Introduction
Breast malignancies are one of the commonest malignancies in Indian women. Increasing urbanization is attributed to raise of breast cancers and have surpassed cervix cancer in recent times and are now ranked top in some metros. 1 FNA is used as an important diagnostic tool as a part of triple assessment. The international academy of cytology system for reporting breast fine needle aspiration cytology was formed in the year 2016 by a set of cytopathologists, radiologists, surgeons, and oncologists. 2 According to IAC Yokohama system of reporting breast cytology, 5 different categories have been classified as follows:
This type of reporting is helpful in organizing the way of reporting breast FNA samples. It provides more appropriate information to the clinician in decision making for patient care management and improves mutual communication.3 Also the FNA procedure has the advantage of being easier, quicker to perform and less cumbersome. By using the IAC Yokohama system the samples received in our pathology department were classified into different categories and ROM was also calculated for the same.
Materials and Methods
The present study was carried out in the department of pathology, ESIC medical college and hospital, Sanathnagar, Hyderabad, India. The study was carried out over a period of 2 years, retrospectively from June 2019 to May 2021. 305 breast FNA samples were collected and categorized according to the IAC Yokohama system for reporting breast cytopathology. All were female patients. 95 cases of these had histopathological correlation and statistical parameters, ROM were calculated on the obtained data.
P-value was also calculated by using the chi-square test.
Results
A total of 305 FNA samples were obtained and all these are categorized according to the IAC Yokohama system after thorough review by an experienced pathologist. The age group for all the cases was 11 – 80 yrs (Table 1) and those cases with palpable breast lump were taken. The most common age group with lump in the breast observed in our study was 31 – 40 yrs. The earliest age presented with breast malignancy was 33 and we have observed 10 malignancies in the age group of 31 – 40 yrs.
All the FNA samples obtained are put in one of the 5 categories according to the IAC Yokohama system of reporting. The percentage distribution of cases according to IAC Yokohama are shown in (Table 2).
For 305 FNA samples received, 95 cases were obtained for HPE correlation (Table 3). The ROM is calculated for each category. Sensitivity, Specificity, PPV, NPV, Diagnostic accuracy are calculated for the present study using MS EXCEL sheet.
Chi-square test for categorical data was used for calculation of p-value to assess statistical significance (Table 4). p-value < 0.05 is considered as significant. In the present study p- value obtained was 0.0001 which is very significant.
Table 1
Age distribution of FNA samples
|
Age range |
No. of cases |
|
11 – 20 |
24 |
|
21 – 30 |
72 |
|
31 – 40 |
96 |
|
41 – 50 |
81 |
|
51 – 60 |
27 |
|
61 – 70 |
4 |
|
71 – 80 |
1 |
Table 2
Distribution of cases according to IAC Yokohama system
|
IAC yokohama category |
Total no. of cases |
% of distribution |
|
Insufficient |
21 |
6.89% |
|
Benign |
221 |
72.46% |
|
Atypical |
10 |
3.28% |
|
Suspicious of malignancy |
10 |
3.28% |
|
Malignant |
43 |
14.09% |
|
Total |
305 |
100% |
Table 3
Cyto – histopathology correlation
|
IAC yokohama category |
Cytology |
Histopathology |
|
Insufficient |
21 |
4 |
|
Benign |
221 |
50 |
|
Atypical |
10 |
5 |
|
Suspicious of malignancy |
10 |
7 |
|
Malignant |
43 |
29 |
|
Total |
305 |
95 |
Table 4
Distribution of histopathological cases according to IAC Yokohama and chi-square and p-value calculation
Table 5
Risk of malignancy for each category
|
IAC yokohama categories |
ROM |
|
Insufficient |
0% |
|
Benign |
2% |
|
Atypical probably benign |
0% |
|
Suspicious of malignancy |
71.43% |
|
Malignant |
100% |
Discussion
Breast FNA is a quick, precise and highly convenient diagnostic procedure which can be done in OPD. It has less complications and can diagnose a wide spectrum of diseases with high accuracy and has less turnaround time than HPE. So in this era of core biopsies, FNA is still continuing as an important diagnostic tool along with clinical imaging and self assessment as a part of triple assessment. It has high sensitivity, specificity and high reproducibility.4, 5, 6, 7, 8, 9, 10, 11
