Journal of Cytology
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 Table of Contents    
Year : 2013  |  Volume : 30  |  Issue : 4  |  Page : 233-236
Expansion of Masood's cytologic index for breast carcinoma and its validity

1 Department of Pathology, JSS Medical College, A Constituent College of JSS University, Mysore, India
2 Departmemt of Statistics, Manipal University, Manipal, Karnataka, India

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Date of Web Publication6-Feb-2014


Background: The incidence of breast carcinoma is increasing in developing countries due to adoption of western life-style. Fine-needle aspiration cytology is the initial method to evaluate the palpable breast lesions. The neoadjuvant therapy is helpful in treating high grade rather than low grade breast carcinomas. Masood cytologic index (MCI) delineates all the breast lesions into four groups. The carcinoma group is not graded further.
Aim: The present study proposes a method for the expansion of carcinoma group into three grades.
Materials and Methods: A total of 50 breast carcinoma cases were prospectively studied by comparing expansion of MCI with modified bloom Richardson (MBR) grading over a period of 3 years.
Results: Altogether 43/50 cases (86%) had concordance with histopathological grading. The analysis revealed a R2 value of 60%, which was significant. The P value of anisonucleosis, nucleoli and chromatin pattern were 0.001, 0.049 and 0.02 respectively, which were significant.
Conclusions: The present study with the expansion of carcinoma category of MCI into three grades similar to MBR will help the treating surgeon to plan the management accordingly. The results obtained in this study need to be subjected to multicentric study with a large number of cases.

Keywords: Breast cancer; cytological grading; Masood cytologic index

How to cite this article:
Rekha T S, Nandini N M, Dhar M. Expansion of Masood's cytologic index for breast carcinoma and its validity. J Cytol 2013;30:233-6

How to cite this URL:
Rekha T S, Nandini N M, Dhar M. Expansion of Masood's cytologic index for breast carcinoma and its validity. J Cytol [serial online] 2013 [cited 2020 Sep 19];30:233-6. Available from:

   Introduction Top

The life-style of women in developing countries is changing due to a shift in age at marriage and child bearing. Working mothers show a low inclination toward breast feeding and an increased trend in early weaning. All these could have resulted in increase in the incidence of breast carcinoma. Fine-needle aspiration cytology (FNAC) of palpable breast lesions has become a boon in developing countries since it is a quick, easy and cost-effective technique. In many centers, FNAC is the only pre-operative investigating procedure to analyze the breast tumors. FNAC of breast lesions began as a screening procedure. Now, however, it has become a tool to differentiate between various benign and malignant lesions of the breast.

Masood [1],[2] developed a cytological grading system to delineate benign and malignant lesions into four groups based on the cellular arrangement, the degrees of cellular pleomorphism and anisonucleosis, the presence of myoepithelial cells and nucleoli and the status of the chromatin pattern. This has been recognized as the Masood cytologic index (MCI) [Table 1].
Table 1: Grading system for interpretation of FNAC by Masood cytologic index[1]

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Similar to the Nottingham prognostic index [3],[4] that provides a useful guideline for deciding the systemic adjuvant therapy, studies have revealed that neoadjuvant therapy can minimize the morbidity and enhance the prognostication in breast carcinoma. [5]

The overall aim of the present study was to propose an expansion of malignant category of MCI to target the neoadjuvant therapy to appropriate patients. Specific objectives were (a) to construct an expansion of malignant category of MCI based on scoring of selected cytological features, (b) to validate the same by comparing with the gold standard histological grading system (i.e., modified Bloom Richardson [MBR] grading system) [6] and (c) to assess the role of various cytological features in determining the grading scores.

   Materials and Methods Top

This was a prospective study of 50 cases of breast carcinoma over a period of 3 years. Women diagnosed with breast carcinoma on FNAC and subsequently subjected to surgical excision were selected for the study. FNAC was done using 23G needle, fixed to a 10 syringe mL. The aspirate was expressed and thinly spread on 4-5 clean dry glass slides. Hematoxylin-eosin and Papanicolaou stains were used for the slides, which were fixed in 95% ethyl alcohol. Air-dried smears were stained with May-Grόnwald Giemsa. Papanicolaou stained smears were subjected for grading since the nuclear morphology was better preserved. [7]

Proposed expansion of MCI

Scores ranging from 1 to 4 were assigned to each of the 6 features under consideration as described in [Table 1] by two independent blindfolded observers. These 6 scores were added to arrive at the final score for grading of the carcinoma. Thus, the final grading score for each of the individual cases ranged from a minimum of 6 to a maximum of 24. These scores were classified into different tumor grades as following.

