Causes of Referral for Breast Ultrasonography in General Practice in South Jordan

The commonest age of presentation was between 25-39 years, where 70 patients presented in this age group (53.0%).  The patients older than 70 years were male patients (Table II).

Patients were most likely to present initially with breast pain 46/132 (35.11%), mass 40/132 (29.77%) or a painful mass 14/132 (10.69%).  These categories comprise 100/132 (75.57%) of the total population of study. Nipple related complaints such as discharge and retraction were reported in 3.82% (5/132) patients.

 In patients who had been followed up for previous breast pathology, no changes were reported compared to the latest ultrasound examination. All these patients had follow up interval between 3-4 months. In the rest of the study group (118 patients), ultrasound findings were normal in 45 patients. The malignant changes were reported in nine patients while benign breast findings were reported in 64 patients. Four of the patients with malignant  changes  were aged  younger  than 39 years (30 -35 years), other four were aged older than 40 years (45-55 years) and one patient was aged 70 years (Table III).

The benign ultrasound findings included dilated lactiferous ducts, normal looking small axillary lymph node, benign looking cyst or solid lesion.

In this review, we went over the indications and their ultrasound findings from the radiology department archive in a retrospective manner. The patients were sent for their referring physician and further investigations were done accordingly. The results were based on radiological diagnosis.

The complaints were variable according to the age of the patient. Breast pain was the commonest presenting symptoms through all age categories mainly in patients aging 25-39 years old.  Mass was the second most common presenting symptom (Table IV).

Discussion

Breast cancer is a heterogenous disease clinically and radiologically. Tumour size at presentation, histological grade, histological type, lymph node metastasis, vascular space invasion and tumor necrosis and other factors may help in predicting prognosis.⁽³⁾  Age at presentation is a significant factor that affects management.⁽⁴⁾

 Pregnancy and lactation are special health situations in which the breast can be affected by a variety of breast diseases ranging from benign disorders to breast carcinoma.⁽⁵⁾ Tremendous advances have been made in the management of breast problems, mainly through advances in diagnostic breast imaging.

Breast cancer is the most common malignancy affecting females all over the world with lowest incidence in Asia and Africa.⁽⁶⁾ Although breast cancer rarely occurs in young women, about 2% of the patients with breast cancer are <35 years old at diagnosis.⁽⁷⁾ The majority of  lesions that occur in the breast are benign so that most patients require reassurance of the benign nature of their complaint, still up to 15% will require further therapy.⁽⁷⁾

In our study most of the patients were young between 24-39 years old and most of them presented with mastalgia.  Mastalgia is a common and annoying condition and it may be severe enough to affect the patient’s usual activity.^(8.9) Mass and painful mass were seen in 28 patients.  The discovery of a breast mass, detected by the patient or by the physician is a common event.⁽¹⁰⁾

Significant number of patients had benign breast pathologies which constituted about half of the study population (after excluding the follow up patients). Normal findings were reported in 45 patients (38.1%). The malignant (suspicious) breast changes were seen in only nine (7.9%) patients. The male patients in this study complained of gynecomastia. No ultrasonic abnormality was reported in any of them. Compared to Hieken et al. who studied 660 patients 31% of them had normal ultrasound results. Benign results are reported in 18% of patients while focal complex or solid abnormality is reported in 51 % of their study population.

In the next session we will discuss briefly some breast pathologies in relation to the clinical entities reported in this review. ⁽¹¹

Mastalgia: Mastalgia is a common and enigmatic condition; the cause and optimal treatment are still inadequately defined.⁽⁸⁾  Mastalgia - breast pain - is the most common breast-related complaint of patients seeking care at both primary care clinics and breast referral centers.⁽⁹⁾ Two thirds of screened patients in most series complain of breast pain.⁽⁹⁾ It is classified into cyclical and non-cyclical types according to relation to menstrual cycle. Its nature varies with its class and may be sever enough to interfere with patient’s life. In this review pain is still the commonest presenting symptom constituting about one third of presenting symptoms (35.7 %). Breast pain was commonest to be seen in patients aged 25-39 years old, 25 patients out of 70 patients.

Breast mass:  A palpable breast mass is a common presentation of a breast pathology. It varies from a cyst to a malignant mass. Dilated lactiferous ducts might present with a palpable breast area which may painful. Ultrasound is very beneficial in differentiating between cystic and solid mass. It even characterizes a solid mass in terms of site, echogenicity, site, and some other criteria which might all help in differentiate benign from malignant mass. Breast mass which may be painful and breast pain constitute over 80% of the breast problem that requires hospital referral.⁽¹⁾ This is comparable to the results we obtained in this review. Nineteen patients (27.14%) presented with mass alone while nine patients (12.86%) had combined symptoms. In patients < 24 years old and those between 40- 54 years old the presenting symptoms were comparable in percentages. The exact details of these symptoms are shown in Table III.

 Enlarged axillary lymph nodes: Lymph nodes are most commonly located in the lateral breast mainly in the upper outer quadrant (no nis seen). The accurate prediction of axillary lymph node status is essential for staging and planning of treatment for patients with breast cancer.⁽¹²⁾ Still, different studies are arguing the criteria for needle biopsy because in some cases those nodes that are suspected of malignant changes on ultrasound are biopsied while in other cases all nodes are biopsied regardless to their appearances on ultrasound or their size.⁽¹³⁾ The axillae are examined in all patients presented with breast complaint and to report all detectable axillary lymph. Any abnormal ultrasonic finding about size or shape of lymph node would be included in the radiological report.  Axillary lymph nodes were seen in 26 patients. All detectable lymph nodes were recorded. No significant abnormalities concerning the shape of lymph nodes, neither the fatty hilum nor the cortical thickening were reported.

