|Year : 2017 | Volume
| Issue : 2 | Page : 123-127
Triple approach for diagnosing breast lesions-experience at a Tertiary Care Hospital
Ritu Mehta1, Kunal Tewari2, Neeti Goyal3, U Basak1, Arun Gupta4
1 Department of Pathology, INHS Asvini, Mumbai, Maharashtra, India
2 Department of Anaesthesia and Community Medicine, INHS Asvini, Mumbai, Maharashtra, India
3 INHS Patanjali, Karwar, Karnataka, India
4 PMO, INS Kadamba, Karwar, Karnataka, India
|Date of Web Publication||13-Feb-2018|
Dr. Ritu Mehta
Pathology and Oncopathology, Assistant Professor Department of Pathology INHS Asvini Mumbai - 400 005
Source of Support: None, Conflict of Interest: None
Background: Breast lesions are always a diagnostic challenge and range from benign to malignant. Fine-Needle Aspiration Cytology (FNAC) is done in patients with breast lesions. However, to get an accurate and diagnostic yield is difficult at times. Aims: The aim of this study is to highlight the role of triple approach in diagnosing breast lesions. Design and Setting: This is an observational prospective study carried out in the Department of Pathology at a tertiary care hospital over 2 years. Materials and Methods: One hundred and fifty cases of breast lump were studied. Clinical findings, imaging findings, and cytology along with histopathological findings were correlated. Results: Cytological findings were benign in 102 out of 107 patients, who were otherwise clinically and radiologically benign. In rest five patients, Breast Imaging Reporting and Data Systems (BIRADS) BIRADS II category was given on mammography. In four of these five patients, there was cytological atypia. Biopsy in these four patients showed features of fibroadenoma with mild cytological atypia and one patient showed infiltrating duct carcinoma. Mammography was suggestive of malignant breast lump in 43 patients. In three patients, breast lump was diagnosed as benign on cytological examination. However, histopathological examination confirmed the mammography findings of malignancy. Conclusion: FNAC is a well-established procedure for diagnosing breast lesion but has got many pitfalls. Hence for diagnosis a breast lesion, the triple approach consisting of histopathological examination in addition to mammography and FNAC, should be considered.
Keywords: Carcinoma breast, fibro epithelial, fibrocystic, mammography
|How to cite this article:|
Mehta R, Tewari K, Goyal N, Basak U, Gupta A. Triple approach for diagnosing breast lesions-experience at a Tertiary Care Hospital. J Mar Med Soc 2017;19:123-7
| Introduction|| |
Diseases of the breast are very common in all age groups. It can be benign or malignant and can affect both males and females. The most common presenting symptoms are palpable mass nipple discharge and pain. Benign lesions range from fibrocystic disease and fibroepithelial lesions to inflammatory lesions. The incidence of breast cancer is increasing in both developing and developed countries. Breast cancer is the second most common cancer affecting females in the developing countries. It is the most common cause of morbidity and mortality in females. The incidence of breast carcinoma is about 22.2%. Breast carcinoma affects females in younger age group. Early diagnosis can reduce the mortality and morbidity in breast cancer patients. The FNAC is a known nonoperative procedure used for diagnosis of breast lesions. It was first done by Martin and Ellis in 1930. It is a well-established method which allows rapid diagnosis and is a cost effective outpatient procedure. The sensitivity of FNAC is 91%. However, FNAC has got many pitfalls as results depend on the representative aspirate, the quantity of the aspirate obtained and also on the experience of the reporting pathologist. Delay in the diagnosis might reduce the survival of the patients. Early definitive diagnosis is required for initiation of the treatment. Core biopsy should be done in FNAC negative patients. FNAC should always be correlated with radiological findings and biopsy. In the absence of mammography and clinical details, FNAC findings can mislead a pathologist and may lead to erroneous diagnosis. We hereby highlight the importance of triple approach in diagnosing breast lesions. This study is aimed to ascertain the diagnostic significance of FNAC along with mammography and histopathology findings.
| Materials and Methods|| |
This is an observational prospective study carried out at tertiary care hospital over 2 years. Consent was obtained from all patients before the study.
We included 150 cases who presented to our department with a clinical diagnosis of breast lump. Both image-guided (ultrasound) and blind fine needle aspiration cytology FNAC were included in the study. Image-guided FNAC was done in cases of deep-seated lumps and in those patients who presented with ill-defined lesions which were not palpable on examination. The age of the patient varied from 18 years to 75 years. Known cases of breast carcinoma were excluded from the study. Postchemotherapy and radiotherapy patients were also not included in the study. The clinical details included age, sex, presenting symptoms, site of the lesion, radiological findings, and FNAC findings. The final diagnosis was based on histopathological examination.
