Spectrum of benign breast diseases

Tariq Wahab Khanzada¹, Abdul Samad², Champa Sushel³

ABSTRACT

Objective: To determine the frequencies of various benign breast diseases (BBD) in female patients in three private hospitals of Hyderabad.

Methodology: This is a prospective cohort study of all female patients visiting the surgical clinic with breast problems. This study was conducted at Isra University Hospital Hyderabad and two other private hospitals of Hyderabad over a period of about three years starting from March 2004 to February 2007. All female patients visiting the surgical clinic with breast problems were included in the study. Patients with obvious clinical features of malignancy or those who on work up were diagnosed as carcinoma were excluded from the study.

Results: A total of 275 patients were included in the study. About 44% (120/275) patients belonged to 3rd decade of life (age between: 21-30 years) followed by 33% from 4th decade (age between: 31 – 40 years). Fibroadenoma was the most common benign breast disease, seen in 27% (75/275) of patients, followed by fibrocystic disease seen in about 21% (57/275) patients.

Conclusion: Benign Breast Diseases (BBD) are common problems in females of reproductive age. Fibroadenoma is the commonest of all benign breast disease in our set up mostly seen in 2nd and 3rd decade of life. Fibrocystic disease of the breast is the next common BBD whose incidence increases with increasing age.

KEY WORDS: Benign breast disease, Fibroadenoma, Fibrocystic diseases.

Pak J Med Sci    April - June 2009    Vol. 25 No. 2    265-268

How to cite this article:

Khanzada TW, Samad A, Sushel C. Spectrum of benign breast diseases Pak J Med Sci 2009;25(2):265-268.

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1. Dr. Tariq Wahab Khanzada FCPS, FRCS,
Assistant Professor,
2. Dr. Abdul Samad FCPS,
Associate Professor
3. Dr. Champa Sushel FCPS,
Assistant Professor, Dept. of Surgery,
1-3: Isra University Hospital,
Hyderabad, Pakistan.

Correspondence

Dr. Tariq Wahab Khanzada,
Flat. No. C-51, Hasnain Square,
Liberty Market, Jacob Road,
Hyderabad, Pakistan.
E-mail: tariqwahab@yahoo.com

* Received for Publication: September 24, 2008

* Accepted: February 5, 2009

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INTRODUCTION

The term "benign breast diseases" (BBD) encompasses a heterogeneous group of lesions, that may present a wide range of symptoms or may be detected as incidental microscopic finding.1 BBD includes all nonmalignant conditions of the breast, including benign tumours, trauma, mastalgia, mastitis and nipple discharge. Benign tumours include pathologic changes that do not increase a patient’s risk for developing cancer, lesions that confer a slightly increase risk and lesions that are associated with up to 50% risk of developing breast cancer.2 BBD can present with a palpable mass, pain and nipple discharge or nipple inversion.

The issue of BBD is a relatively neglected aspect of breast diseases and has received step motherly treatment as compared to the malignant lesions of the breast. This is despite the fact that vast majority of the lesions that occur in the breast are benign and it has been reported that benign lesions of the breasts are far more frequent than the malignant ones.1,3 It has also been reported that at least 90% of the patients visiting breast clinics will have non-malignant disorders.4,5 With this back ground scenario, it was considered appropriate to determine the spectrum of BBD in this part of world. The objective of this study was to determine the frequencies of various BBD in female patients in three private hospitals of Hyderabad.

METHODOLOGY

This was a prospective cohort study carried out at Isra University Hospital Hyderabad and two other private hospitals of Hyderabad over a period of about three years starting from March 2004 to February 2007. All female patients visiting the surgical clinic with breast problems were included in the study. Patients with obvious clinical features of malignancy or those who on work up were diagnosed as carcinoma were excluded form the study. Detailed histories of patients were recorded that included age, marital status, parity, age of menarche, age at first pregnancy and age at menopause. Patients aged 50 years or above and having no menses for at least two years at the time of presentation were considered to be postmenopausal.

Family history of breast diseases especially breast cancer, history of contraception used was recorded. Detailed examination of lump and axilla was made with especial attention to any clinical signs of malignancy. Ultrasonography or mammograms were done when required necessary. Fine needle aspiration cytology (FNAC) was performed in patients with lumps to confirm the diagnosis. Core biopsy and / incisional or excision biopsy was done in patients with inconclusive FNAC report. Data was entered on pre-designed proforma and frequencies of various BBD in different age groups were calculated.

RESULTS

A total of 275 patients were included in the study during the three years from March 2004 to February 2007. About 44% (120/275) patients belonged to 3rd decade of life (age between: 21-30 years) followed by 33% from 4th decade (age between: 31 – 40 years), 11% from the 5th decade (age between: 41 – 50 years) and 10.5% from 2nd decade (age between: 11 – 20 years) of lives.

