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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 7  |  Issue : 3  |  Page : 89-94

Clinical, radiological, and histopathological findings of benign breast diseases: A comparative study


Department of General Surgery, SVS Medical College, Mahabubnagar, Telangana, India

Date of Web Publication29-Oct-2018

Correspondence Address:
Dr. Korumilli R Kumar
Plot No-70, Gruha Laxmi Colony, Old Kakaguda, Secunderabad - 500 015, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ais.ais_47_16

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  Abstract 


Background: Breast lesions are more prevalent in the present population. Eighty percent (80%) of lesions are benign. No clinical examination or investigation is accurate in the detection of benign breast disease (BBD). Accuracy of diagnosis increases when clinical examination, ultrasonography (USG) breast, and fine-needle aspiration cytology (FNAC)/histopathological examination (HPE) are combined. The objective of this study was to compare the role of clinical examination, USG/mammography, and HPE study in the diagnosis of BBDs.
Patients and Methods: Consecutive female patients presented with breast diseases to the Department of Surgery, SVS Medical College and Hospital, Mahabubnagar, Telangana, India, between October 2013 and September 2015. Detailed history of the patient was noted to find out the reasonable risk factor. Clinical examination was done followed by USG/mammography of the breast and FNAC/HPE.
Results: On analysis of our study, it was found that the incidence of benign breast lumps was found to be more in the age group of 21–30 years. One hundred and twenty cases were studied, of which 99 cases (82.5%) complained of lump in the breast. This was closely followed by pain (9 cases, 7.5%) and discharge from nipple (5 cases, 4.2%). Most of the lumps (65.8%) were <3 cm. Fibroadenomas cases (63.3%) were the commonest. Left-sided lesions were more (59 cases, 49.7%). Most of the lesions were solitary (113 cases, 94.17%). FNAC/HPE was done in all the cases and was diagnostic. USG could clearly suggest if the lesion was cystic or solid but further typing of the lesion had limitations, even though fibroadenoma would be diagnosed accurately.
Conclusion: The accuracy of BBD diagnosis increases when all the three modes, i.e. clinical examination, imaging, and FNAC/HPE are employed. Triple assessment may avoid many unnecessary surgeries for benign lesion.

Keywords: Benign breast disease, Fine-needle aspiration cytology, Mammography, Triple assessment, Ultrasonography breast


How to cite this article:
Krishna DM, Kumar KR, Teja PP, Aditya T, Srikanth J. Clinical, radiological, and histopathological findings of benign breast diseases: A comparative study. Arch Int Surg 2017;7:89-94

How to cite this URL:
Krishna DM, Kumar KR, Teja PP, Aditya T, Srikanth J. Clinical, radiological, and histopathological findings of benign breast diseases: A comparative study. Arch Int Surg [serial online] 2017 [cited 2020 Jul 11];7:89-94. Available from: http://www.archintsurg.org/text.asp?2017/7/3/89/244408




  Introduction Top


The Elwin Smith papyrus, discovered at Thebes, Egypt in 1862, is the oldest known medical document that is thought to date between 3000 and 2500 BC. It contains the oldest known reference to tumors or ulcers of the breast.[1] Hippocrates, the Father of Medicine (460–370 BC), was the first to distinguish benign from malignant breast neoplasm.[1] Brodie is thought to have provided the first clear description of cystic disease in 1846.[2] Cheatale and Cutler were the first to acknowledge that nodularity of the breast was not necessarily pathologic but occurred regularly under physiological conditions such as menstruation.[1] Geschictter et al. and Patey continued to differentiate among the clinical syndromes, pain, nodularity, and cystic diseases.[3]

Various authors, such as L.E. Hughes, Parks, and Sandison in 1960, demonstrated that the changes commonly described as fibroadenosis were widely distributed in patients who had not claimed to be symptomatic or demonstrated overt disease.[4] Breast health awareness has resulted in increasing detection of early breast cancer and corresponding decrease in breast cancer morbidity. Symptomatic breast lesions are traditionally evaluated by clinical, cytological, and radiologic methods. However, each one when used individually has higher false negative rate. Hence, it is important not to rely on just one modality and use all three modalities, i.e. triple assessment. In this study, we assessed the accuracy of these three modalities in accurately diagnosing benign breast disease (BBD).


