Histological pattern of breast diseases in children and adolescents in North Central Nigeria

Solomon Raphael; Kevin Nwabueze Ezike

doi:10.4103/nnjcr.nnjcr_10_20

ORIGINAL ARTICLE

Year : 2020 | Volume : 9 | Issue : 16 | Page : 39-43

Histological pattern of breast diseases in children and adolescents in North Central Nigeria

Solomon Raphael¹, Kevin Nwabueze Ezike²
¹ Department of Pathology and Forensic Medicine, University of Abuja and University of Abuja Teaching Hospital, Gwagwalada, Nigeria
² Anatomic Pathology and Forensic Medicine Unit, Asokoro District Hospital and Nile University of Nigeria, Abuja, Nigeria

Date of Submission	08-May-2020
Date of Decision	11-Sep-2020
Date of Acceptance	21-Sep-2020
Date of Web Publication	26-Nov-2020

Correspondence Address:
Dr. Solomon Raphael
Department of Pathology and Forensic Medicine, University of Abuja, Gwagwalada, FCT
Nigeria

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/nnjcr.nnjcr_10_20

Abstract

Background: Breast lesions are said to be rare and predominantly benign in the pediatric population. However, several case reports of malignant breast lesions in this demography exist, hence, the need to carefully examine breast masses when seen in children and adolescents to ascertain their nature. Aim: The aim of this study is to document the frequency, sex, and age distribution of the histologic subtypes of breast diseases seen in children and adolescents in a district hospital. Patients and Methods: Data were collated retrospectively from patients' request forms and duplicate copies of histology reports of all cases of breast lesions seen over a 5-year period at the pathology unit of Asokoro District hospital, Abuja, North Central Nigeria. Data were analyzed using Microsoft Excel, expressed using measures of central tendencies and percentages, and displayed using simple tables. Results: One-hundred and thirty-six cases of breast lesions were seen in the children and adolescent population (≤19 years), representing 16% of all the breast specimens during the study period. Females accounted for 97% with female-to-male ratio of 33:1. Their ages ranged from 10 to 19 years with modal age at presentation of 16 years. One (0.74%) case of invasive cribriform carcinoma was seen in a 17-year old boy. They presented as unilateral breast lesions in 88.6%, bilateral lesions in 9.6%, and unstated in 5.8% of patients, respectively. The most common lesion was fibroadenoma (74.3%), followed by fibrocystic change (10.3%). Conclusion: Breast lesions are common among older children and adolescents in our environment, mostly benign in nature and strikingly affect females. Fibroadenoma was the most common histologic lesion seen.

Keywords: Adolescents, benign, breast lesions, children, malignant

How to cite this article:
Raphael S, Ezike KN. Histological pattern of breast diseases in children and adolescents in North Central Nigeria. N Niger J Clin Res 2020;9:39-43

How to cite this URL:
Raphael S, Ezike KN. Histological pattern of breast diseases in children and adolescents in North Central Nigeria. N Niger J Clin Res [serial online] 2020 [cited 2023 Apr 1];9:39-43. Available from: https://www.mdcan-uath.org/text.asp?2020/9/16/39/301637

Introduction

The human body developmental and growth changes are common events in children and adolescents. These changes are most prominent in the pubertal and peripubertal period, with the breast being one of the organs where these changes are most noticeable, especially among the females.^[1],[2],[3] Diseases of the breast are not as common in children and adolescents as they are in young women and adults. They may be underreported as it is argued that these may be overlooked or misdiagnosed because of the thinking that they are developmental changes.^{[1],[2],[3],[4],[5]} More so, the relatively few available studies on breast diseases demonstrate that they are mostly benign.^{[2],[6],[7],[8],[9],[10],[11],[12],[13],[14]} This is complicated by limited and controversial data regarding the best management approach to breast masses in the pediatric population.^[2],[3],[6] However, several case reports in Nigeria^{[15],[16],[17]} and elsewhere^{[4],[5],[18],[19]} have documented breast malignancies in this age group. This knowledge and the increased awareness about the increasing incidence and unusually high mortality associated with breast cancer among adults in our clime cause apprehension among parents and surgeons when a breast mass is seen in older children and adolescents.^[6],[8] There is a paucity of data on the histopathology pattern of children and adolescent breast diseases in Nigeria and Africa. To the best of our knowledge, there is no report on the subject from North Central Nigeria. This study aims to document the incidence, frequency, histologic spectrum, sex, and age distribution of breast diseases seen in children and adolescents in our environment and compare their clinicopathologic profile with similar series within and outside Nigeria.

