|Ahead of print publication
Clinicohistopathological study of benign breast lesions in surgically excised specimens in a tertiary care hospital
Saswati Boral, Sunil V Jagtap
Department of Pathology, Krishna Institute of Medical Sciences “Deemed to be University,” Karad, Maharashtra, India
|Date of Submission||07-Jun-2020|
|Date of Decision||16-Jul-2020|
|Date of Acceptance||15-Sep-2020|
|Date of Web Publication||23-Jul-2021|
Sunil V Jagtap,
Department of Pathology, Krishna Institute of Medical Sciences “Deemed to be University,“ Karad - 415 110, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Distinguishing benign breast diseases (BBDs) from malignant breast diseases is a worrisome entity and should also have knowledge of the pattern of occurrence of the disorders in their geographical location. This research aimed to study the clinical and histopathological pattern of BBD in Indian patients.
Materials and Methods: The study was conducted on 153 specimens from lumpectomy, core needle biopsy, and mastectomy. Data regarding patients' age, sex, presenting complaints, duration of the complaints, and history of menstrual cycles and lactation were collected from the biopsy requisition forms and case papers. The tissue bits were processed and stained with hematoxylin and eosin, and a histopathological examination was performed.
Results: Most of the patients in the present study were females (n = 151, 98.7%). The mean age of the patients was 30.45 years. Most of the BBD cases (n = 118, 77.14%) were benign, of which fibroadenoma (101 cases) accounted for 66%. Majority of the lesions were in the upper outer quadrant (39.22%). Of the 153 cases, 94 cases of fibroadenoma, one case of breast abscess, nine cases of fibrocystic change, four cases of phyllodes, three cases of lipoma, and one case of gynecomastia diagnosed clinically correlated well with histopathology (n = 112, 73%).
Conclusion: BBDs are mostly seen in female patients in the age group of 21–30 years. Fibroadenoma is the most common BBD. Clinical assessment followed by histopathological examination provided an accurate diagnosis. The clinical diagnosis correlated well with histopathology.
Keywords: Benign breast diseases, breast, breast neoplasms, female, fibroadenoma
| > Introduction|| |
Breast lesions constitute a heterogeneous group of diseases, with etiologies ranging from inflammatory, benign lesions, to malignancies. Fortunately, the incidence of benign breast diseases (BBDs) is far more common than malignancies and also the most common cause of breast problems in females., Annually, 200,000 breast disorders are identified, and most of the presenting lesions are benign. Of these, around 30% of the women with BBDs require treatment at some point in their lives.
The breast is a dynamic organ which is susceptible to hormonal changes throughout the reproductive period of a woman, undergoing numerous morphological and physiological changes from puberty to menopause. Although a lot of studies have been conducted on breast malignancies, the BBDs have been somewhat neglected. Although BBDs are not life-threatening, some of them carry an increased risk of malignancy (e.g., atypical hyperplasia). In such patients, prompt diagnosis and treatment is advised to avoid further complications. Many BBDs such as inflammatory conditions can produce substantial morbidity. In addition, a breast lump is a source of great anxiety due to the fear of malignancy. An early diagnosis helps in alleviating avoidable anxiety about breast cancer in such patients. Furthermore, most BBDs can be treated conservatively or with lumpectomy. Thus, a rapid and accurate diagnosis prevents unnecessary surgical procedures and follow-ups.
A triple assessment consisting of a thorough clinical examination, followed by appropriate imaging such as ultrasonography or mammography and a histopathological examination is considered the standard protocol. Clinical diagnosis requires a thorough understanding of the anatomy, etiology, and presentation of BBDs to make a precise diagnosis. This study attempts to describe the various clinical aspects of BBDs and their correlation with clinical and histopathological examination.
| > Materials and Methods|| |
This was a descriptive, observational, cross-sectional study conducted on 153 specimens of lumpectomy, core needle biopsy, and mastectomy, which had been referred to the department of pathology of a tertiary care hospital over a period of 2 years from June 2017 to May 2019 for histopathological examination. Ethical clearance was obtained from the institutional ethics committee.
The initial sample size consisted of 273 cases, of which 120 were diagnosed as malignant on histopathological examination. Thus, they were excluded from the study. The excisional/lumpectomy specimens accounted for 153 out of the 273 cases, and the remaining were 20 and 100 cases of core needle biopsy and mastectomy, respectively.
