European Journal of Cardiovascular Medicine

Mammary glands or breasts are a distinguishing future of mammals¹. From puberty to death the breast is subjected to constant physical and physiological changes that relate to menses, pregnancy, gestation, lactation and menopause under the control of numerous hormones.

Benign breast diseases are common disorder, upto 30% of women will suffer from benign breast diseases requiring treatment at sometimes in their lives².Growing public awareness have increased referrals to hospital clinics for breast symptoms and currently malignant to benign ratio of 1 : 10 are being seen in breast clinic (Barclay et al 1991)³.The term benign breast disease, (BBD) encompasses a heterogenous clinical and pathological condition which ranges from inflammatory condition to benign neoplastic conditions.

During the past decade there has been an increasing interest in BBD for the reasons like its high incidence, patients demanding investigations and treatment for symptoms of diseases and the question of premalignant disorder in which surveillance may be beneficial.

The concept of ANDI (Aberrations of Normal Development and Involution) as described by Prof. Hughes is recommended as a framework for understanding majority of benign conditions. Breast complaints are one of the most common reasons for surgical consultation. The majority ultimately prove to have a benign origin⁴.

Breast lesions may present with a variety of symptoms often confusing clinical evaluation leading to error in treatment of essentially benign conditions.

This clinico-pathological study of benign breast diseases which include 100 cases, where all possible attempts to study the various aspects of the diseases and its management have been made, excluding inflammatory breast diseases and carcinoma of breast.

AIM:

1. To assess the role of ANDI classification in the management of benign breast diseases.

OBJECTIVES:

1. To categorise benign breast diseases with reference to ANDI classification.
2. To assess the role of ANDI classification as a tool to select the modeof benign breast diseases.

The present study is a prospective study done on 100 female patients who presented with complaints of benign breast diseases under ANDI classification conducted in Sri Venkateswara Ramnarain Ruia Government General Hospital, Tirupati from October 2024 to February 2025.The patients were required to give written informed consents prior to enrolment in the study and clearance was taken as per institute’s ethical committee guidelines.

INCLUSION CRITERIA:

• All female patients who attained menarche presenting with complaints of benign breast conditions under ANDI classification attending Out patient and Inpatient in the Department of General Surgery.

EXCLUSION CRITERIA:

• Patients with Carcinoma breast, breast abscess and those who are not willing to give consent.
• The study compromises 100 cases of benign breast diseases which includes 60 cases of Fibroadenoma, 30 Cyclical mastalgia with nodularity, 5 cases of Incapacitating Mastalgia, 3 cases of Duct ectasia and 2 cases of Giant Fibroadenoma from Outpatient and In patient wards in the department of General surgery, Sri VenkateswaraRamnarainRuiaGovernament General Hospital, Tirupathi .
• A detailed history is taken regarding lump, pain, nipple discharge, menstrual history, obstetric history,family history, previous surgery if the patients have undergone, history of oral contraceptive pills. General physical examination isdone. A detailed local and systemic examination is carried out and clinical diagnosis is made.
• Patients are subjected to routine blood examination and specific investigations like FNAC, Ultrasonography of the breasts, Mammography. The excised specimens were sent for histopathological examination for confirmation of clinical diagnosis.
• After studying in detail about 100 cases, with regards to the age of the patient, presenting complaints, diagnostic investigations and treatment received, the most common and rare benign breast diseases are represented in the form of tables,graphs and charts to detect them early based on symptoms and to arrive at correct diagnosis without a delay on unnecessary investigations.
• Total number of benign breast diseases studied - 100

TABLE I: Percentage of various benign breast diseases

The most common benign breast disorder is Fibroadenoma, accounting for about 60 cases (60%), followed by cyclical mastalgia with nodularity which accounts for 30 (30%) cases, incapacitating mastalgia accounting for 5 cases (5%), duct ectasia for 3 (3%) and giant fibroadenoma for 2 cases (2%).

The most common condition is Fibroadenoma which is either painless or very rarely painful to present with. It is followed by mastalgia either cyclical with noduarity or severe and incapacitating variant.

BAR DIAGRAM I - INCIDENCE OF BENIGN BREAST DISEASES

TABLE II: Age distribution of different Benign Breast Diseases

In my study, the most commonly affected age group of benign breast disease is 20 to 30 years, 56 cases(56%), followed by 31 to 40 years, 27 cases(27%). But the majority of the breast diseases showed their expression in the age groups of 31 to 40 years. The peak incidence of Fibroadenoma is 21 to 30 years age group with 42 cases(42%) followed by 11 to 20 years with 15 cases (15%) . Cyclical mastalgia with nodularity is noted in its peak in 31 to 40 years of age group - 16 cases(16%) Incapacitating mastalgia and Duct Ectasia are also noted in its peak in 31 to 40 years of age group – 5 cases(5%) and 2 cases(2%) respectively.  Giant Fibroadenoma are predominantly found among     age groups of 21 to 40 years.

