|Year : 2013 | Volume
| Issue : 4 | Page : 297-301
Evaluation of clinico: Pathologic findings of breast carcinoma in a general hospital in Southern India
M Mohapatra, S Satyanarayana
Department of Pathology, Ganni Shubha Laxmi Medical College and General Hospital, Andhra Pradesh, India
|Date of Web Publication||24-Dec-2013|
Department of Pathology, Ganni Shubha Laxmi Medical College and General Hospital, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Background and Objectives: Breast cancer is the second most common cancer in the Indian female population. As per our hospital data, breast cancer is also found to be the second leading malignancy in women. Hence, we undertook this study to evaluate the clinical profile, histopathologic types, grade, stage and the prognosis of the disease in our patients. Majority of our patients are from rural areas. Materials and Methods: This study was undertaken over a period of three years comprising of 178 patients who underwent modified radical mastectomy following preliminary diagnosis of carcinoma on fine needle aspiration cytology or histopathological examination of the lumpectomy or trucut biopsy specimens. Clinico-pathological evaluation was done in all of these cases following standard protocols. Result: The study comprised of 175 female patients and 3 male patients in the age range of 28 to 76 years. Majority (111/62.3%) of the cases were within the age range of 31-50 years of age with mean age of 48.7 years. Two females had bilateral breast cancer and one female had synchronous papillary serous cystadenocarcinoma of the ovary. Invasive ductal carcinoma no special type was the most common histopathologic pattern, and was seen in 172 (95.5%) cases. Most tumors were Scarff Bloom Richardson grade II and American Joint Committee on Cancer pathologic stage II. Prognostically, majority of tumors (49.5%) was assessed as 'good' as per the Nottingham prognostic index score. Conclusions: This study gave an insight to the clinico-pathological profile of breast cancer in our area. Long term study with follow up of the patient is needed for better understanding of the case.
Keywords: Breast cancer, grading, histopathology, staging
|How to cite this article:|
Mohapatra M, Satyanarayana S. Evaluation of clinico: Pathologic findings of breast carcinoma in a general hospital in Southern India. Indian J Cancer 2013;50:297-301
|How to cite this URL:|
Mohapatra M, Satyanarayana S. Evaluation of clinico: Pathologic findings of breast carcinoma in a general hospital in Southern India. Indian J Cancer [serial online] 2013 [cited 2020 Nov 27];50:297-301. Available from: https://www.indianjcancer.com/text.asp?2013/50/4/297/123594
| » Introduction|| |
Worldwide, breast cancer is the most common form of cancer in women and listed as second leading cause of cancer death among women. , Early detection with screening mammography and multimodality treatment has reduced the cancer mortality in western countries; however, it still continues to have a high prevalence in the developing countries. Every year 75,000 new cases of breast cancer are diagnosed in Indian women,  and it is regarded as the most common cancer in women in many metropolitan cities such as New Delhi, Mumbai, Ahmadabad, Kolkata and Trivandrum, and the second most common cancer in the rest parts of the country. , The pathogenesis of breast cancer is complex and many factors, such as, genetic, dietary, environmental and life style related have been extensively studied and implicated. The prognosis and treatment of the disease depends on various parameters such as the tumor size, lymph node status, histopathologic type, the grade and stage of the cancer.
As per our hospital data, breast cancer is the second most frequently observed malignancy in females, and second to cervical cancer constituting 15.0% of all cancer cases. Hence, the present study was undertaken to include patients from November 2007 to November 2010 to characterize the clinical profile, histopathologic types, grades and stage of the disease and to assess the prognosis of the disease in our patients.
| » Materials and Methods|| |
A total number of 231 cases confirmed as carcinoma breast on histopathological examination of modified radical mastectomy (MRM), trucut biopsy and lumpectomy specimens during the study period were reviewed. Out of 231 cases, 178 cases that underwent MRM were selected for the present study. Two of the cases had bilateral carcinoma, and thus the total sample size was of 180 MRM specimens. Detailed clinical examination was done in all 178 cases. Histopathological evaluation of the 180 MRM specimens was done from paraffin embedded sections stained by Haematoxylin and Eosin (H and E) stain following the standard protocol. Histopathological grading of the tumor based on Scarff Bloom Richardson's (SBR) grading system and TNM staging [where, T describes the size of the tumor and whether it has invaded nearby tissue, N describes regional lymph nodes that are involved, M describes distant metastasis (spread of cancer from one body part to another)] based on American Joint Committee on Cancer (AJCC) was done in all tumors. , The prognosis of all of these cases was assessed by Nottingham prognostic index (NPI) scoring system. 
