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Table of Content - Volume 12 Issue 3 - December 2019


 

Clinico-morphological pattern of breast lump in tertiary care hospital

 

Nitesh Jumnake1, Sudhir Deshmukh2*, Satish Gireboinwad3

 

1Assistant Professor, 2Dean, 3Associate Professor, Department of General Surgery, SRTR Medical College Ambajogai, Beed, Maharashtra, INDIA.

Email: knlpisre77@gmail.com

 

Abstract               Background: For developing countries, where the facility for detecting cancer at an early stage is not possible, symptomatic findings can be used as an indication for early diagnosis which could prevent the women from late stage presentation of disease. Aim: To describe some of the clinico-morphological features of the breast lump cases seen at a tertiary level hospital. Material and Methods: In clinically selected 100 cases, triple approach including clinical examination coupled with ultrasonographic examination (USG) and mammography was also carried out. USG was carried out to assess the extent of the axillary lymph nodes more precisely. Diagnosis was confirmed by core-cut biopsy, tru-cut biopsy and frozen section biopsy. Results: Out of 52 clinically diagnosed as carcinomas 50 were proved correct on histopathologically while 86 fibroadenomas diagnosed on clinical examination 2 turned out to be malignant on histopathology. Conclusion: Patients of breast cancer are coming to a tertiary level hospital very late, mostly with clinical features of advanced disease. Understanding its clinical and morphological features holds a great promise for early detection and prevention of this cancer.

Key Words: Breast lump, fibroadenoma, malignancy, clinical diagnosis, histopathology.

INTRODUCTION

Breast cancer is the most common malignancy in world and second most common in India after cancer cervix. Among humans it is widely distributed throughout the world. It is now considered as systemic disease rather than loco-regional disease.1 Early detection of breast cancer through organized screening in unselected women with an average risk in target populations has been impressive in reducing the mortality from the disease. Moreover, awareness regarding the diagnosis of early signs and symptoms in symptomatic population with access to high quality treatment service is another way of preventing the fatal outcome. Detection refers to the recognition of any sign of symptom of disease. Technique used for the detection include history, physical examination, mammography, thermography, fine needle aspiration cytology and biopsy. By contrast there is only one method of making a definitive diagnosis –Histological examination of a tissue specimen.2 For developing countries, where the facility for detecting cancer at an early stage is not possible, symptomatic findings can be used as an indication for early diagnosis which could prevent the women from late stage presentation of disease. We proposed a study to examine the clinical validity of the symptoms as well as the associated between symptoms and tumors characteristics. The ever increasing incidence of malignancy in general and breast in particular, associated with increased consciousness among females for any abnormal feel in the breast, and lack of much data about breast lumps from different parts of our country, have prompted us to study the clinico-morphological pattern of breast lump cases.

 

MATERIAL AND METHODS
This prospective study of the clinical evaluation of breast lumps was conducted at Tertiary Health Care Centre over a period of two years.
Inclusion criteria
• Any patient attending the surgical department directly or referred with a definite breast lump.
Exclusion criteria
• Pre-pubertal females with breast buds being perceived as lumps.
In clinically selected 100 cases, triple approach including clinical examination coupled with ultrasonographic examination (USG) and mammography was also carried out. USG was carried out to assess the extent of the axillary lymph nodes more precisely. Axillary lymph node examination was done clinically as well as by ultrasound. Most of the patients of breast cancer that we receive are locally advanced cancers and have palpable lymph nodes. In case of male breast, past history of hepatitis, malnutrition, renal failure, chronic chest diseases and Hansen’s disease along with drugs history of taking estrogen, tranquilisers, diuretics
and steroids
was done. Examination of genitalia (testis) was also done. Diagnosis was confirmed by core-cut biopsy, tru-cut biopsy and frozen section biopsy.

RESULTS
One hundred cases suffering from various types of breast lumps have been studied, and a large majority 52 were clinically suspected to be suffering from cancer; while 96 were neoplastic and 52 were non-neoplastic. In neoplastic (benign), fibroadenoma were suspected in 86 cases, duct papilloma 2 cases and gynaecomastia 8 cases; while in non-neoplastic group, inflammatory lumps were 46 cases and fibroadenosis in 6 cases. Majority of benign cases were found to be in the age-group of below 40 years, while malignant lumps were found to be in age group above 40 yrs. Majority of the inflammatory cases (abscess) were found to have early onset of symptoms with acute history of less than 2 wks while non- inflammatory cases like carcinoma and fibroadenomas have history of more than 2 wks.

