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Breastfineneedleaspirationcytologypracticesandcommonlyperceiveddiagnosticsignificanceofcytologicalfeatures:ApanIndiasurvey

JCytol.2012JulSep29(3):183189.

PMCID:PMC3480767

doi:10.4103/09709371.101168

Breastfineneedleaspirationcytologypracticesandcommonlyperceived
diagnosticsignificanceofcytologicalfeatures:ApanIndiasurvey
HrushikeshTukaramGarud, 1,2DebdootSheet, 1ManjunathaMahadevappa, 1JyotirmoyChatterjee, 1AjoyKumarRay, 3,4
andArindamGhosh5
1
SchoolofMedicalScienceandTechnology,IndianInstituteofTechnologyKharagpur,Kharagpur,India
2
VideoSignalProcessing,TexasInstruments(India)Pvt.Ltd.,Bangalore,India
3
DepartmentofElectronicsandElectricalCommunicationEngineering,IndianInstituteofTechnology,Kharagpur,India
4
BengalEngineeringandScienceUniversity,Shibpur,Howrah,India
5
DepartmentofPathologySubDivisionalHospital,Kharagpur,India
Addressforcorrespondence:Mr.HrushikeshGarud,SchoolofMedicalScienceandTechnology,IndianInstituteofTechnologyKharagpur,
Kharagpur721302,India.Email:hrushikesh.garud@ti.com
Copyright:JournalofCytology
ThisisanopenaccessarticledistributedunderthetermsoftheCreativeCommonsAttributionNoncommercialShareAlike3.0Unported,which
permitsunrestricteduse,distribution,andreproductioninanymedium,providedtheoriginalworkisproperlycited.

Abstract
Background:

Methodicalandmeticulousunderstandingofclinicopathologicalproceduresanddecisionmakingprocessof
cancerdiagnosisandidentificationofaspectsthatarewellsuitedforcomputeraidedanalysisarefirststeps
towarddevelopmentofassistivecomputationaltoolforanalysisofbreastfineneedleaspirationcytology
(FNAC)slides.
Aims:

ToidentifyvariablesinpracticeofFNACasusedfordiagnosisofbreastlesionsandcommonlyperceived
diagnosticsignificanceofcytologicalfeaturesfordiagnosisofbenignormalignantconditionofbreast
lesions.
MaterialsandMethods:

AnIndiawidequestionnairebasedsurveyofcytopathologists/pathologistsbreastFNACreportingpractices
andtheiropinionondiagnosticsignificanceofcytologicalfeaturesindiagnosisofbenignormalignantnature
ofbreastlesionwereconducted.
Results:

Fiftyoneexpertsworkingwithvariousmedicaleducationinstitutes(~52%ofparticipants),oncological
tertiarycarecenters(~28%)andprimarycarecenters/privatediagnosticpathologylaboratories(~20%)
spreadover13statesofIndiahaveparticipatedinthesurvey.Constantsandvariablesobservedinclinico
cytopathologicalpracticesandcombinedopinionoftheparticipantsondiagnosticsignificanceofcytological
featuresarepresentedhere.
Conclusions:
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Thereexistanalogousaswellasvariedcomponentsinclinicopathologicalproceduresanddiagnostic
interpretationbyindividuals.TheseconstantsandvariablesinthepracticeofbreastFNACshouldbe
considered,whendrawingupspecificationsforanassistivecomputationaltoolforanalysisofbreastFNAC
slides.Theestimateforcommonlyperceivedsignificanceofcytologicalfeaturesobtainedthroughthisstudy
willhelpintheirselectionforcomputeraidedanalysisofbreastFNACslidesandfurtherinselectionof
correspondingfeaturequantificationtechniques.
Keywords:Breast,clinicalpractices,FNAC,survey
Introduction
Fineneedleaspirationcytology(FNAC)isapartoftripleassessmentofbreastlesionsandhasbeen
recognizedasthemostcosteffectiveprocedurewithshortestturnaroundtime.[1]Incurrentpracticeofbreast
FNAC,diagnosisisbasedonsubjectiveassessmentofmicroscopicappearanceoftheaspirates,therefore,
difficultiesinmaintainingconsistencyandreproducibilityinfindingsareinevitable.Moreover,thereexistsan
overlapincytologicalfeaturesofbenignandmalignantlesionswhichmayleadtoequivocaldiagnosis.[2]
Whenusingfivereportingcategoriesforbreastcytology(i.e.,C1inadequateC2benignC3atypicalC4
suspiciousandC5malignant),[3]atypicalandsuspiciousfindingsindicateequivocaldiagnosiswherein
tissuebiopsyisnecessaryfordefinitediagnosis.Thesefindingscombinedtogetherhavereportedratesof
6.920%,[2]whereas,AlKaisai[4]foundthatthetruegrayzoneinbreastcytologyis2%ofallcases.Thus
thereisascopetoreducetherateofequivocaldiagnosis.
Alsothereexistsdifferentialpreferenceforclinicocytopathologicalproceduresanddiscordanceamong
expertcytopathologists/pathologistsinmorphometricdiagnosis.Pathologistseitherdonotusethesame
criteriafordiagnosisorapplythesamecriteriadifferentlyfromoneanother.[5]Alternativelyithasbeen
observedthatgloballycytopathologists/pathologistsseethesamebutlocallytheyseedifferentthings.[6]
Toovercometheinherentlimitationspresentedbysubjectiveevaluationofcytologicalsmearsandimprove
thereliabilityofdiagnosis,itisimportanttodevelopanduseassistivecomputationaltoolsforbreastcancer
diagnosisthatoperateonobjectivefeaturesandquantitativemeasures.Inliterature,manysuchcomputational
toolsforbreastcancerdiagnosiscanbefoundwithmostofthemconcentratingonclassificationofFNAC
slidesasbenignormalignantandsomefocusingonstagingofmalignancy.[7]Whendesigningand
developingsuchcomputationalaiditisnecessarytounderstandpracticesandperceptionsoftheexpertsto
identifyaspectssuitableforcomputeraidedanalysis.Thiswillalsohelpdefineusercentricfunctionality
aspectsofthesystem.InthisregardanationwidequestionnairebasedsurveytitledPracticeofFNACasa
screeningtoolinclinicalmanagementofsymptomaticpatientsofbreastcancerwasconducted.Thefindings
ofthesurveyarereportedhere.
MaterialsandMethods
Surveydesign

Thesurveywasdesignedwithprimarygoalsto
Identifycommonpracticesandvariablesinclinicocyopathotologicalproceduresofaspiration,sample
processingandvisualassessmentusingmicroscopeinreportingofbreastFNAC.Thiswillhelpdefine
usercentricfunctionalityaspectsofthesystem
Identifycommonlyperceiveddiagnosticsignificanceofcytologicalfeaturesfordiagnosisofbenignor
malignantconditionofbreastlesions.Thiswillhelpdevelopbetterpatternrecognitionalgorithms.
Tocomplementthesegoals,thequestionnaireforpathologistcomprisedoftwoparts.Firstpartofthe
questionnaireincludedquestionsonclinicocytopathologicalproceduressuchassamplecollectionand
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processingtechniquesused,typeofstainsusedandadditionalinvestigationsperformedroutinelyinbreast
FNAC.
Inthesecondpartofthequestionnaire,participantswereaskedtospecifytheimportanceleveltheyattachto
eachcytologicalfeatureduringdiagnosisofbenignormalignantconditions.Foreachcytologicalfeature,the
participantshadtoselectoneofthefivepredefinedlinguisticsignificancelevelsi)Notsignificant(0),ii)
Slightlysignificant(1),iii)Moderatelysignificant(2),iv)Significant(3)andv)Mostsignificant(4).
Numericalvaluesinthebracketsrepresentcorrespondingnumericalvaluesusedtocombineindividual
opinionsandfindcommonperception.Simultaneously,participantsalsohadtospecifythemicroscope
objectivemagnificationtheypreferablyusewhileassessingconditionofcytologicalfeatures.Participants
werealsorequestedtoprovidedetailsabouttheirreportingexperienceandpersonalconfidencelevelon
FNACasascreeningtoolinmanagementofsymptomaticpatientsofbreastcancer.Helpofscholarlytextsin
clinicalpathologysuchasManualandAtlasofFineNeedleAspirationCytology,[8]FineNeedle
AspirationCytology:DiagnosticPrinciplesandDilemmas,[2]Cytology:DiagnosticPrinciplesandClinical
Correlates[9]andTextbookofPathology[10]wastakenwhilepreparingthequestionnaire.
Targetexperts