Processing of material
FNAC smears were stained with Leishman's stain. Papanicolaou stain was also done in each case. Biopsy tissue was fixed in formalin. Hematoxylin and eosin (H and E) stain was done on formalin-fixed paraffin-embedded tissue blocks. Special stains like Ziehl–Neelsen (ZN) stain for granulomatous breast lesions were also done.
| Results|| |
The age of the patients varied from 18 years to 75 years is shown in [Table 1]. Out of 150 cases included in the study, two patients were male and 148 patients were female. Eighty-six patients presented with right-sided breast lump (57.3%). Sixty-four patients presented with left-sided breast lump (42.6%). The most common location was upper outer quadrant, seen in 97 patients (64.6%). Ten patients presented with upper inner quadrant lump (6.6%). Three patients present with bilateral breast lumps (2%). Eighteen patients presented with lower outer breast lump (12%). Fifteen patients presented with lower inner quadrant breast lumps (10%). Seven patients presented with subareolar region lump (4.6%). The most common presenting symptom was painless swelling noted by the patient 82% (123 patients). Nipple discharge was noted in 18% (27 patients). The breast lump was clinically malignant in 43 patients and was benign in 107 patients. Mammography was done in all patients.
Mammography was done in all the patients irrespective of age. Patients in the six BIRADS categories were as follows:
- Category 0: No patient
- Category I: One patient
- Category II: 66 patients
- Category III: 40 patients
- Category IV(a): 18 patients
- Category IV(b): 12 patients
- Category IV(c): 10 patients
- Category V: Three patients
- Category VI: No patient
FNAC was done in each patient. Image-(ultrasonography) guided FNAC was done where ever it was necessary. Based on the cytological examination, the patients were divided into following categories. Inflammatory lesion were diagnosed in 13 cases (9%), benign breast lesions were diagnosed in 25 cases (17%), fibroepithelial lesions were diagnosed in 64 cases (43%), lesions were diagnosed as atypical in 5 cases (3%), and malignant in 43 cases (29%).
Types of inflammatory lesion (13 cases)
There were 6 cases of acute mastitis (4%), 3 cases of granulomatous mastitis (2%), 1 case of microfilaria (1%), and 3 cases of fat necrosis (2%).
Types of benign breast disease (25 cases)
There were 19 cases of fibrocystic disease (12%), 1 case of mucocele, 4 cases were found to have lactational changes (3%) and one patient of intraductal papilloma [Figure 1]a.
|Figure 1: (a) H and E stained section showing intraductal papilloma (×100). (b) H and E stained section showing fibroadenoma (×100). (c) Leishman stain showing the bimodal population of benign ductal and myoepithelial cells – suggestive of fibroadenoma (×400). (d) H and E stained section showing invasive ductal carcinoma –NO specific type (×100). (e) H and E stained section showing metaplastic carcinoma (×100X)|
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Types of fibroepithelial lesion (64 cases)
There were 62 cases of fibroadenoma [Figure 1]b and 2 cases of Phyllodes tumor [Figure 1]c.
Types of malignant lesions (43 cases)
Forty-one patients (27%) were diagnosed with invasive ductal carcinoma. One patient was diagnosed as metaplastic carcinoma, and one patient was diagnosed as lobular carcinoma [Figure 1]d and [Figure 1]e.
Atypical cells were seen in five patients. Fine-needle aspiration from these patients showed atypical cells which were not fulfilling the criteria of either benign or malignant lesion. Hence, these cases were reported as atypical. All these five cases were suggestive of benign pathology on mammography as well as clinically. However, FNAC was not clear and was reported as atypical cell seen.
Histopathological examination including core biopsy/excision biopsy was done in all patients. Tissue was fixed in formalin. H and E stain was done in all cases. Special stains were like ZN stain for Acid fast bacilli (AFB) was also done depending on the diagnosis of the patient. Histopathological diagnosis was compared with cytological and mammographic findings.
Imaging findings were suggestive of benign lesion in 107 out of 150 cases. This correlated with clinical findings. There was nearly 100% accuracy in clinical and imaging findings. The lump was clinically malignant in 43 patients and the same findings were also seen on the radiology.
