Mahesh S. Patil

Abstract

Abstract Introduction: Abnormal Uterine Bleeding (AUB) is the most common clinical presentations in pre and postmenopausal women and is caused by various etiological factors ranging from inflammatory, benign to malignant lesions. The microscopical examination of the endometrium carries an important role in diagnosing various etiopathological factors in cases of AUB. Objectives: To know the spectrum of lesions of the endometrium with respect to age. To determine histopathological correlation of endometrial samples in pre and postmenopausal women. Materials and Methods: A cross sectional study was conducted from October 2009 to September 2011,involving 250 female patients, 40 years and above presenting with AUB. The patient’s endometrial samples were collected by biopsy, D & C or hysterectomy. Results: The maximum incidence of AUB in premenopausal women were seen in 40-42 years age group (38.42%), while in postmenopausal women, highest incidence of AUB cases were seen in the age group of 50-52(43.3%). years In the present study there was a high association between histopathological spectrum of endometrial lesions and age. Proliferative pattern was the commonest endometrial profile in the age group of 50-54 years (30.31%), where as secretory pattern (30.29%) was common in the age group of 45-49 years, atrophic Endometrium (100%) is seen in the age group of 65-69 years, polyps (24.9%) in the age group of 60-64 years, endometritis (9.0%) in age group of 45-49 years, irregular shedding (21.6%) in the age group of 40-44 years, simple hyperplasia (19.6%) in the age group of 45-49 years, whereas endometrial adenocarcinoma was more frequent in the age group of 55-59 years (11.7%). In premenopausal women, the most common endometrial pattern was secretory (26.8%), while in postmenopausal women majority of the endometrial profiles were atrophic (41.7%). Conclusion: This study showed that other than normal physiological changes in both pre and postmenopausal women, various benign and malignant conditions also occurred with increasing frequency. There was high association between the various bleeding presentations and spectrum of endometrium lesions found. Hence, the symptom “abnormal uterine bleeding”, requires prompt attention with respect to the etiology whether physiological or pathological and cannot be ignored. Therefore, microscopic analysis of the endometrium must be considered in all elder women presenting with AUB. Keywords: AUB, Endometrial histopathology, Pre and postmenopausal women. Introduction Abnormalities in menstruation are a common cause of general practice consultations inthe primary or tertiary care centre[1].Endometrium is the mirror of hormonal status in a female.[2]Menstrual dysfunction continues to be a huge burden on the healthcare system with varying etiology and considerable social implications. Abnormal uterine bleeding (AUB) has been defined as change in frequency of menses, duration of flow, or amount of blood loss In adolescents, vaginal bleeding[3] which occurs before menarche is abnormal, while in women of child bearing and premenopausal age, any change in menstrual period, frequency, duration or amount of flow, as well as bleeding between cycles, are considered as abnormal. In post menopausal women, AUB is described as vaginal bleeding for 12 months or more, after the cessation of menses or unpredictable bleeding in those who have been receiving hormonal therapy for 12 months or more.[4] Abnormal uterine bleeding can be a harbinger of sinister pelvic pathology or denote a relatively minor problem, therefore a thorough investigation into the problem is called for in every patient presenting with this complaint.[5] The gold standard is hysteroscopy and endometrial biopsy, the latter which is usually the first step in the diagnosis of AUB, along with diagnostic endometrial curettage which is mandatory without delay in all cases of perimenopausal and postmenopausal bleeding to rule out malignancy. The microscopical examination of the endometrium plays an important role in diagnosing various etiopathological factors in cases of AUB.[6] This study is therefore conducted to know the various endometrial lesions among pre and postmenopausal women with abnormal uterine bleeding in Navodaya Medical College Hospital and Research Centre, Raichur. Aims and Objectives To know the spectrum of lesions of the endometrium with respect to age. To determine histopathological correlation of endometrial samples in pre and postmenopausal women. Materials and Methods Source of data:All female patients in the premenopausal group (45 + 5 years) and postmenopausal group (50 years and above) presenting with abnormal uterine bleeding, admitted in the inpatient ward of tertiary care hospital and from other peripheral referral centers, are the subjects of this study. A cross sectional study for a period of two years has been done. Methods of collection of data: Samples of the endometrial tissue were obtained by: D and C Endometrial Biopsy Hysterectomy. Detailed Requisition forms with clinical data of the study subjects were received along with samples of the endometrial tissue in 10% formalin bottles. The tissue samples were fixed in 10% formalin solution for 12 hours and prepared for microscopic examination by a series of Histopathology processes. Inclusion criteria: All patients in the premenopausal group (45 + 5 years) and post menopausal group (50years and above) presenting with abnormal uterine bleeding. Exclusion criteria: Patients < 40> Patients complaining of abnormal uterine bleeding due to non endometrial causes like lesions of the myometrium and adnexa. Patients with uterine bleeding due to Intra –uterine Devices. Patients presenting with abnormal uterine bleeding due to pregnancy and its related complications Methods of Study A prospective study of 250 AUB cases was conducted and the results were analyzed according to age and histopathological spectrum of endometrial lesions. Descriptive statistics were applied according to variable (i.e), frequency and percentage were calculated for bleeding patterns and histopathological spectrum of endometrial lesions in 250 AUB cases. Maximum and minimum age of the study group was described and mean age was calculated. The data was expressed in proportion of Chi - square test(or Fisher’s Exact test in case of a small