|Ahead of print publication
A clinicopathological study of benign breast diseases in females
Sandesh Bharat Singh1, Nilay Chakrabarti2
1 Senior Resident, Department of Surgery, K.J.Somaiya Medical College and Research Centre, Mumbai, Maharashtra, India
2 Head of Department, Department of Surgery, K.J.Somaiya Medical College and Research Centre, Mumbai, Maharashtra, India
|Date of Submission||24-May-2020|
|Date of Decision||20-Jul-2020|
|Date of Acceptance||07-Aug-2020|
Department of Surgery, K. J. Somaiya Medical College, Research Centre and Hospital, Sion, Mumbai - 400 022, Maharashtra
Source of Support: None, Conflict of Interest: None
Introduction: Benign breast diseases are often considered as aberrations of normal development and involution. The increasing campaigns for breast health have increased awareness among women causing an increase in the number of cases detected. Around 70%–80% of the biopsies performed are of benign nature. The most common complaints are lump, pain, and discharge. Aim: Our primary aim was to study the clinicopathological correlation of benign breast disease and view it in the context of other similar studies in the past. Materials and Methods: Sixty patients attending the Outpatient and Inpatient Department of Surgery at a tertiary care hospital from June 2011 to December 2012 was carried out. Various parameters such as age, sex, disease pattern, lesion types, histopathological diagnosis, and clinical diagnosis were studied and compared. Cramer's V test was applied. Results: In our study, fibroadenoma (66.7%) was the most common lesion which occurred in patients in the age group of 21–30 years, followed by fibroadenosis (16.7%) which occurred mostly in the age group of 21–30 years. The lesion mostly occurred in the age group between 21 and 30 years (40%). The most common complaint in women was lump (73.33%), followed by lump and pain. Conclusions: Epidemiology of benign breast diseases still remains the same when analyzed with a past and recent study on benign breast diseases. Triple assessment remains the key in the evaluation of breast lumps.
Keywords: Aberrations in the Normal Development and Involution, benign, clinicopathological study
| Introduction|| |
The breasts are an important feature of female anatomy and form an integral part of the female reproductive system. They are a part of secondary sexual characters and have a significant role to play in the reproductive life of a patient.
Benign breast diseases are often considered as aberrations of normal development and involution. The increasing campaigns for breast health have increased awareness among women causing an increase in the number of cases detected. Around 70%–80% of the biopsies performed are of benign nature. The most common complaints are lump, pain, and discharge. Triple assessment is done for diagnosing patients with symptomatic breast lesions.
Our primary aim was to study the clinicopathological correlation of benign breast disease and view it in the context of other similar studies in the past.
| Materials and Methods|| |
A prospective study of 60 female patients attending the Outpatient and Inpatient, Department of Surgery at a tertiary care hospital from June 2011 to December 2012 was carried out. Some of the patients were diagnosed and treated on an outpatient basis while some required admission. Informed consent was taken. Institutional ethical clearance was done on December 19, 2012. A detailed history was taken from each patient, followed by thorough clinical examination.
While most investigations could be carried out on an outpatient basis (including referral for mammography outside the hospital since the facility was not available in the hospital itself), some patients were admitted for completion of investigations and treatment. Various parameters such as age, sex, disease pattern, lesion types, histopathological diagnosis, and clinical diagnosis were studied and compared.
Data were tabulated and analyzed in detail covering the various clinicopathological aspects of benign breast disease presenting with a lump. An appropriate statistical test (Cramer's V test was applied) was applied in this analysis, and appropriate conclusions were drawn. Those patients fulfilling the inclusion and exclusion criteria were selected.
All females from menarche to 50 years of age.
- Postmenopausal women
- Patients with carcinoma breast
- Premenarche females.
| Results|| |
On analysis of the study [Chart 1], it was found that benign lump incidence was more in the age group of 21–30 years (24 patients, i.e., 40%), followed by 31–40 years in 20 cases.
Most of the patients presented with complaints of lump in the breast 44 cases (73.33%), followed by lump and pain in 10 (16.7%) cases and lump, pain, and fever in the other 6 (10%) cases.
