MINISTRY OF MINISTRY OF HEALTH

EDUCATION AND TRAINNING

HAIPHONG UNIVERSITY OF MEDICINE AND PHARMACY

NGUYEN THI LAN OANH

CLINICAL FEATURES AND HISTOPATHOLOGICAL RESULT

OF BREAST MASS AND ASSESSMENT OF PATIENT’S
POSTOPERATIVE CONDITION IN HAIPHONG HOSPITAL
OF OBSTETRICS AND GYNAECOLOGY
FROM JANUARY 2017 TO DECEMBER 2018

GENERAL DOCTOR GRADUATE THESIS

COURSE: 2013 – 2019

HAIPHONG – 2019
 MINISTRY OF MINISTRY OF HEALTH
EDUCATION AND TRAINNING
HAIPHONG UNIVERSITY OF MEDICINE AND PHARMACY

NGUYEN THI LAN OANH

CLINICAL FEATURES AND HISTOPATHOLOGICAL RESULT

OF BREAST MASS AND ASSESSMENT OF PATIENT’S
POSTOPERATIVE CONDITION IN HAIPHONG HOSPITAL
OF OBSTETRICS AND GYNAECOLOGY
FROM JANUARY 2017 TO DECEMBER 2018

GENERAL DOCTOR GRADUATE THESIS

COURSE: 2013-2019
Code:

SUPERVISORS:
1. Assoc. Prof. PhD. Vu Van Tam
2. Ms. MD. Nguyen Thi Mai Phuong

HAI PHONG – 2019

 DECLARATION

I assure this thesis is my own study; the data and research results are honest
and have never been published in other research projects.

Author

Nguyen Thi Lan Oanh

 ACKNOWLEDGMENT

I would like to express my sincere gratitude and my great thanks to:

Assoc. Prof. PhD. Vu Van Tam, Director of Haiphong hospital of

Obstetrics and Gynecology who spent lots of his precious time training and
directly instructing me in implementing this research.
Ms. MD. Nguyen Thi Mai Phuong – lecture of Haiphong university of
Medicine and Pharmacy who trained and helped me correct my thesis with
medical terms.
The Rector Board and Training Department of Haiphong University of
Medicine and Pharmacy.
The doctors and staffs of General Planning Department of Haiphong
hospital of Obstetrics and Gynecology.
My family and friends who always encourage and help me study and
complete my research.

Haiphong, May 25th 2019

Author

Nguyen Thi Lan Oanh

 LIST OF ABBREVIATIONS

ALNs Axillary lymph nodes

LIQ Lower inner quadrant
LOS Length of stay
LOQ Lower outer quadrant
NICE National Institute for Health and Care
UICC Union for International Cancer Control
UIQ Upper inner quadrant
UOQ Upper outer quadrant
US Ultra-sound
VABB Vacuum-assisted breast biopsy
WHO World Health Organization

TABLE OF CONTENTY
Contents Pag

e
INTRODUCTION...........................................................................................1
Chapter 1: LITERATURE REVIEW...........................................................3
1.1. Anatomy, histology and physiology of the adult female breast.............3
1.1.1. Anatomy and histology of the normal breast...................................3
1.1.2. Physiology of normal mammary gland............................................8
1.2. Breast mass.............................................................................................9
1.2.1. Clinical manifestations of a breast mass..........................................9
1.2.2. Histopathological results of breast mass........................................11
1.3. Manegement of breast mass..................................................................13
1.3.1. Surgical method..............................................................................13
1.3.2. Other methods................................................................................15
1.4. Postoperative status of breast mass.......................................................15
1.5. Several of breast mass researches in the world and Vietnam...............17
Chapter 2: RESEARCH SUBJECT AND METHODOLOGY................19
2.1. Subjects of study...................................................................................19
2.1.1. Criteria of selection........................................................................19
2.1.2. Criteria of exclusion.......................................................................19
2.2. Methodology.........................................................................................19
2.2.1. Research design..............................................................................19
2.2.2. Sample size.....................................................................................19
2.2.3. Place and time of study..................................................................20
2.3. Contents of study..................................................................................20
2.3.1. Content of some characteristics of the research subjects...............20
2.3.2. The 1st objective research content...................................................20
 2.3.3. The 2nd objective research content..................................................21
2.4. Variables of research............................................................................21
2.4.1. Variables of some characteristics of the subjects..........................21
2.4.2. Variables of clinical characteristics and histopathological results. 22
2.4.3. Variables of surgical methods and postoperative status of patient.23
2.5. Some evaluation criterias in research...................................................23
2.6. Steps of doing research.........................................................................24
2.7. Data analysis.........................................................................................24
2.8. Ethics of study......................................................................................25
2.9. Limitation of study................................................................................25
Chapter 3: RESULTS OF STUDY..............................................................26
3.1. The sociademographic characteristics of the research subjects............26
3.2. The clinical characteristics and histopathological results of subjects...29
3.2.1. The clinical characteristics.............................................................29
3.2.2. The results of breast mass histopathology......................................32
3.3. The surgical methods and postoperative status of patient....................37
Chapter 4. DISCUSSION.............................................................................42
4.1. Discussion about the sociademographic characteristics of subjects.....42
4.1.1. The distribution of patient’s age.....................................................42
4.1.2. The menstrual status of patients.....................................................44
4.1.3. The relationship between patient delay and patient’s age group....45
4.2. Discussion about the clinical characteristics and histopathological
results of subjects......................................................................................47
4.2.1. The clinical signs and symptoms....................................................47
4.2.2. The number and the size of mass...................................................48
4.2.3. The distribution of mass by side and by breast quadrants..............48
4.2.4. The histopathological results..........................................................51
 4.2.5. The relationship between the histopathological results and patient’s
age, patient delay......................................................................................52
4.2.6. The relationship between the histopathological results and the
clinical signs and symptoms.....................................................................53
4.2.7. Relationship between the histopathological results and the number
and the size of mass..................................................................................55
4.2.8. The relationship between the histopathological results and the
distribution of mass by side and by breast quadrants...............................55
4.3. Discussion about surgical methods, early postoperative complications
and length of stay......................................................................................56
CONCLUSION..............................................................................................59
PROPOSAL...................................................................................................60
REFERENCES
APPENDIX
 LIST OF TABLE

Table 3.1. Relationship between patient delay and patient’s age group.............26
Table 3.2. Relationship between distribution of mass by breast quadrants and
by sides................................................................................................................29
Table 3.3. Relationship between histopathological results and patient’s age.....31
Table 3.4. Relationship between histopathological results and patient delay.....31
Table 3.5. Relationship between histopathological results and clinical signs
and symptoms......................................................................................................32
Table 3.6. Relationship between histopathological results and number of
mass, the distribution of mass by sides...............................................................33
Table 3.7. Relationship between histopathological results and distribution of
mass by breast quadrants.....................................................................................34
Table 3.8. Relationship between the histopathological results and size of
mass.....................................................................................................................35
Table 3.9. Relationship between using postoperative analgesics and surgical
methods................................................................................................................36
Table 3.10. Relationship between the results of histopathology and early
postoperative complications................................................................................37
Table 3.11. Relationship between early postoperative complications and size,
number of mass, surgical methods......................................................................38
Table 3.12. Relationship between surgical methods and length of stay..............39
Table 4.1. Breast mass patient’s age in several studies.......................................41
Table 4.2. Menstrual status of patients................................................................43
Table 4.3. The distribution of mass by side.........................................................48
Table 4.4. The results of histopathology of breast mass.....................................50
Table 4.5. Comparison between open surgery and ultrasound-guided vacuum-
assisted breast biopsy procedure.........................................................................55
 LIST OF PICTURE AND FIGURE
Picture 1.1. Anatomy of female breast ..............................................................4
Picture 1.2. Anatomy and histological structures of breast ................................5
Picture 1.3. Lumpectomy procedure...................................................................13
Picture 2.1. Breast quadrants (UICC) .................................................................23
Figure 3.1. Distribution of patient’s age..............................................................25
Figure 3.2. Menstrual status of patients...............................................................26
Figure 3.3. Frequency of popular signs and symptoms of breast mass...............27
Figure 3.4. Number of mass and distribution of mass by sides..........................28
Figure 3.5. Size of mass.....................................................................................30
Figure 3.6. Results of breast mass histopathology.............................................30
Figure 3.7. Surgical methods .............................................................................35
 INTRODUCTION

Breast is a glandular organ influenced by hormones in females with

various structures giving rise to different types of lesion and masses. In breast
disease, breast mass is the most important lesion, especially breast cancer [1]
{Dương Thị Cương, 1999 #17}. Breast masses have a variety of etiologies,
benign and malignant. Most masses are benign about 80% [55]. Fibro-
adenoma is the most common benign breast mass [3, 56]. However,
proliferative changes can sometimes transform into malignancy which
imparts importance of accurate diagnosis and treatment [57].
Breast cancer is the most common cancer and the second leading cause
of cancer deaths in women.  Approximately 1.7 million women worldwide
were diagnosed with breast cancer and over 522,000 women died from this
disease in 2012. There were over 2 million new cases of breast cancer in 2018
[75]. According to World Health Organization, the average frequency of
breast cancer has increased gradually in recent years, averagely increase of
1.5% annually [76].
In Vietnam, in 2012, approximately 11,060 cases of female breast cancer
were diagnosed, with 64.7% of the cases below age 50 [76]. Up to now,
18/100000 people have breast cancer, most of them are women. There is an
average of 11,000 new cases and over 5,000 deaths are reported each year. In
Haiphong, in period of 2011 – 2016, the rate of breast cancer is 23.7/100000
people [8]. It’s alarming numbers, therefore early detection and diagnosis of
breast mass is essential.
The clinical presentation of breast mass is variable. Some masses are
detected on a patient's self-breast examination while others are found on a
routine clinical breast examination. Some masses may be associated with
pain and/or nipple discharge (eg, blood, green, white, yellow) [77]. Self-
breast examination and clinical breast examination plays an important role in
early detection [78]. Clinical features help the physicians have preliminary
diagnosis of those masses as benign or malignant, and the preliminary
diagnosis will be determined by results of histopathology after surgical
treatment.
Surgery is the first choice and the major treatment of both benign breast
mass and breast cancer (especially in cases with no metastasis) depending on
the diagnosis and the individual [8]. Types of surgery include: lumpectology,
mastectomy, sentinel node biopsy, axillary lymph node dissection,
reconstruction. In Haiphong, from June 2018, a new method was applied and
had some efficient results. It was ultrasound-guided vacuum-assisted breast
biopsy procedure. Up to now, there are many studies in the world and few
studies in our country have evaluated clinical characteristics and result of
histopathology of breast mass and postoperative status of patient after
ultrasound-guided vacuum-assisted breast biopsy procedure or open surgery.
Therefore, the topic "Study of clinical features and histopathological
result of breast mass and assessment of patient’s postoperative condition
in Haiphong hospital of obstetrics and gynecology" was conducted with
two objectives:
(1) Assessing the clinical characteristics and histopathological results
of patients diagnosed with breast mass at Haiphong hospital of Obstetrics and
Gynecology from January 2017 to December 2018;
(2) Assessing postoperative status of patient underwent breast mass
removal surgery with US-guided VABB procedure or open surgery.
 Chapter 1
LITERATURE REVIEW
1.1. Anatomy, histology and physiology of the adult female breast
1.1.1. Anatomy and histology of the normal breast
The mammary gland is a gland located in the breasts of females that is
responsible for lactation, or the production of milk. Both males and females
have glandular tissue within the breasts; however, in females the glandular
tissue begins to develop after puberty in response to estrogen release [16].
- Location: The mature female breast extends inferiorly from the level of
the second or third rib to the inframammary fold, which is at about the level
of the sixth or seventh rib, and laterally from the lateral border of the sternum
to the anterior or mid-axillary line [6,17].
 Anatomical and histological structures of normal breast
 Outside appearance
Morphologically the breast is tear-shaped [18]. The size and shape of
breast varies depending on the individual and each stage of human
development. It consists of 3 parts [6].
- The corpus mammae naturally determined by the support of the
suspensory Cooper's ligaments, the underlying muscle and bone structures of
the chest, and by the skin envelope. The breast is positioned, affixed to, and
supported upon the chest wall, while its shape is established and maintained
by the skin envelope [19].
- The papilla mammaria (the nipple) is a conical raised region of tissue
on the surface of the breast from which, milk leaves the breast through
the lactiferous ducts to feed an infant. The nipple is also used as an anatomical
landmark. It marks the T4 (fourth thoracic vertebra) dermatome and rests over
the approximate level of the diaphragm [20].
 Picture 1.1. The anatomy of the female breast [20]
- The areolar mammae is the pigmented area on the breast around
the nipple. There are “Montgomery tubercles” - the portions of Montgomery
glands which visible on the areolar area secreting “protective” oily substances
during lactation [21].
 Histological structure:
- Breast tissue is heterogeneous, associating connective and glandular
structures, which grow and change cyclically under hormonal regulation [22].
- The histological structure of the breast contains 3 layers from the
outside in [4,6]:
+ The skin layer: Usually between 0.5 – 2 mm thick. It is composed of
epidermal cells containing sebaceous gland and hair follicles. The skin is
enhanced by the smooth muscular fibers in the areolar [6].
+ The subcutaneous layer: The subcutaneous tissue that also contains a
variable quantity of adipose tissue encloses the mammary gland. The adipose
tissue, also known as fat, is the anatomical term for loose connective tissue
composed of adipocytes, concentrates into fat pits separating by fibrous
capsules [6,23].
+ Mammary tissue (parenchyma) layer: The epithelial tissue is
considered the functional tissue (grandular tissues) of the breast including
terminal ductolobular unit, lobules, lobes, lactiferous duct and the stromal
tissue includes fat and connective tissues.
- The parenchyma of the breast is composed of the glandular tissue
supported by fibrous tissue that holds the gland and interlobular adipose tissue
that is also enriched with blood vessels and nerves. The breast parenchyma is
pale yellow in color, with the lobulated tissue supported by connective tissue.
It is usually composed of 15–20 lobes, with each lobe comprised of the same
number of tubuloalveolar lobules connected by a single lactiferous duct. They
are arranged in a radial pattern and orientation from the areola.

