|Year : 2017 | Volume
| Issue : 2 | Page : 166-170
Accuracy of clinical and ultrasound examination of palpable breast lesions in a resource-poor society
Uzoamaka R Ebubedike1, Eric O Umeh1, Stanley N. C. Anyanwu2, Eric C Ihekwoaba2, Ochonma A Egwuonwu2, Cornelius O Ukah3, Mike E Onwukamuche3, Chiemelu D Emegoakor2, Igwebuike V Onyiaorah3, Daniel D Anyiam2, Gabriel U Chianakwana2
1 Department of Radiology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria
2 Department of General Surgery, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria
3 Department of Histopathology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria
|Date of Web Publication||14-Nov-2017|
Uzoamaka R Ebubedike
Department of Radiology, Nnamdi Azikiwe University Teaching Hospital, Nnewi
Background: Palpable breast masses are common presentations in resource-poor societies. Clinical and ultrasonographic breast examinations are commonly available means of evaluation. Objective: The objective of this study was to compare the accuracy of clinical breast examination (CBE) and ultrasonography in the diagnosis of palpable breast masses. Methodology: Consenting females presenting with palpable breast masses at the general surgical outpatient clinic were assessed clinically by the most senior surgeon, ultrasonographically by two radiologists, and the diagnosis compared with histologic examination. Results: One hundred and thirteen patients were recruited during the study period from January 2013 to April 2014. Of these, 53 patients (46.9%) had breast core biopsy, while 60 (53.1%) had open surgical biopsy. Only 67 (59.3%) patients had their histological results available. The mean age was 41.58 years (range 16–78). CBE achieved a sensitivity of 82.1%, specificity 67.9%, positive predictive value (PPV) 78%, negative predictive value 73%, overall accuracy 76.1%, false positive rate 32.1%, and false negative rate 17.9%. Breast ultrasonography had a sensitivity of 86.8%, specificity 72.4%, PPV 80.5%, negative predictive value 80.8%, overall accuracy 80.6%, false positive rate 27.6%, and false negative rate 13.2%. Conclusion: This study revealed no statistical significant difference between the accuracy of CBE and breast ultrasonography. We recommend that both should be used in the evaluation of palpable breast masses.
Keywords: Clinical breast examination, palpable breast masses, ultrasound
|How to cite this article:|
Ebubedike UR, Umeh EO, Anyanwu SN, Ihekwoaba EC, Egwuonwu OA, Ukah CO, Onwukamuche ME, Emegoakor CD, Onyiaorah IV, Anyiam DD, Chianakwana GU. Accuracy of clinical and ultrasound examination of palpable breast lesions in a resource-poor society. Trop J Med Res 2017;20:166-70
|How to cite this URL:|
Ebubedike UR, Umeh EO, Anyanwu SN, Ihekwoaba EC, Egwuonwu OA, Ukah CO, Onwukamuche ME, Emegoakor CD, Onyiaorah IV, Anyiam DD, Chianakwana GU. Accuracy of clinical and ultrasound examination of palpable breast lesions in a resource-poor society. Trop J Med Res [serial online] 2017 [cited 2019 Jun 25];20:166-70. Available from: http://www.tjmrjournal.org/text.asp?2017/20/2/166/218222
| Introduction|| |
Breast disease is increasingly common in 3rd world practice comprising about 30% of general surgical attendances among females. In the absence of dedicated screening programs, a majority of patients with palpable lumps and also in regions with infrastructure challenges, the clinician is faced with challenges of expeditiously making a diagnosis of benignity or otherwise and offering treatment for patients. Whereas most breast disease in advanced communities are screen detected, the situation is not the same in impoverished regions. Palpable breast masses are common and usually benign, but efficient evaluation and prompt diagnosis are necessary to rule out malignancies. A thorough clinical breast examination (CBE), imaging, and tissue sampling are needed for a definite diagnosis. CBE is effective in detecting masses and can help determine whether a mass is benign or malignant., CBE can detect up to 44% of cancers, up to 29% of which would not be detected by an imaging modality such as mammography.,
In a study by Wishart et al., comparing the performance and accuracy of CBE on 16,585 symptomatic women among clinicians, there was marked variation in sensitivity between clinicians (range 44.6%–65.9%). Some studies done in Nigeria as well as the Breast Health Global Initiative Early Detection Panel 2007 Guidelines have recommended CBE as a tool for assessing breast diseases.,,,, Despite its accuracy, CBE alone is not adequate for definitive diagnosis of breast cancer. Further evaluation, including follow-up examinations, imaging and tissue sampling are required in all patients with breast masses.
