A study of histopathological spectrum of non-malignant breast lesions

Background: Breast Lesions include a variety of Non-malignant and malignant lesions sometimes producing diagnostic difficulty for both Clinicians as well as Pathologists. In certain cases, histopathological examination, particularly microscopy is the only way to reach to the final diagnosis, so our present study is undertaken to know about the Spectrum of variousnon-malignant breast lesions and Frequency of their occurrence. Materials & Methods: The present study is carried out in the Department of Pathology, GMERS Medical College-Junagadh from September 2015 to August 2018. Excisional and incisional breast biopsies as well as lumpectomy specimens from surgical department have been evaluated both grossly and microscopically for this present study. Results: Out of 200 cases studied during last 3 years, 155 cases belong to non-malignant (non-neoplastic and benign) lesions while 45 cases belong to malignantlesions (breast cancers). The incidence of non-malignant breast lesions is found to be 77.50 % of all breast lesions. Out of all non-malignant breast lesions, Fibroadenoma is found to be the commonest one (Total 75 cases, 48.39%) followed by Fibrocystic Disease found in 15 cases (9.68%). Conclusion: Non-malignant breast lesions include a variety of inflammatory lesions, benign tumors and tumor like conditions. Histopathological evaluation becomes necessary for such cases and plays a pivot role in their final diagnosis.


Introduction
Lump or Mass in the breast is an issue of worry or anxiety particularly for female patients of all age groups and sometimes produces diagnostic difficulty for both Clinicians as well as Pathologists. Benign breast Diseases is defined as any non-malignant breast condition and encompasses a wide range of clinical and pathologic disorders [1]. It is one of the most common diseases in the females of any society [2].
Though majority complains are neglected [3]. In order to provide relief to the patients from anxiety, timely, precise and accurate diagnosis is must. Accuracy and Precision save a patient's life in breast cancers and in cases of non-malignant lesions, they avoid unnecessary mutilating radical surgery and preserve patient's breast. In other words one can say that to prevent unnecessary loss of breast, perfect diagnosis of non-malignant lesions is of utmost importance. Non-malignant lesions include both non-neoplastic and neoplastic lesions. Histopathological examination is now considered a gold standard approach to the diagnosis of breast lump [4]. They also include tumor like conditions e.g. Hamartomas. The incidence of benign breast lesions begins toriseduring the second decades of life and peaks in the fourth and fifth decades [5,6]. So in our present study, we have used the more accurate term "Nonmalignant" instead of the term "Benign". Main purpose of this study is to know about the Histopathological Spectrum of variousnon-malignant breast lesions and Frequency of their occurrence. After fixation in 10% formalin, gross examination and dissection of specimens are done in order to obtain necessary tissue bits. These bits are further processed, embedded in paraffin wax and microtomy is done to obtain thin tissue sections that can be examined further under microscope after staining with routine H & E method. On the basis of both gross and microscopic findings, final diagnosis is given in the form of histopathology report having a specific Performa.All data are analyzed by simple statistical method with Statistical Package for the Social Sciences (SPSS) software, p value <0.05 is considered as statistically significant.

Inclusion Criteria
1. All female patients with Age range: 10 years and above.

Exclusion Criteria
1. MRM specimen which is malignant clinically or on FNAC.

Results
During last three years from September 2015 to August 2018, a total number of 200 cases of breast lesions have been received and out of them 155 cases are of non-malignant lesions. The incidence of non-malignant lesions in our present study is found to be 77.50%. Out of these non-malignant lesions, Fibroadenoma is found to be the commonest one (Total 75 cases, 48.39%) followed by Fibrocystic Disease in frequency (15 cases, 9.68%).  Fibroadenoma was most common benign lesion with 48.39% incidence. They prevalent in age group of 15-25 years with average being 20 years.
Fibrocystic disease was next common non malignant lesion with 9.68% incidence with age range 30-45 years with average being 37 years. The youngest patient was 15 years old with having diagnosis of fibroadenoma.
Presenting complains of patients were mostly lump (55%) alone followed by Lump with pain (30%). Few are having complain of only pain & discharge.

Original Research Article
Pathology Update: Tropical Journal of Pathology & Microbiology Available online at: www.pathologyreview.in 444 | P a g e Out of 155 non -malignant lesions of breast that we had received, 90 patients had a right sided lesion and 55 left sided lesion while bilateral lesion was present in 10 patients. FNAC was carried out in 137 cases, out of which the results were confirmed to be similar to the histopathologic examinations in126 cases. Ultrasound was carried out in 18 patients where FNAC results were acellular, inconclusive or could not be relied on due to in sufficient material and inpatients with nonpalpable lesions.  Figure 2A shows picture of Benign Phylloids Tumor having a leaf like architecture or growth pattern due to over growth of stromal component. Figure 2B shows Lactating Adenoma having dilated lactating ducts lined by a single layer of epithelium. Figure 2C shows Tuberculous Mastitis having a large central area of Caseous Necrosis surrounded by Epitheloid Macrophages, Langhan's Giant Cells and chronic inflammatory cells. Figure 2D shows picture of Fibroadenosis having proliferation of uniform round to oval glandular components admixed with fibrous or stromal tissue. Ratio between glands and stroma is increased in each breast lobule.
Out of 155 cases, only 7 cases are male (4.52%) and rest of 148 cases are females (95.48%). Majority of the cases belong to age group of 21-30 years (total 61 cases, 39.35%) followed by age group of 11-20 years (total 38 cases, 24.52%). Nonmalignant lesions are seen mostly in younger females particularly those who are in their reproductive period of life. Such lesions become uncommon after menopause. The commonest non-malignant breast lesion in males is Gynecomastia that is seen in all 7 cases and affects all age groups.

Discussion
Inflammatory diseases of the breast are uncommon, accounting for less than 1% of women with breast symptoms. Women usually present with an erythematous swollen painful breast. "Inflammatory breast cancer" mimics inflammation by obstructing dermal vasculature with tumor emboli, resulting in an enlarged erythematous breast, and should always be Fibroadenoma is the most common benign tumor of the female breast. Most occur in women in their 20s and 30s, and they are frequently multiple and bilateral. Young women usually present with a palpable mass and older women with a mammographic density or mammographic calcifications. The epithelium of the fibroadenoma is hormonally responsive, and an increase in size due to lactational changes during pregnancy, which may be complicated by infarction and inflammation, can mimic carcinoma. Phyllodes tumors can occur at any age, most present in the sixth decade, 10 to 20 years later than the peak age for fibroadenomas. The majority are detected as palpable masses, but a few are found by mammography. The tumors vary in size from a few centimeters to massive lesions involving the entire breast.
The larger lesions often have bulbous protrusions ("leaflike") due to the presence of nodules of proliferating stroma covered by epithelium.

Conclusion
Non-malignant breast lesions include a variety of inflammatory lesions, benign tumors and tumor like conditions. Fibroadenoma was most common benign lesion with 48.39% incidence with age range isof 15-25 followed by Fibrocystic disease with 9.68% incidence with age range 30-45 years. Most common presenting symptoms for non malignant lesions are lump. Thus breast self-examination and education to females is very importantincasesofbenignbreasttumors.Histopathologica l evaluation becomes necessary for such cases and plays a pivot role in their final diagnosis. It also becomes helpful to surgeons for making decision of further operative management of the patient.