A Descriptive study on the Clinical Profile of Benign Breast Diseases

1

A DESCRIPTIVE STUDY

on the clinical profile of

BENIGN BREAST DISEASES

Dissertation submitted to

THE TAMILNADU DR. M.G.R.

MEDICAL UNIVERSITY, CHENNAI

With partial fulfillment of the regulations for the award of the degree

of

M.S (General Surgery)

Branch-I

Government Kilpauk Medical College,Chennai 10

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BONAFIDE CERTIFICATE

This is to certify that the dissertation entitled ‘A DESCRIPTIVE STUDY on the clinical profile of BENIGN BREAST DISEASES’ at Govt. Kilpauk Medical College Hospitalis a bonafide work of Dr. A.SHRI

RANJANI submitted to The Tamilnadu Dr.M.G.R Medical University in

partial fulfillment of requirements for the award of the degree of M.S.

BRANCH I (GENERAL SURGERY) examination to be held in MAY, 2019.

Prof .Dr.V.Vijayalakshmi MS,DGO Prof. Dr. V.Ramalakshmi, M.S.,

Professor of General Surgery H.O.D, Dept. of General Surgery

Govt. Kilpauk Medical College, Govt. Kilpauk Medical College,

Chennai – 600 010. Chennai – 600 010.

PROF. P.VASANTHAMANI, MD., DGO.,MNAMS, DCPSY, MBA.

DEAN

Government Kilpauk Medical College & Hospital

3

DECLARATION BY THE CANDIDATE

I hereby declare that this dissertation titled “A Descriptive study on the

clinical profile of Benign Breast Diseases.” at Govt. Kilpauk Medical College

Hospital is a bonafide and genuine research work carried out by me in the

Department of General Surgery, Government Kilpauk Medical and Hospital,

Chennai-10, under the guidance of our Chief Prof.Dr.V.VIJAYALAKSHMI

MS,DGO, Government Kilpauk Medical College and Hospital.

This dissertation is submitted to THE TAMILNADU DR. M.G.R.

MEDICAL UNIVERSITY, CHENNAI in partial fulfilment of the University

regulations for the award of M.S degree (General Surgery) Branch I,

examination to be held in MAY 2019.

Date:

4

CERTIFICATE BY THE GUIDE

This is to certify that the dissertation titled “A Descriptive study on the

clinical profile of Benign Breast Diseases.” done in the General Surgery

Department at Govt. Kilpauk Medical College Hospital is a bonafide research

work done by Dr. SHRI RANJANI.A, a post graduate in M.S. General Surgery,

Government Kilpauk Medical College & Hospital, Chennai-10 under my direct

guidance and supervision in my satisfaction and in partial fulfillment of the

requirements for the degree of M.S. General Surgery.

Date:

Place : Chennai

Prof. Dr. V.VIJAYALAKSHMI M.S., DGO,

Professor of General Surgery,

Govt. Kilpauk Medical College,

Chennai-10

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ACKNOWLEDGEMENT

I am most thankful to Prof.Dr.P.VASANTHAMANI MD.,DGO.,MNAMS,

DCPSY, MBA. Dean, Kilpauk Medical College and Hospital for giving me the opportunity to conduct this study in the Department of General Surgery,

Government Kilpauk Medical College & Hospital, Chennai-10.

I thank Prof. Dr. V.RAMALAKSHMI M.S, Professor and Head of the

Department of General Surgery for the relentless care and concern that she has

shown towards me to bring out this dissertation.

I would like to express my deepest gratitude to my Chief, guide and mentor

Prof. DR.V.VIJAYALAKSHMI M.S,DGO., Professor of Department of

General Surgery, Kilpauk Medical College, who has been instrumental in my

development as a better student and surgeon and who has guided me in the right

direction always.

I would like to acknowledge the invaluable advice and inputs received from

my Assistant Professors Dr. Arun. D M.S and Dr.Amilthan M.S in shaping up

this study. I am forever grateful to the both of them for their teachings, care and

6

Also this study would have not been possible without the support of my fellow

post graduates and interns who have been a great support to me.

The most important part of any medical research are the patients. I owe a great

deal to each and every one of them.

I would like to thank God for all that he has bestowed upon me.

I would like to thank my parents for making me the person I am today and

supporting me in my every endeavour.

7

TABLE OF CONTENTS

S.NO TITLE PAGE NO

1. INTRODUCTION 1

2. AIM OF STUDY 3

3. REVIEW OF LITERATURE 4

4. METHODS AND MATERIALS 48

5. METHODOLOGY 51

6. DATA ANALYSIS 54

7. STATISTICS 55

8. DISCUSSION 72

9. CONCLUSION 74

10. REFERENCES 75

11. ANNEXURES 79

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INTRODUCTION

Breast diseases are 10 times more common in the East than in the West.

50-55% of women suffer from complaints of Breast Disease and 30% of Benign

Breast Diseases require treatment eventually. Recent studies have

demonstrated an increase in the Incidence of Breast Diseases especially over

the past decade.

JUSTIFICATION FOR THE STUDY

With increasing patient awareness more and more patients are presenting in

outpatient clinics with complaints regarding Breast diseases.