Of the patients presenting with lump, 33 of them had been detected as fibroadenoma. Except in one case which presented with lump and pain, the rest cases of fibroadenosis presented as lump.
In this study of 60 patients [Chart 2], 40 cases (67.7%) had fibroadenomas, followed by fibroadenosis in 10 cases (16.7) and breast abscess in 6 cases (10%). Thus, fibroadenoma is found to be the most common lesion, followed by fibroadenosis in our current study.
Clinical versus fine-needle aspiration cytology/high platelet reactivity diagnosis
These two [Table 1] compare the various benign breast diseases detected clinically and on fine-needle aspiration cytology (FNAC)/histopathology and their percentages.
|Table 3: Correlation of Age distribution in the present study with Mima Maychet B. Sangma et al.|
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V is equal to the square root of Chi-square divided by sample size, n, times m, which is the smaller of (rows-1) or (columns-1): V =
X2 = 191.500, P = 0.00, n = 60, m = 4.
The Cramer's V test shows a very high association between the two diagnoses and is significant.
| Discussion|| |
Benign breast disease is a group of condition which ranges from normal to aberrations to disease. Patients of benign breast diseases usually present with the following complaints – breast lump, breast pain, or nipple discharge. Patients with discrete breast lump should undergo a triple assessment to reach an early diagnosis.
In the Western population, benign breast diseases are 10 times more common than breast cancer. For majority of the patients, once cancer has been excluded, reassurance is the keystone of management. Women are ignorant of the lump and other associated complaints due to lack of education. Fibroadenoma is the most common benign breast lump presenting in young females. Patients usually want removal of the lesions for social reasons and also for the fear of malignancy.
Knowledge of general features of individual breast diseases such as incidence, age distribution, symptoms, and palpatory findings is important to make accurate diagnosis. The literature available suggests that benign conditions of breast are significantly more common than the malignant conditions in developing countries.
There is usually a delay in the diagnosis and management of benign as well as malignant lesions in developing countries because of illiteracy, social taboo, and unawareness. Triple assessment of the breast which is a combination of clinical examination, breast imaging, and aspiration cytology has been shown to be accurate in preoperatively diagnosing breast lumps.
On analysis of our study [Table 1], it was found that benign lump incidence was more in the age group of 21–30 years (24 patients, i.e., 40%), followed by 31–40 years.
In the age group of 21–30 years, there were 40 patients. This was almost similar to the observation which was made by Mima et al. [Table 6] In the present study, most of the patients belonged to the active reproductive years (20–40 years) depicting the occurrence of aberrations as described in literature in the most active years. In our study, the youngest patient was 14 years old and the eldest was 40 years. The common age group affected with benign breast diseases was 21–30 years. The mean age was 26.58 years, with a standard deviation of 8.074. Thus, benign breast diseases are found more commonly in the age group of 21–40 years, i.e., the reproductive age group. The incidence increases with age.
|Table 5: Clinical diagnosis of various benign breast diseases versus fine-needle aspiration cytology/histopathology diagnosis|
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|Table 6: Correlation of disease pattern in the present study with Mima Maychet B. Sangma et al.|
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Most of the patients presented with complaints of lump in the breast 44 cases (73.33%).
In the study by Mima et al., [Table 4] the frequency of breast lump was 87%. The corresponding figure for our study was 100%. The incidence of breast pain in our series was 26.67%, which was nearly equal to Mima et al.
|Table 4: Correlation of symptomatology in the present study with Mima Maychet B. Sangma et al.|
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Mima et al. reported that the incidence of nipple discharge was 9% of all the breast complaints in his study, but no patient with complaints of discharge was found in our study.
In the study of Foxcroft et al., they had found that 87.4% of the women who attended the Wesley Breast Clinic had complaints of breast lump, while in the series of Ratanachaikanont, breast lump was the present in 72.35% of the 331 patients suffering from benign breast disease.
Memon et al. in their study of 500 young females between the ages of 15 and 25 years found that breast lumps were present in all the 500 patients examined while pain in the breast was complained by 210 patients.
