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Major Research Interest:
Topic:
The role of Fine Needle Aspiration Cytology in Breast Cancer Control
Programme(BCCP) A Positive approach in reducing Mortality rate of
Breast Cancer(An experience of >15 years of hands on experience): An
analysis of 2936 cases.
Introduction of FNAC:
Cancer is a camouflaged lethal destroyer and unanimously accepted as the global
problem. Due to sharp changes in the life-style pattern during the last two centuries like
innumerable proliferation of industrialized cities and tremendous dynamicity of life, have
exposed many people to enormous number of known and unknown natural and artificial
agents. So, from the epidemiological point of view it has been observed that the
occurrence of cancer can be attributed to many risk factors like; occupation, personal
habit or changing personal habit, living condition, geographical location etc. and thereby
such type of neoplasms can be prevented by keeping oneself away from the risk factors.
Cancer steals into our body unobtrusibly and by the time its symptoms appear it may be
or usually too late. Even a clinical examination may pronounce one to be cancer free, but
like a wily enemy it may be hiding somewhere biding its time to deal a fatal blow. In
such situation , prevention or cure of cancer is possible only during the early stage. So
for cancer control and prevention, the early detection of cancer is becoming a highly
creditable approach throughout the World. Looking to such necessities, the
cytomorphological evaluation of disease processes is leaning much forward to meet the
demands and the technique of Fine-needle aspiration cytology is becoming an
indispensable diagnostic armamentarium.
It was George N. Papanicolaou who for the first time attempted to study cytology in a
systematic way.
In 1920, as a perceptive extention of his study of vaginal cytology in animals,
Papanicolaou started the study of vaginal secretions in the human being. In 1923, he saw
for the first time cancer cells in” vaginal smear”. Possibly this was the crucial land-mark
to develop the modern diagnostic cytology. Since then Papanicolaou established the
exfoliated cytological study into a much broader field including all possible hollow
visceras.
Following this advent, it is very soon felt the need of study of cells which donot
desquamate or exfoliate from the body. To determine the pathologic nature of these kinds
of lesions, fine-needle aspiration cytology is evolved. For many years there had been a
marked fluctuation in clinical application of FNAC which was performed intermittently
in the later half of the last century(Hellendal, 1899; Horder,1909). At this position, most
of the aspirations were done with large bore needles(12-18 gauge, outer diameter 1.2-2.6
mm) and the complications following the needle aspirations restrained its clinical
applications. But during the middle part of the twentieth century European Scientists
(Cardoza, 1954; Soderstrom,1966 and Esposti et al, 1968) had very much improved the
technique of FNAC. The initial attempts were performed mainly on palpable superficial
lesions and among them aspiration on breast lump was notable with high success rate.
Other superficial lesions aspirated are thyroid gland, parathyroid gland, salivary gland
and lymph nodes, with relatively high yield cytological results.
The development of image intensification and television facilitated the transthoracic and
transabdominal FNAC under fluoroscopic or computerized tomographic control. Due to
improved radiological and aspiration techniques, control of complications, and high
accuracy in experienced hands, FNAC has been increasingly recognized as an excellent
diagnostic tool for several organs. So, other than superficial lesions, deep-seated tumours
or lesions like intra-thoracic, intra-hepatic, pancreatic, adrenal and other neuro-endocrine
organs, renal and prostatic tumours, all are showing persistently high success rate on
FNAC and also while comparing with soft-tissue and bone lesions.
Now the FNAC is becoming an integral part of major diagnostic tool in many centres
including in our institution, where a separate division of cytology and two important
projects on aspiration cytology have been conducted, mainly on breast lump and on
lymph node with admirably high success rate of 98 percent and 79 percent respectively.
Evolution of Fine Needle Aspiration Technique:
The study of cells aspirated from solid tumours through a needle is not a new concept. As
mentioned by Philips et. Al , there were sporadic cases of its use reported as early as the
1880s. Soft-tissue sarcoma was also studied from aspirate during the last decade of the
nineteenth century, when Hamilton reported the first case diagnosed as round cell
sarcoma. Since then there had been a marked fluctuation in clinical applications of needle
biopsy which was performed intermittently in the later half of the last century, Hellendal,
in 1899, and Horder in 1909. Other notable contributions during this period were
reported by Ward in 1912, Goeller in 1920, Guthrie in 1921 and Forkner in 1927.