 BAR CHART II -  AGE DISTRIBUTION OF BENIGN BREAST DISEASES

Table III: DURATION OF SYMPTOMS IN THE STUDY

In the study out of 60 cases of fibroadenoma, 32 cases presented with a history of 1 to 3 months , 26 cases presented with a history of 4 to 6 months and 2 cases with 7 to 9 months history.

Out of 30 cases of Cyclical mastalgia with nodularity,6 cases presented in 1 to 3 months, 16 cases in 4 to 6 months, and 8 cases in 7 to 9 months.

Out of 5 cases of Incapacitating mastalgia 3 cases presented in 1 to 3 months and 2 cases presented in 4 to 6 months. Two cases of Duct ectasia presented in 4 to 6 months and one case in 1 to 3 months history. Two cases of Giant Fibroadenoma presented with 7 to 9 months history.

BAR CHART III - DURATION OF SYMPTOMS IN THE STUDY

PIE CHARTS SHOWING SYMPTOMS OF VARIOUS BENIGN BREAST DISEASES

Table  -  IV : Mode of presentation

In the present study,Fibroadenoma presented as painless lump in majority of cases(50%),and as a painful lump in 10% of cases.Cyclical mastalgia with nodularity presented with pain in the breast with multiple nodules or lumps in the breast (30%)and the same is with Incapacitating mastalgia but the pain tends to be more severe.

Duct ectasia presents with painful lump and with nipple discharge in most of the cases. Gaint  fibroadenoma like fibroadenoma mainly presented as a painless lump.

PIE CHART SHOWING MODE OF PRESENTATION OF BENIGN BREAST DISEASES

BAR CHART IV -  MODE OF PRESENTATION OF VARIOUS BENIGN BREAST CONDITIONS

Table  V  : Site of involvement

In the present study, the majority of the fibroadenoma cases presented in the right breast 34% followed by left breast 25% and in both the breasts in 1% of cases.

The cases of Cyclical mastalgia with nodularity presented mainly in both the breasts(30%) as it is same with Incapacitating Mastalgia(5%).

Duct ectasia mainly presented in the right breast 2% followed by left breast1% of cases. Giant fibroadenoma was seen in only left breast in the present study

BAR DIAGRAM V -  THE SITE OF INVOLVEMENT OF BENIGN           BREAST DISEASES

Table VI: Quadrant topography of diseases

BAR CHART VI - QUADRANT TOPOGRAPHY OF BENIGN BREAST DISEASES

TABLE VII : INVESTIGATIONS DONE IN PRESENT STUDY

In cases of Fibroadenoma and Giant Fibroadenoma, the investigaions done are Ultrasonogram and FNAC(Fine Needle Aspiation Cytology) and routine blood investigations they may need if surgery is planned.

For Cyclical mastalgia with nodularity and Incapacitating mastalgia routinely Mammogram is done. For cases of Duct ectasia, Ultrasonogram and Cytology of the nipple discharge is done.

TABLE VIII : TREATMENT OF BENIGN BREAST DISEASES

Out of 100 cases, 60 patients needed surgery and 40 patienTS were given medical management.

In the present study, 56 cases of Fibroadenoma underwent surgery and 5 cases are managed medically. All the cases of Duct ectasia and Giant fibroadenoma were managed with Microdochectomy.

All cases of Incapacitating mastalgia and Cyclical mastalgia with nodularity responded well with medical management. This clearly shows not all the benign breast conditions need surgery.

BAR CHART VII -  TREATMENT GIVEN IN THE PRESENT STUDY

Benign breast disease is a common disease affecting the women from puberty to menopause. In the present study 100 women who presented with complaints of benign breast diseases in the Department of General surgery, were studied with clinical examination,radiological and pathological investigations.

In the present study 100 cases of benign breast diseases were studied in only female patients attending the Department of General surgery in SVRRGGH, Tirupathi.

           In the present study of 100 cases, 15% of the cases were in the age group of 11 to 20 years. 56% of cases are in the age group of 21 to 30years of age followed by 27% of cases in 31 to 40 years of age group. Only 2% of the cases are in 41to 50 years of age group.

          The present study shows the most common age group is 21 to 30 years of age. It is similar to the study done by SushilaKhannaet al⁵ in which 40.06% of cases were in the age group of 21 to 30 years.

The maximum number of cases belonged to the age groups of 21 to 40 years of age(83%). This is similar to SushilaKhannaet al⁵ study in which 58.53% of patients belonged to the age group of 20 to 40 years of age. Another study conducted by Rangabashyamet al⁶ showed that maximum number of cases (70%) are between 20 to 30 years of age group. Hadfield⁷ reported that majority of the patients were about 40 years of age group.

In the present study around 57% of the patients with Fibrodenoma  were observed in 11 to 30 years of age group. In an Indian study by Rangabashyamet al⁶ maximum number of cases (75.39%) were noted in 11 to 30 years of age group. In the same way in SushilaKhanna et al⁵ study 82.78% of cases of  Fibroadenoma were presented between 11 to 30 years of age group.

