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Cytohistological Correlation of Palpable Breast Mass : A Study of 300 Cases

Background: The present study is aimed at correlation of cytological and histological findings of palpable breast mass and evaluate efficacy of FNAC as a first line of investigation modality in breast lump. Material Method: Total 378 female patients with breast lump were subjected to fine needle aspiration cytology examination and reported by using five tire system for breast cytology. Out of 378 cases, in 300 cases cytological findings were correlated with histological diagnosis. Results: In present study, all benign, malignant and suspicious cases on cytology were well correlated with their histological diagnosis. The sensitivity, specificity and positive predictive value of FNAC for palpable breast lump are 97.7%, 98.8% and 97.7% respectively. Conclusion: FNAC of breast lump is an effective, rapid, cost effective, though simple diagnostic procedure with excellent patient compliance. It is giving high accuracy rates when practiced by and experienced hand; making it one of the most reliable modality for evaluation of palpable breast mass.


Introduction
Palpable breast mass is the commonest presentation at surgical OPD. Breast malignancy is one of the commonest malignancy in women worldwide and its incidence increases with age. (1) It is very essential to evaluate palpable breast mass before any surgical intervention. Most of the countries are now adopting "triple test" diagnostic approach for breast lesions i.e. clinical, radiological and pathological which include fine needle aspiration cytology as first line of investigation modality. (2) FNAC carried out by a well trained, experienced hand, has high accuracy rate observed in many series. (3,4) This makes it most reliable element of the triple test in cases where the three modalities are no concordant. (5,6) Moreover, FNAC is a cost effective, simple diagnostic procedure for palpable breast lumps, (7) which can be used on OPD basis without hospitalization of the patient. It is a minimally invasive procedure, less painful and having less chances of development of hematoma as compared to core needle biopsy. Patient compliance is best with this procedure even if it has to be repeated.
However, fine needle aspiration cytology can be presumptive in some cases. It is not a substitute of core needle biopsy. Final diagnosis can be obtained by histological examination of biopsy tissue. So present study is done to evaluate efficacy of FNAC in cases of palpable breast lesions, which is done by correlating cytological findings with histological diagnosis.
Aim of study: 1) To analyse various cytological findings of aspirates from palpable breast masses presented to cytology department and categorised them according to Five tire reporting system of breast cytology. 2) To correlate cytological diagnosis with histological examinations of breast lesions. 3) To evaluate sensitivity, specificity and predictive value of fine needle aspiration cytology in diagnosis of breast lesion.

Materials and Methods
The present study is performed in a tertiary health care centre in central Gujarat, from December 2014 to December 2016. During this period total 1560 patients referred from various outdoor patient departments were registered in cytology section of pathology department. Out of total 1560 patient, 378 female patients with palpable breast lesions were included in present study. Male patients with breast lump are not included in this study.
All the study participants were subjected to FNA examination after obtaining a written consent. The procedure of FNA was performed in supine position in a well lighted, properly ventilated room with maintaining privacy of the patients. The aspirations were taken using 23 The bar diagram also shows maximum numbers of benign breast lesions (C2 category) havebeen found in age range of 20 to 30years. Commonest benign breast lesion found in present study wasfibroadenoma.
Maximum number of malignant breast lesions was found between 5 th and 6 th decade of life. All the six cases above70 years of age were diagnosed malignant. Not a single benign case found in this age group. Maximum number of suspicious lesions (category C3,C4) were found between 35 to 50 years of age.
Out of total 378 cases of breast FNAC, histological correlation was available in 300 cases (79.3%). Table 3 shows correlation between cytological and histological diagnosis of all the 300 cases in both malignant and benign categories. From the obtained data, sensitivity, specificity, positive predictive value, false negative rate and false positive rate for Breast cytology were calculated. (Table 4).
G needle attached to 10ml disposable syringe. The material obtained subsequently smeared on standard microscope glass slides, fixed with alcohol fixative and stained with H & E stain and modified Giemsa stain. A quick review of cellularity obtained in each aspiration was done on the spot immediately after staining the slides. The reporting of cytology slides was done using five tyre system for breast cytology. (table 1).
Out of these total 378 cases diagnosed cytologically, 300 cases subsequently subjected to histolopathological intervention. Cytological and histological diagnosis correlated in all the 300 cases. From the obtained data, statistical analysis was done.