Cytological findings were suggestive of beign lesions in 102 out of 107 patients, who were also clinically and radiologically benign. In five patients, there was a discrepancy between the mammography, clinical and cytology findings. These five patients were given BIRADS II on mammography and were clinically benign. In four of these five patients, there was cytological atypia with focal absence of myoepithelial cells. The presence of atypical cells was given on FNAC report. Histopathological examination in these four patients showed features of fibroadenoma with mild cytological atypia. There was no evidence of malignancy in these cases. One of these five patients showed cellular atypia, pleomorphism, cells with high Nuclear: Cytoplasm N:C ratio and prominent nucleoli. Histopathological examination in this patient showed Grade II infiltrating duct carcinoma. This patient was diagnosed with a benign breast disease on clinical as well as on radiology and turned out to be infiltrating duct carcinoma on histopathological examination. The cases would have been missed if triple approach for diagnosis was not followed. Comparison of cytological findings of our study with other studies are illustrated in [Table 2].
|Table 2: Comparison of cytological findings of the present study with the various other studies|
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Mammography was suggestive of malignant breast lump in 43 patients. In 3 out of 43 patients breast lump was diagnosed as benign on cytological examination. However, histopathological examination was done due to high clinical and radiological suspicion of malignancy. Histopathological examination confirmed three cases of mammography suggestive of malignancy. Cytohistopathological comparison is illustrated in [Table 3].
|Table 3: Cyto-histopathological comparison of 150 cases of breast lesions of the present study|
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| Discussion|| |
The study included the cytological findings in breast lump in 150 patients. FNAC findings were compared with histopathological findings in all patients. Age of patient in our study ranged from 18 to 75 years. The commonly affected age group was 41–50 years. This was similar to the study conducted by Khan et al. Lumps were more common on the right side and the most common location was the upper outer quadrant. Various other studies conducted showed breast lump was more common in left breast and upper outer quadrant was commonly affected. In this study, the breast lump was more common in upper outer quadrant of the right breast. Aspirates were adequate in 144 patients. In six patients no aspirate could be obtained and hence, repeat FNAC was done. Aspiration cytology results were divided into benign, inflammatory, atypical, fibroepithelial, and malignant. Thirteen cases of inflammatory breast disease were diagnosed. One case was of microfilaria. Three cases of granulomatous mastitis were identified. ZN stain was done in these patients. However, ZN stain was negative in all cases. Thus, diagnosis of granulomatous mastitis was made. Six patients presented with painful swelling. In these six patients, diagnosis of acute mastitis was made as smear showed acute inflammatory infiltrate. Benign ductal cells admixed with myoepithelial cells were also seen. One patient presented with a small lump in the right breast of 7 months duration. Clinical and imaging diagnosis of fibroadenoma was given. FNAC from the swelling revealed benign ductal and myoepithelial cells along with microfilaria. Fat necrosis was seen in three patients.
Benign breast disease
The majority of the patients who come for breast FNAC have a diagnosis of benign breast disease. In this study, 19 patients were diagnosed to have fibrocystic disease. Cytology smears from these patients showed moderately cellular smears comprising of both ductal and myoepithelial cells. Apocrine changes were also seen. Numerous cyst macrophages were seen in the background. One smear showed multinucleated giant cells. No atypical features were seen in any of these patients. In one patient, diagnosis of mucocele was given. BIRADS II was given on mammography. FNAC cytology smear showed mucinous material with only a few clusters of benign ductal cells. No tumor cells were seen. Thus, correlating with imaging, clinical, and cytological findings diagnosis of mucocele was made. Histopathological examination was done in this patient which showed pools of extracellular mucin without any atypical cells thus ruling out mucinous carcinoma of the breast. It is difficult to distinguish mucocele from mucinous carcinoma. Mucin may be seen in both the conditions. The presence of atypical cells in these mucinous pools is diagnostic of mucinous carcinoma. In one patient, diagnosis of intraductal papilloma was made and BIRADS III was given on mammography. Aspiration smear showed densely cellular smears comprising of benign ductal and myoepithelial cells arranged in sheets and papillary fashion. The background showed cyst macrophages and bare nuclei. Histopathological examination was also done in this case which showed complex papillary structures lined by benign ductal and myoepithelial cells. Fibrovascular cores were also identified. No atypia was seen in this case. Four patients were lactating and presented with painful swelling in the breast. Smear showed increased cellularity showing benign ductal and myoepithelial cells on a foamy background. Ductal cells showed prominent nucleoli. However, they were benign. No cytological atypia was noted. Nuclear membrane was normal with maintained N:C ratio. Lactation changes can be misinterpretated as secretory carcinoma. Cytological findings should always be reported taking clinical picture into account.
In this group, two diagnoses were made. These were fibroadenoma and phyllodes tumor. Fibroadenoma was the most common benign tumor seen in the young patient. In 62 patients, diagnosis of fibroadenoma was made based on the classical cytological findings. The smears were cellular and showed benign ductal and myoepithelial cells arranged in monolayered sheets. The background showed numerous bare nuclei. No atypia was seen. Mammography in all these patients was suggestive of benign lesions. In five patients, there was cytological atypia with the focal absence of myoepithelial cells. Histopathological examination confirmed clinical diagnosis of fibroadenoma in four patients. One patient was diagnosed to have infiltrating duct carcinoma. FNAC findings can be misleading in atypical fibroadenoma. Atypia features can be erroneously diagnosed as breast carcinoma; features should be interpretated along with clinical and imaging findings. Mammography was suggestive of the benign lesion in all these five patients. In two patients, diagnosis of benign Phyllodes was made. There was stromal hypercellularity with occasional clusters of benign ductal and myoepithelial cells. It is difficult to differentiate fibroadenoma from benign Phyllodes. There was increased stromal cellularity in two patients. Features suggestive of benign phyllodes were given. Mammography was suggestive of benign lesion. Excision biopsy was done in these cases which confirmed the diagnosis of benign phyllodes tumor. No atypical features, mitosis or necrosis was seen in these patients.