Score range: Tumor grade

6-10: Non-proliferative breast disease

11-14: Proliferative breast disease without atypia

15-18: Proliferative breast disease with atypia

19-20: Carcinoma, Grade I

21-22: Carcinoma, Grade II

23-24: Carcinoma, Grade III

Wherever the scores differed between the two observers, the slides were reviewed for final score.

Validation of the above expansion

Since the cases under study also underwent excision surgery and specimens were histopathologically examined, these carcinomas were graded according to MBR grading system. This grading system was taken as the gold standard to validate the proposed expansion of MCI grading. We estimated concordance rates for the same, for individual grades as well as for the overall grade.

Role of different features in grading

Multiple regression analysis was performed to assess the role of different cytological features in the grading scores of a carcinoma. The regression coefficients were tested for the significance applying Student's t-test at 5% level.

   Results Top

Proposed expansion of malignant section of MCI has been presented in the previous section. For validation of the proposed method, we cross-tabulated 50 cases under study according to the two grading systems: The proposed one and the MBR. MBR classified 14% of the cases under study as Grade I carcinomas, 54% Grade II and the remaining 32% Grade III. All the 7 Grade I carcinomas were classified as Grade I according to the proposed method also giving a concordance rate for Grade I carcinomas as 100%. Similarly for Grade II and Grade III carcinomas [Figure 1], the concordance rates were 85% and 81% respectively. 43 of 50 cases graded by the proposed method were in consistency with the MBR giving an overall concordance rate of 86%. Thus, the performance of the proposed grading system appears to be almost perfect for early carcinomas and is useful for advance carcinomas.
Figure 1: Breast carcinoma: (a-c). The left panels showing expanded Masood's cytological Grade I, II and III respectively (Pap, ×400) (d-f) the right panels showing corresponding histopathology with Grade I, II and III (H and E, ×200)

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The results of multiple regression analysis of grading scores on the 6 cytological features under study have been presented in [Table 2]. The analysis revealed a R2 value of 60% indicating that 60% of the variation in grading scores could be explained by the 6 parameters under study. [Table 2] shows that anisonucleosis, nucleoli and chromatin pattern had a significant role in the prediction of overall grading scores. Quantitatively, chromatin pattern was the highest contributor to the total grading score, followed by anisonucleosis. A unit change in the score of chromatin pattern was associated with a change of 0.63 in the total grading score.
Table 2: Multiple regression analysis of expanded Masood's cytologic index

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   Discussion Top

The breast is an easily palpable organ and so, more importance is being given to early diagnosis of breast carcinoma than the various treatment modalities. FNAC has been practiced for more than 160 years. [8] Even though, breast FNAC has been known for such a long time, its utility was underestimated. It is easy to access lump in the breast for FNAC procedure. Diagnosis of palpable breast lesions in developing countries by FNAC is the initial method of pathological assessment as a component of triple test. [9],[10],[11] With increasing use of FNAC in the diagnosis of palpable and non-palpable breast lesions, the scope of cytology has been gradually shifting from the mere identification of malignancy to accurate cytologic categorization of various benign and malignant breast lesions. [12] Several studies were conducted to accurately diagnose and categorize benign and malignant lesions.

The evaluation of malignant breast aspirates, should provide not only the diagnosis of malignancy and type of carcinoma, but also information on the cytological grade of ductal carcinomas. [13] Patients with Grade I carcinomas have a significantly better survival than those with Grade II and III carcinomas. [14] A grading system based on cytology would be helpful in the selection of patients for appropriate therapy. [15] Cytological grading has not established despite histological grading having gained a strong foothold.

