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ORIGINAL ARTICLE
Year : 2020  |  Volume : 47  |  Issue : 1  |  Page : 23-27

Cell block versus fine-needle aspiration cytology in the diagnosis of breast lesions


Department of Pathology, D Y University School of Medicine, Navi Mumbai, Maharashtra, India

Date of Submission22-Feb-2020
Date of Acceptance30-Apr-2020
Date of Web Publication23-Jun-2020

Correspondence Address:
Dr. S Sudhamani
Department of Pathology, D Y University School of Medicine, Nerul, Navi Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jss.JSS_12_20

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  Abstract 


Background: Breast cancer is the most common cancer worldwide. Fine-needle aspiration cytology (FNAC) is an outpatient simple procedure, which gives a quick cytological diagnosis for breast lesions. Cell blocks prepared from the aspirated material of these breast lumps not only serve as useful adjunct to FNAC, but also give tissue diagnosis comparable to breast biopsies. Aims and Objectives: This study was undertaken to assess the utility of cell block technique in diagnosing various breast lesions in correlation with FNAC findings. Subsequent histopathology diagnosis was obtained and compared with cytological diagnosis wherever possible. Materials and Methods: A prospective cross-sectional study was done for a period of 2 years. A total of 130 cases of breast lumps were studied with both FNAC and cell block techniques. The cell block findings were then correlated with FNAC diagnosis and statistically analyzed. Histopathology findings of subsequent biopsy or excision specimen of breast lumps were obtained wherever possible. Results: Out of the total 130 cases, most of the cases were benign lesions (58%), with fibroadenoma being the most common (97%). Among malignant tumors, invasive mammary carcinoma of no special type was the most common type (94.7%). Cell blocks were more accurate (88.8%) compared to FNAC (69.2%) in diagnosing both benign and malignant lesions. Conclusion: Cell block method is superior to FNAC in the diagnosis of both benign and malignant tumors of the breast and helps to eliminate the need for invasive breast biopsies

Keywords: Breast cytology, breast lesions, cell block technique


How to cite this article:
Kawatra S, Sudhamani S, Kumar SH, Roplekar P. Cell block versus fine-needle aspiration cytology in the diagnosis of breast lesions. J Sci Soc 2020;47:23-7

How to cite this URL:
Kawatra S, Sudhamani S, Kumar SH, Roplekar P. Cell block versus fine-needle aspiration cytology in the diagnosis of breast lesions. J Sci Soc [serial online] 2020 [cited 2020 Jul 15];47:23-7. Available from: http://www.jscisociety.com/text.asp?2020/47/1/23/287477




  Introduction Top


Breast cancer is emerging as the most common cancer of women worldwide including developing countries like India. Early diagnosis and treatment is of utmost importance to prevent morbidity and mortality in these patients. When a patient presents with a palpable breast lump, fine-needle aspiration cytology (FNAC) is the most helpful preliminary test in categorizing lesions as benign and malignant, as this is inexpensive and minimally invasive. To further improve diagnosis and to carry out immune markers, cell blocks prepared from aspirated material have emerged not only as a useful technique but also have the potential to replace the necessity of doing invasive breast biopsies.

Cell blocks are microbiopsy which employs retrieval of small tissue fragments from FNA specimen and is then fixed and processed with standard histopathology technique. It offers high diagnostic accuracy, cost-effectiveness, and rapidity of results. Even though simple and cost-effective, there is still a lack of awareness regarding its preparation and utility in many centers.

The present study was undertaken to evaluate the efficacy of cell block in comparison to FNAC in various breast lesions and correlated with histopathology findings of subsequent specimens.


  Materials and Methods Top


This study was a prospective cross-sectional study of a total of 130 patients studied over a period of 2 years in a tertiary care teaching hospital. All patients referred for diagnostic FNAC of palpable breast lumps were included in the study. Cases in which cell blocks were acellular, hemorrhagic, or only necrotic were excluded from the study as FNAC correlation was not possible in such cases.

After taking informed written consent, an external examination of breast lumps was done, and FNAC was performed following standard procedure using 5–10 ml of disposable syringe with 22–24G needle. At least two aspirates were collected, and FNA smears were prepared immediately. The smears were either air-dried for Giemsa stain or fixed in alcohol fixative for hematoxylin and eosin (H and E) and Papanicolaou stain.