Male and female patients of any age group with histopathologically diagnosed BBDs were included in the study. Patients with malignant diseases or a history of treatment for malignancy were excluded from the study.
A detailed history regarding patients' age, sex, presenting complaints (such as lump in the breast, pain, nipple discharge, and fever), duration of the complaints, history of menstrual cycles, lactation, etc., was collected from the biopsy requisition forms and case papers and noted in a pro forma.
The surgical specimens were subjected to a detailed gross examination. Small specimens were fixed whole, but the larger ones were inked prior to sectioning and immersion in 10% neutral buffered formalin. The number of tissue bits taken from each lump depended on the overall size of the lesion. A minimum of four bits were taken. The tissue bits were then processed by routine paraffin embedding techniques. Sections of 4–5-μ thickness were cut and stained with hematoxylin and eosin. Special stains such as Ziehl–Neelsen (20%) stain and periodic acid–Schiff stain were also utilized whenever required. The sections were studied microscopically, and malignant cases were excluded from the study.
The benign breast lesions were further subcategorized as follows,
- Inflammatory and reactive lesions
- Nonproliferative lesions
- Benign proliferative lesions
- Benign neoplastic lesions
The clinical diagnosis of the benign breast lumps was compared with the histopathological findings and their correlation was studied.
The data were collected and recorded in MS Excel. Qualitative data were presented in the form of frequency and percentage. R studio version 3.0.6 software. was used for data analysis. The correlation and degree of agreement between the clinical and histopathological findings were determined using Cohen's kappa coefficient (κ).
| > Results|| |
Of the 273 samples initially considered, 120 cases (44%) were diagnosed as malignant and 151 as breast lesions on histopathological examination [Figure 1]. Most of the patients in the present study were females (n = 151, 98.7%) and only two patients (1.30%) were males. The age of the patients varied between 11 and 65 years, with the mean age being 30.45 years. Majority of the lesions were located in the upper outer quadrant (39.22%) followed by the upper inner quadrant (16.99%). Involvement of multiple quadrants was seen in 9.80% cases [Table 1]. Most of the cases presenting with breast lumps did not complain of pain (81.72%), whereas 21 cases (13.72%) presented with painful lumps, 4 cases (2.61%) had painful lumps with nipple discharge, 1 case (0.65%) presented with lump and nipple discharge, and 2 cases (1.30%) presented with only nipple discharge [Table 2]. Majority of the cases were observed in the right side (51.64%) which was followed by left and bilateral occurrence with 38.56% and 9.80%, respectively.
|Figure 1: Pie-chart showing distribution of benign and malignant breast lesions|
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The maximum number of BBD cases (n = 118, 77.14%) were benign, of which fibroadenoma alone (101 cases) accounted for 66% of all the cases. The size of the fibroadenoma in the present study ranged from 1 to 13 cm. The second most common were inflammatory lesions (n = 12, 7.85%) followed by benign proliferative lesions (n = 11, 7.18%) [Table 2].
In the present study, the maximum number of patients belonged to the age group of 31–40 years (36.6%) and 21–30 years (26.82%). Fibroadenoma was the most common BBD in the age group of 31–40 years accounting for 67.8% of all cases in this group [Table 3].
|Table 3: Age-wise distribution of benign breast diseases based on histopathology|
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Out of 153 cases, 94 cases of fibroadenoma, 1 case of breast abscess, 9 cases of fibrocystic change, 4 cases of phyllodes, 3 cases of lipoma, and 1 case of gynecomastia diagnosed clinically correlated well with histopathology (n = 112, 73%). The fibroadenoma architecture revealed pericanalicular pattern which was observed in 55 cases, intracanalicular pattern in 31 cases, and both patterns in 15 cases.
Cases which were clinically diagnosed as lump in the breast were histopathologically diagnosed as sclerosing adenosis, tubular adenoma, adipomastia, lipoma, phyllodes, fibroadenoma, fibroadenomatoid hyperplasia, and juvenile papillomatosis. Nine cases had been diagnosed as breast carcinoma. Histopathologically, these cases were diagnosed as nodular fasciitis, hamartoma, duct ectasia, intraductal papilloma, and phyllodes. [Table 4] shows the clinical and histopathological correlation of BBDs.
|Table 4: Clinical and histopathological correlation of benign breast diseases|
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| > Discussion|| |
BBDs are frequently observed in females and are important as they mimic malignancy. Although they affect women of a large age range from puberty to postmenopause, they have not been studied as thoroughly as malignancies. As their frequency is higher than that of malignancy, a clinician will encounter BBDs more frequently than malignancy. A thorough understanding of the clinical parameters would help alleviate patient anxiety until the histopathological results are obtained.
