Clinical spectrum study of female patients with benign breast diseases in surgery department of tertiary care centre

INTRODUCTION

Breast forms important feature of female anatomy in addition to having an integral part of female reproductive system. It is a dynamic organ undergoing physiological changes like developmental changes, cyclical changes, pregnancy changes, lactation and involution changes throughout the reproductive period of a woman. In fully developed non-lactating female breast, the epithelial component which comprises less than 10% of total volume is more significant pathologically since majority of lesion arises from this portion of breast. The breasts are composed of specialized epithelium and stroma that may give rise to both benign and malignant lesions. The pathogenesis of benign breast diseases involves disturbances in the breast physiology extending from an extreme of the normality to well defined disease process.^1,2

Benign breast disease is one of the most common diseases in the female of any society. The most common symptoms are breast pain, lump or engorgement. Benign breast disease constitutes a heterogeneous group of lesions that include developmental abnormalities, inflammatory lesions, epithelial and stromal proliferative and benign neoplasms.³

The objective of the study is to correlate between clinical, pathological and radiological parameters of benign breast diseases and to study different modes of presentation.

METHODS

Study type

It was non-interventional, cross sectional observational study of patients who were detected to have benign breast disease.

Study place

Study conducted at government medical college, Aurangabad.

Study period

The study was conducted over a period of 2.5 years from November 2017 to March 2020

Selection criteria of patients

Patients with any benign breast disorders and willing to participate in the study.

Exclusion criteria

Patients with malignant breast diseases and patient who did not give consent for the study.

All the patients categorised according to age, diagnosis, clinical presentation and correlated them radiologically and histopathologically.

Ethical committee clearance was taken before commencing the study in the form of synopsis approval from Maharashtra university of health sciences.

Statistical analysis

All data was filled in Microsoft excel spreadsheet; student t test was used to find significance of study parameters on continuous scale between two groups on metric parameters. Chi-square test was used to find significance of study parameters on categorical scale between two/ more groups. Data analysis was done with help of SPSS software trial version 22.

RESULTS

We observed 200 patients diagnosed with benign breast disease. Result obtained analyzed and tabulated.

The highest number of benign breast diseases were seen in the age group of 20-29.

Diagnosis of fibroadenoma predominates in age group 20-29 and fibroadenosis predominates in group 30-39.

The most common complaint was the breast lump followed by pain.

The most common clinical findings were size 1-3 cm with firm consistency.

The predominant diagnosis was fibroadenoma followed by fibroadenosis.

The predominant diagnosis was fibroadenoma followed by fibroadenosis confirmed radiologicaly and histopathologicaly.

Most of the patients were treated surgically.

DISCUSSION

In the present study we observed 200 patients diagnosed with benign breast disease.

Subjects were studied according to different age groups presenting with benign breast diseases which is highlighted in Table 1. In age group 12 to 19 were 02 (1%). In the age group 20 to 29 number of cases were 90 (45%). In age group 30 to 39 number of cases were 83 (41.5%) In age group 40 to 49 number of cases were 21 (10.5%) in age group above 50 years of age, there were 4 (2%) cases.

In the similar study Memon et al found out of them 500 (62.5%) were young females of 15-25 years of age.⁴ Gupta et al 85% of all patients of benign breast disease fall in the reproductive age group of 15-40 years.⁵ Majority (38.75%) of them belong to age group of 20-30 years with average age being 22.38 years. Shilpa Kumara et al found Out of 58 patients, maximum (23) was in the age group of 10-19 years, comprising 39.7%, followed by 16 patients in age group 20-29 years.⁶ Only 5 (8.6%) patients were more than 40 years. Janaki et al found age wise distribution revealed most women between the age groups of 21-60 years.⁷

The presentation of different benign breast disease in different age groups which is depicted in Table 2 were studied in the age group of 12 to 19 there were 2 cases of Fibroadenoma. In the age group of 20 to 29, there were 51 cases of fibroadenoma, 22 cases of fibroadenosis, 5 cases of ductal ectasia, 5 cases breast abscess and 7 cases of mastitis. In the age group of 30 to 39 years there were 31 cases of fibrodadenoma, 40 of fibroadenosis, 5 of ductal ectasia, 1 of breast abscess, 3 of phylloids and 7 cases of mastitis. In the age group of 40 to 49, 17 cases of fibrodenoma and 4 cases of phylloids were present.

