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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 6  |  Issue : 2  |  Page : 92-95

The pathological profile of Saudi females with palpable breast lumps: Knowledge that guides practice


Department of Surgical Pathology, University of Dammam, King Fahd Hospital of the University, Khobar, Saudi Arabia

Date of Web Publication15-Sep-2017

Correspondence Address:
Areej Al Nemer
Department of Surgical Pathology, University of Dammam, King Fahd Hospital of the University, Khobar
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjhs.sjhs_66_16

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  Abstract 

Objective: The objective of this study is to determine the spectrum of pathologies of palpable breast lumps in females and their significance in different age groups in a setting where breast cancer (BCa) is prevalent in the younger population. This knowledge is crucial for modifications in the current screening programs. Materials and Methods: All needle biopsies for the complaint of breast mass felt by the female patients were retrospectively included over 4 years. Fisher exact test was used to determine the age of significant cancer risk. Results: Out of 140 cases met the inclusion criteria, 110 were BCa. The median age of BCa was 46 years. There was 68% positivity for BCa in cases belong to females below 40 years, and 75% in patients aged younger than 50 years. The age of 40 years old shows significant cancer risk. Conclusions: The results showed that almost 4 out of 5 females with palpable breast lumps subjected to needle biopsy had BCa. Although this risk is higher with increased age, BCa is a disease of young in the population under study. Review of the current preventive and management measures is critically needed.

Keywords: Breast, cancer, lump, palpable, pathology


How to cite this article:
Al Nemer A. The pathological profile of Saudi females with palpable breast lumps: Knowledge that guides practice. Saudi J Health Sci 2017;6:92-5

How to cite this URL:
Al Nemer A. The pathological profile of Saudi females with palpable breast lumps: Knowledge that guides practice. Saudi J Health Sci [serial online] 2017 [cited 2017 Oct 19];6:92-5. Available from: http://www.saudijhealthsci.org/text.asp?2017/6/2/92/214855


  Introduction Top


Although breast cancer (BCa) is the most common malignancy in females worldwide and in Saudi Arabia for the past 15 years with a continuously rising incidence,[1],[2],[3],[4] benign breast diseases (BBDs) are still more prevalent.[4],[5],[6],[7] The most frequent presentations to breast clinic are due to mastalgia, nipple discharge, breast mass, or combination of these symptoms. BCa is not commonly present itself with pain or discharge. While the incidence of BCa shows less geographic variability than many other malignancies such as prostate cancer,[8] the biologic behavior is, however, different. Many local studies, including old and recently dated, have documented the earlier age of onset in Arab females and a more advanced stage at the time of diagnosis.[5],[9],[10],[11],[12],[13],[14],[15] The Saudi society is known for its conservative nature that females refrain seeking medical advice if the problem in the breast out of shyness to be examined by male physician until the disease is advanced. Both morbidity and mortality of BCa have been shown to be effectively reduced by early detection of the disease.

The real implementation of mammogram public screening programs was not common until 2007, and the uptake is not satisfactory yet.[2],[16] Mammogram is recommended for 50–74-year-old females once every other year.[17] The Saudi population is young and only 5.1% fall in this age range while 78% of them are under 40 years old.[18] Breast self-examination for palpable masses is not an effective method for detecting BCa.[16] There is no statistics available on the spectrum of breast diseases first presented as a palpable mass in the setting where BCa is prevalent in young age. We conducted this study to investigate the significance of autodetection of breast mass in the different age groups. This knowledge is crucial for planning future screening programs and their management strategies.


  Materials and Methods Top


This laboratory-based study was conducted in a university hospital serving a representative subset of the population residing the Eastern Province of Saudi Arabia, where most cases of BCa clusters.[19]

After getting the institutional review board approval, all needle biopsies for the chief complaint of breast mass felt by the patient herself were retrospectively included over 4 years [January 2010 till December 2013]. Cases were excluded if it belongs to male patients, has no definite diagnosis due to the insufficient material, is duplicated, or has the previous history of BCa. Patients' e-charts and pathology reports were reviewed for demographic, medical, and pathologic data. Breast pathologist selectively revised some slides for assessment of atypia. Diagnoses were then classified into two broad categories; malignant lesions which includes invasive ductal carcinoma (IDC), invasive lobular carcinoma (ILC), invasive carcinoma of special types, and ductal carcinoma in situ (DCIS). The second category includes all benign neoplasms along with nonneoplastic lesions. Fibrocystic change (FCC) was divided according to cancer risk into three subtypes; nonproliferative FCC (NPFCC), proliferative without cytological atypia (PFCC), and proliferative with cytological atypia (PFCC-A). Cases were then stratified into five groups according to age: <30 years, 30–39 years, 40–49, 50–59 years, and >60 years. Data were tabulated in Excel spreadsheet using Microsoft Excel 2010, and statistical analysis was conducted using GraphPad Prism version 6.00 for Windows, GraphPad Software, La Jolla California, USA, www.graphpad.com. Results were considered statistically significant if two-tailed P < 0.05.