sample) which was used to examine association between age, and histopathological spectrum of endometrial lesions. Avalue < 0> Observations and Results Age incidence of AUB cases in pre and menopausal women A total number of 250 cases were enrolled in the study over a period of 2 years, out of which, 160 cases (64%) were premenopausal women and90 cases (36%) were postmenopausal women. The Age incidence of the premenopausal women varied from 40 to 49 years with a mean(Standard deviation) age of 43.6 (+3) years. Highest number of patients wereseen between 40 to 42 years, whereas minimum were seen in 48 years and above age group and the same is shown below in the table. Table 1: Age incidence of AUB cases in premenopausal women. Age(in years) Frequency(Cases) Percentage (%) 40-42 73 38.42 43-45 61 32.10 46-48 30 15.78 >48 26 13.68 Total 190 100.0 Table 2: Age incidence of AUB cases in postmenopausal women Age (in years) Frequency(cases) Percentage(%) 50-52 26 43.3 53-55 09 15.0 56-58 08 13.3 59-61 11 18.3 62-64 04 6.7 65-67 02 3.3 Total 60 100 Table 3: Age incidence of histopathological spectrum of endometrial lesions Age in years Proliferative Secretary Atrophic Polyp endometritis Endmetrits TB endmetrits Irregular shedding Simple hyperplasia Simple hyperplasia with cystic change Complex hyperplasia Adenocarcinoma Stromal tumor Total 40-44 36 (26.9) 35 (26.1) 3 (2.2) 6 (4.5) 7 (5.2) 1 (0.7) 29 (21.6) 11 (8.2) 5 (3.7) 1 (0.7) 0 0 134 (53.6) 45-49 11 (19.6) 17 (30.3) 2 (3.6) 4 (7.1) 5 (8.9) 1 (0.8) 5 (8.9) 7 (12.5) 4 (7.1) 0 0 0 56 (22.4) 50-54 10 (30.3) 3 (9.1) 7 (21.2) 1 (3.0) 0 1 (3.0) 6 (18.2) 0 2 (6.1) 1 (3.0) 1 (3.0) 1 (3.0) 33 (13.2) 55-59 1(5.9) 0 10 (58.8) 2 (11.8) 0 0 1 (5.9) 1 (5.9) 0 0 2 (11.7) 0 17 (6.8) 60-64 0 0 6 (75.0) 2 (25.0) 0 0 0 0 0 0 0 0 8(3.2) 65-69 0 0 2 (100) 0 0 0 0 0 0 0 0 0   2(0.8) Total 58 (23.2) 55 (22.0) 30 (12.0) 15 (6.0) 12 (4.8) 3 (1.2) 41 (16.4) 19 (7.6) 11 (4.4) 2 (0.8) 3 (1.2) 1 (0.4) 250 (100.0) In the present study there was also a high association between histopathological spectrum of endometrial lesions and the age (p Proliferative pattern (30.29%) was the most common endometrial profile in the age group of 50-54 years, secretory pattern (30.3%) was common in the age group of 45-49 years, atrophic endometrium (100%) in the age group of 65-69 years, polyps (25%) in the age group of 60-64 years, endometritis (8.9%) in age group of 45-49 years, irregular shedding(21.6%) in the age group of 40-44 years, simple hyperplasias (19.6%), in the age group of 45-49 years, whereas endometrial adenocarcinoma (11.7%) was more frequent in the age group of 55-59 years. Table 4: Spectrum of endometrial lesions in pre and postmenopausal women. S.no Type of endometrium Pre menopausal Women (n-190) Percentage (%) Post menopausal women (n-60) Percentage (%) 1 Proliferative 47 24.7 11 18.3 2 Secretary 51 26.8 4 6.7 3 Atrophic 5 2.6 25 41.7 4 Polyps 10 5.3 5 8.3 5 Endometritis 12 6.3 0 0 6 TB Endometritis 2 1.1 1 1.7 7 Irregular shedding 33 17.4 8 13.3 8 Simple hyperplasia 18 9.5 1 1.7 9 Simple hyperplasia with cystic change 10 5.3 1 1.7 10 Complex hyperplasia 2 1.1 0 0 11 Adenocarcinoma 0 0 3 5 12 Stromal Tumor 0 0 1 1.7   Total 190 100 60 100 Commonest endometrial pattern in premenopausal women, was secretory (26.8%),followed by proliferative (24.7%), irregular (17.4%), simple hyperplasia (14.8%) and endometritis (6.3%), whereas in postmenopausal women, majority of the endometrial profiles were atrophic (41.7%) followed by proliferative (18.3%), irregular shedding(13.3%), polyps (8.3%), secretory (6.7%) and adenocarcinoma of the endometrium(5%). The following table depicts endometrial profiles in pre and postmenopausal Women. Discussion Total number of 250 patients presented with abnormal uterine bleeding were included in the study. Age incidence of AUB cases The age incidence of the patients with abnormal uterine bleeding, varied from 40 to67 years and maximum presentation was seen in the age group of 40 to 49 years (64%) in the present study, which correlated with studies conducted by Shekhar P[7] and Tariq Sarfraz[8] In this study, premenopausal women with AUB accounted to 64%, whilepostmenopausal women accounted to 36%, the findings of which varied with similar studies by Baral R[9].who reported AUB in 46.6% of premenopausal and 4.6% postmenopausal women. Incidence of various endometrial profiles in aub cases In the present study, the incidence of various endometrial lesions in descending order of frequency were proliferative (23.2%), secretory (22%), irregular shedding (16.4%),atrophic (12%), simple hyperplasia (12%), polyps (6%), endometritis (4.8%), tuberculous endometritis (1.2%), endometrial adenocarcinoma (1.2%), complex hyperplasia (0.8%) and stromal tumour (0.4%). Proliferative endometrial pattern (23.2%) which is the predominant endometrialprofile in this study, correlated with the observations of Veena et al,[6] in their similar study who also reported high incidence (30.8%), whereas the incidence of the same in separate studies conducted by Muzaffir et al[10] (25.8%) and Dangal G11 (17.8%) were low, when compared to our study. Irregular shedding in our study accounted to 16.4% of cases, where as the findings of Baral et al[9] reported a high incidence (26.6%) in their study and lower incidences were documented by authors like Veena M et al[6] (7.7%) and Muzaffar et al[10] (0.8%).In the present study, the incidence of simple hyperplasia was 12% which was similar to the findings of Veena M et al[6](14.5%), Baral R et al[9](12.3%) and Dangal G[11](10%), whereas the studies of Muzaffar et al[10] (23.5%), showed comparatively higher incidence. Among the endometrial profiles in this study, endometritis (4.8%) was comparatively less common, the findings of which were consistent with that of Dangal G[11] in which they recorded 6%, but varied with the study conducted by Muzaffaret al[10] which showed 13%. Table 5: Comparison of spectrum of endometrial lesions in the present study with other studies S.no Type of endometrium Veena M et al(1996)6 (%) Dangal G(2003)11 (%) Muzaffer et al(2005)10 (%) Baral R et al(2001)9 (%) Present study(2011) (%) 1 Proliferative 30.8 17.8 25.8 16.0 23.2 2 Secretary 25.8 10.7 35.4 15.6 22.0 3 Atrophic 0.9 34.5 0.0 5.0 12.0 4 Polyps 2.9 0.0 1.2 1.3 6.0 5 Endometritis 0.9 6.0 13 2.6 4.8 6 TB Endometritis 3.8 0.0 0.0 0.0 1.2 7 