With the ease of screening and confirmatory tests available in these modern

ages the subsequent diagnosis of breast conditions - both Benign and

Malignant is on the rise.

Therefore Accurate Diagnosis both Clinical and Pathological is crucial, so

that

- Proper Reassurance can be given in patients - as certain diseases

(Non proliferative lesions) have no proven association with malignancy

whatsoever.

- Whereas certain others ( Atypical proliferative lesions) which have

9

- Regular Screening can be instituted or

- appropriate Treatment as in Excision Or Mastectomy can be

undertaken.

This study will therefore provide valuable information on the clinical profile of

various Benign Breast Diseases and thereby aiding in establishing definite

10

AIM OF THE STUDY:

To study the Clinical Profile ofBenign Breast Diseases

OBJECTIVES:

To describe BBDs in terms of,

 Age and Parity wise distribution,

 Side and Quadrant wise distribution,

 Relative Proportions of the various types of BBDs

11

REVIEW OF LITERATURE

CLINICAL CASE DEFINITION OF BBD

Includes patients with one or more the following symptoms - breast

pain, breast lump and/or nipple discharge and no obvious signs of

malignancy as in a hard immobile lump or ulceration/ fungation of skin

12

ANATOMY OF THE BREAST

THE PECTORAL REGION:

Lies external to Anterior Thoracic Wall.

Anchors the upper limb to the trunk.

Has 2 compartments:

SUPERFICIAL COMPARTMENT- Skin, Superficial fascia andBreasts

DEEP COMPARTMENT – muscles and associated structures

13 The breast is a modified sweat gland.

Anatomically, the breast is said to extend from the 2nd to 6th ribs and between

the sternal lateral border and the Anterior axillary line. Surgically however it

has a greater extent than which is clinically apparent – extending from the

clavicle above to the 7th or the 8th ribs below and between the midline to the

edge of Latissimus dorsi laterally. Therefore this marks the extent of sugery in

case of a mastectomy.

The Axillary tail of Spence marks the superolateral extension of the breast

beyond the pectoral muscles into the respective axilla. This is of surgical

importance as this can be seen or palpable in a few women during menstruation

or lactation and can be mistaken for a tumor or lymph node.

The structural unit of breast is a Lobule of which there maybe 10 to 100 each

draining into ductules which then join to form Lactiferous ducts about 15 – 20

in number. These ducts are lined by myoepithelial cells and have a terminal

ampulla which act as a milk reservoir.

Ligaments of Cooper are projections of fibrous tissue extending between the

14

15

16

The areola is an involuntary muscle in the subcutaneous tissue on the summit

of the breast. It contains numerous sebaceous glands which hypertrophy into the

Montgomery’s tubercles during pregnancy and lactation.

The nipple is a corrugated erectile structure composed of smooth muscles. The

lactiferous ducts open in it’s apex.

17

ARTERIAL SUPPLY

 LATERALLY, from vessels of AXILLARY ARTERY –

 Lateral thoracic

 Thoraco acromial

 Superior thoracic

 Subscapular arteries.

 MEDIALLY, Internal Thoracic artery

 Second to Fourth Intercostal Arteries

18

VENOUS DRAINAGE:

Veins run parallel to the arteries ultimately draining into

 axillary

 internal thoracic and

 intercostal veins

INNERVATION:

– By Anterior and Lateral cutaneous branches of the 2nd to 6th Intercostal

nerves.

19

20

LYMPHATIC DRAINAGE:

Lymphatics of the breast drain into the Axillary and Internal mammary/thoracic

group of nodes.

 The Internal Mammary group drains the posterior part of the

breast and are located along the internal mammary vessels deep to

the costal cartilages.

 The Axillary group however receives the majority of the drainage,

about 85%. It has the following subgroups:

- Lateral group– along the axillary vein

- Anterior group along the Lateral thoracic vessels

- Posterior group along the subscapular vessels

- Central group in the centre of fat in axilla

- Interpectoral group aka Rotter’s located between the

pectoral muscles

- Finally, the Apical group lying in direct continuation with

the lateral group and sending off efferents to the

21

LEVELS OF LYMPH NODES:

Based on the relationship to the Pectoralis minor muscle:

LEVEL 1 – BELOW and LATERAL to it – scapular, humeral and

pectoral group

LEVEL 2 – DEEP to it – central and interpectoral group

LEVEL 3 – ABOVE and MEDIAL to it – subclavicular group

22

EMBRYOLOGY OF THE BREAST

THE MILK LINES

At the FIFTH or SIXTH WEEK of fetal development, two ventral bands

of thickened ectoderm – THE MAMMARY RIDGES/ MILK LINES

develop extending b/w future axilla to the inguinal area.

These usually regress except those in the pectoral region.Failure of this

results in POLYMASTIA or POLYTHELIA

Ingrowth of the ectoderm into the mesenchyme forms the primary bud.

