Data were analyzed using Statistical Package for Social Science (SPSS) software version 20 (IBM Corp, Armonk, NY, USA).

DPAS scores are expressed as mean ± SD and the 95% confidence intervals (CIs) of the calculated means. The χ2 test was used to compare the differences in categorical variables between the different tests. Relationships between variables were analyzed using Pearson’s correlation analysis. p<0.05 was considered statistically significant. Chi-square analysis was used to obtain all the p values in this study24, 25, 26.

All participants were fully informed about the aims and outcomes of the study, and they were asked to sign a written consent form before the specimen was obtained by the pathologist in-charge. The results were presented to and discussed with the patients. Ethical approval was obtained from the National Ribat University Ethical Research Committee in accordance with the Declaration of Helsinki principles, and consent was obtained from all patients before sample and data collection. The patient’s information was highly secured and not used for purposes other than scientific inquiry. Risk and benefits for the patients from the outcomes of the research was ensured.

Approval reference number: NRU-REC/05-021./07

Approval date: 26/5/2021

Table 1

Age group	Cytological diagnosis
	Benign lump	Inflammation	Suspicious of malignancy	Malignant	Total
	N (%)	N (%)	N (%)	N (%)	N (%)	Chi	p
< 15 years	2 (7.4%)	10 (8.9%)	1 (5.9%)	1 (2.2%)	14 (7.0%)	27.2	0.011*
15 - 25 years	4 (14.8%)	37 (33.0%)	3 (17.6%)	6 (13.3%)	50 (24.9%)
26 - 35 years	10 (37.0%)	39 (24.8%)	6 (35.3%)	23 (51.1%)	78 (38.8%)
36 - 45 years	10 (37.0%)	14 (12.5%)	2 (11.8%)	6 (13.3%)	32 (15.9%)
> 45 years	1 (3.7%)	12 (10.7%)	5 (29.4%)	9 (20.0%)	27 (13.4%)
Total	27 (100.0%)	112 (100.0%)	17 (100.0%)	45 (100.0%)	201 (100.0%)

* Significant (P value < 0.05)

Table 2

	Cytological diagnosis
	Benign lump	Inflammation	Suspicious of malignancy	Malignant	Total	Chi	P
Co-morbidity	N (%)	N (%)	N (%)	N (%)	N (%)
None	6 (22.2%)	32 (28.6%)	2 (11.8%)	3 (6.7%)	43 (21.4%)	22.4	0.010*
Diabetes	6 (22.2%)	34 (30.4%)	6 (35.3%)	22 (48.9%)	68 (33.8%)
Hypertension	10 (37.0%)	39 (34.8%)	9 (52.9%)	19 (42.2%)	77 (38.3%)
Anemia	5 (18.5%)	7 (6.3%)	0 (0.0%)	1 (2.2%)	13 (6.5%)
Total	27 (100.0%)	112 (100.0%)	17 (100.0%)	45 (100.0%)	201 (100.0%)

* Significant (P value < 0.05)

Table 3

Family history of breast cancer	Cytological diagnosis
	Benign lump	Inflammation	Suspicious of malignancy	Malignant	Total
	N (%)	N (%)	N (%)	N (%)	N (%)	Chi	P
Yes	1 (3.7%)	4 (3.6%)	10 (58.8%)	43 (95.6%)	58 (28.9%)	59.1	0.001*
No	26 (96.3%)	108 (96.4%)	7 (41.2%)	2 (4.4%)	143 (71.1%)
Total	27 (100.0%)	112 (100.0%)	17 (100.0%)	45 (100.0%)	201 (100.0%)
Affected family member
Mother	1 (100.0%)	3 (75.0%)	2 (20.0%)	21 (48.8%)	27 (46.6%)	5.9	0.210**
Sister	0 (0.0%)	1 (25.0%)	8 (80.0%)	21 (48.8%)	30 (51.7%)
Aunt (father side)	0 (0.0%)	0 (0.0%)	0 (0.0%)	1 (2.4%)	1 (1.7%)
Total	1 (100.0%)	4 (100.0)	10 (100.0%)	43 (100.0%)	58 (100.0%)
Consanguinity
First degree	1 (100.0%)	4 (100.0)	10 (100.0%)	42 (97.7%)	57 (98.3%)	3.0	0.734**
Second degree	0 (0.0%)	0 (0.0%)	0 (0.0%)	1 (102%)	1 (1.7%)
Total	1 (100.0%)	4 (100.0)	10 (100.0%)	43 (100.0%)	58 (100.0%)

