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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 8  |  Issue : 2  |  Page : 54-58

Pattern of breast ultrasound findings in Zaria, North Western Nigeria


1 Department of Radiology, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
2 Department of Pathology, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
3 Department of Radiology, Usman Danfodiyo Teaching Hospital, Garba Nadama Rd, Sokoto, Nigeria

Date of Web Publication30-May-2019

Correspondence Address:
Dr. Sefiya A Olarinoye-Akorede
Department of Radiology, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ais.ais_16_18

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  Abstract 


Background: With increasing level of breast cancer awareness among Nigerians, more patients are presenting with breast symptoms. Ultrasound is relied upon significantly since mammographic facilities are few and breast magnetic resonance imaging is either too expensive or unavailable. Our study aimed at presenting the breast ultrasound findings among symptomatic and asymptomatic patients at Ahmadu Bello University Teaching Hospital, Zaria.
Patients and Methods: This was a retrospective review of 603 patients who were referred from Surgical and general out-patient departments of our hospital for breast ultrasound scan between January 2015 and July 2017. Whole breast scans were performed using a single Mindray DC-8 (2011) Ultrasound machine, fitted with a 7–12 MHz transducer. The findings were described, recorded, and a final assessment category assigned using the American College of Radiology (ACR) Breast Imaging Reports and Data systems (BI-RADS) classification as follows: 1 (negative), 2 (benign), 3 (probably benign), 4 (suspicious), 5 (highly suggestive for malignancy), and 6 (known biopsy proven malignancy). Histological diagnoses were sought for abnormal ultrasound findings. Data analysis was done using Statistical Package for Social Sciences (SPSS) software for Windows version 20, Chicago, IL.
Results: The patients comprised of 591 females and 12 males, with a mean age of 35.7 ± 13.0 years. The most common indication was breast lump (44.3%). BI-RADS 1 was the most common category (44.6%), followed by BI-RADS 3 (25.9%). Mass lesion was the most frequent sonographic finding (45.3%). Others were calcifications, 33 (5.5%); architectural distortion, 67 (11.1%); edema, 52 (8.6%); vascular lesion, 1 (0.16%); and ductal abnormalities, 55 (9.1%). The incidence of breast cancer increased with increasing age.
Conclusion: Our predominant ultrasound findings were negative (normal or benign). This supports the use of ultrasound as a first-line diagnostic breast imaging modality in our community. Its added advantage of availability, radiation safety, and less cost makes it an indispensable tool.

Keywords: BI-RADS, breast, ultrasound, Zaria


How to cite this article:
Olarinoye-Akorede SA, Aliyu H, Yunusa HG. Pattern of breast ultrasound findings in Zaria, North Western Nigeria. Arch Int Surg 2018;8:54-8

How to cite this URL:
Olarinoye-Akorede SA, Aliyu H, Yunusa HG. Pattern of breast ultrasound findings in Zaria, North Western Nigeria. Arch Int Surg [serial online] 2018 [cited 2019 Aug 20];8:54-8. Available from: http://www.archintsurg.org/text.asp?2018/8/2/54/259456




  Introduction Top


Breast ultrasound has experienced a surge in recent times because of increased awareness about breast cancer. In the past, ultrasound was mainly used for discriminating between solid or cystic breast masses.[1],[2] However, worldwide its use has been revolutionized due to use of full digital high-frequency transducers, tissue harmonic imaging, automated whole breast scanning techniques, and color and power Doppler imaging techniques.[2],[3],[4] In our environment, it is an attractive breast imaging modality due to availability of equipment even at local government areas, and at relatively less cost when compared with mammography or breast magnetic resonance imaging. In addition, dense breast parenchyma is the predominant pattern among Nigerian women,[5] thus increasing physicians' preference for breast ultrasound. Knowledge of the prevailing ultrasound findings and reliability of ultrasound is, thus, vital for patient management.

This study was undertaken to document the pattern of breast ultrasound findings among symptomatic and asymptomatic women in Zaria.


  Patients and Methods Top


This was a descriptive cross-sectional study comprising of 603 patients who had breast ultrasound examination between January 2015 and June 2017. Ethical approval was obtained from the hospital's ethical committee but informed consent was waived due to the retrospective design of the study. The breast scans were performed on a Mindray machine DC-8 (2011) China, with a 7–12 MHz linear transducer. The patients were required to fill a breast information sheet prior to the ultrasound examination. Physical examination of the breast(s) and axilla with the patient in sitting position was carried out by the performing radiologist before commencing the scan. Overlapping transverse and longitudinal ultrasound scans as well radial and antiradial techniques were employed until the whole breast(s) were scanned. The nipple–areolar complex and lastly the axilla were also examined sonographically.