This in turn initiates development of 15 to 20 secondary buds. Lactiferous

ducts develop and open onto the MAMMARY PIT. Proliferation of the

mesenchyme turns the mammary pit into the nipple – failure of this leads

23

PHYSIOLOGY OF THE BREAST

HORMONAL STIMULI:

 Estrogen  Progesterone  Prolactin  Oxytocin

 Thyroid hormone

 Cortisol

 Growth hormone

EFFECTS OF HORMONES ON THE BREAST

 ESTROGEN

o ductal development

 PROGESTERONE

o epithelial differentiation, Lobular development

 PROLACTIN

o Primary stimulus for lactogenesis, Upregulation of hormonal

receptors, Epithelial development

 OXYTOCIN

24

HYPOTHALAMIC- PITUITARY- OVARIAN AXIS

GnRH is released by MEDIAN EMINENCE and ARCUATE NUCLEUS of

HYPOTHALAMUS.

Which in turn controls FSH and LH released by ANTERIOR PITUITARY

Continuous release of GnRH causes suppression of gonadotropins and hence

ovarian functions, whereas, pulsatile release of GnRH cause vice versa effects.

FSH causes ripening of ovarian follicles and hence ESTROGEN production

which inturn exerts a negative feedback on FSH and a POSITIVE FEEDBACK

on LH.

LH in conjunction with FSH causes ovulation and aromatisation of

androgens produced by ovarian stroma to estradiol.

After birth, estrogen and progesterone levels in the female neonate remains

low because of the higher sensitivity of this axis to negative feedback from

these hormones.

After puberty, the axis becomes less sensitive to negative feedback and more

25

The physiological fluctuations in hormonal levels affects the breast tissues

causing:

 Engorgement & epithelial proliferation at the beginning of

menstrual cycle

 With onset of menstruation this engorgement subsides.

26

CHANGES IN PREGNANCY

– Increased levels of circulating estrogen and progestins

– Hence there is breast enlargement, areolar skin darkening and the prominent MONTGOMERY’S GLANDS (accessory areolar glands)

FIRST AND SECOND TRIMESTER– development and branching of minor

ducts

THIRD TRIMESTER– alveolar epithelium accumulates fat , alveolar and

ductal spaces get filled with colostrum, prolactin stimulates synthesis of milk

fats and proteins

LACTATION:

MILK PRODUCTION AND RELEASE IS BY NEURAL REFLEX ARCS

originating from nerve endings in nipple-areola complex.

Through the 2 reflexes:

 THE PROLACTIN REFLEX and

27

28

THE MILK EJECTION/ LET DOWN REFLEX

MENOPAUSE:

Decrease in circulating levels of estrogen and progesterone causes

INVOLUTION OF DUCTS AND ALVEOLI. Fibrous connective tissues

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INVESTIGATIONS

A)NON INVASIVE TECHNIQUES:

ULTRASOUND:

Investigation of choice in patients <35 years as the dense nature of the breast in young women make it difficult to be interpreted by means of mammography.

Particularly useful for distinguishing solids from cystic lesions. Also used in

image guided percutaneous biopsy of small lesions.

30

MAMMOGRAPHY:

Investigation of choice in patients >35 years of age. Radiation dose is 0.1cGy

and hence a very safe investigation. Screening mammogram is done annually in

women above 40 years of age. 5% of carcinomas are however missed by

population screening. Digital mammograms allowing image manipulation and

computer aided diagnosis are increasingly being made available in many

institutions and we are proud to say we have it here in our hospital

31

MRI:

Investigation of choice in cases of cancer recurrence, breast implants and to

assess multicentricity and multifocality. Also utilised as a screening tool in

women with positive family history.

32

B) MINIMALLY INVASIVE TECHNIQUES

Fine needle aspiration cytology [FNAC]:

Provides a cellular diagnosis but unfortunately is operator and cytologist

dependent and subject to sampling error. Obviously it cannot differentiate

33

CORE NEEDLE BIOPSY:

This overcomes the hurdles faced by aspiration cytology. When coupled with

vacuum systems it can act as a therapeutic tool too in cases of certain benign

lesions.

34

What is TRIPLE ASSESSMENT?

The combination of clinical assessment with radiology and pathological

35

BENIGN BREAST DISORDER CLASSIFICATION

– Congenital

 Supernumerary breasts/ nipples

 Amazia

 Nipple inversion

 Sebaceous cysts

– Injury

 Hematoma

 Traumatic fat necrosis

– Inflammation or Infection

 Breast abscess

 Tuberculosis of the breast

 Duct ectasia/ periductal mastitis

– ANDI

 Cyclical mastalgia  Non cyclical mastalgia  Breast cysts

 Fibroadenoma  Fibroadenosis  Phyllodes tumor

– Pregnancy related

 Galactocele

36

DESCRIPTION OF RELEVANT BBDs

CONGENITAL ANOMALIES:

 AMASTIA – developmental arrest of the mammary ridge

 SYMMASTIA – Webbing b/w the breasts across the midline

 POLYMASTIA – occurs as a component of TURNER’S and

FLEISCHER’S

 POLAND’S SYNDROME- Hypoplasia of breasts or Amastia, costal

cartilage and rib defects, absence of sternocostal part of Pectoralis

Major and Brachysyndactyly.

