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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 7  |  Issue : 12  |  Page : 43-47

Palpable breast masses in a tertiary institution of South-South Nigeria; fine-needle aspiration cytology versus histopathology: A correlation of diagnostic accuracy


1 Department of Pathology, University of Port Harcourt Teaching Hospital, Portharcourt, Nigeria
2 Department of Pathology, University of Abuja Teaching Hospital, University of Abuja, Abuja, Nigeria

Date of Web Publication19-Nov-2018

Correspondence Address:
Solomon Raphael
Department of Pathology, Forensic Medicine, University of Abuja, PMB 117, Abuja
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/nnjcr.nnjcr_20_17

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  Abstract 


Background and Objective: Fine-needle aspiration cytology (FNAC) of the breast, as part of the triple assessment approach to the diagnosis of palpable breast masses, has become a valuable preoperative tool. It is fast, inexpensive, and minimally invasive and thus has gained wide acceptance in the preoperative assessment of breast masses. This study aims to determine the diagnostic accuracy of FNAC of palpable breast masses in a tertiary hospital in Nigeria. Materials and Methods: This is a prospective comparative study comprising the reports of the FNAC of palpable breast masses and their subsequent tissue biopsy diagnoses recorded over 1 year from September 1, 2013, to August 31, 2014. Results: A total of 100 consecutive FNAC reports were made during the study period. There were 98 females (98%) and 2 males (2%). The age range of the patients was 18–65 years with a mean age of 42.5 years at presentation. On cytodiagnosis; 14 (14%) cases were inadequate samples (C1), 52 (52%) cases were benign (C2) lesions, 2 (2%) cases were suspicious probably benign (C3) lesions, 4 (4%) cases were suspicious probably malignant (C4) lesions, and 28 (28%) were malignant (C5) lesions. The cytology reports were correlated with the subsequent histological diagnoses. Of the 14 C1 reports, 13 were confirmed on tissue histology as benign lesions and the remaining 1 as malignant. Fifty-one of the 52 C2 reports were confirmed as truly benign (true negatives) and the remaining 1 as malignant (false negative). The overall suspicious rate (C3 and C4) was 6% with the 2 C2 reports confirmed as benign and 3 of the 4 C4 reports confirmed on histology as malignant. All 28 malignant (C5) reports were confirmed by tissue histology as malignant (true positive). The absolute sensitivity was 84.9%, complete sensitivity was 93.9%, specificity was 98.2%, positive predictive value (C5) was 100%, negative predictive value (C2) was 98.2%, false-negative rate was 3.0%, and suspicious rate was 4.3%. Conclusion: FNAC of palpable breast masses shows high sensitivity and specificity in our center. It is strongly recommended to be done on all patients presenting with palpable breast masses to ensure quicker pathologist–surgeon communication, patients' triage, and early establishment of definitive treatment outline.

Keywords: Breast, cytology, predictive value, sensitivity, specificity


How to cite this article:
Stephen MI, Daye SF, Raphael S. Palpable breast masses in a tertiary institution of South-South Nigeria; fine-needle aspiration cytology versus histopathology: A correlation of diagnostic accuracy. N Niger J Clin Res 2018;7:43-7

How to cite this URL:
Stephen MI, Daye SF, Raphael S. Palpable breast masses in a tertiary institution of South-South Nigeria; fine-needle aspiration cytology versus histopathology: A correlation of diagnostic accuracy. N Niger J Clin Res [serial online] 2018 [cited 2020 Oct 24];7:43-7. Available from: https://www.mdcan-uath.org/text.asp?2018/7/12/43/245786




  Introduction Top


Globally, breast cancer is the most common cancer and the second leading cause of cancer-related mortality in women after lung cancer.[1] The incidence of breast cancer is rising, and early detection of breast cancer plays a pivotal role in prognosis and survival. This is especially important in our setting where late presentation is the norm. With increasing compliance to self-breast examination among the populace, patients presenting with palpable breast masses have become a common clinical feature in the surgical outpatient departments.[2] However, it is often difficult to determine whether such lumps are benign or malignant simply from clinical assessment. The associated anxiety about the possibility of the lesion being malignant is extremely common. Therefore, further definitive investigative methods are necessary. These methods must be accurate, reproducible, easy to perform, and acceptable to the patient and must not require too much preparation or expensive equipment.[3]

Early diagnosis and treatment of the malignant breast masses are important. Open biopsy and histologic diagnoses of these masses are the most accurate methods of assessing these diseases and ascertaining whether the lesion is benign or malignant. Open- and core-needle biopsies have their disadvantages: high cost, long tissue processing time, patient discomfort such as pain and hematoma, and the risk of seeding of malignant tumors along the needle track.[3],[4] The role of nonoperative techniques in the definitive diagnosis of malignancy of breast lumps is to enable rapid referral for treatment, ideally in one operative procedure.[5] This will cut down on the cost of managing breast masses, with cost been a major reason for late presentation in our resource-limited setting.