  Patients and Methods Top


Source of data: Consecutive female patients with breast diseases who attended outpatient department were admitted to wards in Department of Surgery, SVS Medical College and Hospital, Mahabubnagar, Telangana, India, between October 2013 and September 2015.

Method of collection of data: Detailed history of the patient was noted to find out the reasonable risk factor and complaints were recorded in chronological order by senior resident under supervision of consultant. Clinical examination was done to find out the various modes of presentation, followed by imaging of the breast, fine-needle aspiration cytology (FNAC), and histopathological examination (HPE).

Data were analyzed by Microsoft Excel and GraphPad Prism software. Data were summarized by mean ± standard deviation (SD) for continuous data and percentages for categorical data. The association between the variables was done by Chi-square test for categorical data. All P values <0.05 were considered as statistically significant.

Inclusion criteria: All cases diagnosed clinically BBDs irrespective of age were included in the study.

Exclusion criteria: Those patients recruited in this study as BBD and later proved to be having malignancy after investigation and acute inflammatory conditions were excluded from the study.


  Results Top


The present study was undertaken in the Department of Surgery at SVS Medical College and Hospital. A total of 120 female patients aged between 16 and 32 years who attended surgery outpatient department of SVS Medical College and Hospital with various forms of BBDs were recruited for the study to evaluate patterns of breast disease in females and to compare role of clinical examination, radiological, and histopathological study in the diagnosis of BBDs. After obtaining informed consent, history was taken and necessary clinical details were carried out. This was followed by ultrasonography (USG) of the breast and FNAC/HPE. The data obtained were analyzed using Statistical Package for the Social Sciences software version 20.0. Appropriate statistical tests were used to compare clinical examination, USG/mammography, and histopathological diagnosis. Descriptive results are expressed as mean and SD of various parameters. Probability value (P value) was used to determine the level of significance, P value <0.05 was considered as significant, and P value <0.01 was considered as highly significant.

It was observed that benign breast lesions were more common in the 21–30 years age group 48.4%, followed by 11–20 years (25.8%) and 31–40 years (25.8%) [Figure 1] and [Table 1]. The mean age group in the present study was 25.6 ± 6.6 and majority of patients 82.5% presented with lump in the breast, followed by pain 7.5% and discharge from nipple 4.2%. Seven patients had more than one symptoms, 4 patients (3.3%) presented with lump and pain, 2 patients (1.7%) presented with lump and discharge, and 1 patient (0.8%) presented with pain and discharge [Figure 2] and [Table 2].
Figure 1: Simple bar diagram for the age (in years) distribution of all subjects

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Table 1: Age (in years) distribution of all subjects

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Figure 2: Simple bar diagram for the symptoms distribution of all subjects

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Table 2: Symptoms distribution of all subjects

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The size of lump was divided based on the maximum diameter. Size of lump <3 cm in diameter was considered as small size, those between 3 and 5 cm as intermediate size, and those >5 cm as giant size. Most of the patients 65.8% had lump size <3 cm [Figure 3] and [Table 3].
Figure 3: Simple bar diagram for the lump size (in cm) distribution of all subjects

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Table 3: Lump size (in cm) distribution of all subjects

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63.3% of patients who presented with BBD were diagnosed as fibroadenoma, followed by 16.67% cases with fibroadenosis, 4.17% cases with nonspecific mastitis, 5% cases with galactocele, 2.5% cases with atypical ductal hyperplasia and duct ectasia, respectively, 1.67% cases with simple cyst, intraductal papilloma, phyllodes tumor, respectively, and 0.8% cases with cyst [Figure 4] and [Figure 5], [Table 4].
Figure 4: Simple bar diagram for the breast disease distribution of all subjects

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Figure 5: Cluster bar diagram for the association between breast disease and age (in years)

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Table 4: Breast disease distribution of all subjects

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Also 52.6% cases of fibroadenoma presented in the age group of 21–30 years, followed by 35.5% between age group 11 and 20 years. 50% cases of fibroadenosis presented in the age group of 31–40 years, followed by 45% between age group 21 and 30 years. 100% cases of nonspecific mastitis presented in the age group of 21–30 years. 50% cases of galactocele presented in the age group of 11–20 years, followed by 33.3% cases presented between age group 21 and 30 years and 16.7% cases presented between age group 31 and 40 years, respectively. 66.7% cases of atypical ductal hyperplasia and duct ectasia presented between age group 31 and 40 years. 100% cases of cysts, intraductal papilloma, and phyllodes tumor presented between age group 31 and 40 years [Table 5].
Table 5: Association between breast disease and age (in years)