Irregular shedding 7.7 0.0 0.8 26.6 16.4 8 Simple hyperplasia 14.5 6.0 8.5 12.3 7.6 9 Simple hyperplasia with cystic change 0.0 4.0 15 0.0 4.4 10 Complex hyperplasia 3.8 0.7 1.2 2.0 0.8 11 Adenocarcinoma 2.9 9.5 0.4 1.0 1.2 12 Stromal Tumor 0.9 0.0 0.0 0.0 0.4 The incidence of endometrial adenocarcinoma in the present study was very low(1.2%) and similar findings was noted in the studies conducted by VeenaM et a[6](2.9%) and Baral R[9] et al (1%). But, contradictory to our study Dangal G[11] reported ahigher incidence (9.5%) of this lesion. Age incidence of histopathological spectrum of endometrial lesions There was high association between age and histopathological spectrum of endometrial lesions in our study subjects (p[12] who reported 66.1% in the above mentioned age group, whereas Muzaffar et al10 in their study documented that, secretory profile &#40;41.3%&#41; was more common in the age group of 45-54 years. In our study atrophic endometrium (41.7%) was seen commonly in the age group of50 years and above, which was similarly observed by Ali Hassan et al[13] (42%) and Narula[14] (41.7%) in their studies, who reported a high incidence in the same age group. Cases of irregular shedding of the endometrium (17.4%) in our study were seen occurring with increasing frequency in the age group of 40-49 years and was similar to the findings of Baral R et al[9] (32%) in their study, who reported an increasedincidence in the above age group. In the present study, polyps (14.8%) were the next common among the endometrial lesions in the age group of 55 years and above, which corroborated with the study of Ali Hasan et al[13] (17.9%), whereas, inflammatory conditions like endometritis (7.3%) was mostly seen in age group of 40-49 years, the supportive findings of which were seen in the studies conducted by BaralR[9](3%) and Muzaffar (11.1%) et al.[10] Endometrial hyperplasia occurred more in the age group of 40-49 years (15.7%) in this study and this finding corroborated with the study of Ali Hassan et al[13] (15.2%),but varied with the observations of Narula[14] (31.25%), Baral R et al[9](29%), DangalG[11] (23%) and Muzaffir et al[10] (20%). Table 6: Comparison of endometrial adenocarcinoma in the present study with various studies Authors Narula (1967)14 Dangal G (2003)11 Muzaffer et al (2005)10 Ali Hassan et al (2010)13 Baral et al (2011)9 Present study (2011) Percentage % 31.25 23 20 15.2 29 15.7 The peak incidence of endometrial adenocarcinoma in the present study was seen inthe age group of 55-59 years (11.7%) which almost correlated with the studyconducted by Dangal G11 (17.7%) and Ali Hassan13 (7.5%), whereas in the study of Baral R et al[9] there was a correlation with the age, but a higher incidence of thislesion was observed (21%). Table 7: Comparison of endometrial adenocarcinoma in the present study with various studies. Authors Dangal G (2003)11 Ali Hassan et al (2010)13 Baral et al (2011)9 Present study (2011) No of cases Percentage % 8(17.7) 7 (7.5) 3(21) 3(11.7) Age group in years >55 55-64 >55 55-59 Spectrum of endometrial lesions in pre and post menopausal women: Premenopausal Women In this study, in premenopausal women, the most common endometrial pattern was secretory (26.8%), followed by proliferative (24.7%), irregular shedding (17.4%), endometrial hyperplasia (15.9%), endometritis (6.3%) and polyps (5.3%). In premenopausal women, majority of the endometrial profiles were secretory(26.8%) and proliferative patterns (24.7%) which corroborated with the observations of Dangal G11 (23% and 38.5%), but varied with the studies conducted by Muzaffir etal[10] (18.5% and 14.1%) and Baral R et al[9](13% and 10%) who reported comparatively lower incidences. The profile of irregular shedding in our study was 17.4%, which was higher than the findings of Baral R et al[9] (6%) and Muzaffir et al[10] (0.4%). In the present study, cases of endometritis accounted to 6.3%, which was consistentwith the studies of Muzaffiret al[10](6.8%), but a lower incidence was seen in the studies of Baral R[9] (3%). Polyps, in our study accounted to 5.3%, on the contrary to Muzaffiret et al[10] whoreported a low incidence of 0.4%. In the present study, the incidence of endometrial hyperplasia was 15.9%, which was similar to the findings of Muzaffiret et al[10] (20%) and Dangal G[11] (23%) whereas, the studies of Baral R et al[9] (29%), showed comparatively higher incidences. Table 8: Incidence of Endometrial profiles in Premenopausal Women in present study and their Comparison with various studies. Authors Dangal G (2003)[11] Muzaffer et al (2005)[10] Baral et al (2011)[9] Present study (2011) Lesions % % % % Proliferative 38.5 14.1 10.0 24.7 Secretory 23.0 18.5 13.0 26.8 Atrophic 0 0.0 3.0 2.6 Irregular shedding 0 0.4 6.0 17.4 Endometritis 0 6.8 3.0 6.3 Polyps 0 0.4 0.0 5.3 Endometrial hyperplasia 23.0 20.0 29.0 15.9 Postmenopausal Women In postmenopausal women, majority of the endometrial profiles were atrophic (41.7%). This finding corroborated with the observations of Ali Hassan et al[13], and Dangal G[11] the former who reported a high incidence of 42%, while the latter reported an incidence of 64.4%.The profile of irregular shedding in our study was 13.3%, which was similar to the findings of Baral R9 (14%). Polyps in our study accounted to 8.3% of cases, whereas a slightly higher incidence (13.3%) was reported by Ali Hassan et al.[13] Endometrial hyperplasia were less common (3.4%) in this study, the findings of which comparatively varied with the findings of Baral R et al[9] and Ali Hassan et al[13] who reported higher incidences of 21% and 13.2% respectively. A low incidence was seen in TB endometritis (1.7%) which corroborated with the observations of Nasira S et al[15] (0.6%), while stromal sarcomas (1.7%) in the present study also occurred in low incidence, but varied with the study of Ashraf et al[16] (16%) who reported a high incidence. In the present study, all of the cases of endometrial adenocarcinoma (5%) presented in postmenopausal women, which was consistent with the studies of Ali Hassan et al[13](7.7%), but a higher incidence was seen in the studies of Baral R et al[9](21%) and Dangal G[11] (17.7%). Table 9: Incidence of endometrial profiles in postmenopausal women in the present study and their comparision with various studies. Authors Dangal G (2003)11 Ashraf et al(2006)16 Nasira et