Fibroadenoma was the most common benign breast disease seen in 27% (75/275) of patients, followed by fibrocystic disease seen in about 21% (57/275) patients. Breast abscess was seen in 16% (45/275) patients, duct ectasia in 12% (34/275) and mastalgia in 11% (31/275) patients. Other benign diseases noted were duct papilloma in 4.7% (13/275), galactocele in 2.5% (7/275), and tuberculous mastitis was seen in 4% (11/275) of patients.

About 57% patients with fibroadenoma belonged to 3rd decade of life followed by 32% from 2nd decade of life. About 51% of patients with fibrocystic disease were from 4th decade, 26% from 5th decade and 17.5% from 3rd decade. Breast abscess was commonly seen in patients (58%) of 3rd decade and in 33.3% patients of 4th decade. About 38% of patients with duct ectasia were seen from 4th decade followed by 35% from 3rd decade and 26% from the 5th decade of life. About 45% of cases of mastalgia were from 3rd decade of life followed by 35% from 4th decade. Galactocele which accounted for 2.5% (7/275) of all BBD was seen in 57% of patients in 4th decade of life. Duct papilloma was equally common in both 3rd and 4th decade of life while granulomatous mastitis was more commonly seen (54%, 6/11) in 3rd decade of life. A detailed account of these BBD according to the various age group is shown in Table-I.

DISCUSSION

Breast is a dynamic structure and undergoes various stages of physiological changes, i.e. development, cyclic changes, pregnancy, lactation and involution. These physiological changes create a concept of aberration of normal development and involution (ANDI). This does not mean that BBD does not occur, but that the term should be reserved for disorders of such severity that they are frankly abnormal.

In our study about 82% of the patients with BBD were in the age group between 11-40 years with peak incidence (43.5%) in age group between 21-30 years. These results are consistent with the study of Out AA6 in which majority of the patients were below the age of 30 years. Ihekwaba in his study from Western Africa showed that about 80.5% of the BBD occur in females between 16-35 years of age.7 Chaudhary et al found almost equal incidence of BBD in patients between age group of 21 - 30 & 31 - 40 years.8 However Dunn et al., contradicts the results of all above mentioned studies in which the mean age of the patient with BBD was 50 years.9

In our study fibroadenoma was the most common BBD seen in 75 of patients. Fibroadenoma was most commonly seen (57%) in patients with 3rd decade (21 - 30 years) of life and 32% in patients with 2nd decade (11 - 20 years) of life. This observation is also noted in two local studies where they found fibroadenoma as common BBD with incidence of 42% and 45% respectively.10,11 Murilllo et al also found 38% incidence of fibroadenoma in a study of about 698 patients with BBD.4 No significant difference was noted in the recent literature regarding the age groups having fibroadenoma.8 This is because of its presentation as freely mobile discrete lump in the breast of young females and more awareness among females due to electronic media and education.

Fibrocystic disease was the second most common (21%) BBD seen in our study. The vast majority of the patients (51%) with fibrocystic disease were from 4th decade followed by 26% from 5th decade of life. Ali et al11 and Rashid et al10 also noted fibrocystic disease as second common BBD after fibroadenoma accounting for 36% and 17% respectively. Stern et al12 found fibrocystic disease as the most common in females of all ages especially in the middle age group. Chaudhary et al8 in his study of 234 patients, found fibrocystic disease as the most common BBD with maximum age incident in the 5th decade of life while Kamal et al found about 65% of patients with fibrocystic disease of breast were from 31–50 years of age where as peak incidence (36%) was between 31-40 years.13 The difference between the age group in patients with fibrocystic disease differs geographically. The possible reasons being social accustom, age of menarche and parity, and breast feeding procedures, use of contraceptive pills and self awareness. Because of low literacy rate among females and more rural areas, the female affected with fibrocystic disease tend only to see surgeon when the symptoms are alarming. Recently it has been observed that fibrocystic changes constitute the most common and frequent BBD. Such changes generally affect the premenopausal women between 20-50 years of age.1,2 Although many other names have been used to describe this entity over the years including (fibrocystic disease, Cystic mastopathy, chronic cystic disease, mazoplasia, Reclus’s disease), the term "fibrocystic disease" is now preferred because this process is observed clinically in up to 50% and histologically in 90% of the women.14,15

Breast abscess was seen in 16% of the patients in our study with peak incidence in patients from 3rd decade of life. This was most commonly observed in lactating females during the first three months after delivery. Barton et al found acute bacterial mastitis common at any age but most frequently in lactating breasts.16

Mammary duct ectasia, also called periductal mastitis is a distinctive clinical entity that can mimic invasive carcinoma clinically.1 In our study, 12% of the patients had duct ectasia with almost equal incidence seen in 3rd and 4th decade of lives. Duct ectasia is commonly seen in the 30 - 50 years age groups in Western population and more than 40% have substantial duct dilatation by the age of 70 years.3 It usually presents with nipple discharge, a palpable subareolar mass, pain, nipple inversion (Slit like) or nipple retraction. Smoking has been implicated as an etiological factor in mammary duct ectasia.17,18 No relationship of smoking and duct ectasia was seen in our study.