However, a systematic study on aspiration cytology was published by Martin and Ellis in
1930 and Stewart in 1933. At this position, most of the aspiration biopsies were done
with large bore needles(12-18 gauge, outer diameter 1.2-2.6). The many complications
following needle biopsies with large bore needles restrained its clinical applications. So,
by then Cardoza(1954), Franzen et. Al (1960), Zajicek(1965), Soderstrom(1966),
Esposti(1968) and later Stromy and Ackerman(1973), all had modified and improved the
technique of FNAC. Zajicek extensively and successfully used this technique and
described its implications in a well documented monograph on aspiration cytology.
BCCP(Breast Cancer Control Programme) at Assam Cancer Society&Rural Based
Preventive Oncology Research Centre:
BCCP
.
Preliminary information about anatomy of breast.
Possible risk of developing Cancer in research areas.
Screening Modules : (a) Self examination, (b) Clinical examination, (c)
FNAC(it is preferred now in the present research study (d)
Mammography(MM)[not recommended in the present study], (e)
Xeroradiography, (f) Ultrasound study, (g) C. T. Scan, (h) Nipple discharge for
cytology study (exfoliative
cytology), (i) Histopathological study, (j) TNM classification, (k) ICD-O tumour
nomenclature by
morphological coding, etc. are various modules of BCCP; but in the present
series of study we will pay attention to BSE,CBE,FNAC only.
Usually cancer when detected it is referred to proper treatment center.
Provide emotional support.
Guide for possible treatment modules in each case.
Post treatment support.
Chemotherapy.
Follow-up.
FOR BENIGN LUMP :
Non-hormonal lump Surgery is advised.
Hormonal lump conservative treatment, follow-up, occassionally referred to
higher centre for review.
NORMAL POPULATION :
Advocating : self examination every month(BSE),
Clinical examination every 2nd year(CBE),
age group 40 y.o onward and recommendation is for CBE and FNAC every 2
yearly.If any lump is found then any age can undergo check-up as
recommended.
However, BSE,CBE & FNAC usually employed for reproductive women like BSE
to be done in every month and CBE in every 2-3 years in asymptomatic cases.
RESEARCH REQUIREMENTS:
The requirements are very simple[will be quoted later if required] and less hazardous to
the population under screening. (datas are available at this time from my own paper).
Data from the paper compiled:At ACS&RBPORC:
Title of Paper :
Breast Lump – Experience of fine-needle aspiration cytological diagnosis with 2936 cases from
1987 to 1990
Author’s Name:
Debnath S. K
ASSAM CANCER SOCIETY&
Rural Based Preventive Oncology Research Centre.
Bokakhat- 785612, Assam, India.
Name: Dr. Surjya kumar Debnath, M.B.B.S., M.D.
Telephone (03776)268377/268790/269552
Fax: 0091-3776-268770
E-mail: [email protected]
=============================================================
INTRODUCTION
Fine needle aspiration cytology (FNAC) is one of the major diagnostic tool in establishing a
disease process in various tissues of the body. This method is simple, rapid, inexpensive and
reliable. Other advantages are that it can be done on out patient and requires no anaesthesia or
sophisticated equipments.
So, the FNAC diagnosis is fast becoming popular. It is felt that the limitations of this procedure
must be clear and of its useful applications to be brought into medical practice. For example, in
breast lump, many authors [2,5,6,8] attempted to subclassify various benign lesions like
pericanalicular and intracanalicular fibroadenoma, mastitis, cystic mastopathy etc. by FNAC. The
value of which is minimal in medical practice. So, this type of application of FNAC may bring
contempt rather than popularity. As it is evident that such subtyping for a benign process
indicates ignorance of limitations.
Inorder to get a better effective utilization of FNAC in a field screening procedure , in a busy
hospital it is sufficient to categorize precisely malignant, benign or other types of lesions.
If this is possible then most of the beneficial aspects of FNAC can be utilized for fast treatment
planning. The subtyping of the lesion can be done on subsequent surgical specimens.
