Fine needle aspiration study of non neoplastic and neoplastic breast lesions

Introduction: The role of FNA cytology is widely accepted as a reliable technique in the evaluation breast lumps. Objectives: To study the cytology of lesions of the breast and its histopathological correlation where ever necessary and to have clinicopathological correlation with respect to age and clinical features. Materials and Methods: Two year prospective study, includes 110 Patients presenting with breast lumps. Results: Maximum of 41 cases (38%) were in the age group 31-40 years. Left breast was more commonly involved with 60 cases (56%). The most common presenting symptom was a Palpable mass seen in all 108 patients. The aspirate was adequate in 108 cases (98.1%). The non neoplastic lesions accounted to 31 cases (28%). The benign conditions comprised of 59 cases (77%) and the malignant conditions comprised of 18 cases that included duct carcinoma, lobular carcinoma, Medullary carcinoma and 2 Suspicious. The 2 Suspicious cases were confirmed as malignant on histopathology. Maximum number of cases in the Non neoplastic category was seen in 21-30 years age group and the minimum was seen in the 11-20.The maximum number of cases in the Neoplastic category was seen in the 31-40 year age group with 27 cases and the minimum in the 51-60 and 61-70 year age group with three cases each. Conclusion: FNAC on breast lumps offers many advantages to clinicians and pathologists as it is an easy and reliable method of establishing the diagnosis of various breast lesions from inflammatory to non neoplastic to malignant conditions.


Introduction
With growing awareness in the general population about breast pathologies, a lady with breast lump is one of the most common presentations in the outpatient department 1 .
Various benign and neoplastic lesion of the breast may present for needle aspiration. The spectrum of lesions of the female breast are classified as Inflammatory lesions, lesions caused by trauma, Benign Proliferative disorders, Benign tumors, Malignant tumors and Metastatic tumors. 2 The fine needle aspiration cytology has become the investigation of choice for the diagnosis of the breast malignancy. FNAC is widely accepted as a reliable technique as the procedure is simple, safe, cost effective, minimally invasive, rapid, and causes minimal morbidity. Hence, an attempt is made to diagnose the spectrum of Non neoplastic and neoplastic lesions of the breast by fine needle aspiration cytology, in our institute.

Aims and Objectives
To study the cytology of lesions of the breast and its histopathological correlation where ever necessary and to have clinico-pathological correlation with respect to age and clinical features.

Materials and Methods
Source of Data: All female patients presenting with Non neoplastic and neoplastic breast lesions attending Hospital and other peripheral referral centers are the subjects of the study. Methods of collection of data: All the patients referred to the department of pathology, Navodaya Medical College Hospital and Research center and from peripheral referral centres, for FNAC of breast lesions were enrolled for the study. The patients were clinically evaluated, and the details were obtained. FNAC was done and the standard method for the procedure was adopted. All the slides were reviewed and their diagnosis was made according to their respective criteria. Study Period: A two year cross sectional study with desired sample size of 100 cases Inclusion Criteria: All female patients presenting with lesions of the breast aged between 15 and 70 years are included in the study. Exclusion criteria: Patients' refusal / non willingness for the procedure, male patients, aspirates with paucicellularity, hemorrhagic acellular smears, Patients presenting with lesions of the skin of the breast, lesions of the chest wall, lymph nodes in the axillary tail of the breast, are excluded from the study.

Results
This study comprised of a total number of 110 cases, which included both Non neoplastic and Neoplastic lesions of the breast. 2 cases were considered as inconclusive and excluded from the study. The remaining 108 cases were included in the study, where Non neoplastic lesions of the breast accounted to 31 cases (28%) and Neoplastic lesions to 77 cases (71.3%).
Age of the patients of the cases in the study ranged from 15 to 70 years. The maximum number of 41 cases (38%) was seen in the age group of 31-40 years, and the minimum number of 3 cases (2.8%) was seen in the age group of 51-60 years.
Presenting Symptoms: Clinical evaluation of all the cases were done in this study which showed most common symptoms like palpable mass in all 108 cases (100%), followed by mastalgia -60 cases (56%) while the least common symptom was nipple discharge -5 cases (4.7%), Incidence of non neoplastic lesions: Non neoplastic lesions of the breast in the present study accounted to 31cases (28%) of the total 108 cases. Of the 31 cases, according to the decreased order of frequency, the lesions were, Acute mastitis -13 cases (42%), Fibrocystic disease -9 cases (29%), Simple cyst -4 cases (13%), Galactocele -1 case (3.2%), Chronic mastitis -1 case (3.2%), Granulomatous mastitis -1case (3.2%), Duct ectasia -1 case (3.2%) and Fat necrosis -1 case (3.2%).  The 2 remaining cases (11.1%) which were considered as Suspicious for malignancy, were finally confirmed as Invasive duct carcinoma -NOS in both the cases, after subjecting them to histopathological examination.  Out of a total number of 108 cases, 38 cases were subjected for histopathological examination that included 2 Non neoplastic lesions and 36 Neoplastic lesions.
In the Nonneoplastic category, out of 2 cases available for histopathological correlation, 1 correlated and was a case of Granulomatous mastitis. The other case which did not correlate was a case of Invasive Duct carcinoma NOS (Mixed type) which was initially diagnosed on cytology as Fibrocystic disease.
In the Neoplastic category, 24 cases of Benign lesions and 12 cases of malignant lesions had histopathology slides available for correlation.
Of the 24 benign lesions, 23 cases showed good correlation and 1 did not correlate. Out of 23 cases that showed correlation, 20 cases were of Fibroadenoma and the remaining 3 cases were of Phyllodes tumor, Lipoma and Atypical duct hyperplasia, comprising of one case each. One case that did not show correlation was initially diagnosed as Benign duct hyperplasia on cytology and was confirmed as Atypical duct papilloma on histopathology.