al(2010)15 Ali hasan et al (2010)13 Baral et al(2011)9 Present study (2011) Lesions % % % % % % Proliferative - - 19.2 - 2 18.3 Secretory - - 4.5 - 1 6.7 Atrophic 64.4 - 21.2 42 5 41.7 Irregular shedding - - 1.9 - 14 13.3 Polyps - - 5.1 13.7 - 8.3 TB Endometritis - - 0.6 - - 1.7 Endometrial hyperplasia - - 9.0 13.2 21 3.4 Endometrial Adenocarcinoma 17.7 - 8.3 7.7 21 5 Stromal tumor - 16.0 - - - 1.7 Conclusion The present study was undertaken firstly, to know the spectrum of lesions of the endometrium with respect to age and secondly, to determine various histological patterns of the endometrium in pre and postmenopausal women. This study showed that other than normal physiological changes in both pre and postmenopausal women, various benign and malignant conditions also occurred with increasing frequency. There was also high association between the various bleeding presentations and spectrum of endometrium lesions found. Hence, the symptom “abnormal uterine bleeding”, requires prompt attention with respect to the etiology whether physiological or pathological and cannot be ignored. Therefore, microscopic analysis of the endometrium must be considered in all women over 40 years of age presenting with AUB. The categorization of the endometrial causes of AUB among pre and postmenopausal women has been hampered by applying inconsistent nomenclature, making it difficult to compare studies performed by different researchers, on homogenous populations of patients experiencing AUB. Thus, for the development of a more extensive ‘living’ document that includes nomenclature of bleeding patterns, endometrial profiles and classifications of Abnormal Uterine Bleeding, these recommendations should be the starting point for further debate and research. Conflict of Interest: None. References ^ Prentice A, Singh M. Epidemiology of abnormal uterine bleeding. Best Practiceand Res Clinl Obstet Gynaecol 2007; 21(6):887-888. ^ Sanyal M.K, Sanyal S, Bhattacherjee K and Choudhuri R. Clinico Pathologicalstudy of the endometrium: A review of 3920 cases in different gynaecologicalabnormalities. J Obstet Gynaecol India 1980;29(4):816-821. ^ Vilos G A., Lefebvre G and Graves G.R. Guidelines for Management ofAbnormal Uterine Bleeding, SOGC, Clinical Practice Guidelines. J Obstet Gynaecol Canada 2001;146:1-4. ^ Albers J.R, Hull S.K and Wesley R.M. Abnormal Uterine Bleeding, 2008; articleavailable on www.aafp.org/afp, assessed on August 24th 2010 ^ Padubidri V.G and Daftary S.N. In: Howkins and Bourne Shaw’s textbook ofGynaecology. 13th edition. Great Britain. Elsevier, 2004; pg 38-47.4. Maheshwari V, Chakraborty A, Tyagi S, Sharma R, Alam K. and Mohsin S.Endometrial changes in abnormal uterine bleeding. J Obstet Gynaecol India 1996;33(4): 389-394. a, b, c, d, e Veena M, Chakraborty A, Tyagi S, Sharma R, Alam K. Mohsin S, et al. Endometrial changes in abnormal uterine bleeding. J Obstet Gynaecol India 1996;33(4): 389-394. ^ Purandare S and Jhalam L. Pathological picture in hysterectomy done forabnormal uterine bleeding. J Obstet Gynaecol India 1993;(1-3):418-421. ^ Tariq S, Humaira T. Histopathological findings in menorrhagia: A study of 100 hysterectomy specimens. Pal J pathol 2005;16(3): 83-85. a, b, c, d, e, f, g, h, i, j, k, l, m, n, o Baral R and Pudasaini S. Histopathological pattern of endometrial samples inabnormal uterine bleeding. J Pathol Nepal 2011;1:13-16. a, b, c, d, e, f, g, h, i, j, k, l Muzaffir M, Akhtar K, Yasmin S, Rehman M, Iqbal W, and Khan M. Menstrualirregularities with excessive blood loss: a clinic-pathological correlation. J Pak med assoc 2005;55:486. a, b, c, d, e, f, g, h Dhangal G. A Study of Endometrium of Patients with Abnormal Uterine Bleedingat Chitwan Valley. Katmandu Univ Med J 2003;1(2):110-112. ^ Bhosle A and Fonseca M. Evaluation and histopathological correlation ofabnormal uterine bleeding in perimenopausal women. Bombay Hosp J 2010;52(1):69-72. a, b, c, d, e, f, g Hassan A and Mudhir N et al. Postmenopausal bleeding: clinicopathologicalstudy in Babel province between the years 2000-2009. J Babylon Univ 2010;18(3):44-51. a, b Narula R.K. Endometrial Histopathology in Dysfunctional Uterine Bleeding. J Obstet Gynecol India 1967;17:614-618 ^ Dawood N, Peter K, Ibrar F and Dawood A. Postmenopausal bleeding: causes andrisk of genital tract malignancy. J Ayub med coll Abbottabad 2010;22(2):117-119. ^ Ashraf T, Behtash N, Shariat M and Mosavi A. Low grade endometrial stromalsarcoma of uterine corpus, a clinic-pathological and survey study in 14 cases. World j surg oncol 2006;50(4):1477-1479.

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Abstract Introduction: The role of FNA cytology is widely accepted as a reliable technique in the evaluation breast lumps. Objectives: To study the cytology of lesions of the breast and its histopathological correlation where ever necessary and to have clinico-pathological correlation with respect to age and clinical features. Materials and Methods: Two year prospective study, includes 110 Patients presenting with breast lumps. Results: Maximum of 41 cases (38%) were in the age group 31-40 years. Left breast was more commonly involved with 60 cases (56%). The most common presenting symptom was a Palpable mass seen in all 108 patients. The aspirate was adequate in 108 cases (98.1%). The non neoplastic lesions accounted to 31 cases (28%). The benign conditions comprised of 59 cases (77%) and the malignant conditions comprised of 18 cases that included duct carcinoma, lobular carcinoma, Medullary carcinoma and 2 Suspicious. The 2 Suspicious cases were confirmed as malignant on histopathology. Maximum number of cases in the Non neoplastic category was seen in 21-30 years age group and the minimum was seen in the 11-20.The maximum number of cases in the Neoplastic category was seen in the 31-40 year age group with 27 cases and the minimum in the 51-60 and 61-70 year age group with three cases each. Conclusion: FNAC on breast lumps offers many advantages to clinicians and pathologists as it is an easy and reliable method of establishing the diagnosis of various breast lesions from inflammatory to non neoplastic to malignant conditions. Keywords: FNAC, Breast-Non noplastic and Neoplastic lesions. Introduction With growing awareness in the general population about breast pathologies, a lady with breast lump is one of the most common presentations in the outpatient department[1].  