Most of the author studies mentioned above have shown that breast lump is the most common presenting symptom in females suffering from benign breast disease, followed by breast pain and nipple discharge.
The only exception being a study by Krishnaswamy in 2003 which mentioned breast pain being the most common presenting symptom followed by breast lump.
Social taboo associated with the examination of a woman by a male doctor plays an important role in preventing women with complaints related to the breast to take medical advice.
Thus, breast lump is the most common presenting feature in females presenting for benign breast diseases, followed by breast pain.
Most of the women probably think that if there is a lump, it might be cancer, and it is only then that they visit a clinician as shown by the high incidence of women presenting with breast lump in our study [Table 4].
Fibroadenomas accounted for 66.7% of the benign breast lumps in our study. Our findings were nearly in agreement with most of the available literature on benign breast lumps, which showed the frequency of fibroadenoma ranging from 46.6% to 55.6%.,,, The peak incidence of fibroadenoma ranged from the second to the third decade of life, which was consistent with the findings of other studies [Table 4]. FNAC was the quickest and the most reliable diagnostic investigation for making the diagnoses of the breast lumps.
The result of this study shows that fibroadenoma is the most common benign breast lesion in this locality. Khanzada et al. in Pakistan also reported similar findings.
Most fibroadenomas occur at a slightly earlier age group than fibroadenosis, thus depicting the fact that fibrocystic changes are variations of the repeated cyclical changes that occur in the form of menstruation, pregnancy, and lactation.
Siddiqui reported in their study the incidence of fibroadenomas as 17% as it was based on histopathological analysis. He had studied 3279 cases of benign breast disease at a tertiary care hospital.
Arihiro reported a higher incidence of fibroadenomas at 84.6% in their study. The study was based on data which were retrieved from the tumor tissue registry file between 1973 and 1995.
Akhator reported the incidence of fibroadenomas to be around 68.0% in their study. It was a 5-year retrospective review of all histologically proven benign breast lesions. He had not included lesions such as mastalgia in his study. study. As seen in [Table 6] the correlation between diseases is similar between our study and that by Mima et al. Irabor reported an incidence of fibroadenomas to be 64.3% in their study which was a retrospective data of all breast biopsies done over a period of 8 years and 3 months.
The study by Selvakumaran et al. comprised 168 patients with benign breast disease; the most common was fibroadenoma which formed 55.9%, followed by fibroadenosis 20.8%.
There was no significant difference noted in the recent literature regarding the age groups of patients presenting as fibroadenoma. This was probably because of its presentation as a freely mobile discrete lump in the breast of young females. There is more awareness among females due to electronic media and education.
The lesion has a relationship to the estrogen sensitivity as it occurs predominantly in the second and third decades of life. In the present study, the common age of presentation of a case of fibroadenoma was also the second decade which was comparable to the above reports.
Two studies, which were considered to provide strong evidence of reliability according to El-Wakeel and Umpleby, show that the relative risk of developing breast cancer in patients who had surgically excised fibroadenomas increases in the presence of complex features within the fibroadenomas, ductal hyperplasias, or a family history of breast carcinoma (in a first-degree relative). No genetic instabilities, manifested as loss of heterozygosity or microsatellite instability, have been found in any fibroadenoma components.
Some physicians prefer excision for tissue diagnosis, but conservative management will likely replace surgical treatment in the near future, on the basis of the young age of the patient, findings of benign imaging and clinical characteristics, and benign findings on either FNA biopsy or needle core biopsy. Minimally invasive techniques, such as ultrasound-guided cryoablation, seem to be an excellent treatment option for fibroadenoma in women who wish to avoid surgery. The lesion may be treated with observation and periodical follow-up.
The fibrocystic changes were the next most common condition in our study, and a majority of these patients belonged to the second and third decades. Many authors like Adesunkanmi and Agbakwuru et al. found in their study that the incidence of the fibrocystic changes ranged from 29.5% to 42.2% for the benign breast lumps. We had a smaller figure, with 16.7% of the patients suffering from fibrocystic disease. The incidence of fibrocystic diseases varies geographically. It is the second most common condition in many studies from India and Pakistan.,
The difference between the age groups in which the patient presents with fibrocystic diseases of breast differs geographically. The possible reasons for the variation were as follows: different social cultures, the age of menarche and parity, breastfeeding, use of contraceptive pills, and self-awareness about the various breast diseases and their presenting features. Females affected with fibrocystic disease tend to visit the surgeon only when the symptoms are alarming; this is probably due to the low literacy rates among females of the rural areas.