  Results Top


A total of 140 cases were recruited. Patients' age range from 14 to 79 years old, with a median of 46 years. The spectrum of confirmed tissue diagnoses is shown in [Table 1]. One hundred and ten cases (79%) were positive for BCa. [Table 2] highlights the age distribution of the lesions. Most cases clustered in the fifth, fourth, and sixth decades; in order. The majority of malignant cases (34.55%) were diagnosed in the fifth decade, followed by the sixth and fourth decades (25.5 and 24.5, respectively). As expected, there are higher fractions of malignant disease with increased age [Figure 1]. The median age of BCa was 46 years (range; 22–79 years). The vast majority of cases (n; 92, 83.6%) were IDC. Both DCIS and classic ILC were seen in six cases; each, collision IDC and ILC and mucinous carcinoma were seen in couple of cases per each, pleomorphic ILC and metaplastic carcinoma were seen each as a single case.
Table 1: Pattern of breast diseases (n=140)

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Table 2: Age distribution of lesions

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Figure 1: The fraction of positive breast cancer cases in each age group

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Testing the age of 40 years for significant cancer risk

There were 68% positivity for BCa in cases belong to females below 40 years versus 83% in those aged 40 years or older. Using Fisher exact test, being forty or older showed significant risk for having BCa (two-tailed P = 0.0488).

Testing the age of 50 years for significant cancer risk

Positive cases constituted 86% and 75% in patients aged fifty and older against younger, respectively. Hence, there was no significant risk associated with age 50 (P = 0.194).

Nonmalignant masses

The median age was 42 years old (range; 14–75 years). FCC accounted for 33.3% of cases. Median age was 44 years. Only 30% of them were NPFCC, and out of the PFCC, 28.8% were with cytological atypia. Fibroadenoma was the second popular benign finding with a median age of 40 years (range; 14–53 years).


  Discussion Top


This study disclosed that almost 4 out of 5 females with palpable breast lumps subjected to needle biopsy had BCa. Although this risk is higher with increased age, BCa is a disease of young in the population under study. Thus, efforts are needed to increase awareness for the early detection of masses in females at all age groups. Females should be encouraged not to ignore any breast mass, as any lump in female above 30 years old should be probably screened for cancer [Figure 1] and lumps in patients above 60 years old should be considered as BCa until verified otherwise.

Studying the pathologic profile of breast lesions in different countries revealed BCa rate in the range of 10%–30%.[20],[21],[22],[23],[24] In Saudi Arabia, studies from different provinces showed up to 43% BCa rate, with mean age in 40's in seven different studies.[5],[6] The reason that our BCa rate is much higher than others is that we studied only female population that presented first with palpable mass. Most biopsies received based on radiologic abnormality or due to other symptoms such as nipple discharge or breast pain turn to be negative for BCa. Likewise, the vast majority of biopsy belongs to males show only gynecomastia. On the other hand, when a female patient presents with a palpable lump like in our series, there is low chance of getting borderline pathology such as atypical duct hyperplasia, atypical lobular hyperplasia/lobular carcinoma in situ, flat epithelial atypia or even papillomas. These precursors/risk indicators are best detected by mammography. The ultimate challenge is to find these cases before developing the lumps and enroll them in a regular professional clinical examination and mammography. This will not only reduce the morbidity and mortality rates of BCa but also ease the burden on health-care facilities being the most prevalent malignancy.[1],[2],[3],[4] The intention of limiting our study on palpable lumps in female breasts is that we want to investigate the significance of this common presentation in our patients' population.

Our data showed that 68% and 75% of BCa cases are under the age of 40 and 50 years, respectively. Another study conducted by another hospital in the region also showed that 57.5% of BCa cases are diagnosed before the age of 50 years versus 12.5% in the USA according to Surveillance, Epidemiology, and End Results records.[12] Another study also showed 78% of cases belongs to patients younger than 50 years.[9] In Lebanon, another Arab country, 50% of BCa cases are younger than 50 years,[25] and the mean age for Yamani females diagnosed with BCa was 44.3 years in a recent study.[24] Contradictory, In the USA, Shields et al. and others found that patients younger than 50 years have about 90% chance of negative biopsy.[26] The biology and etiology of breast diseases are variable among different races and ethnic groups, and younger age usually conferred worse prognosis.[10],[13],[25] Therefore, our results emphasize the necessity to search for possible risk factors, environmental and/or genetic, which causes BCa in a relatively young age group. Furthermore, knowing that participation rate of screening programs is unsatisfactory despite being available free of charge to all citizens,[20] it is essential to design educational programs for young females, probably at schools to advocate BCa screening starting at a younger age than the recommended internationally to detect premalignant diseases or BCa in its earlier stages.

For BBDs, the low frequency for fibroadenoma in our cohort does not necessarily reflect the genuine incidence rate in our population, because most patients with typical clinical and radiological presentation do not undergo biopsy. They either choose to keep it or they excise it to alleviate their anxiety without going through needle biopsy. The age overlap between benign pathologies and BCa is evident [Table 2]. Therefore, clinical judgment is crucial. Training dedicated medical staff in breast diseases is another vital issue to avoid delay in diagnosis and treatment especially in countries where the disease burden is high in younger ages such as in Saudi Arabia.

This study is distinctive because it is the first one that analyzed the profile of palpable breast masses in a female population where going to screening is suboptimum, and BCa is common even in young age. An important limitation in this study is its retrospective nature and its focus on lesions selected for needle biopsy. This might not give the exact scope of breast diseases, but it still establishes a range of expected profiles for biopsy outcome in such settings.


  Conclusions Top


This work offers a baseline data in our biopsy profile belonging to females with breast masses. Based on our findings, it seems that review and update of the current preventive and management measures is critically needed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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