Int J Biol Med Res.

2022 ;13(4):7503-7509
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Review article
Assessment Of Clinical & Morphological Prognostic Features On Mastectomy
Specimen
P. PATANGIAa*, N. N. RAIb
a
*Senior Resident, Department of Pathology, Government Medical College, Kota, Rajasthan. Pin code : 324005
b
Senior Professor, Department of Pathology, Government Medical College, Kota, Rajasthan. Pin code : 324005

ARTICLE INFO ABSTRACT

Keywords:
Objective: To assess clinical and morphological prognostic features of breast cancer, to evaluate
Breast Cancer
and determine the prognostic usefulness of Nottingham prognostic index(NPI) and its
Histopathological Stage
Lymph Nodes components. Methods: A prospective and retrospective study was conducted on 123
Nottingham Prognostic Index (NPI) consecutive modified radical mastectomy specimens received in our department during period
Tumor Size from January 2013 to June 2014 (retrospective and prospective study). We evaluated the
significance of the various prognostic features like age, stage at diagnosis, histopathological
grade, and number of axillary lymph nodes retrieved and involved. The Nottingham Prognostic
Index was also calculated Results: The age range was 20- 75 years with a mean (±SD) of 49
±11.5 years. Infiltrating duct carcinoma NOS (IDC NOS) was the most common type of
carcinoma breast seen in 86.2% and BR Grade 2 was seen in 85.7% patients. Maximum number
of cases (95.12%) had TNM stage II (47.15% ) and III (47.97%). Majority of cases i.e.47% were
classified under poor prognostic group with NPI Score more than 5.41. Conclusion: Based on
the findings of the present study it may be concluded that assessment of tumor size, histological
grade and lymph node involvement along with NPI Score are important determinants of breast
carcinoma prognostication and should be incorporated in planning therapy of patients with
breast carcinoma. The Nottingham grading system when adequately carried out provide a
simple, non-expensive, accurate and validated method for assessing patients prognosis

c
Copyright 2010 BioMedSciDirect Publications IJBMR - ISSN: 0976:6685. All rights reserved.

Introduction

Breast cancer is the most commonly occurring female
cancer in the world with a lifetime risk of up to 12%, a risk of
death of up to 5%[1] & with an age-standardized incidence rate
(ASR) of 39.0 per 100,000, which is more than double that of the
second ranked cancer (cervical cancer ASR=15.2 per 100,000?).
[2,3]
The most important morphologic prognostic factors in
invasive carcinoma of breast include size of the primary tumor,
microscopic grade, axillary lymph node metastases, blood and
lymph vessel emboli, tumor necrosis, skin invasion, and nipple
invasion. The prognostic factors are indicators of the inherent
aggressiveness of the tumor as well as of the extent of the disease
and based on these factors, treatment decisions are being taken
up by the clinicians. The three strongest prognostic determinants
in operable breast cancer are: lymph node status (LN), primary
tumor size and histologic grade. The prognostic variables
* Corresponding Author : Dr. Priyanka Patangia
Senior Resident
Department of Pathology, Government Medical College,
Kota, Rajasthan.Pin code : 324005,Mobile no.: 9461656729
Drpriyanka1406@gmail.com
c Copyright 2011. CurrentSciDirect Publications. IJBMR - All rights reserved.
provides the substantial information, which are useful in guiding
the oncologist in determining the choice of treatment for the
individual patient.
Tumor size correlates with prognosis, patient with small
tumor size have better survival than those with large tumors.[4]
Histological grading, when adequately carried out, provides a
simple, inexpensive, and highly accurate method for assessing
tumor biological characteristics and patient prognosis. This is of
particular importance for breast cancer patients in parts of the
world where access to new molecular technology is not currently
available. The assessment of histological grade is an important
determinant of breast cancer prognostication and should be
incorporated in staging systems and in algorithms to define
therapy for patients with breast cancer. The pathologic
characteristics of the tumor also have prognostic significance,
certain subtypes such as tubular, mucinous, and medullary have a
more favourable prognosis than unspecified breast cancer.[5-7]
The Nottingham Prognostic Index (NPI) [8] was constructed for
patients with primary, operable breast cancer which was used for
prognostic stratification of patients. It comprises of 3 strong
predictors of prognosis grade, number of LN and size of tumor.
 P. PATANGIA and N. N. RAI /Int J Biol Med Res.13(4):7503-7509
7504

