Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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On Sep 2018

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On Aug 2018

Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
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Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
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Dr. Mamta Gupta
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Aug 2018

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"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
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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.
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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)
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.
On April 2011

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
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : June | Volume : 16 | Issue : 6 | Page : PC01 - PC04 Full Version

Triple Assessment for the Diagnosis of Carcinoma Breast in a Tertiary Care Hospital of Tripura: A Cross-sectional Study

Published: June 1, 2022 | DOI:
Tamal Sarkar, Damodar Chatterjee, Diptendu Chowdhury, Pradip Sarkar

1. Senior Registrar, Department of Surgery, AGMC and GBPH, Agartala, Tripura, India. 2. Associate Professor, Department of Surgery, AGMC and GBPH, Agartala, Tripura, India. 3. Associate Professor, Department of Surgery, AGMC and GBPH, Agartala, Tripura, India. 4. Professor, Department of Surgery, AGMC and GBPH, Agartala, Tripura, India.

Correspondence Address :
Dr. Pradip Sarkar,
Shyamali Bazar, opposite to Fire Service (Aastha Diagnostic Centre), Kunjaban-799006, Agaftala, Tripura, India.


Introduction: A combination of invasive and non-invasive procedures, clinical examination, radiological imaging (mammography/ ultrasonography/ Magnetic Resonance Imaging (MRI)) and fine needle aspiration cytology called the triple assessment test is being increasingly used in place of the more invasive core needle biopsy and histopathology.

Aim: To evaluate accuracy of triple assessment in the preoperative diagnosis of patients with breast carcinoma and to determine sensitivity and specificity with regards to histopathology in the diagnosis of the disease.

Materials and Methods: A cross-sectional study was conducted among 61 women of more than 25 years of age having palpable breast lump, attending the surgery Outpatient Department (OPD) and breast clinic of a tertiary care hospital from January 2017 to February 2019. Data on socio-demographic status, menstrual and obstetric information, clinical examination performed, mammography, Fine Needle Aspiration Cytology (FNAC), High resolution sonography breast and histopathology were recorded into predesigned and pretested proformas and analyzed using Statistical Package for Social Sciences (SPSS) version 25.0.

Results: Out of total 61 patients participated in the present study, most patients were of 41-50 years of age, with a mean age of 44.23±7.37 years, married, non-vegetarian and without any past history of alcohol consumption. Sensitivity and specificity of triple assessment was 98.3% and 100% respectively. The positive predictive value of Triple Assessment was 100% while the negative predictive value was 66.7%. All values were significantly better than both clinical breast examination and FNAC in detecting malignancies.

Conclusion: The triple test was also found to be as accurate in diagnosing breast carcinoma in this geographical region. A patient with a negative triple test report can be safely followed up without the need for biopsy.


Carcinoma breast, Triple assessment, Sensitivity, Specificity

Breast cancer is the most common cancer in women worldwide, with nearly 1.7 million new cases diagnosed every year and second most common cancer overall representing about 12% of all new cancer cases and 25% of all cancers in women (1),(2). It is also the most common cause of cancer mortality among women in developing countries and second most common in developed countries. Signs of breast cancer varies, and may include change in the breast shape, dimpling of the skin, fluid coming from the nipple or a red scaly patch of the skin. In those with distant spread of the disease, there may be bone pain, swollen lymph nodes, shortness of breath and yellow skin (3). However, the most common way the disease presents itself is with the presence of a growing lump in the breast that is felt by the woman (1).

An estimated 1,45,000 new breast cancer patients are diagnosed annually in India and about 76,000 women are expected to die from the disease every year (2),(4),(5). It has been suggested that the primary reason for such a high mortality among breast cancer patients in the country is the fact that the early diagnosis of the disease is still very low. Most of the breast cancer patients have no access to screening procedures, and in cases where screening is availed, adequate follow-up of the patients do not occur. This leads to most of the breast cancer cases progressing to a more advanced form of the disease which is associated with much poorer prognosis and outcomes (1). In Tripura, breast cancer is the one of the commonest forms of cancer among females, second only to uterine cancer (6).

Although the diagnosis of breast cancer can be suggested by clinical examination, it largely depends on the degree of clinical suspicion of the disease. Presence of a lump or space occupying lesion in the breast raise suspicion of being benign or malignant. Differential diagnosis of breast lesion includes traumatic fat necrosis, acute and chronic breast abscess, fibro-adenosis, breast cysts etc. In those with distant spread of the disease, there may be bone pain, swollen lymph nodes, shortness of breath and yellow skin (7),(8). Furthermore, patients who are overtly cautious and fearful of cancers can feel a lump in their breasts even when none exists. Histopathological examination of tissue from a suspected lesion remains the gold standard for the diagnosis of breast cancer. However, since the procedure is invasive, other modalities have since been developed to screen for and diagnose the disease (7). A combination of invasive and non-invasive procedures, i.e. clinical examination, radiological imaging (mammography/ ultrasonography/ Magnetic Resonance Imaging (MRI)) and fine needle aspiration cytology called the triple assessment test have been used with a fairly high accuracy to diagnose palpable breast lumps. Studies have been done comparing triple assessment with histopathology in the diagnosis of breast cancer. However, a thorough literature search of the existing literature revealed that there were very few studies that have been done to explore this scenario in India (4),(8). As the availability, accessibility and utilization of cancer screening services are still low in the country, this study aims to fill in the gaps that exist in the existing knowledge regarding the accuracy of triple assessment in the Indian setting, especially in Tripura.