Previous ultrasound exams or mammograms where available were reviewed alongside. The ultrasound findings were recorded using the standard Lexicon recommended by the American College of Radiology (ACR), which include the presence of a mass, architectural distortion, calcification, skin thickening (>3 mm), lymphatic dilatation, and ductal and vascular abnormality. Where a mass was found, notes were made of its size, shape (round, oval, irregular), margins (circumscribed, noncircumscribed, spiculated), echogenicity (hypoechoic, hyperechoic, anechoic, isoechoic, heterogenous), orientation to skin (parallel, nonparallel), presence of calcification, and posterior acoustic characteristics (none, enhancement, shadowing, combined). Any associated finding was also documented. A final ACR Breast Imaging Reports and Data systems (BI-RADS) assessment category[6] was assigned with recommendations as follows: BI-RADS 1 (negative), BI-RADS 2 (benign finding), BI-RADS 3 (probably benign), BI-RADS 4 (suspicious abnormality), BI-RADS 5 (highly suspicious abnormality), and BI-RADS 6 (histologically proven malignancy) [Table 1].[6]
Table 1: Final ACR BI-RADS assessment categories with recommendations[6]

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Where more than one lesion was identified with different categories, the highest BI-RADS score was recorded.

We further classified the findings according to modified ACR which groups negative finding as BI-RADS 1–3 and positive findings as BI-RADS 4–6. The appropriate recommendation for the BI-RADS category was made. Thereafter, histopathological diagnosis for biopsied masses were sought and recorded.

The data were analyzed using the Statistical Package for Social Sciences software for windows version 20 (SPSS Inc., Chicago, IL, USA).


  Results Top


The 603 consecutive patients recruited for this study included 591 (98%) females and 12 (2.0%) males. They ranged in age between 40 days and 90-year old, with a mean age of 35.67 (±12.89) years [Table 2], among the females, 84.2% were premenopausal, whereas 15.7% were postmenopausal (68.8% primarily and 31.2% secondary to cancer therapy). Out of the total breast ultrasound evaluation, routine examination constituted only 4.8% with diagnostic examination accounting for 95.2%. Family history of breast cancer was present in 6.3% and personal history of breast cancer in 8.1% [Table 2].
Table 2: Patient characteristics

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Breast lump alone was the most common presentation (44.3%), followed by pain (28.7%). Breast lump and pain was seen in 6.3%, nipple discharge in 4.8%, and skin rash in 1.0%. There were 6.1% who had ultrasound scan for post-treatment evaluation for breast cancer [Table 3].
Table 3: Indications for breast ultrasound examination

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The sonographic abnormality with the highest frequency was breast mass, which constituted 45% [Figure 1].
Figure 1: Showing the frequency of breast ultrasound abnormalities

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Other sonographic lesions included calcifications, 33 (5.5%); architectural distortion, 67 (11.1%); edema, 52 (8.6%); vascular abnormality, 1 (0.16%); and ductal abnormalities, 55 (9.1%) [Figure 1].

BI-RADS 1 (negative finding) was the most common category, which constituted 44.4%. This was followed by BI-RADS 3 with 25.4%. BI-RADS 2 constituted 16.6%, whereas BI-RADS 4 (4.5%), BI-RADS 5 (8.6%), and BI-RADS 6 (0.8%), respectively [Figure 2].
Figure 2: Showing the distribution of final BI-RADS categories

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When the final BI-RADS assessment categories were compared with histological diagnosis, ultrasound correctly diagnosed 117 out of 122 benign lesions and 71 out of 73 malignancies [Table 4].
Table 4: Comparison of BI-RADS assessment with histological diagnosis

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The frequency of breast cancer was found to increase with age [Figure 3].
Figure 3: Showing increasing frequency of breast cancer with advancing age

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  Discussion Top


Improved scanning techniques with the use of high-frequency, high-resolution transducers have greatly enhanced breast ultrasound imaging.[2],[3],[4] It is nonionizing, thus safe for patients across all age groups. The youngest patient in this study was 40-day old, whereas the oldest was 90 years. The mean age was 35.67 (±12.89) years, which is lower than the patients studied by Jose et al. in Brazil[2] (49.67 ± 12.09 years) and Omidiji et al.[7] in Lagos, Nigeria (41.7 ± 11.34) years.

Breast lump was the most common presentation among the patients (44.4%), followed by breast pain (24.4%). Because breast lump is the most common symptom for breast cancer,[8],[9] it is a cause of anxiety when lump is felt and thus patients seek medical attention. However, in Calabar, Southern Nigeria, routine evaluation was the major reason why the patients presented for breast evaluation,[10] whereas in Lagos,[7] Enugu,[11] and Nnewi,[12] the chief complaint was breast pain.

