|Year : 2022 | Volume
| Issue : 3 | Page : 709-712
Diagnostic utility of imprint cytology for assessment of breast lumps
K Vinod1, Tirou Aroul1, K Anand Raj Vaithi2
1 Department of General Surgery, Mahatma Gandhi Medical College and Research Institute, Sri Balaji Vidiyapeeth, Pondicherry, India
2 Department of Pathology, Mahatma Gandhi Medical College and Research Institute, Sri Balaji Vidiyapeeth, Pondicherry, India
|Date of Submission||16-May-2020|
|Date of Decision||30-Dec-2020|
|Date of Acceptance||07-Jan-2021|
|Date of Web Publication||2-Nov-2022|
Dr. Tirou Aroul
Department of General Surgery, Mahatma Gandhi Medical College and Research Institute, Sri Balaji Vidiyapeeth, Pondicherry
Source of Support: None, Conflict of Interest: None
Background: Breast lesions are a commonly encountered complaint in the surgical outpatient department. Although majority of these lesions are benign, breast carcinoma is the second most common malignancy in women. Fine-needle aspiration cytology (FNAC) is a well-established preoperative diagnostic measure, whereas histopathological examination (HPE) forms the gold standard for the postoperative diagnosis. Imprint cytology (IC) is a rapid, inexpensive intraoperative diagnostic method under investigation. This study attempted to compare IC with FNAC and HPE for the diagnosis of breast lesions. Materials and Methods: This study included 65 patients with breast lesions. In each case, a diagnosis was established by preoperative FNAC, an intraoperative IC, and their sensitivity and specificity were compared to the diagnosis by HPE which was considered the gold standard for the diagnosis. Results: Sensitivity of IC for diagnosing malignant lesions was 91.6% and specificity was 100%. Similarly, for FNAC, the sensitivity for diagnosing malignant lesions was 91.6% and specificity was 100%. Conclusion: Intraoperative IC is a good diagnostic modality comparable to FNAC in the diagnosis of breast lesions and a reliable adjunct to HPE.
Keywords: Biopsy, breast neoplasms, cytodiagnosis, fine needle, histopathology, sensitivity specificity
|How to cite this article:|
Vinod K, Aroul T, Vaithi K A. Diagnostic utility of imprint cytology for assessment of breast lumps. J Datta Meghe Inst Med Sci Univ 2022;17:709-12
| Introduction|| |
Breast lesions constitute a heterogeneous group of diseases with etiologies ranging from inflammatory, benign lesions to malignancies. Around 200,000 new cases of breast lesions are diagnosed annually. Breast cancer is the second-most common malignancy in women after carcinoma of the cervix, accounting for 19%–34% of all cancers in the female population. In India, it is detected in 20/100,000 women. Fortunately, benign breast diseases are more prevalent as compared to malignant and inflammatory.
Malignancy and the surgical procedure associated with it is a source of great anxiety and concern. The successful outcome of this procedure greatly depends on appropriate preoperative diagnosis and efficacious intraoperative decision-making. Fine-needle aspiration cytology (FNAC) is a well established, minimally invasive, preoperative diagnostic modality in detecting breast lumps. The accurate intraoperative diagnosis of breast diseases remains a vital parameter for surgical success to avoid revision surgeries and achieve adequately clear margins while conserving as much breast tissue as possible for cosmetic reasons. Imprint cytology (IC) is beneficial in differentiating between benign and malignant lesions, thus helping surgeons decide the type of surgery for patients' intraoperatively. While FNAC has been accepted as an excellent preoperative diagnostic method, the use of intraoperative IC is still under question. This study attempts to compare the efficacy of FNAC and IC as a diagnostic aid.
A wide variety of imaging modalities have evolved in recent times, extending from mammogram, breast-specific gamma imaging to nano medicine. However, histopathological examination (HPE) remains the gold standard for diagnosing breast lesions.,, The disadvantage of histopathology is that it is dependent on lengthy processing techniques which cause a delay in reporting which makes it disadvantageous in an intraoperative diagnosis. IC is an intraoperative examination obtained by touching the bisected specimen on a glass slide, rapidly staining it and examining the cells. Despite its undisputable benefit in giving rapid intraoperative diagnosis as well as assuring the surgeon of the status of the surgical margins, IC remains a debatable topic, especially when comparing it to its alternative in intraoperative diagnosis, frozen section. Therefore, to standardize and evaluate the utility of IC, it makes sense to measure its accuracy using HPE as the gold standard. The aim of this study was to assess the diagnostic utility of IC in the diagnosis of breast lesions.
| Materials and Methods|| |
The present study was a prospective, observational, cross-sectional study conducted at a tertiary care center from May 2017 to October 2019 after Institutional Human Ethics clearance. A total of 65 sequential patients with breast lesions were included in the study.
The sample size was calculated conveniently by consecutively recruiting every patient that reported to the outpatient department within the set criteria.
(i) Patients above 18 years of age and presenting with a breast lump and (ii) whose patients who underwent FNAC for preoperative diagnosis of the breast lump were included in the study.
(i) Patients below the age group of 18 years and (ii) those who were unwilling to participate/uncooperative or not-consented for the study were excluded from the study.