In our study, we observed the most common age group affected with breast malignancies are between 31 – 40 yrs and the earliest age group presenting with breast lump was 13 years. The present study is comparable to Badge SA et al 12 and Sreedevi CH et al13 where there are no malignant cases in the age group of 11-20yrs. In our study we have observed 1 malignant case in the age group 21-30 and no malignant cases between 71-80. This could be because of increased incidence of breast cancers in younger age group when compared to elderly probably because of urbanization. The % of benign and malignant cases obtained in the present study is comparable to the studies of Sreedevi CH et al13 and Badge SA et al. 12(Table 7)
Table 7
Comparison of age wise distribution of FNA cases
|
Age |
Sreedevi CH et al 13 |
Badge SA et al 14 |
Present study |
|||
|
Benign |
Malignant |
Benign |
Malignant |
Benign |
Malignant |
|
|
11-20 |
22 |
0 |
10 |
0 |
24 |
0 |
|
21-30 |
36 |
0 |
36 |
0 |
71 |
1 |
|
31-40 |
17 |
4 |
82 |
17 |
84 |
12 |
|
41-50 |
8 |
4 |
27 |
29 |
61 |
20 |
|
51-60 |
2 |
5 |
7 |
4 |
11 |
16 |
|
61-70 |
0 |
1 |
0 |
6 |
2 |
2 |
|
71-80 |
1 |
0 |
0 |
2 |
1 |
0 |
|
Total |
86(86%) |
14(14%) |
162(73.63%) |
58(26.37%) |
254(83.27%) |
51(16.73%) |
In the present study we obtained 305 breast FNA samples of female patients and these were categorized into one of the 5 given categories according to the IAC Yokohama system and the number of cases obtained in each category was subsequently compared with other studies done in India and
elsewhere showing that the relative proportion of malignant cases are growing in the Indian context.(Table 8)
Table 8
Comparison of IAC Yokohama distribution of cases with other studies
|
IAC Yokohama Category |
Montezuma D et al., 14 |
Wong S et al., 15 |
Poornima V Kamatar et al., 16 |
Apuroopa M et al., 17 |
Present study |
|
Insufficient |
209 (5.77%) |
301 (11%) |
22 (5%) |
39 (4.3%) |
21 (6.89%) |
|
Benign |
2660 (73.38%) |
1937 (72%) |
332 (71%) |
522(58%) |
221 (72.46%) |
|
Atypical probably benign |
498 (13.74%) |
117 (4.3%) |
7 (1%) |
160 (17.7) |
10 (3.28%) |
|
Suspicious |
57 (1.57%) |
59 (2.2%) |
8 (2%) |
63 (7.2%) |
10 (3.28%) |
|
Malignant |
201 (5.54%) |
278 (10%) |
101 (21%) |
116 (12.8%) |
43 (14.09%) |
|
Total |
3625 |
2696 |
470 |
900 |
305 |
ROM calculated for each category was comparable to the study of Poornima V Kamatar et al., 16 In the present study we observed 0% ROM in insufficient and atypical categories. Atypia associated with malignant lesions has been appropriately recognized and was put up in higher categories which is responsible for low ROM with atypical category. The ROM is comparatively less in the present study when compared to other studies. So, more diligence has to be paid in categorizing suspicious lesions.(Table 9)
Table 9
Comparison of ROM with other studies
|
IAC Yokohama Category |
Montezuma D et al, 14 |
Poornima V Kamatar et al., 16 |
Apuroopa M et al., 17 |
Present study |
|
Insufficient |
4.8% |
0% |
5.0% |
0% |
|
Benign |
1.4% |
4% |
1.2% |
2% |
|
Atypical probably benign |
13% |
66% |
12.5% |
0% |
|
Suspicious |
97.1% |
83% |
93.65% |
74.43 |
|
Malignant |
100% |
99% |
100% |
100% |
The sensitivity, specificity, positive predictive value, negative predictive value, diagnostic accuracy are calculated and these statistical parameters are comparable to studies of Moschetta M et al 18 We observed 100% sensitivity and negative predictive value in our studies.
p-value is also calculated for present study and it is <0.0001 which is very significant and it implies that the recognition of various Yokohama categories in ESIC setup has largely been successful and is comparable to the established standards of IAC Yokohama and this has helped the department in giving appropriate guidance to the surgeons in dealing with breast lesions.(table 10)
Table 10
Comparison of statistical parameters with other studies`
|
Statistical parameters |
Montezuma D et al., 14 |
Moschetta M et al., 18 |
Poornima V Kamatar et al., 16 |
Apuroopa M et al.,17 |
Present study |
|
Sensitivity |
97.56% |
97% |
94.59% |
95.9%, |
100% |
|
Specificity |
100% |
94% |
98.9% |
97.89%, |
96.66% |
|
Positive predictive value |
100% |
91% |
98.59% |
96.79%, |
94.59% |
|
Negative predictive value |
98.62% |
98% |
95.74% |
97.64% |
100% |
|
Diagnostic accuracy |
99.11% |
95% |
96.97% |
91.5 % |
97.89% |
Conclusion
Application of IAC Yokohama system of reporting breast cytopathology helps in easy categorization of breast FNA samples and it improves the efficacy of cytopathologist. It also provides better clarity to the clinicians in the management of the patient and can reduce unnecessary surgeries.