The NPI not only predicts prognosis with a level of accuracy
but also help to distinguish groups of patients suitable for different
forms of therapy.[4]
The purpose of this study is to study the prevalence of
various clinical and morphological features in patients having
mastectomy for breast cancer, their role in prognostication and
guiding clinicians for therapy and review the relative importance
of various prognostic and predictive factors.
MATERIAL & METHOD
Source of Data :
All the modified radical mastectomy (MRM) specimens
received in histopathology section during the period from January
2013 to June 2014 (retrospective and prospective study). A total of
122 cases with 123 mastectomy specimens were included in the
present study.
Infiltrating duct carcinoma NOS (IDC NOS) (Figure 1,2) was the
most common type of carcinoma breast seen in 86.2% patients
followed by infiltrating lobular carcinoma(Figure 3) (Table 3). In
present study maximum number of patients were having BR
Grade 2(Table 4). In maximum number 63% of cases resected
margins were negative for tumor (Table 5). (Figure 7)
In present study maximum number of patients i.e. 56.1%
had T2 stage at presentation; N1 stage for lymph node was more
common (33.3%) (figure ). Only 2 cases had M1 stage with distant
metastasis (Table 6). Maximum number of cases (95.12%) were in
TNM stage II (47.15% ) and III (47.97%). NPI score was
calculated for 119 cases (Table 7). Maximum number of cases
i.e.47% were classified under poor prognostic group with NPI
Score more than 5.41 (Table 8).

Methods of Collection of Data:

Clinical data of retrospective cases were obtained from the
case files retrieved from the Medical Records and requisition
forms received with the MRM specimen in the department. In
prospective cases the mastectomy specimen received in
Department of pathology were included. Specimens were sliced at
1cm thickness and fixed in 10% buffered formalin for at least 24
hours before giving sections. The specimens were then examined
for gross details like nipple, areola and skin, size of growth, its cut
surface, type of tumor margin, margin of resection and number of
lymph nodes in axillary tail, their size and cut surface. The sections
were given from all representative areas. They were processed
routinely in automated tissue processor followed by paraffin
embedding and block formation. Then 3 to 5 micron thick sections
were made from paraffin embedded blocks. These sections were
routinely stained with Haematoxylin and Eosin followed by
mounting. Finally slides were examined microscopically.

TNM staging was done based on tumor size, node positivity

and distant metastasis. NPI score was calculated using 3
parameters: size, positive LN and BR-grade.

Inclusion Criteria :
All modified radical mastectomy specimen with axillary
dissection received in the department irrespective of age were
included in the study.

Exclusion Criteria:
1). History of previous lumpectomy ;
2). Patient who had taken preoperative chemotherapy ;
3). Conservative surgery of breast ;
4). Biopsy samples of recurrent cases.
The data was analysed using percentage while continuous data
was expressed as Mean ± SD.

RESULTS

A total of 123 cases were included in the study . The age of

patients in this study ranges from 20- 75 years with a mean (±SD)
of 49 ±11.5 years(Table 1). In the present study 98.4% cases had
unilateral involvement by carcinoma breast while only 1.6%
(n=2) were bilateral. Most of the patients in present study
presented with lump breast in upper outer quadrant (48%). In this
study majority of patients i.e 49.6 % had tumor size ranging
between 2-5 cm which was followed by patients with tumor size
>5 cm (30.9%) and <2 cm (19.5 %) (Table 2)
 P. PATANGIA and N. N. RAI /Int J Biol Med Res.13(4):7503-7509
7505

Table. 4. Nottingham Modification of Scarff-Bloom

Richardson Grading in Carcinoma Breast

Figure 1. IDC NOS BR Grade 3 with Comedopattern in intraductal

component (A);marked Nuclear Pleomorphism and Mitosis(B)
(H&E 200X & 400X)
 P. PATANGIA and N. N. RAI /Int J Biol Med Res.13(4):7503-7509
7506

Figure 2. Infiltrating Duct Carcinoma BR Grade 2 showing Figure 5.. Apocrine carcinoma showing Muscle
nuclear pleomorphism and mitosis (H&E 400X) Invasion (H&E 200X)

Figure 6. Tumor involving deepest resected margin

Figure 3. Infiltrating Lobular Carcinoma (Indian File ( H & E 1 0 0 X )
Pattern) (H&E 200X)