ParticipationinthesurveywasvoluntaryandquestionnairebookletcarriedStatementofPurposewhich
apprisedparticipantsaboutpurposeofthesurvey.Hundredquestionnairesweresenttotheheadsofthe
pathology/cytologydepartmentsatrenownedmedicaleducationandresearchinstitutes,oncologicaltertiary
carecentresandprimarycarecentres/privatediagnosticpathologylaboratories(total50institutes).Thehead
ofthedepartments(institutes)wererequestedtodistributethequestionnaireswithintheirinstitutestothe
concernedcytology/pathologyexpertstheyfeltcouldbestprovidetherepresentativeinformation.
ResultsoftheSurvey
Responses

Currentlywehavereceivedresponsesfrom51cytopathologists/pathologistsfromrenownedmedical
educationinstitutes(52%oftheresponsesreceived),oncologicaltertiarycarecentres(28%)andprimarycare
centres/privatediagnosticpathologylaboratories(20%)spreadover13statesofIndia(Assam,Andhra
Pradesh,Bihar,Chandigarh,Karnataka,MadhyaPradesh,Maharashtra,Punjab,NewDelhi,Orissa,
Rajasthan,TamilNaduandWestBengal).Individualreportingexperiencesoftheparticipantsareinthe
rangeof241yearswithaveragereportingexperienceof17years.
Herefindingsofthesurveyarereportedintwoparts.PartIpresentsfindingsofthesurveyrelatedtobreast
FNACprocedures,whichincludetissuesamplecollection,processing,stainingtechniquesand
immunocytochemicalinvestigationsusedbycytopathologists/pathologists.PartIIpresentsfindingson
commonlyperceivedsignificancelevelofthecytologicalcriteriaindiagnosisofbenignormalignant
conditionofbreastlesions.
PartI:TheconstantsandvariablesinbreastFNACpractices
Needlesize Mostoftheparticipantsofthesurveyusedifferentsizesoftheneedlesforaspirationvarying

fromcasetocase,withmostofthemusingfinerneedles(>22G).Approximately62%oftheparticipantsof
thissurveyuse23Gneedle,while39%oftheparticipantsprefer22Gneedles[Table1].
Imageguidanceduringaspirationofbreastlesionsishelpfulforexact
localizationofthelump.Overall74%percentoftheparticipantsuseimageguidanceforaspiration.
However,imageguidancemightnotbenecessaryforaspirationofobviousandpalpableorsuperficialand
definitelesions,whichisevident,as62%oftheparticipantshavereportedusingitonlysometimes(notfor
Imageguidanceforaspiration

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everyaspirationperformed[Table2]).
Seventyninepercentoftheparticipantsusingimageguidancepreferultrasound.Availability,easeofuse,
costofownershipandoperation,andrealtimeinterventioncapabilitiesseemtoinfluencechoiceofthe
imagingmodalityforguidedaspiration.Theusagedatafordifferentimagingmodalitiesisreportedin
Table3.
FixationandstainingmethodsusedforprimarydiagnosisfromFNAC