The aim of this study was to evaluate accuracy of triple assessment in the preoperative diagnosis of patients with breast carcinoma and to determine sensitivity and specificity with regards to histopathology in the diagnosis of the disease.

Material and Methods

A cross-sectional study was conducted from January 2017 to February 2019 in the Department of General Surgery of a tertiary care teaching institute in Agartala, Tripura, India. The study was conducted among the patients attending the surgery OPD and breast clinic of the hospital. Ethical permission regarding the study was obtained from the Institutional Ethics Committee of Agartala Government Medical College (F.4(5-192)/ AGMC/ Academic/ IEC Meeting/2015/ 090). Written informed consent was obtained from each participant before conducting the study as well as before performing any clinical procedures on them. Confidentiality and anonymity of the participants was ensured.

Inclusion criteria: All patient’s age more than 25 years, having palpable breast lump and presented in the Department during the study time period were included.

Exclusion criteria: Patients unwilling/incapable of giving informed consent, pregnant patients or those currently suffering from other medical illnesses like fever, acute cholecystitis, Chronic Obstructive Pulmonary Disease(COPD), cardiovascular diseases, pancreatitis etc. or those patients who remain absent on follow-up, presenting with frank malignant mass with skin infiltration and patients with atypia on Histopathological Examination (HPE) or inconclusive reports were not included in the study.

Sample size and sampling technique: The sample size was calculated based on the specificity of 90% as reported by Kharkwal S and Sameer AM (4) utilizing the formula:

n = [Z1-(α/2) X v{2π0X (1-π0)} + Z1-β v{π1(1- π1) + π2(1-π2)}]2 /(π2-π1)2

where, π0 = 12) / 2
π1 = specificity of the new test = 90%
π2 = specificity of the reference test = 100%
α = significance level = 10%
1 – β = power = 80%

The minimum calculated sample size was 57. A complete enumeration of the patients attending the general surgery OPD during the study period was done as a sampling technique. A total of 65 eligible patients were found, of whom, four were excluded as per the exclusion criteria, leaving the final sample size obtained by this method to be 61 (Table/Fig 1).


The data collection was done using a researcher administered questionnaire [Annexure-1]. After obtaining written informed consent, the participants provided information regarding their socio-demographic status, menstrual and obstetric information, and clinical information. After obtaining data pertaining to the questionnaire, following clinical examinations were performed.

Mammography: A lateral oblique and a craniocaudal view of each breast was taken and examined. Criteria such as irregular borders, micro-calcifications, speculated density, loss of architecture and skin retractions were considered as characteristic of a malignant lump, while well-circumscribed mass with regular borders was considered a benign disorder.

High resolution Ultrasonography (USG): Ultrasonography of breast was performed with the patient placed in a supine or oblique position with ipsilateral arm above the head, with the breast being scanned in either a transverse or sagittal or radial planes. Characteristics observed on USG which suggested the lesion to be malignant included sonographic spiculations, microlobulations, thick hyperechoic halo, and the lesion being deeper than wide. A well-circumscribed lesion which was wider than deep, with gently curving smooth lobulations was considered to be benign.

Fine-needle aspiration cytology (FNAC): FNAC of the breast lumps was done with 22-gauge needle, mounted on a 20 mL syringe. Prepared slides were sent for staining and histopathological diagnosis to the pathology laboratory of the study institution.

Triple assessment: A combination of these three tests, that is clinical examination, radiological imaging (mammography/ ultrasonography) and FNAC, called the triple assessment test is being used increasingly as a non-operative tool for breast cancer diagnosis instead of the more disfiguring core needle biopsy.

Grades of alcohol intake were defined as ‘never’ if someone had never taken alcohol in his lifetime, ‘occasional’ as consuming less than one alcoholic drink per day and ‘moderate’ as having more than 1 to 2 alcoholic drinks per day. Any clinical examination performed (mammography, FNAC, High resolution sonography breast and histopathology) were done with proper informed consent and the patients were explained about the procedure fully before undergoing it. In all of the clinical examinations done, it was ensured that the patient had a female attendant.

