benign breast lesion had breast lump ranging in size from 2-5 cm, 24.05% had lump less than 2 cm and 1.2% had lump more than 5 cm. 78.1% of cases with malignant breast lesion had size of the breast lump ranging in size from 2-5 cm.

Analysis of Result of Histology

Of 132 women who had FNA cytology of breast only 39 women went forward and had biopsy for histological diagnosis. On histological analysis among the benign lesions maximum number of cases i.e. 14 (43.58%) were of fibrocystic change, followed by fibroadenoma, 9 cases (23.07%) and infiltrating ductal carcinoma, 6 cases (15.38%). Other diagnosis rendered on histology are shown in table given below-

Correlation of Fine Needle Aspiration Cytology and Histology

Out of 30 cases reported as benign breast disease on cytology, 27 cases were reported as benign on histology while 3 cases had normal breast tissue/inadequate sample on histological examination as shown in table 4. One of the cases diagnosed as fibroadenoma on cytology was reported as fibrocystic change on histology while one case reported as ductal papilloma on cytology was reported as adenomatoid hyperplasia on histology. One of the case which had unsatisfactory sample on FNAC was reported as fibrocystic change on histology while there was one case which had unsatisfactory sample on both FNAC and histology.

Statistical analysis revealed Kappa score of 69% (43.6 – 94.3) indicating a moderate degree of concordance between FNA cytology and histology. For the purpose of statistical analysis, unsatisfactory results have not been considered for analysis. The sensitivity of FNAC is 100% (95% CI 51.6–100), specificity is 96.4% (95% CI – 79.7 – 99.8%), positive predictive value is 85.7% (95% CI – 42 – 99.2%) and negative predictive value is 100% (0.07–57.9%) in our study. Likelihood ratio of FNAC for positive result is 28                           (4.08–191.8 0).

DISCUSSION

Breast lump is one of the most common surgical problems in females. Virtually every woman with a breast lump, breast pain or discharge from nipple fears that she has breast-cancer. Early diagnosis is the key to increase survival. However social factors, religious factors, unawareness of fatality of the disease, false vanity and fear of infertility hinder early diagnosis and treatment. Cancer of the breast is the most common cancer in women worldwide and patients usually present with a palpable breast lump. Not only the malignant lesions pose a major public health problem, but benign lesions also contribute to the morbidity and they can masquerade as malignancy which can cause significant mental anguish to the patients. Breast cancer is the most common cancer in women all over India. Due to lack of awareness and almost non-existent breast screening practices, most of the patients present in advanced stages of disease.