37

Supernumerary breasts

DIFFUSE HYPERTROPHY:

Usually bilateral and common during Puberty and pregnancy. Occurs due to

hypersensitivity of the breast to estrogen.

Treatment consists of trial with Anti estrogens and ultimately Reduction

38

INJURIES OF THE BREAST:

HEMATOMA:

Mimics a lump especially the resolving ones. Overlying skin bruising is usually

helpful in diagnosis.

TRAUMATIC FAT NECROSIS:

Presents as a painless lump following trauma. May even cause tethering and

nipple retraction thereby mimicking carcinoma.

39

BREAST ABSCESS / BACTERIAL MASTITIS:

Associated with lactation in most of the cases – commonly caused by

Staphylococcus aureus which is a common commensal in the baby’s throat. A

cracked or inverted nipple also contribute to this condition owing to the

possibility of ascending infection and stasis in the ducts providing a nidus for

multiplication of bacterial organisms.

Initially the patient presents with signs of inflammation and cellulitis that later

develop into an abscess

Early stages are treated with antibiotics. Patient can continue breastfeeding if

manageable.

In case of abscess development the pus has to be let out without any doubt.

Repeated aspirations under antibiotic cover is the current recommendation. In

40

TUBERCULOSIS OF THE BREAST:

Presents as multiple chronic abscesses or sinuses in association with

concomitant pulmonary tuberculosis or cervical lymphadenitis.

Treatment is Antituberculous therapy. Healing is delayed. Mastectomy may be

necessary in cases of persistent infection.

41

MONDOR’S DISEASE:

Aka superficial thrombophlebitis of the breast ,chest wall and arm.

Cause is obscure. Seen as a thrombosed subcutaneous cord attached to the skin.

Appears as a shallow groove on raising the arm above the head.

Resolves spontaneously over the course of a few months.

42

DUCT ECTASIA/ PERIDUCTAL MASTITIS:

Dilatation of lactiferous ducts often associated with periductal inflammation.

Dilatation of ducts leads to stasis of secretions and discharge, this in turn leads

to periductal inflammation and mastitis/abscess/fistula.

In some cases it develops into a chronic subareolar mass called Zuska’s

disease.

Ultimately there occurs fibrosis leading to slit like retraction of nipple.

43

Subareolar abscess in Duct ectasia.

44

Treatment is Surgical excision though a trial of antibiotics maybe tried.

45

ANDI [ABERRATIONS OF NORMAL DEVELOPMENT AND

INVOLUTION]:

Breast is a dynamic structure that undergoes cyclical changes much like the

uterus. ANDI encompasses conditions which are mere disturbances of normality

to actual disease processes. It is often found that the patient’s symptoms seldom

match the histology of the breast.

The disease process consists of the following elements in varying combinations

and extent:

 Cyst formation

 Fibrosis

 Hyperplasia of ductal epithelium with or without atypia

46 Symptoms are lumpiness and/or pain.

47

CYCLICAL MASTALGIA

Lumpiness and pain may be bilateral or occasionally confined to one quadrant.

These changes may be aggravated prior to menstruation.

NON CYCLICAL MASTALGIA:

More common in peri menopausal age group. Care must be taken to exclude

Tietze syndrome.

Treatment is firm reassurance, adequate breast support, avoiding caffeine.

If this doesn’t help then oil of evening primrose for duration of 3 months or

48

FIBROCYSTIC DISEASE OF BREAST:

Occurs in women of age group of 30 – 40. Usually multiple and bilateral.

Treatment consists of aspiration.

If it recurs better to go for local excision.

MAMMOGRAM OF BILATERAL FIBROCYSTIC DISEASE OF THE

49

GALACTOCELE:

Occurs as a solitary, subareolar cyst in lactating women

Treatment is aspiration

.

50

FIBROADENOMA:

Occurs in women aging between 15 – 25 years. It is nothing but hyperplasia of a

single

Lobule of size 2 to 3 cm. Those tumours larger than 5 cm are called giant

fibroadenomas.

Treatment is surgery – enucleation. Recent alternatives are HIFU or Core needle

biopsy with vacuum system or cryo ablation

51

PHYLLODES TUMOUR:

Aka serocystic disease of Brodie or Cystosarcoma phylloides. Usually in 4th

decade. Presents as a large uneven tumour, usually benign but some exhibit

malignant potential and may spread via blood stream.

52

HPE IMAGE OF A CYSTOSARCOMA PHYLLOIDES. NOTE THE

‘LEAF LIKE ARCHITECTURE’.

In benign types – Enucleation / Wide local excision. In massive, recurrent or

53

PATHOLOGICAL CLASSIFICATION OF BENIGN BREAST

DISEASES:

A] Non proliferative disorders of the

breast

• Cysts and apocrine metaplasia

• Duct ectasia

• Mild ductal epithelial hyperplasia

• Calcifications

• Fibroadenoma and related lesions

B] Proliferative breast disorders

without atypia

• Sclerosing adenosis

• Radial and complex sclerosing lesions

• Ductal epithelial hyperplasia

• Intraductal papillomas

C] Atypical proliferative lesions • Atypical lobular hyperplasia

54

RISK OF CANCER ASSOCIATED WITH BENIGN BREAST DISEASES

Non proliferative lesions No increased risk

Intraductal papilloma No increased risk

55

MATERIALS AND METHODS:

STUDY DESIGN: Descriptive study

PLACE OF THE STUDY : Department of General Surgery, KMCH

STUDY POPULATION:

Female patients

- Attending the Outpatient clinics of the Department of General

Surgery, GKMCH with complaints pertaining to breast disease.

