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Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."
Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011
Dr. Shankar P.R.
"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."
Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011 Anuradha
Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.
Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020
Original article / research
Full Version
Diagnostics Role of Haematological Parameters in Benign and Malignant Breast Lesions: A Retrospective Observational Study from a Tertiary Healthcare Centre in Tamil Nadu, India
Correspondence Address :
Priyadarshini Kumaraswamy Rajeswaran,
Assistant Professor, Department of Pathology, PSG Institute of Medical Sciences and Research, Avinashi Road, Peelamedu, Coimbatore, Tamil Nadu, India.
E-mail: drpriyadarshini.kr@gmail.com
Introduction: Breast cancer is the most common malignancy diagnosed in women, and despite advancements in diagnosis and treatment, it still leads to significant morbidity and mortality. Distinguishing between benign and malignant breast disease is clinically challenging, and there is currently no serum biomarker available for early breast cancer detection. As part of the preoperative work-up for breast lesions, a Complete Blood Count (CBC) analysis is typically performed.
Aim: This study aimed to evaluate the utility of CBC parameters in diagnosing malignant breast lesions and to analyse the diagnostic role of haematological parameters within benign and malignant breast lesions, as well as different histological breast cancer stages.
Materials and Methods: This retrospective observational study was conducted for one year, from January to December 2021, at the Department of Pathology of PSG Institute of Medical Sciences and Research in Coimbatore, Tamil Nadu, India. The study included 60 female patients with both benign and malignant breast lesions. Histopathological examination confirmed the diagnoses of these lesions. CBC parameters, including haemoglobin, Total White Cell Count (TWBC), neutrophil count, lymphocyte count, monocyte count, platelet count, and Mean Platelet Volume (MPV), were collected from a total of 120 cases. Additionally, the Neutrophil-Lymphocyte Ratio (NLR), Monocyte-Lymphocyte Ratio (MLR), and Platelet-Lymphocyte Ratio (PLR) were calculated from the obtained CBC parameters for all cases. The values were expressed as mean and standard deviation, and an independent t-test was used to compare the two groups. A p-value less than 0.05 was considered significant.
Results: Malignant breast lesions showed a significant increase in neutrophils (64.1±8.4%) and a significant decrease in lymphocytes (25.9±8%) and MPV (7.6±0.76 pg) compared to benign breast cases. The calculated ratios, such as NLR (2.9±1.7), MLR (0.32±0.2), and PLR (14.4±8), were also found to be increased in malignant cases. However, there were no significant variations in CBC parameters across the various stages of breast malignancy.
Conclusion: Among the CBC parameters evaluated, neutrophil count, lymphocyte count, MPV, NLR, MLR, and PLR were significantly altered in breast malignancy compared to benign breast masses. Measuring CBC parameters and their derived ratios are fast, simple, inexpensive, and readily available method that can assist physicians in predicting breast malignancy.
Breast cancer, Clinical value, Complete blood count, Diagnosis, Prognosi
Breast cancer is one of the most commonly diagnosed cancers and the leading cause of cancer-related deaths in women worldwide. In 2020, the cancer registry data of India projected a risk of 1 in 56 for breast cancer in women (1). According to a report from the National Institute of Cancer Prevention and Research (NICPR), in India, one woman dies for every two newly diagnosed cases of breast cancer (1). The increasing cancer burden poses a significant financial strain on healthcare systems globally, and many cancer patients lack access to timely and quality diagnosis and treatment. This is particularly concerning in countries like India, with a large rural population and limited diagnostic facilities. Raising awareness and utilising resources for early diagnosis are crucial in initiating early treatment and reducing breast cancer-related mortality and morbidity (1).
Hormonal imbalances contribute to the development of both benign and malignant breast lesions. Predominant oestrogen stimulation and relative progesterone deficiency are involved in the pathophysiology of benign breast lesions (2). Several hypotheses propose that oestrogen plays a role in causing breast cancer. One hypothesis suggests that oestrogen promotes cellular proliferation, leading to errors in Deoxyribonucleic acid (DNA) replication when oestrogen binds to its receptors. If these errors are not repaired, they can result in mutations that lead to cancer development. Another hypothesis suggests that metabolites of oral oestrogen react with breast tissue DNA, exerting oncological effects. Women undergoing hormonal replacement therapy for premenstrual symptoms have a higher risk of developing breast cancer (3). However, the exact causes of breast lesion development are still unknown.
Pre-treatment cases of breast cancer often exhibit haematological abnormalities due to bone marrow infiltration by cancer cells, leading to suppression of haematopoiesis (4),(5). In India, 60% of breast cancer patients have pre-treatment anaemia (6). The causes of anaemia may include malnutrition, tumour-related bleeding, abnormal iron metabolism, erythropoietin suppression by tumour cells, and compromised bone marrow function (7),(8). Thrombocytopenia, characterised by a low platelet count, is caused by cancer cells frequently activating coagulation (9). Some studies have found thrombocytosis in breast cancer patients, which can be attributed to the ability of cancer cells to increase platelet count and aggregation (4),(10).