Over the years, many names have been used to describe fibrocystic disease including fibrocystic disease, cystic mastopathy, chronic cystic disease, mazoplasia, and Reclus' disease. However, the term “fibrocystic disease” is now preferred because this process is observed in up to 50% of the patients clinically and in 90% of the patients histologically.
Memon et al. in their study had concluded that the pattern of fibroadenomas in young females is changing from fibroadenoma to fibroadenosis and fibrocystic disease and that fibroadenoma itself is getting from soft, smooth, regular, and mobile toward firm to hard, irregular, and adherent type. This changing pattern of presentation of benign breast lump in young females needs further evaluation to find the reasons. It could be due to different environmental, social, nutritional, or hormonal factors, as most of these girls were from lower socioeconomic class. They were anxious and unmarried which may lead to altered hormonal status of body causing lump formation.
Granulomatous inflammatory breast changes can be related to infectious agents such as mycobacterium tuberculosis. Noninfectious diseases such as sarcoidosis, foreign body such as silicon, paraffin or the suture material, or trauma with fat necrosis and granuloma formation can all lead to the formation of granulomatous inflammatory breast lesions. Granulomatous mastitis had been described in young parous women who had presented with a tender breast lump following pregnancy by a period ranging from 1 to 78 months and who were suspected clinically of having some malignancy.
We observed acute mastitis and breast abscess more in the third decade of life as a case of puerperal or lactational mastitis. The early diagnosis at acute mastitis stage before developing an abscess is important as it is at this stage the disease can be managed by needle aspiration and antibiotics without the need for surgery with excellent results. In this study, there were three cases of acute mastitis and six cases of breast abscess, all managed successfully.
Breast abscess was seen in 10% of the patients in our study with peak incidence in patients from the third decade of life. This was most commonly observed in lactating females during the first 3 months after delivery. Breast abscess is often related to lactation period.
The increased incidence of breast abscess during the lactational period may be due to the lack of hygiene and improper breastfeeding. In the present study, all the women with breast abscess were married and were between 20 and 40 years. Barreto et al. found in their study that acute bacterial mastitis commonly presents at any age but most frequently occurs in lactating breasts. There was one case of galactocele in our study.
The majority of the patients with a clinical breast lesion will have benign process.
Thus, the most common lesions in our study include fibroadenoma and fibroadenosis, as is described, followed by breast abscess and mastitis in that order.
The clinical diagnosis matches with the FNAC/histopathological diagnosis in our study.
| Conclusions|| |
Early diagnosis and understanding of the clinicopathological correlation is essential in patients with benign breast disease. Appropriate counseling and treatment can go a long way in reducing anxiety in majority of patients with benign breast disease resulting in a better quality of life for them. Epidemiology of benign breast diseases still remains the same when analyzed with a past and recent study on benign breast diseases. Triple assessment remains the key in the evaluation of breast lumps.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Kumar N, Prasad J. Epidemiology of benign breast lumps, is it changing: A prospective study. Int Surg J 2019;6:465-9.
S. Selvakumaran, Mimamaychet B. Sangma. Study of benign breast disease. Int Surg J 2017;4:339-43.
Dahri FJ, Awan MS, Leghari AA, Khaskheli NM, Soomro I, Memon ZI. An early diagnosis of benign breast diseases. J Surg Pak Int. 2010;15(4):186.
Krishnaswamy U. Profile of benign breast disease in the urban India. Indian J Surg 2003;65:178-81.
Qureshi S, Sultan N. Topical nonsteroidal anti inflammatory drugs versus oil of primrose in the treatment of mastalgia. J R Coll Surg Edinb Irel 2005;3:7-10.
Akram M, Iqbal M, Daniyal M, Khan AU. Awareness and current knowledge of breast cancer. Biol Res 2017;50:33.