Fine-needle aspiration cytology (FNAC) of the breast, as part of the triple assessment (clinical examination, imaging, and FNAC) approach to the diagnosis of palpable breast masses, has become a valuable preoperative tool. It is fast, simple, inexpensive, and minimally invasive and thus has gained wide acceptance in the preoperative assessment of breast masses.[6] FNAC of breast masses serves two goals; to confirm radiological and clinically benign lesions, thus avoiding unnecessary surgery, and to confirm radiological and clinically malignant diagnoses, thus enabling definitive treatment planning.[7] In this respect, FNAC of the breast masses has been proven to reduce the number of open breast biopsies and has become useful also in staging of breast carcinoma and assessment of metastatic disease at distant sites following treatment for cancers.[3],[6]

This study is aimed at determining the diagnostic accuracy of FNAC in the evaluation of palpable breast masses in the Department of Anatomic Pathology of the University of Port Harcourt Teaching Hospital, Port Harcourt, Rivers State, Nigeria.


  Materials and Methods Top


This was a 1-year prospective comparative study from September 1, 2013, to August 31, 2014. Biopsy materials from all patients who underwent FNAC and subsequent histopathological diagnoses of their breast lesions in the departments of anatomical pathology and general surgery of institution were prospectively used for this study. Patients on chemotherapy or with recurrent malignancy as well as those who underwent FNAC but did not undergo surgical excision of the palpable masses with final histopathological diagnoses were excluded from the study. Clinical data such as age, sex, and site of the breast mass were obtained from the patients' records.

Aspirates were obtained using 22G-needle using either freehand or attached to a 20-ml syringe/syringe holder. Smears were fixed in alcohol and/or air-dried and stained with Papanicolaou and Diff Quik (Giemsa) stains, respectively. The slides were evaluated and reported according to the 5-tier NCI guidelines;[8] C1 for inadequate smear, C2 for benign smear, C2 for suspicious, probably benign smear, C4 for suspicious, probably malignant smear, and C5 for malignant smear. These initial cytological reports were correlated with the final histopathological diagnoses. The diagnostic accuracy of the FNAC of the palpable breast masses in terms of quality assurance statistical parameters of sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), false-positive rate (FPR), false-negative rate (FNR), and the suspicious rate was calculated. These were then compared with the minimum requirements for breast cytology performance set by the UK National Health Service Breast Screening Pathology (NHSBSP).[9]


  Results Top


A total of 100 consecutive FNAC findings compared and correlated with the corresponding histologic findings of the same lesions from patients with palpable breast masses were analyzed in this study.

There were 98 females (98%) and 2 males (2%). The age range of the patients was 18–65 years with a mean of 42.5 years. Sixty-seven of the 100 patients had benign lesions while thirty-three had malignant lesions on histology. The highest frequency of benign breast masses was mostly in the age range of 21–30 years and the highest frequency of malignant breast lumps was found in the age group of 41–50 years.

Sixty-three percent of the patients presented with mass in the left breast and two patients having bilateral masses.

Cytodiagnosis

On cytology [Table 1], 14 (14%) patients had inadequate sample. Fifty-two (52%) patients had C2 lesions [Figure 3]. Two cases (2%) were reported as having C3 lesions [Figure 2], 4 cases had C4 lesions (4%), and 28 patients (28%) had C5 lesions [Figure 1].
Table 1: Cytodiagnosis

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Figure 3: Smear shows tight clusters of epithelial cells with irregular borders (“Staghorn appearance”) having bland nuclear features, C2: Benign (H and E, ×200)

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Figure 2: Smear shows discohesive and mildly pleomorphic hyperchromatic epithelial cells with abundant eosinophilic cytoplasm, C4: Suspicious probably malignant (H and E, ×200)