So, the present study aims at making an effective utilization of FNAC technique and comparison
of cytological results to that of histopathological examination with post operative surgical
specimens where ever applicable.
MATERIALS AND METHOD:
THE BREAST(ANATOMY):
Comparative and surgical anatomy:== Mammals are distinguished and so called because they
are provided with mammary glands.
In anatomical works the protuberant part of human breast is generally described as overlying the
second to sixth ribs, and extending from the lateral border of the sternum to the anterior axillary
line. Actually a thin layer of mammary tissue extends considerably farther on all sides,viz: to the
clavicle above, to the seventh or eighth ribs below, to the midline medially, and to the edge of the
latissimus dorsi posteriorly. This fact is of importance to a Surgeon when he or she seeks to
remove the whole breast. The full extent of the breast is apparent in cases of milk engorgement.
As age advances, the parenchyma of the breast undergoes considerably atrophy and becomes
loose in texture , making the detection of lumps within it easier.
The Axillary Tail: of the breast is of considerable importance both for surgeon and for Clinical
Cytopathologist to locate a lump for Fine Needle Aspiration Cytology(FNAC). In some normal
cases it is palpable, and in a few it can be seen in the pre-menstrual phase and during lactation.A
well developed axillary tail is sometimes mistaken for a mass of enlarged lymph nodes or a
lipoma.
The Lobule: It is the basic structural unit of the mammary gland. In the human breast the number
and size of the lobules vary exceedingly: they are the largest and most numerous during early
womanhood. From ten to more than a hundred lobules empty by means of ductules into a
lactiferous duct, of which there are from fifteen to twenty. Each lactiferous duct is provided with an
ampulla—a little reservoir for milk or abnormal discharges.
The ligaments of Cooper are hollow conical projections of fibrous tissue filled with breast tissue,
the apices of the cones being attached firmly to the deeper layers of the skin overlying the breast.
These ligaments account for the dimpling of the skin overlying a scirrhous carcinoma, or other
lesions of the breast accompanied by fibrosis.
The Aerola—The subcutaneous tissue contains involuntary muscle arranged in concentric rings
as well as radially. The aerolar epithelium contains numerous glands of three kinds--- sweat
glands, sebaceous glands , and accessory mammary glands The sebaceous glands (known as
the glands of Montgomery) enlarge strikingly during pregnancy and serve to lubricate the nipple
during lactation. The accessory mammary glands are minute, inconstant, and possess ducts that
open on the aerola.
The Nipple is covered by a thick and rather crinkle skin. Near its apex, very difficult to see
because of the cutaneous corrugations, lie the orifices of the lactiferous ducts. The nipple
and the aerola of a nullipara are pink; with succeeding pregnancies they become
pigmentated by deposits of melanin. The nipple contains smooth muscle fibres arranged
concentrically and longitudinally; thus it is an erectile structure and, for the convenience
of the infant in arms, points forward and outwards.
Lymphatics------The lymphatic vessels of the breast drain into (1) lymph nodes that lie between
the greater and lesser pectoral muscles ; (2) the thoracic chain of lymph nodes along the lateral
thoracic artery; (3) the subscapular chain that extends from the lateral thoracic wall to the axillary
vein, and thence along the axillary vein, most of the lymph nodes being on the caudal aspect of
that vessel; (4) the central group which is the largest, lying at the apex of the axilla. The highest of
these lymph nodes is sheltered beneath the clavicle.
It is highly important to know that: (a) there is free communication between the subclavicular and
the supraclavicular lymph nodes which are involved in 33 percent of cases in which the axillary
lymph nodes are the seat of secondary deposits of carcinoma; (b) that the postero-cervical chain
of lymph nodes is linked with those of the axilla, and that (c) the lymph nodes along the internal
mammary artery are involved in about half the cases in which the axillary lymph nodes are
implicated.
Structure:The breast is in essence a modified sweat gland. The normal virgin breast in the
intermenstrual period consists of a small number of ducts with rudimentary acini. They are
surrounded by a specialized loose connective tissue, the periductal tissue, which is under
hormonal influence and is quite distinct from the general stroma of the breast. The combined
glandular and specialized connective tissue form a series of islands known as lobules or gland
fields.