Various benign and neoplastic lesion of the breast may present for needle aspiration. The spectrum of lesions of the female breast are classified as Inflammatory lesions, lesions caused by trauma, Benign Proliferative disorders, Benign tumors, Malignant tumors and Metastatic tumors.[2] The fine needle aspiration cytology has become the investigation of choice for the diagnosis of the breast malignancy. FNAC is widely accepted as a reliable technique as the procedure is simple, safe, cost effective, minimally invasive, rapid, and causes minimal morbidity. Hence, an attempt is made to diagnose the spectrum of Non neoplastic and neoplastic lesions of the breast by fine needle aspiration cytology, in our institute. Aims and Objectives To study the cytology of lesions of the breast and its histopathological correlation where ever necessary and to have clinico-pathological correlation with respect to age and clinical features. Materials and Methods Source of Data: All female patients presenting with Non neoplastic and neoplastic breast lesions attending Hospital and other peripheral referral centers are the subjects of the study. Methods of collection of data: All the patients referred to the department of pathology, Navodaya Medical College Hospital and Research center and from peripheral referral centres, for FNAC of breast lesions were enrolled for the study. The patients were clinically evaluated, and the details were obtained. FNAC was done and the standard method for the procedure was adopted. All the slides were reviewed and their diagnosis was made according to their respective criteria. Study Period: A two year cross sectional study with desired sample size of 100 cases Inclusion Criteria: All female patients presenting with lesions of the breast aged between 15 and 70 years are included in the study. Exclusion criteria: Patients’ refusal / non willingness for the procedure, male patients, aspirates with paucicellularity, hemorrhagic acellular smears, Patients presenting with lesions of the skin of the breast, lesions of the chest wall, lymph nodes in the axillary tail of the breast, are excluded from the study. Breast slides were systemically evaluated for the following features Cellularity: It is increased in neoplastic and proliferative processes. Background: Blood does not always indicate a more serious etiology and it is important to look for necrosis or the lipoproteinaceous background accompanying lactation. Myoepithelial cells: Looking for their presence in the background and whether they are numerous or present in association with large cohesive groups. Single cells with intact cytoplasm: Abundant single cells with intact cytoplasm are suggestive of malignancy. Pattern: Looking for sizes and shapes of groups and a cohesive versus a dyscohesive pattern. Results This study comprised of a total number of 110 cases, which included both Non neoplastic and Neoplastic lesions of the breast. 2 cases were considered as inconclusive and excluded from the study. The remaining 108 cases were included in the study, where Non neoplastic lesions of the breast accounted to 31 cases (28%) and Neoplastic lesions to 77 cases (71.3%). Age of the patients of the cases in the study ranged from 15 to 70 years. The maximum number of 41 cases (38%) was seen in the age group of 31-40 years, and the minimum number of 3 cases (2.8%) was seen in the age group of 51-60 years. Presenting Symptoms: Clinical evaluation of all the cases were done in this study which showed most common symptoms like palpable mass in all 108 cases (100%), followed by mastalgia - 60 cases (56%) while the least common symptom was nipple discharge - 5 cases (4.7%), Incidence of non neoplastic lesions: Non neoplastic lesions of the breast in the present study accounted to 31cases (28%) of the total 108 cases. Of the 31 cases, according to the decreased order of frequency, the lesions were, Acute mastitis - 13 cases (42%), Fibrocystic disease - 9 cases (29%), Simple cyst – 4 cases (13%), Galactocele –1 case (3.2%), Chronic mastitis –1 case (3.2%), Granulomatous mastitis – 1case (3.2%), Duct ectasia -1 case (3.2%) and Fat necrosis – 1 case (3.2%). Table 1: Incidence of non neoplastic breast lesions S. no. Non neoplastic lesions Number of cases Percentage 1. Acute mastitis 13 42.00% 2. Fibrocystic disease 09 29.0 % 3. Simple cyst 04 13% 4. Galactocele 01 3.2% 5. Chronic mastitis 01 3.2 % 6. Granulomatous mastitis 01 3.2% 7. Duct ectasia 01 3.2% 8. Fat necrosis 01 3.2%   Total 31 100.00 Incidence of meoplastic lesions Of the total 108 cases in this study, Neoplastic lesions comprised of 77 cases (71.3%) among which, Benign lesions were 59 cases (77%) and the Malignant were 18 cases (23.4%). Benign Lesions: The Benign lesions comprised of 59 cases (77%) out of 77 Neoplastic lesions and the incidence according to the decreased order of frequency, were Fibroadenoma with 45 cases (76.3%), Benign duct hyperplasia – 11 cases (18.6%), Benign Phyllodes tumor - 1 case (1.7%), Lipoma - 1 case (1.7%) and Atypical duct hyperplasia - 1 case (1.7%). Table 2: Incidence of benign lesions S. no. Benign Lesions Number of cases Percentage    1. Fibroadenoma 45 76.3%    2. Benign duct hyperplasia 11 18.6%    3. Benign phyllodes tumor 1 1.7%    4. Lipoma 1 1.7%    5. Atypical duct hyperplasia 1 1.7%   Total 59 100.0% Malignant Lesions The Malignant lesions comprised of 18 (23.4%) out of 77 Neoplastic lesions. Of the 18 cases, 16 were diagnosed as malignant on cytology and 2 were considered in the Suspicious category. Of the 16 cases diagnosed as malignant on cytology, 14 (77.7%) were Invasive duct carcinoma of the NOS type, 1 case (5.6%) was of Invasive lobular carcinoma and 1 case (5.6%) of Medullary carcinoma.  