Breast ultrasound is an important imaging modality in the evaluation of palpable breast masses because it is readily available, affordable, and usually the first option among imaging modalities requested by the clinician in assessment of palpable breast masses. Ultrasound can effectively distinguish solid masses from cyst, which account for approximately 25% of breast lesions., It is also useful in discriminating between benign and malignant solid masses., Some authors have reported high sensitivities and accuracy for breast ultrasound examination thus making breast ultrasound an important tool for palpable breast mass evaluation.,, Several studies have advocated the use of “triple test” which consists of CBE, radiologic examination, and cytopathology.,,, Ultrasound as well as CBE are observer dependent and interobserver variations exist.
Previous studies have been done in our environment and some other tertiary health institutions in Nigeria, on accuracy of CBE for palpable breast masses.,,,, Study has neither evaluated the accuracy of breast ultrasound nor compared the accuracy of CBE and breast ultrasound in the diagnosis of palpable breast masses in our environment. The aim of this study is to compare the accuracy of CBE and breast ultrasound in the diagnosis of palpable breast masses using histological diagnosis as gold standard.
| Methodology|| |
Consenting females presenting with palpable breast masses at the general surgical outpatient clinic were assessed clinically by the most senior surgeon, ultrasonographically by two radiologists, and the diagnosis compared with histologic examination from January 2013 to April 2014. Patients with nonpalpable breast masses were excluded from this study. Approval was sought and obtained from the Ethical Committee. Informed written consent was obtained from all the patients. The most senior surgeon made a diagnosis of benignity or malignancy based on clinical assessment. This information was blinded to the radiologists; subsequently, patients underwent ultrasound examination at the radiology department. The ultrasound examinations were done by the radiologists using an Aloka ProSound SSD-2500SX ultrasound machine with a linear transducer (frequency of 7.5 Mhz) and color Doppler capability. The patients had core needle biopsy or open surgical biopsy as determined by the attending surgeon. After the biopsy, the patients were directed to the histology laboratory which operates a fee-for-service structure for histology and histology reports by the pathologists obtained. Thereafter, the following parameters were calculated, namely, accuracy, sensitivity, specificity, positive predictive value (PPV), negative predictive value, and false positive and negative rates.
Statistical analysis of data was done using Statistical Package for Social Sciences (SPSS) Software, IBM Corp, Released 2012, IBM SPSS Statistics for Windows, Version 21.0 Armonk, NY.
| Results|| |
One hundred and thirteen patients were recruited during the study period from January 2013 to April 2014. Of these, 53 patients (46.9%) had breast core biopsy, while 60 (53.1%) had open surgical biopsy. Only 67 (59.3%) patients had their histological results available. The mean age was 41.58 years (range 16–78). CBE achieved a sensitivity of 82.1%, specificity 67.9%, PPV 78%, negative predictive value 73%, overall accuracy 76.1%, false positive rate 32.1%, and false negative rate 17.9%. Breast ultrasonography had a sensitivity of 86.8%, specificity 72.4%, PPV 80.5%, negative predictive value 80.8%, overall accuracy 80.6%, false positive rate 27.6%, and false negative rate 13.2%. There was discordance between CBE and histology in 25.45% and with ultrasound and histology in 20.9%. [Table 1] and [Table 2] show comparison of clinical and ultrasound diagnosis with histological diagnosis of palpable breast masses. As shown in [Table 3], there is no significant difference in the sensitivity, specificity, positive and negative predictive values, overall accuracy, and false positive and negative rates of clinical and ultrasound breast examinations.
|Table 3: Diagnostic validities of clinical breast examination and breast ultrasonography|
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| Discussion|| |
Significant percentage of patients 46 (40.7%) did not return with histology reports. This poor adherence to the physician's recommendations has been noted by other workers in the environment., They reasons they adduced included limited knowledge of cancer and its causes, lack of health insurance, influence of spiritual beliefs, need for secrecy, high dependence on complementary and alternative medicine therapies. Furthermore, high default rate among patients sent for investigation in our environment is due to poor income where a significant population earns less than a dollar daily and 70% of the population live below the poverty line. This coupled with increasing failure of the extended family network can make fee-for-service payment for chronic ailments such as cancer quite challenging.
Many oncology workers in the region have advocated subsided pathology services to encourage accurate diagnosis and treatment. Both clinical and ultrasound breast examinations show fairly high accuracy because of the palpable nature of the lesions and clinical diagnosis in the experienced hands was not too difficult, especially in the young and very old patients. Furthermore, on ultrasound, the larger the size of the palpable breast lesions the easier the ultrasound assessment.
In this study, the sensitivity of clinical diagnosis is higher than the upper limit of overall range of sensitivity, 17.2%–58.3% reported by Smith et al. though their studies involved early stages of the disease., Furthermore, higher than that of Humphrey et al. which was on early stage and involved age group 17–80yrs. The age range for study by Humphrey et al. is comparable to the age range in our study. Many of our patients presented in late stage of the disease.