Table 1: Physical findings in different breast lumps histopathologically proved

Clinical findings

Carcinoma

Fibro

adenoma

Fibro

adenosis

Inflammatory

Duct papilloma

Gynae

comstia

Breast

Right

Left

Bilateral

 

22

28

02

 

44

40

02

 

04

02

--

 

24

22

--

01

01

--

 

04

04

--

Nipple position

Normal

Destruction

Retraction

Displacement

Discolouration

Deviation

Discharge

 

04

02

26

12

--

06

02

 

82

--

03

01

--

--

--

 

06

--

--

--

--

--

--

 

22

02

02

--

--

20

--

 

--

02

--

--

--

--

--

 

08

--

--

--

Areola

Normal

Crack

Fissure

Ulcer

Eczema

Discharge

 

40

02

02

04

--

04

 

80

02

--

--

04

--

 

06

--

--

--

--

--

 

44

--

--

01

--

01

 

02

--

--

--

--

--

 

08

--

--

--

--

--

Skin over breast

Normal

Redness

Dimpling

Retraction

Puckering

Peau’d orange

Tethering

Fungation

Ulceration

 

06

08

04

03

03

18

04

02

04

 

84

02

--

--

--

--

--

--

--

 

06

--

--

--

--

--

--

--

--

 

05

40

--

--

--

--

--

--

--

 

02

--

--

--

--

--

--

--

--

 

06

02

--

--

--

--

--

--

--

Breast

Normal

Enlarged

Retracted

 

20

18

14

 

80

06

--

 

06

--

--

 

06

40

--

 

02

--

--

 

08

--

--

Quadrant involved

Upper outer

Upper inner

Lower inner

Lower outer

Central

Tail of spence

All quadrants

 

20

06

08

10

04

02

02

 

27

18

18

19

04

--

--

 

02

01

01

--

--

--

02

 

08

05

06

20

--

--

02

 

--

--

--

--

02

--

--

 

05

02

01

--

--

--

--

Table 2: Morphological characteristics of different breast lumps

Lump characters

Carcinoma

Fibro

adenoma

Fibro

adenosis

Inflammatory

Duct papilloma

Gynae

comstia

Size

1x1 cm and below

2x2 cm

3x3 cm

4x4 cm and above

 

06

12

18

16

 

19

19

25

23

 

--

--

03

03

 

08

06

16

16

01

01

--

--

 

--

--

04

04

Shape

Rounded

Discoid

Irregular

 

18

16

18

 

48

21

17

 

--

04

02

 

42

--

04

 

--

--

02

 

04

03

01

Margins

Well organized

Diffuse

 

10

42

 

84

02

 

--

06

 

24

22

 

--

02

 

08

--

Tenderness

Present

Absent

 

16

36

 

50

36

 

05

01

 

34

12

 

--

02

 

08

--

Consistency

Soft

Firm

Hard

 

04

20

28

 

08

56

22

 

04

02

--

 

12

34

--

 

--

02

--

 

--

08

--

Fixity of lump

Mobile

Breast alone

Breast and skin

Breast and skin and muscle

Chest wall

 

06

08

22

14

02

 

74

12

--

--

--

 

06

--

--

--

--

 

14

32

--

--

--

 

--

--

02

--

--

 

08

--

--

--

--

All the patients came with lump as primary complaints except in cases of duct papilloma, in which patient came with nipple discharge as a primary complaint. The second most common feature was pain seen in remaining patients while patients of breast carcinomas had noticed retraction of nipple.

 

Table 3: Common presenting symptoms in different lumps histopathologically proved

Diagnosis

Lump

Pain

Nipple Retraction

Skin Involvement

Nipple discharge

Carcinoma

42

20

24

16

2

Fibroadenoma

66

12

-

-

-

Fibroadenosis

4

4

-

-

-

Inflammatory

6

34

-

-

-

Duct Papilloma

2

2

-

-

2

Male breast

 

Gynaecomastia

8

6

-

2

-

Carcinoma

2

2

1

1

-

All the patients diagnosed as carcinoma are having metastasis in axillary lymph node; in only 2 cases were having the distant metastasis. In fibroadenoma, only two cases were having the lymph node involvement while 26 cases were lymph node involvement in inflammatory group.

Table 4: Clinically diagnosed distribution of cases studied

Clinical diagnosis

No. of cases

Percentage

Non neoplastic (n=52)

Inflammatory

Fibroadenosis

 

46

06

88.4%

11.6%

Neoplastic (n=96)

Fibroadenoma

Duct Papilloma

Gynaecomastia

 

86

02

08

 

89.5%

2.1%

8.3%

Malignant (n=52)

Female

Male

 

50

02

96.1%

3.9%

In malignant group, male breast lumps 2 were clinically suspected of cancer. All these lumps were subjected to biopsy for histopathological confirmations of diagnosis. Out of 52 clinically diagnosed as carcinomas 50 were proved correct on histopathologically while 86 fibroadenomas diagnosed on clinical examination 2 turned out to be malignant on histopathology.