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Regarding the laterality of the disease, 49.7% presented with breast pathology on left side, followed by 48.3% presented with pathology on right side and 2.5% had bilateral lesions [Figure 6] and [Table 6]. With regards to the number of lesions, 96.67% cases presented with single lesion and 3.33% cases presented with multiple lesions [Figure 7] and [Table 7].
Figure 6: Simple bar diagram for the side distribution of all subjects

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Table 6: Side distribution of all subjects

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Figure 7: Pie diagram for the number of lesions distribution of all subjects

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Table 7: Number of lesions distribution of all subjects

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It was also observed that there was a significant positive correlation between clinical examination and FNAC/HPE of BBD. However, on clinical examination, 5 cases of fibroadenosis, 2 cases of nonspecific mastitis, 1 case of atypical ductal hyperplasia, 3 cases of cyst, and 1 case of intraductal papilloma were diagnosed as fibroadenoma. Of the 20 cases of fibroadenosis, 5 cases were diagnosed as fibroadenoma and 4 cases were diagnosed as galactocele on clinical examination. Of the 20 cases of nonspecific mastitis, 2 cases were diagnosed as fibroadenoma, 2 cases were diagnosed as fibroadenosis, and 1 case was diagnosed as galactocele on clinical examination. Of the 3 cases of atypical hyperplasia, 1 case was diagnosed as fibroadenoma and 2 cases were diagnosed as fibroadenosis. Of the 3 cases of duct ectasia, 1 case was diagnosed as intraductal papilloma. Of the 2 cases of intraductal papilloma, 1 case was diagnosed as fibroadenoma and 1 case was diagnosed as duct ectasia [Figure 8] and [Table 8].
Figure 8: Cluster bar diagram for association between clinical and FNAC/HPE

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Table 8: Association between clinical and FNAC/HPE

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There was a significant positive correlation between ultrasound diagnosis and FNAC/HPE of BBD. However, ultrasound examination overdiagnosed fibroadenoma, wherein 5 cases of fibroadenosis, 2 cases of atypical ductal hyperplasia, 3 cases of cyst, and 1 case of intraductal papilloma were diagnosed as fibroadenoma. Of the 20 cases of fibroadenosis, 5 cases were diagnosed as fibroadenoma and 1 case was diagnosed as galactocele on clinical examination. All the cases of nonspecific mastitis were diagnosed as BBD. Of the 3 cases of atypical hyperplasia, 2 cases were diagnosed as fibroadenoma and 1 case was diagnosed as fibroadenosis. Of the 2 cases of intraductal papilloma, 1 case was diagnosed as fibroadenoma [Figure 9] and [Table 9].
Figure 9: Cluster bar diagram for the association between USG and FNAC/HPE

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Table 9: Association between USG and FNAC/HPE

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  Discussion Top


BBD is a common disease affecting women in India. This study includes 120 cases of benign diseases that were admitted and treated at SVS Medical College and Hospital, Mahabubnagar, Telangana, India, between October 2013 and September 2015.

Sex distribution, inflammatory breast conditions, gynecomastia, and carcinoma breast have been excluded from this study. There were 120 cases of BBDs; all patients were of the female sex. In the present study, it was found that incidence of BBD was found to be more in age group of 21–30 years (58 pwatients, i.e. 48.4%), followed by 11–20 years and then 31–40 years. In a study done by Khanna et al., the authors have analyzed 1031 cases of BBDs in which the age group of 413 patients was 21–30 years, i.e. 40.06%.[5]

On disease pattern in the present study, most of fibrocystic disease of breast were seen in the age group of 31–40 years.[6] Rangabashyam et al. showed that maximum number of cases (70%) were between the age group of 20 and 30 years.[6] Around 88.1% of fibroadenomas were observed in 11–30 years age group in the present study. In an Indian study by Rangabashyam et al., maximum number of cases (75.39%) was noted in 11–30 years age group.[6] Similarly, in a study by Khanna et al., 82.78% of fibroadenomas were seen in the age group of 11–30 years.[7]