Patients and Methods

This is a cross-sectional, retrospective, descriptive review of all breast lumps seen in children and adolescents at the pathology unit of Asokoro District Hospital, Abuja, North Central Nigeria, over a 5-year period, from January 01, 2015, to December 31, 2019. Asokoro District Hospital receives samples from the 13 hospitals under the Federal Capital Territory (FCT) Administration health system and private hospitals in the FCT and from hospitals in the neighboring North Central states of Nasarawa, Niger, and Kogi. Request forms and duplicate copies of reports of all histologically diagnosed breast lesions during the study period were retrieved, and sex, age, and histopathological data were collated. The corresponding slides were then retrieved and reviewed. New slides were made from formalin-fixed, paraffin-embedded blocks where such slides were missing or faded. Where the above data or slides or blocks could not be found, those were excluded from the study. All biopsies had been fixed in 10% neutral buffered formalin. The tumors were classified according to the 2012 WHO International Classification of breast tumors.^[20] All data were entered in a Microsoft Excel worksheet utilizing the 2019 Microsoft Excel Software Programme (Microsoft Company, New York, USA) and analyzed. Continuous variables were summarized using range, mean, and standard deviation (±SD), whereas categorical variables presented as percentages were determined using descriptive statistics. Data are displayed using tables.

Results

A total of 838 cases of breast lesions were seen at the department from all age groups during the study period. One hundred and thirty-six eligible cases were seen in the children and adolescent population (≤19 years), representing 16% of all the breast specimens. They were received from 132 females (97%) and 4 males (3%), giving a female-to-male ratio of 33:1. Their ages ranged from 10 to 19 years with modal age at presentation of 16 years [Figure 1]. No case was seen before 10 years with only two cases seen in 10 years old, and no cases were seen in 11- and 12-year-old patients. One (0.74%) case of invasive cribriform carcinoma was seen in a 17-year old boy. This patient had no positive history of radiation exposure, radiotherapy for any cause, nor family history of cancer. The lesions presented as unilateral breast lesions in 115 (88.6%) patients, bilateral lesions in 13 (9.6%) patients, and unstated in 8 patients [Table 1]. Fibroadenoma (74.3%) was the most common lesion [Table 2] followed by fibrocystic change (10.3%).

Figure 1: Fibroadenoma, intracanalicular pattern - see fibromyxoid stroma and compressed glandular spaces (H and E, ×100)

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Table 1: Age and frequency distribution of breast lesions in children and adolescents

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Table 2: Anatomical location of breast lesions in children and adolescents

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Discussion

In our setting, breast lesions in children and adolescents accounted for 16% of all breast diseases seen during the study period. This estimate is slightly higher than 11.1% and 11.5% reported in Benin City^[7] and Uyo,^[8] respectively, but far higher than the report of 3.2% in Western literature.^[3],[13] This demonstrates that breast lesions are common in children and adolescents in our environment and corroborates the observation that breast tumors occur earlier in women of African descent.^[21]

No cases were seen in children before 10 years of age, but the incidence rose steadily through the older children and adolescent age, with peak in the 18-year age group [Table 3]. This clinical profile of the rarity of breast diseases in young children with rising incidence with age is congruent with reports by Ademuyiwa et al.^[6] in Lagos, Olu-Eddo and Ugiagbe^[7] in Benin, and Umanah et al.^[8] in Uyo, Nigeria and elsewhere.^[12],[13] This is not surprising as it has been argued that adolescence is the age of sexual awareness with late teenagers able to notice changes in their bodies earlier than younger children.^[6]

Table 3: Frequency distribution of the histologic subtypes of breast lesions in children and adolescents

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Clinically, breast lesions presented mainly as unilateral breast lumps [Table 1] with the left breast most commonly affected (43.4%). While the unilateral presentation is more common in the literature,^{[6],[9],[10],[11],[12],[20]} this dominant affectation of the left breast is at variance with the reports from Lagos,^[6] Port Harcourt,^[9] and India.^[12]

Benign breast lesions in the age group studied accounted for 99.3% in this study. This is in accord with recorded literature.^{[1],[2],[6],[7],[8],[9],[10],[11],[12],[13],[14]} Fibroadenoma (74.3%) was the most common histologic subtype of breast lesions seen in this study [Table 2] and [Figure 1]. This is concordant with previous accounts locally^{[6],[7],[8],[9],[10],[11]} and globally.^{[1],[2],[3],[12],[13],[14]} Fifty-nine percent (59%) of the cases of fibroadenoma were seen in the adolescent (17–19 years) age bracket. This agrees with an earlier account that fibroadenoma represented the main subtype of breast masses among teenagers of the Igbo (eastern Nigeria) extraction^[10] and African American origin.^[13] Fibroadenomas are biphasic neoplasms with stromal and epithelial components that present clinically as well circumscribed, usually multiple and bilateral rubbery nodules in young women. The epithelial component is estrogen sensitive and increases in size during puberty, pregnancy, and lactation. The resultant size increase is frequently associated with necrosis, dystrophic calcification, and inflammation, which causes a clinical presentation that raises the suspicion of malignancy.^[2],[21] Although a mild risk of cancerous transformation is associated with fibroadenoma due to its proliferative epithelial element, this risk is seen in those with complex features, namely, sclerosing adenosis, epithelial calcifications, papillary apocrine change, or cysts larger than 0.3 cm.^[21] The reporting pathologist is beholden, therefore, to alert the managing clinician about the import of these findings in the pathology report.