| » Results|| |
The study comprised of 178 cases of which 175 (98.3%) were females and 3 (1.7%) were males. The age of the patients ranged from 28 to 76 years with mean age of 48.7 years. Majority of the patients (111/178, 62.3%) were between 31-50 years of age, 61 (34.3%) cases above 50 years and 6 (3.4%) cases were below 30 years of age [Figure 1]. The mean age of breast cancer seen in the males was 52.6 years. Two of our female patients had carcinoma involving both the breasts. [Table 1] discerns the salient findings of histopathologic examination of the total 180 specimens. The most common site of tumor was the upper outer quadrant (UOQ) accounting for 65.0% of all the cases. Predominantly the tumors were of solid type, seen in 175 out of 180 specimens (97.2%), whereas both solid and cystic type of growth were seen in rest 5 (2.8%) of the tumors [Figure 2]a and b. Five percent of the tumors had ulceration of the overlying skin and 1.1% tumors showed fungating type growth [Figure 2]c and d. The size of the tumors varied from 1.0 cm to 10.0 cm, with majority (76.6%) of the tumors belonging to T2 (2.0 to 5.0 cm) stage, followed by T3 (5.0 to 9.0 cm) and T1 (<2.0 cm) stage (Table -I). Invasive ductal carcinoma no special type (IDC NST) was observed to be the most common histopathologic type seen in 172 of 180 (95.5%) specimens. Invasive lobular carcinoma, mucinous, papillary and metaplastic carcinoma was seen in 3 (1.7%), 2 (1.1%), 2 (1.1%) and 1 (0.6%) specimens respectively [Table 1], [Figure 3]a-d. The three male patients with breast cancer and two female patients having bilateral breast cancer also had invasive ductal carcinoma NST. One of the female patients had synchronous papillary serous cystadenocarcinoma of the ovary. Majority of tumors were SBR grade-II as observed in 59.5% of the total 180 MRM specimens followed by grade I and grade III seen in 26.1% and 14.4%, respectively. Sixteen (8.9%) out of 180 specimens revealed coagulative necrosis whereas 22 (12.2%) showed in situ ductal carcinoma component. Pathological metastasis in ipsilateral axillary node was observed in 106 (58.9%) of cases. Of those, majority (54.7%) belonged to TNM stage pN1 involving 1 to 3 lymph nodes, followed by pN2 stage (39.6%) involving 4 to 9 lymph nodes, and 5.7% cases belonged to pN3 stage with involvement of more than 10 lymph nodes (Table I). No significant correlation was found between the tumor grade and nodal metastasis. None of the cases had evidence of distant metastasis.
|Figure 2: Clinical and gross photographs. (a) Gross findings of a solid tumor. (b) Gross findings in a solid and cystic tumor. (c) Clinical photograph of an ulcerated tumor. (d) Gross photograph of a fungating growth|
Click here to view
|Figure 3: Histopathological patterns. (a) Photomicrograph of Invasive ductal carcinoma no special type grade II (H and E, ×100). (b) Photomicrograph of Invasive ductal carcinoma no special type grade III IDC NST – III (H and E, ×400), (c) Photomicrograph of Invasive papillary carcinoma (H and E, ×100), (d) Photomicrograph Mucinous|
carcinoma (H and E, x100)
Click here to view
|Table 1: Summary of the findings (N=180) of histopathological examination of the patients in the study|
Click here to view
With AJCC staging [Figure 4], it was observed that most of the tumors belonged to pathological stage II comprising of IIA and IIB each, attributing to 31.7% followed by stage III in 27.8% of the tumors. Out of the three male cases, two belonged to grade II and third one to grade I. One of the two female cases with bilateral breast carcinoma had stage IIA in the left breast and stage I in the right breast. The second patient had stage IIB in the left and IIIA in the right breast. With the NPI scoring system 49.5% of the tumors showed 'good' prognosis followed by 'moderate' and 'poor' prognosis in 43.3% and 7.2% of the tumors respectively [Figure 5].