Fenton et al. reported a much lower sensitivity 21.6% which may have resulted from their study population being in asymptomatic females with age range of 40–65 years. The higher value seen in our study was likely because our patients were symptomatic since similar studies done for palpable breast masses in same environment and similar age group correlated.,,,
Sensitivity of breast ultrasound diagnosis was higher than that reported by Mansoor et al. 57.14% and Kolb et al. 78.6% whose patients had late stage of the disease but in younger age group (≤50 years). Higher sensitivities were reported by Pande et al. in his study involving age group similar to that in our study but early stage of the disease. Stavros et al. involved patients in early stage of the disease and reported a higher sensitivity 98.4%.
CBE achieved a specificity of 67.9% while higher specificities were reported in the literature by previous authors.,,,,, Ultrasound achieved a specificity of 72.4% which is lower than specificity reported by Pande et al. 94.10% and Ngotho et al. 98.1%. Study by both authors was in early stage of the disease. However, Ngotho's study was for patients under 35 years of age. CBE had a PPV of 78% which is lower than that reported by Madubogwu et al. 88.7% while higher than 60% reported by Ngotho et al.
PPV achieved by ultrasound is lower than PPV reported by Pande et al. 95.5% and comparable to PPV of 83.3% reported by Ngotho et al. It is much higher than PPV reported by Vetto et al. 33% whose study was on patients under 40 years with early stage of the disease.
The false positive rate from CBE is high like those reported by some previous authors, all done in the same environment., High positive rate shows that clinical diagnosis or USS alone has high probability of making false diagnosis of cancer. High false negative rate shows that many malignancies could be missed until they become advanced with resultant poor prognosis and high cost of management.
In all, the sensitivities and specificities were fairly high and also found to have no statistical significant difference likely reason being that the study was carried out by experienced surgeons and radiologists.
| Conclusion|| |
No statistical significant difference was found in this study between the accuracy of ultrasound and CBE. We recommend that both breast examinations should be taken into consideration in the evaluation of palpable breast masses. Young patients <25 years with clear clinical and radiological features of benignity should have low priority on theater space demand and could be managed on observation so that only higher risk patients would have priority on theater space.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Anyanwu SN. Temporal trends in breast cancer presentation in the third world. J Exp Clin Cancer Res 2008;27:17.
Klein S. Evaluation of palpable breast masses. Am Fam Physician 2005;71:1731-8.
Barton MB, Harris R, Fletcher SW. The rationale clinical examination. Does this patient have cancer? The screening clinical breast examination: Should it be done? How? J Am Med Assoc 1999;282:1270-80.
Baines CJ, Miller AB. Mammography versus clinical examination of the breasts. J Natl Cancer Inst Monogr 1997;22:125-9.
Wishart GC, Warwick J, Pitsinis V, Duffy S, Britton PD. Measuring performance in clinical breast examination. Br J Surg 2010;97:1246-52.
Anyanwu SN, Egwuonwu OA, Ihekwoaba EC. Acceptance and adherence to treatment among breast cancer patients in Eastern Nigeria. Breast 2011;20 Suppl 2:S51-3.
Onwere S, Okoro O, Chigbu B, Onwere A. Practice of antenatal clinical breast examination as a method of early detection of breast cancer by health care providers in a low resource setting. Arch Gynecol Obstet 2008;278:115-7.
Awodele O, Adeyomoye AA, Oreagba IA, Dolapo DC, Anisu DF, Kolawole SO, et al.
Knowledge, attitude and practice of breast cancer screening among nurses in Lagos University Teaching Hospital, Lagos Nigeria. Nig Q J Hosp Med 2009;19:114-8.
Okobia MN, Bunker CH, Okonofua FE, Osime U. Knowledge, attitude and practice of Nigerian women towards breast cancer: A cross-sectional study. World J Surg Oncol 2006;4:11.
Omolara KA. Feasible cancer control strategies for Nigeria: Mini review. Am J Trop Med Public Health 2011;1:1-10.
Moss HA, Britton PD, Flower CD, Freeman AH, Lomas DJ, Warren RM. How reliable is modern breast imaging in differentiating benign from malignant breast lesions in the symptomatic population? Clin Radiol 1999;54:676-82.
Berg WA, Compassi CI, Loffe OB. Cystic lesions of the breast: Sonographic-pathologic correlation. Radiology 2003;227:183-91.
Lister D, Evans AJ, Burrell HC, Blamey RW, Wilson AR, Pinder SE, et al.
The accuracy of breast ultrasound in the evaluation of clinically benign discrete, symptomatic breast lumps. Clin Radiol 1998;53:490-2.