Picture 1.2. Anatomy and histological structures of the breast [24]

 These lobules drain to the lobes through the lactiferous duct and sinuses
just underneath the areola. The sinuses are reservoirs that are connected to the
narrow papilla that transmit milk to the orifices in the nipple. The lactiferous
ducts, lined with stratified squamous epithelium, transition into lactiferous
sinuses lined with cuboidal and myoepithelial cells located beneath the areola.
Each of the lobules contains hundreds of secretory acini. The ducts have
columnar epithelia and lined by the basal lamina and myoepithelium at the
periphery of the ducts. It is from within these ducts that invasive ductal
carcinoma arises. Larger ducts have two or three layers of epithelium,
becoming keratinizing stratified squamous epithelium at the opening. The
morphology of the secreting gland varies greatly with age and hormonal
influence. The inactive breast undergoes mild cyclical changes associated
with the menstrual cycle. Conversely, significant cellular hypertrophy of the
breast occurs throughout pregnancy [6,22,25].
The connective tissue: Ducts and mammary lobules are surrounded by
connective tissue composed of blood and lymphatic vessels, nerves,
adipose and fibrous tissue which supply nutrition and provide support. The
proportion of adipose and fibrous tissues varies from one patient to another
and changes with the time [6,22,25]. The Cooper’s ligaments are connective
tissues in breast running from the clavicle and the clavipectoral fascia,
branching out through and around breast tissue to the dermis of the skin
overlying the breast. The intact ligament suspends the breast from the clavicle
and the underlying deep fascia of the upper chest. This has the effect of
supporting the breast in its normal position, and maintaining its normal shape.
 The blood supply and innervation of the breast
- Arterial supply to the medial aspect of the breast is via the internal
thoracic artery, a branch of the subclavian artery.
 - The lateral part of the breast receives blood from four vessels [25]
{Riker, 2015 #18}:
 Lateral thoracic and thoracoacromial branches; 
 Lateral mammary branches; 
 Mammary branch – originates from the anterior intercostal artery.
- The veins of the breast correspond with the arteries, draining into
the axillary and internal thoracic veins.
- The breast is innervated by the anterior and lateral cutaneous
branches of the 4th to 6th intercostal nerves. These nerves contain both
sensory and autonomic nerve fibres (the autonomic fibres regulate smooth
muscle and blood vessel tone). It should be noted that the nerves do not
control the secretion of milk. This is regulated by the hormone prolactin,
which is secreted from the anterior pituitary gland [6].
 Lymphatic drainage of the breast
The lymphatic drainage of the breast is of great clinical importance due
to its role in the metastasis of breast cancer cells. There are three groups of
lymph nodes that receive lymph from breast tissue – the axillary nodes (75%),
parasternal nodes (20%) and posterior intercostal nodes (5%) [5,25].
There are six commonly described groups at three anatomic levels
[17,26]: axillary vein group, external mammary group, scapular group,
central group subclavicular group, Rotter’s group.
The axillary lymph node groups are divided according to their lateral and
medial relationship to the pectoralis minor muscle into levels I–III. Level I
nodes are located inferior to the lower border of the pectoralis minor and are
composed of external mammary, axillary vein, and scapular lymph node
groups. Level II nodes are located posterior to the pectoralis minor and include
the central lymph node group. Level III nodes are located superomedial to the pectoralis
minor and are composed of the subclavicular group.
1.1.2. Physiology of normal mammary gland
The breasts begin to develop at puberty [27]. Breast is an endocrine
receptor of the hormone Estrogen and Progesteron, the breast has changes in
the correlation with Estrogen and Progesteron level in the menstrual cycle [7].
During puberty, enlargement of the mammary glands is primarily due to
ovarian estrogen. Estrogens stimulate growth of the breasts’ mammary
glands plus the deposition of fat to give the breasts mass. In addition, far
greater growth occurs during the high-estrogen state of pregnancy, and only
then does the glandular tissue become completely developed for the
production of milk [27]. The lactiferous ducts branch to form a solid spherical
mass of glandular cells that are potentially still able to develop into alveoli
[25]. At the end of puberty, there is dense fibrous stroma that separates the
scattered ducts lined with epithelium and fat in the mammary gland.
Increasing serum estradiol concentrations promote fat deposition and the
formation of new ducts by branching and elongation. In summary:
Estrogens stimulate the growth of the ductal system of the
breast, increase the permeability of the capillaries swelling
the connective tissue. [7]
Progesterone promotes development of the breasts: Progesterone has
both antagonistic and synergistic effects with Estrogen. Final development of
the breasts into milk-secreting organs also requires Progesterone. Once the
ductal system has developed, progesterone—acting synergistically with
estrogen, as well as with the other hormones just mentioned—causes
additional growth of the breast lobules, with budding of alveoli and
development of secretory characteristics in the cells of the alveoli.
 Also important for growth of the ductal system are at least four other
hormones: growth hormone, prolactin, the adrenal glucocorticoids, and
insulin. Each of these hormones is known to play at least some role in protein
metabolism, which presumably explains their function in the development of
the breasts.
The hormonal dependence of the mammary gland is the risk of causing
mammary gland disease when the balance of hormonal is disrupted (common
during childbirth period and menopause) and is the basis of the treatments of
breast diseases by hormone [2,5].
1.2. Breast mass
A breast mass is a nodule or growth of tissue that represents an
aggregation of coherent material. Breast masses are broadly classified as
benign or malignant. Common causes of benign breast lesions include
fibrocystic disease, fibroadenoma (see the image below), intraductal
papilloma, and abscess. Malignant breast disease encompasses many
histologic types that include, but are not limited to, in situ ductal or lobular
carcinoma, infiltrating ductal or lobular carcinoma, and inflammatory
carcinoma. The main concern of many women presenting with a breast mass
is the likelihood of cancer. Reassuringly, most breast masses are benign.
1.2.1. Clinical manifestations of a breast mass
The clinical presentation of a breast mass is variable. Some masses are
detected on a patient's self-breast examination while others are found on a
routine clinical breast examination. Some masses may be associated with
pain and/or nipple discharge (eg, blood, green, white, yellow) [28,29]. Some
common clinical manifestations contain [30]:
- Location of the mass: Fibrocystic change and fibroadenoma are usually
located in the upper outer breast quadrants. The well-circumscribed nodules
of intraductal papilloma may be located under the areola or in the ducts at the
breast periphery. Mammary duct ectasia and cysts of Montgomery are
subareolar.
- Consistency of the mass (cystic versus solid): Mammary duct ectasia
and cysts of Montgomery are cystic, whereas fibroadenoma, phyllodes
tumors, fat necrosis, and malignant breast tumors are usually solid.
- Size of the mass: Fibroadenomas are usually smaller than phyllodes
tumors (average of 2 to 3 cm versus 7 cm) [31,32]. The size of the mass can
be monitored through the menstrual cycle.
- Mobility of mass: Fibroadenomas are usually mobile, while malignant
breast tumors are usually (but not always) fixed to the underlying tissue.
- Tenderness may be present before the onset of menses in adolescents
with fibrocystic change and fibroadenoma. Tenderness also may occur in
patients with infection or trauma.
- Overlying skin changes may occur in large fibroadenomas, phyllodes
tumors (the skin is shiny and stretched from rapid growth), and in breast
cancer (peau d'orange, retraction).
- Nipple discharge may occur in fibrocystic disease (nonbloody green or
brown), cysts of Montgomery (clear to brown), intraductal papilloma
(bloody), mammary duct ectasia (multicolored, sticky), phyllodes tumor
(bloody), infection (purulent) and breast cancer (bloody).
- Appearance of the nipple: The nipple may appear to be blue or to have
a blue mass under it in patients with mammary duct ectasia. Nipple retraction
may occur in patients with breast cancer.
- Lymphadenopathy may be present in patients with breast infection or
breast cancer.
- Hepatosplenomegaly may be an indication of metastatic cancer.
1.2.2. Histopathological results of breast mass
The definitive diagnosis of a benign or malignant breast mass is based
upon the histopathology from a core, incisional or excisional tissue biopsy.
 Benign: Breast masses are very common in women, and most masses are
benign [33,34]. Approximately 90 percent or more of breast masses in women
in their 20s to early 50s are benign; however, excluding breast cancer is a
crucial step in the assessment of a breast mass in a woman of any age [35].
The following types of masses are among the most common benign breast
masses palpated.
- Fibroadenoma is a benign solid mass. It typically is identified in young
women but can also be identified as a calcified mass in older women. The
mass is firm and described as "mobile," as it can be rolled onto an edge. A
fibroadenoma may be solitary, multiple, and bilateral.
- Cyst is a benign fluid-filled mass that can be palpated as a component
of fibrocystic changes of the breast.Breast cysts are commonly found in
premenopausal, perimenopausal, and occasionally postmenopausal women.
- Fibrocystic changes – Fibrocystic changes in the breast are common,
particularly in premenopausal women, and may be prominent and organized.
However, the breast tissue tends to be more diffuse and tender, and generally
does not form a discrete or well-defined mass. Most patients present with
breast pain that may be cyclical or constant, bilateral or unilateral or focal.
The breast tissue, particularly in the upper outer quadrants, may increase in
size prior to the onset of menses, then return to baseline after the onset of the
menstrual flow. On the clinical examination, the breast tissue frequently is
nodular.
- Fat necrosis is a benign breast mass that can develop after blunt trauma
to the breast; injection of native or foreign substances such as fat [36],
paraffin, or silicone [37]; an operative procedure such as breast reductive
surgery [38] or autologous breast reconstruction [39]; and radiation therapy to
the breast. Fat necrosis from trauma is generally associated with skin
ecchymosis. Fat necrosis can often be clinically difficult to distinguish from a
malignant mass.
 Malignant: The differential diagnosis of a malignant breast mass
includes multiple invasive histology and noninvasive cancer. Further review
of the pathology of breast cancer is discussed separately.
- The most common breast cancer is an infiltrating ductal breast
carcinoma [56]. This invasive histology accounts for approximately 70 to 80
percent of invasive breast cancers. Other invasive breast cancers include
infiltrating lobular carcinoma and mixed ductal/lobular carcinoma. There are
also variants of the invasive ductal carcinomas that can be detected as a
palpable mass.
- Most breast cancers present as a hard mass, although less aggressive
histology, such as tubular carcinoma, may present as a very firm mass.
- Locally advanced breast cancer frequently presents as a large mass that
may be fixed to the chest wall or skin and may be associated with matted or
fixed axillary lymph nodes. Patients with inflammatory breast cancer
typically present with a painful, enlarging, erythematous breast and may not
have a palpable mass detected.
- Less commonly, noninvasive cancers with or without micro-invasion
can develop into a mass.
1.3. Manegement of breast mass
1.3.1. Surgical method
Surgery is the first choice and the major treatment of both benign breast
mass and breast cancer (especially in cases with no metastasis) depending on
the diagnosis and the individual. Surgery is considered primary treatment for
early-stage breast cancer; many patients are cured with surgery alone. The
goals of breast cancer surgery include complete resection of the primary
tumor with negative margins to reduce the risk of local recurrences and
pathologic staging of the tumor and axillary lymph nodes (ALNs) to provide
necessary prognostic information [40].
Types of breast mass removal surgery include [41]: lumpectomy,
mastectomy, sentinel node biopsy and axillary lymph node dissection,
reconstruction. Because of the most frequent of benign breast tumors,
lumpectomy is the most popular technique applied.
Lumpectomy: This involves removing the tumor and a small amount
healthy tissue around it. This can help prevent the spread of the cancer. This
may be an option if the tumor is small and likely to be easy to separate from
the tissue surrounding it [42]. Traditionally, a lumpectomy was performed
only to diagnose a breast mass. However, this procedure can be performed as
part of the definitive management of a breast malignancy or benign lesions
that have previously been diagnosed by needle biopsy.
 Picture 1.3. Lumpectomy procedure [42]