| » Discussion|| |
In the present study, majority, 111/178, (62.3%) cases belonged to 4 th to 6 th decade of age with the mean age of 48.7 years which is similar to that reported in Indian and Asian literature. ,,, The occurrence of breast carcinoma above 50 years of age in our study constituted 34.3% cases, which is different from western literature that depict nearly 75.0% of patients with breast cancer are above 50 years of age.  The finding of carcinoma in 3 (1.7%) male patients and bilateral breast carcinoma in 2 (1.1%) cases are not surprising as studied by other authors. ,,
The commonest site of the tumor was UOQ of breast as observed in 65.0% of all the specimens which is similar to the reported literature saying that nearly 50.0% of the tumors are located in upper outer quadrant. , In our study, more than 75% of the tumors belonged to TNM stage T2 which agrees with the study conducted by Ahmed et al.,  in Pakistan who also observed T2 or T3 stage in majority of their studied breast cancer cases. The most frequently observed histopathological pattern was invasive ductal carcinoma NST as seen in 172, 95.5% of the total 180 specimens followed by other histological types such as invasive lobular carcinoma, mucinous, papillary and metaplastic carcinoma as seen in 1.7%, 1.1%, 1.1% and 0.6% of the total specimens, respectively, which corroborates with the observations made by various authors. ,,, One of the studied cases had synchronous papillary serous cystadenocarcinoma of ovary that substantiate the facts documented in literature. ,,
Histopathologic grade based on SBR grading system is one of the minor prognostic factors predicting the probable outcome of the disease in carcinoma breast. Various studies describe that the high grade tumors have more propensity for metastases to the regional lymph nodes, frequent systemic recurrences and have a high mortality compared to those with low grade tumors. ,, Hence, accurate pathologic grading of tumor is essential in order to assess the prognosis of the disease. In our study, majority of tumors belonged to SBR grade II as seen in 59.5% cases which coincided with that of Ahmed et al.,  who also ascribed IDC NST grade II type to be the most frequently observed tumor as seen in 76.0% of their studied 120 cases. Lymph node metastasis is one of the most important prognostic factors in carcinoma breast as the 10 year survival rate is 70-80% in women with node negative carcinoma; 35-40% in carcinoma with 1 to 3 positive lymph nodes and 10-15% in patients with more than 10 lymph nodes.  In our study ipsilateral axillary nodes were positive in 106, 58.9% of all the specimens which reflects that majority of our patients are detected in advanced stage of the disease. This observation is consistent with the fact that almost half of the patients who present with a palpable lump in the breast will have spread metastases to the regional lymph nodes at the time of presentation.  Although, it has been described that high grade tumors do have more positive lymph nodes, in our study no significant correlation was observed between tumor grade and nodal metastasis.
Histopathologic grade was coincident with AJCC stage as majority of our patients belonged to SBR grade II and AJCC stage II. This observation is quite interesting as in no other literature this association has been mentioned. The NPI scoring has been widely adopted as a prognostic tool for assessing the prognosis in breast carcinoma patients. It is based on three parameters (Tumor size, tumor grade and axillary node status).  The index is defined as four subtypes basing on the score such as 'excellent' (<2), 'good' (2 to 3.4), 'moderate' (3.41 to 5.4) and 'poor' (>5.41). The five year survival rate varies from 80% in patients with 'good' prognosis to 42% and 13% in patients with 'moderate' and 'poor' prognosis, respectively. In our study, maximum number of cases (49.5%) had "good" prognosis index.
| » Conclusion|| |
The present study has provided information about the clinico-pathological aspects of breast cancer in patients who are from rural areas. We observed invasive ductal carcinoma breast in three males, bilateral breast carcinoma (IDC NST) in two females and synchronous papillary serous cystadenocarcinoma of ovary in one case. The finding of invasive ductal carcinoma NST grade II, AJCC stage II as well as 'good' NPI score in majority of patients is noteworthy. Based on the findings, the five year survival of the study population is predicted to be nearly 60 to 75% which needs a long term follow up for validation.
| » Acknowledgment|| |
The authors are thankful to the Dr. Sameer R. Nayak, Associate Professor of Surgery, and the technicians of the histopathology division of pathology. Department of Ganni Shubha Laxmi Medical College, Rajahmundry for their help and cooperation.