Statistical Analysis

After collecting all data, data entry was done in a spreadsheet. For the statistical analysis, Statistical Package for the Social Sciences (SPSS) version 25.0 was used. Descriptive statistics, such as frequency, percentage, mean, median, and standard deviation were used. In this study, the result was divided into two groups: benign, and malignant. Sensitivity and specificity were calculated for clinical breast examination, FNAC, USG and triple assessment against the gold standard (histopathology).


It was seen that most patients were of 41-50 years of age, with a mean age of 44.2±7.4 years. Over 45(73.8%) patients had married and 10 (16.4%) patients were unmarried. Only six participants were divorcees. The mean Systolic Blood Pressure (SBP) of the patients was 111 ±5.6 mm Hg and the mean Diastolic Blood Pressure (DBP) was 91.3 ±4.6 mm Hg. Only one participant had a positive family history of breast cancer (Table/Fig 2). The mean age of menarche among the participants was 13±0.8 years, with the minimum being 12 years and the maximum being 14 years. The average number of children of the participants was 1.5 ±0.7, with a mean breastfeeding duration of 8.3±5.4 months (Table/Fig 3).

Histopathology of the tissue from the breast lumps, the gold standard for the diagnosis of breast cancer showed that 59 patients (96.7%) had malignant masses, while only two (3.3%) participants had non-malignant masses. Analysis of sensitivity and specificity showed that the sensitivity of the triple assessment test in detecting breast cancer in women was 98.3% as compared to the gold standard (histopathology). The specificity of triple assessment was found to be 100%, with a 66.7% negative predictive value (Table/Fig 4).


The current study found that 17(27.9%) patients had 31-40 years of age, 31(50.8%) patients had 41-50 years of age and 13 were in 51-60 years of age. The mean age of patients was 44.2 ± 7.4 years. This finding is supported by previous research where the incidence of malignancy was found to be higher in populations of 40-49 years old (9),(10),(11). Kharkwal S and Sameer AM reported that the women over 40 years of age but under 50 accounted for almost 35% of breast lump cases (4). This preponderance of malignancy occurrence in comparatively younger population is characteristic to the subcontinent, as reported by Khokar A (12). Similar findings were also observed by Saxena S et al., in their study of 569 breast cancer patients in Delhi (13).

Thus, the sensitivity of the clinical breast examination was found to be 88.1%, specificity of 50%, positive predictive value to be 98.1% and the negative predictive value to be 12.5%. These findings are similar to those reported by Yang WT et al., where the sensitivity, specificity and positive predictive value of clinical breast examination was found to be 88%, 92%, and 67% respectively (14). Malignant lesions were detected better by USG as compared to clinical breast examination (15). The sensitivity of the ultrasound modalities was found to be 96.7%, with the positive predictive value and the specificity both being at 100% and the negative predictive value at 50%. USG modalities detected five more lumps as being malignant as compared to clinical breast exam, all of which were confirmed by histopathology. Similar sensitivity and specificity for USG modalities have been reported by Pande AR et al., in their study (15). The current study reported FNAC as a poorer diagnostic modality than USG, with a sensitivity of 94.9% and the negative predictive value of 40%. This is, however, in contrast to the findings elsewhere. M Jan et al. reported a sensitivity of 100% for FNAC with a negative predictive value of 100% (8). Similarly, Martelli G et al., (16) and Steinberg JL (17) reported FNAC to be a better diagnostic modality as compared to USG for breast cancer diagnosis. ,

When triple assessment was compared with histopathology for the diagnosis of breast cancer, it was seen that the sensitivity was 98.3%, negative predictive value was 66.7% and both the specificity and positive predictive value were 100%. Jan M et al., in their study conducted among patients in Kashmir reported a sensitivity and specificity of 100% and 99.3% respectively (8). Martelli G et al. also reported similar values, with positive predictive value of 100% and sensitivity of the modality at 95% (16). According to Steinberg JL et al., the triple test was better than other modalities, with sensitivity of 95.5% and specificity of 100% (17).


The current study had several limitations. Firstly, the sample size was small, and the study was conducted in a single tertiary care hospital. This predisposed the study to selection biases.


The study found that triple assessment is a very useful diagnostic tool to evaluate patients with breast lumps and detect patients with breast cancers. The triple test is valid and reliable, with a high degree of accuracy for the diagnosis of breast lumps. The triple test was also found to be as accurate in diagnosing breast carcinoma in this geographical region as have been reported elsewhere. Of all the three components of the triple test, USG modalities were found to be the most accurate. Therefore, it can be said that a patient with a concordant benign triple test report can be safely followed up without the need for biopsy.


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DOI and Others

DOI: 10.7860/JCDR/2022/52732.16438

Date of Submission: Oct 21, 2021
Date of Peer Review: Dec 10, 2021
Date of Acceptance: Jan 04, 2022
Date of Publishing: Jun 01, 2022

• 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? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

• Plagiarism X-checker: Oct 22, 2021
• Manual Googling: Jan 03, 2022
• iThenticate Software: Feb 07, 2022 (22%)

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