 


DISCUSSION

The present study is comprised of 200 cases of breast lump that were studied prospectively at tertiary health care centre situated in rural area. Carcinoma of the breast occurs mainly in the 4th and 5th decade. The disease occurs generally a decade earlier in Indians as compared to white population. Breast carcinoma is rare in males. We found 2 cases of carcinoma in males and 8 cases of gynaecomastia. Out of 52 cases of carcinoma 28 were having left breast involvement, 22 were having right breast involvement and 2 cases were having bilateral breast involvement. In the study by Nuruzzaman HSM, left breast was affected in 67% cases, 28% in the right breast and the rest had bilateral involvement.3 Classically there is a left sided predominance.2 The side affection possibly does not have much effect so far the treatment and prognosis are concerned. In our study, retracted nipple was most common finding in carcinoma breast whereas 40 cases of carcinoma breast were having normal areola. Most common finding was a peau‘d orange in cases of breast skin involvement. 68% among all cases of breast lump were having normal breast size. In Nuruzzaman HSM study, 71.66% cases presented with painless lump, 28.33% with painful lump, 20% with ulceration, 8.33% with nipple discharge and 40% with nipple retraction.3 Haagensen study shows that 75% to 80% of women suffering from carcinoma breast presents with a lump in the breast.4 Nair et al have shown that lump in the breast was the presenting symptom in 88%, ulceration 8% and nipple retraction in 8% cases.5 Another study was carried out by Vinod Raina et al in India, where 96% of the patient in premenopausal women presented with breast lump, 15.8% with pain and 4.4% came with nipple discharge.6 Upper outer quadrant was the most common site of involvement in cases of carcinoma. In a study by Nuruzzaman HSM, the most frequent site involved was upper outer quadrant (in 54% cases). In 15% cases it was central, 13% in Lower outer quadrant, 10% in lower inner, 5% in upper inner quadrant and overlapping lesions were in 3% cases.3 A study carried out in Kerala, India has shown 31% of the growth in upper-outer quadrant, 8% in lower-outer quadrant, 11% in the upper-inner and 29% affected the whole breast.5 In present study, 34 cases presented when their lump size was more than 3 centimetre. 42 cases out of 52 were having diffuse margins as compared to 10 cases with well-defined margins. 28 cases were having hard palpable mass, 20 were having firm and 4 cases were having soft palpable mass among all the cases of carcinoma breast. Firm mobile mass was the most common finding on examination in cases of fibroadenomas. 22 cases of carcinoma breast were having skin involvement and only 2 cases had chest wall involvement suggesting advanced disease. A study carried out in USA by Swanson et al showed that 65.5% of the younger women presented with a lump more than 2 cm in diameter.7 Another study carried out by Raina V et al showed 74.1% patients presented with tumor size more than 2 cm but less than 5 cm and 12.3% with tumor size more than 5 cm.6 This shows that our patients present quiet late and with a higher stage of disease to a tertiary center. Palpable lump with nipple retraction was the most common finding on clinical examination in cases of carcinoma breast. Axillary group of lymph nodes were the most common lymph nodes involved in cases of carcinoma (44 cases). Only 6 cases were having cervical lymph node involvement, and 1 each were having other axilla involvement and distant metastasis. In the series by Nuruzzaman HSM, among the 60 patients, 52 patients had clinically palpable lymph nodes (86.66%). Among them 48% had one group of lymph node involved, 23% had two groups and 29% had more than two groups involved. The rest (13.33%) had no lymph node palpable clinically.3 Out of 200 cases 52 were suspected as carcinomas and 86 were suspected as fibroadenomas. After FNAC 2 cases among suspected carcinomas were reported as fibroadenomas whereas 2 cases among suspected fibroadenomas were reported as carcinomas.

 

CONCLUSION

Patients of breast cancer are coming to a tertiary level hospital very late, mostly with clinical features of advanced disease. Early detection of carcinoma can avoid distant metastasis and advanced breast carcinoma. Only 1 patient in our study had distant metastasis and 1 patient had spread to other axilla. On clinical examination correct diagnosis was found in 96.2% of malignancy and 98.6% of benign lesions.

 

REFERENCES

    • National Cancer registry Programme Consolidated report of the population based cancer registries 1990–1996. Indian Council of Medical Research, New Delhi. 2001.
    • Kumar V, Abbas AK, Fausto N;Robbin’s and Cortan Pathologic Basis of Disease, 7th edn.Elsevier Saunders,Philadelphia;2004:1129-1149.
    • Nuruzzaman HSM. Clinico-Morphological Pattern of Breast Cancer at In patient Department of Dhaka Medical College Hospital – Study of 60 Cases. J Shaheed Suhrawardy Med Coll 2015;5(2): 49-53.
    • Haagensen CD. Disease of Breast, 3rd ed. W.B. Saunders, Philadelphia: 1986.
    • Nair MK; Overall survival from breast cancer in Kerala, India, in relation to menstrual, reproductive and clinical factors. Cancer 1993;71:1791-6.
    • Raina V, Bhutani M, Bedi R, Sharma A, Deo SV, Shukla NK, Mohanti BK, Rath GK; Clinical features and prognostic factors of early breast cancer at a major cancer center in North India. Indian Journal of Cancer 2005;42(1):40-45.
    • Swanson GM, Haslam SZ; Breast cancer among young African-American women. American Cancer Society Journal, 2005; 97(1-suppl):273-279.