| » References|| |
|1.||Dumitrescu RG, Cotarla I. Understanding breast cancer risk-where do we stand in 2005? J Cell Mol Med 2005;9:208-21. |
|2.||Chandra AB. Problems and prospects of cancer of the breast in India. J Indian Med Assoc 1979;72:43-5. |
|3.||Chopra R. The Indian scene. J Clin Oncol 2001;19 18 Suppl:106S-111S. |
|4.||Available from: http://www.breastcancerindia.net/bc/statistics.htm/breast cancer scenario in India, catched [Last accessed on 04 Sep 2012]. |
|5.||National cancer Registry programme: Consolidated report of population based cancer registries 1990-96.New Delhi: Indian Council of Medical Research; 2001. |
|6.||Available from: http://www.imaginis.com/histologic grades of breast cancer helping determine a patient′s outcome. [Last retrieved on 04 Sep 2012]. |
|7.||Singletary SE, Allred C, Ashley P, Bassett LW, Berry D, Bland KI, et al. Staging ststemfor breast cancer: Revisions for the 6 th edition of the AJCC cancer staging manual. Surg Clin North Am 2003;83:803-19. |
|8.||Galea MH, Blamely RW, Elston CE, Ellis IO. The Nottingham Prognostic Index in Primary breast cancer. Breast Cancer Res Treat 1992;22:207-19. |
|9.||Saxena S, Rekhi B, Bansal A, Bagga A, Chintamani and Murthy NS. Clinico-morphological patterans of breast cancer including family historyin a New Delhi hospital, India-A cross sectional study. World J Surg Oncol 2005;3:67. |
|10.||Malik IA. Clinico-pathological features of breast cancer in Pakistan. J Pak Med Assoc 2002;52:100-4. |
|11.||Sandhu DS, Sandhu S, Karwasra RK, Marwah S. Profile of breast cancer at a tertiary care hospital in north India. Indian J Cancer 2010;47:16-22. |
|12.||Lester SC. The Breast. In: Kumar. Abbas. Fausto, editors. Robbins and Cotran pathologic basis of Disease, 7 th ed. India: Saunders; 2004:1131-46. |
|13.||Korde LA, Zujewski JA, Kamin L, Giordano S, Domchek S, Anderson WF, et al. Multidisciplinary meeting on male breast cancer: Summary and research recommendations. J clin Oncol 2010:2114-22 |
|14.||AI Jurf AS, Jochimsen PR, Urdantea LF, Scott DH. Factors influencing survival in bilateral breast cancer. J Surg Oncol 1961;16:343-8. |
|15.||Pomerantz A, Murand T, Hines JR. Bilateral breast cancer. Am Surg 1989;55:441-4. |
|16.||Ahmad Z, Khursid A, Qureshi A, Idress R, Asghar N, Kalyani N. Breast carcinoma grading, estimation of tumor size, axillary lymph node status, staging and Nottingham Prognostic index scoring on mastectomy specimens. Indian J Pathol Microbiol 2009;52:477-81. |
|17.||Ellis IO, Pinder SE, Lee AH, Elston CW. Tumors of the breast. In: Fletcher CD, editor. Diagnostic histopathology of tumors, 2 nd ed. Edinburgh: Churchill Livingstone; 2002. p. 900. |
|18.||Kadouri L, Hubert A, Rotenberg Y, Humberger T, Saqi M, Nechushtan C et al. Cancer risks in carriers of BRCA1/2 Ashkenazi founder mutations. J Med Genet 2007;44:467-71. |
|19.||Thompson D, Easton DF; Breast Cancer Linkage Consortium. Cancer incidence in BRCA1 mutation carriers. J NatlCancer Inst 2002;94:1358-65. |
|20.||Cancer risks in BRCA2 mutation carriers. The Breast Cancer Linkage Consortium. J Natl Cancer Inst 1999;91:1310-6. |
|21.||Henson DE. Histological grading of breast cancer: Significance of grade on recurrence and mortality. Arch Pathol Lab Med 1988;112:1091-6. |
|22.||Hopton DS, Thorogood J, Clayden AD, MacKinnon D. Histological grading of breast cancer: Significance of grade on recurrence and mortality. Eur J Surg Oncol 1989;15:25-31. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
|This article has been cited by|
||A COMPARATIVE STUDY OF CLINICO- PATHOLOGICAL AND RADIOLOGICAL FEATURES OF PALPABLE BREAST LESIONS
| ||Vinu Sugathan,Sheela Varghese,Laila Raji N |
| ||Journal of Evolution of Medical and Dental Sciences. 2017; 6(10): 770 |
|[Pubmed] | [DOI]|
||CLINICO-PATHOLOGICAL STUDY: 48 CASES OF CARCINOMA BREAST AT TERTIARY CARE CENTRE IN RURAL AREA
| ||Pravin Wamanrao Nikhade,Ajay Dnyanoba Subhedar,Shakuntala Limbaji Shelke,Avinash Shivaji Pawara |
| ||Journal of Evolution of Medical and Dental Sciences. 2016; 5(101): 7429 |
|[Pubmed] | [DOI]|