The epithelium lining the commencement of the lactiferous duct is stratified as far as the ampulla,
where it gives place to tall columnar epithelium. When the small ducts are reached the epithelium
becomes cuboidal, and the terminal acini are lined with the same variety. Although at first sight it
appears as if the ducts were lined by one layer of epithelial cells, there is in reality a second
flattened layer outside,which may be described as a reserve layer for reproducing the lining cells,
much as the basal layer of the epidermis replaces the cells lying superficial to it. Its cells
proliferate and enlarge in pathological conditions, so that it is common to find the ducts and acini
lined by a definite double layer of cells. A single layer can seldom be found in a fibroadenoma, in
cystic hyperplasia the cells are frequently several lyers in depth, and in carcinoma they have
begun to invade the connective tissue stroma.
In addition to the ordinary epithelial lining of the ducts myo-epithelial cells may be observed at
short intervals lying beneath the low columnar epithelium and within the basement membrane.
These cells have their long axix tangential to the circumference of the duct, intensy
hyperchromatic nuclei, and cytoplasm which stains red with Masson’s hematoxylin-erythrocinsafron technique.It is of interest to note, in view of the fact that the breast is a modified sweat
gland, that in the sweat glands of the skin spindle –shaped cells resembling smooth muscle cells
are arranged longitudinally around the secretory portions of the tubules, their contractions
possibly assisting in expelling the sweat.
The Lymphatics of the breast are extremely numerous, unfortunately for the woman who
develops carcinoma. They drain into two main basins, namely the axillary nodes and the nodes of
the internal mammary chain. A rich plexux surrounds the lobules which communicates with the
subaerolar plexus and by large vessels with the deep fascial plexus underlying the pectoral
fascia. Main trunks pass to the axillary and supraclavicular groups of nodes. On the medial side
of the breast lymphatics follow the perforating branches of the internal mammary artery, draining
into the nodes along that vessel and into the mediastinal nodes. There are also crossed
anastomosis with the lymphatics in the opposite breast and also with the abdominal network.
From this account it will be evident that removal of the axillary nodes is but a feeble attempt to
arrest the outward march of carcinoma cells by the lymphatic routes.
Development: The development of the breasts is first indicated by an ectodermal thickening
along a line running from the axilla to the groin on both sides; these are known as the milk
lines.The epithelial cells along these lines have the ability to grow into the underlying
mesenchyme and form mammary glands. In the human the breast only develops at one site; in
other animals it is variables depending upon animal species. Sometimes in the human female
supernumery nipple and even breast develops along the milk line; that sometime require surgical
removal. Even such findings are occassionally seen in male person also.The enlargement of
breasts at puberty is due to an accumulation of the fat in these modified sweat glands. These
changes at puberty are due to action of estrogen, so that they do not occur in the male. The
development of true secretory units must await the complex stimulus of pregnancy.
Hormonal Stimulation: Just as the endometrium is not a static structure but shows cyclic
changes due to ovarian stimulation, so also thus the breast. Indeed there is no organ which
shows a wider range of structural variation in health. Up to the time of puberty the parenchyma
consists only of ducts. At puberty under the influence of estrogen active budding of the ducts
occurs, and from these buds the acini are formed later. It is during pregnancy and lactation that
the changes are more marked. The breast in pregnancy consists of a mass of glandular tissue
which entirely replaces the fat, and which has been likened to the pancreas in structure. When
the placental stimulation is withdrawn lactation (secretion) begins, and this is accompanied by a
marked invasion of lymphocytes. After lactation comes involution, but this is never complete and
the glandular overgrowth doesnot entirely disappear. At the menopause the glandular tissue is
replaced by connective tissue. This is complete involution.
During each menstrual cycle the hormonally influencing cells are undergoing through various
steps.The combined glandular and specialized connective tissue form a series of islands known
as lobules or gland field.Only a certain proportion of the gland fields undergo menstrual changes.
At the menses some of the epithelial cells are desquamated, the remainder atrophy, and there is
shrinkage of the ducts. A few days after the period of duct system begins to proliferate, the
epithelial cells increase in size and number, and there is development of soft,pale,periductal
connective tissue, mucoid in character and infiltrated wuth lymphocytes. Wide morphological
variations may occur, which are beautifully illustrated in Helen Ingleby’s paper.
