Accuracy of High Resolution Sonography in Diagnosis of Fibroadenosis Compared with Histopathological Diagnosis

Background: Fibrocystic breast condition is a common, non-cancerous condition that affects premenopausal woman between 20 and 50 years of age. Because of non-specific nature of clinical presentation, diagnosis is not that easy. Linear array sonography has been helpful for detection of mammary dysplasia. Objective: The purpose of this study was to determine the sensitivity, specificity, accuracy, positive predictive value and negative predictive value of superficial sonography in the diagnosis of chronic cystic mastitis. Materials and Methods: This study was carried out in department of Radiology & Imaging of Enam Medical College and Hospital during June 2013 to October 2017. Sonography was done in 1350 women suspected of having fibrocystic disease. Among them FNAC was done only in 1020 cases. Ultrasonographic findings and histopathological reports were analyzed using SPSS 13.0. Results: According to our study the sensitivity of superficial sonography was 92.4%, specificity 88.8%, positive predictive value 93.8%, negative predictive value 86.4% and accuracy 91% in the diagnosis of fibrocystic changes. Conclusion: With the validity test result, it can be concluded that high frequency sonography provides an accurate diagnosis of fibroadenosis.


Introduction
Fibrocystic changes (FCCs) of the breast is the benign alteration in the terminal ductal lobular unit of the breast with or without associated fibrosis.It constitutes the most frequent benign disorder of the breast.Such changes generally affect premenopausal women between 20 and 50 years of age. 1 Although many other names have been used to describe this entity over the years (including fibrocystic disease, cystic mastopathy, chronic cystic disease, mazoplasia, Reclus's disease), the term 'fibrocystic changes' is now preferred, because this process is observed clinically in up to 50% and histologically in 90% of women. 2 FCCs may be multifocal and bilateral.The most common presenting symptoms are breast pain and tender nodularities in breasts. 3,4Although the exact pathogenesis is not clear, hormonal imbalance, particularly estrogen predominance over progesterone, seems to play important role in its development. 5CCs comprise both cysts (macro and micro) and solid lesions, including hyperechoeic fibroglandular tissue, epithelial hyperplasia with or without atypia, apocrine metaplasia, radial scar and papilloma. 6roup was of 35-44 years contributing 45% of total cases in the study (Table I).Mean age of the patients was 38.5 ± 4.1 years.
Over the years, it has been one of the major issues to determine whether these lesions are a risk factor for the subsequent development of breast cancer.As the use of mammography and identification of benign breast disease become more common, it is crucial to identify women with dense breast. 7The establishment of the clinical diagnosis of FCCs is difficult.Its vague presenting symptoms and diagnosis without histopathological confirmation is difficult to obtain.The evaluation of the high resolution sonography in the diagnosis of FCCs have received attention, with small series reporting sensitivities and specificities of up to 87% and 98% respectively. 8cause sonography is frequently the initial imaging study in patients with dense breast, with advent of high resolution sonography fibroadenosis can be diagnosed with a high degree of accuracy.The purpose of these study was to describe the ultrasonographic features of FCCs, to compare radiologic and histopathologic findings of FCCs and to determine whether a radiological diagnosis of FCCs can be considered to be concordant with the histopathological findings. 9,10

This cross-sectional study was carried out in the Department of Radiology & Imaging in Enam Medical
College & Hospital from June 2013 to October 2017.Patients were referred for breast ultrasound for a variety of standard indications.High resolution US was done in 1350 patients.Of them 1020 cases were included in the study as these patients had histopathological evaluation reports for review.
Patients were evaluated via superficial ultrasound as clinically indicated.The scans were performed using 7.5 MHz.Color Doppler interrogation was used during the study period.The diagnosis of FCCs was made prospectively at the time of original scan.
We analyzed these women by recording age and clinical symptoms.US findings were recorded.Histopathology reports were compared with superficial sonographic findings.

Results
A total of 1020 cases were included in this study.Age of the patients ranged from 15-64 years.

Discussion
Fibrocystic changes of the breast constitute the most frequent benign disorder of the breast.It is seen as a wide spectrum of altered morphology in the female breast from innocuous to those associated with risk of carcinoma. 11It is observed clinically up to in 50% and histologically in 90% of the women. 2Fibrocystic change is unusual before adolescence.These are most often diagnosed between the age of 20 and 50 years with the peak before or at menopause.
As compared to the general population, women with nonproliferative lesions have no significant elevation in risk of developing a breast carcinoma while those with proliferative disease have a greater risk. 3Hormonal alteration with estrogen dominance over progesterone is considered to be an important factor.The alterations are subdivided as nonproliferative and proliferative.
Cysts and fibrosis are more common and included in nonproliferative group.Proliferative disease includes atypical epithelial cell hyperplasia of the ducts or ductules and sclerosing adenosis. 4In various study, it has been shown that the great majority of breast cytology (up to 70%) show nonproliferative lesions.
In our study, common diagnostic sonological findings were prominent fibroglandular tissue in the area of lumpiness in 550 (84.62%) cases followed by small cysts in mammary zone in 500 (76.92%)showed presence of prominent fibroglandular tissue and mammary cysts on sonography as features of fibrocystic changes.Superficial sonography similarly describes ill-defined masses and prominent mammary ducts. 12 the study of Revelon et al 13 sensitivity and specificity of high resolution sonogram for the diagnosis of FCCs were in the range of 80-87% and 74-96% respectively, where hyperechoeic fibroglandular tissue was used as the diagnostic criteria.One author differed, saying that the most common sonographic findings in patients with FCCs is the presence of small cysts in mammary zone. 14Our experience is similar to that reported by Revelon et al. 13 These investigators reported 80% sensitivity and 74% specificity for superficial ultrasonogram to detect focal fibrosis of breast. 13Szep et al 15

Table V :
Distribution of FCCs by ultrasonographic diagnosis and histopathlogical diagnosis (n=1020) 17so reported sensitivity 86%, specificity 86%, PPV 71% and NPV 98% in a group of 108 patients with pathologically proven FCCs.Berg et al16reported a sensitivity of 80% with a specificity of 90% in a group of 98 patients with diffuse FCCs.Shetty and Shah 14 reported a sensitivity of 86% and specificity of 50% for the use of high resolution sonography in the identification of FCCs.Chang et al17initially noted the presence of small cystic spaces as an important finding in patients with fibroadenosis.According to our study, high resolution US has significant sensitivity, specificity, positive predictive value, negative predictive value and accuracy in diagnosis of fibrocystic disease.So we can conclude that superficial sonography is a sensitive imaging tool in diagnosis of mazoplasia.Fibrocystic disease is a common finding in women of reproductive age.It is a non-fatal medical condition characterized by a lumpiness feeling in the breast which is painful on certain days of the menstrual cycle.The diagnosis of cystic mastopathy by sonography has been well defined and has diagnostic capabilities comparable to histopathological reports.According to our study, superficial sonography is significantly sensitive, specific accurate in diagnosis of fibrocystic disease.When a diagnostic imaging modality is required for suspected fibroadenosis, high frequency sonography can be used as an initial investigation due to its efficacy, safety and low cost.