* Significant (P value < 0.05)

Table 4

DPAS score	Frequency N	Percentage %
± Negative	28	13.9
+	114	56.7
++	27	13.4
+++	32	15.9
Total	201	100.0

Table 5

Cytological assessment	DPAS score
	± Negative	+	++	+++	Total
	N (%)	N (%)	N (%)	N (%)	N (%)
Benign lump	27 (96.4%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	27 (13.4%)
Inflammation	1 (3.6%)	110 (96.5%)	1 (3.7%)	0 (0.0%)	112 (55.7%)
Suspicious of malignancy	0 (0.0%)	4 (3.5%)	12 (44.4%)	1 (3.1%)	17 (8.5%)
Malignant	0 (0.0%)	0 (0.0%)	14 (51.9%)	31 (96.9%)	45 (22.4%)
Total	28 (100.0%)	114 (100.0%)	27 (100.0%)	32 (100.0%)	201 (100.0%)

Chi squire 23.18; P value 0.017

Table 6

AC grade	N	%
AC2	30	14.9
AC3	112	55.7
AC4	27	13.4
AC5	32	15.9
Total	201	100.0

Table 7

Cytological assessment	AC grade
	AC2	AC3	AC4	AC5	Total
	N (%)	N (%)	N (%)	N (%)	N (%)
Benign lump	27 (90.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	27 (13.4%)
Inflammation	3 (10.0%)	108 (96.4%)	1 (3.7%)	0 (0.0%)	112 (55.7%)
Suspicious of malignancy	0 (0.0%)	4 (3.6%)	12 (44.4%)	1 (3.1%)	17 (8.5%)
Malignant	0 (0.0%)	0 (0.0%)	14 (51.9%)	31 (96.9%)	45 (22.4%)
Total	30 (100.0%)	112 (100.0%)	27 (100.0%)	32 (100.0%)	201 (100.0%)

Chi squire 29.41; P value 0.014

Figure 1

Figure 2

In this study, the mean age was 33.6 ± 5.9 years, and the most prevalent age group was 26 – 35 years (78, 38.8%). There was a significant association between age group and malignant findings (P = 0.011).

In the medical history, 77 (38.3%) patients had hypertension, 68 (33.8%) had diabetes, and 13 (6.5%) had anemia. It should be noted that 43 (21.4%) of the women had no medical history. There was a significant association between co-morbidity and malignancy (P = 0.010).

Family history of breast cancer was reported in 58 (28.9%) women: 30 (51.7%) reported breast cancer in a sister, 27 (46.6%) in their mother, and 1 (1.7%) in an aunt from the father’s side. There was a significant association between family history of breast cancer and malignant findings (P = 0.001); however, there was no significant correlation between malignancy and having an affected family member with breast cancer (P = 0.210) or consanguinity (relative degree) (P = 0.734).

The DPAS scores were: negative (±) (28, 13.9%), one plus (+) (114, 56.7%), two plus (++) (27, 13.4%), and three plus (+++) (32, 15.9%).

There was a significant association between DPAS score and cytological assessment category; malignant findings were significantly associated with a DPAS score of three plus (+++) (P = 0.017).

Of the 201 women, the AC grades were: AC2 (30, 14.9%), AC3 (112, 55.7%), AC4 (27, 13.4%), and AC5 (32, 15.9%).

Comparison of the AC grades among the studied women according to the International Academy of Cytology (IAC) system with their cytology results revealed that AC2 was observed in 27 (90%) women in the benign group and 3 (10%) women in inflammation group, AC3 was observed in 108 (96.4%) women in the inflammation group and 4 (3.6%) women in the suspicious of malignancy group, AC4 was observed in 14 (51.9%) women in the malignant group and 12 (44.4%) women in the suspicious of malignancy group, and AC5 was observed in 31 (96.6%) women in the malignant group and 1 (3.1%) woman in the suspicious of malignancy group.

We upgraded 11 cases from suspicious of malignancy in AC4 to malignant in AC5. Furthermore, there was a significant association between AC grade and cytology result; malignant findings were significantly associated with AC5 (P = 0.014).

The age of the patients ranged from younger than 15 years to older than 45 years. The mean age was 33.6 ± 5.9 years, and the most prevalent age group was 26–35 years (78, 38.8%).

