Most countries have now adopted a triple assessment approach for diagnosis of breast cancer. This approach utilizes clinical imaging and pathological methods to diagnose a breast mass [1]. Fine-needle aspiration cytology (FNAC) is considered now the first line pathological investigation in both screening and symptomatic populations with the exception of macro-calcification, Pathologists specialized in cytopathology are best qualified to collect and interpret FNAC samples but this is not always possible [2]. Radiology may be needed to ensure good image guidance. When triple assessment is coresident, final treatment may proceed on the basis of cytology without tissue biopsy. FNAC should be used in diagnosing benign symptomatic lesions. Core biopsy (C. B.) may be needed in the presence of macrocalcifications and suspicions FNAC finding and malignancies when radiology cannot guarantee stoma invasion [3]. Obtaining a definitive pre-operative/pretreatment diagnosis has become the main element of a modern management approach to breast cancer Excision biopsy of the lesion in order to establish if it is benign or malignant is no longer acceptable mode of diagnosis FNAC is cost effective easy to perform and time saving approach however, it can be applied only in those institution where services of a cytopathologist are available. [3] The results of FNAC can be reported as unsatisfactory, benign, suspicious probably benign suspicious probably malignant or malignant. European and U.S.A reporting categories for FNAC results were established [5]. In the last decade, FNAC technique was improved by the development of new cytological methods allowing standardization of fixation and assuring constant results with ancillary tests such as immune-cytochemistry and in situ molecular biology also one of the advantages of FNAC is the management of smell tissue fragments permitting a repetitive evaluation of the chronological evolution in expression of tumor biomarkers [6]. FNAC has minimal Invasiveness with minimal discomfort it can be performed repetitively and can give rapid diagnostic information equivalent to that of frozen sections [7]. FNAC could be an excellent alternative when radiographic screening of breast is not available. It can be used in patients with morbidity like senile patients. patients with cardiac disease or diabetes. It is of value in the follow up of new lesions in patients treated for breast cancer and evaluation of biomarkers [8]. It was demonstrated that FNAC has a sensitivity of 92.7% and a specificity of 94.8% except in the unsatisfactory samples [9]. If the FNAC result was negative, the probability of breast cancer is about 8% [7]. Most of false negative FNAC results of sampling error or discordance between clinical and histological observations [10]. After an indeterminate FNAC, core needle biopsy should be performed to obtain a reliable preoperative diagnosis. Although FNAC is easier to perform, it is not sufficient for small and non -palpable lesions or diagnosis of micro- calcifications as those for in situ carcinoma [10]. The aim of this study is to evaluate the role played by FNAC done at breast clinic at Al-Yarmouk teaching hospital in the early detection and proper management of patients with breast cancer.

This is a prospective study done at Al-Yarmouk teaching hospital during the period from Jan. the 2015 to Dec. 2015. All female patients, irrespective of age, who presented to the surgical consultant clinic and clinic for early detection of breast malignancy complaining of a breast lump were included. They were evaluated by full history taking and focused clinical examination and if a breast mass was discovered ultrasonography and/or mammography was done If a mass was confirmed radiologically, FNAC was done. The total number of patients was 112. The results of FNAC were tabulated and further management analyzed. Those referred for surgical intervention were followed closely. The findings at surgery were recorded and the surgical procedure done reported The final histopathological results were obtained and compared with the results of the FNAC Statical analysis was done.

