Clinical, Radiological, and Pathological Analysis of Breast Lump

Introduction

Breast cancer is a type of cancer that originates in the cells of the breast. It can occur in both men and women, but it is more commonly diagnosed in women. The breast undergoes many physical and physiological changes during the menstrual cycle, pregnancy, lactation, and menopause.^1,2

Aberrations of normal development and involution (ANDI) include benign breast disorders that occur in women at various stages of their reproductive cycle. Pathogenesis includes disturbances in breast physiology, ranging from normal to well-defined disease processes, often with little correlation between the histological patterns of the breast tissue and symptoms. It is based on changes in the three normal phases of breast-lobular, cyclical, and involution physiology. These changes occur in premenopausal women with areas of lumpiness and mastalgia that may be more cyclical than non-cyclical.^3,4,5

The changes can vary from mild inflammatory swelling to cellular atypia, with an increased risk of breast carcinoma. About one-third of women who give birth develop some of these changes later in life. Public awareness regarding breast carcinoma has increased the use of screening methods. With the increasing use of imaging techniques such as ultrasound and mammography, there is a trend of rapid increase in diagnosis worldwide, and it has become easier to determine the type of breast lump and distinguish it from breast carcinoma through tissue examination. Benign breast lesions are ten times more common than malignant.^1-9

Breast lumps are characterized by growth abnormalities, inflammatory lesions, epithelial and stromal proliferation, and cysts. It can manifest with varied symptoms or arise seemingly without a specific pattern. The incidence of breast cancer begins to increase in the twenties and reaches a maximum at four or five years of age. Unlike malignant diseases, its incidence increases after menopause, but its incidence is low.^5-14 Detailed examination, imaging such as mammography, ultrasound and magnetic resonance imaging , and needle biopsy (triple examination) are used to diagnose breast cancer with a good result at a rate as high as 99.9%.^14-18 Histopathological tissue diagnosis, Although it is a reliable method, minimally invasive fine needle aspiration cytology of the breast is still an important part of a triple assessment of breast lump.^14-18

Since most benign lesions are not associated with subsequent cancer risk, unnecessary surgical procedures can be avoided by using screening techniques and tissue biopsy.^16-18 Accurately diagnosing benign lesions and differentiating them from in situ and invasive breast cancer allows the best treatment to be planned and proceeded accordingly.

Materials and Methods

This prospective cross-sectional study was conducted from August 2020 to July 2023 in the Department of Surgery. All female patients aged > 18 years who presented with a palpable breast lump and had undergone clinical breast examination, FNAC, and USG for breast lump and subsequent histopathological study were included in the study. Initially, the patient underwent clinical breast examination, which included a detailed history, inspection, palpation of the breast, and systemic examination, and underwent ultrasound examination. The sonographic interpretation was made as benign, suspicious, or malignant. FNAC was performed after imaging studies, and the results of palpation-guided FNAC were analyzed by pathologists and reported as benign, suspicious, or malignant. After all workups, patients were subjected to an excisional biopsy. The final histopathological results were analyzed using the results of clinical breast examination, ultrasonography, and fine-needle aspiration cytology examination. Demographic details, etiological factors, clinical presentation, particularly the duration, mode of onset of the lump, its progress, pain, nipple discharge, history of trauma, and fever were collected from eligible patients. Patients with recurrent breast lumps and who were not willing to study were excluded.

Statistical analysis

Data were analyzed using IBM SPSS 25.0 version software. The collected data were spread on an Excel sheet, and graphs were constructed. For quantitative data analysis of descriptive statistics, the mean and standard deviation were calculated initially; the independent samples “t” test was used to compare the mean values between two variables. For qualitative data analysis, Fisher’s exact and chi-square tests were applied. The significance level was set at P ≤0.05.

Results

Fifty patients with breast lumps were included in this study. The patients underwent clinical examination, followed by USG breast and FNAC evaluation. Breast lumps were diagnosed based on the correlation of clinical findings, ultrasonography, and FNAC/HPR.

This study observed that the majority of breast lump incidences 40 (80.0%) was found in the age group of 21- 30 years, followed by 4 (8.0%) of breast lump patients in the age groups 18-20 years and 31-40 years (Table 1). The mean age of females was 26.12 years.

Most of the patients presented with a complaint of lumps in the breast 34 (68.0%), followed by pain 13 (26.0%) and discharge from nipple 3 (6.0%).

