research article preoperative peripheral blood count in...

Research ArticlePreoperative Peripheral Blood Count in Breast Carcinoma:Predictor of Prognosis or a Routine Test

Amrit Pal Singh Rana,1 Manjit Kaur,2 B. Zonunsanga,1

Arun Puri,2 and Amarjit Singh Kuka1

1Department of Surgery, GGS Medical College, Faridkot 151203, India2Department of Pathology, GGS Medical College, Faridkot 151203, India

Correspondence should be addressed to Amrit Pal Singh Rana; [email protected]

Received 25 July 2015; Revised 8 November 2015; Accepted 11 November 2015

Academic Editor: Vladimir F. Semiglazov

Copyright © 2015 Amrit Pal Singh Rana et al. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.

Background. Peripheral blood count is the first investigation to be done in every patient before surgery. As strong relationship existsbetween cancer and immune response of the body, clinical stage at presentation and altered hematological parameters can influencethe progression of cancer and vice versa. Settings and Design. It is a case control study of total 50 cases (35 cases of carcinomabreast and 15 cases of benign breast disease).Methods. A case control study was carried out; 35 cases of breast cancer patients weretaken prior to surgery and chemotherapy with 15 cases of benign breast disease as control. Clinical staging according to the tumor,node, and metastasis classification (TNMc) was done and was correlated with complete blood count (CBC). Results. All the cancerpatients were females with overall mean age of 47.96 ± 13.84 years. Amongst all altered blood parameters, correlation of absolutelymphocytic count (𝑝 value 0.001) with TNMc staging was found significant. Particularly, decrease in absolute leucocytic count wasobserved with increase in stage of breast carcinoma. Conclusions. The stage-specific mean values of absolute lymphocytic counts ofpreoperative breast cancer patients can be used as an economical tool to know the evolution of disease.

1. Introduction

Complete blood count especially lymphocytic count reflectsthe response of cellular immunity in a cancer patient.Any alteration in hematological parameters influences thedisease progression. Depending upon the clinical presen-tation (TNMc staging), response of various hematologicalparameters has been correlated and studied. Hemoglobin(Hb) and packed cell volume (PCV) are indirectly associatedwith increased risk of cardiac failure in cancer patients [1].Total leucocytic count (TLC), if elevated, predicts poorerprognosis [2]. The prognostic significance of neutrophils,lymphocytes, plasma cells, mean platelet volume (MPV),platelet/lymphocyte ratio, and neutrophil/lymphocyte ratiostudied in gastric cancer patients showed influence on overallsurvival [3].

So it is also important to study complete blood count inbreast carcinoma and its correlation with TNMc staging.

2. Methods

This was a case control study carried among the breast cancerpatients (35 cases) who have undergone breast surgeries at atertiary health care centre. Patients who had taken chemo-therapy were excluded. Breast cancer patients were stagedprior to surgery.The patients were staged clinically accordingto the tumor, node, and metastasis (TNM) classification.Stage I tumor is <2 cm in greatest dimension, with no nodalinvolvement and no metastasis. Stage II ranges from none-vident tumor to tumor >5 cm in greatest dimension witheither no nodal involvement ormetastases inmovable ipsilat-eral axillary lymph node(s) but no distant metastases. StageIII tumor size ranges from either not evident to tumor ofany size with direct extension to (a) chest wall or (b) skin,with no evidence of regional lymph nodemetastases ormeta-stases in ipsilateral infraclavicular lymph node(s) with orwithout axillary lymph node involvement or in clinically

Hindawi Publishing CorporationInternational Journal of Breast CancerVolume 2015, Article ID 964392, 5 pageshttp://dx.doi.org/10.1155/2015/964392

2 International Journal of Breast Cancer

Table 1: Age-wise distribution of cases in different stages of carcinoma and benign group.

Number of cases (total = 50) Percent of cases (%) within group Age (mean ± SD) Minimum age Maximum ageCarcinoma stage-wise (𝑛 = 35)

1 08.5 49.0 ± 2.8 47 512 34.2 45.8 ± 11.0 18 603 42.8 48.3 ± 14.3 15 754 14.2 52.5 ± 18.8 35 80

Benign group (𝑛 = 15) 30 35.4 ± 12.6 24 58

Table 2: Hb, RBC, and PCV parameters in relation to four stages of carcinoma and benign group.

