Breast cancer in young female patients represents a public health problem in developing countries. The objectives of the study were to study the epidemiological and histological characteristics of breast cancer in female patients under 35 years of age. This was a retrospective analytical study of a series of 158 cases of breast cancer in female patients under 35 years of age, conducted at the University Teaching Hospital of Lomé between 2000 and 2015. A total of 158 cases were collected, representing 36.2% (436) of all breast cancer cases. The average age of the patients was 30.9 years (range, 16–35 years). A family history of breast cancer at the 1st or 2nd degree was identified in 13.9% of cases. Genetic mutation studies were carried out for 7 patients, 5 of which revealed mutations (4 BRCA1 and 1 BRCA2). According to the locus, the cancer was located preferentially in the left breast in 88 cases (55.7%). Malignant mammary lesions were epithelial tumors (n=144 cases, 91.1%), infiltrating (n=125 cases, 79.1%) and non-infiltrating (n=19 cases, 12.0%). The other histological groups consisted of 8 cases of sarcomas (5 cases of angiosarcoma, 2 cases of fibrosarcoma and 1 case of Kaposi's sarcoma), 5 cases of lymphomas and one case of melanoma. Not otherwise specified infiltrating ductal carcinomas were SBR II and III in 43.2 and 35.2% of cases, respectively. The tumors classified as T4 were the most frequent (30.4%). Regarding the lymph node status, lymph node metastasis was noted in 22.8% of cases. Studies of hormone receptors were carried out in 23 patients and were positive for 11 patients: Estrogen receptor (ER)+plus progesterone receptor (PR)+(7 patients), ER+PR-(4 patients). Of the aforementioned 8 cases of sarcoma, 5 were angiosarcoma. The lymphomas were predominantly Burkitt's type for 4 cases. Mammary ultrasonography was performed in 45.6% of the patients and 54.4% underwent the combined ultrasonography and mammography. Ultrasound identified one or more sign of malignancy in 67 patients (42.4%), and combined ultrasonography and mammography classified 51.9% of lesions in BIRADS 4 and 5. The incidence of breast cancer in young Togolese patients is high. It is a disease distinguished by a delay in diagnosis, which contributes to the high number of cases that initially diagnosed at an advanced stage, particularly the high histo-prognosis grades of infiltrating ductal carcinoma. These results indicate a genetic origin; therefore, a thorough investigation into genetic mutations should be carried. In addition, further collaborative studies are required to verify these results.
Breast cancer is the most-diagnosed type of cancer in female patients worldwide, accounting for ~25% of cancer cases in females; it has a higher prevalence in developed countries and an average age of onset of 50–70 years (
Regarding radiological screening of any mammary symptoms in females under the age of 35 years, ultrasound should be performed as a first-line diagnosis test. The breast tissue of young females is dense, with a satisfactory echogenicity allowing the effective exploration of the mass lesions (
In Africa in general, and in Togo in particular, data regarding patients with cancer are scarce due to the unavailability of effective collection and collation tools, including a national cancer registry (
The present study comprised a retrospective analysis of a series of breast cancer cases in female patients ≤35 years that were diagnosed between January 2000 and December 2015 (15 years) at the University Teaching Hospital of Lomé (Lomé, Togo). These cases were collected from the registers contained within the hospital. The study material consisted of biopsy and surgical tissue specimens fixed in 10% formalin and treated according to conventional histology techniques (hematoxylin and eosin staining). Each cancer tissue sample was characterized according to the World Health Organization histological classification and graded according to the Scarff-Bloom-Richardson (SBR) system and prognostic stage of tumor-node-metastasis (TNM).
For immunohistochemical analysis carried out on certain tissue samples, the parameters were as follows: estrogen receptor (ER); progesterone receptor (PR); over expression of human epidermal growth factor receptor 2 (HER2). The imaging aspects observed during the ultrasound exam and mammography are considered. Ultrasound lesions were categorized as those with no associated malignant criteria and those with ≥1 associated malignant criterion. On the ultrasonography-mammography pair, lesions were classified according to the Breast Imaging Reporting and Data System of the American College of Radiology.
