Clinical and histopathological features of breast tumors in women: a cross-sectional study at three hospitals in the Kingdom of Saudi Arabia
Mohamed Abdel Razik1,&, Alhumaidi Mazyad Alsubaie2, Hassan
Mohammed Alsetri2, Khalid Abdulrahman Albassam2, Abdulrahman
Omar Alkhurayyif2, Mazen Mohammed Altamimi2, Sultan Mohammed
1General Surgery Department, College of Medicine, Prince Sattam Bin Abdulaziz University, Al-Kharj, Saudi Arabia, 2College of Medicine, Prince Sattam Bin Abdulaziz University, Al-Kharj, Saudi Arabia
Mohamed Abdel Razik, General Surgery Department, College of Medicine, Prince
Sattam Bin Abdulaziz University, Al-Kharj, Saudi Arabia
there is a dearth of data on the epidemiology of breast tumors in the Kingdom of Saudi Arabia (KSA). This study aimed to determine the demographics, clinical patterns, and their association with histopathological types of breast tumors among females presently residing in KSA.
a multi-centric, cross-sectional study including female patients with symptoms suggestive of breast tumor was conducted at three hospitals in KSA from February 2019 to February 2020. The patient´s electronic health records were used to collect information related to their demographics, clinical findings including comordbities and symptoms and investigations. Binary logistic regression models were used to determine factors associated with the breast tumors.
a total of 270 female patients were included in the study. The most frequently
encountered symptom was a breast lump (95.9%, n = 259), followed by pain (18.9%,
n = 51). More than half the population (53%, n = 143) had a histopathological
diagnosis of fibroadenoma. Multivariate analysis revealed that patients > 46
years of age were less likely to present with fibroadenoma (AOR:0.049 95% CI
0.02 - 0.15; p < 0.005). Those in the 31 - 45 years age group were less likely
to present with ductal/lobular/papillary carcinomacompared to the less than
30 years group (AOR: 0.42, 95% CI 0.18 - 0.97; p = 0.04).
in this population of Saudi women with symptoms suggestive of breast tumor, those aged less than 40 years were more likely to have a fibroadenoma whereas those above 40 years were more likely to have breast cancer.
Breast cancer is one of the most common and leading cause of mortality among women worldwide. Globally, new cases of women breast cancer were reported to be 2.1 million in the year 2018 . Furthermore, breast cancer incidence is increasing in all age groups  primarily in those countries with lower social development index (SDI) . Breast cancer is frequently reported in Saudi women with a prevalence of 21.8% . According to World Health Organization (WHO), about 3954 people were diagnosed with breast cancer and 1095 people died of it in Kingdom of Saudi Arabia (KSA) in the year 2020 . In this context, breast cancer has been reported to be 9th leading cause of mortality in KSA . Like the other countries of the world, breast cancer incidence is expected to increase in next few decades . Breast cancer accounts for 29% of all cancers reported in KSA .
Clinically, breast cancer usually presents as a lump in breast, pain, change
in breast size, or discharge from nipple . The most
frequent presentation is a breast swelling . Factors
like age, lifestyle and family history play important role in the development
of breast cancer . Breast tumors may be classified into
various subtypes based on specifichistology, anatomical origin, or hormone
receptivity. The most frequent type of breast cancer among Saudi women has
been reported to be ductal carcinoma (81.80%) followed by lobular carcinoma
(3.40%) . Different subtypes of breast cancer possess
different characteristics and prognoses. Ductal carcinoma in situ (DCIS) refers
to noninvasive and non-infiltrating neoplasms which remain localized within
mammary ducts . Likewise, lobular carcinoma in situ
(LCIS) refers to those from the lobules . DCIS and
LCIS are associated with higher risk of invasive breast cancer .
Invasive ductal carcinoma that grows like a cohesive mass often presents as
a discrete palpable lump. On the contrast, the invasive lobular carcinoma consisting
of non-cohesive cells organized in a linear pattern are not well palpable and
often present late with multifocal, multicentric, or contralateral involvement
Therefore, each type of breast cancer presents differently which may require
different treatment modalities and prognosis .
Although many articles on breast cancer have been published from KSA [16, 17]; however, detailed information on the histopathological types of breast cancer and their relationship with clinical presentation is still lacking. Therefore, the objectives of the study wereto determine the demographics, clinical presentations, and their association with types of breast tumors among females presently residing in KSA.
Study design and setting
This was a multi-centric, cross-sectional study conducted at three
hospitals in the Kingdom of KSA viz. King Khalid Hospital and Prince
Sultan Center for Health Services, Prince Sattam Bin Abdulaziz University
in Al Kharj, KSA, and Al Kharj Military Industries Corporation
hospital. The study period was from February 2019 to February 2020.
We included 270 cases in this study. Based on the prevalence of histopathologically
diagnosed Lobular Carcinoma in a large retrospective medical record
database study, 344 (7.8%), the minimum sample size required was calculated
to be 226, for a 95% confidence interval with a 2.5% margin of error .