Figure 7. Lymph Node Metastasis showing capsule,

lymphoid follicle and tumor cells (H&E 100X)
Figure 4. Medullary Carcinoma showing pleomorphism
and lymphocytic infiltration (H&E 200X)
 P. PATANGIA and N. N. RAI /Int J Biol Med Res.13(4):7503-7509
7507
DISCUSSION
The present study was done over a period of one and a half
year (January 2013 to June 2014) which included 122 cases of
carcinoma breast who underwent modified radical mastectomy.
Male breast cancer is extremely rare, accounting less than 1% of all
breast cancers, and less than 1% of all cancer deaths in men.
In the present study 99% patients were females and the males
accounted for only 1% of the primary invasive breast carcinoma
diagnosed. Many population based descriptive studies held
internationally such as in US[9], Israel [10], Scandinavia[11],
Central Italy[12], Iceland[13] reported comparable findings with
respect to male breast cancer incidence <1%.
Age of the cancer patient is an important factor both for
occurrence and management of the cases. It is the strongest risk
factor for breast cancer after gender. Indian women are prone to
develop breast cancer at earlier age than their western
counterparts and it peaks from 45-50 years in India. In the present
study, mean age of presentation of patients with breast cancer was
49 ± 11.5 years. The age range was 20 – 75 years with maximum
number of patients in age group 41-50 years (34.4 %) followed by
31-40 years (25.41%). Our results were comparable to studies
done in south India [14,15] The results of present study were also
comparable to the various studies on breast cancer done in other
countries.[16-20] Our results for mean age were lower than a
report from Spain [21] which showed mean age 59±13 years.
In the present study left breast cancer (54.1%) outnumbered
the right breast cancer (44.3%). This results correlated with a
study from south India.[15] Our result were also supported by
Ekanem and Aligbe's report.[22] In contrast studies like Adeniji
KA et al.[23] had shown that breast cancer is occurring more
frequently in the right than the left.
Breast cancer usually presents with a unilateral single hard
lump as is evident in the present study with occurrence of
bilaterality in only 2 out of total 122 cases which is 1.6% . Bilateral
cases reported in some studies were 0.88% [24] and 3% .[23]
In present study 48% patients had growth in upper outer
quadrant which was followed by upper inner quadrant in 20%
cases. The present study has confirmed previously reported
findings that the distribution of breast cancer is not even
throughout the breast but is higher in the Upper outer quadrant.
Our results were in concordance with various studies in India [25]
and other countries like Great Britain[26],the West Indes[27] and
Italy,[28] and irrespective of race within any one country.[29]
Conservative nature of our society and lack of awareness play
a role in the advanced stage of presentation at the time of
diagnosis. Various studies have shown that the gross size of tumor
is one of the most significant prognostic factors in breast
carcinoma and there is increased incidence of axillary lymph node
metastases and decreased survival with increasing size of the
tumor.[30,31]
In the present study mean tumor size was 4.6 ± 2.5 cm and was
ranging from 0.5 to 13 cm in size. Our results were almost similar
to Sharif MA et al [32] (4.4 cm). Lower results for mean tumor size
were reported by Albegeria et al.(3.11 ± 2.00 cm). [21] Majority of
cases in our study had tumor size ranging between 2-5 cm
(49.6%) which was comparable to Sharif MA et al.[32]and
Albegeria et al.[21] But various studies in developing countries
like Pakistan[33,34]showed a tumor size > 5 cm in majority of
cases. In other Muslim countries like Indonesia and Jordan, the
mean tumour size reported was between 2-5 cm by Arryandono et
al.[19] and 5 cm by Almasri et al.[35] respectively.
Histological typing has been proved to be an important
prognostic factor. Patients with Infiltrating duct carcinoma (IDC-
NOS) (Figure 1,2) have a poor survival compared to other