In our low-income setting, breast ultrasound is a first-line investigation, and its performance is supported by the findings of Omidiji et al.[7] It exceeds its role as a supplementary tool to mammography, which is the practice in developed countries where mammographic screening is well established.[13],[14]

Nonetheless, the widespread use of ultrasound even in developed countries led to the introduction of the first edition BI-RADS Lexicon for ultrasound in 2003[6] with the goal to standardize breast ultrasound reporting among radiologists.

The report from this study shows that BI-RADS 1 (normal study) was the most common BI-RADS category. This finding was also reported in other parts of the country.[15],[16],[17]

The authors believe that this reflects an improved breast health seeking practice, which is due to recent heightened level of breast cancer awareness.[18],[19]

Mass lesion was the most frequent ultrasound abnormality. The historic advantage of ultrasound was in identifying whether a mass is cystic or solid which cannot be achieved easily with mammography. Ultrasound also gives useful information about the shape, size, margin, echogenicity, and posterior acoustic characteristics of breast masses and state of the adjacent parenchyma, thus allowing a final sonographic assessment as either a benign or malignant finding.[6] In this study, benign findings (BI-RADS 1-3) predominated in 86%, whereas malignancies (BI-RADS 4-6) were recorded in 14% of the patients.

Out of the abnormal scan results, the majority were benign lesions (BI-RADS 2 AND 3). BI-RADS 2 (definitely benign) and BI-RADS 3 (probably benign) both accounted for 42% of all cases. The most common benign lesion was fibroadenoma. This is consistent with the findings of Akinola et al.,[20] Adesunkanmi et al.,[21] Bangaru et al.,[22] Kumar et al.,[23] and Khanzada et al.[24]

However, in the study by Chou et al. in Taiwan[25] and Obajimi et al.,[26] fibrocystic disease occurred in 37.7% and 60%, respectively, whereas fibroadenomas occurred in 21.5% and 10%, respectively.

Ultrasound detected yield for malignancy was low in this study (13.1%); with BI-RADS 4 accounting for 4.5% and BI-RADS 5 accounting for 8.6% of all the cases. The sonographic finding that is most consistent with malignancy was hypoechoic mass with irregular margin, posterior shadowing, and diffuse skin thickening. Ultrasound correctly diagnosed 71 malignancies out of a total of 73 histologically confirmed ones, giving a concordance rate of (97.3%). The incidence of malignancy (BI-RADS 4 and 5) was seen to increase with advancing age; from <2% in first and second decades up to 50% in the seventh decade.

However, the major limitation of breast ultrasound is in the detection of microcalcifications, one of the earliest signs of breast cancer which could be missed.[27] Calcifications were detected in 5.5% of the lesions which might have been underestimated. Hence, mammography is still the preferred imaging modality for breast screening.[27] However, the use of higher frequency transducers have improved the ultrasound detection rate for calcifications.[28]

Another sonographic abnormality was architectural distortion which was present in 65 women. The breast architecture may be distorted by both benign lesions (inflammation, postprocedure) and malignant conditions (carcinoma). In 16 out of the 65 women (24.6%), it was due to benign conditions, whereas it was due to malignancy in 49 out of 65 women (75.3%). A thorough clinical and past surgical history is useful in making appropriate diagnosis.

Breast edema was either diffuse or focal. All the cases of diffuse edema were due to the malignancy except in one patient who had generalized edema from systemic illness. Focal edema on the other hand was seen only in benign conditions such as infection or inflammation. Vascular abnormality was rare, and it was seen one patient with Mondor's disease which resolved spontaneously on subsequent examination.

All the ductal abnormalities were either due to pregnancy, ductal ectasia, or benign intraductal masses.

On the whole, male breast disease was not frequent in this study. Only 12 (2%) of our patients were males; there were eight male patients (67%) with benign conditions, out of which seven were gynecomastia (n = 7) and pseudogynecomastia (n = 1). Malignancy was seen in two men, whereas the remaining two male patients had a normal scan. Overall, the incidence of male breast cancer in this study was 0.3%, which agrees with the <1% documented in previous literature.[29],[30],[31]


  Conclusion Top


In conclusion, breast lesions in our environment are mostly benign; therefore, a noninvasive imaging technique is adequate as an initial work-up tool. Ultrasound is a reliable modality for diagnosis, intervention, and follow-up. However, despite its high performance in this study, its role as a sole screening tool is yet to be fully established.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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