During the period of the study, 112 patients presented with a complaint of a breast lump. Sixty-four (57.1%) were in the 3rd and the 4th decades and 34 (30.3%) were with 5th and 6th decades. Ninety-seven (86.7%) had 1-4 children, twelve (10.7%) had more than 5 children and 3 (2.6%) were childless. Twenty-one (37.5%) were smokers. 96 (85.7 %) live in urban areas and 9 (12 %) live in rural areas. Seventy-one (63.4 %) were government employees and 41 (36.6 %) were housewives. Forty-two (37.5 %) had history of chronic medical diseases and 48 (42.8%) had history using contraceptive pills. The main clinical presentation was a breast mass in 74 patients (66 %). Of these ,69 were discovered on self-examination, 18 during routine clinical examination, 15 accidentally and 10 during examination for other complaints. Local pain mastalgia was the main complaint in 12 patients (10.8%) and there was nipple discharge in 10 (8.9 %), axillary lump in 9 (8.1%) and increased breast size in 2 (1.8 %). A mass was clinically confirmed in 102 (91%) the site was in the upper outer quadrant in 56 (50%), lower outer in 42 (37.5%), lower inner in 5 (4.5%) and 3 (2.7) in upper inner quadrant. There was nipple discharge or retraction in 38 (37%). axillary mass in 13 (10%) and skin changes in 7 (6%). Ultrasonographic studies revealed a solid mass in 35 (31.3%). cystic mass in 9 (8%) and mixed lesions in 68 (60.7%). Mammographic studies showed a mass with features suggesting malignancy in 71 (63.3%). The mass was >2 cm in diameter in 32 (28-5%), <2 cm in 39 (34.8%), irregular borders in A (21 %), regular borders in 58 (51.7%), regular borders in 13 (11.6%) and micro-calcification in 90 (80%). FNAC was positive for malignant cells in 78 patients (69.9%). suspicious in 34 (30%). In 18 (16%) patients, the decision for surgery was bused only on the results of FNAC. The type of surgical procedure was modified radical mastectomy in 104 (92.8%), simple mastectomy in 6 (5.3%) and quadrantectomy in 2 (1.7%). The definitive histopathological diagnosis was ductal cell carcinoma in 99 (88.4 %), of those 90 % showed moderate invasiveness. (Table 1-3).

There were 6 (5.4%) with lobular carcinoma, 3 (2.7%) with inflammatory carcinoma, 4 (3.5 %) with anaplastic carcinoma. The grading score was grade 1 in 13 (11.6%), grade 2 in 92 (82.1%) grade 3 in 7 (6.3%). Study for estrogen and progesterone receptors was positive in 70 % of the patients. According to Columbia classification, 59 (52.7%) was of stage A 32 (28.6%) stage b, 18 (16.1 %) in stage C and 3 (2 .7%) stage D (Table 4-7).