types.(36) In the present study the commonest histological
subtype was infiltrating duct carcinoma (86%) followed by
infiltrating lobular carcinoma (4.9%) (Figure 3). The special
histological types were diagnosed in 9% of patients comprising
medullary carcinoma (Figure 4) in 2.4% , apocrine carcinoma
(Figure 5) in 1.6 %, tubular carcinoma in 0.8%, intracystic
papillary carcinoma in 0.8%, IDC-ILC in 0.8%, DCIS in 1.6%, LCIS in
0.8% of cases. Our results were supported by Chandrika Rao et
al.[14] with Infiltrating ductal carcinoma in 88%. This
presentation is similar to earlier local studies by Malik et al.,[37]
Siddiqui et al.[34] and Wahid et al. [33]
Histologic grade has also been found to be useful predictor of
prognosis in patients with different stages of disease.[38] Higher
tumour grade is associated with poor prognosis. Subramaniam
Sivakumar et al.,[15] Siddiqui et al.[34] and Sharif MA et al [32]
showed majority of cases in grade 2 which is in consonance with
the present study where grade 2 tumours constituted the highest
number of cases at 85.7% followed by grade III (10.1%) and grade
I (4.2%). In contrast to this study high grade tumor i.e. grade III
was more common according to reports by Chandrika Rao et
al.,[14] Malik et al. [37] and Albegeria et al. [21] (Figure 2)
The status of resected margins and the definition of a positive
or close surgical margin following surgical therapy for breast
cancer has been a subject of substantial debate.[39,40] In this
study only 15 (12%) patients were positive for tumor at deepest
resected margins which was comparable to some study (Figure
6). [41] Only a single case had muscle invasion in this study.
The present study showed maximum number of cases in pT2 stage
(56.1%) which was followed by pT3 (26%) and only 9.8% and
8.1% cases were seen in pT1 and pT4 stage respectively. A study
from Pakistan [42] showed comparable results with pT2 seen in
maximum number of patients (44.16%) followed by pT3
(41.66%). Similar results were also reported by several studies
with pT2 being the most common stage.[21,43] These results
show that when large majority of our patients seek medical
attention for the first time they had tumors of large size.
The positivity of axillary lymph nodes for metastases is one of
the most important prognostic parameters in carcinoma breast
[44] with sharp differences in survival rates between those with
negative and positive nodes. Patients with increased number of
metastatic lymph nodes represent a higher stage of presentation.
Axillary lymph nodes were positive in 86 out of 123 cases (69.9%),
while 37 (30.1%) cases were negative for metastasis. (Figure 7)
Our results were almost similar to Chandrika Rao et al. [14]
Earlier, Malik et al. [37] had reported 74% cases with lymph node
metastasis in their study out of which 30% had more than 3
positive lymph nodes. Arryandono et al. [19] reported 38.3% and
Sharif MA et al.[32] 46% patients with more than 3 positive lymph
nodes.
 P. PATANGIA and N. N. RAI /Int J Biol Med Res.13(4):7503-7509
Among cases with positive lymph nodes 33.3% were pN1a
(metastasis in 1-3 axillary lymph nodes), 25.2% were pN2a
(metastasis in 4-9 axillary lymph nodes) and 11.4% were pN3
(metastasis in ≥10 axillary lymph nodes). Our results were
comparable to a study done in Pakistan by Ahmad et al [42]
showing maximum number of cases in pN1a (27.1%) and pN2a
(24.3%). These results shows that most of the patients axillary
lymph nodes are positive for metastatic tumor when they seek
first medical attention and majority being pN2a and pN3a.
Out of 123 cases only 2 (1.6%) patients had distant metastasis
with M1 stage. In the present study 47.97% cases were in stage III
(IIIA-30.1%; IIIB-7.3%; IIIC-10.6%), 47.15% in stage II (IIA-
20.3%; IIB-26.8%). Maximum number of cases were in stage IIIA
this was lower than results of a study done in south India [15] on
50 cases showing 70% cases in stage IIB.
The presence of lymphocytic infiltration and desmoplastic
reactions are being assessed as potential prognostic indicators in
