European Journal of Cardiovascular Medicine

Fine needle aspiration cytology (FNAC) as a component of a triple test along with mammography and clinical examination is considered the gold standard for evaluating palpable breast lumps.1,2,3FNAC is a simple, reliable, rapid, minimally invasive, and cost-effective tool for the preoperative evaluation of breast lesions.3However, in certain categories, overlapping morphological features may lead to diagnostic errors. A single morphological feature cannot be relied upon to differentiate benign, premalignant, and malignant breast lesions, so in the year 2005, Shahla Masood introduced a scoring index that categorizes breast lesions based on different cytological parameters, which includes cellular arrangement, degrees of cellular pleomorphism, anisonucleosis, presence of myoepithelial cells, nucleoli and the status of the chromatin pattern.4Various cytological grading systems are being utilized for the categorization of breast lesions.

In the year 2011, Modified Masood’s scoring System (MMSS) was established to improve diagnostic accuracy of non-proliferative breast disease (NPBD) and proliferative breast disease (PBD) without atypia cases by modifying the Masood scoring system and shifting score 9 and score 10 from NPBD to PBD without atypia. Thus, NPBD becomes a score of 6–8 and PBD without atypia becomes a score of 9–14.5 the present study aimed to assess the diagnostic utility of the cytological scoring system (Modified Masood’s Scoring System) in the evaluation of breast lesions on fine needle aspiration cytology.

This present retrospective study was conducted in the cytology section of the Department of Pathology, MGM Medical College, Navi Mumbai, India from June 2021 to December 2022. It included 40 female patients who presented with clinically palpable breast lump and had undergone FNAC along with histopathological examination whereas, males with palpable breast lump, FNAC smears with inadequate material, cases without histopathology specimen andinflammatory breast lesions were excluded from this study. The detailed history and relevantclinical data was obtained from the medical record department of the institution and theFNACrequisitionforms.

Cytology smears: Papanicolaou (PAP) and May-Grunwald Giemsa (MGG) stained smears were retrieved from the cytology section of the department and evaluation of these smears was done according to Modified Masood scoring system [Table 1] and conventional method of cytology [Based on “Five tier method of reporting system for breast lesions” categorized (C1-C5) according to the International Academy of Cytology].8 The corresponding histopathology sections (trucut biopsy/ lumpectomy/ mastectomy) were assessed and the diagnosis of each case was categorized chiefly into 4 categories. The final histopathological diagnosis was correlated with the cytological diagnosis. The study was approved by the institutional ethics committee.

Statisticalanalysis was done using MSExcelandbasicanalysislikefrequencypercentage were calculated along with graphs. The sensitivity, specificity, the positive and negative predictive values and diagnostic accuracy of the MMSS were calculated considering histopathology as reference standard.

The present study included 40 female patients presenting with breast lumps. The mean age was 38.12 years with an age range of 17 to 70 years. Maximum number of cases were seen in the age group of 21-30 years (10 cases, 25%).  The left breast (55%) was more commonly affected than the right breast (42.5%). Unilateral involvement of breast was seen in 39 cases whereas, bilateral involvement of breast was seen in only one case (2.5%).

The most common presenting symptom was the presence of palpable breast lump followed by pain, fever, puckering of skin, nipple discharge, and nipple retraction. The most commonly affected quadrant was the upper outer quadrant of the breast (Right upper outer quadrant: 13 cases, Left upper outer quadrant: 8 cases). Out of 40 cases, 35 cases presented with a single lump and 5 cases presented with multiple breast lumps. Most of the lumps were of size <4cm (23 cases) in diameter followed by 4-7cm (16 cases) and >7cm. The majority of the lumps were firm (31 cases) followed by soft (5 cases) and hard (4 cases) in consistency.

Non-Proliferative Breast Disease (NPBD, Category I):  This category is characterized by cytological features which include a monolayer sheet of uniform-sized cells, monomorphic cellular arrangement, and the presence of several myoepithelial cells. Nuclear features that include were absence of anisonucleosis, prominent nucleoli, and clumped chromatin. Background shows few cases with apocrine changes and cyst macrophages.  