In the present study too, of the 273 samples initially considered, the incidence of benign breast was 153 (56%). The finding was in concordance with two other studies wherein the majority of the cases were benign breast lesions., However, the incidence was less as compared to studies by Pudale and Tonape who reported 71.15% BBDs in their study. This difference may be due to the larger sample size in that study (n = 759).
Lesions of the breast are predominantly confined to females. In the present study, out of the 153 cases, 151 patients were females (98.70%) and only 2 (1.30%) were males. This finding is concurrent with that of Koorapati and Kishan who reported 250 cases of benign breast lesions, of which 247 (98.8%) were females and 3 (1.2%) were males. In males, the breast is a rudimentary structure, relatively insensitive to endocrine influences. This may be the reason for the strong affinity between breast lesions and females.
In the present study, a majority of the lesions (36.6%) were noted in the age group of 31–40 years followed by 26.82% in those aged 21–30 years. This finding is concurrent with studies by Pudale and Tonape, Pandey et al., and Tiwari and Tiwari.,, This predilection for the fourth decade differentiates BBDs from malignancies. The incidence of BBDs begins to rise in the second decade of life and peaks in the fourth or fifth decades, whereas the incidence of malignant lesions continues to rise after menopause.
We observed that the majority of breast lumps (39.24%) were located in the upper outer quadrant followed by the upper inner quadrant (16.99%). This finding was mirrored in the studies by Kulkarni et al. and Koorapati et al. The preference for the upper outer quadrant may be due to the greater amount of breast tissue in this quadrant. Interestingly, breast malignancies in this quadrant are associated with a better prognosis than any other site.
Most of the cases (81.72%) presented with painless breast lumps followed by breast lumps with pain (13.72%). Similar findings were reported by Rasheed et al. and Jabbo et al., This finding demonstrates that most of the cases are painless, and patients present only when a breast lump is palpable. As this finding is similar to a breast carcinoma, a thorough understanding of the presentations of BBDs would help alleviate the psychological distress.
Fibroadenoma was the most common BBD in this study, accounting for 66% of all the cases. Our finding was in agreement with most of the studies in the available literature on benign breast lumps., The peak incidence of fibroadenoma ranged from the second to the third decade of life, which was consistent with the findings in other studies. These benign masses may enlarge slowly without associated pain or nipple and skin changes, but fluctuations in size may occur with the menstrual cycle. Small-sized lesions may be treated conservatively, whereas lesions which are growing in size or are symptomatic may need to be surgically excised. The size of the lumps of fibroadenoma in the present study ranged from 1 to 13 cm. This finding was similar to a study by Al-Atrooshi et al. who reported the lump size of fibroadenoma to be 1.5–19 cm.
Out of the 153 cases, 112 cases correlated well with histopathology (73%). There was a good correlation of fibroadenoma clinically and histopathologically. Out of 101 histopathologically diagnosed cases of fibroadenoma, 94 cases were clinically diagnosed. Clinical misdiagnosis as breast carcinoma occurred in nine cases. Histopathologically, these cases were diagnosed as nodular fasciitis, hamartoma, duct ectasia, intraductal papilloma, and phyllodes. In these cases, histopathology was the gold standard for diagnosis.
Thus, a thorough clinical knowledge of BBDs allows for efficient diagnoses which could correlate well with histopathology. The limitation of this study, in addition to being a relatively small sample size, was ignorance of the third aspect of the triple-assessment protocol – imaging. A multicenter study with a larger sample size with correlation studies between clinical assessment, imaging, and histopathology would allow for a more accurate diagnostic protocol.
| > Conclusion|| |
BBDs are a heterogeneous group of diseases seen preponderantly in female patients in the age group of 21–30 years. Fibroadenoma is the most common BBD, and the clinical diagnosis of the same correlates well with histology. Thus, fibroadenoma may be diagnosed accurately clinically, for a rapid alleviation of patient anxiety. However, histopathology is the gold standard when a malignancy is suspected. Clinical assessment followed by histopathological examination provides an accurate diagnosis of BBDs.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]