Recently, neoadjuvant therapy is gaining more attention as primary medical treatment for breast carcinoma, resulting in more importance for cytological grading. Neoadjuvant therapy acts mainly upon mitotically dividing cells. Administering neoadjuvant therapy to low-grade carcinomas leads to overtreatment and increased morbidity that can be avoided. [16] The need to assess the biological aggressiveness of breast carcinoma by cytological grading before any surgical intervention is thus mounting. Therefore, neoadjuvant therapy with tamoxifen gives better result by more rapidly shrinking the carcinoma when given to high-grade (Grade III) than low-grade carcinomas (Grade I). [17] The Nottingham prognostic index is a useful and sensitive guide for selecting adjuvant systemic therapy and there is no reason why such an index should not be developed for neoadjuvant treatment. [18]

With the advent of neoadjuvant therapy, the need for grading of malignant lesions of FN aspirates has increased. [19] This necessity has given rise to various cytological grading systems. [15],[16],[20],[21] With all this, the importance of breast FNAC has been upgraded as a diagnostic, therapeutic and prognostic procedure.

The concordance rate by Masood [22] was 85%, Mridha et al.[23] was 86% and in our study it is 86%, which is consistently high in all three studies. Even though, MCI has been helpful in delineating all categories of breast carcinomas, there were no studies to further grade the carcinoma category. Here, an attempt has been made to grade them without altering the scoring and grouping methods described by Masood.

On multiple regression analysis, the nuclear features such as anisonucleosis, chromatin clumping and nucleoli were significant, showing a P < 0.05, while the cellular arrangement, presence or absence of myoepithelial cells and cellular pleomorphism were not significant. In a manner similar to that of the MBR system, where emphasis is laid on the nuclear features, it seems that the same features may also help in grading malignancies through the MCI system. Since the nuclear grade provides such important prognostic information and is a fundamental cytologic parameter, the nuclear grade should appear in fine-needle aspiration biopsy reports on breast carcinomas. [24] Discriminant analysis by other authors showed that the features with the closest correlation with histological grade were nuclear diameter, nuclear pleomorphism and the presence of nucleoli. A scoring system based on these three parameters enabled the classification of carcinomas into high and low cytological grades, which showed a close correlation with histological grade. [15]

   Conclusions Top

Similar to the standardization of the histopathological grading system, there is a need to standardize cytological grading systems. The present study, with the expansion of carcinoma category of MCI into three grades similar to MBR, will help the surgeon to plan the management accordingly. The other cytological grading methods will help only in grading the malignant breast lesions. However, the expanded MCI will help the cytologist to classify benign breast lesions into different categories as well as grade malignant breast lesions. Hence, this novel cytological grading system will help the cytologist to categorize any breast lump accordingly. The results obtained in this study need to be subjected to multicentric study with a large number of cases.