 Ductectasia:  Ductectasia is dilated lactiferous ducts may be asymptomatic and only detected at imaging evaluation. Ductectasia may manifest as a painful and/ or palpable area.  It may be associated with nipple discharge .Theses ducts are seen on ultrasound as tubular anechoic structures sometimes filled with debris.   Ductectasia was observed in 19 patients of the population of the review who presented with variable presentation.

 Nipple discharge:  This is a symptomatic problem that causes many women discomfort and anxiety. Spontaneous clear, serous or blood containing discharge secreted unilaterally from one duct orifice need further evaluation.⁽¹⁴⁾ Ultrasonography is not typically used unless the nipple discharge is accompanied by a palpable mass or a positive mammographic finding. Although benign intraductal papilloma is a common cause of nipple discharge, carcinoma is found in 10-15% of cases.⁽¹⁵⁾ Lesions that present with nipple discharge are not typically visualized by mammography or ultrasound and only detected on galactography.⁽¹⁴⁾ High-resolution ultrasonography techniques are becoming more sensitive for the visualization of intraductal changes. Tiny, solitary papilloma can sometimes be visualized by using this sophisticated technology Magnetic resonance imaging (MRI) may play an adjunctive role, aiding in the differentiation of benign ductal abnormalities from malignant ones. High-resolution ultrasonography is relatively new and expensive however it is operator dependent and requires expertise for the identification of small intraductal pathologies limit its use in diagnosis of nipple discharge.).In this review three patients (2.27%) presented with nipple discharge. Ultrasound examinations were normal for these patients and further investigations were advised.

 Nipple retraction: The nipple – areolar complex may be affected by a variety of diseases.⁽¹⁶⁾ Patients who has unilateral, recent nipple retraction should be further assessed by ultrasound and mammography. Differential diagnosis includes inflammatory conditions such as duct ectasia periductal mastitis and tuberculosis as well as malignancy.⁽¹⁶⁾ Two patients had presented with nipple retraction, one had bilateral while one had associated duct ectasia.

 Pregnancy and lactation: Pregnancy and lactation are exceptional physiological states that induce significant changes in mammary gland in response to hormonal stimulation.⁽¹⁷⁾ Most disorders related to pregnancy and lactation are benign. The pregnancy related breast carcinoma (PRBC) represents about 3% of all breast malignancies.⁽¹⁷⁾ In our study one pregnant patient presented with breast pain which was revealed by ultrasound examination to be dilated lactiferous ducts. Of the eight lactating patients: three presented with   palpable mass, three presented with skin changes suggestive of inflammatory process and two presented with breast mass. Ultrasound findings were, abscess collection, mastitis, galactocele and Ductectasia.

 Gynecomastia: Gynecomastia is defined as benign proliferation of male breast glandular tissue.⁽¹⁸⁾  It has three peaks, neonatal, pubertal and elderly males.^(18,19)  It is common being present in 30-50% of healthy men.⁽²⁰⁾  It may be asymptomatic detected on routine examination and may be asymmetrical or unilateral.⁽²¹⁾ The main etiology of gynecomastia is the imbalance between estrogen actions relative to androgen action at the breast relative to androgen action at the breast tissue level.⁽¹⁸⁾ Accordingly, gynecomastia may be physiological in neonates due to the effect of maternal hormones, pubertal due to hormonal imbalance or pathological due to liver or renal diseases. A long list of drugs results in gynecomastia.

 Mastitis: This is a cellulitis of interlobar connective tissue within mammary gland that usually occurs in the first 6 weeks postpartum.⁽²²⁾ The significance of this entity is the fact that inflammatory breast cancer simulates an infectious or inflammatory causes. It may develop without a palpable mass lesion.⁽²⁾ So most patients with inflammatory breast cancer are diagnosed after initial treatment with antibiotics and anti-inflammatory drugs failed to show clinical improvement.⁽²⁾ The clinical presentation of mastitis varies between simple inflammatory process to abscess formation with systemic manifestations. In this review, eight patients presented with skin changes suggestive of mastitis, three of them had abscess collection detected by ultrasound examination. Skin changes may include itching, eczematous changes, which are beyond the scope of this article.

 Suspicious breast lesion: Several studies are discussing the criteria that are suggestive of malignant changes.⁽²³⁾ These include the contour of the lesion, speculations, depth of the lesion, presence of calcifications, axillary L.N.E.   Clinical findings are also of great significance. Doppler US is playing a more important role as recent studies are focusing on its role in differentiating benign from malignant masses. This depends on the fact of neovascularization a malignant mass would cause.⁽²⁴⁾

Conclusion

Breast symptoms in adolescent and adults are common presentation to the primary care practice, regardless of the sex. Mastalgia is the commonest presenting symptom for seeking medical advice in our practice.  In our study, benign breast diseases were far more common than malignant ones. Male patients were not excluded from referral for breast problems.

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