The high incidence of breast malignancy, its relatively easy detection at an early stage, and effective treatment in the form of conservative surgery and chemotherapy had prompted a worldwide initiation of triple assessment i.e. clinical (Palpation), radiologic (Ultrasonography or mammography), and cytological (FNAC) assessment. The age of the patients in our study ranged from 7-88 year with mean age of 36 year. Maximum incidence of breast lesions was seen in the age group of 21-30 year. Maximum number of benign breast disease were seen in the age group of 21-30 year and maximum number of malignant breast diseases were seen in the age group of 41-50 year. Our findings were comparable with other studies.^9,10,11,12 As per statistics from Breast Cancer India (BCI), the average age of developing a breast cancer has undergone a significant shift over last few decades. An increasing number of patients are in the 25 to 40 year of age. In our study 65.6% cases were seen in the age group of 31-50 year. In our study, left breast was more commonly involved in females which is comparable with the study done by Supriya et al¹³. The most common presenting symptom in females in our study was lump breast (96.5%) while 3.4% had diffuse swelling. Our findings are comparable with Homesh et al,¹² who showed that 88.5% of their patients presented with breast lump. Most common location of lump in in our study was upper half of breasts (51.8%) while 32.4% cases presented with lump in lower half of breasts. Our finding are comparable with other studies.^11,14,15 Upper outer quadrant was the most commonly involved quadrant in females. 50% females had lump in the upper outer quadrant in the study done by Saha et al.(2016)¹¹ and El-Ghorori et al.(2004)¹⁴ in their study reported that 58% presented with lumps in upper quadrants. Hussain (2005),¹⁶ in his series had 58% of female patients in whom upper outer quadrant of breast was involved. The size of lumps varied from 0.2 cm to 10 cm in our study. Out of 7 breast lumps with size more than 5 cm, 57.1 % were malignant and 42.8% were benign. In our study, 98.6% of benign lesions were up to 5cm in size while 90.6% of malignant lesions were more than 2 cm in size. These findings suggest that lumps of larger size had more chances of being malignant than of smaller size lumps. The goal of the breast cancer screening is to reduce deaths due to breast cancer by detecting breast cancer early, and reduce the incidence of advanced disease. Breast cancer has to reach a certain size to be detected. Breast cancers found by clinical breast examination or by a woman herself have a median size of 2 to 2.5 cm.¹⁷ Such cancers are more likely to be in advanced stage and are more likely to have already spread to the axillary lymph nodes and are more likely to be lethal. Breast cancers found with high-quality, two-view screening mammography are relatively small, with median size 1.0 to 1.5 cm.¹⁷ Approximately 10% of invasive cancers 1 cm in size or smaller have spread to lymph nodes at the time of detection, compared to close to 35% of those 2 cm in size and 60% of those 4 cm or larger in size.¹⁸ The measured size represented by the largest dimension of a mammary carcinoma is one of the most significant prognostic variables. Numerous studies have shown that survival decreases with increasing tumour size and that there is a coincidental rise in the frequency of axillary lymph node metastases ^19,20,21 In our study, out of 16 malignant cases, 5 presented with palpable axillary lymph nodes, 2 with retracted nipple, 1 with ulcerated lesion and 2 cases with peau d’ orange appearance of the overlying skin. Axillary lymph nodes are usually the first anatomic site to be involved by metastases in patients with breast carcinoma. Ioachim et al.²² opined that axillary lymph nodes are palpable in 50% to 60% of patients with clinically detected primary breast carcinomas and the frequency of palpable lymph nodes is much lower in patients in whom the primary breast neoplasms are not detected by physical examination and usually identified by mammography. Whether or not cancer has spread to lymph nodes is the most important prognostic factor for carcinoma breast. Carcinoma breast that has spread to lymph nodes has a higher risk of recurrence and a less favourable prognosis than breast cancer that has not spread to the lymph nodes. The number of metastatic lymph nodes is also important. The more positive lymph nodes there are, the higher the risk that carcinoma breast will recur. On evaluation of breast lumps using FNAC, in our study major group of disease in our study were benign breast lesions (74.24%). Among the benign diagnosis, 34.84% cases were Fibroadenoma, 20.45% were Fibroadenomatosis, 16.66% were fibrocystic change. In our study fibroadenoma is the most common benign lesion which correlates with the other studies.^23,24,25 The incidence of fibrocystic change in our study is 16.66 and its incidence is very variable in different series.^24,25,26 It is important to distinguish benign breast lesions from breast carcinoma because the majority of benign lesions are not associated with an increased risk for subsequent breast cancer, hence unnecessary surgical procedures can be avoided. It is also important to distinguish benign lesions from in-situ and invasive breast cancer and to assess a patient’s risk of developing carcinoma breast, so that the most appropriate treatment modality for each case can be established. In our study, 12.12% cases were reported as carcinoma on FNAC, which is comparable with other studies.^24,27,28,29 In our study, there were 13.63% cases of benign inflammatory lesions and majority of these were acute mastitis and breast abscess. Incidence of inflammatory lesions also vary in different series.³⁰ The other lesions diagnosed by FNAC were fat necrosis and granulomatous mastitis.

In our study the absolute sensitivity of FNAC is 100% (95% CI 51.6 – 100), specificity is 96.4% (95% CI – 79.7 – 99.8%). The positive predictive value is 85.7% (95% CI – 42 – 99.2%) and negative predictive value is 100% (0.07 – 57.9%). Likelihood ratio of FNAC for positive result is 28. Literature review reveals that there is a variation in sensitivity, specificity, positive predictive value and negative predictive value.^31,11,12 This difference in sensitivity and specificity of FNAC may be because of difference in patient population, operator dependant FNAC procedure and type of lesion.

CONCLUSION

In our study, maximum number of cases were of benign lesions (74.2 %) followed by 12.4 % inflammatory lesions (12.4%) and malignant lesions (10.06%). 10.06 % cases of carcinoma. Among the benign diagnosis, Fibroadenoma (20.06 %) was the most common. Absolute sensitivity of FNAC is 100 % (95 % CI 51.6-100), specificity is 96.4 % (95 % CI – 79.7-99.8 %). The positive predictive value is 85.7 % (95 % CI – 42-99.2%) and negative predictive value is 100 % (0.07-57.9 %). Likelihood ratio of FNAC for positive result is 28. That means fine needle aspiration can fairly distinguish inflammatory, benign and malignant lesions of breast. Therefore, fine needle aspiration can be used for mass screening of population for carcinoma breast.