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Figure 1: Smear shows nest and isolates of discohesive hyperchromatic and moderately pleomorphic epithelial cells with abundant eosinophilic cytoplasm. The background is hemorrhagic. C5: Malignant (H and E, ×400)

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Histopathologic diagnosis

Out of 100 patients, who underwent incisional or excisional biopsy of palpable breast lesion and subsequent histology of same, 67 (67%) were benign lesions. Among these, cases were 44 fibroadenomas (65.7%), 7 (10.4%) fibrocystic change, 2 (3%) gynecomastia, 8 (11.9%) inflammatory lesions/chronic mastitis/abscesses, 2 (3%) fat necrosis, 3 (4.5%) intraductal papilloma, and 1 (1.5%) lactating adenoma. The remaining 33 (33%) cases were diagnosed as carcinoma of the breast on histology.

Among the malignant tumors, 30 (90.9%) cases were of infiltrating ductal carcinoma, 2 (6.06%) cases of invasive lobular carcinoma, and 1 (3.03%) case of in situ ductal carcinoma. Out of the 30 cases of infiltrating ductal carcinoma, 4 (13.3%) were poorly differentiated infiltrating ductal carcinoma, Scarff–Bloom–Richardson (SBR) Grade III, and 26 (86.7%) were moderately differentiated infiltrating ductal carcinoma, SBR Grade II.

Fourteen cases reported as C1 lesions (14%) were reported on histology as benign lesions (6 fibrocystic diseases, 4 fibroadenomas, 2 breast abscesses, 1 fat necrosis, and 1 invasive lobular carcinoma). A case reported as C2 lesions turned out to be an invasive ductal carcinoma of the breast. The two cases reported as C3 lesions were fibroadenomas on histology. Three of the four C4 (4%) lesions were malignant on histopathology while one case was diagnosed as fibroadenoma. All the 28 C5 lesions were confirmed as malignant on histology [Table 3].
Table 3: Fine-needle aspiration cytology versus histopathology result (n=100)

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  Discussion Top


FNAC as a preoperative diagnostic tool and one of the components of triple assessment in the screening/management of breast lesions has gained acceptance by pathologists and clinicians due to its high accuracy, simplicity, and cost-effectiveness.[3] FNAC of palpable breast masses has the advantage of being an immediate and excellent method for on-site examination and one-stop diagnosis at breast outpatient clinics.[10] This study included 100 consecutive patients with palpable breast masses seen over a 1-year period. It recorded an absolute (complete) sensitivity of 84.9% (93.9%), a specificity of 98.2%, a PPV (C5) of 100%, a NPV (C2) of 98.2%, FPR of 0%, and FNR of 3.0%. These values satisfy the UK NHSBSP acceptable minimum threshold for breast cytology performance [Table 4] and compare favorably with findings from works done in Nigeria[11],[12],[13],[14],[15],[16],[17],[18] and elsewhere.[19],[20]
Table 4: Comparison of analysis of the present study with three previous studies

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This study documented a high PPV (100%) similar to the studies by Obaseki et al.[11] in Benin, Daramola et al.[17] in Lagos, and Yusuf and Atanda[13] in Kano. This gives justification for definitive surgery following a malignant (C5) cytology report, especially with the concomitant report of 0% FPR and acceptable 3.0% FNR.

The FNR in this work is lower than that documented in Ibadan[21] and Kano[13] but higher than the values in Lagos[17] and Benin.[11] These may be due to experience and inter-observer differences on breast cytodiagnosis. The most common cause of FNR is sampling error and/or inadequate sampling.[9],[22],[23] Invasive lobular carcinoma mostly and invasive ductal carcinoma occasionally are also associated with FNR and equivocal diagnosis.[9],[22] This study recorded one false-negative case of invasive ductal carcinoma. This diagnostic dilemma occurs when smears are made from benign-looking and paucicellular areas of malignant lesions.[9],[22]

Four atypical/suspicious cytological reports were made and one turned out to be fibroadenoma on histology. Fibroadenoma makes up the largest cause of both false-negative and false-positive diagnoses, and when they exhibit discohesion and pleomorphism, can lead to false suspicious or malignant diagnosis.[9] Fibroadenoma accounted for the most common lesion and the most common benign neoplasm seen in this study [Table 2].
Table 2: Histopathologic diagnoses