Result
Data recorded from all the 378 female patients with palpable breast mass, entered in Microsoft Excel sheet. The age of the female patients in included in the present study ranged from 12 to 73years. The age wise distribution of all the five categories (C1 to C5) is shown in a bar diagram, which shows more than 50 % patients with palpable breast mass falls in age range of 20 to 40years. This is the age range where maximum number of patients with palpable breast

Discussion
FNAC of palpable breast masses is considered as a quick, inexpensive, painless and safe procedure. Also, it gives reliable results as far as early detection of breast cancer is considered. This technique is very well accepted by the patient even if it had to be repeated. The only complication arises that is development of hematoma; which can be very well prevented by applying gentle pressure over the site of procedure for short duration.
Most countries have now adopted triple assessment approach (clinical, radiological, and pathological) for palpable breast masses, with FNAC as the first-line pathological investigation in both screening and symptomatic populations. (5) In present study, we observed that maximum number of benign lesions were found in 2 nd decade of life. Among these benign lesion, most common benign lesion was fibroadenoma. Similar findings have been observed by Ferguson et al. which shows commonest benign breast lesion is fibroadenoma occurring before age of 25years. (8) Assessing malignant breast lesions in present study, we observed that peak incidence of malignant breast lesion is in 5 th to 6 th decade of life. Similarly peak age of breast malignancies is 50.8 years in a study done by Murali and Annals of Pathology and Laboratory Medicine, Vol. 4, Issue 6, November-December, 2017 Cunden. (9). In present study, we obtained that most frequent malignant lesion was invasive ductal carcinoma of Not Otherwise Specified type (IDC-NOS). Such findings are comparable with a study done by Sigh et al, in which they found ductal carcinoma was most frequently diagnosed breast malignancy. (10) In present study, total 32 cases where FNAC smears were inadequate / unsatisfactory. That gave proportion of inadequate cases in present study was 10.5%. This rate is higher than that obtained in a study done by Daramola et al. (11) This propotion of undiagnosed cases on cytology can be reduced by immediate evaluation of cytology smear by pathologist using a rapid staining technique. This "onsite" evaluation makes FNAC even more cost effective modality and reducing chances of recalling patients for re-aspiration. (12) Technical skills of a cytopahtologist performing FNAC are having very much influence of diagnostic yield. Unsatisfactory cytological smears can be due to insufficient experience of a pathologist, poor technique in performance of FNAC or due to the nature of lesion itself. Provision of adequate sample by an experienced pathologist can prove FNAC as highly reliable diagnostic tool. (13) In present study, total two false negative cases were diagnosed. In one of that, we obtained heavily blood stained smears with mixed cytological features. Cytologically, this was diagnosed as a cystic lesion. On histological evaluation, it turned out to be an invasive ductal carcinoma of NOS type. Yeoh and Chan have also observed such pitfalls in cytodiagnosis. In their study, they got 6 false negative cases including 4 cases misdiagnosed as cystic lesions. (14) Such type of 'missed diagnosis' on cytology can be obtained due to either heavily blood stained smear hindering cytological features or the smear contains mixed cytological findings.  (11,15,16) . The table shows the results obtained in this study is quite comparable regarding sensitivity, specificity and positive predictive values of FNAC as a diagnostic modality in detective malignant breast pathologies.

Conclusion
Palpable breast mass is one of the common presentation at surgical OPD. Chances of a breast lump being malignant are definitely present. So the proper evaluation of a breast lump is very essential part of patient management. FNAC of breast lump is now proved to be a rapid, reliable, cost effective diagnostic procedure with high degree patient compliance. Present study observed that the findings of breast FNACs are well correlated with histological diagnosis of respective breast lesions. This proves that cytodiagnosis by FNAC when in experienced hand are extremely useful in the evaluation of breast lumps.
Moreover, a benign diagnosis on FNA allows a time period in which a surgery can be planned or delayed, while a positive diagnosis of carcinoma on cytology allows preoperative discussion/ counselling of the patient and further planning of the therapy and reduces morbidity.