Mastalgia was seen in 11% of patients in our study. Twenty five percent of the referral to breast clinics in West are due to mastalgia3 and it affects up to 70% women at some times during their lives.8 Ninety percent of the patients with mastalgia in our study were from 11 - 40 years of age group, highest being from 3rd decade. However this was more common in the 4th and 5th decade of lives in western women. Duct papilloma was seen in 4.7% of the patients in our study, the commonest presentation being nipple discharge.

Granulomatous mastitis resulting from infectious etiology, foreign material or systemic autoimmune disease can involve breast.1 In our study, 11 patients (4%) had granulomatous mastitis. Though rare in Western world but the fact that traveling from one place to another in the global world has been increasing and that the prognosis for complete cure with appropriate antituberculous therapy is excellent. The overall incidence is less that 0.1% of all breast lesions in developed countries and 3-4% in developing countries.19

CONCLUSION

BBD are common problems in females of reproductive age. The common problems for which women consult or are referred to breast clinic are palpable lump, breast pain and nipple discharge. Fibroadenoma is the commonest of all benign breast disease in our set up mostly seen in 2nd and 3rd decade of life. Fibrocystic disease of the breast is the next common BBD whose incidence increases with increasing age.

REFERENCES

1. Guray M, Sahin AA. Benign breast Diseases: Classification, Diagnosis, and Management. The Oncologist 2006;11:435-49.

2. Miltenburg DM, Speights VO Jr. Benign breast disease. Obstet Gynecol Clin North Am 2008;35:285-300.

3. Caleffi M, Filho DD, Borghetti K, Graudenz M, Littrup PJ, Freeman-Gibb LA et al. Cryoablation of benign breast tumours: evolution of technique and technology. Breast 2004;13:397-407.

4. Murillo Ortiz B, Botello Hernandez D, Ramirez Mateos C, Reynaga Garcia FJ. Benign breast diseases: clinical, radiological and pathological correlation. Ginecol Obstet Mex 2002;70:613-8.

5. Pollitt J, Gateley CA. Management of benign breast diseases of the breast. Surgery 2004;66:164-8.

6. Out AA. Benign breast tumours in an African Population. J R Coll Surg Edinb 1990;35:373-5.

7. Ihekwaba FN. Benign breast disease in Nigerian women: a study of 657 patients. J R Coll Surg Edinb 1994;39:280-3.

8. Chaudhary IA, Qureshi SK, Rasul S, Bano A. Pattern of benign breast diseases. J Surg Pak 2003;8:5-7.

9. Dunn JM, Lacarotti ME, Wood SJ, Mumford A, Webb AJ. Exfoliative cytology in the diagnosis of breast disease. Br J Surg 1995;82:789-91.

10. Rashid R, Haq SM, Khan K, Jamal S, Khaliq T, Shah A. Benign breast disorders, a clinicopathological Study. Ann Pak Inst Med Sci 2005;1:187-90.

11. Ali K, Abbas MH, Aslam S, Aslam M, Abid KJ, Khan AZ. Frequency of benign breast diseases in female patients with breast lumps – a study at Sir Ganga Ram Hospital, Lahore. Ann King Edward Med Coll 2005;11:526-8.

12. Stern EE. Age related breast diagnosis. Can J Surg 1992;35:41-5.

13. Kamal F, Nagi AH, Sadiq A, Kosar R, Khurshid I, Hussain S, et al. Fibrocystic disease of breast – age frequency and morphological patterns. Pak J Pathol 2000;11:11-4.

14. Rosai J. ed. Chapter Breast. In: Rosai and Ackerman’s Surgical Pathology, Ninth Edition. Philadelphia: Mosby 2004;1763-1876.

15. Santen RJ, Mansel R. Benign breast disorders. N Engl J Med 2005;353:275-85.

16. Barton AS. The Breast. In: Pathology. Rubin E Farber JL. 2nd Edi: Philadelphia: JB Lippincort Co 1994;978.

17. Furlong AJ, Al-Nakib L, Knox WF. Periductal inflammation and cigarette smoke. J Am Coll Surg 1994;179:417-20.

18. Rahal RMS, deFreitas Junior R, Paulinelli RR. Risk factors for duct ectasia. Breast J 2005;11:262-5.

19. Hanif A, Mushtaq M, Malik K, Khan A. Tuberculosis of breast. J Surg Pak 2002;7:26-8.

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