Previous studies found the most prevalent age range to be between 30 and 60 years; however, other studies suggested that the increase in incidence was directly proportional to age, but that the disease was uncommon under 30 years old27. Patient age was associated with method of breast cancer detection28.

Regarding medical history, 77 (38.3%) women had hypertension, 68 (33.8%) had diabetes, and 13 (6.5%) had anemia. It should be noted that 43 (21.4%) of the women had no medical history.

In accordance with our findings, a meta-analysis study demonstrated that hypertension was associated with increased risk of breast cancer, especially among postmenopausal women29. Another study mentioned that some chronic conditions were considered risk factors for cancer, including as hypertension and diabetes30.

Family history of breast cancer was reported by 58 (28.9%) women; 30 (51.7%) reported it in a sister, 27 (46.6%) in their mother, and 1 (1.7%) in an aunt from the father’s side. There was a significant association between family history of breast cancer and malignant findings (P = 0.001).

In accordance with our findings Barnard et al. (2015) reported that the risk of developing breast cancer in those who had a family history of breast cancer was high, especially in those who had a first-degree relative with breast cancer31.

The DAPS scores were: negative (±) (28, 13.9%), one plus (+) (114, 56.7%), two plus (++) (27, 13.4%), and three plus (+++) (32, 15.9%).

Analysis of the DPAS scores versus the cytological categories (cytology results) revealed that negative score (±) was reported in 27 (96.4%) women in the benign group and 1 (3.6%) woman in the inflammation group, one plus score (+) was reported in 110 (96.5%) women in the inflammation group and 4 (3.5%) women in the suspicious of malignancy group, two plus score (++) was reported in 14 (51.9%) women in the malignant group and 12 (44.4%) women in the suspicious of malignancy group, and three plus score (+++) was reported in 31 (96.9%) women in the malignant group and 1 (3.1%) women in the suspicious of malignancy group. DPAS positivity (++, +++) was correlated with malignancy.

Eleven cases were reliably upgraded from suspicious of malignancy DPAS positivity two plus (++) to diagnostic of malignancy based on DPAS positivity three plus (+++). DPAS positivity in atypical cells in FNA aspirates may assist in upgrading from a suspicious to a malignant diagnostic result.

There was a significant association between DPAS score and cytological assessment category; malignant findings were significantly associated with DPAS score three plus (+++) (P = 0.017), which was in line with results obtained by Johnson and Wadehra21.

Intracytoplasmic PAS-D-positive globules may be helpful in differentiating between benign and malignant lesions of the breast; a higher grade of PAS-D positivity has been shown to correlate well with malignancy32.

The results of the previous study was in line with our findings. Our results revealed that 11 cases were reclassified from suspicious of malignancy to malignancy after using DPAS.

AC grades among the studied women according to IAC system were: AC2 (30, 14.9%), AC3 (112, 55.7%), AC4 (27, 13.4%), and AC5 (32, 15.9%). Furthermore, there was a significant association between AC grade and cytology results; malignant findings were significantly associated with AC5 (P = 0.014).

Our findings were in line with the reports of the IAC33 and Johnson and Wadehra21.

DPAS positivity (++, +++) was correlated with malignancy. Eleven cases were reliably upgraded from suspicious of malignancy DPAS positivity two plus (++) to final reports diagnostic of malignancy based on DPAS positivity three plus (+++). DPAS positivity within atypical cells in FNA aspirates may assist in upgrading lesions from suspicious of malignancy to a malignant diagnostic result. There was a significant association between DPAS score and cytological assessment category; malignant findings were significantly associated with DPAS score three plus (+++).

AC: Aspiration cytology, CIs: Confidence intervals, DCIS: Ductal carcinoma in situ, DPAS: Diastase-Resistant Periodic Acid Schiff, FNA: Fine-Needle Aspiration, H&E: Hematoxylin and Eosin, IAC: International Academy of Cytology, MGG: May Grunwald Giemsa, Pap: Papanicolaou

Thanks for all participants involved in this research.

AAI and AAM conceived the design and carried out the experiments. NAO obtained, analyzed and interpreted the data. NAO and EAA wrote and revised the manuscript. AAI provides financial support for all experiments. All authors have critically reviewed and approved the final draft and are responsible for the content and similarity index of the manuscript.

None.

Not applicable.

This study was conducted in accordance with the amended Declaration of Helsinki. The institutional review board approved the study, and all participants provided written informed consent.

Not applicable.

The authors declare that they have no competing interests.