- Admitted as Inpatients for the purpose of treating those diagnosed

with Benign Breast Diseases.

56

INCLUSION CRITERIA:

 Female patients with breast complaints as in -

- breast pain,

- breast lump or

- nipple discharge.

 Any patient with a Clinical Diagnosis of a Benign Breast

Disease who was then subsequently proven to have a

malignant disease pathologically.

EXCLUSION CRITERIA:

 Female patients with clinically evident malignant disease

or

 Those with history of being treated for a Malignant

57

SAMPLE SIZE CALCULATION:

With,

p - Anticipated % frequency of Fibroadenoma being 50 and

Confidence limits as +/- 10% of 100,

A Confidence level of 97% can be achieved with a sample size of 118.

58

METHODOLOGY

After obtaining appropriate consent for enrolling in the study,

Patients presenting with the CLASSIC complaints – Breast Lump, Breast Pain

and Nipple Discharge will be subjected to careful History Taking and the Triple

assessment – clinical exam, non invasive investigation and invasive

investigation in that order.

STEP 1

Based on the examination findings they will be fitted into the following

categories –

• Physiological swelling and tenderness

• Nodularity

• Palpable lumps

• Breast pain

• Nipple discharge and

• Infection or inflammation.

59

• Congenital abnormalities

• Injuries of the breast

• Breast abscess

• Galactocele

• Fibroadenoma

• Fibroadenosis

• Phyllodes tumor

• Duct Ectasia

STEP 2

Based on the age of the patient she is then subjected to either Ultrasonogram or

Mammography –

Age < 35 years - Ultrasonogram will be done and for those with Age> 35 years

Mammography is preferred.

STEP 3

The patient will then be subjected to

FNAC or Core needle biopsy.

60

• Non Proliferative Lesions

• Proliferative Lesions Without Atypia

• Atypical Proliferative Lesions

61

DATA ANALYSIS

• Age and Parity Wise Distribution,

• Side and Quadrant Wise Distribution

• Incidence of Benign Breast Diseases

• Relative proportions of various Benign Breast Diseases

• Clinical Diagnostic Accuracy

• Clinical correlation with Pathological Findings will be evaluated.

62

STATISTICS

1.AGE DISTRIBUTION

Mean age of the study participants was 28.9 years and standard deviation was

9.4 years.

Younger the age group more the chance of the breast pathology being BENIGN.

Also Implying that the younger generation are quick to seek medical advice

owing to better awareness about the Breast cancer in recent times. Meaning that

the government’s awareness programs have not been in vain.

Age

groups

Number Percentage

14-25 51 43.2

26-35 34 28.8

36-45 30 25.4

>45 3 2.6

63 43.2 28.8 25.4 2.6 0 5 10 15 20 25 30 35 40 45 50

14-25 26-35 36-45 >45

Per

ce

n

tage

64

2. MARITAL STATUS

Majority of the study participants are married women. Though one third have

been young unmarried girls suggesting possible undue panic.

The women were quiet difficult to reassure suggesting the possible need for

moderation about awareness campaigns.

Marital

status

Number Percentage

Married 81 68.6

Unmarried 37 31.4

65

81, 69% 37, 31%

Marital status

66

3. PARITY WISE DISTRIBUTION

Near 90% of the married women had children. It is well known that pregnancy

is protective when it comes to breast cancer.

Parity Number Percentage

Parous 74 90.1

Nulliparous 7 9.9

Total 81 100

90.1 9.9 0 10 20 30 40 50 60 70 80 90 100

Parous Nulliparous

Per

ce

n

tage

67

4. SIDE WISE DISTRIBUTION

Side Number Percentage

Right 52 44.1

Left 55 46.6

Bilateral 11 9.3

68

When it comes to the Side of the breast being involved, the percentage of BBDs

involving right and left are near equal with the left breast being involved

marginally higher. And near 10% of women had Bilateral involvement

predominantly in those conditions encompassed under ANDI.

44.1 46.6

9.3 0 5 10 15 20 25 30 35 40 45 50

Right Left Bilateral

Per

ce

n

tage

69

5. QUADRANT WISE DISTRIBUTION

Quadrant Number Percentage

All quadrants 18 15.3

Central 2 1.7

UO 34 28.8

LO 27 22.9

UO, LO 10 8.5

UO, LO,

Central

1 0.8

UI 12 10.2

LI 11 9.3

UI, LI 3 2.5

70

The quadrant with maximal involvement as expected is the Upper Outer

quadrant -29% owing to fact that the greater percentage of breast tissue is

contained in it. Another finding is that about 15% of all BBDs involved all the

quadrants, predominantly those being Mastalgia - both cyclical and non

cyclical and Fibroadenosis. And approximately quarter the cases had

involvement of more than one quadrant.