The 2 remaining cases (11.1%) which were considered as Suspicious for malignancy, were finally confirmed as Invasive duct carcinoma – NOS in both the cases, after subjecting them to histopathological examination. Table 3: Age distribution of non neoplastic breast lesions Non neoplastic lesions 11-20 21-30 31-40 41-50 51-60 61-70 Total Acute mastitis 1(7.7%) 8(61.5%) 4(31%)       13 Galactocele   1(100%)         1 Chronic mastitis           1(100%) 1 Granulomatous mastitis   1(100%)         1 Duct ectasia     1(100%)       1 Fat necrosis   1(100%)         1 Fibrocystic disease   2(22.2%) 7(77.7%)       9 Simple cyst   2(50%) 2(50%)       4 Total 1 15 14     1 31 ?2 = 0.671, df=1, p=0.413 Table 4: Age distribution of neoplastic breast lesions Neoplastic lesions 11-20 years 21-30 years 31-40 Years 41-50 Years 51-60 Years 61-70 Years Total Benign               Fibroadenoma 12(26.6%) 16(35.5%) 14(31.1%) 2(4.4%) 1(2.2%)   45 Benign Phyllodes       1 (100)     1 Lipoma   1 (100)         1 Benign duct hyperplasia   1(9.1%) 8(72.7%) 2(18.2%)     11 Atypical duct hyperplasia         1 (100)   1 Malignant               Invasive duct carcinoma   1(7.14%) 4(28.6%) 6(43%) 1(7.14%) 2(14.3%) 14 Invasive lobular carcinoma     1(100%)       1 Medullary carcinoma           1(100%) 1 Suspicious       2(100%)     2 Total 12 19 27 13 3 3 77 ?[2] = 13.55,df=1, p=0.0002 Out of a total number of 108 cases, 38 cases were subjected for histopathological examination that included 2 Non neoplastic lesions and 36 Neoplastic lesions. In the Nonneoplastic category, out of 2 cases available for histopathological correlation, 1 correlated and was a case of Granulomatous mastitis. The other case which did not correlate was a case of Invasive Duct carcinoma NOS (Mixed type) which was initially diagnosed on cytology as Fibrocystic disease.           In the Neoplastic category, 24 cases of Benign lesions and 12 cases of malignant lesions had histopathology slides available for correlation. Of the 24 benign lesions, 23 cases showed good correlation and 1 did not correlate. Out of 23 cases that showed correlation, 20 cases were of Fibroadenoma and the remaining 3 cases were of Phyllodes tumor, Lipoma and Atypical duct hyperplasia, comprising of one case each. One case that did not show correlation was initially diagnosed as Benign duct hyperplasia on cytology and was confirmed as Atypical duct papilloma on histopathology. Click here to view Fig. 1 & 2.Histology of normal female breast with ducts/ lobules in a fibrous stroma with adipose tissue.(Left side, H&E,10x) and Normal breast acinus showing epithelial cells lining the lumen with apocrine secretion(Right Side Click here to view Fig. 3: & 4: Acute mastitis: Sheets of neutrophils with duct cells (MGG,40x) & Simple cyst: Foamy macrophages with scattered duct cells (MGG, 10x) Click here to view Fig. 5: & 6: Granulomatous mastitis: A multinucleated giant cell along with scattered breast ductal cells and fat cells. (MGG,10x) Fibroadenoma: Staghorn pattern of duct cells with bare nuclei in the background.(MGG,10x). Click here to view Fig. 7: & 8: Atypical ductal hyperplasia: Cellular fragment displaying pleomorphism with enlarged crowded nuclei and focal three- dimensional architecture. (Pap, 40x) Ductal carcinoma: Tumor cells in irregular fragments, loosely arranged and displaying uniform “plasmacytoid” appearance (MGG,10x) Discussion Fine needle aspiration of the breast is one of the most valuable diagnostic tools in the assessment of benign and malignant lesions.[3] Patients with breast lesions underwent FNAC and with adequate aspirate accounted to 108 cases in the present study of 2 years, between August 2009 and August 2011. The age incidence of the patients with breast lesions varied from 15-70 years. The maximum incidence of 41 cases (38%) was seen in the age group of 31-40 years and the minimum -3 cases (2.8%) were seen in the age group of 51-60 years. Studies conducted by Rocha P D et al[4] also reported similar incidences (40.7%) with respect to 31-40 years age group, whereas Talpur K.A.H et al[5]and Kumar R[6] on the contrary, documented maximum incidences (28% and 36%) in the age group of 11-20 years and 21-30 years, respectively. The minimum incidence of cases in the present study correlated with the study of K.A.H. Talpur et al[5] and Kumar R[6](3.33% and 2.0%) in 61-70 years age group, on the contrary, Rocha P D et al[4] recorded a slightly higher incidence (9.1%) in the age group of 51-60 years. Table 5: comparison of incidence of presenting symptoms of the present study with various studies             Breast symptoms Talpur KAH [5] Kumar M et al[7] Bell D A[8] Present study Palpable mass 100% 84.1% 88.9% 100.0% Mastalgia 53.33% 64.7% 5.12% 56.0% Nipple discharge 3.33% 5.5% - 4.70% Comparison of incidence of non neoplastic lesions in present study with various studies In the present study, the Non neoplastic breast lesions accounted to 31 cases (28%) of the total 108 cases and the incidence according to the decreased order of frequency were Acute mastitis (42%), Fibrocystic disease (29%), Simple cyst (13%), Galactocele (3.2%), Chronic mastitis (3.2%), Granulomatous mastitis (3.2%), Duct ectasia (3.2%) and Fat necrosis (3.2%). Acute mastitis: The incidence of Acute mastitis (42%) is one of the predominant Non neoplastic lesions in this study which nearly correlated with the observation of Malik M[9](36.1%) while lower incidences of the lesion were reported by Tiwari M et al (21.4%)[10], and Pradhan M (11.5%).[11] Galactocele: Galactocele in our study accounted to 3.2% and was comparable to the study of Malik M (3.81%),[9] but was significantly higher in the studies of Amr SS[12] and Tiwari M[10] and Singh A et al [13], who reported incidences of 5.7%, 18% and 17.5% respectively. In contrast, Singh K[14] and Pradhan M[11] reported lower incidences of 1.8% and 1.1% respectively, when compared to the present study. Chronic mastitis: In the present study, Chronic Mastitis accounted to 3.2% and correlated with the study of Amr SS (2.8%)[12] whereas Qasim M et al[15]and Malik M. et al[9] reported significantly higher incidences accounting to 44.4% and 8.47%, respectively. Granulomatous mastitis: Granulomatous mastitis accounted to 3.2% in the present study, which corroborated with the study of Malik M. et al (2.96%),[9]but studies conducted by Amr SS (4.1%),[12] Singh K (4.7%)[14]and Qasim M et al (11.1%)[15]reported higher incidences while Pradhan M (0.6%)[11] reported a lower incidence when compared to the present study. Duct ectasia: The incidence of Duct ectasia in our study was 3.2% and was significantly lower when compared with the studies conducted by Amr SS[12], Tiwari M [10]and Malik M. et al[9]who reported significantly higher incidences of 11.7%, 17.9% and 19.49% respectively, while Pradhan M[11]reported a lower incidence of 1% compared to this study. Fat necrosis: In the present study, the incidence of Fat necrosis was 3.2% which was lower when compared with the studies of Singh K[14]and Qasim M et al[15] who reported significantly higher incidences of 5.7% and 22.2% respectively. Fibrocystic disease: Fibrocystic disease in our study accounted to 29% of cases, which correlated with the findings of Qasim M et al (22.2%),[15] Malik M. et al (27.1%)[9]and Singh A et al (30%),[13] whereas Amr SS[12]reported a significantly higher incidence of 50.5% in their study while lower incidence of this lesion were documented by Tiwari M (17.9%)[10] and Pradhan M et al (7%)[11] when compared to the present study. Simple cyst: The incidence of Simple cyst (13%) in the present study was higher compared to the findings of Pradhan M et al (2.2%).