US-guided VABB procedure: The Mammotome is a diagnostic tool used

under stereotactic or with ultrasound guidance, but it can be used in breast
mass removal surgery [43].
Mammotome biopsy is a percutaneous large core biopsy needle
developed specifically for breast biopsies. The system consists of a disposable
sterile probe and a reusable, non-sterile driver. A piercing tip is mounted at
the distal end of the probe to penetrate breast tissue. The sterile probe
contains a tissue sampling chamber with a vacuum line at its bottom, giving
the probe an oval configuration. The chamber is located just below the tip and
opens along one side of the probe shaft. The mammotome uses a vacuum
system that draws tissue into a sampling chamber, a rotating cutter that
excises the tissue, and a second vacuum system that transports tissue back
through the probe without the need to withdraw it each time. The aperture can
be rotated 360°, allowing for multidirectional tissue sampling. After rotation
of the probe, the process is repeated until samples are harvested in all
directions around the needle tip. A given lesion can be cored more rapidly and
completely because the device remains in the breast at the location of the
lesion while the tissue is harvested. Therefore, vacuum-assisted breast biopsy
procedure allows for a single needle insertion yielding large tissue cores
without fragmentation. The procedure can be done under ultrasound guidance,
where tissue acquisition can be monitored by ultrasound, as well as
stereotactic guidance [44,45].
In patients with benign tumors, the residual lesion typically did not
require excision surgery. Patients with malignant tumor, residual lesions were
not problematic because additional breast cancer surgery was performed [46].
1.3.2. Other methods
- Benign breast mass: Medical treatment is indicated for trial treatment
before deciding to perform surgery such as inflammatory mammary or breast
cysts.
- Breast cancer: Adjuvant treatment of breast cancer is designed to treat
micrometastatic disease (ie, breast cancer cells that have escaped the breast
and regional lymph nodes but which have not yet had an established
identifiable metastasis). Adjuvant treatment for breast cancer involves
radiation therapy and systemic therapy (including a variety of
chemotherapeutic, hormonal and biologic agents [40].
1.4. Postoperative status of breast mass
- Early complication after surgery: Because breast is a peripheral soft
tissue organ, many wound complications related to breast procedures are
relatively minor and frequently are managed on an outpatient basis. It
therefore is difficult to establish accurate incidence rates for these events [47].
The non-specific complications: postoperative pain, wound infections, seroma
formation, hematoma.
- Acute pain: After breast surgery, patients experience significant amount
of pain just after surgery, reflecting the inadequacy of conventional pain
management. Most of the responses of the human body to post-surgical pain
(pain after surgery) have been proven to be detrimental to the patient’s
homeostasis (normal body function) and recovery [48].
- Wound infection: Rates of postoperative infections in breast
and axillary incisions have ranged from less than 1% of cases
to nearly 20%. Staphylococcal organisms introduced by means of skin
flora usually are implicated in these infections[49],[50]. Several investigators
have found that patients undergoing definitive surgery for cancer had a lower
risk for wound infection if the diagnosis had been established by prior needle
biopsy rather than by an open surgical biopsy [51],[52].
- Hematoma [52]: Bleeding complications can be diminished by
meticulous hemostasis, but even in the best hands, they will occur. A minority
of patients may present with excessive bruising or a small hematoma at the
site of the lumpectomy. These cases resolve spontaneously. However, an
expanding hematoma, either at a lumpectomy site or underneath the skin flaps
of a mastectomy, must be recognized as quickly as possible because
significant blood loss can occur. Postoperative hemorrhage is often secondary
to arterial perforators of the thoracoacromial vessels or internal mammary
arteries [47]
- Seroma formation [47,52]: The rich lymphatic drainage of the breast
from intramammary lymphatics to the axillary, supraclavicular, and internal
mammary nodal basins establishes the tendency for seroma formation within
any closed space that results from breast surgery. It has been proposed that
the low fibrinogen levels and net fibrinolytic activity within lymphatic fluid
collections account for seroma formation [53]. Most breast cancer surgery is
performed in the outpatient setting, and patients must be instructed about
proper drainage catheter care to prevent seroma formation.
1.5. Several of breast mass researches in the world and Vietnam.
There are a lot of studies about clinical features and histopathological of
breast mass and surgical methods in the world but most of those is about
breast cancer. Breast cancer is the most common cancer and the second
leading cause of cancer deaths in women.  Approximately 1.7 million women
worldwide were diagnosed with breast cancer and over 522,000 women died
from this disease in 2012. There were over 2 million new cases of breast
cancer in 2018. Belgium had the highest rate of breast cancer in women,
followed by Luxembourg [75]. According to WHO, the average frequency of
breast cancer has increased gradually in recent years, averagely increase of
1.5% annually. Some studies about breast mass in general demonstrates that
the average age of breast mass patients is around 35 years old [46,54,78]. The
clinical presentation of a breast mass is variable. Some masses are detected on
a patient's self-breast examination while others are found on a routine clinical
breast examination but mass always is the most important symptom in the
disease. Other symptoms and signs are insignificant [46,57,77,78]. Surgery is
the first choice and the major treatment of both benign breast mass and breast
cancer (especially in cases with no metastasis) depending on the diagnosis
and the individual [40].
In Vietnam, in 2012, approximately 11,060 cases of female breast cancer
were diagnosed, with 64.7% of the cases below age 50 [76]. Up to now,
18/100000 people have breast cancer, most of them are women. There is an
average of 11,000 new cases and over 5,000 deaths are reported each year. In
Haiphong, in period of 2011 – 2016, the rate of breast cancer is 23.7/100000
people [8]. There are a lot of studies about breast cancer and benign breast
mass in Vietnam, but the studies about breast mass in general is less. Several
studies was conducted in National Hospital for Obstetrics and Gynecology of
Lam Van Tien (2001) [9] , Nguyen Thi Ngoc Thuy (2001) [10], Nguyen Thu
Hang (2004) [11]. In Haiphong, from June 2018, a new method was applied
and had some efficient results. It was ultrasound-guided vacuum-assisted
breast biopsy (US-guided VABB) procedure. Up to now, there is no study in
Vietnam about US-guided VABB procedure in surgical treatment of breast
mass.
 Chapter 2
RESEARCH SUBJECT AND METHODOLOGY
2.1. Subjects of study
Including 206 patients diagnosed clinically with 248 breast masses
which have histopathological results were treated at Haiphong Hospital of
Obstetrics and Gynecology from January 1st 2017 to December 30th 2018.
2.1.1. Criteria of selection
- Patients with medical records underwent diagnosis of breast mass (both
benign and malignant) were operated with ultrasound-guided vacuum-
assisted breast biopsy (US-guided VABB) procedure or open surgery;
- The patients had results of histopathology after surgery;
- Medical records are full of research information according to the
objectives and content of the study.
2.1.2. Criteria of exclusion
- Patients were diagnosed with breast mass but were not treated by
surgery (due to not indicating or giving up treatment);
- Patients didn’t have results of histopathology after surgery;
- Patient’s medical records are incomplete with the information needed
for research.
2.2. Methodology
2.2.1. Research design
- A descriptive cross-sectional study.
2.2.2. Sample size
- Convenient samples including all the medical records which are
appropriate to our criteria;
- During the study period, 206 patient’s medical records were analyzed.
2.2.3. Place and time of study
- Place of study: Haiphong hospital of Obstetrics and Gynecology.
- Time of study: From January 1st 2017 to December 30th 2018.
- Duration of research: From January to May 2019.
2.3. Contents of study
2.3.1. Content of some characteristics of the research subjects
- Distribution of patient’s age (average age, min, max);
- Menstrual status of patients;
- Patient delay (average time, min, max) and the association between
patient delay and patient’s age.
2.3.2. The 1st objective research content
- Assessing the clinical characteristics and histopathological results of
patients diagnosed with breast mass at Haiphong hospital of Obstetrics
and Gynecology from January 2017 to December 2018.
 Clinical features of breast mass:
+ Describe the frequency of some common symptoms and signs of
breast mass: Self-palpable breast mass, breast pain, abnormal nipple
discharge, changes breast skin area, breast deformation, palpable
neighboring lymph nodes.
+ The number of breast masses and the distribution of masses
according to anatomical location.
+ The size of breast mass (average size, min, max).
 Histopathological results: benign or malignant mass.
+ The percentage of breast cancer and benign breast mass based on the
histopathological results.
+ The relation between histopathological results and patient’s age,
patient delay.
 + The relation between histopathological results and of some common
symptoms and signs of breast mass, number of masses, anatomical
location and size of mass.
2.3.3. The 2nd objective research content
- Assessing postoperative status of patient underwent breast mass
removal surgery with US-guided VABB procedure or open surgery.
+ Percentage of patients operated with US-guided VABB procedure or
open surgery
+ Percentage of patient using postoperative analgesics
+ Percentage of early postoperative complication (bleeding, hematoma,
wound infection) and the relation between complication and some
features: size of mass, number of masses, histopathological results,
surgical methods.
+ The relation between hospital length of stay (LOS) (average time,
min, max) and surgical methods.
2.4. Variables of research
2.4.1. Variables of some characteristics of the subjects
- Patient’s ages (years old):
+ ≤ 19
+ 20 – 50
+ ≥ 50
- Menstrual status of the patients
+ Prepubertal
+ Having menstruation
+ Pre-menopause, menopause
 - Patient delay (months):
+ ≤3
+ >3
2.4.2. Variables of clinical characteristics and histopathological results
 Clinical characteristics of breast mass: signs and symptoms
+ Breast pain: Yes/No
+ Self-palpable breast mass: Yes/No
+ Abnormal nipple discharge: Yes/No
+ Breast deformation: Yes/No
+ Overlying skin changes: Yes/No
+ Characteristics of mass:
 Location: left-sided or right-sided. Breast quadrants:
 Upper outer quadrants (UOQ)
 Upper inner quadrants (UIQ)
 Lower inner quadrants (LIQ)
 Lower outer quadrants (LOQ)
 Central region
 Size of mass (centimeters):
 ≤2
 2-≤5
 >5
+ Palpable neighboring lymph nodes: Yes/No
 Histopathological results: benign or malignant mass.
2.4.3. Variables of surgical methods and postoperative status of patient
- Surgical methods:
+ Open surgery
+ US-guided VABB procedure
- Using postoperative analgesics: Yes/No
- Early postoperative complication
+ Seroma: Yes/No
+ Hematoma: Yes/No
+ Wound infection: Yes/No
- Patient’s hospital length of stay (LOS)
2.5. Some evaluation criterias in research
- Pre-puberty [58]: is defined as the period of life immediately
prior to sexual maturation, often marked by accelerated physical
growth, not having period.
- Pre-menopause [7]{Dương Thị Cương, 1999 #17}: is defined as the
period of the first symptoms of menstrual disorders due to the decline
of ovarian cysts. Usually begins at age 40 and ends by the last
physiological menstrual cycle.
- Menopause [7]: is a phenomenon of amenorrhea in women for at least
12 months.
- Patient delay [59]{V Arndt, 2002 #26}: is defined as the duration of
symptoms in days before the first medical consultation.
- Patient’s hospital length of stay (LOS) [60]: is defined as the duration
of a single episode of hospitalization. Inpatient days are calculated by
subtracting day of admission from day of discharge.
- Breast quadrants (UICC): 5 regions in the figure below
 - Size of mass [62]: is measured by the pathologist based on the largest
diameter of the resected specimen, estimated to the nearest millimeter.
However, size evaluation is inexact, and pathologists tend to round the
mass size to the nearest centimeter or half-centimeter.