Hb, RBC, and PCV parameters Carcinoma stage Benign group1 2 3 4

Hb (mean ± SD) 12.6 ± 1.48 10.4 ± 2.1 11.6 ± 1.35 12.2 ± 1.66 10.5 ± 1.65Minimum Hb 11.6 4.9 9.0 10.1 8.2Maximum Hb 13.7 13.5 14.1 14.3 13.2RBC (mean ± SD) 4.45 ± 0.02 4.16 ± 0.88 4.3 ± 0.44 4.5 ± 0.55 4.5 ± 0.62Minimum RBC 4.5 2.57 5.36 3.89 3.3Maximum RBC 4.6 5.97 3.36 5.31 5.6PCV (mean ± SD) 42.8 ± 3.39 33.6 ± 7.7 35.9 ± 3.6 38.8 ± 3.8 35.0 ± 5.5Minimum PCV 40.4 16.7 27.0 33.1 27.2Maximum PCV 45.2 42.7 42.4 43.5 44.0

apparent ipsilateral internal mammary lymph node(s) andin the presence of clinically evident lymph node metastasisin ipsilateral supraclavicular lymph node(s) with or withoutaxillary or internal mammary lymph node involvement.There is no distant metastasis. Stage IV shows involvementof distant metastases regardless of tumor or nodal status. Allpatients with a breast mass were carefully examined and themass was measured. The presence or absence of any signs oflocal advancement (inflammation, peau d’orange, ulceration,satellite nodules, direct chest wall involvement, mobile orfixed axillary nodes, and supraclavicular lymph node) wasnoted and recorded. Abdomen and spine were also examinedfor evidence of spread. CBC records were reevaluated for Hb,PCV, mean corpuscular volume (MCV), mean corpuscularhemoglobin (MCH), andmean corpuscular hemoglobin con-centration (MCHC), TLC, differential leucocytic count (DLC)with absolute counts, and platelet parameters and were com-pared with CBC records of 15 cases of benign breast disease.

3. Statistics

The results of 35 histologically diagnosed, prechemotherapybreast cancer patients were analyzed. Patients already onchemotherapy before presentation were excluded from thestudy. Data were analyzed using SPSS version 16.0. The des-criptive data were given as means ± SD. The Pearson chi-square test and analysis of variance were used for the ana-lytic assessment and the differences were considered to bestatistically significant and very significant when the 𝑝 valueobtained was <0.05, <0.002, respectively. Results were com-pared with findings of 15 samples of benign breast lesions.

4. Results

A total of 50 cases of breast disease were studied. Out of them,35 cases of breast carcinoma were analyzed. All the patientswere females with overall mean age of 47.96 ± 13.84 years(Table 1).

A total of 60.0% of the cases had Hb < 12mg% atpresentation. Using PCV > 38% as the cut-off, 62.9% of caseswere anaemic, while 37.1% had normal PCV. The minimumPCV for cases was 16.7%,maximumwas 45.2%, and themeanwas 35.87 ± 6.0%.The PCV was found not to be significantlyassociated with staging (𝑝 = 0.54). Also no significant corre-lation between PCV of the patients and the staging was notedon analysis of variance. Hb, RBC, and PCV parameters ofall the cases in the context of carcinoma staging and benigngroup are given in Table 2.

Red cell indices for different stages of carcinoma are givenin Table 3. The overall mean MCV, MCH, and MCHC ofcases of carcinoma were 89.98 ± 5.29 fl, 26.8 ± 0.90 g/L, and31.64 ± 0.84 g/L, respectively, with no significant correlationwith staging (𝑝 value 0.99, 𝑝 value 0.62, 𝑝 value 0.95, and 𝑝value 0.96, resp.).

While the meanWBC counts (TLC), absolute neutrophilcount (N), absolute lymphocytic count (L), absolute mono-cytic count (M), and absolute eosinophilic count (E) of caseswere 7.57 ± 1.0, 4.56 ± 8.8, 2.49 ± 1.2, 2.9 ± 1.4, and 1.34 ± 7.7,respectively (Table 4), the mean platelet count was 2.61 ±0.4 (Table 5). Very significant correlation of total leucocyticcount (𝑝 value 0.002) and lymphocytic count (𝑝 value 0.001)was noted. Significant correlation was observed in case ofmonocytes (𝑝 value 0.008).

