Prevalence of benign proliferative breast lumps among females with benign breast diseases in Sohag governorate

Prevalence of benign proliferative  breast lumps among females with benign breast diseases in Sohag governorate

Hosam F AbdElhameed, MD; Samir AAbdEbneguid, MD; Mohamed MALI, MD; Ahmed E Ahmed, MD

Surgery Department, Sohag University Hospital, Egypt.

Background: Benign breast diseaseis animportantrisk factor for a later breast cancer, which can develop in either breast. It includes  a spectrum of histologic entities,  usually subdivided into non-proliferative  lesions,  proliferative lesions  without atypia,  and atypical hyperplasia, with an increased risk of breast cancer associated with proliferative or atypical lesions.

Aim:  To estimate  the prevalence of benign proliferative breast lumps that carry a risk of developing breast cancer in Sohag governorate.

Patients  and  methods:   This prospective  study included  416  female patients presented  to

Breast Clinic  with clinically  palpable  benign  breast lump(s)  at Sohag  University  Hospital; only 390 of them were enrolled in the study. All patients were subjected to thorough clinical examination,   sana-mammography  and  fine  needle  aspiration  cytology.  Those  who  were pregnant or proved to be malignant were excluded. Data including use of contraceptives, Parity, menarche,  menopausal  status,  family history  of breast cancer  were collected  prospectively using a pre-test questionnaire in a  face to  face interview.  All biopsies taken  form the excised lumps were examined by three pathologists  with experience in breast diseases.

Results:  Of 416  females with clinically benign breast lump(s),  only 390 were recruited in

the study. The prevalence  of BPBD was 78/390 (20%)while non BPBD  was 312/390  {80%). BPBD  with atypia was 24/390  (6.1%),  while BPBD  without atypia was 54/390 (13.8%).The commonest  breast lesions  were fibroadenoma,  fibrocystic disease and duct ectasia (54.1%), (25 6%) and (5.6%) respectively.

Conclusion: Benign proliferative breast lumps are common among premenopausal  women in Sohaggovernorateand  a significant proportion ofBPBD had atypical proliferation.

Key words: Breast, benign proliferative disease, atypia, risk factor, aetiology.

Introduction:

Benign breast disease (BBD) account for about 90% of whole breast diseases. Because of the  increased awareness  of breast cancer, benign breast lumps have assumed increasing attention nowadays.l-3 Benign breast lesions carry a risk factor for development  of either unilateral   or   contralateral   breast   cancer.4

Histologic  entities  of  benign  breast  lesions

areusually subdivided into non-proliferative breast lesions, proliferative breast lesions without atypical hyperplasia, and proliferative breast lesions with atypical hyperplasia.5-7 It has been postulated that inflammatory breast disease and non proliferative breast disease do

not increase the risk of cancer. Proliferative breast disease without atypia and with atypia confers mild and moderate risk respectively, whereas carcinoma in situ is associated with substantial risk,8 so it is important to pick up the benign lesions having risk of breast cancer development and know its incidence. The aim of our study is to determine the prevalence of benign proliferative breast diseases at risk of developing breast cancer.

Patients and  methods:

This prospective study was conducted at general surgery department, Sohag University Hospital From February 2009 to June 2013;

it included 416 female  patients presented to Breast Clinic with clinically palpable benign breast lump(s).

All patients were subjected to thorough clinical  examination,  sono-mammography and  fine  needle  aspiration  cytology.  Those who  were  pregnant  or  with  clinical  and/ or radiological sings of malignancy were excluded. Fine needle aspiration cytology (FNAC)was done as an outpatients procedure using Fine-gauge number 23 single-use disposable  needles  in  combination  with regular 10 cc single-use airtight disposable plastic syringe. Two to three dry clean slides were used for preparing the smears. All slides were  labelled  with  a  glass  pencil  and  air­ dried then were fixed with 95% alcohol and stained with eosin and haematoxylin stain. Those  who  had  cytological  report  negative for malignancy  were  included  in the  study. Data including use of contraceptives,  Parity, menarche, menopausal status, family history of breast cancer were collected prospectively using a pre-test questionnaire in a face to face interview. A written informed consent was obtained from all patients .The study design was approved by the local research ethics committee. All biopsies taken form the excised lumps were  examined  by three  pathologists with experience  in breast diseases each one was initially blinded from findings of the others.  In case  of discrepancy  in reporting, the final decision was by consensus. Gathered data were processed using SPSS version 15 (SPSS Inc., Chicago, IL, USA). Quantitative data were expressed as mean ±SD while qualitative  data were expressed  as numbers and   percentages   (%).   Student   t  test  was used to test significance of difference for quantitative variables while Chi square was used to test significance of difference for qualitative   variables.   A  probability   values (p-value) :S0.05  was considered  statistically significant.

Results:

This  prospective  study  was  carried  out in  the  period  from  February  2009  to  June

2013 at department of general surgery, Sohag

University  hospital,  Egypt. It included  416

patients attended breast clinic with clinical features of benign breast lumps, only 390 of them were enrolled in the study. All patients were females; their ages ranged from (12-67 years) with average 27.6 years. The average diameters  of the masses were 2.9cm (range:

1.0-7.0 em). The patients, characteristics are shown in Table (1).Benign proliferative breast lesions (BPBL) were found in (20%) 78/390, while (80%) 312/390  were non proliferative. Among the BPBL there were 50 patients who did not use hormonal contraception while 28 had been using contraception. The prevalence ofBPBLwas 7.1 and 12.8% among hormonal contraceptive users and non-hormonal contraceptive  users  respectively.  35.8% (24/78) patients with BPBL had atypia while (69.2%) 54/78 patients with BPBL were without atypia. The prevalence of BPBL with atypia was 6.1% (24/390) and prevalence of BPBL without atypia was 13.8% (54/390).