Cases with Modified Masood’s score of 6-8 were grouped into category I. Number of cases with a score 7 was 1/40 (2.5%) and cases with a score 8 were 3/40 (7.5%).  Number of cases of NPBD diagnosed by conventional cytology were 17/40 cases. On application of Modified Masood’s scoring system, 4 cases were grouped under NPBD.

Proliferative Breast Disease without Atypia (Category II):

This category is characterized by cytological features including moderate to high cellularity, mild cellular pleomorphism, and mild anisonucleosis with a moderate number of myoepithelial cells. Mild nuclear overlapping, with occasional micronuclei and chromatin clumping. The background shows occasional bare nuclei and apocrine cells.

Cases with Modified Masood’s score of 9-14 were grouped into category II. Out of 40 cases, 10 cases were classified as PBDwithout atypia on conventional cytology. By MMSS, 23 cases were grouped under this category. To these, 16 cases were added which were of category NPBD on conventional cytology. The number of cases with score 9 were 20/40 (50%) and cases with score 10 were 3/40 (7.5%). When compared with histopathology, a concordance rate of 38.5 % and 88% was observed by conventional cytology and MMSS respectively. [Table 3]

Proliferative Breast Disease with Atypia (Category III):

This category is characterized by cytomorphological features which overlap with carcinoma.  It includes a moderate to high degree of cellularity, a moderate degree of cellular pleomorphism, and anisonucleosis. The nuclear features include a significant increase in the number of micronuclei and chromatin clumping along with a few myoepithelial cells and a decrease in the number of bare nuclei.

In conventional cytology, 3/40 cases belonged to category III. Cases with Modified Masood’s score of 15-18 were grouped into category III. The present study showed that the least number of cases were of PBD with atypia having one case each with a score of 15 and 18 respectively. Both cases diagnosed by MMSS as PBD with atypia, turned out to be breast carcinoma on subsequent histopathological examination. When FNAC diagnoses were compared with histopathology, cases of this category were diagnosed as DCIS (1 case) and IDC (2 cases).

Carcinoma (Category IV)

This category was characterized by cytomorphological features of loosely arranged cellular pattern, high cellularity, nuclear pleomorphism, chromatin clumping with frequent macronucleoli and absence of myoepithelial cells.The background shows necrosis and hemorrhage.

Cases with Modified Masood’s score of 19-24 were grouped into category IV. In the current study, there were 4 cases with a 20 score, 3 cases with a score of 23, and 2 cases each with a score of 19 and 22. 11/40 cases were grouped into this category by MMSS and 10/40 cases by conventional cytology. All the cases diagnosed by both methods were correctly diagnosed on histopathology.

It was observed that there was a higher concordance rate between MMSS and HPE diagnosis as compared to diagnosis made on conventional cytology. Amongst the four categories, Groups II and IV showed a higher concordance rate.

Modified Masood scoring system: In this system, the minimum score is 6, and the maximum score is 24. In the present study, a maximum number of cases were of category II (20/40 cases) with a score of 9 followed by 4/40 (10%) cases of category IV with a score of 20. The minimum number of cases 1/40 (2.5%) were seen with scores of 7 (category I), 15, and 18 (category III).

Conventional cytology: we observed, a maximum number of cases 17/40 (42.5%) were of
category I followed by categories II & IV (10 cases each). The least number of cases belonged to category III (3 cases). On histopathological correlation, 92.7% of cases showed concordance and 7.5% cases showed discordance. The discordance cases were grouped under PBD with atypia which were diagnosed as carcinoma breast on HPE.

Histopathological examination: Out of 40 cases, 27 cases were benign and 13 cases were malignant. Among the benign lesions, fibroadenoma (24 cases), and among the malignant lesions, infiltrating ductal carcinoma (10 cases) were the commonest.