Conflicting explanations which we cannot go into here given for the changes that characterize the
breast in pregnancy as the result of hormonal stimulation. It is obvious that estrogen from the
placenta and progesterone at first from the corpus luteum and later from the placenta are all
important, but anterior pituitary hormones also play a part.In animals from whom the ovaries have
been removed anterior pituitary extract causes enlargement of the breasts, and in absence of the
pituitary estrogen and progesterone are without effect. It would appear that growth of the breast is
dependent on these three groups of Hormones.
=======================================
[mentioned above also; but here it is a part of my paper]
BREAST CANCER SCREENING PROGRAMME(BCSP) :
Application of BCSP in Rural and in metropolitan city areas are as follows :
Preliminary information about anatomy of breast.
Possible risk of developing Cancer in our areas.
Screening Modules : (a) Self examination, (b) Clinical examination, (c) FNAC, (d)
Mammography, (e)
Xeroradiography, (f) Ultrasound study, (g) C. T. Scan, (h) Nipple discharge for cytology study
(exfoliative
cytology), (i) Histopathological study, (j) TNM classification, (k) ICD-O, ICD-9, ICD-10 and update
etc. for tumour nomenclature by
morphological coding.
Usually cancer when detected it is referred to proper treatment cantre.
Provide emotional support.
Guide for possible treatment modules in each case.
Post treatment support.
Chemotherapy.
Follow-up.
FOR BENIGN LUMP :
Non-hormonal lump Surgery is advised.
5
Hormonal lump conservative treatment, follow-up, occassionally referred to higher centre for
review.
NORMAL POPULATION :
Advocating : self examination,
Clinical examination every 2nd year,
age group 30 y.o onward upto 65 years old in Indian Subcontinent.
POPULATION ON 1991 CENSUS : ACS & RBPORC RECORDED CASES FROM THESE
AREAS FOR BREAST CANCER SCREENING PROGRAMME.It include mostly rural areas of
North East India, West Bengal and Calcutta, a model study of Metropolitan city of India. Here
specially we devoted with cases complaining as below:
a. Lump in breast usually non-tender,(b) Change in skin colour,(c) Painful lump,(4)
Retraction of nipple,(5) lump tithered to skin,(6) Blood and other type of Nipple dischare
(7) painless Lump in axilla (8) Enlarged Supraclavicular Gland and various complains that
usually found in late stages of breast cancer. So, this is the usual scenario here with
clinically suspected cases.
So, I have stressed on FNAC here for fast diagnosis whether malignant or not ie. I took less than
an hour to diagnose a case and sending them to respective treatment centres. Since, clinically
the cases are found simple in above 90% cases I have used 24 gauge needle and one and half
inch long. This is found sufficient here.However, debate in various paper noted regarding the
needle gauge; as some scientists are using needle size varying fron 14 gauge to 21 gauge( for
HPE) and for FNAC also it is found variable.
PLACE
POPULATION
AREA (in sq. K.M.)
ASSAM
2,22,94,562
78,438
ARUNACHAL
8,58,392
83,743
TRIPURA
2744,827
10,486
NAGALAND
12,15,573
16,579
MANIPUR
18,26,714
22,327
MIZORAM
6,86,217
21,081
MEGHALAYA
17,60,626
22,429
WEST BENGAL
6,79,82,732
88,752
CALCUTTA
(MetropolitanCity):
10,916,278
In the present study total 2936 patients with breast lump were considered. Fine needle aspiration
cytological study followed by histopathological confirmation were prime diagnostic technique
employed. Cytological examination was done in each case and emphasis had been given to
distinguish between benign, malignant and other pathological lesions.
Aspiration materials for cytological study had been collected from each patient. Conventional
cytological technique & May Grunwald Giemsa (MGG) stain had been employed. Cytodiagnosis
had been considered as pre-operative diagnostic procedure and later surgical specimens were
subjected to histopathological examination and compared with cytological results in every case.
DATAS ARE AS BELOW:
RESULTS:
Total 2936 cases were analysed and results were shown below:
Cases
No. of patients in different
lesions
Percentage
Malignant
1612
54.91%
Benign
720
24.52%
False positive
2
0.07%
False negative
7
0.24%
Others
595
20.26%
Total
2936
100.00%
Table:1- Percentage distribution of various lesions in different categories of patients.