As  regard  the  histological   diagnosis  of the breast lesions, (54.1%)  211/390 patients had fibroadenoma; this was followed by Fibrocystic  disease  in  (25.6%)  100/390 patients. Duct ectasia, the third commonest diagnosis  was found  in  (5.6%)  22/390 patients. Chronic abscess, lactating adenoma and fat necrosis were found in (4.6%) 18, (3.5%)  14, and (2%) 8 patients respectively and 17 patients (4.3%) had other diagnoses as shown  in Table (2). The proliferative  nature of all lesions was limited to the fibrocystic disease and fibroadenoma, 35/78 (44.8%) and

24/78 (30.7%) respectively.

Discussion:

Benign breast disease is a well-established risk  factor  for  a later  breast  cancer,  which can develop in either breast.4  It encompasses a spectrum of histologic entities, usually subdivided into non proliferative lesions, proliferative lesions without atypical, and atypical  hyperplasia,  with an increased  risk of breast cancer associated with proliferative or  atypical   lesions.9-ll   Studies  of  benign breast disease can clarify whether there is a continuum ofbreast alterations that culminates in breast cancer. However, it remains unclear which   of   the   benign   entities   are   actual

Table 1: Participants' characteristics with BPBD  and non BPBD.

(P-value <:::0.05) =stgmficant

Table 2:  Frequency  of histological types of breast lesions.

precursors  and  which  reflect  a  background of increased  risk involving  all breast tissue in a woman.l2 Retrospective  and prospective studies  have shown  a relative risk of breast cancer of 1.5 to 1.6 for women with benign breast   disease   as  compared   with  women in  the   general   population.   The  histologic appearance  of the  benign  lesion is strongly associated with the risk of breast cancer; with non-proliferative changes the relative risk was

1.27 as compared with a relative risk of 1.88

for  proliferative  changes  but  no atypia  and of 4.2 for atypical hyperplasia.9,13-18 Among

women with BBD, a family history of breast cancer  (BC)  further  increases  BC  risk  and women with a family history ofBC are more likely to be diagnosed with BBD, especially at younger ages.l2 Important questions remain, however, about the degree of risk associated with  the  common  non-proliferative  benign entities and the extent to which family history influences the risk of breast cancer in women with proliferative or atypical lesions. Dupont and   Page   found   that   women   with   non­ proliferative disease did not have an increased risk of a later breast cancer.9 By contrast, a

Adjuvant Breast and Bowel Project (NSABP) found a relative risk of 1.6 for women who received  a diagnosis  of a "lower  category"

of benign breast.13 In our governorate where

a  large  proportion  of  women  with  breast cancer are pre-menopausal,  it was important to  examine  and  characterize  the  nature  of benign breast lesions encountered  in routine clinical practice in our locality. We set out to establish the prevalence of benign proliferate breast lesions with atypia and without atypia. We found  that  benign  breast  lesions  are  a common   presentation;   93.7%  as  the  case elsewhere.  In our study 20%  (78/390) of all benign  breast  lumps  were  proliferative   in nature. Atypia  which is considered  to  carry two to four  folds risk for  developing  breast cancer  (19,  20)  was present in 6%  (24/390) of  the  benign  proliferative  lumps.  Also we found  that  83%  (20/24) of the women  with atypia  were  premenopausal.    This  came  in accordance  with  a  study  by  Schnitt  et  al,

1993,  which found the prevalence  of BPBD

in Japan was as high as 18%  among women younger  than  40  years.21 A similar  finding was  documented   in  North  America.22  In our series Fibroadenoma was the most frequently diagnosed lesion 54.1%, followed by  fibrocystic  change  25.6%.  Duct  ectasia was  the  third  most  commonly   diagnosed lesion. Almost all of the benign proliferative lesions were found in the fibrocystic change and  fibroadenoma   catergories.   This  result came  in accordance  with result of Chengqu an et al, Shrestha  et al and Okota et al. 23-25

As   regard  family   history   we  found   that there is a significant association between the positive history of breast cancer and BPBD. In literature  the association  between  family history of breast cancer and risk of BPED is mixed, with some studies finding a positive association26-27 and others28-33 observing  no association.  In relation to  parity;  we found that there  is an inverse  association  between the  parity and  the  risk of  BPBD  and  there

are only three studies27,29,32 that support this

result, while the remaining  studies observed no association. 28-30,33-36

Several  studies  have  also  examined  the

use.29,33,37-41,42 Four studies  two cohort33,42

and  two  case-control,29,37  have  presented results   for   the   association   between   oral

contraceptive  (OC)  use and  risk  of  BPBD, with  two  showing  that  risk  of  BPBD  was reduced in association  with OC use29,42 and the others37,33 showing no association. Several other studies (all case-control) havereported on the association  between OC use and risk of BBD by degree of histological atypia.36-40

Findings for these studies have varied from those  showing  reduced risk of all grades of atypia36 to those showing no reduction in risk with any grade of atypia.37 In this study, no association  is  found  between  any  measure of oral contraceptive  use and risk of BPBD. The association between age at menarche and BPED of the breast has been investigated in nine  case-control  studies26-29,31,32,34,35  and

one cohort study,33 none of which has shown alterations in risk and this came in agreement with our result.

Conclusion:

Benign proliferative breast lumps are common    among    premenopausal    women in Sohag governorate and a significant proportion of it had atypical proliferation. Fibroadenoma  and fibrocystic  disease  were the   commonest   benign   breast   disease   in our locality. An accurate breast cancer risk estimate study for BPBD is recommended.

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