The criteria for inclusion in this study were females, aged 17 and above,
presently residing in the KSA, who presented to the general surgery clinics,
surgical wards, and emergency surgery clinics at the three hospitals during
the study period, with symptoms suggestive of breast tumors such as breast
lump or change in breast size, mastodynia, breast abscess, nipple discharge.
Male patients, those in the pediatric age group, those with incomplete or
missing data points, those who refused diagnostic testing, patients for
whom we could not get permission from their legal guardians, and those who
did not consent to participate in the study were excluded.
The patient´s electronic health records were used to collect information
related to their age, ethnicity, clinical history of present illness, including
any symptoms suggestive of breast tumors, family history of breast cancer,
and presence of comorbid diabetes mellitus. We also assessed their medical
reports related to diagnostic investigations such as breast mammogram, histopathological
diagnosis with fine needle aspiration cytology (FNAC) or biopsy of breast
lump and lymph node biopsy. Further, we collected information regarding the
type of surgeries performed for breast tumor treatment.
The data was analyzed using IBM SPSS Statistics version 22.0 for
Windows (Chicago, Illinois, USA). A descriptive analysis was performed
to characterize the study population demographics, medical history,
diagnostic investigations, histopathological diagnosis and surgical
interventions. Categorical variables are expressed as n (%) while
age, the only
variable is expressed as mean ± standard deviation. We constructed
binary logistic regression models to determine factors associated
with the four most frequently occurring histopathological diagnoses
in our study,
namely´ fibroadenoma, invasive ductal/lobular/papillary carcinoma,
hyperplasia (ductal/lobular), and lobular carcinoma in situ.
Statistical analyses were two-tailed and set at a confidence interval
The study was approved by the Medical Ethics Committee of the Prince
Sattam Bin Abdulaziz University (Ethics approval number REC-HSD-72-2021).
Informed consent was obtained from the patients (or their legal guardians,
where applicable) before participating in the study. Patient information
obtained from electronic health records was completely anonymized.
Data was included from a total of 270 participants who met the selection
criteria. The study population was all-female, aged 33.7 ± 10.75
years, mostly Saudis, 188 (69.6%), without comorbid diabetes mellitus, 233
(86.3%), nor a family history of breast cancer, 209 (77.4%). Patients presented
with an array of symptoms clinically suggestive of breast tumors. The most
frequently encountered symptom was a breast lump, 259 (95.9%), followed
by pain, 51 (18.9%), breast abscess, 13 (4.8%) and nipple discharge, 7 (2.6%).
Most were negative for cancer as per breast mammogram, FNAC or breast lump
biopsy, or lymph node biopsies, 262 (97%), 233 (86.3%), and 239(88.5%),
respectively. Nearly all women suffered ailments in either breast, 262 (97%),
while a small few had bilateral afflictions, 8 (3%). Most underwent a standard
excision biopsy, 245 (90.7%). A tabulation of demographic characteristics,
medical history, and diagnostic investigations is shown in Table
The distribution of histopathological diagnosis among our study population is tabulated in Table 2. More than half the population, 143 (53%), had a histopathological diagnosis of fibroadenoma. Invasive ductal/lobular/papillary carcinoma and hyperplasia (ductal/lobule) were the other two frequently encountered histological diagnoses, 43 (15.9%) and 18 (6.7%), respectively.
Tumor association and associated factors
Those patient characteristics that were significant on bivariate
analysis (p < 0.25) were used as independent covariates to model binary
logistic regressions predicting the likelihood of the three most
frequently encountered histological tumor diagnoses viz. Fibroadenoma, invasive
carcinoma, and hyperplasia (ductal/lobular). These associations
are depicted in Table
4 and Table
Fibroadenoma: bivariate analysis revealed numerous associations. Age, residence, familial history of breast cancer, presence of comorbid diabetes mellitus, whether ailment was unilateral/bilateral, presence of a breast lump, and mastodynia were significantly associated with the presence of fibroadenoma, p < 0.25. In the multivariate model, age remained statistically significant in predicting a histopathological diagnosis of fibroadenoma. Those in the 31-45 years age group were 54% less likely to have fibroadenoma than those less than 30 years of age, adjusted odd´s ratio, AOR: 0.46 (0.25-0.84), p < 0.012. Those greater than 46 years of age were 95.1% less likely to present with fibroadenoma, AOR:0.049 (0.02 - 0.15), p < 0.001, evidently depicted as 40(87%) of those aged 46 and were not diagnosed with fibroadenoma.
Invasive ductal/lobular/papillary carcinoma: we found age, familial history of breast cancer, comorbid diabetes mellitus, and mastodynia to be significantly associated with invasive ductal/lobular/papillary carcinoma on bivariate analysis, p < 0.25. Apart from age, no other covariate included in the model proved significant in the multivariate regression model. Those in the 31 - 45 years age group had a 58% reduction in the likelihood of having these invasive breast carcinomas when compared to the younger, < 30 years age group, AOR: 0.42(0.18 - 0.97), a statistically significant finding, p = 0.04.
Hyperplasia (ductal/lobular): we found age, residence, familial history of breast cancer, and comorbid diabetes mellitus to be significantly associated with ductal or lobular hyperplasia on bivariate analysis, p < 0.25. However, on multivariate analysis, we found no significant associations.