15.3 1.7 28.8 22.9 8.5 0.8

10.2 _9.3

71

6. CHIEF COMPLAINTS

Complaints Number Percentage

Lump only 70 59.3

Pain only 14 11.9

Lump and pain 31 26.3

Lump, pain and nipple

discharge

3 2.5

72

Chief complaints in BBDs were predominantly found to be Lump and Pain.

With near one third of patients seeking help for the pain for which treatment

was predominantly Reassurance and Analgesics. The recommended Vitamin E

and Evening primrose oil tablets are unavailable in our health care system as of

now and proved to be only marginally helpful in those who were able to afford

it.

59.3 11.9

26.3 2.5

0 10 20 30 40 50 60 70

Lump only Pain only Lump and pain Lump, pain and nipple discharge

Percentage

73

7. CLINICAL DIAGNOSIS

Clinical diagnosis Number Percentage

Fibroadenoma 66 55.9

Fibroadenosis 21 17.8

Cyclical mastalgia 8 6.8

Non-cyclical mastalgia 6 5.1

Breast abscess 6 5.1

Duct ectasia 4 3.4

Phyllodes tumor 4 3.4

Galactocele 3 2.5

74

About 56% of the BBDs presenting in our op clinics are Fibroadenomas. With

few of those patients being very insistent on surgical excision despite adequate

reassurance. 18% of the patients were those of fibroadenosis and many had poor

pain relief despite treatment for the same. Approximately 10% had only

mastalgia and those that were Non cyclical had epidodes of pain free periods

with treatment lasting a few months before seeking medical help again

ultimately. The Breast abscess patients were predominantly lactating mothers.

Phyllodes tumors are rare but histological exam is the only way to differentiate

benign ones from the malignant ones with certainty

55.9 17.8 6.8 5.1 5.1 3.4 3.4 2.5

0 10 20 30 40 50 60

75

8. HISTOPATHOLOGICAL DIAGNOSIS

Pathological diagnosis Number Percentage

Fibroadenoma 66 63.5

Fibroadenosis 19 18.3

Fibrocystic disease 2 1.9

Acute suppurative pathology 6 5.8

Duct ectasia 4 3.8

Phyllodes tumor 4 3.8

Milky fluid suggestive of

galactocele

3

2.9

76

63.5 18.3

1.9 5.8 3.8 3.8 2.9

0 10 20 30 40 50 60 70 Fibroadenoma

Fibroadenosis Fibrocystic disease Acute suppurative pathology Duct ectasia Phyllodes tumor Milky fluid suggestive of galactocele

Percentage

77

9. DIAGNOSTIC ACCURACY OF CLINICAL ASSESSMENT

HPE Correct

clinical

diagnosis

Sensitivity Specificity PPV NPV

Diagnosis Number

Fibroadenoma 66 66 100 100 100 100

Fibroadenosis* 19 19 100 97.7 90.5 100

Fibrocystic

disease

2 0 0 100 0 98.1

Breast abscess 6 6 100 100 100 100

Duct ectasia 4 4 100 100 100 100

Phyllodes tumor 4 4 100 100 100 100

Galactocele 3 3 100 100 100 100

Total 104 102

*Two cases of fibrocystic disease were wrongly clinically diagnosed as

78

It was clinically not possible to differentiate Fibroadenosis from Fibrocystic

disease.

Otherwise clinical assessment by a trained professional is almost as good as

Tissue diagnosis. This study reiterates that the combined efforts of clinical,

radiological and pathological assessment – the so called Triple assessment is

near infallible in its diagnostic accuracy.

100 100

0

100 100 100 100

100 _97.7 100 100 100 100 100

0 20 40 60 80 100 120 Per ce n tage

Diagnostic accuracy of clinical diagnosis

79

DISCUSSION

In our study many of the study participants have been in the age bracket 14-35

years with a mean age of 28.9 years. 74 of the study participants were married

parous women. the Left breast was found to be involved at a rate slightly higher

than the Right. As expected the upper outer quadrant was involved the most

owing to the greater breast tissue in it. Predominant chief complaints were lump

and pain.

Lumps in cases of fibroadenoma patients with size more than 2cm were excised.

Sometimes smaller lumps had to be excised if the patients were particularly

insistent on it. Results were predominantly satisfactory in cases of lumps. As for

pain the same could not be said. Many patients did not have any satisfactory

pain relief whatsoever and sought recurrent reviews representing the same.

As for Phyllodes tumor only histological assessment can provide definite

distinction between benign and malignant ones and they were treated

accordingly with either wide local excision or mastectomy accordingly.

Mastalgia both cyclical and non cyclical are predominantly clinical diagnoses

and precludes any histological assessment due to lack of findings other than

pain.

Fibrocystic disease mimics fibroadenosis in that both are characterised only by

80

difficult to pick up by palpation. Treatment in both consists of firm Reassurance

and analgesics for the pain if any.

Finally the Triple Assessment as professed holds good and has once again stood

the test of time.