The present study received approval from the Head of the Laboratory Department of the University Teaching Hospital of Lomé where the study was to be conducted. As the study included only records analysis, patient consent was not required. However, during the data collection and analysis, patient names were omitted in order to preserve confidentiality.
In the present study, 158 cases of breast cancer were collated, representing ~38.3% (n=412) of all confirmed cases of breast cancer in female patients identified in the Department of Pathology of the University Teaching Hospital of Lomé. The annual frequency was 10.5±1.6 cases. The mean age at diagnosis was30.9 years (range, 16–35 years), with 69.6% (n=110) of the patients being between 30 and 35 years of age. A total of 22 patients (13.9%) had a familial history of breast cancer. Gene mutation studies were performed for 21 patients, and genetic mutations were observed in 3 patients (2 BRCA1 and 1 BRCA2). According to the location, the cancer was in the left breast in 88 cases (55.7%), the right breast in 65 cases (41.1%) and bilateral in 5 cases (3.2%). The 5cases of bilateral cancer were all classified as T4, with lymph node invasion (N+) observed in 4 of these cases. The epidemiological characteristics of the patients are summarized in
The tissue samples examined consisted of 142 cases (89.9%) of surgically resected tissues, including 79 nodulectomy cases and 63 mastectomy cases. Node dissection was associated with mastectomy in 44 cases. The average weights of the tissue samples were as follows: Nodulectomy (60 g); mastectomy (600 g). Specimens from micro-biopsies of breast lesions accounted for 16 cases (10.1%). Tumor necrosis and hemorrhagic remodeling were identified in 98 cases (69%). Histological, the malignant mammary lesions were either epithelial tumors (n=144 cases, 91.1%), infiltrating (n=125 cases, 79.1%) or non-infiltrating (n=19 cases, 12.0%). The other histological groups consisted of 8 cases (5.1%) of sarcomas (5 cases of angiosarcoma and 2 cases of fibrosarcoma and one case of Kaposi's sarcoma), 5 cases (3.2%) of lymphomas and one case (0.6%) of melanoma. Non-infiltrating epithelial tumors were observed at an average age of 27. 2 years, consisting of 17 cases of intra-ductal carcinoma and 2 cases of intra-lobular carcinoma.
Intracanal carcinomas consisted of comedocarcinoma subtypes in 11 cases (64.7%), intracanal carcinoma of subtype mass in 3 cases and papillary carcinoma in 3 cases. Infiltrating epithelial tumors occurred at an average age of 30.6 years. Non-specific infiltrating ductal carcinoma (n=102, 81.6%) was the most frequent histological type of lobular carcinoma infiltrating (n=10, 8%) and mixed carcinoma (n=13).
Non-specific infiltrating ductal carcinomas were SBR III (n=38, 43.2%), SBR II (n=31, 35.2%) and SBR I (n=19, 21.6%). The evaluation of the prognostic stage TNM of the carcinomas in 46 cases had noted: T4 (n=14, 30.4%), T3 (n=13, 28.3%), T2 (n=8, 17.4%). Lymph node metastasis was recorded in 36 cases (22.8%). Paget's disease of the nipple was present in 5 cases. Studies of hormone receptors were carried out in 23 patients and were positive for 11 patients: ER+PR+ (7 patients), ER+PR-(4 patients).
