Evaluation of Breast Masses by Sonomammography and X-ray Mammography in Correlation with Histopathological Findings

INTRODUCTION

Breast lumps are common presenting complaints in the female surgical outpatient department, which are due to varied breast pathologies. Breast infection most commonly affects women aged 18 to 50 years; in this age group, it can be divided into lactational and non-lactational infections. The process can affect the skin overlying the breast, where it can be a primary event, or it may be secondary to a lesion, such as sebaceous cyst or hidradenitis suppurativa.^1,2

Breast masses can be broadly classified as benign or malignant. Common causes of a benign breast mass include fibrocystic disease, fibroadenoma, cyst, galactocele, and abscess. Malignant breast disease encompasses many histologic types that include infiltrating ductal or lobular carcinoma and in situ ductal or lobular carcinoma. The main concern of many women presenting with a breast mass is the likelihood of cancer; however, most breast masses are benign.

In our study, an attempt is made to evaluate various breast masses using ultrasonography (USG) and mammography and histopathological correlation separately or in combination, to describe suitable indications, advantages, and limitations of each technique and differentiate the benign breast lesions from the malignant ones.

MATERIALS AND METHODS

This was a prospective analytical study done from September 2015 to August 2016 in the Department of Radiodiagnosis in a tertiary care hospital. All patients with palpable breast lump, patients who were screened for lump, and all cases of nipple discharge were included in the study.

RESULTS

In this study, totally 50 patients complaining of breast mass in one or both breasts were examined clinically and evaluated with USG and mammography. All patients were abnormal and categorized according to the pathology and breast imaging reporting and data system final assessment categories (BI-RADS) classification (Table 1). Patients were in the age range of 11 to 70 years, with a mean of 38.54 years. It was found that the most benign lesions were seen in the younger age group (1st–2nd decades) as compared with that of the malignant lesions (3rd–7th decades). The mean age of the patients with benign lesions is 31.60 years, which is lower, and the mean age for malignant lesions is 47.36 years, which is higher. In the present study, most of the lesions ([19/50] and [21/50]) are located in the upper outer quadrant and upper inner quadrant respectively. About 78.26% of the malignant lesions were markedly hypoechoic (Graph 1). Smooth margins were noted in 92% of the benign lesions, which are more than findings of Cole-Beuglet et al,³ where 75% of benign lesions showed smooth margins (Graph 2). In the present study, 92% of the benign lesions showed posterior enhancement (Graph 3). The lesions were confirmed on histopathology (fine-needle aspiration cytology) (Graph 4), where maximum number of cases came out to be fibroadenoma. Few of the cases from our study are described (Figs 1 to 4).

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Fig. 1:

A 45-year-old female came for USG; transverse USG image reveals a typical larger transverse than anteroposterior diameter, homogeneous echotexture, and a posterior enhancement

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Fig. 2:

A 45-year-old female came for screening mammogram; mammogram shows well-defined, smooth, marginated, rounded soft tissue density radiopacity in lower outer quadrant

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Fig. 3:

A 52-year-old woman with no personal or family history of cancer; mammogram showed a well-circumscribed mass with microcalcifications

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Fig. 4:

Malignant lesions. Transverse scan USG shows a typical malignant lesion, i.e., taller than wide, with hypoechoic echotexture with irregular spiculated margins

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DISCUSSION

The USG and mammography play an integral part in the evaluation and treatment of breast masses. These advances have allowed better delineation of various descriptive characteristics of breast masses.

The present study was conducted in the Department of Radiodiagnosis, which characterized 50 breast lumps in 50 female patients.

MARKED HYPOECHOGENICITY

Markedly hypoechoic lesions should be defined as less echogenic than the relatively homogeneous medium-level echogenicity of the surrounding fat. More useful information can be gained by comparing lesion echogenicity to a structure that has an echogenicity near the middle of the gray-scale spectrum. In the breast, periductal elastic tissue, terminal ductal lobular units, and fat have an echogenicity near the medial of the gray-scale spectrum. Of these, fat is uniformly present in all patients; therefore, fat is the tissue against which the echogenicity of solid lesions can most consistently be compared from patient to patient.

In the present study, 78.26% of the malignant lesions were markedly hypoechoic. Similarly, Stavros et al⁸ found that two-thirds of the malignant lesions (66.66%) were markedly hypoechoic compared with fat.

It was concluded that even though marked hypoechogenicity is a worrisome finding for malignancy, isoechogenicity/mild hypoechogenicity are not necessarily reassuring and should be considered as indeterminate findings. Chao et al⁹ found 60% of the malignant lesions to be markedly hypoechoic and Hong et al¹⁰ found 62% of the malignant lesions to be markedly hypoechoic.

Skaane and Engedal⁴ and Popli¹¹ in their studies have mentioned marked hypoechogenicity as a feature of malignancy.

GRAY-SCALE SONOGRAPHIC CRITERIA FOR BENIGNITY