Low-grade chronic inflammation plays a vital role in cancer pathogenesis. Neutrophils and monocytes produce Reactive Oxygen Species (ROS) and Nitric Oxide (NO), unstable molecules usually neutralised by antioxidants. If not balanced, they react with DNA, proteins, and lipids, causing damage and accumulation. This leads to genetic instability and the development of cancer (11). Inflammatory biomarkers, such as White Blood Cell Count (WBC) and derived ratios like NLR, MLR, and PLR, have been found helpful as diagnostic and prognostic markers in various malignancies.
CBC is a routine investigation to assess a patient’s nutritional, immunological, and inflammatory state. Cancer-promoting inflammation plays a critical role in conferring the hallmarks of cancer, including angiogenesis, invasion, metastasis, and genomic instability [12,13]. Changes in peripheral blood counts can assess the extent of cancer-related inflammation. Haematological parameters like red cell indices, leucocyte count, NLR, PLR, MLR, MPV, and platelet counts have shown diagnostic and prognostic importance in different types of malignancies (14),(15),(16). Some studies have found the utility of haematological parameters like NLR, PLR, and MLR as prognostic markers in breast malignancy (17),(18),(19),(20). However, the application of these simple and inexpensive parameters has not been extensively explored in India, except for three studies from Punjab and Karnataka (21),(22),(23) that focused on differentiating between benign and malignant breast diseases in the preoperative period. If the results show a high predictive value, clinicians in resource-limited settings can utilise the haematological parameters to predict the occurrence of malignancy in a breast mass. These parameters are cost-effective, thus alleviating the healthcare cost burden in the country.
The incidence of breast carcinoma in Coimbatore is 14% (24), and no studies to date have examined the use of haematological parameters for diagnosing and prognosticating breast carcinoma in this population. Therefore, we attempted to test the utility of CBC parameters in this population to enable early prediction and forecasting of malignant breast disease by comparing them with benign breast lesions.
The present study was an observational, retrospective study conducted from July 2022 to September 2022. The data were retrieved from a continuous 12-month period (January to December 2021) after obtaining ethical clearance from the Institutional Ethics Committee (22/146). The study included 154 adult female patients diagnosed with benign or malignant breast disease on histopathology.
Inclusion criteria: Females with breast lesions older than 20 years diagnosed as either benign or malignant on histopathology.
Exclusion criteria:
1. Patients with benign or malignant breast lesions diagnosed only on radiology or cytology.
2. Breast carcinoma patients who have undergone chemotherapy, radiotherapy, or surgery.
3. Patients with a diagnosis of inflammatory breast disease.
4. Patients with a previous underlying haematological disorder.
5. Patients with underlying infections.
6. Patients with no availability of CBC parameters at the time of breast lesion diagnosis.
The clinical and pathological stages of breast cancer were determined using the 7th Edition of the American Joint Committee on Cancer (AJCC), and the type of histology was classified according to guidelines from the World Health Organisation (WHO) [25,26]. The Histopathological grades of the tumour were classified using the Nottingham-Bloom-Richardson system (modified) (27).
After applying the inclusion and exclusion criteria, there were 120 female patients, including 60 patients with malignant breast lesions and 60 with benign breast lesions. The incidence of malignancy is known to occur in a higher age group than benign breast lesions (23). Hence, the age could not be matched between the two groups. However, an equal number of patients were included in the two groups.
Data collection: Whole blood venous samples were collected in K2 EDTA for baseline CBC examination for all 120 patients during the preoperative period. The blood samples were analysed on the Beckman Coulter LH-780 Haematology analyser (Beckman Coulter, Brea, CA) within four hours of collection. Patient information such as age, lesion size, histopathology diagnosis, and stage of malignancy was noted. The CBC parameters such as haemoglobin (Normal: 12.0-14.9 g/dL), TWBC (normal: 3800-12500/μL), neutrophil count (normal: 40-70%), lymphocyte count (normal: 20-40%), monocyte count (normal: 2-10%), platelet count (normal: 151-532×103/μL), and MPV (normal: 6-10.5 fl) [28,29] were recorded for all the patients. The ratio between the absolute number of neutrophils and lymphocytes was calculated as the NLR (normal: 1.70±0.70), and the ratio between the absolute number of monocytes and lymphocytes was the MLR (normal: 11.15±3.14). The PLR (normal: 117.05±47.73) was calculated as the ratio between the absolute number of platelets and lymphocytes. NLR, MLR, and PLR were calculated for all 120 patients (30).
