Breast lumps are focal abnormal lesions that differ from nearby normal breast tissue consistency [1]. Not every breast lump means cancer as it can characterize a sign for altered diagnosis [2]. Breast lumps remain the main presenting complaint that worries women and made them look for help [3]. Breast cancer is increasing nowadays in women all over the world [4-5] and still the most common cancer among Iraqis [6]. Nearly 10% of breast masses will be malignant, this requires taking care of women presenting with such a symptom; besides, to be the commonest cancer in Iraq, it is also the leading cause of death amongst women suffering from cancer [1,4]. The breast cancer incidence varies from one country to another, being high in developed countries (>80 per 100,000 populations) than that in developing parts of the world (<40 per 100,000 populations) [4-7]. Women older than 40 years of age are the most affected with breast cancer in the USA [8]. However, that is not true in developing countries where younger age are at risk for breast cancer resulting in a major health problem [4-9] self-examination, seeking medical advice early and early treatment remains the best method for decreasing death and spread of breast cancer [4-6,10].
After clinical examination radiological imaging techniques play a major role in diagnosis and follow up of proved cases this is based on Breast Imaging Reporting And Data System (BIRADS) that was used by radiologists to give a final impression about the breast lesion, BIRADS motive the surgeon and pathologist as well to work together with the radiologist as a multidisciplinary team to reduce mistake and improve communication with the patients and other medical doctors [11].
A BIRADS category V is where the concern for breast cancer risk is greater than 95% and where the breast cancer treating physician should take action [12-13].
This was a retrospective study that enrolled 42 patients who complained of palpable breast mass referred from the surgical unit of early detection of breast cancer to the Radiology Unit in the Oncology Teaching Hospital, Medical City Complex, Baghdad during the period from May 2019 to August 2020. Their age was between 29 to 92 years.
All patients after clinical examination by a specialist surgeon were referred for breast ultrasound examination which was performed by a specialist radiologist using GE Voluson E6 machine (Korea). The scanning was performed using a 7-12 megahertz linear transducer. The ultrasound examination of the patients was performed by asking the patient to lie flat on the couch with both breasts completed exposed, arms above the head and the axillae were fully visible. The breast was assessed for any mass, its location, margin, echogenicity, and size, were documented, assessment of the axilla for suspicious lymph nodes; recording their shape, hilum, and cortical thickness was also documented.
The next step was FNAC which performed by a specialist cytologist using a 22 G needle either by palpation or under an ultrasound guide. Then aspiration was done, the sampled cells were prepared on the slide, immerged in an absolute alcohol jar, and then stained by Papanicolaou stain and examined cytologically for the presence of any atypical, or malignant cells.
Forty-two patients presenting with breast lump were included in this study. Their ages ranged between 29 to 92 years (mean age 60 years).
The ultrasound findings of those 42 patients were as follow irregular lesion seen in the majority of cases (55%), an ill-defined lesion was documented in (26%), no mass seen in 2 cases which only revealed pathological lymph nodes, multifocal lesions within one breast seen in three cases. Pathological Lymph nodes are seen in 50% of the cases (details regarding the ultrasound findings are illustrated in Table 1).
| No. (Percent) | |
| Mass | |
| Well defined | 6 (14) |
| Poorly demarcated | 11 (26) |
| Irregular | 23 (55) |
| No mass | 2 (4) |
| Multifocal lesions | 3 (7) |
| Lymph nodes | 21 (50) |
The Findings of FNAC cytology are shown in Table 2, Mammary carcinoma was the major finding in the cytopathological reports seen in 93%,the remaining 7% were documented as severe atypia.
| Fine needle aspiration finding of breast mass | No. | % |
| Malignant cells | 39 | 93 |
| Severe atypia | 3 | 7 |
| Total | 42 | 100 |
BIRADS V was documented in 32 cases and BIRADS IV in 9 cases, one case score as BIRADS III, this is shown in Table 3.
| BIRADS | No. | % |
| V | 32 | 76 |
| IV | 9 | 21.50 |
| III | 1 | 2.50 |
When correlating the BIRADS score (summating BIRADS IV and V) with FNAC result, it shows the high sensitivity of ultrasound in the detection of malignant lesion reaching 97% with a high positive predictive value of 92.5% and overall accuracy of 90.5%, detailed information was given in Table 4 below.
| FNAC | Total | ||
| Ultrasound | Positive | Negative | |
| Positive | 38 | 3 | 41 |
| Negative | 1 | 0 | 1 |
| Total | 39 | 3 | 42 |
| Sensitivity | 97% | ||
| Specificity | 0% | ||
| Positive predictive value | 92.60% | ||
| Negative predictive value | 0 | ||
| Accuracy | 90.50% |
When compared to the core needle biopsy, FNAC presents a quick, simple, easy, safe, and relatively cheap maneuver through which breast tumors could be easily diagnosed [14-15]. Fibrosis versus chest wall recurrence still a dilemma that can be solved using FNAC, as well as in the evaluation of the axilla for suspicious lymph nodes [16]. In Iraq, FNAC remains the leading choice for solving the suspicious lesion detected by breast ultrasound or mammography according to National guidelines for early detection of breast cancer [17]. however, the restriction of FNAC include difficulty in giving the precise histopathology of breast cancer as being ductal carcinoma in situ or invasive carcinoma, sometimes impossible differentiation between ductal and lobular carcinoma in poorly differentiated cases as well as the failure of providing hormonal receptors and HER2 status if the aspirated samples are inadequate [18].
The accurate diagnosis demands the availability of efficient cytopathologists; professionals in aspiration and clarification of the findings and well-qualified technicians to ensure the preparation of quality smears [17]. In our study, there was a high concordance between the ultrasound diagnosis of the BIRADS category and the results of FNA. A confirmed cytological diagnosis of mammary carcinoma was observed in 75% of BIRADS V lesions and 21.5% of BIRADS IV labeled ultrasound reports, These figures are in line with those reported by Abdullateef Aliasghar Mustafa [19].
In our study, malignant cells were observed more in poorly demarcated and irregular lesions (26% and 55%) respectively and in 6% of well-circumscribed lesions and this is in agreement with a study done by Sudheer Gokhale [20].
In our study, the overall accuracy of ultrasound in the diagnosis of breast cancer was 90.5%, this was not in agreement with Mubuuke Aloysius Gonzaga [21] which shows the accuracy of 57%, but in concordance with a study done by Augustina Badu-Peprah and Yaw Adu-Sarkodie [22] who show a sensitivity of 100%.
In conclusions, ultrasound is an efficient, relatively cost-effective tool and with excellent resolution for detecting suspicious breast lesions; utilizing no ionizing radiation, that it’s considered as a first-line investigation in any patient coming with breast mass, especially when performed by professional personals and well-trained radiologists it yields a highly productive and a precise diagnosis.
The author design the study,collect the sample, and write the article.