In our study Fibroadenoma was the commonest BBD followed by

fibroadenosis. The same was observed by Mima Maychet B et al 2013 [1],

Irabor et al (2008)[2] and Akhator A et al (2007)[3].

In our study left side was found to be slightly more commonly involved than

the right. Akhator A et al (2007)[4] reported left side as common as well. In the

study by Rameshkumar Pandey et al (2016) [4] and Mima Maychet B et al

(2013)the right side was reported to be most commonly involved.

In our study Mastalgia both cyclical and non cyclical was about 12% as was the

case by Rameshkumar Pandey et al (2016) (13%) and 11% of all BBD cases

observed by Khanzada et al 2009[5].

The sensitivity of clinical diagnosis was 100% in all except those of

81

CONCLUSION

Benign breast diseases are much more common than malignant breast tumors

and have largely been an undervalued entity. Many women with BBDs suffer

significant physical and psychological stresses which need to be addressed with

better care and concern by the concerned professionals in our country. Not

many studies or treatments or training programs are available in the current

set-up and resources need to be directed in these areas.

The common BBDs encountered in a city based tertiary care hospital were

fibroadenomas followed by fibrooadenosis, cyclical and non cyclical mastalgia,

breast abscess, duct ectasia, phyllodes tumor and galactocele in that order.

Clinical assessment by a trained professional is as good as histological

82

REFERENCES

1. Mima B. Maychet Sangma, Kishori Panda, Simon Dasiah. A

clinico-pathological study on benign breast diseases. Journal of Clinical and

Diagnostic Research., 2013 Mar; 7(3): 503 – 506.

2. Irabor DO. An audit of 149 consecutive breast biopsies in Ibadan,

Nigeria. Pak J Med Sci., 2008; 24(2): 257 - 62.

3. Akhator A. Benign Breast Masses in Nigeria. Nieg Jr of Surg Sciences.,

2007; 17: 105 - 8.

4. Rameshkumar Pandey, Ravinder Narang, Bhupendra Mehra and Dilip

Gupta et al -Pattern of benign breast diseases: a neglected entity ejpmr,

2016,3(2), 158-161

5. Khanzada TW, Samad A, Sushel C. Spectrum of benign breast diseases

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6. B.V. Amruthavalli M.S., V. Srihari M.S., et al Clinical Study of Benign

Breast Diseases (IOSR-JDMS) e-ISSN: 0853, p-ISSN:

2279-0861.Volume 14, Issue 11 Ver.X (Nov. 2015), PP 34-40

7. Breast lumps in adolescent girls. Br Med J. 1978;1(6108):260–61.

8. Njeze GE. Breast Lumps: A 21-Year Single-Center Clinical and

Histological [2] Analysis. Niger J Surg. 2014;20(1):38–41.

9. Aslam HM, Saleem S, Shaikh HA, Shahid N, Mughal A, Umah R.

Clinico-[3] pathological profile of patients with breast diseases. Diagn

Pathol. 2013;8:77.

10.Kotepui M, Piwkham D, Chupeerach C, Songsri A, Charoenkijkajorn L.

[4] Epidemiology and histopathology of benign breast diseases and breast

cancer in southern Thailand. Eur J Gynaecol Oncol. 2014;35(6):670–75.

11.Worsham MJ, Raju U, Lu M, Kapke A, Botttrell A, Cheng J, et al. Risk

factors for [5] breast cancer from benign breast disease in a diverse

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12.[6] Maiti PK, Gangopadhyay S. Changing trends in prevalence of cancer

sites in West Bengal--a hospital based study. J Indian Med Assoc.

2012;110(11):803–06.

13.Olson RA, Nichol A, Caron NR, Olivotto IA, Speers C, Chia S, et al.

Effect of [7] community population size on breast cancer screening, stage

distribution, treatment use and outcomes. Can J Public. 2012;103(1):46–

52.

14.Muka T, Imo D, Jaspers L, Colpani V, Chaker L, van der Lee SJ, et al.

The global [8] impact of non-communicable diseases on healthcare

spending and national income: a systematic review. Eur J Epidemiol.

2015;30(4):251–77.

15.El-Shinawi M, Youssef A, Alsara M, Aly MK, Mostafa M, Yehia A, et

al. Assessing [9] the level of breast cancer awareness among recently

diagnosed patients in Ain Shams University Hospital. Breast.

2013;22(6):1210-14.

16.Bobdey S, Balasubramanium G, Kumar A, Jain A. Cancer Screening:

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Care in Developing Countries? Int J Prev Med. 2015;6:56.

85 18. Gray’s anatomy student’s edition

19. Grant’s atlas of anatomy

20. Mudaliar and menon’s textbook of obstetrics

86

ANNEXURES

87

PLAGIARISM CERTIFICATE

This is to certify that this dissertation work titled ‘A Descriptive study

on the clinical profile of Benign Breast Diseases.’of the candidate

Dr.Shri Ranjani .A with registration number 221611167 for the award of MS

in the branch of GENERAL SURGERY. I personally verified the urkund.com

website for the purpose of plagiarism check. I found that uploaded thesis file

contains from introduction to conclusion pages and result shows 8 percentage of

plagiarism in the dissertation.