Table 1 shows that out of 2936 cases 1612 cases were malignant (54.91%) and 720 were benign
case (24.52%). The false negative cases were considered inconclusive, and biopsy confirmation
was recommended prior to any surgical intervention. But 2 false positive cases were later
confirmed only on histopathoogical specimens as fibro-cystic diseases with ductal hyperplasia.
Sl No.
Name of the series Studied
Total cases
detected
Accuracy in
%
1.
Hajdu S.I. and Melamed, M.R.I
456
86%
2.
Zajicek, J
2111
77%
3.
Zajdela A. et al.
2772
88%
4.
Present series Debnath S.K
2332
99.62%
Present series ( total malignant and benign cases brought into consideration for comparison with
other series) had been compared with three different series and obviously a high success rate
obtained (99.62%) 1,6,8.
DISCUSSION:
Needless to say, that in the present study various pathological lesions eg. Inflammatory,
granulomatous and many pin point histological typing had been avoided from cytological
materials alone. Berast lumps were attempted by earlier authors [8] to divide into unnecessary
histological typing just from cytological smears eg. Distinction between pericanalicular and
intracannacular fibroadenoma, mastitis, mammary dysplasia etc, Such observations are not
getting priority in the present study as it may confuse and unwanted competition with
histopathological typing may jeoparadise the very existence of cyto-diagnostic procedure. Not
only that it will lead to utter distress to make a final decision for treatment by clinician, but also the
value of aspiration cytology would loose its potential. To pin point a diagnosis from cytological
material alone it will simply indicate that there is over exposure of cytological diagnostic criteria
than what is really exists.
Finally, I like to comment that the present mode of aspiration cytology results are found to be
satisfactory for clinicians on Oncological practice to make a decision within a short period of time
for effective treatment.
REFERENCES:
1. Hajdu, S.I. and Melamed, M.R.: The diagnostic value of aspiration smears. Am. J. Clin.
Path. 59: 350, 1973.
2. Kline, T.S., Neal H.S.: Fine needle asp. Biopsy: a critical appraisal eight years and 3267
specimens later. JAMA 239: 26-39, 1978.
3. Kline, T.S. & Neal H.S. Needle asp. Of the breast why bother? Acta Cytol. 20: 324-327,
1976.
4. Kline, T.S., Joshi L.P. & Neal H.S.: Fine needle asp. Of breast: diagnosis and pitfalls. A
review of 3545 cases. Cancer 44: 1458-1464, 1979.
5. Wilson, S.L. Ehrmann R.L.: The cytologic diagnosis of breast aspirations. Acta Cytol.
22:470-475, 1978.
6. Zajdela A. et al. The value of aspiration cytology in the diagnosis of breast cancer:
experience at the foundation Curie. Cancer 35: 499, 1975.
7. Zajicek J. et al.Cytologic diagnosis of mammary tumours from aspiration biopsy smears.
Acta Cytol 14: 370, 1970.
8. Zajicek, J.: Aspiration Biopsy Cytology. Basel. S. Karger, 1974.
Key Words:
BCCP(Breast Cancer Control Programme), FNAC(Fine Needle Aspiration Cytology),
BSE(Breast Self Examination), CBE(Clinical Breast Examination).TNM(Tumour node
and metastasis). CT(Computerized tomography,USG(Ultrasonography).ICDO[International Classification of Disease for Oncology.ACS&RBPORC(Assam Cancer
Society and Rural Based Preventive Oncology Research Centre(Cancer Awareness
Campaign).
ACKNOWLEDGEMENT:
I am indebted to my late mother Ashalata Debi, who inspired me all along to work for mankind.
DATA SOURCES:
The study was conducted 1987 to 1990 covering a wide range of areas in India e.g. metropolitan
city and rural areas cited above.
Copy Right: Reserved.
For Contact: Dr. S.K.Debnath,MD,
Assam Cancer Society&RBPORC.
P.O.Bokakhat-785612.
Phone:91377626377.MOBILE; +91-9435478305 AND 9435690822.