Mostnumberofparticipantsofthesurveyreportusingbothwetfixationandairdryingfixationtechniquesin
slidepreparation[Table4],whereasthreestainingmethodsareroutinelyusedinbreastprimarycyto
diagnosis,namelyRomanowsky,hematoxylinandeosin(HandE)andPapanicolaou(Pap).However,every
cytopathologist/pathologistseemstofavorthemethodthatwasusedinhis/hertraininginstitute.Mostofthe
participantcytopathogists/pathologists,inthissurvey,usemorethanoneslidepreparedfromtheaspirateofa
singlelump.Useofbothwetfixedandairdriedslidesforeachaspirateisdoneby66%oftheparticipants[
Table5].Ithasalsobeenobservedthattheuseofonlyairdryingfixationduringslidepreparationismore
commonamongsttheparticipantsfromprimarycarecenters/privatepathologylaboratoriesascomparedto
participantsfrommedicaleducationinstitutesortertiarycarecenters.
Additionalstainingmethods

Inadditiontoroutinestainingcombinations,moretypesofstainingtechniques[Table6]areusedby20%of
theparticipants.Sixtypercentoftheparticipantsusingadditionalstainsarefrommedicaleducationinstitutes
andremainingfromprimaryortertiarycarecenters.Stainsusedforconfirmationofmucinouscarcinoma,are
themostcommonlyusedadditionalstains.
Immunocytochemicalinvestigations

Immunocytochemicalinvestigationsareperformedby27%oftheparticipantsofthissurvey71%ofthe
participantsperformingimmunocytochemicalinvestigationsarefromtertiarycarecentersandrest29%from
educationalinstitutions.Noneoftheparticipantsfromprimarycarecenters/privatepathologylaboratories
performimmunocytochemicalinvestigations.Almost87%oftheparticipantsfromtertiarycarecenters
practiceimmunocytochemistry,ascomparedto15%fromeducationalinstitutes.Prognosticinvestigations
suchascheckforestrogenprogesterone(ER/PR)receptorstatusandhumanepidermalgrowthfactor
receptor2(HER2/neuorcerbB2)statusarethemostcommonlyusedimmunocytochemicalinvestigations
practicedby24%and14%oftheoverallparticipants,respectively.Useoftumormarkerssuchascytokeratin
(CK),vimentin(VIM),neuronspecificenolase(NSE),prostatespecificantigen(PSA),cathepsinD
(CATHD),leukocytecommonantigen(LCA)andp53hasalsobeenreportedbytheparticipants.The
usagedatafordifferentimmunocytochemicalinvestigationsinbreastFNACisgiveninTable7.
PartII:Commonlyperceiveddiagnosticsignificanceofthecytologicalcriteria