The patients were divided into those with a lump < 3 cm (small size) in diameter, those between 3 and 5 cm (intermediate size), and those > 5cm (giant size). In this study, most of the patients 27 (54.0%) had a lump size of 3-5 cms.

In this study, out of 50 patients, 29 (58.0%) had fibroadenoma and 9 (18.0%) had fibrocystic diseases, followed by 7 (14.0%) with breast abscesses (Tables 2 and 3).

Most of the patients presented with pathology on the right side 27 (54.0%), followed by the left side 16 (32.0%). FNAC was performed in all cases and was diagnostic (92.25%). Although fibroadenomas can be accurately diagnosed by USG (72.4%), USG can detect cystic or parenchymal lesions, but there is a limitation in further identification of lesions (72.4%). There was a significant difference between clinical diagnosis and USG diagnosis (P<0.05), but incompatibility with clinical diagnosis was detected in 10 (20.0%) of 50 patients. There was a correlation between USG and histopathological diagnosis (P< 0.05), but the diagnosis was related to histopathology in 34 of 50 patients (68.0%) and 16 of 50 patients (32.0%) not consistent (Tables 4 and 5, respectively). There was a statistically significant correlation between the clinical findings, USG, and histopathological diagnosis (P<0.05).

Discussion

Breast lumps are more common in women in India, and 80% of breast lumps are benign. In the present study, there were 50 women with breast lumps. In a study by Khanna et al., in which they have analyzed 1031 cases of breast lump in which 94% were females and 6% were male.¹⁹

All cases of fibrocystic disease of the breast were found in the age group 21-30 years. This finding was not consistent with the study conducted by Khanna et al., in which 58.53% of patients were age group 30-40 years.¹⁹ Another study by Rangabashyam et al. revealed that the highest incidence (70%) was observed in patients age group 20-30 years.²⁰

In this study, 100% of the fibroadenomas were observed in the 18-30 age group. In an Indian study by Rangabashyam et al., the age group of 11-30 years reported the highest incidence (75.39%) of fibroadenomas, and 82.78% of fibroadenomas were observed in the age group of 11-30 years in a study by Khanna et al.^19-20

Most cases in this study were in the childbearing age group. Three patients complained of menstrual cycle irregularity, and none had significant changes in tumor size during or before menses.

In the present study, the most common presenting complaint was breast lump, constituting approximately 34 cases (68%), 13 cases presented with pain (26%), and 3 presented with discharge (6%). All fibroadenoma cases presented as lumps, and two fibroadenoses presented with lumps and pain. A single case of galactocele was presented at discharge. However, in the study by Khanna et al. it was revealed that the most common presenting complaint in breast disease was lump, constituting about 77.4% in their study.1⁹

In the present study, of the 50 cases, the right breast was involved in 27 cases (54%), 16 on the left side (32%), and 7 presented with bilateral involvement (14%). This corresponds to most studies that state that the right breast is more commonly involved with lesions than the left breast.^19,20

A spectrum of benign findings was recorded on USG. In the current study, USG could identify the lesion if it was cystic or solid, but although fibroadenoma can be accurately diagnosed, further differentiation of the lesion has its limitations.

Klein et al. show 97% percent diagnostic accuracy for benign palpable masses on USG.²¹ In the Eltair et al. study, USG showed a sensitivity of 88.9% and a specificity of 97.4%.²² In a study by Devkota et al., USG had 88.90% sensitivity and 68.80% specificity.23 Most of these studies correlated with the present study, in which the diagnostic accuracy was 72.4%.

Fine-needle aspiration cytology (FNAC) is a valuable diagnostic tool for breast lumps. In all cases, FNAC was performed, and in 90% of cases, an accurate diagnosis was made. It is worth noting that in the study conducted by Eltair et al., the FNAC achieved a diagnosis rate of 97.3%, whereas in the study by Panwar et al., the diagnostic rate was 97%.^22,24 The accuracy of breast lump diagnosis is improved when three modalities are used: clinical examination, imaging, and FNAC. Triple assessment may avoid many unnecessary surgeries for benign lesions.²⁵ In our study, we found a statistically significant correlation between clinical, USG, and histopathological diagnoses.

Conclusion

USG can be employed to differentiate between solid and cystic lesions and the majority of fibroadenomas can be diagnosed by sonography. The accuracy of breast lump diagnosis increases when all three modalities, that is, clinical examination, USG, and FNAC, are combined. Triple-modality diagnosis of breast lumps may avoid many unnecessary surgeries.

Conflict of Interest

Nil