Introduction

Breast cancer is a public health problem in Côte d'Ivoire. In 2012, 2,248 new cases were identified with a mortality rate of 18.5 per 100,000 inhabitants.^[1]

These epidemiological characteristics justified the establishment in September 2015 of a senology unit at social cost at the Treichville University Hospital (CHU of Treichville). This center, equipped with state-of-the-art equipment (digital mammography, ultrasound with elastography, and micro-biopsy equipment) aimed to help improve the management of breast cancer in terms of early diagnosis.

Key sources of information, the imagery of female breast cancer is characterized by polymorphic aspects.^[2,3,4,5] These aspects have been insufficiently reported in the African series in general and the Ivorian in particular,^[6] unlike those from the West.

The aim of this preliminary work was to identify the different mammo-echographic characteristics of lesions suggestive of breast neoplasia and to specify their histopathological profile.

Subjects and Methods

We have done a retrospective and descriptive review of the breast pathologies files diagnosed between October 2015 and January 2016 (4 months) at the senology unit of the Treichville University Hospital.

We included patients with a strong suspicion of breast cancer.

Their mammo-ultrasound results should have been archived in a database allowing re-reading. All of the patients had an echo-guided breast micro-biopsy with histological examination of the samples.

The mammography unit was of the Lilyum type XM12 brand and the Mindray model DC brand. Each patient had a frontal and an oblique external incidence for each breast and the ultrasound examination was bilateral in B mode with exploration of the axillary cavities. The examinations were interpreted based on the BI-RADS (Breast Imaging Reporting and Database System) 2013 of the American College of Radiology (ACR) descriptive lexicon,^[7] by senior radiologists with expertise in senological imaging.

As for the echo-guided micro-biopsies, they were performed under local anesthesia by a senior radiologist using an automatic pistol, a 14G-caliber needle and 20 millimeters of travel with minimum 03 samples per patient. The samples were fixed in formalin diluted to 10% and treated according to conventional rules in anatomopathology.

The judgment criteria were as follows: general characteristics of our patients, mammo-echographic aspects as well as the histological profile (histological type and histo-prognostic grade according to Elston Ellis).^[8] The determination of the HER2 onco-receptor for hormone receptors and of Ki67 subsequently carried out was not taken into account in our work.

Results

General characteristics of the patients:

During the study period, 68 patients out of the 219 files collected met the inclusion criteria.

The mean age was 45.92 years ((± 11.4 years) with extremes of 27 and 71 years.

The palpable nodule was the main discovery circumstance (75%).

The lesions were located mainly in the left breast (57.3%), with a predominance in the upper-outer quadrant (34%) and the middle third (57.3%).

Mammo-echographic aspects:

The breast density was type b (54.4%).

The mammographic aspects are summarized in [Table 1] and are illustrated in [Figures 1, 2].

Sixty-three of the 68 patients had dense masses, one patient had architectural distortion and the examination was inconclusive in four patients.

The ultrasound aspects are summarized in [Table 2] and are illustrated in [Figures 3, 4]. Sixty-five of the 68 patients had a hypoechoic mass and three patients had non-mass.

The associated signs are summarized in [Table 3] and are associated with each other. The first five variables were found in all patients. Lymphadenopathy were observed in thirty-eight of the 68 patients.

The lesions were classified BI RADS 5 (63.2%).

Histopathological aspects:

The histopathological aspects are summarized in [Table 4]. Elston Ellis' histo-prognostic score and grade were specified in sixty-two of the 68 patients.

Discussion

The relatively large average size of mammographic lesions in our study as in that of other North African series testified to the locally advanced nature of our patients.^[9,10] These characteristics differ from those observed in the Western series.^[11,12] In fact, in these countries the higher number of subclinical mammographic lesions is a reflection of the early detection systems put in place.

Most of the masses in our series had an irregular shape and uncut contours characteristic of malignancy. The micro-lobulations were linked to a micro invasion of the stroma. As for the spicules, they were induced by a major retractile reaction stroma corresponding to the progressive attraction of the peri-tumoral breast tissue.^[13]

According to Moifo et al,^[14] the ultrasound signs observed in our study are linked to tumor development along the axis of the lactiferous canals in terms of non-parallel orientation. An important fibrous contingent with strong desmoplastic reaction would explained the posterior attenuation; the posterior reinforcement or the absence of posterior signs, would be in connection with a hyper cellularity, a strong inflammatory component and a weak desmoplastic reaction.^[15]

The presence of skin abnormalities and edema underlie a relatively high rate of inflammatory cancer. Indeed these are associated in 96% of cases of carcinomatous mastitis according to Günhan-Bilgen.^[16] Skin involvement also reflects the embolization of tumor cells in the lymphatic system under the dermis (carcinomatous lymphangitis under the dermis).^[17] The overall increase in the echogenicity of the breast parenchyma with thickening of Cooper's ligaments reflects the presence of edema.

It is a therapeutic emergency in breast oncology and therefore an unfavorable prognosis. Unlike western countries (02 to 05% in the United States, 03 and 10% in France),^[17,18] this aspect is frequent in Africa south of the Sahara as evidenced by Nkoua-Mbon's work (40% of cases) and Konan (46% of cases) respectively in Congo and Côte d’Ivoire.^[6,19] This pathological entity requires increased awareness and early detection.

The high frequency of lymphadenopathy indicates a strong presumption of metastatic lymph node involvement and must consequently be the subject of histological confirmation.^[20] This confirmation is essential in the therapeutic strategy; metastatic lymph node extension constituting an independent prognostic factor correlated with poor survival.

Histologically, non-specific invasive carcinoma (CINS) was also found in other African series.^[6,21,22] These infiltrative forms associated with other prognostic factors (histo-prognostic grade II and III of Elston Ellis) reflected the late nature of the diagnosis in our daily practice.

Conclusion

In Abidjan, breast cancer in women is characterized by radio-histopathological factors linked to a poor prognosis. In young patients, it combines bulky carcinoma-like masses infiltrating with a high rate of carcinomatous mastitis. All this data requires a real mass breast cancer screening policy in our country.