Table 1: Age Incidence

Table 2: Demographic Data

Table 3: Clinical Data

Table 4: Radiology

Table 5: Cytology and Histopathology

Table 6: Columbia Clinical Classification

Table 7: FNA Compared with Histopathology Results

The incidence of female breast cancer continues to rise in Iraq and worldwide, much of the increase in developing and poor countries breast cancer in Iraq is showing an obvious trend to affect pre-menopausal women. [11]. The study by al - alwan showed that one third of the diagnosed patients were between 40 and 49 years of age [12]. In this study, the incidence was higher in the third and fourth decades of life (57.2 %). In AL-ALwan study, 71.9% of patients came from urban areas, 75% were married, 63.1% had history of lactation and 29% had received hormonal therapy [11]. They reported family history of breast cancer in 12% of patients. In this study, 61% of patients came from urban areas, 77.6% were married 10.7% were multiparous with more than 5 children, 86.7 % with less than 5 children. In a study done at Iraqi Kurdistan revealed an average patient’s age of 47.4 years and 59.5% were pre-menopausal [12]. In AL-Alwan study 90.6% of patients detected a lump on self-examination but only 32% sought medical advice within the first month [11]. In this study, 66 % of patients presented with a breast lump and of those 61.7 % were detected during self - examination, while 13.4 % were detected accidentally or during routine examination (16%). Many cases of early breast cancer are asymptomatic, particularly if they were discovered during screening programs. Only 5% of patients with a malignant disease present with breast pain [13]. In this study, 10.8 % had mastalgia. Others presented with change in breast size (1.7%) nipple discharge (8.9%) and axillary lump or pain (8.1%). Evaluation of a suspected breast lump should be approached in an orderly fashion. Triple assessment (clinical, radiological and pathological tests) seems to fulfill these requirements. This approach lends itself to a gradually increasing degree of invasiveness, so that when a diagnosis is obtained, the process can be stopped with the minimum amount of invasion and consequently, minimum discomfort to the patients [14]. The aim of evaluation of a breast lesion is to judge whether surgery is required and if so to plan the most appropriate surgery. The ultimate goal of surgery is to achieve the most appropriate degree of breast conservation while minimizing the need for reoperation. The least invasive method of breast mass biopsy is FNAC, in this study 30% of specimens were definitely positive for malignancy. In 70% of specimen the results were suspicious with a larger biopsy sample greater accuracy and more information is obtained but at the expense of increased invasiveness ideally needle biopsy should be performed after imaging to help prevent distortions of imaging due to tissue trauma and hematoma. Franco et al. [15] confirmed that the diagnostic accuracy of FNA for breast lesion is very high with minimal complication. they suggested a positive predicative value approaching 100% which allow to establish therapy based on FNA results [16]. There were no recorded complications related to FNA in our study. the three main areas where FNA plays a major role include the diagnosis of benign disease in symptomatic palpable lumps, staging of breast carcinoma, particularly in presence of preoperative axillary lymph nodes. FNA and intra- operative sentinel node imprints and diagnosis of metastatic diseases at distant site following treatment of carcinoma [17]. when the results of FNA are supported by clinical and radiological results (concordant triple assessment), the final treatment may be ensued without open biopsy, as was done in 18 patients in this series. 

In cases were ultrasonography and clinical examination are in agreement with FNAC, open biopsy or frozen section examination are unnecessary. FNA has an advantage of being an immediate and excellent method for onsite examination and one–step diagnosis at breast outpatient clinics sneeze the majority of patients attending these clinics have benign disease, they benefit from rapid diagnosis. Because the reports of FNAC suggested presence of suspected malignant cell and not definite malignancy in 70% of patient, excisional biopsy was performed to confirm the diagnoses. Most of the patients in this study had modified radical mastectomy (92.8%). Simple mastectomy with axillary clearance and sampling was done in 5.3 % and quadrantectomy in 1.7 %. Early diagnosis of breast cancer allows for the performance of breast conservative surgery, mainly in the form of lumpectomy [18]. Breast conserving surgery lumpectomy and axillary dissection plus radiotherapy provides comparable overall and disease - free survival to modified radical mastectomy [18]. Quadrantectomy and a skin - sparing mastectomy can also be used in early cases of breast cancer Earlier diagnosis of breast cancer can even allow for immediate reconstruction of the breast during the primary surgical procedure [19]. The final pathological diagnosis was ductal cell carcinoma in 88.4 % of patients, alveolar carcinoma in 5.4% and inflammatory carcinoma in 2.7 %. Regarding grading, 11.6 % were of grade 1, 82.1 % grade 11 and 6.3 % of grade 111. Hormonal receptor studies were positive for estrogen and progesterone in 70% of the patients. Applying Columbia classification 52.7 % of the patients were in stage A, 28.6 % were in stage B. 16 % in stage C and 2.7 % in stage D. Patients in stage A and B are more amenable to curative treatment, (80 %) of patients in this series 1. By contributing to early diagnosis, FNAC was vital in ensuring more favorable results regarding prognosis. Out of 78 instants in which FNAC results were suspicious, 21.8 % proved to be benign and 78.2 % malignant. On the other hand, out of 34 cases with FNAC showing malignant cells 14.7 % proved benign and 85.3% were malignant. Jaekman showed that most of false negative FNAC results of sampling error or discordance between clinical and histological observation [19]. In conclusion FNAC as an investigation for probable breast lesion suspected of malignancy has high sensitivity and specificity. It is preferable to be used as part of triple assessment It is safe economical and accurate technique for breast cancer evolution.

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