Fibrocystic change [Figure 2], an entity which comprises a group of nonproliferative morphologic changes (adenosis, cysts, and fibrosis), is the second most common lesions in our study like others.^{[2],[3],[6],[7],[8],[9],[10],[11],[12],[13]} Calcifications in the lumens of glands and cysts and fibrotic changes following cyst rupture that present as mammographic density and palpable nodule may mimic cancer radiologically and clinically. Like in the case of fibroadenoma, this point that secondary changes within the common benign lesions in children could cause cancer-like presentation should be borne in mind and should warrant thorough evaluation of all breast masses in children before any aggressive management is instituted. Tubular adenoma, benign phyllodes tumor, and gynecomastia were the distant, relatively more common lesions after fibrocystic change in our setting [Table 2].

Figure 2: Fibrocystic change - see stromal fibrosis, cystic dilatation of ducts, and apocrine metaplasia (H and E, ×100)

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Primary malignancy of the breast is infrequent in the pediatric population, with a prevalence of 1/1,000,000 in women <20 years of age in Western literature.^{[2],[13],[14]} Our study documented only one case of breast carcinoma, representing a relative frequency of 0.74%, corroborating the relative rarity of cancer in this population. This is similar to accounts from other parts of Nigeria with no case to four cases recorded, representing relative frequencies of 0% to 2.5%,^{[6],[7],[8],[9],[10]} but slightly higher than 0.02% documented in the west.^[13] While our case was seen in a 17-year–old boy, breast malignancy has been reported in younger patients with case reports of patients as young as 6 and 7 years old.^[5],[18] Malignant phyllodes tumor has been reported as the most common primary malignancy in the pediatric population, while secretory carcinoma is reported as the most common carcinoma subtype.^[2],[3],[4] This observation is buoyed by most case reports,^{[4],[5],[15],[18],[19]} but our finding like others across Nigeria differs.^{[7],[8],[9],[10],[11]} Our case was invasive cribriform carcinoma [Figure 3], while malignant breast tumors in adolescence reported in other studies in Nigeria included invasive ductal carcinoma, alveolar soft part sarcoma, non-Hodgkin's lymphoma, and metastatic carcinoma.^{[7],[8],[9],[10],[11]} The main risk factors associated with breast cancer in this age group are radiation exposure to the chest wall, radiotherapy for lymphoma, and family history of breast cancer.^{[1],[2],[3],[13]} None of these were positive in the index case.

Figure 3: Invasive cribriform carcinoma – see atypical cribriform structures invading a hyalinized, fibrotic stroma (H and E, ×40)

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Breast lesions in the pediatric age group are treated differently from those in adults.^{[2],[3],[6],[14]} Because the teenage girls' breasts are still developing and are crucial to their body image, diagnostic and interventional modalities have to be carefully chosen to prevent causing the breasts significant injury and disfigurement. Ultrasonography is the preferred imaging technique for the evaluation of pediatric breast masses because it does not produce ionizing radiation and has a higher sensitivity and specificity of detecting suspicious findings within the radiodense breast tissue of young patients.^{[2],[3],[14],[21]} It is advocated that suspected benign lesions with typical clinical and findings are conservatively managed by clinical and ultrasound follow-up, while suspicious lesions are followed up with preferably fine-needle aspiration for confirmation.^[2],[3],[14] As much as is clinically possible, tissue-sparing surgery is advised for malignancy and persistent symptomatic or rapidly growing benign masses.^[2],[3],[14] The risk-benefit analysis should be thoughtfully considered based on the cancer type and stage before adjuvant chemotherapy and/or radiotherapy are administered to children and adolescents.^[14]

The primary limitation of this study is its retrospective nature, which implies that the accuracy of demographic details is dependent on the accuracy of the initial recording. Furthermore, it is a single institution-based study; hence, some details may not be completely reflective of the general population. Notwithstanding, we consider that overall, the presented data are representative and have important clinical and scientific implications.

Conclusion

Breast lesions are generally common in the pediatric population and more common among older children and adolescents in our environment. They are mostly benign in nature and strikingly affect females. Fibroadenoma was the most common histologic lesion seen followed by fibrocystic change, with only a case of malignancy recorded.

Acknowledgment

We are greatly indebted to Ms. Juliet Itakpe, the secretariat lead, who has made electronic data entering, storage, and retrieval easy in the pathology unit. We sincerely appreciate all Corp members (past and present) who assist her in discharging her duties.

Financial support and sponsorship

Nil.

Conflict of interest

Nil.

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