Diagnostic Accuracy of Cytological Scoring: On applying MMSS, the diagnostic accuracy was increased as compared to conventional cytology. The overall diagnostic accuracy, sensitivity, specificity, Positive Prediction Value (PPV) and Negative Prediction Value (NPV) of the Modified Masood Scoring System (MMSS) in various breast lesions was 95%, 84.6%, 100%, 100%, and 93.1% respectively whereas, the overall diagnostic accuracy, sensitivity, specificity, Positive Prediction Value (PPV) and Negative Prediction Value (NPV) of conventional cytology was 92.5%, 7.96%, 100%, 100%, and 90% respectively.

Benign breast lesions are classified into non-proliferative breast lesions, PBL-without atypia, and PBL-with atypia.9 These lesions can be evaluated by the application of triple assessment (Clinical breast examination, Radiological imaging and FNAC)2 and helps to identify patients at risk of developing breast carcinoma.9 Shahla Masood developed a cytological grading system (Masood’s scoring index) for interpretation of various breast lesions into four different categories on FNAC.4In the year 2011, Nandini et al5., in their study observed that by shifting 9 and score 10 from NPBD and PBD without atypia of the original Masood scoring index can improve the diagnostic accuracy of both categories I & II. They designated this as the Modified Masood Scoring Index wherein, NPBD becomes a score of 6-8 and PBD without atypia becomes a score of 9-14.

Category I: Conventional cytology diagnosed 17/40 cases as compared to 1/40 cases on HPE. The conventional cytology showed a concordance rate of 5.9%, which was increased to 25% after the application of MMSS. [Table 3] Agrawal et al.10 reported 29/69 cases of category I after the application of MMSS and showed 100% histopathology correlation. William et al.1and Abraham B and Sarojini TR.11 also observed that on the application of MMSS, a better concordance rate was seen on HPE as compared to conventional cytology.

Joseph et al.12 reported 36/61 cases under NPBD (category I) on cytological aspirate after applying the Modified Masood scoring system and all the cases correlated with histopathology showed a 100% concordance rate.

Category II: In this current study, we reported 23/40 cases of proliferative breast disease without atypia as per MMSS, which on histopathology showed a higher concordance rate (88%) than conventional cytology (38.5%) [Table 3]. Kumar et al.13 in their study, reported similar observations. William et al.1 in their study of 67 cases, reported 24 cases of proliferative breast disease without atypia by MMSS and were in 100% concordance with histopathology diagnosis. They also observed a higher concordance rate with MMSS (100%) when compared to conventional cytology (62.5%). Agrawal et al.10 in their study, observed 50% concordance rate in category II. They reported total of 4/69 cases wherein, two cases were of carcinoma and two were of epithelial proliferative lesion on histopathology.

Category II: Has an increased risk of developing breast cancer (relative risk: 1.3-2)9 hence, proper diagnosis of FNAC is crucial to differentiate PBD without atypia from NPBD. Few cytological features are consistently seen in PBD without atypia comprising more complexity of epithelial groups, slit-like luminal spaces, a mixture of apocrine metaplastic cells, nuclear pleomorphism, very large epithelial groups/sheets, and cell swirling/streaming.5,14Sneige et al.15has stated that both cytological and architectural features are more helpful in diagnosing FNA smears of proliferative breast lesions and low-grade carcinoma.

Category III: This category is very important as it has a higher risk of developing breast malignancy (Relative risk: 4-6)9 and also exhibits cytological features that overlap with features of proliferative breast lesions without/ with atypia and low-grade carcinoma. In the present study, we observed that on application of six parameters of MMSS, can be very helpful in diagnosing lesions of category III.