Statistical Analysis
All analyses were performed using IBM SPSS software, version 23.0 (SPSS, Chicago, IL), and values were expressed as mean±standard deviation. The independent t-test was used to compare mean values between the two groups. A p-value of less than 0.05 was considered significant.
This study included 120 patients with benign and malignant breast diseases, for whom pre-treatment CBC data were available before surgery or biopsy. Among the 60 benign breast cases, the most frequent disease diagnosed was fibroadenoma (48/60 cases), followed by benign phyllodes tumour (6/60 cases), sclerosing adenosis (4/60 cases), mild usual ductal hyperplasia (1/60 cases), and pseudoangiomatous stromal hyperplasia (1/60 cases). Among the malignant breast diseases, most cases were of ductal origin (56/60 cases), followed by lobular carcinoma (2/60 cases), metaplastic carcinoma (1/60 case), and tubular carcinoma (1/60 case).
Baseline clinicopathological variables are presented in (Table/Fig 1),(Table/Fig 2),(Table/Fig 3). There was a significant difference in the mean age of occurrence between benign (37.5 years) and malignant (56.6 years) breast disease at the time of diagnosis. The two breast lesions showed no significant difference in lesion size (Table/Fig 1).
The comparison of CBC parameters, NLRs, MLRs, and PLRs between benign and malignant breast disease is summarised in (Table/Fig 4). There was no significant difference in haemoglobin, total WBC, absolute monocyte count, and platelet count between benign and malignant breast diseases. However, there was a significant difference in neutrophil count, lymphocyte count, MPV, NLR, MLR, and PLR between benign and malignant breast diseases (Table/Fig 4). Similarly, age, lesion size, and CBC parameters were compared between the various stages of breast malignancy (Table/Fig 5). No significant change was observed in stages 1 to 4.
The utility of CBC parameters as clinical values was analysed in breast lesions, including 60 benign and 60 malignant cases. There was no significant difference in size between benign and malignant breast lesions, which aligns with the common diagnosis of breast cancer after age 50 (31). Unlike other studies, this analysis did not find a decrease in Hb levels in malignant cases compared to benign cases (32),(33). The cause of anaemia in those studies was attributed to malnutrition, decreased erythropoietin, and bone marrow suppression. There was no significant change in total WBC count between benign and malignant breast diseases. Neutrophilia, an increase in neutrophils, was observed in all types of malignancies, including this study (34),(35),(36),(37). A decrease in lymphocyte count was found in malignant cases compared to benign cases. Monocyte count did not differ between benign and malignant cases. Derived ratios like NLR, PLR, and MLR were significantly increased in malignant cases, consistent with similar studies (38),(39),(40),(41). Another study found that as breast malignancy stages progressed, haemoglobin, WBC count, and absolute lymphocyte count decreased, while platelet count increased. RBC indices and absolute neutrophil count did not change across stages. NLR and PLR showed a significant increase in Stage-4 compared to other stages (1 to 3). Neutrophil%, lymphocyte%, and MPV were increased in malignant breast cases compared to benign cases. However, there were no significant changes in CBC parameters across the various stages of breast carcinoma, possibly due to a limited number of cases in advanced stages. Other studies have reported increased neutrophils, monocytes, platelet count, and MPV in advanced tumours, along with a decrease in lymphocyte count. The cellular and humoral immune responses play a vital role in limiting cancer initiation and progression by recognising and eliminating them. Higher levels of inflammation cause increased growth factors and cytokines, inducing an angiogenic switch to promote tumour angiogenesis (42). It has been found that cytokines and inflammatory mediators generate reactive oxygen and nitrogen species, leading to further DNA damage and genomic instability (43), thus exacerbating the situation.
Recently, immune-based therapies have been included in the treatment of cancers. Breast cancer, often considered a “cold” tumour due to its limited ability to induce immune responses, has shown benefits from immune checkpoint inhibitors (44), resulting in improved therapeutic outcomes and long-term survival. Therefore, we can assess the extent of inflammation by monitoring changes in peripheral blood counts.
Limitation(s)
This study has limitations, including its retrospective design and small sample size. Thus, a prospective study with a larger sample size is needed to validate our research findings.
The analysis of CBC parameters in breast lesions showed variations in the differential counts of WBC and its derived ratios, such as NLR, PLR, and MLR, in malignant breast diseases. These parameters can be utilised to predict malignant cases early among breast lesions.
DOI: 10.7860/JCDR/2023/62635.18237
Date of Submission: Jan 03, 2023
Date of Peer Review: Feb 27, 2023
Date of Acceptance: Apr 19, 2023
Date of Publishing: Jul 01, 2023
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? No
• For any images presented appropriate consent has been obtained from the subjects. Yes
PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Jan 04, 2023
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• iThenticate Software: Apr 12, 2023 (16%)
ETYMOLOGY: Author Origin
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