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BREAST RADIOLOGY Table of Contents   
Year : 2000  |  Volume : 10  |  Issue : 3  |  Page : 147-151
Physiology, pathology and imaging of the young breast


Dept of Radiological imaging, Institute of Nuclear Medicine and Allied Science, Lucknow Road, Delhi 110054, India

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Keywords: breast, young, physiology, pathology and imaging

How to cite this article:
Popli M. Physiology, pathology and imaging of the young breast. Indian J Radiol Imaging 2000;10:147-51

How to cite this URL:
Popli M. Physiology, pathology and imaging of the young breast. Indian J Radiol Imaging [serial online] 2000 [cited 2019 Sep 22];10:147-51. Available from: http://www.ijri.org/text.asp?2000/10/3/147/30602
There is increased awareness of breast cancer among Indian women, today. This has caused a significant rise in referrals for mammography (which is regarded as synonymous to breast cancer screening), and inappropriate requests for investigations in patients less than 30 years. Breast physiology, pathology and imaging in this younger group is discussed, with the proposal of a protocol, which is being followed at our istitution.

With rapid control of communicable diseases, non-com­municable diseases like cancer are emerging as important public health problems. Rapid industrialization, urbanization and increased stress of daily life are also contributory factors.

Brest cancer is the commonest inevitable cancer in women and is the second commonest cancer after cancer of the cervix in India. The incidence is rising. Recently, Mumbai and Delhi registry data showed that breast cancer has become the number one cancer, superseding cervix cancer [1]. Today, more women are working outside their homes resulting in late marriage, late pregnancies leading to greater age at which the first child delivered, less number of children and shorter period of lactation. All these are risk factors for developing brest cancer. Increased awareness of breast cancer and nodular character of the young breast have resulted in increased number of referrals for vague and questionable lesions. There is increasing confusion about the breast imaging to be requested and carried out.


   Breast physiology and pathology in the young Top


The embryonic breast tissue lies dormant in childhood until the onset of puberty, at which time branching of the ductal system and formation of lobules occurs. Lobular formation continues up to the age of 30 years. Increasing estradiol levels result in ductal proliferation and enlargement of the alveoli.

Progesterone produces alveolar development and secretary activity as well as edema of the surrounding intralobular connective tissue. The breast lobules are surrounded by dense collagenous interlobular connective tissue layers. These are continuous with the breast capsule, surrounding the entire organ.

Following puberty, sequential alterations occur in breast tissue during each menstrual cycle in response to changes in circulating hormone concentrations. The intralobular connective tissue reacts cyclically to circulating hormones, whereas the connective tissue surrounding the entire breast does not respond to hormonal changes. Enhanced estrogenic activity associated with the proliferative phase of each menstrual cycle primarily affects the ductal system and results in cellular hyperplasia. The secretary phase of the menstrual cycle is associated with increased concentration of progestational hormones that cause alveolar proliferation and secretary activity. This cyclic hormonal activity sets up a series of regressive and proliferative secretary phases within the breast from one month to another [2].

Symptomatically the patient may complain of heaviness and tenderness of the breast which is also cyclic in nature, more in the pre- menstrual phase and less or absent in menstrual and post-menstrual phase. Slight

imbalance between estrogen and progesterone levels disturbs the balance between regressive and proliferative secretary phases within the breast (hormonal dysplastic changes), which often results in breast symptoms, pain and tenderness, which do not vary with the phase of the menstrual cycle.

The commonest complaint of referred young patients is lumpiness of the breast and pain. Lumpiness of the breast felt is because of more glandular tissue at this age. The patients may complain of tenderness or heaviness in the premenstrual period, which may be attributed to the cyclic regressive and proliferative changes in the breast. Pathological breast lumps at this age are mostly either fibroadenomas or cysts. Fibroadenoma is the most common mass in a young woman. They are multiple in 10% - 20% of patients and bilateral in three percent or more [3,4]. Various studies have shown that 25% of all palpable lesions in the breast are cysts [5][6][7]. Breast carcinoma is uncommon in women below 30 years and is even rarer below the age of twenty-five. The annual incidence of breast carcinoma in a study carried out by the RCR breast group in 1989 [8], was 4.2 cases/100,000 women aged 25-29 and only 0.6 cases/100,000 in women between 20-24 years of age.


   Breast imaging in the young Top


The normal lumpy character of the breast tissue in the young and increasing awareness of breast cancer cause referrals for vague and questionable lesions. Two clinically accepted methods for detection of breast pathology are physical examination and X-ray mammography (commonly referred to as mammography). In almost 60­65% of women, physical examination is insensitive in detecting masses less than one centimeter, and except for advanced cases does not give specific diagnosis. Fat lobules, cysts and neoplasm on palpation may give similar findings.

Mammography remains the most sensitive of the currently available breast imaging methods [9-11]. It resolves submillimeter calcifications and depicts fine architectural distortions. Whereas the density of a cancerous lesion stands out clearly in fatty breasts of older woman, such tumors may be impossible to detect in younger patients [Figure - 1]. The sensitivity of x- ray mammography is sharply reduced in such patients because of dense fibroglandular tissue in their breasts. Mammography also often lacks specificity and masses varying as widely in histology as cysts and medullary carcinomas may have almost similar mammographic appearances [Figure - 2]. In young patients with non­specific symptoms, mammography is not likely to contribute any more reliable information than would physical examination alone. Lesions may be missed in younger women on mammography. This is attributed to greater density of the young dense glandular tissue [12][­13]. The feeling of assurance that physicians and young women patients derive from mammogram seen as a normal study may result in false security and delay appropriate clinical follow up.