[11] Comparison of incidence of neoplastic lesions of the present study with various studies Of the total 108 cases in this study, Neoplastic lesions comprised of 77 cases (71.3%) among which, Benign lesions were 59 cases (77%) and the Malignant were 18 cases (23.4%). Benign lesions: In the present study, the incidence of various benign lesions in the decreasing order of frequency were Fibroadenoma (76.3%), Benign duct hyperplasia (18.6%), Benign Phyllodes tumor (1.7%), Lipoma (1.7%) and Atypical duct hyperplasia (1.7%). Fibroadenoma: Fibroadenoma was the predominant benign lesion in this study accounting to 76.3% which was consistent with the observation of Amr SS[12](74%) whereas Tiwari M[10](97.2%) and Pradhan M. et al[11] (91.3%), reported higher incidences compared to the present study. Malik M [9] on the other hand reported comparatively lower incidence of 58.51%. Benign Phyllodes tumor: The incidence of Benign Phyllodes tumor in the present study (1.7%) corroborated with the study of Pradhan M. et al[11]who reported a similar incidence (2%), while lower incidences were reported by Amr SS[12] and Malik M[9] (0.7% and 0.6% respectively) when compared to the present study. Lipoma: A case of Lipoma with an incidence of 1.7% was observed in the present study, which was lower compared to the studies of Amr SS[12] and Pradhan M. et al[11]who reported slightly higher incidences of 3.4% and 3.5% respectively. Benign duct hyperplasia: The incidence of Benign duct hyperplasia of 18.6% in the present study was significantly higher when compared to the findings of Dahri F J et al,[16] who reported a much lower incidence of 3.2%. Atypical duct hyperplasia: The incidence of Atypical duct hyperplasia in the present study (1.7%) was comparable to the studies of Tiwari M[10]and Pradhan M. et al,[11]who showed similar incidences of 2.7% and 3% respectively. Comparison of incidence of malignant lesions in the present study with various studies The Malignant lesions comprised of 18 (23.37%) out of 77 Neoplastic lesions. Of the 18 cases, 16 were diagnosed as malignant on cytology and 2 were considered in the Suspicious category. Of the 16 cases diagnosed as malignant on cytology, 14 cases (77.7%) were Invasive duct carcinoma of the NOS type, one case (5.6%) of Invasive lobular carcinoma and a case (5.6%) of Medullary carcinoma.  The two remaining cases (11.1%) which were considered as Suspicious for malignancy, were finally confirmed as Invasive duct carcinoma – NOS (Mixed subtype) in both the cases, after subjecting them to histopathological examination. Invasive duct carcinoma: The incidence of Invasive ductal carcinoma in the present study was 77.7% which corroborated with the study of Rocha PD et al[4](79.2%) while Singh K et al (85%)[14] reported a slightly higher incidence. But contradictory to our study, Malik M et al[9] reported a significantly lower incidence (30.5%) of this lesion. Invasive lobular carcinoma: The incidence of Invasive Lobular carcinoma in the present study was 5.6% whereas the study of Malik M[9](8.1%) reported a slightly higher incidence, while Amr SS[12]reported a lower incidence of 2.2% when compared to the present study. Medullary carcinoma: A case of Medullary carcinoma with an incidence of 5.6% was reported in the present study which corroborated with that of Amr SS[12](5.03%), while Malik M[9]reported a slightly higher incidence of 12% when compared with our study. Suspicious: The cases categorized as Suspicious which has an incidence of 11.1% in the present study was consistent with the findings of Singh K et al (12.5%)[14], but the study by Rocha PD et al (21%)[4] reported a significantly higher incidence while Malik M et al[9] reported a much lower incidence (0.4%) when compared to the present study. Comparison of age distribution of non neoplastic breast lesions in the present study with various studies. Acute mastitis: In the present study, highest number of cases of Acute mastitis was seen in the age group of 21-30 years which was comparable to the studies conducted by Amr S S et al,[12] Khanzada T W et al[17] and Dahri F J et al,[16] who also reported maximum number of cases in the same age group. Galactocele: The age group for maximum number of cases of Galactocele in the present study which was 21-30 years correlated with the study of Dahri F J et al[16]who also reported the highest number of cases in the same age group. Chronic mastitis: In the present study one case of Chronic mastitis was reported at a much higher age group of 61-70 year which varied with the study conducted by Amr SS[12]who reported a lower age of occurrence of the lesion at 28 years. Granulomatous mastitis: A case of Granulomatous mastitis seen in the present study was reported in the age group of 21-30 years which corroborated with the studies of Khanzada T W et al[17]and Dahri F J et al[16]who also reported the maximum number of cases of the lesion in the above said age group, whereas Amr SS[12]reported maximum number of cases at the age of 41 years, compared to the present study. Duct ectasia: Highest number of cases of Duct ectasia in the present study was reported in the age group of 31-40 years which corroborated with the studies conducted by Khanzada T W et al[17] and Dahri F J et al[16] who also reported maximum number of cases in the same age group. This was in contrast to Amr SS[12]who reported maximum cases at a higher age of 51 years. Fat necrosis: A case of Fat necrosis was reported in the present study in the 21-30 years age group in contrast to the study conducted by Khanzada T W et al[17]who reported maximum number of cases at a higher age group of 31-40 years. Fibrocystic disease: Highest