Picture 2.1. Breast quadrants (UICC) [61]

2.6. Steps of doing research
- Developing the instrumentation plan;
- Collecting data and filtering data of the medical records of patients
stored at Medical record store of General planning department of
Haiphong hospital of Obstetrics and Gynecology from January 1st 2017
to December 30th 2018;
- Marking the records;
- Copying information according to data collection form;
- Importing and processing data;
- Writing discussion and completing the research.
2.7. Data analysis
- Managing and processing data by using SPSS 22.0 program.
 - The mean values are expressed as Mean ± SD and comparing the
difference of mean values between the two groups by T – test or
ANOVA test.
- Qualitative variables are expressed in terms of frequency and
percentage. Comparison of the qualitative variables was performed by
Chi-square test or Fisher exact’s test.
- p < 0.05 indicates statistically significant difference.
2.8. Ethics of study
- Honestly report data, results, methods and procedures, and publication
status, not fabricate, falsify, or misrepresent data.
- The research was conducted in accordance with the content of the
registration form which is approved by the Scientific Council.
- The study outline has been adopted and approved by the scientific
council of Haiphong university of Medicine and Pharmacy and
conducted at Haiphong hospital of Obstetrics and Gynecology.
- Patient information is kept confidential, used only for study purposes
but not for any other purposes. The study outcomes are used only for
study purposes but not for any other purposes.
2.9. Limitation of study
- The sample size is small, medical recodes were not shown some clinical
characteristics of breast mass such as: consistency of the mass, mobility
of the mass, tenderness.
- Because the US-guided VABB procedure was a new technique applied
in recent months so the number of patients operated by this technique
was small.
 Chapter 3
RESULTS OF STUDY

During the study period from January 1st 2017 to December 30th 2018,
we selected 206 medical records of breast mass patient operated in Haiphong
Hospital of Obstetrics and Gynecology and they were appropriate to the
criteria of research.

3.1. The sociademographic characteristics of the research subjects

X ± SD = 35.7±13.1, min - max = 13 - 86

70

60

50

40 35
Percentage
30 (%)

20

10 6.3

0
≤ 19 20 - 39 ≥ 40

Age group

Figure 3.1 Distribution of patient’s age

Comment:
- The incidence of patients aged 20 – 39 years old is highest with
58.7% of total patients, followed by age group of ≥ 40 is 35.0% and age
group ≤ 19 accounted for the lowest rate of 6.3%.
- The average age of patients is 35.7 ± 13.1 years old, ranged from 13
to 86 years old.
 Chưa hành kinh; 1
Tiền mãn kinh, mãn kinh; 24

Còn kinh; 75

Figure 3.2. Menstrual status of patient

Comment:
- Most patients having period accounted for 75.8%, significantly
higher than that of premenopausal and menopause patients with 23.7%,
especially there is only 1 prepubertal patient accounted for 0.5%.

Table 3.1. Relationship between patient delay and patient’s age distribution

Patient delay (months) ≤3 >3

p
Age groups n % n %
≤ 19 10 76.9 3 23.1
20 – 39 79 65.3 42 34.7
≥ 40 48 66.7 24 33.3 >
Total 137 66.5 69 33.5
0.05
X ± SD 20.7 ± 15.3
min – max 1 – 120

Comment:
- 137 (66.5%) patients delayed less than or equal to 3 months and
33.5% of total patients delayed more than 3 months.
 - The mean patient delay in months is 20.7 ± 15.3 and ranged is 1 – 120
months.
- The percentage of patient aged 20 – 39 years old delayed more than 3
months is 34.7% higher than that in the other age groups, and the figure
for patients aged 19 or less delay ≤ 3 months is highest (76.9%),
however, the difference has non-statistical significance (p > 0.05).

3.2. The clinical characteristics and histopathological results of subjects

3.2.1. The clinical characteristics

Palpable neighboring node 11

Overlying breast skin changes 2

Breast deformation 1

Signs and symptoms

Abnormal nipple discharge 5

Self-palpable breast mass 190

Breast pain 62

0 20 40 60 80 100 120 140 160 180 200

Cases

Figure 3.3. Frequency of popular signs and symptoms of breast mass

Comment:
- Self-palpable breast mass is the most common symptom, accounting
for 92.2%, followed by breast pain accounting for 30.1%.
 - Symptoms are less frequency such as palpable neighboring lymph
nodes (5.3%), abnormal nipple discharge (2.4%), overlying breast skin
changes (1%), breast deformation (0.5%).

1 mass
20%

Left-sided breast
45% Right-sided
breast
55%

2 masses
80%

Figure 3.4. Number of mass and distribution of mass by sides

Comment:
- Most patients have 1 mass accounted for 79.6% and only 42 patients
(20.4%) have 2 masses.
- The proportion of mass in right breast is slightly higher than left
breast with 55.3% and 44.7% respectively.
 Table 3.2. Relationship between distribution of mass
by breast quadrants and by sides

Breast sides Right breast Left breast Total

n % n % n %
Breast quadrants
Upper outer quadrants (UOQ) 66 48.2 51 45.9 117 47.2
Upper inner quadrants (UIQ) 32 23.4 31 27.9 63 25.4
Lower inner quadrants (LIQ) 12 8.8 11 9.9 23 9.3
Lower outer quadrants (LOQ) 14 10.2 7 6.3 21 8.5
Central region 13 9.4 11 9.8 24 9.6
p > 0.05

Comment:
- Mass located higher in the UOQ accounted for 47.2% compared to the
UIQ (25.4%), LIQ (9.3%), central (9.6%), or LOQ (8.5%).
- The proportion of mass in UOQ in the right breast is slightly higher
than that in the left breast with 48.2% and 45.9%, respectively.
However, the difference has non-statistical significance (p > 0.05).

X±SD = 1.8 ± 0.9, min - max = 1 - 6

90 85.1
80
70
60
50
Percentage
40 (%)
30
20 13.7
10 1.2
0
≤2 Size of
2 -mass
≤5 >5
(cm)

Figure 3.5. Size of mass

Comment:
- The average size of mass is 1.8 ± 0.9 (cm), ranged from 1 to 6 (cm)
 - Most masses is 2 (cm) or less in size accounted for 85.1%,
particularly there are 3 cases (1.2%) having mass which greater than 5
(cm).

3.2.2. The results of breast mass histopathology

Có mô ung thư
7%

Không có mô ung thư

93%
 Figure 3.6. The results of breast mass histopathology
Comment: 230 masses are benign at 92.7% and the other 18 masses are
malignant (7.3%).
Table 3.3. Relationship between histopathological results and patient’s age
Histopathological Breast
Benign mass 95%
result cancer OR p
CI
Age group n % n %
≥ 40 15 20.8 57 79.2 3.8 – <
17.3
< 40 2 1.5 132 98.5 78.4 0.001

Comment:
- The breast cancer rates of patients in the age group of 40 or more is
14 times higher than that of patients in the age group under 40
accounted for 20.8% and 1.5% respectively (p <0.001).
- The risk of breast cancer of patients aged 40 or more is 17.3 times as
much as that of its counterpart.
- The difference has a statistical significant, OR = 17.3, 95%CI: 3.8 –
78.4, p < 0.001.
Table 3.4. Relationship between histopathological results
and patient delay
Histopathological Breast Benign
result cancer mass
OR 95%CI p
Patient delay
n % n %
(months)
>3 8 11.6 61 88.4 <
1.865 1,2 - 5.1
≤3 9 6.6 128 93.4 0.05
Comment:
- The breast cancer rate of patients delayed more than 3 months is 2
times higher than that of patients delayed less than 3 months or equal (p
< 0.05).
- Patient delay more than 3 months increase 1.8 times more chances of
getting breast cancer than patient delay less than 3 months or equal
- The difference has a statistical significant, OR = 1.8, 95%CI: 1.2 –
5.0, p < 0.001.

Table 3.5. Relationship between histopathological results

 and some clinical signs and symptoms
Histopathological Breast
Benign mass
results cancer
OR 95%CI p
Signs and
n % n %
symptoms
0.7 – >
Breast pain 7 11.3 55 88.7 1.7
4.7 0.05
Abnormal nipple 1.3 – <
2 40 3 60 8.2
discharge 53.3 0.05
Breast deformation 0 0 1 0 _ _ _
Overlying skin
2 100 0 0 _ _ _
changes
Palpable neighboring 5.3 – <
6 54.5 5 45.5 20.0
nodes 76.1 0.001
Comment:
- There is a statistically significant relationship between breast cancer
and signs: nipple discharge and palpable neighboring nodes. In
contrast, breast cancer isn't associated with breast pain, breast
deformation and overlying skin changes (p > 0.05).
- The breast cancer risk of patients with palpable neighboring lymph
nodes is 20 times higher than the patients without lymph nodes (OR =
20. 95%CI = 5.3 – 76.1, p <0.001).
- The patients with abnormal nipple discharge increase 8 times more
chances of breast cancer than the patients without that sign (OR = 8.2,
95%CI = 1.3 – 53.3, p < 0.05).
- The patients with breast pain increase 1.7 times more chances of
breast cancer than the patients without that sign, however difference
has a non-statistical significant, OR = 1.7, 95%CI = 0.7 – 4.7, p > 0.05.
- 100% of patients having overlying skin changes have breast cancer
 Table 3.6. Relationship between histopathological results
and number of mass, distribution of mass by sides
Benign
Histopathological Breast
breast
results cancer OR 95%CI p
mass
Characteristics
n % n %
1 16 9.8 148 90.2 1.1 – <
Number of mass 4.8
2 1 2.4 41 97.6 8.7 0.05
Breast mass Right 12 8.8 125 91.2 0.6 – >
1.7
location by side Left 6 5.4 105 94.6 4.6 0.05
Comment:
- The breast cancer rate of patients having 1 breast mass is 4 times as
high as that of patients having 2 masses (p < 0.05).
- The risk of breast cancer of patients having 1 breast mass is 4.8 times
higher than that of patients having 2 masses (OR = 4.8, 95%CI = 1.1 –
8.7, p < 0.05).
- The rate of breast cancer in the right sided breast is 1.5 times higher
than that in the left sided breast, however, the difference has non-
statistical significance (p > 0.05).

Table 3.7. Relationship between histopathological results

and distribution of mass by breast quadrants
Histopathological Breast cancer Benign mass p

results
n % n %
Breast quadrants
UOQ 8 44.4 110 47.6 >
UIQ 6 33.3 57 24.8
LIQ 0 0 23 9.9 0.05
LOQ 3 16.7 18 7.8
 Central region 1 5.6 23 9.9
Total 18 100 231 100
Comment:
- Breast cancer location was higher in the UOQ (44.4%) compared to
the UIQ (33.3%), LOQ (16.7%), central region (5.6%), and there is no
case in LIQ. In UOQ, the percentage of breast cancer is slightly higher
than it of benign mass with 47.6% and 44.4% respectively. However,
the difference has non-statistical significance (p > 0.05).