Thisworkhasbeeninitiatedwiththebeliefthatcommonlyperceiveddiagnosticsignificanceofacytological
criterionrepresentsitsrealabilityindiscriminatingbenignandmalignantconditionofabreastlump.
ParticipantspercentageopinionisgiveninFigure1.Inordertocombineindividualopinionsandfind
commonperceptionoftheparticipantsmeanshifttechnique[11]hasbeenused.Whencombiningavailable
individualopinionsthreeexperimentswereperformed.Numericalfindingsoftheseexperimentsare
presented[Table8].
Infirstexperiment,opinionsofalltheparticipantswerecombinedtocomputeoverallmeansignificance
score(commonlyperceivedsignificance)forthefeatures.Also,thecoefficientofvariationaboutthemean
wascomputedtoestimatethevariabilityinopinion[Figure2].Thefeaturesareorderedinnonincreasing
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fashionofoverallmeansignificancescores.
FromoverallmeansignificancescoresitcanbeobservedthatNuclearchromatinistheonlymost
significantfeaturenatureofbackground,andvolumeandcolorofcytoplasmareinmoderately
significantcategory,whereas,allothercytologicalfeaturesbelongtothesignificantcategory.FromFigures1
and2itcanalsobeobservedthatthereexistsaconsiderabledegreeofconcordanceamongtheparticipants
aboutdiagnosticsignificanceofmostofthecytologicalcriteria.Onlyinthecaseoffourcriteria,namelysize
andshapeofaggregates,natureofbackground,numberofnucleoli,andvolumeandcolorofcytoplasm
participantsexhibitrelativelyhigherdegreeofdisagreementwithcoefficientofvariation[12]ofmorethan
0.3.
Insecondexperiment,theresponsesweredividedinthreegroupsasfromprimarycarecenters/private
pathologylabs,medicaleducationinstitutionsandtertiarycarecenteres,andgroupwisecollective
significancescorewerecomputed[Figure3].Theoverallmeansignificancescoreshavealsobeenplottedfor
comparativeevaluation.Perceivedsignificanceplotsshowhighdegreeofdisparityamongthreehierarchical
levelsofhealthcaredelivery,withcollectiveopinionoftheparticipantsfrommedicaleducationinstitutions
closelyfollowingthetrendsoftheoverallmeanopinion.Thecollectiveopinionoftheparticipantsfrom
primarycarecentres/privatepathologylabsshowshighdynamismanddivergencefromtheoverallmean
opinion.
Inexperimentthree,variationsinperceptionofexpertsaccordingtotheirreportingexperiencewasstudied.
Theresponsesweredividedinthreegroupsaccordingtothereportingexperienceinyears,asbelow5years,
morethan5yearsbutlessthanaveragereportingexperience(17years)andmorethanaverageexperience
groupwisecollectivesignificancescorewerecomputed.Perceivedsignificancescoreshavebeenplotted
alongwithoverallmeansignificancescores[Figure4].Thisfigureshowsconvergingtrendinperceived
significancelevelswithincreasingexperience,alsodifferenceofopinionwiththeoverallopiniondecreases
withincreasingreportingexperience.
Discussion
Amongthecytopathologist/pathologistsconcurrenceisseenonthetypeofneedlesandimageguidancetobe
usedforaspirationofbreastlumps.Interestinglymorethanhalfoftheparticipantsreportofsometimes
usingimageguidanceforaspirationtheyotherwiseperformfreehandprocedures.Thismightbeattributedto
apossiblereflectionofthescenariowherelatepresentationofthediseasewithobviousandpalpablelumpsis
common.Also,whenchoosingtheimagingmodalityforguidedaspiration,availability,easeofuse,costof
ownershipandoperation,andrealtimeinterventioncapabilityofthemodalitiesseemtoinfluencethe
decision.
Thefindingsalsoindicatehighestdegreeofvariationinpracticeofspreadingandstainingtechniquesused
forprimarydiagnosis.Althoughmostofthesurveyedrespondentsagreeonusemorethanoneslides
preparedfromtheaspirateofasinglelumpacytopathologist/pathologistmostlyfavorthestainingmethod
thatwasusedathis/hertraininginstitute.Itisalsoseenthatnomorethan25%participantsusesamestain
combinations.Additionaldiagnostic/prognosticinvestigationslikespecialstainingandimmunocytochemical
investigationsshowhighdegreeofdivergenceamongdifferenthealthcaredeliverylevels.These
investigationsarenotperformedbyanyoftheparticipantsfromtheprimarycarecentres/privatepathology
labsonlyparticipantsfrommedicaleducationinstitutesandtertiarycarecentersreportofperformingthem.