Kumar M, Ray K, Harode S, Wagh DD. The pattern of benign breast diseases in rural hospital in India. East Central African J Surg 2010:15:59-64.
Mima B. Sangma M, Panda K, Dasiah S. A clinico-pathological study on benign breast diseases. J Clin Diagn Res 2013;7:503-6.
Foxcroft LM, Evans EB, Hirst C, Hicks BJ. Presentation and diagnosis of adolescent breast disease. Breast 2001;10:399-404.
Ratanachaikanont T. Clinical breast examination and its relevance to diagnosis of palpable breast lesion. J Med Assoc Thai 2005;88:505-7.
Memon A, Parveen S, Sangrarasi AK, Malik AM, Laghari A, Talpur KA. Changing pattern of benign breast lumps in young females. World J Med Sci 2007;2:21-4.
Giri, R., Bhandari, R., Mahato, I., Poudel, M., Kumari, S., & Yadav, A. Breast problems in women. Health Renaissance. 2013;11:33-7.
Adesunkanmi AR, Agbakwuru EA. Benign breast disease at Wesley Guild Hospital, Ilesha, Nigeria. West Afr J Med 2001;20:146-51.
Marumoto A, Steinemann S, Furumoto N, Woodruff S. An uncommon pairing of common tumors: Case report of ductal carcinoma in situ
within fibroadenoma. Hawaii J Med Public Health 2019;78:39-43.
Geethamala K, Vani BR, Srinivasa MV, Radha M. Fibroadenoma: A harbor for various histopathological changes. Clin Cancer Investig J 2015;4:183-7. [Full text]
Khanzada TW, Samad A, Sushel C. Spectrum of benign breast diseases. Pak J Med Sci 2009;25:265-8.
Siddiqui MS. Breast diseases - A histopathological analysis of 3279 cases at a tertiary care centre in Pakistan. Jr Pak Med Asso 2003;53:5.
Arihiro K. Trends in benign breast tumors in Japanese women, 1973-1995: Experience of hiroshima tumor tissue registry. Jpn J Cancer Res 2002;93:610-5.
Akhator A. Benign breast masses in Nigeria. Nieg Jr Surg Sci 2007;17:105-8.
Irabor DO. An audit of 149 consecutive breast biopsies in Ibadan, Nigeria. Pak J Med Sci 2008;24:257-62.
Chaudhary IA, Qureshi SK, Rasul S, Bano A. Pattern of benign breast diseases. J Surg Pak 2003;8:5-7.
El-Wakeel H, Umpleby HC. Systematic review of fibroadenoma as a risk factor for breast cancer. Breast 2003;12:302-7.
Geisler DP, Boyle MJ, Malnar KF, McGee JM, Nolen MC, Fortner SM, et al
. Phyllodes tumors of the breast: a review of 32 cases. Am Surg 2000;66:360-6.
Khemkha A, Chakrabarti N, Shah S, Patel V. Palpable breast lumps: Fine needle aspiration cytology versus histopathology: A correlation of diagnostic accuracy. Internet J Surg 2009;18:1.
Chen YY, Fang WH, Wang CC, Kao TW, Chang YW, Yang HF, et al
. Examining the associations among fibrocystic breast change, total lean mass, and percent body fat. Sci Rep 2018;8:9180.
Rosai J. Chapter 20. Breast. In: Rosai and Ackerman's Surgical Pathology. 9th
edition. Philadelphia: Mosby; 2004. p. 1763-876.
Yukawa M, Watatani M, Isono S, Fujiwara Y, Tsujie M, Kitani K, et al
. “Management of granulomatous mastitis: A series of 13 patients who were evaluated for treatment without corticosteroids.” Int Surg 2015;100:774-82.
Barreto DS, Sedgwick EL, Nagi CS, Benveniste AP. Granulomatous mastitis: etiology, imaging, pathology, treatment, and clinical findings. Breast Cancer Res Treat 2018;171:527-34.
Orr B, Kelley JL 3rd
. Benign breast diseases: Evaluation and management. Clin Obstet Gynecol 2016:59:710-26.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]