In 44 cases, the diagnosis of invasive breast carcinoma was made. In 3 of these patients, FNAC was suggestive of fibroadenoma. Tru-cut biopsy was done due to radiological and clinical suspicion of malignancy. Tru-cut biopsy showed features of infiltrating duct carcinoma. The smears were moderately cellular and showed atypical cells arranged singly as well as in small discohesive clusters. The cells showed high N:C ratio, pleomorphism and prominent nucleoli. Mitosis and necrosis were also seen. In one of these patients diagnosis was given as suspicious for malignancy on FNAC. Biopsy from this case also showed features of invasive ductal carcinoma, Grade II. One of these 44 patients showed features of lobular carcinoma in the form of monomorphic cells arranged in discohesive clusters as well as singly spread. Mucin was also noted. Tru-cut biopsy was done in this patient, which confirmed the diagnosis of lobular carcinoma. In one patient, smears showed atypical ductal cells exhibiting pleomorphism, high N:C ratio. Cells exhibiting squamous differentiation were also seen. Diagnosis of invasive carcinoma was made. Excision biopsy was done which showed features of metaplastic carcinoma.
FNAC findings can be misleading as it is a blind procedure and sometimes, the material which is aspirated might not be representative. One should never ignore mammographic and clinical findings. In FNAC negative cases if mammography is suggestive of malignancy, biopsy should be done.
| Conclusion|| |
FNAC is a rapid and relatively safe procedure which allows early diagnosis. The accuracy of the FNAC depends on the representative material present on the smears, the staining of the cytology slides and the experience of the pathologist reporting theses aspiration cytology. FNAC is a blind procedure, and radiological guidance is always required. For diagnosis a breast lesion, the triple approach should be considered. Diagnosis should always be made based on imaging, clinical, and pathological findings.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Muddegowda PH, Lingegowda JB, Kurpad R, Konapur P, Shivarudrappa A, Subramaniam P. The value of systematic pattern analysis in FNAC of breast lesions: 225 cases with cytohistological correlation. J Cytol 2011;28:13-9.
] [Full text]
Faerlay JB, Pisani P, Parkin DM. GLOBOCAN 2000; Cancer Incidence, Mortality and Prevalence Worldwide. Ver. 1.0. Geneva: WHO; 2001.
Martin HE, Ellis EB. Biopsy by needle puncture and aspiration. Ann Surg 1930;92:169-81.
Purasiri P, Abdalla M, Heys SD, Ah-See AK, McKean ME, Gilbert FJ, et al.
A novel diagnostic index for use in the breast clinic. J R Coll Surg Edinb 1996;41:30-4.
Mizuno S, Isaji S, Ogawa T, Tabata M, Yamagiwa K, Yokoi H, et al.
Approach to fine-needle aspiration cytology-negative cases of breast cancer. Asian J Surg 2005;28:13-7.
Westenend PJ, Sever AR, Beekman-De Volder HJ, Liem SJ. A comparison of aspiration cytology and core needle biopsy in the evaluation of breast lesions. Cancer 2001;93:146-50.
Arisio R, Cuccorese C, Accinelli G, Mano MP, Bordon R, Fessia L. Role of fine-needle aspiration biopsy in breast lesions: Analysis of a series of 4,110 cases. Diagn Cytopathol 1998;18:462-7.
Khan A, Jamal R, Jan M, Tasneem M. Correlation of fine needle aspiration cytology and histopathology diagnosis in the evaluation of breast lump. Int J Med Stud 2014;2:37-40.
Ishita P, Singh PK. Cytomorphologic study of palpable breast lesions and histopathologic correlation. J Cytol 2003;20:129-32.
Datta S, Davies EL. Breast benign disease. Surgery (Oxford) 2013;31:22-6.
Smith GE, Burrows P. Ultrasound diagnosis of fibroadenoma – Is biopsy always necessary? Clin Radiol 2008;63:511-5.
Ahmed I, Nazir R, Chaudhary MY, Kundi S. Triple assessment of breast lump. J Coll Physicians Surg Pak 2007;17:535-8.
[Table 1], [Table 2], [Table 3]