Additionalstainingtechniquesarepredominantlyusedbymedicaleducationinstituteswhile
immunocytochemicalinvestigationsaremostlyperformedattertiarycarecentres.
Overallperceptiononthesignificancelevelofthecytologicalfeaturesindiagnosticinterpretationofbreast
FNACslidescanbeconsideredtorepresenttheactualdiscriminationabilityofthefeature.Thecollective
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opinionshowsdisparityfromonelevelofhealthcaredeliverymodeltotheother.Fromthefindingsofthe
surveyitcanbeenobservedthatnuclearfeatureslikenuclearchromatin,prominenceofnuclei,nuclear
membrane,mitoticfigureareconsideredmoresignificantbyparticipantsfrommedicaleducationinstitutes
andtertiarycarecentersnuclearfeaturesandgrosscytoarchitecturalpatternssuchassizeandshapeof
aggregates,cohesivenessofclustersandpresenceofbarenucleiarefavoredbyparticipantsfromprimary
carecentersothercytologicalfeaturesviz.,myoepthelialcellpopulation,nuclearcytoplasmicratioand
cellularpleomorphismarepreferredequallybyalltheparticipants.Alsoasobservedearlier,theperception
aboutthefeaturesshowsconvergingtrendwithincreasingexperience.Theperceivedsignificancevaries
widelyamongthedifferentexperiencegroupsforfeaturessuchascohesivenessofepithelialcells,number
ofnucleoli,natureofbackground,andvolumeandcolorofcytoplasmwhereastheperceived
significanceoffeaturesnuclearcytoplasmicratio,mitosis,bimodalpatternofaggregates,nuclearshape
andnuclearsizeisalmostsimilarforallexperiencegroups.
Conclusions
FromthenationwidesurveyonpracticeofFNACasascreening/diagnostictoolinbreastcancerdiagnosis,it
hasbeenobservedthatthereexistanalogousaswellasvariedcomponentsinclinicopathologicalprocedures
anddiagnosticinterpretationbyindividuals.TheseconstantsandvariablesinpracticeofFNACforbreast
cancerscreening/diagnosisshouldbeconsidered,whendrawingupspecificationsforanassistive
computationaltoolforanalysisofbreastFNACslides.Suchacomputationaltoolusingobjectivefeatures
willensureprovisionofrelevant,appropriateandaccurateassistanceindiagnosticinterpretationandits
subsequentbroadacceptability.Theestimateforcommonlyperceivedsignificanceofcytologicalfeatures
obtainedthroughthisstudywillhelpinselectionofcytologicalfeaturesandselectionofcorresponding
objectivefeaturequantificationtechniquestobeusedinanalysisofbreastFNACslides.
Acknowledgments
Wearegratefulofalltheinstitutesandindividualswhokindlyrespondedtoourcallandparticipatedinthis
survey.WearealsothankfultooursponsorsTexasInstruments,AuthoritiesatSMST,IITKharagpurandall
thosewhodirectlyorindirectlysupportedusinthisactivity.
Footnotes
SourceofSupport:Nil
ConflictofInterest:Nonedeclared.

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FiguresandTables
Table1

UsagedatafordifferentneedlesizesinbreastFNACaspiration
Table2

Usagedataforimageguidanceforaspirationofbreastlumps
Table3

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Usagedataofimagingmodalitiesforguidanceduringbreastlumpaspiration
Table4

UsagedatafortissuefixationtechniquesinbreastFNACslidepreparationforprimarydiagnosis
Table5

StainingmethodsusedinbreastFNACslidepreparationforprimarydiagnosis
Table6

UsagedataforadditionalstainingtechniquesinbreastFNAC
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Table7

Immunocytochemicalinvestigations
Figure1

Participantspercentageopinion
Table8
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Commonlyperceivedsignificanceofthecytologicalcriterion
Figure2

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Overallopinionandtheextentofvariationamongparticipants
Figure3

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Perceivedsignificanceofcytologicalfeaturesatdifferenthierarchicallevelsofthehealthcaredelivery
Figure4

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Perceivedsignificanceofcytologicalfeaturesandeffectofexperienceonit
ArticlesfromJournalofCytology/IndianAcademyofCytologistsareprovidedherecourtesyofMedknow
Publications

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