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The inadequate rate of 14% in this study, although acceptable according to the breast cytology performance set by the UK NHSBSP,[9] is higher than those of comparative studies done in the country.[11],[12],[15],[16],[17] The role of sampling error, aspiration miss, and lack of on-site facility for checking the adequacy of aspirated material in determining the inadequacy rate is well documented.[22] The diagnostic yield of FNAC is directly related to the experience of the aspirator. Trainee residents perform most FNACs in our center. Their relative “inexperience,” the absence of on-site aspirate adequacy check, and patients' general unwillingness to undergo a repeat of the process are likely contributors to our high inadequate rate. One of the 14 inadequate samples (C1) turned out to be an invasive lobular carcinoma.

The sensitivity of 84.9% in this study is higher than the values reported in Kano,[13] Benin,[11] and Ibadan[15] but lower than the reported findings in Lagos[17] and Maiduguri.[14] Our specificity of 98.2% is higher than those reported in Ibadan,[15] Benin,[11] comparable to that in Maiduguri,[14] and Lagos[17] but lower than the reported values in Kano.[13] Our suspicious rate of 4.3% is the least of the comparative series and highlights the effectiveness of our FNAC of palpable breast masses.

The high sensitivity and specificity obtained in this study compare favorably with reports from international series.[19],[20],[24] This emphasizes the usefulness of FNAC as a preoperative diagnostic tool in the screening/management of palpable breast lesions. The triple assessment approach to the diagnosis of breast lesions involving the multidisciplinary collaboration of clinicians, radiologists, and pathologists working in a “breast clinic” will no doubt improve the quality of FNAC and the preoperative diagnosis of breast lesions, avoid unnecessary surgeries, and conducive to the patients in our center.


  Conclusion Top


Diagnosis of breast lesion using FNAC should be practiced as a routine procedure in our center as there is a high degree of correlation with histopathologic findings. In the presence of budget constraints and personnel shortage, hospitals are required to demonstrate even great cost-effectiveness in the diagnosis of breast lesions.

Therefore, FNAC of palpable breast masses is strongly recommended to be done on all patients presenting with palpable breast lesions to ensure quicker pathologist–surgeon communication, patients triage, and early establishment of definitive treatment outlines.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
International Agency for Research on Cancer. GLOBOCAN 2012: Estimated Cancer Incidence, Mortality and Prevalence Worldwide in 2012. International Agency for Research on Cancer; 2015. Available from: http://www.globocan.iarc.fr/pages/fact_sheets_population.aspx. [Last accessed on 2016 Apr 20].  Back to cited text no. 1
    
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Yong WS, Chia KH, Poh WT, Wong CY. A comparison of Trucut biopsy with fine needle aspiration cytology in the diagnosis of breast cancer. Singapore Med J 1999;40:587-9.  Back to cited text no. 3
    
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Palombini L, Fulciniti F, Vetrani A, De Rossa G, Di Benedetto G, Zeppa P. Fine needle aspiration cytology of breast masses. A critical analysis of 1956 cases in 8 years (1976-84). Cancer 1988;6:2273-7.  Back to cited text no. 5
    
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The uniform approach to breast fine-needle aspiration biopsy. National cancer institute fine-needle aspiration of breast workshop subcommittees. Diagn Cytopathol 1997;16:295-311.  Back to cited text no. 8
    
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Ellis IO, Humphreys S, Michell M, Pinder SE, Wells CA, Zakhour HD. Guidelines for Non-Operative Diagnostic Procedures and Reporting of Breast Cancer Screening-Non-Operative Diagnosis Subgroup of the National Coordinating Group For Breast Cancer Screening Pathology. Publication no 50. Sheffield, UK: National Health Service Breast Screening Programme; 2001.  Back to cited text no. 9
    
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Mohammed AZ, Edino ST, Ochicha O, Alhassan SU. Value of fine needle aspiration biopsy in preoperative diagnosis of palpable breast lumps in resource-poor countries: Nigerian experience. Anna Afri Med 2005;4:19-22.  Back to cited text no. 12
    
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14.
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Kocjan G. Diagnostic dillemmas in FNAC cytology: FNAC technique and preparation/difficult breast lesions. In: Fine Needle Aspiration Cytology: Diagnostic Principles and Dilemmas. Ch. 2/9. Germany: Springer; 2006. p. 23-24, 182-207.  Back to cited text no. 22
    
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