The remaining aspirated material in the syringe was put in a cuvette containing 10% neutral buffered formalin and centrifuged for 5 min; the supernatant was discarded and to the cell button, four drops of plasma and four drops of recombiplastin (thrombin) were added and kept for incubation for 10 min.

The cell button is then put on a filter paper and placed in the tissue cassette for routine histopathology processing. About 3–5 μ-thick paraffin-embedded tissues were cut and stained with standard H and E stain and were studied under a light microscope.

The findings of cell blocks were studied in detail to arrive at a diagnosis and compared with FNAC diagnosis. Findings of subsequent biopsy or resection when done for diagnostic or therapeutic purpose were also noted and correlated with cell block diagnosis.


  Results Top


A total of 130 female patients with palpable breast lumps were studied; their clinical diagnosis, ultrasonography and mammography findings, and family and past history were noted.

It was noted that among 130 patients, the mean age was 37 years, with a range of 13–85 years.

Among neoplastic lesions, benign lesions were more common (56.2%) compared to malignant (35.4%) [Table 1].
Table 1: Types of breast lesions

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The most common benign breast lesion was fibroadenoma (41%), whereas the most common malignant breast lesion was invasive mammary carcinoma-no specific type (38%). Among nonneoplastic breast lesions, chronic and tuberculous mastitis (1.5%) was the most common finding.

The FNAC findings when correlated with the final histopathological diagnosis were found to be correct in 85 cases (65.4%), whereas correctness of cell block was found in 101 cases (78%), proving that cell block gives more accurate results.

Among benign and borderline lesions, out of 41 cases of fibroadenoma, the cell block and FNAC diagnosis were correct in 40 cases (97.6%) and 37 cases (90.2%), respectively [Figure 1]. FNAC diagnosis was benign proliferative breast disorder, which is nonspecific and includes a wide spectrum of benign lesions.
Figure 1: Fine-needle aspiration cytology fibroadenoma (H and E, ×400) benign ductal epithelial cells arranged in staghorn pattern with myoepithelial cells. Cell block fibroadenoma (H and E, ×400) showing ductal cells lining the breast acini arranged in intracanalicular pattern

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Moreover, in case of malignant lesions, out of 38 cases of invasive mammary carcinoma when correlated with cell block diagnosis, the concordance was seen in 36 cases (94.7%), whereas with FNAC, it was seen only in 34 cases (89.5%) [Figure 2]. In other four cases, the diagnosis was inconclusive in FNAC due to decreased cellularity. In case of chronic and tuberculous mastitis, the cell block and FNAC diagnosis were inconclusive, due to inadequate cellularity.
Figure 2: Fine-needle aspiration cytology duct carcinoma (PAP, × 400) showing loosely cohesive clusters showing nuclear pleomorphism along with mitosis and giant cells. Cell block invasive mammary carcinoma (H and E, ×400) showing neoplastic cells with pleomorphism and hyperchromatic nuclei

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In benign and malignant lesions, the accuracy of cell block when correlated with histopathological findings was 80.8% and 82.6%, respectively, compared to FNAC which was 64.4% and 73.9%, respectively [Table 2].
Table 2: Correlation of fine - needle aspiration cytology and cell block with histopathology findings in breast lesions

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The sensitivity (true positive) of the cell block was 100%, whereas that of FNAC was 97.6%, whereas the specificity (true negative) of the cell block was 81.8%, whereas that of FNAC was as low 15.6%. Therefore, the accuracy of the cell block was 88.8%, whereas that of FNAC was 69.2%, proving that cell block is more specific and accurate than FNAC [Table 3].
Table 3: Sensitivity and specificity for fine-needle aspiration cytology and cell block diagnostic accuracy parameters

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  Discussion Top


Breast cancer is the most common female cancer worldwide, and it represents nearly a quarter (25%) of all cancers with an estimated 1.67 million new cancer cases diagnosed in 2012. There is a significant increase in the incidence and cancer-associated morbidity and mortality in the Indian subcontinent as described in various studies.[1]

It has been reported that breast cancer has attained top rank in the individual registries such as Mumbai, Bengaluru, Chennai, New Delhi, and Dibrugarh among females during the period of 2012–2014. This could be attributed to increasing urbanization, westernization, and change in lifestyle and food habits.[1]

Breast lumps are a fairly common presenting feature in the outpatient department, with majority of them being benign. However, malignancy contributes to a significant percentage of breast lumps, and therefore, early diagnosis is a must to treat the patients.[2] Triple assessment, i.e. a combination of physical examination, imaging, and FNAC, can give an accurate diagnosis in 95% of the cases, which can be confirmed on histopathology.[2]

FNAC has its disadvantages such as poor spreading, air-drying artifact, presence of thick tissue fragments, and also sometimes may not yield sufficient information for diagnosis which leads to the risk of false-negative or intermediate diagnosis.[3] In order to overcome these problems, the cell block technique has been introduced to make the best use of the available material and to provide accurate diagnosis.