Immunohistochemical analysis of HER2 was carried out in 17 patients, and was positive in 6 cases. These anatomopathological characteristics and findings are summarized in
The 158 patients had all undergone breast imaging (
Breast cancer, due to the high global prevalence, presents a notable public health issue (
While the highest rates are recorded in the USA and Europe, they are also notably high in certain countries in South America, Asia and Africa (Brazil, Argentina, Pakistan, Kuwait and Egypt) (
The relative risk associated with the presence of a family history of breast cancer is approximately 1.9 for all forms of kinship, and the excess risk is more pronounced in younger women and when the disease developed in a first-degree relative before the age of 50 (
This risk then continues to increase with age (
Histologically, the predominance of infiltrating ductal carcinoma case reported in this series is corroborated in numerous reports in the literature databases (
Given the delayed diagnosis, ~75% of these cancer cases are diagnosed at an advanced stage, with 50–80% lymph node involvement and higher SBR grading (40% SBR 2 and 50% SBR 3). Hormone receptors are less likely to be positive (68% of those <40 years of age vs. 80% of ≥40 years), and HER2 is more frequently over expressed in younger patients than in postmenopausal females (
The imaging diagnosis of breast cancer cases is based on paired ultrasonography-mammography (
In conclusion, the present study demonstrated that cases of breast cancer in female patients ≤35 years of age are frequent in Togo, despite unavailability of a national cancer registry and immunohistochemistry techniques. These breast cancer cases are predominantly infiltrative ducal carcinoma of the breast, typically diagnosed in the advanced stages. These cases of breast cancer in young female patients require attention with regard to early diagnosis for adequate therapeutic management, particularly in countries with limited resources. The results indicate a genetic origin and warrant a thorough search. In addition, collaboration with other pathologists and institutions is required in future studies.
Dr Tchin Darré and Dr Mazamaesso Tchaou were responsible for the design of the study, undertook the field study, performed the data collection, data analysis and interpretation, and composed the manuscript. Dr Koué Folligan, Dr Abdoulatif Amadou, Dr Bidamin N'Timon, Dr Lantam Sonhaye, Dr Abdoul-Samadou Aboubakari, Dr Koffi Amégbor and Professor Koffi Akpadza participated in the design of the study, supervised the data collection and participated in the data analysis. Professor Gado Napo-Koura was responsible for the management of the study, the data analysis and interpretation, and the preparation of the final manuscript. All authors have read and approved the final manuscript to be submitted for publication.
Epidemiological characteristics of patients.
Characteristics | Values, n (%) |
---|---|
Age (year) | |
Average | 30.9 |
Extremes | 16–35 |
Location of the cancer | |
Left Brest | 88 (55.7) |
Right Breast | 65 (41.1) |
Bilateral | 5 (3.2) |
Family history of cancer | |
(1st and 2nd degree) | 22 (13.9) |
Breast cancer + pregnancy | 12 (7.6) |
Pathological characteristics of the patient cohort.
Characteristics | Values n (%) |
---|---|
Histological type (n=158 cases) | |
Canalar carcinoma | 119 (75.3) |
Lobular carcinoma | 12 (7.6) |
Mixed carcinoma | 13 (8.2) |
Other | 14 (8.9) |
Nuclear level (n=88 cases) | |
Grade I | 19 (21.6) |
Grade II | 31 (35.2) |
Grade III | 38(43.2) |
Tumor size (n=44 cases) | |
T1 | 8 (17.4) |
T2 | 11 (23.9) |
T3 | 13 (28.3) |
T4 | 14 (30.4) |
Histological ganglionic involvement (n=36 cases) | |
N+≤3 | 20 (56.6) |
N>3 | 16 (44.4) |
Hormonal receptors (n=23 cases)
Breast lesion characteristics according to the method of imaging used.
Imaging exam | Classification of lesion | n (%) |
---|---|---|
Ultrasonography alone (n=72 cases) | No signs of malignancy | 5 (3.16) |
≥1 sign of malignancy | 67 (42.41) | |
Paired ultrasonography-mammography | BIRADS 1 (normal) | 0 (0.00) |
(n=86 cases) | BIRADS 2 (benign lesion) | 1 (0.63) |
BIRADS 3 (potential benign lesion) | 3 (1.90) | |
BIRADS 4 (potential malignant lesion) | 45 (28.48) | |
BIRADS 5 (malignant lesion) | 37 (23.42) |
BIRADS, Breast Imaging Reporting and Data System.