International Journal of Breast Cancer 3

Table 3: Red cell indices in relation to four stages of carcinoma and benign group.

Red cell indices parameters Carcinoma stage Benign group1 2 3 4

MCV (mean ± SD) 93.6 ± 8.2 82.8 ± 11.7 84.2 ± 7.5 85.4 ± 2.5 79.5 ± 8.1MinimumMCV 87.8 62.1 65.6 81.9 63.0MaximumMCV 99.4 100.3 95.0 89.0 88.9MCH (mean ± SD) 27.6 ± 3.11 26.2 ± 4.3 26.78 ± 2.1 26.0 ± 0.7 26.2 ± 4.2MinimumMCH 25.4 18.3 22.0 26.0 18.0MaximumMCH 29.8 32.5 30.9 28.1 30.3MCHC (mean ± SD) 31.1 ± 3.95 30.5 ± 1.8 32.1 ± 2.1 31.8 ± 1.0 31.8 ± 1.9MinimumMCHC 28.3 26 25.0 30.5 28.0MaximumMCHC 33.9 32.6 34.1 32.9 34.0

Table 4: Relation of various leucocytic parameters with four stages of carcinoma and benign group.

Leucocytic parameters Carcinoma stage Benign group1 2 3 4

TLC (mean ± SD) 9.100 ± 2.998 8.619 ± 2.930 7.404 ± 1.686 6.222 ± 1.580 8.543 ± 2.400Minimum TLC 7.000 16.560 10.970 3.550 4.900Maximum TLC 11.240 5.200 4.630 7.670 14.200N (mean ± SD) 3.800 ± 0.325 5.829 ± 2.907 4.614 ± 1.209 4.454 ± 1.098 5.380 ± 1.760Minimum N 3.600 2.180 7.680 2.730 3.000Maximum N 4.060 14.170 2.850 5.500 9.200L (mean ± SD) 5.800 ± 3.676 2.289 ± 1.024 2.127 ± 0.641 1.379 ± 0.762 2.753 ± 0.656Minimum L 3.200 1.100 0.840 0.500 1.600Maximum L 8.400 4.200 3.500 2.277 3.800M (mean ± SD) 0.33 ± 0.25 0.33 ± 0.26 0.30 ± 0.23 0.20 ± 0.05 0.226 ± 0.209MinimumM 0.150 0.100 0.010 0.138 0.010MaximumM 0.510 1.106 1.106 0.260 0.650E (mean ± SD) 0.06 ± 0.04 0.12 ± 0.07 0.21 ± 0.15 0.10 ± 0.03 0.066 ± 0.066Minimum E 0.030 0.000 0.000 0.040 0.008Maximum E 0.100 0.250 0.550 0.138 0.200

Other parameters have not shown any significant corre-lation.

Benign group showed significant correlation of lympho-cytic count with clinical staging of carcinoma patients (𝑝value = 0). Other parameters showed no significant corre-lation.

5. Discussion

Breast cancer is the second most common carcinoma amongfemales with 99% female prevalence. In the present studyconducted, cases considered for analysis were found to be offemales only. As evidenced in a study conducted in the past,only one percent of breast cancer develops inmales. However,in a study done in Nigeria, 2.0% prevalence of breast cancerwas reported amongst male population. Although prevalenceof breast carcinoma is different in both males and females,prognosis is similar [4–6].

Breast carcinoma is the leading cause of death in womenwith more than 1,00,000 cases occurring annually [7]. Withthe advent of many new techniques, prognosis as well asprogression of cancer can be estimated. As routine blood

investigations are part and parcel of follow-up of carcinomapatients as well as first investigation being done prior tosurgery for carcinoma, it can help in the assessment of diseaseprogression. So it is important to make out that a completeblood cell count (CBC) being low cost, standardized, rou-tinely used tests can still offer useful information regardingthe behavior of different malignancies. In the current studyno significant correlation between anaemia and breast cancercould be identified. In patients with cancer, >60% cases haveHb < 12 gm% along with altered red cell indices; amongstthat 4.7% of the cases had Hb < 7 gm%. Anorexia associatedwith cancers generally can result in nutritional anaemia seenin the cases. On the other hand metastasis to the bonemarrow from breast cancer can be associated with suppres-sion of erythropoiesis. Benign group also have shownanaemia (mean Hb < 10 gm%) probably due to lower socioe-conomic status and poor nutrition [5, 8].