In the present study, Cyclical Mastalgia with nodularity mainly presented in 21 to 40 years of age group.  Incapacitating mastalgia mainly presented in 31 to 40 years of age group.

         The main age group of presentation of Duct ectasia is 31 to 40 years. Giant fibroadenoma presented between 21 to 40 years of age group.

             Majority of cases were in reproductive age group with other complaints such as irregular menses, significant family history and significant increase in pain and size of the swelling in relation to the menstrual cycle.

In the study done by Sukhla et al⁹, majority of the cases presented with Fibroadenoma (46.4%) followed by Fibroadenosis (20.8%) and the rest of the benign breast diseases accounted to 29.3% of the cases.

Like wise study done by Selvakumaran et al¹⁰ in 2015, 55.9% of the cases presented with Fibroadenoma followed by Fibroadenosis in 20.8% of cases. Cystosarcomaphylloides accounted to 2.3% of cases and rest of the benign breast diseases were found in 21% of the study population.

In the present study, majority of the study population presented with Fibroadenoma(60%),followed by Cyclical mastalgia with nodularity (30%), Incapacitating mastalgia (5%), Duct ectasia (3%) and Giant Fibroadenoma (2%) in rest of the cases. The main age group of presentation is 21 to 40 years of age group.

In the present study, the most common symptom is painless lump which constitutes about 50% of cases. Around 40% of cases presented with painful lumps and lumpiness (if no distinct lumps are not made out). The pain is predominately dull aching, pricking either with in the lump or all over the breast.

In total 60 cases of Fibroadenoma, 50 cases presented with painless lump and 10 cases presented with painful lumps. In total 30 cases of cyclical mastalgia with nodularity, almost all the cases presented with painful lumps or indistinct nodularity.

In the present study, out of 100 cases, 36% of cases had the disease manifested in right breast and 29% of cases in left breast and 35% of cases in both the breasts. It showed that majority of the breast conditions are seen in right breast followed by left breast.

Majority of the cases of fibrodenoma presented in right breast(34%) and followed by  left breast(25%) and in both the breasts(1%) in rest of the cases.

Nearly most of the cases of Cyclical mastalgia with nodularity presented in both the breasts and only one case among the rest presented in the left breast. All the cases of Incapacitating mastalgia presented in both the breasts.

Two cases of Duct ectasia presented in right breast and one case in left breast. All the cases of Giant fibroadenoma are presented in the left breast.

Majority of the cases had lesion in the Upper and outer quadrant of the breast. In the cases of Fibroadenoma, out of 60 cases 36 cases are present in upper and outer quadrant of the breast followed by 26 cases in upper inner and 15 cases in outer lower quadrants of the breast. 38 cases occupied more than two quadrants. These findings correspond to the literature by Dr.Dent.D.M.Cant, which stated that most of the lesions arise in upper and outer quadrant of the breast.

Out of 30 cases of Cyclical Mastalgia with nodularity 19 cases presented in upper and outer quadrant of breast, 13 cases in lower and inner quadrant and 9 cases in upper and inner quadrant. 28 cases showed distribution in more than two quadrants. Giant fibroadenoma occupied more than two quadrants i.e; upper outer and inner and upper inner quadrants. Incapacitating mastalgia and Duct ectasia presented with diffuse pain all over the breast and was never localised to a quadrant.

Patients were managed either surgically or medically depending on the condition. Out of 100 cases 60 patients needed surgery and majority of the cases were under the disease – Fibroadenoma.

Out of 60 cases of Fibroadenoma 55 cases underwent surgery and 5 cases were managed conservatively. The most commonly done surgery was excision of the lump. The incisions are given in radial and circum areolar manner depending on the location of the lump. The  excised samples are sent for histopathological examination. Medical management included analgesics and centchromam capsules and flax seeds.

All the cases of Duct ectasia underwent Microdochectomy and Giant fibroadenoma underwent excision. Suction drain was placed whenever necessary and was removed after 48 hours. Post operative antibiotics and analgesics were given and sutures were removed on seventh post operative day

• Most common presentation is lump in the breast, followed by pain in the breast.
• Majority of the benign breast diseases occur in young age group followed by middle age group.
• Fibroadenoma and Mastalgia present as most common disorders. It may be attributed to early menarche.
• The lumps being painless, are often noticed accidentally by the patient.
• Fibroadenoma usually presents as discrete lump in the breast but multiple lumps in one breast and lumps in both the breasts are also noticed.
• Diseases like Duct ectasia and lipoma of axillary tail and Cystosarcomaphylloides are very rare.
• Benign breast diseases most commonly affects upper and outer quadrant of the breast.
• Fine Needle Aspiration cytology and Ultrasonogram nearly confirmed all the cases.
• Surgery proved to be the best way to manage the cases of Fibrodenoma and simple excision was the better procedure.

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