breast cancer. In the present study lymphocytic infiltration was
seen in 30.1% of the cases showing association with good
prognosis. A study showed that IDC grade 3 with prominent
inflammation showed a better prognosis than IDC grade 3
without prominent inflammation.(45) The tumours containing
dense collagenous stroma, and presumably having a low
cellularity and a worse outcome. In the present study 17.9%
patients had stromal desmoplastic reaction which is a poor
prognostic factor as noted by Parham DM et al. [46] and Hamlin
and Alderson et al. [47]
Breast carcinomas in which invasion of the overlying skin has
occurred are associated with a decreased survival rate. [48] In the
present study 7.3% cases showed skin infiltration which is
indicating a poor prognosis.
The Nottingham prognostic index (NPI) is an important
prognostic determinant following surgery in breast cancer. NPI
has been widely adopted as a prognostic tool in breast cancer. [8]
Its usefulness and utility in predicting outcome in treated patients
was proved by few studies. [49,50] It is calculated using three
pathological criteria: the size of the lesion; the number of involved
lymph nodes; and the grade of the tumour.
In the present study, 47 % cases were in poor prognostic category
followed by 26.9 % and 26.1% in good and moderate prognostic
categories respectively. Our results were supported by Hamza et al
[51] with poor NPI 48.0% of patients. But were in contrast to
Subramaniam Sivakumar et al.[15] and Lokuhetty MD et al. [20]
who had 50% and 53.6% patients respectively in the moderate
prognosis category with NPI scores in between 3.4 – 5.4.
Histological grading is an important determinant of breast cancer
prognostication and should be incorporated in algorithms to
define therapy in patients with breast cancer.(52) Tumor size and
lymph node involvement along with NPI Score are also the
important determinants of breast carcinoma prognostication.
The present study demonstrated the meticulous implementation
and application of NPI in stratifying patients in various prognostic
groups. It also provides simple, inexpensive, accurate and
validated method for assessing the prognosis in patients with
primary epithelial breast malignancy.
7508
CONCLUSION
Based on the findings of the present study it may be concluded
that assessment of tumor size, histological grade and lymph node
involvement along with NPI Score are important determinants of
breast carcinoma prognostication and should be incorporated in
planning therapy of patients with breast carcinoma. The
Nottingham grading system when adequately carried out provide
a simple, non-expensive, accurate and validated method for
assessing patients prognosis.
LIMITATIONS OF THE STUDY
This study did not cover hormonal receptors determination
i.e. estrogen and progesterone receptors due to lack of reagents at
our histopathology laboratory, the funding for the dissertation
research is not enough to cover the costs for these reagents which
are very expensive. Long term survival could not be studied
because of time bound nature of the study.
REFERENCES
1. Parkin DM, Bray F, Ferlay J et al (2005). CA Cancer J Clin. Global cancer
statistics, 2002. ; 55: 74–108.
2. Ferlay J BF, Pisani P, Parkin DM. GLOBOCAN 2000: Cancer Incidence,
Mortality and Prevalence Worldwide, Version 1.0. IARC CancerBase No. 5.
2001. Lyon, 2001.
3. Ferlay J SH BFFDMCaPD. GLOBOCAN 2008 v1.2 Cancer Incidence and
Mortality Worldwide. IARC Cancer Base No. 10. [Internet]. 2010 [cited 2011
October 25, 2011].
4. Ellis IO, Pinder SE and Lee AHS. Breast Pathology. In Diagnostic
Histopathology of Tumours Third Edition. Ed. Fletcher CDM. Churchill
Livingstone Elsevier, 2007.
5. Carstens PH, Greenberg RA, Francis D et al. Tubular carcinoma of the breast.
A long term follow-up. Histopathol. 1985; 99 :271-280.
6. Clayton F. Pure mucinous carcinomas of the breast: morphologic features
and prognostic correlates. Hum Pathol. 1986; 17:34-38.
7. Ridolfi RL, Rosen PP, Port A et al. Medullary carcinoma of the breast: a
clinico-pathologic study with a ten year follow-up. Cancer. 1977; 40:1365-