Table 3.8. Relationship between the histopathological results

and the size of mass
Histopathological Breast cancer Benign mass
results p
n % n %
Size of mass (cm)
≤2 10 4.7 201 95.3
2-≤5 7 20.6 27 79.4
< 0.001
>5 1 33.3 2 66.7
Total 18 7.3 230 92.7
Comment:
- The rate of breast cancer increases gradually associated with the size
of mass (p <0.001). 4.7% 2 cm or less in size masses is malignant, and
that rates of 2 -5 cm masses and more than 5 cm masses are 20.6% and
33.3% respectively (p < 0.01).
3.3. The surgical methods and postoperative status of patient
 VABB; 4.9

Mổ mở; 95.1

Figure 3.7. Surgical methods

Comment: Most patients operated with open surgery is 95.1%, only 10
patients operated by US-guided VABB procedure accounted for 4.9%.

Table 3.9. Relationship between using postoperative analgesics

and surgical methods

Comment:
- The figure for patients treated with US-guided VABB procedure
using analgesics is 4 times lower than that with open surgery (p <
0.05).
- Surgery with US-guided VABB procedure have 16% risk of using
analgesics compared with open surgery (OR = 0.16, 95%CI = 0.02 –
1.29, p < 0.05)
 Table 3.10. Relationship between the results of histopathology
and early postoperative complications
Histopathological Breast Benign 95%
Total OR p
results cancer mass CI

n % n % n %
Complications
4.8 – <
Hematoma/bleeding 4 23.5 2 1.1 6 2.9 28.7
17.9 0.001
1– >
Seroma 0 0 1 0.5 1 0.5 1.0
1.1 0.05
2– <
Wound infection 3 17.6 3 1.6 6 2.9 13.2
7.2 0.001
Comment:
- 6 patients have hematoma and 6 patients have wound infection after surgery
with 2.9%. There is only 1 case have seroma accounted for 0.5%.
- The rate of hematoma in breast cancer patients is 23 times higher than it in
benign breast mass patients. Breast cancer patients have 28 times as much risk
of hematoma as patient with benign mass (OR = 28.7, 95%CI = 4.8 – 17.9, p
< 0.001).
- The rate of wound infection in breast cancer patients is 11 times higher than
it in benign breast mass patients. Breast cancer patients have 13 times as
much risk of wound infection as patient with benign mass (OR = 13.2, 95%CI
= 2.0 – 7.2, p < 0.001).
- There is no association between breast cancer and postoperative seroma
formation (p > 0.05).

Table 3.11. Relationship between early postoperative complications

 and the size, number of mass, surgical methods

Complications Wound
Hematoma Seroma
infection
Criteria n % p n % p n % p
Size of >2 0 0 > 0 0 > 0 0 >
mass (cm) ≤2 6 3.5 0.05 1 0.6 0.05 6 3.5 0.05
Number of 1 5 3.0 > 0 0 > 4 2.4 >
mass 2 1 2.4 0.05 1 2.4 0.05 2 4.8 0.05
US-
guided
0 0 0 0 1 10
Surgical VABB > > >
methods procedure 0.05 0.05 0.05
Open
6 3.1 1 0.5 5 2.6
surgery
Comment:
- The is no relationship between early postoperative complications and
the size, number of mass, surgical methods (p > 0.05).

Table 3.12. Relationship between surgical methods

and patient’s length of stay (LOS)
Surgical methods LOS (days) p
 min max X ± SD
US-guided VABB
2 5 3.8 ± 1.1
procedure > 0.05
Open surgery 1 41 6.3 ± 2.4
Comment:
- The average LOS of patients treated with open surgery is 3 days
higher than that of patients treated with US-guided VABB procedure.
- However, the difference has non-statistical significance (p > 0.05).
 Chapter 4
DISCUSSION
4.1. Discussion about the sociademographic characteristics of subjects
4.1.1. Distribution of patient’s age
According to our study, it can be seen obviously from the figure 3.1 that
breast mass can occur at all ages, most commonly in the age group of
reproductive ages from 20 to 39 years old, accounting for 58.7%, followed by
patients aged 40 years old or more with 35.0% and the least common in the
age group of 19 years old or less at 8.8%.
The average age of patient diagnosed breast mass in our study is 35.7 ±
13.1, the youngest patient is 13 years old, the oldest patient is 86 years old.
Compared with other studies in the world and in Vietnam, we have the
table 4.1 below which demonstrates that the average age of breast mass
patients is around 35 years old, so the results of our study about average age
is significantly similar to other studies.
The results of our study shown that breast mass are most common at
reproductive age from 20 to 39 years old, accounting for 58.7%. This is
completely consistent with the research results of the authors Nguyen Thu
Hang (51.5%), Rajendra Kumar (74.1%), Manisha Nigam (67%), Ha Lin Park
(58.2%) (p > 0.05).
 Table 4.1. The breast mass patient’s age in several studies
Distribution of
Place and
Sample age (%)
Authors time of X±SD
size 20 –
research ≤ 19 ≥ 40
39
Nguyen Thu Vietnam,
357 36.4 ± 5.2 8.8 51.5 39.7
Hang [11] 2004
Rajendra
Nepal, 2009 243 34.1 ± 3.8 11.1 74.1 14.8
Kumar [57]
Manisha
India, 2013 400 35.1 ± 12.0 7.5 67.0 25.5
Nigam[78]
Ha Lin Korea,
8748 37.8 ± 4.2 7.3 58.2 34.5
Park[46] 2018
Nguyen Thi Vietnam,
206 35.7 ± 13.1 6.3 58.7 35
Lan Oanh 2019
To explain these results, we believe that due to the imbalance between
the female hormones estrogen and progesterone during pregnancy of the
woman at reproductive age, and the disorders of these two hormones during
the premenopausal and menopausal period leads to changes in mammary
gland structure. These changes occurring in both epithelial tissues and stromal
tissues of breast resulted in benign mass formation and even proliferative
changes can sometimes transform into malignancy. A study of Templeman C
et al. carried on 1526 patients in Kentucky USA also shown that more than 50
percent of women of reproductive age have fibrocystic changes [31]. This
partly confirms our assumption to be correct.
In our study, there is particularly a case of 86-year-old patients
underwent breast surgery. We rarely witness a woman at the age of 86 years
old participated in an operation. Patients were diagnosed as 3 cm breast mass
in size and having breast pain, nipple discharge and lymphadenopathy. These
signs and symptoms made her uncomfortable and nervous. Perhaps because
of that reason, she agreed to undergo an lumpectomy. However, after
removing the mass an immediate biopsy was conducted. The
histopathological result was breast cancer so she had to suffer a mastectomy
and axillary lymphadenectomy. The postoperative status of the patient was
normal, and she left the hospital after 8 days to prepare for adjuvant treatment
involves radiation therapy and systemic therapy (including a variety of
chemotherapeutic, hormonal and biologic agents).
4.1.2. Menstrual status of patients
According to our results, most patients have period made up 75.8%,
significantly higher than that of patients with premenopausal and menopausal
status at 23.7%, especially there is only 1 prepubertal patient (0.5%).
There are several studies in the world and in Vietnam about the
menstrual status of patients undergoing breast mass is shown in the table 4.2
below compared with our results.
The results of our research are similar to the results of Nguyen Thi Ngoc
Thuy, Nguyen Thu Hang and Manisha Nigam showed that the percentage of
breast mass is highest in the group patients having period and decrease
gradually in the group of premenopausal, menopausal patients and
prepubertal patient (p > 0.05).

Table 4.2. The menstrual status of patients

Place and Sample Menstrual status (%)
Prepubety Having Pre-
Authors time of size
period menopause,
research
 menopause
N.T. Ngoc Vietnam,
357 0.9 88.0 11.1
Thuy [10] 2001
Nguyen Thu Vietnam,
351 0 88.2 11.8
Hang [11] 2004
Manisha India,
400 1.2 76.8 22.0
Nigam [78] 2013
N.T. Lan Vietnam,
206 0.5 75.8 23.7
Oanh 2019
Discussion about the case of prepubertal patient having breast mass: The
patient is 15 years old, has not had menstruation, detected breast mass about 1
month before the medical consultation, histopathologically diagnosed as
Phyllodes. It's a benign tumor which is common in adult women but we also
found a number of isolated cases that met at pre-pubertal age according to
other author's studies. The study of Paker SJ and Harries SA was conducted
in Taiwan in 2001 shown that a 10-year-old girl had Phyllodes [63], and
Pistolese CA et al. studied in UK (2009) witnessed a Phyllodes in 8-year-old
girl [64]. These are the particular cases that we need time to study more.
4.1.3. Relationship between patient delay and patient’s age group
Patient delay{V Arndt, 2002 #26} is defined as the duration of
symptoms in days before the first medical consultation[59]. In our research
(table 3.1), 137 (66.5%) patients delayed less than or equal to 3 months and
33.5% of total patients delayed more than 3 months. The mean of patient
delay in months is 20.7 ± 15.3 and ranged is 1 – 120 months.
The result of our research is not similar to that of Nguyen Thu Hang’s
research (conducted in Vietnam, in 2004, n = 351) [11] found that more than
½ of the total patients delayed over 3 months (p < 0.05). The difference can
be explained that perhaps, at the time of our study, the awareness of the
dangers of breast cancer was enhanced, Vietnamese woman were aware of the
signs and symptoms of breast cancer so they came to see doctors earlier.
The proportions of patient delay under 3 months or equal in our research
is less than its in study of V Arndt, T Stürmer et al (studied in Germany,
2001, n = 287) [59] (p > 0.05) showed that there are 5/6 patients had short
delay under or equal to 3 months. It’s probably at that moment, Germany was
the developed countries had a qualified education system and also because of
the developed economics, so German women were fully aware of breast
cancer resulted in shortening patient delay.
The mean patient delay in months is 20.7 ± 15.3 and ranged is 1 – 120
months, there are particular patients went to hospital over 10 years after
having first symptoms because of several personal reasons. To explain about
the patient delay, we assumed that the symptoms and signs of breast mass are
poorly manifest with small mass in size, rarely pain. Patients didn't pay
attention to it until having another signs such as breast pain, palpable
neighboring lymph nodes, abnormal nipple discharge, overlying breast skin
changes or breast deformation.
According to the study results of V Arndt, T Stürmer et al. (studied in
Germany, 2001, n = 287) [59] shown that a bivariate analysis indicated a
strong association between age and patient delay. In general, older women (>
60 years old) waited longer than younger women before presenting their
symptoms to a physician (p = 0.01). However, we found that there was non-
statistical significance of the difference between the patient delay and the
patient's age, possibly due to the small sample size and the proportion of
patients > 60 years old was less.
4.2. Discussion about the clinical characteristics and histopathological
results of subjects
4.2.1. Clinical signs and symptoms
Based on the figure 3.3, we found that the self-palpable breast mass were
the most common symptom, accounting for 92.2%. This percentage,
according to the study of Manisha Nigam [78] (India, 2013, n = 400) is 96.5%
and reaches 100% in the research of Nguyen Thi Ngoc Thuy (Vietnam, 2001,
n = 357) [10]. This indicates that the self-palpable breast mass is the most
loyal symptom of the disease. Thus, breast self-examination plays a crucial
role in detecting breast mass.
It can be seen from the figure 3.3, breast pain is the second common
symptom after self-palpable breast mass. The frequency of breast pain in our
research is 62/206 patients (30.1%).This may be a symptom that makes the
patients uncomfortable and anxious. It can be the most popular reason leads
patient come to see doctors, even with patients having breast mass for a long
time. Comparison to other studies, the rate of our breast pain patients is much
higher than that in studies of Nguyen Thu Hang (3.8%) [11] and Manisha
Nigam (3%) [78] (p < 0.05). Breast pain can be seen in both benign and
malignant masses will be discussed later.
Other symptoms are less frequency such as palpable neighboring lymph
nodes (5.3%), abnormal nipple discharge (2.4%), overlying breast skin
changes (1%), breast deformation (0.5%). These outcome is equal to the result
of Manisha Nigam [78] (India, 2013, n = 400) shown that the palpable
neighboring lymph nodes (3 %), abnormal nipple discharge, overlying breast
skin changes and breast deformation (0.5 – 1.5%) (p > 0.05). It confirms that
the clinical presentation of a breast mass is variable. Some masses are
detected on a patient's self-breast examination while others are found on a
routine clinical breast examination but mass always is the most important
symptom in the disease. Other symptoms and signs are insignificant.
4.2.2. Number and the size of mass
As our results from figure 3.4, breast mass disease usually has only 1
mass with 79.6% of total patients and only 42 patients (20.4%) have 2
masses. The study of Shah Ta et al. was conducted in Nepal in 2013 found
that out of 21 mass cases detected, 17 (80.9%) respondents had a single mass
while 4(19.1%) had multiple breast masses [65]. This result is significantly
consistent with ours (p > 0.05).
The figure 3.5 shows that in our study, the average size of mass is 1.8 ±
0.9 (cm). The proportion of mass being 2 cm or less in size accounted for
85.1%, particularly there are 3 cases (1.2%) having mass which greater than 5
(cm). These are expected numbers. Most patients diagnosed as breast mass
when the mass size is small. There are only 3 cases coming to see doctors
when the size of mass is over 5 cm but not exceed 6cm. Surveying these case,
we found that the clinical symptom was only self-palpable mass without pain
or nipple discharge. Thus, these patients did not pay attention to it until the
size of the mass increase significantly made them nervous and went to
hospital to examine. It proves that the symptoms and signs of breast mass are
poorly and insignificant.