Majority of the cases in the present study were in the reproductive age group (12–49 years). Two cases complained of irregular menstrual cycles and none of them had any significant change in the size of the swelling during or before menstruation. In the present study, on symptomatology, the most common presenting complaint was breast lump in about 99 cases (82.5%), while 9 cases presented with pain (7.5%) and 5 cases presented with discharge (4.2%). However, the study done by Khanna et al. showed that common presenting complaint in BBD was lump constituting about 77.4% in their study.[7]

Laterality and number of lesions in the present study, of the 120 cases, right breast was involved in 58 cases (48.3%), 59 on the left side (49.7%), and 3 cases presented with bilateral involvement (2.5%). This does not correspond to most of the studies, which state that right breast is commonly involved with lesions compared to left breast (51,52). Most lesions (114 cases) were solitary (95%) and multiple lesions were present in 6 cases (5%) on clinical examination. On USG breast, multiple lesions were detected in 7 cases (5.83%) and single lesions in 113 cases ((94.17%).

On USG of breast, a spectrum of benign finding was noted. In the present study, USG could clearly suggest if the lesion was cystic or solid, but further typing of the lesion had limitations, even though fibroadenoma would be diagnosed accurately. Most cases were fibroadenomas on USG breast, multiple lesions were detected in 7 cases (5.83%) and single lesion in 113 cases (94.17%). This USG finding correlates with Thomas et al. study, with 92.3% solitary lesion and 7.6% of multiple lesion.[8] In benign palpable masses, Klein et al. state 97% diagnostic accuracy on USG. Eltair et al. showed USG was sensitive in 88.9% and specific in 97.4% of cases.[9] This USG finding correlates with Thomas et al. study, with 92.3% solitary lesion and 7.6% of multiple lesion.[10] In Malik et al. study, sensitivity of USG for breast masses was 92% for benign, and specificity was 92.4%. In the present study, USG was 100% sensitive and 93% specific (for fibroadenomas).

The management of breast disease has been influenced by breast imaging and FNAC for preoperative diagnosis. We have studied 120 cases of BBD, who have been subjected to clinical examination, imaging of breast, and FNAC/HPE. The accuracy of BBD diagnosis increases when all the three modes are employed. From this present study on BBD, it can be concluded that USG can be employed to differentiate solid and cystic lesions. All cystic lesions and majority of the fibroadenoma can be diagnosed on sonography. Triple assessment may avoid many unnecessary surgeries for benign lesion.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Frykberg ER, Kirby BI. Evolution of surgical principles and techniques for the management of breast cancer. In: Kirby BI, Copeland EM, editors. The Breast – Comprehensive Management of Benign and Malignant Disease, 2nd ed, vol 2. Philadelphia: W B Saunders; 1998. p. 766-801.  Back to cited text no. 1
    
2.
Brodie B. Lecture on serocystic tumours of the breast. London Medical Gazette1840;25:808.  Back to cited text no. 2
    
3.
Geschickter L. Disease of the breast. 2nd ed. Philadelphia: JB Lippincott; 1945. p. 876-95.  Back to cited text no. 3
    
4.
Mansel RE, Singal H. Developmental abnormalities and benign breast disease. In: Farndon JR, editor. Breast and Endocrine Surgery. 4th ed. London: W B Saunders; 1997. p. 197.  Back to cited text no. 4
    
5.
Haagensen CD. Abnormalities of breast growth, secretion and lactation. In: Haagensen CD, editor. Diseases of the Breast. 3rd ed. Philadelphia: W B Saunders; 1986. p. 56.  Back to cited text no. 5
    
6.
Rangabashyam. Spectrum of benign breast lesions in Madras. J Roy Coll Surg 1998;28:369-73.  Back to cited text no. 6
    
7.
Khanna SNC, Aryya, Khanna NN. Spectrum of benign breast disease. Ind J Surg 1988;50:169-75.  Back to cited text no. 7
    
8.
Klein S. Evaluation of Palpable Breast Masses. Am Fam Phys 2005;71:324-43.  Back to cited text no. 8
    
9.
Eltahir A, Jibril JA, Squair J, Heys SD, Ah-See AK, Needham G, et al. The accuracy of “one-stop” diagnosis for 1110 patients presenting to a symptomatic breast clinic. J R Coll Surg Edinb 1999;44:226-30.  Back to cited text no. 9
    
10.
Morris KT, Pommier RF, Morris A, Schmidt WA, Beagle G, Alexander PW, et al. Usefulness of the triple test score for palpable breast masses. Arch Surg 2001;136:1008-12.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]



 

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