Association of Histopathological Parameters and Axillary Lymphnode Metastasis in Primary Breast Carcinoma

The most common malignancy worldwide among females is breast carcinoma and in India, the second most common malignancy next to cervical cancer. In India the disease specific mortality of breast cancer is roughly 50% [1]. The incidence of breast cancer in Kolar region is around 6.41% of all malignancies [2]. The worldwide incidence of breast cancer comprises of 10.4% of all malignancies in female population. Breast cancer, a heterogeneous disease has varied morphological appearance, molecular features and behavior of response to therapy. It is becoming increasingly important to assess the prognosis of breast cancer in each patient before Abstract

axillary lymph node shows higher mortality (four to eight times) than node negative cases. Not only the disease specific mortality increases in node positive patients but also the risk of distant recurrence [6].
This study has been taken up to study association of different histological parameters with axillary Lymph nodes metastasis, which may help in predicting the prognosis and guide the treatment of breast carcinoma.

Materials and Methods
All breast cancer specimens received in the Department of Pathology from R.L.Jalappa Hospital and Research Center attached to Sri Devaraj Urs Medical College, Tamaka, and Kolar over a period of five years. Specimens were cut at 1cm interval and kept in 10% formalin for overnight fixation, and gross examination was done according to standard protocol.Sufficient number of blocks were taken, ensure adequate sampling and routine paraffin embedding was carried out. Standard thin sections (4-6 microns) were taken and stained with routine Haematoxyline & Eosin stain.
Various histopathological parameters were carefully studied in detail. Assessment of Tumor size was done According to American joint committee on cancer; Histological typing was done using WHO. Grading of breast carcinoma was done using modified Bloom Richardson scoring system. Semi quantitive assessment of grading of necrosis was done according to the study done by Richards CH et al [7]. Inflammatory cell infiltrate was studied using a study done by Klintrup et al [8] we also studied lymphatic invasion, Blood vessel invasion, Perineural invasion, Stromal characteristics.

Inclusion Criteria
All operated breast carcinoma specimens with axillary lymph node clearance.

Exclusion Criteria
Carcinoma of breast in male patients and sarcomas of breast. Patients on or receiving radiotherapy or chemotherapy and recurrent tumors were excluded from the study Results 100 breast carcinoma cases were studies in the present study, out of which 53% were above 50 years. 90% of cases presented with breast Lump, 4% presented with ulceration and nipple discharge each and 2% presented with Pagets diasease of breast. 14% of patients had Tumor size <2 cms, 55% were between 2 to 5cms and 31% were >5 cms. 11% were in T1 stage, 48% were in T2 stage, 22% were in T3 Stage and19% were in T4 Stage. Histopathological  Association of pathological parameters with axillary lymph node metastasis: 1. Association between Tumor Size and axillary lymph node metastasis: there was significant association between Tumor size and Lymph node stage (χ 2 =25.24, df =9, p = 0.003) (Figure 1).
3. Association between Grade and axillary Lymph node     [12] with highest number of cases between tumor size of 2 to 5 cms. In our study there was significant association between Tumor size and Lymph node stage as shown in the results. As the tumor size increased, positivity of axillary lympnodes also increased. These findings are similar to study done by Marwah, et al, [13] Ahmad, et al, [14] Postaci et al [15] and Sukla et al [16]. The risk of axillary lymph node metastasis increases as tumor size increases which suggests that nodal metastasis is indicative of tumour chronology [17].
In our study, as shown in the results, the maximum numbers of cases were in T2 stage (48%) which was similar to the study done by Wang M et al 70. T2 was followed by T3 stage (22%), T4 stage (19%) and T1 stage (11%) respectively. Pistelli M et al [18] in his study on early stage breast cancers observed that maximum number of cases were in T1 stage (53.6%) followed by T2 stage (30.8%) which was contrary to the observations made in the present study. The reason could be that the stage IV tumors were excluded in the study by Pistelli M et al 19 and the study was done only on early breast cancer patients.
The present study showed that there was strong association between histological grades of tumor with axillary metastasis. Grade II and III tumors had more positive axillary lymph nodes and grade 1 tumors showed low rate of axillary metastasis. Various studies have analyzed the importance of histological grade as a prognostic factor in carcinoma of the breast [13,14,16,17].
Histopathologically-identified tumor necrosis has been recognized as a potential prognostic marker for a variety of tumors. In the present study, necrosis was seen in 83% of cases in comparable to the study done by Krishnamurthy et. al. [19] whereas Carlomango et. al. [20] observed necrosis in only 20.3% of cases.The observations made in the present study were similar to the study done by Matkowski R et. al. [21]. In our stusy there was a strong association with tumor necrosis and axillary lymph node matastsis. Other Studies have shown that necrosis in the tumor was associated with higher mortality rate, a higher incidence of axillary node metastasis, and a higher mortality rate in patients with axillary node metastasis than were primary malignancy without necrosis.
Several studies outlined the use of the inflammatory infiltrate in breast cancer as a prognostic marker [22,23]. There was statistically significant correlation between the inflammatory infiltrate and axillary Lymph node metastasis i.e. as the inflammatory infiltrate increases, the chance of axillary Lymph node metastasis decreases. Aaltomaa et al [22] examined 489 breast cancer patients metastasis: In the study, there was significant association between Grade and Lymph node metastasis (χ 2 =17.995, df =6, p = 0.006*) (Figure 3).

Discussion
Breast cancer is a leading cause of cancer death among women worldwide. Numerous studies have shown that these malignancies are multifactorial. Life style, genetic and environmental factors play a major role in development of breast carcinomas.
In the present study, the age group ranged from 25 years to 92 years with mean age of 51.68 years, which with up to 10 years follow-up. They found lymphocyte infiltrate (LI) positively correlated to axillary lymph node status, tumour diameter and histomorphological variables.
Multivariate analysis showed that LI was independently related to axillary lymph node status and was able to predict recurrence free survival as well as breast cancer related survival.
In conclusion, in the present study, there was a statistically significant correlation between Tumor size, pathological T stage, Grade of the tumor, Necrosis and inflammatory infiltrate with axillary Lymph node metastasis. increased tumor size, T stage, higher grade, presence of necrosis and low inflammatory infiltrate are associated with increased axillary Lymph node metastasis. Hence, These histopathological factors can be used as prognostic markers in patients with breast cancer in a resource limited setting.