In our study of 130 cases, the age group of patients ranged from 20 to 60 years. The majority of the patients were between 21 and 30 years of age (33.1%). This was similar to studies by Rakesh et al. and Yalavarthi et al., where the most common age groups of presentation were 21–40 years (53%) and 20–30 years, respectively.[2],[4] However, the age group of common presentation was slightly higher at 31–40 years (40%) in a study by Kulashekhar et al.[5]

In our study, 121 cases were breast neoplasms (93.1%) and 9 cases were nonneoplastic or inadequate for opinion (6.9%). Among the neoplastic lesions, maximum cases were of benign breast lesions (56.2%), followed by malignant lesions (35.4%). The nonneoplastic lesions included subareolar abscess, tubercular mastitis, and acute bacterial mastitis.

Similar results were seen in studies done by Rakesh et al., Yalavarthi et al., Raafat et al., and Bhagat et al.[2],[4],[6],[7]

In our study, the most common quadrant involved by both benign and malignant breast lesions was the upper outer quadrant seen in 54 cases (41.5%) and the least common location was nipple areola (9.2%).

Benign lesions were the most common in our study (57.9%), whereas borderline lesions were the least common (1.5%). Fibroadenoma was the most common benign breast lesion (31.5%), followed by fibrocystic disease (17.7%). Invasive mammary carcinoma-no special type was the most common malignancy reported in our study. Other malignancies reported were metaplastic carcinoma; mucinous carcinoma; medullary carcinoma; high-grade malignant small, round cell tumor, probably neuroendocrine carcinoma; and non-Hodgkin lymphoma [Figure 3].
Figure 3: Fine-needle aspiration cytology medullary carcinoma (PAP, × 400) showing malignant ductal epithelial cells. Cell block of medullary carcinoma (H and E, × 400) showing malignant cells separated by the stroma with dense lymphocytic infiltrate

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Subareolar abscess followed by acute and tubercular mastitis was the most common nonneoplastic lesion.

A similar study was done by Bhagat et al.,[7] in which the most common benign breast lesion was fibroadenoma (52.3%), followed by fibrocystic disease (36. 53%). Moreover, among malignant lesions, the most common lesion seen was invasive mammary carcinoma-no special type (84.8%). Our results were also in concordance with studies done by Rakesh et al.[2] and Yalavarthi et al.[4]

In our study, out of the 130 total cases, cell block and FNAC were performed for all the cases, and the results were correlated with the histopathological findings. Cell block diagnosis of 101 cases was similar to the final histopathological diagnosis (78%), whereas in FNAC, only 85 cases had similar diagnosis (65.4%).

Among the benign lesions, correct diagnosis on cell block was seen in cases of fibroadenoma (97.6%), followed by benign phyllodes tumor (50.0%) [Figure 1] and [Figure 4]. The diagnosis of fibroadenoma was made in cases of fibrocystic disease on the cell block. This could be due to the overlapping features in both conditions. Cell block was inadequate in cases of lactating adenoma and duct ectasia, which could be due to scant material obtained in these cases, whereas, maximum correct diagnosis on FNAC was seen in cases of intraductal papilloma (100%), followed by fibroadenoma (90.2%) and benign phyllodes tumor (50%).
Figure 4: Fine-needle aspiration cytology benign phyllodes tumor (H and E, × 400) showing stromal hyperplasia embedded in a loose myxoid tissue. Cell block benign phyllodes tumor (H and E, × 100) showing stromal cellularity having a characteristic leaf-like pattern

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Among malignant lesions, invasive mammary carcinoma-no special type was diagnosed correctly on the cell block and FNAC in 94.7% and 89.5% of cases, respectively compared to the final histopathological diagnosis.