Themean TLCwas decreased with progression of diseasefrom stage 1 to stage 4. It was in contrast with the BlueMoun-tains Eye Study cohort of older Australians, where an elevatedWBC count was seen with cancer mortality, independent ofsmoking, diabetes mellitus, fasting glucose levels, and other

4 International Journal of Breast Cancer

Table 5: Relation of platelets parameters with four stages of carcinoma and benign group.

Platelets parameters Carcinoma stage Benign group1 2 3 4

Platelets (mean ± SD) 1.91 ± 1.32 2.87 ± 0.73 2.59 ± 0.88 2.65 ± 1.1 2.63 ± 0.54Minimum platelets 0.97 1.2 1.36 1.58 1.57Maximum platelets 2.85 3.75 4.81 4.65 3.34

related factors [9]. However, few prospective studies haveexamined the putative association between systemic markersof inflammation and incident cancer [2, 10]. However, abso-lute neutrophil counts of cases have not shown any statisticalsignificance in comparison with staging. But, in cases of stage1, in comparison with control group and other stages, lowcounts were observed. The various studies done in the pasthave emphasized that the patients with an absolute granulo-cyte count of 6000/mm3 or more have a shorter survival thanthe patients with less than 6000/mm3. More or less similarphenomenon was observed independently in patients withadvanced carcinoma of the colon in another study [11, 12].

In the present study conducted, decrease in mean abso-lute TPLC was noted with progression of the disease. It wasobserved that localized tumor in stage 1 has shown lymphocy-tosis (5.800± 36.76) and lymphocytopenia (1.379± 0.762)wasnoted in stage 4.This finding was comparable with reports ofParkin DM and fellows, who observed that the decrease inTPLC was directly proportional to the progress of the disease[7]. In addition, when compared with benign group, stage1 of breast carcinoma showed significantly raised absoluteTPLC and, on the other hand, stage 4 showed significantdecreases in absolute TPLC. Many other studies conductedon breast carcinoma patients have shown similar findings.In one study the peripheral lymphocyte count was found tobe comparative on the higher side in patients with localizedbreast carcinoma as compared with evidence of metastasis[13]. The principal mechanism of tumor immunity is killingof tumor cells by CD8+ cytotoxic T-lymphocyte. The naturalkiller cells are lymphocytes that are capable of destroyingtumor cells without prior sensitization. Lee has reportedthat patients with a higher peripheral blood CD8 countexperienced superior survival in a cohort of 113 women withmetastatic or recurrent breast cancer. Better clinical outcomesassociated with high absolute lymphocyte count have beenalso reported in gastric and head and neck carcinomas [14,15].However,many tumors downregulate expression of class 1major histocompatibility complex (MHC)molecules as a wayof evading immunity. Lymphocyte count may therefore beelevated or depressed. Nemoto et al. and others observed nochange in peripheral lymphocyte count in patients of breastcarcinoma [16–18].

In a study done in Japan, it has been shown that patientswith peripheral bloodmonocyte count >300/mm3 comparedto patients with a count <300/mm3 have worse 5-year cancer-related survival. But in present study conducted, absolutemonocytic count >300/mm3 was observed in stage 1, and itwas higher than benign group also where it was <300/mm3[19].

The mean platelet count of cases (291.51 ± 103.38)was also higher than that of benign group (222.82 ±57.62). Preoperative thrombocytosis has been identified as anadverse prognostic indicator in somemalignancies [20, 21]. Inanother study done on patients with esophageal carcinoma,a high platelet count was found to be associated with tumorprogression and poor survival [22].

6. Conclusion

In summary, breast cancer patients who presented withderanged full blood count pattern were compared with thebenign cases. It was observed that stage-specific mean valuesof absolute lymphocytic counts of breast cancer patients canbe employed as a useful guide to assess the progression ofdisease; however, furtherworkwith large sample sized studiesis needed in this field.

Conflict of Interests

The authors declare that there is no conflict of interestsregarding the publication of this paper.

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