Yang WT, Mok CO, King W, Tang A, Metreweli C. Role of high frequency ultrasonography in the evaluation of palpable breast masses in Chinese women: Alternative to mammography? J Ultrasound Med 1996;15:637-44.
Kolb TM, Lichy J, Newhouse JH. Comparison of the performance of screening mammography, physical examination, and breast US and evaluation of factors that influence them: An analysis of 27,825 patient evaluations. Radiology 2002;225:165-75.
Stavros AT, Thickman D, Rapp CL, Dennis MA, Parker SH, Sisney GA. Solid breast nodules: Use of sonography to distinguish between benign and malignant lesions. Radiology 1995;196:123-34.
Tabbara SO, Frost AR, Stoler MH, Sneige N, Sidawy MK. Changing trends in breast fine-needle aspiration: Results of the Papanicolaou Society of Cytopathology Survey. Diagn Cytopathol 2000;22:126-30.
Bishop J, Coleman M, Cooke B, Davies R, Frost F, Grace J, et al
. National breast cancer. Breast FNA Cytology and Core Biopsy: A Guide for Practice. 1st
ed. Camperdown, NSW: National Breast Cancer Centre; 2004. p. 1-58.
O'Neil S, Castelli M, Gattuso P, Kluskens L, Madsen K, Aranha G. Fine-needle aspiration of 697 palpable breast lesions with histopathologic correlation. Surgery 1997;122:824-8.
Rosen PP. Role of cytology and needle biopsy in the diagnosis of breast disease. Rosen's Breast Pathology. Vol. 48. New York: Lippincott, Raven Publishers; 1997. p. 817-31.
Madubogwu CI, Ukah CO, Chianakwana GU, Onyiaorah IV, Anyiam DC, Anyanwu SN. Diagnostic accuracy of clinical breast examination for breast cancer in patients with palpable breast lump in a middle income country. Orient J Med 2013;25:113-8.
Udoeyop UW. The Role of FNAC in the Management of Breast Diseases in the University of Calabar Teaching Hospital. Postgraduate Medical College of Nigeria 1990; Part II FMCS Dissertation; 1990.
Gukas ID. The Relative Value of Truck Biopsy and FNA Biopsy Cytology in the Management of Breast Lesions at Jos University Teaching Hospital, Jos. Post-Graduate Medical College of Nigeria 1997; Part II FMCS Dissertation; 1997.
Panchalingnam L. Evaluation of FNA Biopsy Cytology in the Diagnosis of Breast Lumps at the Lagos University Teaching Hospital, Lagos. Post-Graduate Medical College of Nigeria 1997; Part II FMCS Dissertation; 1997.
Elsie KM, Gonzaga MA, Francis B, Michael KG, Rebecca N, Rosemary BK, et al.
Current knowledge, attitudes and practices of women on breast cancer and mammography at Mulago Hospital. Pan Afr Med J 2010;5:9.
Sheppard VB, Christopher J, Nwabukwu I. Breaking the silence barrier: Opportunity to address cancer in African-born women. J Natl Med Assoc 2010;102:461-8.
Ezeome ER, Anarado AN. Use of complementary and alternative medicine by cancer patients at the University of Nigeria Teaching Hospital, Enugu, Nigeria. BMC Complement Altern Med 2007;7:28.
Smith RA, Saslow D, Sawyer KA, Costanza ME, Evans WP, Foster RS, et al
. American Cancer Society guidelines for breast cancer screening update. Cancer J Clin 2003;53:141-69.
Humphrey LL, Helfand M, Chan BK, Woolf SH. Breast cancer screening: A summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2002;137:347-60.
Fenton JJ, Barton MB, Geiger AM, Herrinton LJ, Rolnick SJ, Harris EL, et al.
Screening clinical breast examination: How often does it miss lethal breast cancer? J Natl Cancer Inst Monogr 2005;35:67-71.
Mansoor T, Ahmed A, Seyd HH. Role of ultrasonography in the differential diagnosis of palpable breast lumps. Indian J Surg 2002;64:499-501.
Pande AR, Lohani B, Sayami P, Pradhan S. Predictive value of ultrasonography in the diagnosis of palpable breast lump. Kathmandu Univ Med J (KUMJ) 2003;1:78-84.
Ngotho J, Githaiga J, Kaisha W. Palpable discrete breast masses in young women: Two of the components of the modified triple test may be adequate. S Afr J Surg 2013;51:58-60.
Vetto JT, Pommier RF, Schmidt WA, Eppich H, Alexander PW. Diagnosis of palpable breast lesions in younger women by the modified triple test is accurate and cost-effective. Arch Surg 1996;131:967-72.
[Table 1], [Table 2], [Table 3]