   References Top

1.Masood S, Frykberg ER, McLellan GL, Scalapino MC, Mitchum DG, Bullard JB. Prospective evaluation of radiologically directed fine-needle aspiration biopsy of nonpalpable breast lesions. Cancer 1990;66:1480-7.  Back to cited text no. 1
2.Masood S, Frykberg ER, McLellan GL, Dee S, Bullard JB. Cytologic differentiation between proliferative and nonproliferative breast disease in mammographically guided fine-needle aspirates. Diagn Cytopathol 1991;7:581-90.  Back to cited text no. 2
3.Elston CW, Ellis IO. Pathological prognostic factors in breast cancer. I. The value of histological grade in breast cancer: Experience from a large study with long-term follow-up. Histopathology 1991;19:403-10.  Back to cited text no. 3
4.Haybittle JL, Blamey RW, Elston CW, Johnson J, Doyle PJ, Campbell FC, et al. A prognostic index in primary breast cancer. Br J Cancer 1982;45:361-6.  Back to cited text no. 4
5.Kollias J, Elston CW, Ellis IO, Robertson JF, Blamey RW. Early-onset breast cancer - Histopathological and prognostic considerations. Br J Cancer 1997;75:1318-23.  Back to cited text no. 5
6.Elston CW. Grading on invasive carcinoma of the breast. In: Page OL, Anderson TJ, editors. Diagnostic Histopathology of the Breast. Edinburgh: Churchill Livingstone; 1987. p. 300-11.  Back to cited text no. 6
7.Schulte E, Wittekind C. The influence of the wet-fixed Papanicolaou and the air-dried Giemsa techniques on nuclear parameters in breast cancer cytology: A cytomorphometric study. Diagn Cytopathol 1987;3:256-61.  Back to cited text no. 7
8.Bowa K, Jewel J, Mudenda V. Fine needle aspiration cytology in the investigation of breast lumps at the University Teaching Hospital in Lusaka, Zambia. Trop Doct 2008;38:245-7.  Back to cited text no. 8
9.Tham TM, Iyengar KR, Taib NA, Yip CH. Fine needle aspiration biopsy, core needle biopsy or excision biopsy to diagnose breast cancer - Which is the ideal method? Asian Pac J Cancer Prev 2009;10:155-8.  Back to cited text no. 9
10.Zagorianakou P, Fiaccavento S, Zagorianakou N, Makrydimas G, Stefanou D, Agnantis NJ. FNAC: Its role, limitations and perspective in the preoperative diagnosis of breast cancer. Eur J Gynaecol Oncol 2005;26:143-9.  Back to cited text no. 10
11.Koss LG, Melamed MR. The breast. In: Koss LG, editor. Koss′s Diagnostic Cytology and its Histopathologic Basis. 5 th ed. New York: Williams and Wilkins; 2006. p. 1081-147.  Back to cited text no. 11
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13.Katz RL. A turning point in breast cancer cytology reporting: Moving from callowness to maturity. Acta Cytol 1994;38:881-3.  Back to cited text no. 13
14.Elston CW, Ellis IO. Pathological prognostic factors in breast cancer. I. The value of histological grade in breast cancer: Experience from a large study with long-term follow-up. Histopathology 2002;41:154-61.  Back to cited text no. 14
15.Hunt CM, Ellis IO, Elston CW, Locker A, Pearson D, Blamey RW. Cytological grading of breast carcinoma - A feasible proposition? Cytopathology 1990;1:287-95.  Back to cited text no. 15
16.Robinson IA, McKee G, Nicholson A, D′Arcy J, Jackson PA, Cook MG, et al. Prognostic value of cytological grading of fine-needle aspirates from breast carcinomas. Lancet 1994;343:947-9.  Back to cited text no. 16
17.Ohri A, Jetly D, Shukla K, Bansal R. Cytological grading of breast neoplasia and its correlation with histological grading. Indian J Pathol Microbiol 2006;49:208-13.  Back to cited text no. 17
18.Sibbering DM, Galea MH, Morgan DA, Elston CW, Ellis IO, Robertson JF, et al. Safe selection criteria for breast conservation without radical excision in primary operable invasive breast cancer. Eur J Cancer 1995;31A:2191-5.  Back to cited text no. 18
19.Taniguchi E, Yang Q, Tang W, Nakamura Y, Shan L, Nakamura M, et al. Cytologic grading of invasive breast carcinoma. Correlation with clinicopathologic variables and predictive value of nodal metastasis. Acta Cytol 2000;44:587-91.  Back to cited text no. 19
20.Cajulis RS, Hessel RG, Frias-Hidvegi D, Yu GH. Cytologic grading of fine needle aspirates of breast carcinoma by private practice pathologists. Acta Cytol 1997;41:313-20.  Back to cited text no. 20
21.Le Doussal V, Tubiana-Hulin M, Friedman S, Hacene K, Spyratos F, Brunet M. Prognostic value of histologic grade nuclear components of Scarff-Bloom-Richardson (SBR). An improved score modification based on a multivariate analysis of 1262 invasive ductal breast carcinomas. Cancer 1989;64:1914-21.  Back to cited text no. 21
22.Masood S. Cytomorphology of fibrocystic change, high-risk proliferative breast disease, and premalignant breast lesions. Clin Lab Med 2005;25:713-31.  Back to cited text no. 22
23.Mridha AR, Iyer VK, Kapila K, Verma K. Value of scoring system in classification of proliferative breast disease on fine needle aspiration cytology. Indian J Pathol Microbiol 2006;49:334-40.  Back to cited text no. 23
24.Dabbs DJ. Role of nuclear grading of breast carcinomas in fine needle aspiration specimens. Acta Cytol 1993;37:361-6.  Back to cited text no. 24

Correspondence Address:
T S Rekha
818, 13th Main, 4th Stage, T.K. Extension, Mysore - 570 009, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-9371.126647

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