4.2.3. Distribution of mass by side and by breast quadrants

According to our study, it’s obviously seen that the frequency of breast
mass on the right side is slightly higher than that on the left is 55.3% and
44.7% respectively. To compare with the results of several studies, we have
the table 4.3. All our studies agree that breast mass is more popular in the
right side than in the left, but the difference is not significant (p > 0.05). We
also read other documents published about the distribution of breast mass by
side assumed that slightly more breast tumors are diagnosed in the left breast
than the right [66],[67]. Possible explanations have included the left breast is
slightly larger than the right[68] , breast feeding preferentially on the right
breast protects from cancer  , and that right handed women check the left
breast for lumps more often[69]. But these explanations need further
investigation.
Table 3.2 shows that the percentage of mass located higher in the UOQ
accounted to 47.2% compared to the UIQ (25.4%), LIQ (9.3%), central
(9.6%), or LOQ (8.5%). These results are entirely consistent with the results
of Manisha Nigam (India, 2013, n = 400) (p > 0.05) [78] that upper and outer
quadrant was the most common quadrant involved in the studied patients
(48%), whereas central zone of breast was least involved (11%) in the studied
patients. Our outcome is also similar to it of Seth Rummel et al. (USA, 2015,
n = 980) [70] that mass located higher in the UOQ (51.5%) compared to the
UIQ (15.6%), lower outer quadrant (LOQ, 14.2%), central (10.6%), or LIQ
(8.1%) (p > 0.05).
 Table 4.3. The distribution of mass by side
Distribution of mass by
Place and
Sample side
Authors time of
size Right-sided Left-sided
research
breast breast
Nguyen Thi Ngoc Vietnam,
357 50.1 49.9
Thuy [10] 2001
Nepal,
Rajendra Kumar [57] 243 51.4 42.8
2009
India,
Manisha Nigam [78] 400 58.5 42.5
2013
Nguyen Thi Lan Vietnam,
206 55.3 44.7
Oanh 2019

We think that perhaps due to the histological anatomy of the mammary

gland mainly distributed in UOQ (45-55%) [24]. Therefore, breast tissue
changes are also concentrated in this position. That explains why the results
of our research is consistent with many studies in the world that the most
common breast tumor in UOQ of breast.
We also found that breast masses are more common in UOQ on the right
than on the left, but this difference is not statistically significant. This result is
also consistent with the conclusion of Rumi Khajotia (Malaysia, 2014): The
tumour is more common in the upper and outer quadrant of the breast but has
no predilection for side[71]. This is also reasonable with our results that the
difference between the frequencies of breast mass in right breast and left
breast is no significant.
4.2.4. Histopathological results
Most breast masses are benign [33],[34]. Approximately 90 percent or
more of breast masses in women in their 20s to early 50s are benign [35].
According to the histopathological results of our study, we find that most
masses are benign at 92.7% is much higher than the percentage of malignant
masses (7.3%). Comparison to other studies in the world and in Vietnam, we
have table 4.4.
The table 4.4 shows that the results of our research are similar to that of
Manisha Nigam, Rajendra Kumar (p > 0.05) but there is a difference with the
results of Nguyen Thu Hang and Vladimir Egorov (p < 0.05).
We assume this difference is due to our research conducted at the
hospital of Obstetrics and Gynecology, not specialized in Oncology.
Moreover, in Haiphong there are many oncology centers such as at Vietiep
hospital, which has many experiences in screening, classification and
treatment of breast cancer. Therefore, the number of breast cancer patients
whom we studied is only a small of total breast cancer patients treated in
Haiphong, thus the rate of breast cancer in our study is lower than 2 studies of
Nguyen Thu Hang and Vladimir Egorov. However, our research is still
consistent with other studies that patients with benign breast tumors still
account for a large proportion of the total research patients.
 Table 4.4. The results of histopathology of breast mass
Histopathological
Place and
Sample results (%)
time of
Authors size Benign Breast
research
breast mass cancer
Vietnam,
Nguyen Thu Hang [11] 351 78.3 21.7
2004
USA,
Vladimir Egorov [54] 179 82.1 17.9
2009
India,
Manisha Nigam [78] 400 93.0 7.0
2013
Nepal,
Rajendra Kumar [57] 243 93.6 7.4
2010
Vietnam,
Nguyen Thi Lan Oanh 206 92.7 7.3
2019

4.2.5. Relationship between histopathological results and patient’s age,

patient delay
There is a noticeable association between breast cancer and patient’s age.
According to our study (table 3.3), the breast cancer rates of patients in the
age group of 40 or more is 14 times higher than that of patients in the age
group under 40 accounted to 20.8% and 1.5% respectively (p <0.001). The
risk of breast cancer of patients aged 40 or more is 17.3 times as much as that
of its counterpart (OR = 17.3, 95%CI: 3.8 – 78.4, p < 0.001). This result is
consistent with the results of Zosia Kmietowicz (OR = 15.2, 95%CI = 2.7 –
9.3, p < 0.01) [72]. The guideline of NICE (National Institute for Health and
Care excellence) in England that women aged over 40 years who are at
increased risk of developing breast cancer so they should be offered annual
mammography [73]. Scott Klarenbach et al. [74] published the
recommendations on screening for breast cancer in women aged 40–74 years
who are not at increased risk for breast cancer. It confirmed our results is
completely consistent with those results and recommendations.
To explain about this result, we assumed that pre-menopause and
menopause, after 40 years of age, is the period when the mammary gland
begins to changes in the structure of both connective tissue and mammary
gland, and the mammary epithelium cell is sensitive with the pathological
change in cell genesis process so it is easy to develop into cancer cells
[12,13,14].
From table 3.4, we found that the breast cancer rate of patients delayed
more than 3 months is 2 times higher than that of patients delayed less than 3
months or equal (p < 0.05). Patient delay more than 3 months increase 1.8
times more chances of getting breast cancer than patient delay less than 3
months or equal. Thus, the patient delay over 3 months is a risk factor of
breast cancer. (OR = 1.8, 95%CI: 1.2 - 5.0, p < 0.001). According to the
Vietnamese Cancer Society's document, 3 months is the average time for
double breast cancerous cells [15]. A cancerous cell to achieve a 1cm size
tumor must be doubled continuously 30 times in 7-8 years, benign breast
tumors are also progressively unpredictable, when micro changes in structures
increase the risk of breast cancer [3,5]. Therefore, the later patient delayed to
examine, the higher they are at risk of breast cancer.
4.2.6. Relationship between histopathological results and clinical signs
and symptoms
Based on the table 3.5, we find out that there is a statistically significant
relationship between breast cancer and signs: nipple discharge and palpable
neighboring nodes. In contrast, breast cancer isn't associated with breast pain,
breast deformation and overlying skin changes.
In our study, the patients with breast pain increase 1.7 times more
chances of breast cancer than the patients without that sign, however
difference has a non-statistical significant (OR = 1.7, 95%CI = 0.7 – 4.7, p >
0.05). Breast pain is not common symptom in both benign and malignant
breast mass. In benign mass the pain possibly caused by large tumors that
press to surrounding tissues and neurons, but in breast cancer it seems to
occur in a progressive breast cancer [8].
Two symptoms that have remarkable association with breast cancer in
our study are nipple discharge and palpable neighboring lymph nodes. The
breast cancer risk of patients with palpable neighboring lymph nodes is 20
times higher than the patients without lymph nodes (OR = 20. 95%CI = 5.3 –
76.1, p <0.001). Palpable neighboring lymph node is a warning sign of lymph
nodes metastasis in breast cancer. Therefore, any patient having this sign
(axillary lymph nodes, supraclavicular lymph nodes...) needs to be examined
early and be alert to breast cancer. The patients with abnormal nipple
discharge increase 8 times more chances of breast cancer than the patients
without that sign (OR = 8.2, 95%CI = 1.3 – 53.3, p < 0.05). However, the
abnormal nipple discharge is rare and non-specific to breast cancer [8]. 2/17
case in our study having this sign accounted for 11.7% which is similar to
14/98 patients (14.3%) have nipple discharge in study of Nguyen Thi Ngoc
Thuy conducted in 2001 with the sample size = 357 patients [10] (p > 0.05).
 Other signs such as breast deformation, overlying breast skin changes are
very rare in both benign breast and breast cancer. There is only 1 breast
deformation encountered in patients with benign breast mass in lower outer
quadrant, the mass size is 6cm making the left breast larger than the right
breast. Overlying skin changes may occur in large fibroadenomas, phyllodes
tumors (the skin is shiny and stretched from rapid growth), and in breast
cancer (peel orange, puckering, dimpling, a rash, or redness of the skin of the
breast retraction) [30]. 100% patients in our study have breast skin changes
diagnosed as breast cancer. It caused by the skin invasion of cancerous cells.
Benign breast mass rarely have this sign [11].
4.2.7. Relationship between the histopathological results and the number
and the size of mass
The table 3.6 demonstrates the risk of breast cancer of patients having 1
breast mass is 4.8 times higher than that of patients having 2 masses (OR =
4.8, 95%CI = 1.1 – 8.7, p < 0.05).
From the table 3.8, the rate of breast cancer increases respectively with
tumor size, which is statistically significant. The rate of masses being 2 cm or
less in size is malignant accounted for 4.7%, and that rates of 2 -5 cm masses
and more than 5 cm masses are 20.6% and 33.3% respectively (p < 0.01).
Thus, according to our research, the greater tumor is, the more malignant it
can be and contrast. But our hypothesis needs to study more.
4.2.8. The relationship between the histopathological results and the
distribution of mass by side and by breast quadrants
Studying about the link between breast cancer and mass location by side,
we found that the rate of breast cancer in the right side is 1.5 times higher
than that in the left side, however, the difference has non-statistical
significance (p > 0.05). The result is resemble Magid H Amer (USA, 2014, n
= 1520) [79], 50.9% patients presented with left breast cancer, 46.1% with
right breast cancer, and 3.0% with simultaneous bilateral malignancy but
there were no significant differences between the three groups (p > 0.05).
About the distribution of breast cancer by breast quadrant in our study, it
can be seen that breast cancer location was higher in the UOQ (44.4%)
compared to the UIQ (33.3%), LOQ (16.7%), central region (5.6%), and
there is no case in LIQ. Comparison to other results of Nguyen Thi Ngoc
Thuy (2001, n = 357) [10], Sohn VY (2008, n = 425) [80], they all had the
same outcome that breast cancer occurring commonly in UOQ at 57% and
58% respectively.
In UOQ, the percentage of breast cancer is slightly higher than it of
benign mass with 47.6% and 44.4% respectively. But the difference has non-
statistical significance (p > 0.05). To explain these results, we think that
perhaps due to the histological anatomy of the mammary gland mainly
distributed in UOQ (45-55%) [24]. Therefore, breast tissue changes are also
concentrated in this position leads to both benign tumor and breast cancer.
4.3. Discussion about surgical methods, early postoperative complications
and length of stay
Ultrasound-guided vacuum-assisted breast biopsy (VABB) has been
recently regarded as a feasible, effective, minimally invasive and safe method
for removal of benign breast lesions without serious complications [81]. It can
be seen obviously in figure 3.7, most patients operated with open surgery is
95.1%, only 10 patients operated by US-guided VABB procedure accounted
to 4.9%. Perhaps because the US-guided VABB procedure was a new
technique applied in recent months so the number of patients operated by this
technique was small and with the patients diagnosed breast cancer indicated
open surgery.
 Based on the table 3.9, 81/206 patients using analgesics after surgery
accounted for 39.3%, which links to the results of Karamarie Fecho (USA,
2009, n = 485) [82] that nearly 30% of breast surgery patients experience
severe acute postoperative pain, with incidence rates increasing with surgical
complexity and research results by Ahmed Bakir (2016), the number of
patients suffering postoperative pain accounted for nearly 40%. In 81 patients
using analgesics, there is only 1 patient operated by US-guided VABB
procedure. We found that the figure for patients treated with US-guided
VABB procedure using analgesics is 4 times lower than that with open
surgery (p < 0.05). It is possible that the US-guided VABB procedure is a
minimally invasive method which has a lot of advantages compared to open
surgery in the table 4.5.
Table 4.5. Comparison between open surgery and Ultrasound-guided
VABB procedure [83]
US-guided VABB
FEATURES Open surgery
procedure
Probe gently vacuum. Cuts Surgeons create a larger
and removes breast tissue DESCRIPTION incision to remove
through a tiny incision breast tissue
¼ inches INCISION SIZE 1 – 2 inches
Minimal SCARRING Large
INCISION
Adhesive bandage Stitches and bandage
CLOSURE
Immediate RECOVER TIME Few hours
Surgery with US-guided VABB procedure have 16% risk of using
analgesics compared with open surgery (OR = 0.16, 95%CI = 0.02 – 1.29, p < 0.05).
Early complication after surgery: Because breast is a peripheral soft
tissue organ, many wound complications related to breast procedures are
relatively minor and frequently are managed on an outpatient basis. It
therefore is difficult to establish accurate incidence rates for these events [47].
The nonspecific complications: postoperative pain, wound infections, seroma
formation, hematoma.
The number of patients experiencing complications after surgery is
very small, only 13/206 patients, in those 6 patients have hematoma and 6
patients have wound infection after surgery with 2.9%. There is only 1 case
having seroma accounted for 0.5% (table 3.10). This result coincides with the
document of Angelique F. Vitug [47] that having 1 - 20% wound infection, 2
– 10% hematoma, and seroma is rarely common in breast cancer surgery (p >
0.05). May be because breast is a peripheral soft tissue organ, many wound
complications related to breast procedures are relatively minor[47]. In our
study, the rate of hematoma in breast cancer patients is 23 times higher than it
in benign breast mass patients. Breast cancer patients have 28 times as much
risk of hematoma as patient with benign mass (OR = 28.7, 95%CI = 4.8 –
17.9, p < 0.001). The rate of wound infection in breast cancer patients is 11
times higher than it in benign breast mass patients. Breast cancer patients
have 13 times as much risk of wound infection as patient with benign mass
(OR = 13.2, 95%CI = 2.0 – 7.2, p < 0.001). This may be due to breast cancer
surgery method, which contains mastectomy, lymphadenopathy, and other
invasive procedures so it is easy to have complications. We also find that
there is no relationship between early postoperative complications and the
size, number of mass, surgical methods (p > 0.05), possibly because our
sample size is too small, only 13 cases have complications.
Regarding to the LOS of patient (table 3.12) we find out that the
average LOS of patients treated with open surgery is 3 days higher than that
of patients treated with US-guided VABB procedure. However, the difference
has non-statistical significance (p > 0.05) perhaps because of few quantities of
patients underwent US-guided VABB procedure.