In the age group above 50 years, out of the 200 cases studied there were only 2 patients of fibroadenoma and 2 cases of fibroadenosis.

Shanker et al studied the final diagnosis and age wise distribution of BBDs and found that most of the benign breast disorders were found in the reproductive age group between 20 to 35 years of age.⁸

The mode of presentation of different benign breast disease were also studied which is mentioned in Table 3, only breast lump was present in 103 number of cases (52%). Breast lump with pain was present in 66 number of cases (33%). breast lump with nipple discharge was present in 24 number of cases (12 %). Breast pain only was present in 10 number of cases 05%). Only nipple discharge was present in 8 number of cases (4%).

In a study by Chauhan, the most common clinical presentation was lump in the breast. 67 patients (63.80%) presented with lump in the breast without any other complaint followed by 14 patients (13.33%) who complained of a lump with associated pain.⁹

In another study by Gupta et al the commonest complaint was pain in breast which was present in 53 patients (66.25%), out of which 27 had associated complaints like breast lump, nodularity and nipple discharge while 26 patients (32.5%) had complaint of breast pain (mastalgia) only.⁵ The study at Kumar et al found amongst all patients, 23 i.e. 39.7% complained of pain in the breast while 35 i.e. 60.3% didn’t have pain at the time of presentation.⁶ Similar result were found in Kumar et al and Janaki et al.^7,10

In the similar study by Kumar et al out of 425 patients, 181 (47.63%) had right sided breast involvement while 151 (39.73%) patients had left breast involvement whereas bilateral involvement was seen in 48 (12.63%) patients.¹⁰ In a study conducted by Kumar et al, 35 out of 58 patients had lump in upper outer quadrant while 10 patients had lower outer quadrant lump, rest of the patients had lump extending to more than one quadrant of her breast including nipple-areolar complex.⁶ Laxman et al studied 50 patients and found 34% cases had upper lateral quadrant fibroadenoma.¹¹ The 8% of cases had lower medial quadrant fibroadenoma, 26% patients had fibroadenoma in lower lateral quadrant, 20%, patients had fibroadenoma in upper medial quadrant.

Various characteristic features of benign breast lumps in study subjects were studied which is mentioned in Table 4. Regarding 47 cases (26.25%) were of less than 1cm, 105 cases (58.65%) were between 1 to 3 cm. >3 cm cases (15.05%) were present in 27. Regarding consistency of the lumps in the studied subjects, soft/cystic consistency was present in 42 (23.25%) Firm were present in 107 cases (59.77%). Lumps of variable consistency was present in 30 cases (16.75%). Regarding discharge serous was present in 22 cases (68.75%). Hemorrhagic were present in 03 cases (9.37%). Pustular were present in 07 cases (21.87%).

In the similar study Kumar et al found that majority of the solitary fibroadenomas 84 (55.6%) cases had size <2 cm followed by 67 (44.3%) cases having size between 2-5 cm.¹⁰ All the cases of giant fibroadenomas had size more than 5 cm as per definition while majority of multiple fibroadenomas 2 (66.66%) cases had size between 2-5 cm Kumar et al found consistency of 81% of lumps i.e. 47 was firm, 13.8% i.e. 8 were soft while 13 were hard in consistency.⁶ Laxman et al found maximum patients (58%) had large fibroadenomas. Minimum cases (14%) had giant fibroadenomas.¹¹

The various diagnosed benign breast diseases in study subjects are discussed in Table 5. Out 200 cases studied, 103(51.5%) patients had fibroadenoma, 64 (32%) were fibroadenosis, ductal ectasia was found in 10 (05%), Breast abscess was in 06 (03%) cases, 7 (3.5%) cases had phylloids and remaining 10 (5%) cases had mastitis.

Chauhan et al studied the distribution pattern of benign breast disease, the most common presentation was of fibroadenoma in 49 (46.66%) cases, followed by fibroadenosis which were 31 (29.52%).⁹ Breast abscess cases were 07 (6.6%), duct ectasia 05 (4.76%), mastitis was present in 05 (4.76%) cases.