1385.
8. Galea MH, Blamely RW, Elston CE, Ellis IO. The Nottingham Prognostic Index
in Primary breast cancer. Breast Cancer Res Treat 1992; 22:207-19.
9. American Cancer Society. Breast Cancer Facts & Figures. 2011-2012.
10. Steinitz R, Katz L, Ben-Hur M. Male breast cancer in Israel: selected
epidemiological aspects. Isr J Med Sci. 1981;17: 816-21.
11. Ewertz, M., Holmberg, L., Karjalainen, S., Tretli, S. and Adami, H.-O., Incidence
of male breast cancer in scandinavia, 1943–1982. Int. J. Cancer. 1989; 43:
27–31.
12. Crocetti E, Buiatti E. Male breast cancer: incidence, mortality and survival
rates from an Italian population-based series. Eur J Cancer.
1994;30A(11):1732–1733.
13. Jonasson JG, Agnarsson BA, Thorlacius S, Eyfjord JE, Tulinius H. Male breast
cancer in Iceland. Int J Cancer. 1996 ;65(4):446-9.
14. Rao C, Shetty J, Prasad KH. Immunohistochemical Profile and Morphology in
Triple – Negative Breast Cancers. Journal of Clinical and Diagnostic
Research : JCDR. 2013;7(7):1361-1365.
15. Sivakumar S , Devaraj SN. Histopathology of breast cancer patients in
Tamilnadu: Tumor grading and staging through NPI Journal of Pharmacy
Research. 2011;4(10):3635-3637.
16. Thike AA, Chng MJ, Fook-Chong S, Tan PH. Immunohistochemical expression
of hormone receptors in invasive breast carcinoma: correlation of results of
H-scores with pathological parameters. Pathology. 2001;33:21-5.
 P. PATANGIA and N. N. RAI /Int J Biol Med Res.13(4):7503-7509
7509
17. Lertsanguansinchai P, Chottetanaprasith T, Chatamra K, Sampatanukul P,
Wannakrairot P, Rojpornpradit P, et al. Estrogen and progesterone receptors
status in Thai female breast cancer patients: an analysis of 399 cases at King
Chulalongkorn Memorial Hospital. J Med Assoc.2002;85:193-202.
18. Malik IA. Clinico-pathological features of breast cancer in Pakistan. J Pak
Med Assoc. 2002; 52:100-4.
19. Aryandono T, Harijadi, Ghozali A. Correlation of clinical, pathological
status,hormone receptor and c-erbB-2 oncoprotein in breast cancer
patients. Ann Oncol. 2005; 16:1755-61.
20. Lokuhetty MD, Ranaweera GG, Wijeratne MD, Wickramasinghe KH,
Sheriffdeen AH. Profile of breast cancer in a group of women in a developing
country in South Asia: is there a difference? World J Surg. 2009
Mar;33(3):455-9.
21. Albergaria A, Ricardo S, Milanezi F. Carneiro V, Amendoeira I, Vieira D,
Cameselle-Teijeiro J, Schmitt F. Nottingham Prognostic Index in triple-
negative breast cancer: a reliable prognostic tool? BMC Cancer.
2011;11:299-325.
22. Ekanem VJ and Aligbe JU, Histopathological types of breast cancer in
Nigerian women: a 12-year review (1993-2004), Afr J Reprod Health. 10
(2006):71-75.
23. Monsour EG, Kavdin PM, Dressler L: Prognostic factors in early breast
carcinoma. Cancer. 1994; 74:381-400.
24. Saxena S., Rekhi B., Bansal A., Bagga A., Chintamani, Murthy NS.Clinico-
morphological patterns of breast cancer including family history in a New
Delhi hospital, India-A cross-sectional study. World J Surg Oncol. 2005, 3: 67.
25. Hussain MA, Sawkat A, Tyagi SP and Reza H: Incidence of cancer breast at
Aligarh. J Indian Med Assoc. 1994; 92 : 296-297.
26. Darbre PD: Recorded quadrant incidence of female breast cancer in Great
Britain suggests a disproportionate increase in the upper outer quadrant of
the breast. Anticancer Res. 2005; May-Jun 25(3c):2543-50.
27. Raju GC and Naraynsingh V: Breast cancer in West Indian women in
Trinidad. Trop Geogr Med. 41 : 257-260; 1989.
28. Azzena A, Zen T, Ferrara A, Brunetti V, Vasile C and Marchetti M: Risk factors
for breast cancer. Eur J Gynaecol Oncol. 15: 386-392, 1994.
29. Patterson SK, Helvie MA, Joynt LK, Roubidoux MA and Strawderman M:
Mammographic appearance of breast cancer in African-American women:
report of 100 consecutive cases. Acad Radiol. 1998; 5: 2-8.
30. Russo J, Frederick J, Ownby HE, et al. Predictors of recurrence and survival of
patients with breast cancer. Am J Clin Pathol. 1987; 88:123–131.
31. Carter CL, Allen C, Henson DE. Relation of tumor size, lymph node status, and
survival in 24,740 breast cancer cases. Cancer. 1989;63:181-7.