CONCLUSION
1. The clinical characteristics
- Breast mass is most commonly in age group from 20 to 39 years old
(58.7%), followed by age ≥ 40 (35.0%) and ≤ 19 (8.8%).
- 66.5% of patients delayed ≤ 3 months and 33.5% of all delayed > 3 months.
- The self-palpable breast mass were the most common symptom (92.2%)
followed by breast pain (30.1%).
- Most patients have 1 tumor (79.6%) most mass is ≤ 2 cm in size (85.1%).
- Mass located slightly higher in the right breast (55.3%) than the left side
(44.7%) and more common in the UOQ (47.2%), followed by UIQ (25.4%),
LIQ (9.3%), central (9.6%), or LOQ (8.5%).
2. The results of breast mass histopathology
- 92.7% of masses are benign and the other are malignant .
- The rate of breast cancer increases gradually associated with the mass size.
- The factors rising risks of breast cancer are age ≥ 40 years old, patient delay
> 3 months, having 1 mass, palpable neighboring lymph nodes and nipple
discharge. Breast pain, distribution of mass by side and quadrants is no
associated with breast cancer.
3. The surgical methods and postoperative status of patient
- 95.1% of patients operated with open surgery, 4.9% the other patients
operated by US-guided VABB procedure.
- Surgery with US-guided VABB procedure reduces using analgesics.
- 13/206 patients experiencing postoperative complications such as hematoma
(2.9%),wound infection (2.9%) and seroma (0.5%).
- Breast cancer increases risk of hematoma and wound infection after surgery.

PROPOSAL
After the study, we have the following proposal:
- Women at age ≥ 40 years old who have a breast mass, palpable neighboring
lymph nodes and nipple discharge should shorten patient delay and should be
screened early for breast cancer.
- Surgery with US-guided VABB procedure may have some benefits such as
reducing using postoperative analgesics and complication, shortening the
length of stay. In the future, we need to study more about this new technique.
 REFERENCES
Vietnamese references
1. Đinh Thế Mỹ (2000), Lâm sàng sản phụ khoa, "Các bệnh lành tính ở
vú" và "Ung thư vú", Nhà xuất bản y học Hà Nội, 409 - 414 và 415 -
428
2. Trần Văn Thuận, Nguyễn Bá Đức (2003), "Kết quả điều trị nội tiết bổ
trợ nên bệnh nhân ung thư vú tiền mãn kinh giai đoạn II, III có thụ thể
Estrogen (+)", Kỷ yếu công trình nghiên cứu khoa học lần thứ 3 tại
Cần Thơ. Số đặc biệt chuyên đề ung bướu học, 107 - 111.
3. Hiệp hội Ung thư Quốc tế - UICC (1999), Ung thư học lâm sàng, Nhà
xuất bản Y học, 405 - 431
4. Nguyễn Đức Hinh Dương Thị Cương (1999), Bệnh lý tuyến vú, Phụ
khoa dành cho thầy thuốc thực hành, Nhà xuất bản Đại học Y Hà Nội,
119 - 211.
5. Nguyễn Bá Đức và cộng sự (2003), Bệnh ung thư vú Nhà xuất bản Y
học Hà Nội, 1 - 461.
6. Trịnh Văn Minh (2013), Giải phẫu người - Giải phẫu ngực - bụng, Tập
II, Nhà xuất bản giáo dục Việt Nam, 629
7. Bộ môn Phụ Sản ĐHYD Hải Phòng (2018), Tài liệu giảng dạy sản phụ
khoa, Tập 2, Tài liệu lưu hành nội bộ, 302.
8. Nguyễn Lam Hòa (2016), Ung bướu học, Ung thư vú, ed, Trường Đại
học Y Dược Hải Phòng, 73 - 85.
9. Lâm Văn Tiên (2001), Đánh giá thực trạng bệnh u vú và khả năng tái
phát bệnh ung thư vú sau điều trị tại bệnh viện Đa Khoa Trung ương
Thái Nguyên, Luận án thạc sý Y học, Trường Đại học Y Hà Nội, 1 - 69
10. Nguyễn Thị Ngọc Thủy (2001), Nhận xét về đặc điểm lâm sàng - cận
lâm sàng của một số u vú điều trị tại bệnh viện bảo vệ bà mẹ và trẻ sơ
sinh 1996 - 2000, Luận văn tốt nghiệp chuyên khoa cấp II, Đại học Y
Hà Nội.
11. Nguyễn Thu Hằng (2004), Nghiên cứu tình hình chẩn đoán và điều trị
u vú tại viện Bảo vệ bà mẹ và trẻ sơ sinh trong 5 năm (1999 -2003),
Luận văn tốt nghiệp bác sỹ chuyên khoa cấp II, Đại học Y Hà Nội, 57 -
58.
12. Hoàng Mạnh Hùng (1999), "Thay đổi vi thể có thể làm tăng nguy cơ
Ung thư vú", Tin từ BMJ 20/2/1999.
13. Đỗ Kính (1994), Bài giảng mô học và phôi thai học, Vú, Nhà xuất bản
Y học Hà Nội, 236 - 238.
14. Trương Đình Kiệt (1998), Bài giảng mô học, Tuyến vú, Trường Đại
học Y Dược Thành phố Hồ Chí Minh, 448 - 452.
15. Hội Ung thư Việt Nam (1993), Ghi nhận ung thư Hà Nội 1993, Bệnh
viện K.