number of cases of Fibrocystic disease in the present study were described in the age group of 31-40 years which was similar to the studies of Khanzada T W et al[17]and Dahri F J et al[16] who also reported increased number of cases of the lesion in the said age group. Simple cysts: Maximum number of cases of Simple cysts were reported in the 31-40 years age group in the present study which were comparable to that of the study of Hindle W et al[18]who also reported maximum cases at the age of 37 years. Comparison of age distribution of neoplastic lesions in the present study with various studies Benign Fibroadenoma: The maximum number of cases of Fibroadenoma in the present study was seen in the 21-30 year age group which was consistent with the studies conducted by Amr SS et al[12], Khanzada T W et al[17] and Dahri F J et al[16] who also observed highest number of cases in the same age group. Benign Phyllodes tumor: A case of Benign Phyllodes tumor was described in the 41-50 years age group which correlated with that of Malik M[9]who reported the lesion at an age of 39 years whereas Rao C R[19]reported the lesion at a slightly lower age of 35 years. Lipoma: A case of Lipoma was observed in the age group of 21-30 years in the present study which was in contrast to the study conducted by Amr SS et al[12] who reported the lesion at a much higher age of 44 years. Benign duct hyperplasia: The maximum number of cases of Benign duct hyperplasia in this study were reported in the age group of 31-40 years which corroborated with the findings of Dahri F J et al[16]who also reported the highest number of cases of the same lesion in the said age group. Atypical ductal hyperplasia: A case of Atypical ductal hyperplasia was described in the 51-60 year age group in the present study which corroborated with the study conducted by Sneige N et al[20]who reported the lesion at an age of 55 years. Table 6: Comparison of age distribution of benign lesions in the present study with various studies   Benign Lesions Rao CR et al19 1992 Sneige N et al20 1994 Amr SS et al12 1995 Khanzada T W et al17 2009 Dahri F J et al16 2010 Malik M et al9 2010 Present study Fibroadenoma - - 21-30 21-30 21-30 - 21-30 Benign Phyllodes tumor 35   - - - - 39 41-50 Lipoma - - 44 - - - 21-30 BDH - - - - 31-40 - 31-40 ADH - 55 - - - - 51-60 Comparison of age distribution of malignant lesions in the present study with various studies Invasive Duct carcinoma: The maximum number of cases of Invasive duct carcinoma in the present study was seen in the age group of 41-50 years which was similar to the Studies conducted by both Amr SS et al[12]and Malik M[9] who also reported the highest number of cases of the same lesion in the same age group. Another similar study conducted by kumar R[6]also found the highest number at an age of 54 years. Invasive lobular carcinoma: A case of Invasive lobular carcinoma described in the present study was seen in the age group of 31-40 while both Malik M[9]and Amr SS et al[12] reported maximum cases of the same at a higher age group of 41-50 years. Medullary carcinoma: One case of Medullary carcinoma described in the present study was reported in the age group of 61-70 years, while studies conducted by both Malik M[9]and Amr SS[12]reported the lesions at a lower age group of 41-50years. Suspicious of Malignancy: All the cases of Suspicious category in the present study were described in the age group of 41-50 years which were comparable to the study conducted by Rocha PDS[4]who also showed the highest number of cases in the same age group. Table 7: comparison of age distribution of malignant lesions in the present study with various studies   Malignant Lesions Amr SS et al[12](1995) Rocha PDS[4](1997) kumar R[6] (2010) Malik M[6] (2010) Present study Invasive duct carcinoma 41-50 - 54 41-50 41-50 Invasive lobular carcinoma 41-50 - - 41-50 31-40 Medullary carcinoma 41-50 - - 41-50 61-70 Suspicious - 41-50 - - 41-50 Correlation of FNAC and histopathology Out of a total number of 108 cases, 38 cases were subjected for histopathological examination which included 2 Non neoplastic and 36 Neoplastic breast lesions. Of the total 38 cases, 34 cases showed good correlation. In the Non neoplastic category, out of 2 cases available for histopathological correlation, one correlated and was a case of Granulomatous mastitis. The other case that did not correlate was a case of Invasive duct carcinoma- NOS (Mixed type) which was initially diagnosed as fibrocystic disease on cytology. In the Neoplastic category, 24 cases of benign lesions and 12 cases of malignant lesions were available for histopathological correlation. Of the 24 cases of benign lesions available for histopathological correlation, 23 cases showed good correlation and one case did not correlate. Of the 23 cases which correlated, 20 cases were of Fibroadenoma and the remaining were benign phyllodes tumor, lipoma and atypical duct hyperplasia, comprising of one case each. The case that did not show correlation was a case of Atypical duct papilloma, which was initially diagnosed as Benign duct hyperplasia on cytology. Conclusions The present study was undertaken to know the FNAC of breast lesions and compare the results of FNAC with that of histopathology and also to study and assess clinicopathologic features of breast lesions. Breast cytology, particularly fine needle aspiration Cytology (FNAC), has been an integral part in the management of women with breast lesions and FNAC is a simple, cost effective and less traumatic method for diagnosis of breast lump. So we recommend that FNAC of breast lump should be used as preliminary investigation in outdoor patient department as well as a routine method for determining the nature of breast Conflict of Interest: None.   References ^ Khemka A, Chakrabarti N, Shah S. Palpable Breast Lumps: Fine Needle Aspiration Cytology versus Histopathology: A Correlation of Diagnostic Accuracy. Int J Sur 2009;18(1):1-20. a, b Koss LG, Melamed MR. The Breast. In Koss’ diagnostic cytology and its Histologic bases. 5th edition. Lippincott Williams and Wilkins. 2006; 1082-1147. ^ Collaco LM, Lima RSD, Werner B, Torres LFB. Value of Fine Needle Aspiration in the Diagnosis of Breast Lesions. Acta Cytologica1999;43(4):587-592. a, b, c, d, e, f Rocha PDS, Nadkari NS, Menezes S. 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