Discussion
Fine needle aspiration of the breast is one of the most valuable diagnostic tools in the assessment of benign and malignant lesions. 3 Patients with breast lesions underwent FNAC and with adequate aspirate accounted to 108 cases in the present study of 2 years, between August 2009 and August 2011.
The age incidence of the patients with breast lesions varied from 15-70 years. The maximum incidence of 41 cases (38%) was seen in the age group of 31-40 years and the minimum -3 cases (2.8%) were seen in the age group of 51-60 years. Studies conducted by Rocha P D et al 4 also reported similar incidences (40.7%) with respect to 31-40 years age group, whereas Talpur K.A.H et al 5 and Kumar R 6 on the contrary, documented maximum incidences (28% and 36%) in the age group of 11-20 years and 21-30 years, respectively.
The minimum incidence of cases in the present study correlated with the study of K.A.H. Talpur et al 5 and Kumar R 6 (3.33% and 2.0%) in 61-70 years age group, on the contrary, Rocha P D et al 4 recorded a slightly higher incidence (9.1%) in the age group of 51-60 years.

Comparison of incidence of non neoplastic lesions in present study with various studies
In the present study, the Non neoplastic breast lesions accounted to 31 cases (28%) of the total 108 cases and the incidence according to the decreased order of frequency were Acute mastitis (42%), Fibrocystic disease (29%), Simple cyst (13%), Galactocele (3.2%), Chronic mastitis (3.2%), Granulomatous mastitis (3.2%), Duct ectasia (3.2%) and Fat necrosis (3.2%).  9 but studies conducted by Amr SS (4.1%), 12 Singh K (4.7%) 14 and Qasim M et al (11.1%) 15 reported higher incidences while Pradhan M (0.6%) 11 reported a lower incidence when compared to the present study. Duct ectasia: The incidence of Duct ectasia in our study was 3.2% and was significantly lower when compared with the studies conducted by Amr SS 12 , Tiwari M 10 and Malik M. et al 9 who reported significantly higher incidences of 11.7%, 17.9% and 19.49% respectively, while Pradhan M 11 reported a lower incidence of 1% compared to this study. Fat necrosis: In the present study, the incidence of Fat necrosis was 3.2% which was lower when compared with the studies of Singh K 14 and Qasim M et al 15, who reported significantly higher incidences of 5.7% and 22.2% respectively. Fibrocystic disease: Fibrocystic disease in our study accounted to 29% of cases, which correlated with the findings of Qasim M et al (22.2%), 15 Malik M. et al (27.1%) 9 and Singh A et al (30%), 13 whereas Amr SS 12 reported a significantly higher incidence of 50.5% in their study while lower incidence of this lesion were documented by Tiwari M (17.9%) 10 and Pradhan M et al (7%) 11 when compared to the present study.  11 who reported a similar incidence (2%), while lower incidences were reported by Amr SS 12 and Malik M 9 (0.7% and 0.6% respectively) when compared to the present study. Lipoma: A case of Lipoma with an incidence of 1.7% was observed in the present study, which was lower compared to the studies of Amr SS 12 and Pradhan M. et al 11 who reported slightly higher incidences of 3.4% and 3.5% respectively. Benign duct hyperplasia: The incidence of Benign duct hyperplasia of 18.6% in the present study was significantly higher when compared to the findings of Dahri F J et al, 16 who reported a much lower incidence of 3.2%. Atypical duct hyperplasia: The incidence of Atypical duct hyperplasia in the present study (1.7%) was comparable to the studies of Tiwari M 10 and Pradhan M. et al, 11 who showed similar incidences of 2.7% and 3% respectively.