The diagnosis of benign breast disease in study subjects based on clinical, radiological and histopathological examination were studied which is highlighted in Table 5 and 6. Out of the 103 cases of fibroadenoma, 100% cases were accurately diagnosed histopathologically with 98% and 96% accuracy in clinical and radiological methods respectively in diagnosing it. Similarly, out of the 64 cases of fibroadenosis 100% cases were identified on the basis of histopathological examination with 95% cases identified radiologically and 93% cases through clinical examination. In case of ductal ectasia out of the 10 cases 80% cases were identified clinically followed by 60% identified radiologically and a mere 30% identified histopathologically. 100% accuracy of radiological and clinical parameters was present in diagnosing all of the 6 cases of breast abscess with 83% identified clinically. Similar observation was made in case of phylloids tumor were all the 7 cases were (100% identified based on radiological and pathological methods and 71% cases were identified clinically. Out of the 10 studied cases of mastitis, there is 100% accuracy in identifying the pathology clinically with 40% and 30% accuracy radiologically and clinically.

Study by Samal et al showed that there is 100% accuracy in clinical diagnosis of breast abscess with 96% accuracy in diagnosing fibroadenoma and 89% in case of mastalgia.¹²

Out of the 200 patients, 172 patients underwent USG and remaining 18 patients who aged >40 years underwent mammography. The accuracy rate of USG in diagnosing fibroadenoma, mastagia and phylloids were 83%, 67% and 50% respectively. Whereas mammography showed 83% accuracy in detecting breast abscess, 90% accuracy for fibroadenoma and 50% accuracy in case of mastalgia.

The accuracy of FNAC was 100% in identifying fibrodenoma and ductal papilloma.

In a study conducted by Sukanya et al, which was based on the clinico pathological co-relation of benign breast diseases.¹³ Out of the 60 patients studied, the sensitivity of clinical diagnosis in diagnosing fibroadenoma was 97% and in fibroadenosis was 100%. Two cases of phylloids tumor were diagnosed by FNAC, 1 amongst these 2 cases were diagnosed as carcinoma breast and the other was diagnosed as giant fibroadenoma. The overall sensitivity of clinical diagnosis in detecting BBD’s is 97.9%.

Ortiz et al studied the clinical, pathological and radiological co relation in benign breast diseases, 698 breast ultrasounds in women younger 40 years, 52% ultrasound normal and 48% were reported with benign breast pathology: fibroadenomas 38%, cyst 27%, dilated ducts 24%, benign nodule 4%, mastitis 3%, ectasia 2%, and abscess 2%. Out of the 265 cases of fibroadenoma, the clinical examination versus ultrasound correlation was 50%.¹⁴

The different modes of treatment given to study subjects were studied which is mentioned in Table 7. Conservative management was done in 42 cases of fibroadenoma, 48 cases in fibroadenosis, 10 cases of ductal ectasia, 2 cases of breast abscess and all of the 10 cases of mastitis.

Surgical management was done in 61 cases of fibrodenoma, 16 cases of fibroadenosis, 4 cases of breast abscess and all of the 7 cases of phylloides. Conservative treatment in the form of counselling and medical line of management was advised more of the younger age group with <2 cm size of lumps with no symptoms, whereas surgical line of management was opted for patients having breast lump having >2 cm size with symptoms like pain and discomfort. Enucleation was the surgical line of management opted since cryoablation and USG guided vaccum evacuation was not available in the studied institute.

Shanker et al in a similar study mentions that out the 50 studied subjects, excision was performed in 36 (72%) cases, I and D in 6 (12%) cases, wide excision was performed in 3 cases (6%).⁸ Conservative management was done in 5 (10%) patients. Amongst them 24 cases (68%) cases of fibroadenoma underwent excision, all of the breast abscess underwent I and D, all cases of phylloids underwent excision and all of the duct ectasia cases were managed conservatively.

Limitations

The study was only a non-interventional, observational cohort study. The limited sample size hampered the accuracy of presentation. Since it is a study conducted in tertiary institution, we lack the data of rural areas where awareness is a big issue like a country in India.

CONCLUSION

Benign breast disease occupies majority of the total breast diseases. Majority of the BBDs occur in the reproductive age group with Fibroadenoma as the most common lesion. Lump is the most common presentation of all of the benign breast disease. With clinic-radiological-histopathological co-relational parameters used in the diagnosis of benign breast disease almost equal co-relation of clinical and histopathology examination was found in case of Fibroadenoma. Near equal co-relation of all of the 3 parameters is found in fibroadenosis and breast abscess. Ductal ectasia and mastitis were diagnosed more on the basis of clinical basis as compared to the rest of the parameters.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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