32. Sharif MA, Mamoon N, Mushtaq S, Khadim MT. Morphological profile and
association of Her-2/neu with prognostic markers in breast carcinoma in
Northern Pakistan. J Coll Physicians Surg Pak. 2009; 19:99-103.
33. Wahid Y, Mushtaq S, Khan AH, Malik IA, Mamoon N. A morphological study of
prognostic features in carcinoma breast. Pak J Pathol. 1998; 9:9-13.
34. Siddiqui MS, Kayani N, Pervez S, Muzaffar S, Aziz SA, Setna Z. Breast diseases:
histopathological analysis of 3279 cases at a tertiary care centre in Pakistan.
J Pak Med Assoc. 2003: 53; 94-7.
35. Almasri NM, Al-Hamad M. Immunohistochemical evaluation of human
epidermal growth factor receptor 2 and estrogen and progesterone
receptors in breast carcinoma in Jordan. Breast Cancer Res. 2005: 7; 598-
604.
36. Rao DN, Dinshaw KA: Epidemiological review: In Risk factors and survival
rates. Hospital Cancer Registry. Division of Epidemiology and Biostatistics.
Tata Memorial Hospital Mumbai. 1999:1-7.
37. Malik IA, Mushtaq S, Khan AH, Mamoon N, Afzal S, Jamal S, et al. A
morphological study of 280 mastectomy specimens of breast carcinoma. Pak
J Pathol. 1994; 5:5-8.
38. Hopton DS, Thorogood J, Clayden AD. Histological grading of breast cancer:
significance of grade on recurrence and mortality. Eur J Surg Oncol
1989;15:25-31.
39. Meric F, Mirza NQ, Vlastos G, et al. Positive surgical margins and ipsilateral
breast tumor recurrence predict disease-specific survival after breast-
conserving therapy. Cancer. 97(4):926–33.
40. Park CC, Mitsumori M, Nixon A, et al. Outcome at 8 years after breast-
conserving surgery and radiation therapy for invasive breast cancer:
influence of margin status and systemic therapy on local recurrence. J Clin
Oncol. 2000;18(8):1668–75.
41. Yu J, Mushawah FA, Taylor ME, et al. Compromised Margins Following
Mastectomy For Stage I - Iii Invasive Breast Cancer. The Journal of surgical
research. 2012;177(1):102-108.
42. Ahmad Z, Khurshid A, Qureshi A, Idress R, Asghar N, Kayani N. Breast
carcinoma grading, estimation of tumor size, axillary lymph node status,
staging, and Nottingham prognostic index scoring on mastectomy
specimens. Indian J Pathol Microbiol. 2009;52(4):477-81.
43. Pătrană N, Simionescu C, Georgescu C, Fota G, Muntean M.
Histopathological Prognostic Factors Evaluation in Invasive Mammary
Carcinoma Current Health Sciences Journal Vol. 35, No. 2, 2009.
44. Hutter RVP. The influence of pathologic factors on breast cancer
management. Cancer. 1980;46:961-76.
45. Rakha EA, Aleskandarany M, El-Sayed ME, Blamey RW, Elston CW, Ellis IO,
Lee AH. The prognostic significance of inflammation and medullary
histological type in invasive carcinoma of the breast. Eur J Cancer. 2009
Jul;45(10):1780-7.
46. Parham DM, Robertson AJ, and Brown RA. Morphometric analysis of breast
carcinoma: association with survival. J Clin Pathol. 1988 Feb; 41(2):
173–177.
47. Hamlin IME. Possible host resistance in carcinoma of breast: a histological
study. Br J Cancer. 1968;22:383-401.
48. Sears HF, Janus C, Levy W, Hopson R, Creech R, Grotzinger P: Breast cancer
without axillary metastases. Are there high-risk biologic subpopulations?
Cancer. 1982; 50:1820-1827.
49. D'Eredita' G, Giardina C, Martellotta M, Natale T, Ferrarese F. Prognostic
factors in breast cancer: the predictive value of the Nottingham Prognostic
Index in patients with a long term follow up that were treated in a single
institution. European Journal of Cancer.2001;37:(5):591-6.
50. Lee AH, Ellis IO. The Nottingham prognostic index for invasive carcinoma of
the breast. Pathol Oncol Res. 2008;14(2):113-5.
51. Aamir A. Hamza, Saadeldin A. Idris, Mohyad B. Al-Haj, Amal A. Mohammed.
Prognostication of Breast Cancer Using Nottingham Prognostic Index in
Sudanese Patients. International Journal of Public Health Research. 2014;
2(1): 1-5.
52. Rakha EA, Reis-Filho JS, Baehner F, Dabbs DJ, Decker T, Eusebi V, et al. Breast
cancer prognostic classification in the molecular era: the role of histological
grade. Breast Cancer Res. 2010;12(4):207.
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