89 STUDY PROFORMA Name: Age: Sex: Op/Ip no: Contact information: Address: Chief complaints:

- Breast lump YES / NO - Breast pain YES / NO - Nipple discharge YES / NO

Duration of complaints:

Associated complaints if any:

Previous history of breast problems if any:

Age of menarche:

Marital status:

Parity:

Age at first pregnancy;

Last menstrual period:

Oral contraceptive intake: YES / NO

Post menopausal hormonal intake: YES / NO

Treatment for Infertility: YES / NO

Personal History of Cancer: Contralateral breast/ Ovarian/ Colon/ Other malignancies (tick if relevant)

Family history: Breast/ Ovarian/Colon/Other Malignancies

90

Clinical findings:

RIGHT BREAST LEFT BREAST

Provisional Clinical Diagnosis:

USG/Mammography findings: BIRADS GRADE -

FNAC/CNB findings: (mention as appropriate)

- Non proliferative lesions

- Proliferative lesions without atypia - Atypical proliferative lesions - Carcinomas

Definitive Diagnosis:

Treatment planned:

91

Signature of the Researcher Signature of the Guide

படிப்புத் திட்டம்

பபயர்:

வயது:

ஒப் / ஐபி எண் :

பதொடர்பு தகவல்:

முகவரி:

முக்கிய புகொர்கள்:

- மொர்பக கட்டி: ஆம்/ இல்லல - மொர்பக வலி: ஆம்/ இல்லல - கொம்புபவளியயற்றம்: ஆம்/ இல்லல

புகொர்களின் கொலம்:

பதொடர்புலடய புகொர்கலள ஏதொவது இருந்தொல்:

மொர்பக பிரச்சிலனகளின் முந்லதய வரலொறு ஏதொவது இருந்தொல்:

வயதுமுதிர்ந்தவயது:

திருமண நிலல:

குழந்லதகளின்எண்ணிக்லக:

முதல் கர்ப்பத்தில் வயது;

கலடசியொக மொதவிடொய் கொலம்:

வொய்வழி கருத்தலட உட்பகொள்ளல்: ஆம் / இல்லல

மொதவிடொய் நின்ற பிறகு ஹொர்யமொனின் உட்பகொள்ளல்: ஆம் / இல்லல

மலட்டுத்தன்லமகொன சிகிச்லச: ஆம் / இல்லல

தனிநபர் வரலொற்றின் புற்றுயநொய்: மொர்பக / கருப்லப / பபருங்குடல் /பிற

புற்றுயநொய்கள்

குடும்ப வரலொறு புற்றுயநொய்கள்: மொர்பக / கருப்லப / பபருங்குடல் /

92

மருத்துவகண்டுபிடிப்புகள்:

வலது இடது

தற்கொலிகமொனமருத்துவ யநொய் கண்டறிதல்:

யு. எஸ்.ஜி / மம்யமொகிரொஃபி கண்டுபிடிப்புகள்: பியர்ட்ஸ் கியரயட -

FNAC / CNB கண்டுபிடிப்புகள்:

வலரயறுக்கப்பட்ட யநொயறிதல்:

சிகிச்லச திட்டமிடப்பட்டது:

அறுலவசிகிச்லச திசுக்கலளப்பரியசொதித்தல் பயன்முடிவு:

(பபொருந்தினொல்)

93

CONSENT FORM IN NATIVE LANGUAGE

: : o . . .

o (0.1

. .) .

FNAC/ CORE NEEDLE BIOPSY

o / /

.

95

CONSENT FORM

NAME:

AGE:

OP/IP No:

Study title : A Descriptive study on the clinical profile of Benign Breast Diseases.

TICK, IF UNDERSTOOD

o I have decided to participate in this study regarding Benign Breast Diseases, and thereby give my consent to be subjected to examination and investigations required thereof. I agree to furnish all relevant data as I am able. I’m fully aware of the relevant side effects and agree to participate in the above mentioned study.

INFORMED CONSENT FOR X RAY MAMMOGRAM

o I understand there is exposure to a small dose of radiation( 0.1 cGy) during this investigation.

INFORMED CONSENT FOR FNAC/ CORE NEEDLE BIOPSY

o I understand that during this invasive procedure there is a possible risk for Bleeding/ Bruising/ Infection.

SIGNATURE OF THE PATIENT

96

INFORMED CONSENT FOR LUMPECTOMY/SIMPLE MASTECTOMY

I understand that I have been diagnosed with _____________________ and that I have to undergo surgery for this condition as per the Doctor’s recommendation. I understand there are significant threats to life, muscles, nerves and other soft tissues involved both during surgery and anaesthesia and that there maybe a risk of anaphylaxis, hypotension,

postoperative need for elective ventilation and that there maybe a risk of post operative wound infection. I have read and understood all of these risks and agree to undergo the necessary surgery despite the risks. I understand that neither the doctor, hospital nor the medical personnel are held accountable for the same.

SIGNATURE OF THE PATIENT

SIGNATURE OF THE PATIENT’S ATTENDER/GAURDIAN

97