This study aimed to determine demographics, clinical presentations, and their association with histopathological types of breast tumors among women from KSA. Breast lump, breast pain, breast abscess and nipple discharge were the most frequently encountered symptoms. Fibroadenoma was the most common histopathological diagnosis. Multivariate analysis revealed that only age had a significant impact on the type of breast tumors, especially on fibroadenoma and invasive ductal/lobular carcinoma.
Koo et al.  conducted a national audit of
cancer diagnosis to determine typical and atypical presenting symptoms of
breast cancer including 2316 women with breast cancer. They reported breast
lump (83%), nipple abnormalities (7%) and breast pain (6%) as the most common
presenting symptoms in the patients with breast cancer. They also reported
that 1 in 6 women presents without breast lump but with a variety of symptoms
seeking medical advice. These results are comparable with the present study,
however, the present study reported breast lump at presentation in more that
95% cases. This difference may be due the reason that in the study by Koo et
al. , all the patients were histopathologically
confirmed cases of breast cancer while in the preset study the most common
diagnosis was fibroadenoma - a benign breast tumor. In KSA, Al Shamlan et
al.  conducted a study to determine the characteristics
of breast mass detectable on breast ultrasound, reporting breast lump (63.64%)
and breast pain (38.54%) as the most frequent symptoms.
As reported by the present study, Stachs et al. 
have reported fibroadenoma as the most common benign breast tumor. In bivariate
analysis, factor like age, residence in KSA, familial history of breast cancer,
presence of comorbid diabetes mellitus, presence of a breast lump, and mastodynia
showed significant associated with fibroadenoma. However, multivariate analysis
revealed only the significant association of age with fibroadenoma. Fibroadenoma
is the most common breast tumor in women below 30 reported in the present
study as well as in previous literature . A 2014
study among Saudi patients with biopsy proven benign breast disease estimated
fibroadenoma to be the most common lesion, accounting for nearly 45% of all
The present study has revealed significant association of increasing age, familial history of breast cancer, comorbid diabetes mellitus, and mastodynia with invasive ductal, lobular, or papillary carcinoma on bivariate analysis. However, multivariate analysis revealed only significant association of age with invasive ductal, lobular, or papillary carcinoma. Although not significant, the present study reveals that the risk of breast cancer increases with age in Saudi Arabia. Similarly, the previous studies have revealed that increasing age above 40 increases the risk of breast cancer .
This study is limited by its retrospective design, which may result in biased outcome. However, the study has some strengths. Indeed, the study has thoroughly gone through the clinical presentations of the female patients who visited the hospital for the evaluation of breast tumors. In addition, the consideration of histopathological diagnosis of the patients verifies the diagnosis.
Age is an important indicator of type of breast tumors. Age below 40 is associated with fibroadenoma and increasing age above 40 is associated with breast cancer among Saudi women.
What is known about this topic
- Breast cancer is one of the most common and leading cause of mortality among women worldwide;
- Globally, new cases of women breast cancer were reported to be 2.1 million in the year 2018;
- Breast cancer accounts for 29% of all cancers reported in Saudi Arabia.
What this study adds
- Among patients with symptoms clinically suggestive of breast tumors, breast lump was the most frequently encountered (95.9%);
- Fibroadenoma was the most frequently encountered histological diagnosis among patients with breast disease (53%);
- Age greater than 30, patients with a positive family history for breast cancer, patients with symptoms in the right breast (as opposed to both sides), and those with mastodynia were significantly less likely to have fibroadenoma. Patients with symptoms of pain, however, were significantly more likely to have fibroadenoma.
The authors declare no competing interests.
Conception and study design: Mohamed Abdel Razik, Alhumaidi Mazyad
Alsubaie, Hassan Mohammed Alsetri. Data collection : Alhumaidi
Mazyad Alsubaie, Hassan Mohammed Alsetri, Khalid Abdulrahman Albassam,
Abdulrahman Omar Alkhurayyif,
Mazen Mohammed Altamimi, Sultan Mohammed Alanazi. Data analysis
and interpretation: Khalid Abdulrahman Albassam, Abdulrahman Omar
Altamimi. Manuscript drafting: Mohamed Abdel Razik, Alhumaidi Mazyad
Alsubaie, Hassan Mohammed Alsetri, Khalid Abdulrahman Albassam,
Abdulrahman Omar Alkhurayyif,
Mazen Mohammed Altamimi, Sultan Mohammed Alanazi. Manuscript revision:
Mohamed Abdel Razik, Alhumaidi Mazyad Alsubaie, Hassan Mohammed Alsetri,
Khalid Abdulrahman Albassam, Abdulrahman Omar Alkhurayyif, Mazen
Sultan Mohammed Alanazi. All authors approved final version of
Table 1: demographic characteristics, medical history and diagnosis of the patients
Table 2: distribution of histopathological diagnosis
Table 3: association of “fibroadenoma” with associated factors
Table 4: association of “invasive ductal/lobular/papillary carcinoma” with associated factors
Table 5: association of “hyperplasia (Ductal/lobule)” with associated factors
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