The most common complaint of a young patient is pain and lumpiness of the breast and US remains the modality of choice for imaging in such patients. The breast lump in a young woman is either a cyst or a fibroadenoma and US maintains high accuracy in these two areas. The true utility of breast sonography has been found to be its ability to differentiate reliably cystic from solid masses [Figure - 1]C, [Figure - 3]A,B, a task beyond the capabilities of either physical examination of mammography. This differentiation has great clinical relevance because simple cysts invariably are benign, whereas solid lesions are not and often require tissue diagnosis.

Mammography on the other hand does not give any clear benefit over sonography and the patient is exposed to radiation. Radiation dose to the breast with current techniques is < 1 rad/per examination but there is evidence that finite risk from low dose radiation does occur. This risk persists for the patients' life-time and is greatest in women exposed to radiation at younger ages of 10-30 years (14][15][16].

IMAGING PROTOCOL IN THE YOUNG: [Figure - 4]

Sonography, is the imaging modality of choice. Most of the time no further imaging is required in patients with complaints of tenderness and lumpiness of breast if sonography is normal. We were referred 61 patients in the last one year, less than 30 years of age, with complaints regarding the breast. Twenty-one of them gave a history of changes in lump(s)/tenderness in the breast with the menstrual cycle. After clinical examination three of them could be convinced to carry out breast self-examination and report back if there was a lump or discharge. In the other 19 patients ultrasound of the breast was carried out for reassurance, no lump having being found clinically. During US we picked up one small cyst in one of the patients. Indications and results of ultrasound of the breast carried out in 58 patients are shown in [Table - 1]. A total of 42 patients were normal on US. In eight patients, cyst(s) were detected and the patient was advised follow up. A hypoechoic lesion with well-defined margins, and homogeneous internal echopattern, was detected in four patients. Observation, with follow up studies was advised at an interval of six months and was offered as an alternative to excision. In three patients the lesion looked suspicious on US having irregular margins/inhomogeneous echopattern and was sent for FNAC. One of them was reported as a fibroadenoma, the other as a tubercular lesion and the third one as epithelial hyperplasia. Cytology was done for both patients complaining of discharge and the patients a with complaint of single duct discharge was taken up for ductography. In 54 of the 58 patients US stone was enough to reach a diagnosis

To conclude, sonography is the modality of choice to be used in diagnosing any symptomatic breast disease in the young. Very few patients in this age group need any investigatlon beyond ultrasound. Use of US decreases the overuse of mammography in this age group and also unnecessary biopsies of cysts are avoided, as these are detected during sonography.

ACKNOWLEDGEMENT

We thank Mr SR SHARMA for the excellent photographs.

 
   References Top

1.Rao D, Ganesh BN. Estimate of cancer incidence in India 1991. Indian Journal of Cancer 1998; 35:10-18.  Back to cited text no. 1    
2.Picker RH, Fulton AJ. Maturational and physiological changes in the female breast. Semin in ultrasound 1982; 3:34-37.  Back to cited text no. 2    
3.Sickles EA, Filly CA, Callen PW. Benign breast lesions: Ultrasound detection and diagnosis. Radiology 1984; 151:467­ 470.  Back to cited text no. 3    
4.Hughes LE, Mansel RE, Webster DIT et al. Benign disorders and diseases of the breast. London: Bailliere Tindall, 1988: 59-73.  Back to cited text no. 4    
5.Jokich PM, Monticciolo DL, Adler YT. Breast Ultrasonography. Radiol Clin North America 1992; 30:993­ 1009.  Back to cited text no. 5  [PUBMED]  
6.Bassett LW, Kimme-Smith C. Breast sonography. AJR 1991; 156:449-455  Back to cited text no. 6  [PUBMED]  
7.Jackson VP. The role of ultrasound in breast imaging. Radiology 1990; 77:305-311.  Back to cited text no. 7    
8.RCR Breast group. Recommendation by Royal College of Radiologists Breast Group. 1989, Royal college of Radiologists Newsletter, Spring 1989:56.  Back to cited text no. 8    
9.Baker LH. Breast cancer detection and demonstration project : five year summary report. CA 1982, 32:194-225.   Back to cited text no. 9  [PUBMED]  
10.Sickles EA. Mammographic features of early breast cancer. AJR. 1984;143: 461-464.  Back to cited text no. 10    
11.Moskowitz M. Minimal breast cancer redux. Radiol Clin North America 1983; 21:93-113.  Back to cited text no. 11  [PUBMED]  
12.Bassett LW, Ysreal M, Gold RH, Ysnael C. Usefulness of mammography and sonography in women less than 35 years of age. Radiology 1991; 180:831-835.  Back to cited text no. 12    
13.Hall FM. Mammography in woman under 30: is there clinical benefit. Radiology 1987; 168-582.  Back to cited text no. 13    
14.Feig SA. Radiation risk from mammography: is it clinically significant. AJR 1984; 143:469-475.  Back to cited text no. 14  [PUBMED]  
15.Baral E, Larson LE, Mattson B. Breast cancer following irradiation of the breast. Cancer 1977; 40:2905-2910.  Back to cited text no. 15    
16.Boice JD, Land CE, Shore RS, Normal JE, Tokunage M. Risk of breast cancer following low dose radiation exposure. Radiology. 1979; 131:589-597.  Back to cited text no. 16    

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Correspondence Address:
Manju Bala Popli
Dept of Radiological imaging, Institute of Nuclear Medicine and Allied Science, Lucknow Road, Delhi 110054
India
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Source of Support: None, Conflict of Interest: None


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