In a similar study by Patel et al.,[8] 33 breast lesions were correlated on FNAC and cell block. Fibroadenoma was diagnosed correctly in all cases on cell block and FNAC, followed by phyllodes tumor which was diagnosed correctly on cell block but was misdiagnosed as fibroadenoma on FNAC. Invasive mammary carcinoma was correctly diagnosed in all cases on cell block and FNAC. However, the histopathological diagnosis of metaplastic carcinoma did not correlate with the diagnosis on FNAC and cell block, which was reported as duct carcinoma on FNAC and inadequate on cell block. Another study done by Raafat et al. in Egypt revealed similar results.[6]

In cases of lactating adenoma, granulomatous inflammation, and atypical ductal hyperplasia, cell block diagnosis was more accurate, whereas in FNAC, cellularity was insufficient for diagnosis. The cell block and FNAC findings were correlated and were similar in 98 cases (75.5%). Thus, the results of our study were in concordance with other studies.

In the present study, the sensitivity of cell block was 100%, whereas that of FNAC was 97.6%. The specificity of cell block was 81.8%, whereas that of FNAC was as poor as 15.6%. The accuracy of cell block was 88.8%, whereas that of FNAC was 69.2%, showing that cell block is more specific and accurate than FNAC.

In contrast, in a study conducted by Ashwinkumar et al., the accuracy of FNAC was more (81.85%) compared to cell block (79.25%) in diagnosing breast lesions.[9] However, the combined use of the two had the most accurate results (87.40%). Raafat et al.[6] and Patel et al.[8] showed that the combined utility of FNAC and cell block had best results. In a study by Basnet et al.,[3] the cell blocks were found superior in diagnosing neoplasm than FNAC with a diagnostic accuracy of 95.91% and 91.8%, respectively. Thus, our study concurred with other studies and gave similar results except with the study done by Ashwinkumar et al.[9] [Table 4].
Table 4: Comparison with other studies of diagnostic accuracy of cell block and fine-needle aspiration cytology

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  Conclusion Top


It is recommended that cell block technique should be employed in all cases along with FNAC to help in the accurate diagnosis of breast lesions. Cell blocks have an added advantage that it may be used as an alternative to more invasive technique of breast biopsy and the sections of the cell block can be used for special stains and immunohistochemistry.

Our study's findings were in concordance with other studies, and the sensitivity and specificity of cell blocks were superior in diagnosing various benign and malignant tumors of breasts compared to FNAC except in rare forms of cancer where only histopathological examination could show various architectural patterns to arrive at correct diagnosis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Malvia S, Bagadi SA, Dubey US, Saxena S. Epidemiology of breast cancer in Indian women. Asia Pac J Clin Oncol 2017;13:289-95.  Back to cited text no. 1
    
2.
Rakesh S, Ashwani K, Ashish K, Seema G. Clinico-pathological study of lump breast – A study of 100 breast lumps. IOSR-JDMS 2016;15:35-47.  Back to cited text no. 2
    
3.
Basnet S, Talwar OP. Role of cell block preparation in neoplastic lesions. J Pathol Nepal 2012;2:272-6.  Back to cited text no. 3
    
4.
Yalavarthi S, Tanikella R, Prabhala S, Tallam U. Histopathological and cytological correlation of tumors of breast. Med J Dr D Y Patil Univ 2014;7:326-31.  Back to cited text no. 4
    
5.
Kulashekhar B, Damodar C, Nupur M. Diagnostic evaluation of breast lumps and its cyto-histological correlation. IJSR 2016;5:367-75.  Back to cited text no. 5
    
6.
Raafat AH, Abdelmonem AH, Fathy AF, Samir I. Fine needle aspiration cytology and cell block study of various breast lumps. Am J Biomed Life Sci 2014;2:8-17.  Back to cited text no. 6
    
7.
Bhagat R, Bal M, Bodal V, Suri A, Jindal K. Cytological study of palpable breast lumps with their histological correlation. Int J Med Dent Sci 2013;2:128-36.  Back to cited text no. 7
    
8.
Patel MJ, Patel SC. Fine needle aspiration cytology and cell block study of various breast lumps. J Cytol Histol 2018;9:1-5.  Back to cited text no. 8
    
9.
Ashwinkumar KB, Pradeep U, Archana D, Pradeep M, Ahilya D, Ajay J, Dilip S. Diagnostic utility of cell block preparation of Fine Needle Aspiration Material. SJAMS 2017;5:5031-7.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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