Comparison of incidence of malignant lesions in the present study with various studies
The Malignant lesions comprised of 18 (23.37%) out of 77 Neoplastic lesions. Of the 18 cases, 16 were diagnosed as malignant on cytology and 2 were considered in the Suspicious category. Of the 16 cases diagnosed as malignant on cytology, 14 cases (77.7%) were Invasive duct carcinoma of the NOS type, one case (5.6%) of Invasive lobular carcinoma and a case (5.6%) of Medullary carcinoma.
The two remaining cases (11.1%) which were considered as Suspicious for malignancy, were finally confirmed as Invasive duct carcinoma -NOS (Mixed subtype) in both the cases, after subjecting them to histopathological examination. Invasive duct carcinoma: The incidence of Invasive ductal carcinoma in the present study was 77.7% which corroborated with the study of Rocha PD et al 4 (79.2%) while Singh K et al (85%) 14 reported a slightly higher incidence. But contradictory to our study, Malik M et al 9 reported a significantly lower incidence (30.5%) of this lesion. Invasive lobular carcinoma: The incidence of Invasive Lobular carcinoma in the present study was 5.6% whereas the study of Malik M 9 (8.1%) reported a slightly higher incidence, while Amr SS 12 reported a lower incidence of 2.2% when compared to the present study. Medullary carcinoma: A case of Medullary carcinoma with an incidence of 5.6% was reported in the present study which corroborated with that of Amr SS 12 (5.03%), while Malik M 9 reported a slightly higher incidence of 12% when compared with our study. Suspicious: The cases categorized as Suspicious which has an incidence of 11.1% in the present study was consistent with the findings of Singh K et al (12.5%) 14 , but the study by Rocha PD et al (21%) 4 reported a significantly higher incidence while Malik M et al 9 reported a much lower incidence (0.4%) when compared to the present study.

Comparison of age distribution of non neoplastic breast lesions in the present study with various studies.
Acute mastitis: In the present study, highest number of cases of Acute mastitis was seen in the age group of 21-30 years which was comparable to the studies conducted by Amr S S et al, 12 Khanzada T W et al 17 and Dahri F J et al, 16 who also reported maximum number of cases in the same age group. Galactocele: The age group for maximum number of cases of Galactocele in the present study which was 21-30 years correlated with the study of Dahri F J et al 16 who also reported the highest number of cases in the same age group. Chronic mastitis: In the present study one case of Chronic mastitis was reported at a much higher age group of 61-70 year which varied with the study conducted by Amr SS 12 who reported a lower age of occurrence of the lesion at 28 years. Granulomatous mastitis: A case of Granulomatous mastitis seen in the present study was reported in the age group of 21-30 years which corroborated with the studies of Khanzada T W et al 17 and Dahri F J et al 16 who also reported the maximum number of cases of the lesion in the above said age group, whereas Amr SS 12 reported maximum number of cases at the age of 41 years, compared to the present study.  16 who also observed highest number of cases in the same age group. Benign Phyllodes tumor: A case of Benign Phyllodes tumor was described in the 41-50 years age group which correlated with that of Malik M 9 who reported the lesion at an age of 39 years whereas Rao C R 19 reported the lesion at a slightly lower age of 35 years. Lipoma: A case of Lipoma was observed in the age group of 21-30 years in the present study which was in contrast to the study conducted by Amr SS et al 12 who reported the lesion at a much higher age of 44 years. Benign duct hyperplasia: The maximum number of cases of Benign duct hyperplasia in this study were reported in the age group of 31-40 years which corroborated with the findings of Dahri F J et al 16 who also reported the highest number of cases of the same lesion in the said age group. Atypical ductal hyperplasia: A case of Atypical ductal hyperplasia was described in the 51-60 year age group in the present study which corroborated with the study conducted by Sneige N et al 20 who reported the lesion at an age of 55 years.

Correlation of FNAC and histopathology
Out of a total number of 108 cases, 38 cases were subjected for histopathological examination which included 2 Non neoplastic and 36 Neoplastic breast lesions. Of the total 38 cases, 34 cases showed good correlation.
In the Non neoplastic category, out of 2 cases available for histopathological correlation, one correlated and was a case of Granulomatous mastitis. The other case that did not correlate was a case of Invasive duct carcinoma-NOS (Mixed type) which was initially diagnosed as fibrocystic disease on cytology.
In the Neoplastic category, 24 cases of benign lesions and 12 cases of malignant lesions were available for histopathological correlation.
Of the 24 cases of benign lesions available for histopathological correlation, 23 cases showed good correlation and one case did not correlate. Of the 23 cases which correlated, 20 cases were of Fibroadenoma and the remaining were benign phyllodes tumor, lipoma and atypical duct hyperplasia, comprising of one case each. The case that did not show correlation was a case of Atypical duct papilloma, which was initially diagnosed as Benign duct hyperplasia on cytology.

Conclusions
The present study was undertaken to know the FNAC of breast lesions and compare the results of FNAC with that of histopathology and also to study and assess clinicopathologic features of breast lesions.
Breast cytology, particularly fine needle aspiration Cytology (FNAC), has been an integral part in the management of women with breast lesions and FNAC is a simple, cost effective and less traumatic method for diagnosis of breast lump.
So we recommend that FNAC of breast lump should be used as preliminary investigation in outdoor patient department as well as a routine method for determining the nature of breast Conflict of Interest: None.