FNAC of the breast lesion was done as a preoperative screening procedure. A 25G needle attached to a 10 ml syringe was inserted into the lesion. Multiple probes were made into the lesion, and the resulting aspirate was placed on a glass slide, fixed with 95% ethyl alcohol and stained with H and E staining. Intraoperatively, the freshly excised breast lump or breast specimen was taken, bisected, and six to seven imprints were taken on clean slides. Immediately, the slides were submerged in 95% ethanol in a coplin jar. They were then stained with rapid H and E staining method. [Figure 1] shows an IC image of pleomorphic cells in a malignant lesion. A sample of the specimen was also sent for conventional HPE. The same pathologist, who performed and reported the FNAC report, was blinded for the examination and reported the IC slides. The same pathologist was then blinded for reporting the HPE slides. This method eliminated examiner bias as the same examiner examined all the slides. The IC report was then compared with the FNAC and HPE reports.
All the data were entered into a data collection pro forma sheet and were entered into an Excel spreadsheet (MS Excel 2011). Biographical details were also collected including age, gender, date of birth, weight, and height. Statistical analysis was carried out using the Statistical Package for the Social Sciences (SPSS for Windows, Version 22.0 Chicago, SPSS Inc) with regression modules installed.
| Results|| |
The distribution of patients according to age and gender is given in [Figure 1] and [Figure 2], respectively.The Imprint of malignant lesion showing pleomorphic cells is gown in [Figure 3].
|Figure 3: Imprint of malignant lesion H and E ×40 showing pleomorphic cells|
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Histopathology was taken as a gold standard for the diagnosis, and IC was compared with it. The disease distribution according to FNAC, IC, and HPE is presented in [Table 1], [Table 2], [Table 3], respectively. The diseases were then classified into benign and malignant lesions.
|Table 1: Disease distribution according to fine-needle aspiration cytology|
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The distribution of benign lesions in IC and HPE is given in [Table 4]. Similarly, the distribution of malignant lesions in IC and HPE is given in [Table 5]. As shown in [Table 4], true benign lesions diagnosed with HPE were 41. IC diagnosed 43 patients as having benign lesions. Hence, IC for benign lesions had a sensitivity and specificity of 100% and 91.6%, respectively. On the other hand, 22 patients diagnosed with malignancy through IC were positive for malignancy in HPE too. However, HPE showed a total of 24 malignant cases, of which IC missed 2, resulting in 2 false-negative cases. Hence, the sensitivity and specificity of IC for diagnosing malignant lesions are 91.6% and 100%, respectively.
|Table 5: Distribution of malignant cases in imprint versus histopathology|
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[Table 6] and [Table 7] give the distribution of benign and malignant lesions, respectively, in FNAC as compared with histopathology. From the table, it can be inferred that FNAC has a sensitivity of 100% and a specificity of 91.6% for benign lesions. Similarly, it has a specificity of 100% and a sensitivity of 91.6% for malignant lesions.
|Table 6: Distribution of benign cases in fine-needle aspiration cytology versus histopathology|
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|Table 7: Distribution of malignant cases in fine-needle aspiration cytology versus histopathology|
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| Discussion|| |
Breast carcinoma, while forming a small percentage of the entire spectrum of breast lesions is a worrisome experience for the patient and surgeon.
In this study, 56 patients out of 65 were females accounting for nearly 86.2% of the total number of cases. This finding has been echoed in different studies conducted across the world wherein breast diseases are more common in women. A number of reasons have been attributed to this predominance, the most important one being hormonal. In this study, the age group of the patients varied from 13 years to 67 years. The maximum number of patients was in the third and fourth decades of life. In addition, the present study showed a predominance of benign breast lesions in the third decade of life with an increasing incidence of malignancy with advancing age with peak incidence after the fourth decade of life. This finding is similar to a study conducted by Forae et al. The present study found IC to be a highly effective diagnostic aid with high specificity and sensitivity in diagnosing both, benign and malignant lesions. This finding is in agreement with studies conducted by Swain et al.; Francis and Das; and Shashidhar et al., Ahmed et al.,, Although IC has a lower sensitivity than HPE in the diagnosis of benign breast lesions, it is very rapid in yielding results. It has been shown to be as accurate as the frozen section in the intraoperative diagnosis. Moreover, this study exhibited that the diagnostic ability of IC was comparable to that of FNAC. This proves the efficacy of IC as an intraoperative diagnostic aid. This finding is similar to a study conducted by Swain et al. Frozen section requires specialized machinery and a trained pathologist for diagnosis, making it an expensive procedure. This equipment and expertise is rare in underdeveloped countries. Furthermore, the presence of freezing artifacts in frozen sections may distort cellular morphology. IC has its share of limitations, namely its inability to differentiate in situ from infiltrating carcinoma and to evaluate the depth of invasion. Apart from diagnosing breast lesions, it is also being employed in the diagnosis of a wide variety of other lesions including thyroid, sentinel nodes, endoscopic biopsy, and prostate.,
A limitation of this study is its relatively small sample size. In addition, the tumor margins and nodal status were not evaluated using IC. Larger studies involving a larger sample size which evaluate surgical margins are required to further establish the diagnostic accuracy of IC in breast lumps.
| Conclusion|| |
IC is a simple, inexpensive, and rapid procedure with the same accuracy rate as FNAC and frozen sections with excellent preservation of cellular details. This makes it valuable as an intraoperative diagnostic aid in breast lesions in developing countries.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]