On conventional cytology, we reported 3/40 cases, out of which one case was diagnosed as proliferative breast lesion with atypia, but on applying MMSS and subsequent histopathology examination it had a score of 19 and was diagnosed as DCIS. William et al.1in their study of 67 cases of breast lesions showed a concordance rate of 25% and 33.3% on conventional cytology and MMSS respectively. They also reported two false-positive cases by MMSS (fibroadenoma with atypia - one case, atypical ductal hyperplasia - one case), which on subsequent HPE were categorized into category II (Fibroadenoma) and category IV (IDC). Shah et al.16in their study of 50 cases, reported 2/50 cases in conventional cytology and 1/50 cases by MMSS. Out of these 2/50 cases, one case showed discordance and was reported as carcinoma in situ on HPE, with a concordance rate of 50%.

Category IV: All 11 cases diagnosed by MMSS were correctly diagnosed as carcinoma as compared to 13/40 cases on HPE. The two discordant cases in this category were grouped as PBD with atypia, which on HPE was diagnosed as DCIS and IDC breast. We observed a concordance rate of 84.6% [Table 3]with HPE which is comparable to the concordance rate observed by William et al.,1(88.8%), Kaur et al.,17(85%), and Yadav et al.18 (88.68%). In the present study, we observed that the concordance rate of conventional cytology (76.9%) was less as compared to the concordance rate of MMSS (84.6%) [Table 3]. Nandini et al.,5Cherath et al.,6 and Abraham B and Sarojini TR.11 documented 100% cyto-histopathological correlation in this category after the application of the Modified Masood scoring system.

Modified Masood scoring system: In the present study, the diagnostic accuracy of the Modified Masood Scoring System (MMSS) was 95% which is similar to the studies done by Anu et al.3 (94.5%) and Agrawal et al.10(94.2%). Many other authors have shown diagnostic accuracy of MMSS ranging from 93.8% to 97.5%.1,6,11 In our study, the sensitivity of MMSS was 84.6% which is comparable to various other authors with sensitivity ranging from 66.6% to 94.5%.1,3,6,10,11 Both specificity and positive prediction value (PPV) of MMSS was 100% which is similar to observations made by various other authors.1,3,6,10,11,19,20 The Negative prediction value (NPV) MMSS was 93.1% which is similar to the study done by Anu et al.3

In our study, we had observed that MMSS enhances diagnostic accuracy and can improve the concordance rate between cytological and histopathological diagnosis and this finding is similar to the observation made by various other authors in their studies.1,5,6,7,12

Nandini et al.5in the study documented that the application of MMSS showed a 100% concordance rate in the cyto-histopathological correlation of categories III and IV, and categories I and II showed a concordance rate of 95% and 97.7% respectively. Shah et al.¹⁶ have also stated that the application of MMSS in a stepwise manner can increase the diagnostic accuracy of PBD without atypia.

Conventional cytology: In the current study, the diagnostic accuracy of conventional cytology was 92.5% which is similar to the diagnostic accuracy observed by Ogbuanya et al.21in their study of 115 patients with breast lump. Various other authors have shown diagnostic accuracy of 82.1%, 80%, 88.1%, 96.77%, and 98.9% in their respective studies.1,11,18,19,22 We documented a low sensitivity (76.9%) of conventional cytology in diagnosing breast lesions. William et al.,1Tripathi et al.,22and Bisht et al.23 have also documented low sensitivity of 66.6%, 89.3%, and 50% respectively. Specificity (100%) and positive predictive value (100%) of this study were similar to the findings of the studies done by Abraham B and Sarojini TR.,11 Bisht et al.,23Panjvani et al.,24andMohanty SS.25Negative predictive value (90%) of the present study was comparable with the findings observed by  Ogbuanya et al.21(NPV- 92.2%) andMohanty SS25(NPV- 91.71%) in their studies.

FNAC is a useful and effective diagnostic tool in the evaluation of benign and malignant breast lesions and its diagnostic accuracy can be enhanced by the application of Modified Masood’s scoring system to FNAC aspirates with better concordance with histopathological diagnosis. It is beneficial to differentiate non-proliferative breast diseases from proliferative breast diseases as their management and prognosis differ

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