English references
16. José Rafael; Fregnani Macéa, José Humberto Tavares Guerreiro
(2006), "Anatomy of the Thoracic Wall, Axilla and Breast",
International Journal of Morphology. 24, 4.
17. V. Suzanne Klimberg Kirby I. Bland, Edward M. Copeland III,
William J. Gradishar (2018), The breast: comprehensive management
of benign and malignant diseases, 5th, Elsevier, Philadelphia, USA,
164, 4358.
18. Susan M. Love (2015), Dr. Susan Love's Breast Book, 6th, ed, Da Capo
Press, U.S.A.
19. Richard L.; Vogl Drake, Wayne; Tibbitts, Adam W.M. Mitchell (2005),
Gray's anatomy for students, Richard Richardson, Paul. Philadelphia:
Elsevier/Churchill Livingstone, USA.
20. John Hansen (2010), Netter's clinical anatomy, Saunders/Elsevier,
Philadelphia, USA.
21. Sébastien; Soussignan Doucet, Robert; Sagot, Paul; Schaal, Benoist
(2009), "The Secretion of Areolar (Montgomery's) Glands from
Lactating Women Elicits Selective, Unconditional Responses in
Neonates", PLoS ONE.
22. E. Menet J.M. Guinebretiere, A. Tardivon, P. Cherel, D. Vanel (2004),
"Normal and pathological breast, the histological basis", European
Journal of Radiology 54.
23. Wenting Zhu and Celeste M. Nelson (2013), "Adipose and mammary
epithelial tissue engineering", PubMed 3.
24. Barbara L. Hoffman at el (2016), Williams Gynaecology, 3rd ed,
Chapter 12: Breast disease, McGraw-Hill Education, 275 - 297.
25. Adam I. Riker (2015), Breast Disease Comprehensive Management,
Springer New York Heidelberg Dordrecht London.
26. Nieweg OE Estourgie SH, Olmos RA, Rutgers EJ, Kroon BB (2004),
"Lymphatic drainage patterns from the breast", Ann Surg. 239:232, 7.
27. Arthur C. Guyton John E. Hall (2016), Guyton and Hall Textbook of
Medical Physiology, 13th ed, Elsevier, Philadelphia, USA, 1096, 1067.
28. Morrow M. (2000), "The evaluation of common breast problems", Am
Fam Physician. 61:2371.
29. Mansel R.. Santen RJ (2005), "Benign breast disorders.", N Engl J
Med. 353:275.
30. Weldon C DiVasta AD, Labow BI. In: Emans, Laufer, Emans SJ.
( 2012), Goldstein's Pediatric & Adolescent Gynecology,, 6th, The
breast: Examination and lesions. , Laufer MR (Eds), Lippincott
Williams & Wilkins, Philadelphia, 405.
31. Hertweck SP. Templeman C (2000), "Breast disorders in the pediatric
and adolescent patient", Obstet Gynecol Clin North Am. 27, 19.
32. Mituś J Reinfuss M, Duda K, et al. (1996), "The treatment and
prognosis of patients with phyllodes tumor of the breast: an analysis of
170 cases.", Cancer Biology & Medicine. 77, 910.
33. Brem RF. Schoonjans JM (2001), "Fourteen-gauge
ultrasonographically guided large-core needle biopsy of breast masses",
J Ultrasound Med. 20, 967.
34. Klein S. . ( 2005), "Evaluation of palpable breast masses", Am Fam
Physician. 71, 1731.
35. Barton MB Elmore JG, Moceri VM, et al. (1998), "Ten-year risk of
false positive screening mammograms and clinical breast
examinations.", N Engl J Med. 338, 1089.
36. Momoh AO de Blacam C, Colakoglu S, et al. (2011), "Evaluation of
clinical outcomes and aesthetic results after autologous fat grafting for
contour deformities of the reconstructed breast", Plast Reconstr Surg
128, 441.
37. Yang WT. Erguvan-Dogan B (2006), " Direct injection of paraffin into
the breast: mammographic, sonographic, and MRI features of early
complications. ", AJR Am J Roentgenol. 186, 886.
38. Göransson M Lewin R, Elander A, et al.. (2014), " Risk factors for
complications after breast reduction surgery", J Plast Surg Hand Surg
28, 10.
39. Tong WM Wagner IJ, Halvorson EG. (2013), "A classification system
for fat necrosis in autologous breast reconstruction", Ann Plast Surg 70,
553.
40. Pavani Chalasani (2019), "Breast Cancer Treatment & Management",
Medscape, 12 (3), 1-12
41. Abdullah İğci Adnan Aydiner, Atilla Soran (2016), Breast Disease
Management and Therapies, Springer International Publishing
Switzerland, 45 - 60.
42. Xing Y Vo T, Meric-Bernstam F, Mirza N, Vlastos G, Symmans WF,
et al. (2007 ), "Long-term outcomes in patients with mucinous,
medullary, tubular, and invasive ductal carcinomas after lumpectomy",
Am J Surg. 194(3), 527 - 531.
43. Weerasinghe R Soot L, Wang L, Nelson HD. (2014), "Rates and
indications for surgical breast biopsies in a community-based health
system", Am J Surg. 207(4), 499-503.
44. Malich A Boehm T, Goldberg N et al. l. (2001), "Vacuum-assisted
resection of malignant tumors with and without subsequent
radiofrequency ablation: feasibility of complete tumor treatment tested
in an animal model", J Vasc Interv Radiol. 12, 1086 - 1093.
45. Lam HS Hung WK, Lau Y, et al. (2001), " Diagnostic accuracy of
vacuum-assisted biopsy device for image-detected breast lesions", ANZ
J Surg. 71, 457 - 460.
46. KA YOUNG KIM HAI-LIN PARK (2018), "Clinicopathological
Analysis of Ultrasound-guided Vacuum-assisted Breast Biopsy for the
Diagnosis and Treatment of Breast Disease", ANTICANCER
RESEARCH 38, 2455-2462.
47. MD Angelique F. Vitug, Lisa A. Newman, MD, MPH, FACS (2007),
"Complications in Breast Surgery", Surg Clin N Am. 87, 431-451.
48. Dr Ahmed Bakir (2016), "Postoperative pain control after breast
surgery", BMC 15- 20.
49. Sinnett D Gupta R, Carpenter R, et al. ( 2000), "Antibiotic prophylaxis
for post-operative wound infection in clean elective breast surgery.",
Eur J Surg Oncol 26(4), 363-366.
50. Zaleznik DF Platt R, Hopkins CC, et al. (1990), "Perioperative
antibiotic prophylaxis for herniorrhaphy and breast surgery", N Engl J
Med. 322(3), 153 - 160.
51. Langer S Tran CL, Broderick-Villa G, et al. ( 2003), "Does reoperation
predispose to postoperative wound infection in women undergoing
operation for breast cancer?", Am Surg. 69(10), 852-856.
52. FACS Michael S. Sabel MD (2009), Essentials of Breast Surgery,
Surgical Management of Primary Breast Cancer, Elsevier, 41 - 65.
53. Adwani A Pogson CJ, Ebbs SR. (2003), "Seroma following breast
cancer surgery", Eur J Surg Oncol. 29(9), 711-717.
54. Thomas Kearney Vladimir Egorov (2009), "Differentiation of benign
and malignant breast lesions by mechanical imaging", Breast cancer
research and treatment. 118(1), 67 - 80.
55. Jamie Eske (2019), "What does a lump in the left breast mean?",
Medical News Today.
56. Brem RF Schoonjans JM (2001), "Fourteen-gauge ultrasonographically
guided large-core needle biopsy of breast masses", J Ultrasound Med.
20, 967.
57. Rajendra Kumar (2010), "A Clinicopathologic Study of Breast Lumps
in Bhairahwa, Nepal", Asian Pacifc Journal of Cancer Prevention. 11,
855 - 858.
58. The American Heritage Stedman's Medical Dictionary (2002),
Definition of prepuberty, Houghton Mifflin Company, web
https://www.dictionary.com/browse/prepuberal.
59. T Stürmer V Arndt (2002), "Patient delay and stage of diagnosis among
breast cancer patients in Germany – a population based study", British
Journal of Cancer. 86(7), 1034 - 1040.
60. H. Xie, Chaussalet, T.J., Millard, P.H. (2015), "A continuous time
Markov model for the length of stay of elderly people in institutional
long-term care", Journal of the Royal Statistical Society, Series A.
168(1), 51 - 61.
61. Ke-Da Y. Jing Bao, Yi-Zhou Jiang (2014), "The Effect of Laterality
and Primary Tumor Site onCancer-Specific Mortality in Breast Cancer:
A SEERPopulation-Based Study", PLOS ONE. 9(4), 1 - 8
62. MD S.A. Narod, J. Iqbal (2013), "Are two-centimeter breast cancers
large or small?", Curr Oncol. 20(4), 205 - 211.
63. Harries SA Parker SJ (2001), "Phyllodes tumours. ", Postgrad Med J.
77, 428.
64. Tanga I Pistolese CA, Cossu E, et al. (2009), "A phyllodes tumor in a
child", J Pediatr Adolesc Gynecol 22(e21).
65. Shah Ta and Shrestha M (2004), "Prevalence of Breast Lump and Risk
Factors of Breast Cancer among Reproductive Aged Women of
Jabalpur VDC of Sunsari District, Nepal", Journal of Nepal Health
Research Council 2(1), 1 - 4
66. Clemmesen J . Busk TT (1947), "The frequencies of left- and right-
sided breast cancer.", Br J Cancer. 1, 345-351.
67. Putcha V Roychoudhuri R, Mller H (2006), "Cancer and laterality: a
study of the five major paired organs (uk", Cancer Causes Control. 17,
655-662.
68. Lipman RD. Trichopoulos D (1992), "Mammary gland mass and
breast cancer risk", Epidemiology. 3, 523-526.
69. Petrakis NL Ing R, Ho JH ((1977)), "Unilateral breast-feeding and
breast cancer.", Lancet 2, 124-127.
70. Matthew T Hueman Seth Rummel (2015), "Tumour location within the
breast: Does tumour site have prognostic ability?", ecancer. 9(552).
71. Rumi Khajotia (2014), "Unusually large breast tumour in a middle-
aged woman", Canadian Family Physician. 60(2), 142 - 146.
72. Zosia Kmietowicz (2004), "Women aged over 40 who are at increased
risk of breast cancer should get annual mammograms", The BMJ.
328(7455), 1515.
73. NICE Guidance (2006), Familial breast cancer, web
https://www.nice.org.uk/guidance/cg41.
74. Scott Klarenbach (2018), "Recommendations on screening for breast
cancer in women aged 40–74 years who are not at increased risk for
breast cancer", Cmaj. 190(49).
75. Ferlay J Bray F, Soerjomataram I, Siegel RL, Torre LA, Jemal A.
(2018), "GLOBOCAN estimates of incidence and mortality worldwide
for 36 cancers in 185 countries", CA Cancer J Clin.
76. Claudia Mello-Thoms Phuong Dung (Yun) Trieu, and Patrick C.
Brennan (2012), "Female breast cancer in Vietnam: a comparison
 across Asian specific regions", Cancer Biology & Medicine. 12(3), 238
- 245
77. MD Michael S Sabel (2018), " Clinical manifestations and diagnosis of
a palpable breast mass", Uptodate.
78. Dr.Brijendra Nigam Dr.Manisha Nigam (2013), "Triple Assessment of
Breast – Gold Standard in Mass Screening for Breast Cancer
Diagnosis", IOSR Journal of Dental and Medical Sciences. 7(3), 1 - 7
79. Magid H Amer ( 2014), "Genetic factors and breast cancer laterality",
Cancer Manag Res. 6, 191-203.
80. Sohn VY (2008), "Primary tumor location impacts breast cancer
survival.", Am J Surg. 195(5), 641-644.
81. N. Tagaya (2008), "Experience with ultrasonographically guided
vacuum-assisted resection of benign breast tumors". 63(Clinical
Radiology), 396 - 400.
82. PhD Karamarie Fecho, Natalie R. Miller (2009), "Acute and Persistent
Postoperative Pain after Breast Surgery", American Academy of Pain
Medicine. 10(4), 708 - 715.
83. Wenguang Liu Shaobo Pan1 ( 2014), "Ultrasound-guided vacuum-
assisted breast biopsy using Mammotome biopsy system for detection
of breast cancer: results from two high volume hospitals", Int J Clin
Exp Med. 7(1), 239-246.
 Appendix 1

INFORMATION COLLECTION FORM

Medical record code: ……………No: ……

1. Full name: .....................................................................................................
2. Age: ................................................................................................................
3. Address:..........................................................................................................
4. Hospitalized date: .........................................................................................
5. Surgical date:.................................................................................................
6. Hospital leaving date: ...................................................................................
7. Present menstrual status
1. Pre-puberty 2. Having period 3. Pre-menopause, menopause
8. Patient delay: ............................................ (month(s))
9. Clinical characteristics of breast mass
- Breast pain
1. Yes 2. No
- Breast mass after self-breast examination
1. Yes 2. No
- Abnormal nipple discharge
1. Yes 2. No
- Breast deformation:
1. Yes 2. No
- Overlying skin changes
1. Yes 2. No
- Number of mass: ……
- Size of mass: …………(centimeter(s))
- Location of masses:

1 2 2 1
5 5

4 3 3 4

Right sided Left sided

1. Upper outer quadrants (UOQ) 4. Lower outer quadrants (LOQ)
2. Lower inner quadrants (LIQ) 5. Central (CEN - Subareolar)
3. Lower inner quadrants (UIQ)
- Palpable neighboring lymph nodes
1. Yes 2. No
10. Results of histopathology
1. Benign 2. Breast cancer
11. Surgical method
1. Open surgery 2. US-guided VABB procedure
12. Using postoperative analgesics
1. Yes 2. No
13. Early postoperative complication
- Seroma
1. Yes 2. No
- Hematoma
1. Yes 2. No
- Wound infection
1. Yes 2. No
14. Length of stay: ………………. (day(s))
 Appendix 2

LIST OF PATIENTS
Medical
No Full name Age Adress
record code
1 Nguyen Thi L 50 Le Chan 6092
2 Cao Thi A 38 Le Chan 5042
3 Ta Thi Ngoc L 20 Ngo Quyen 4829
4 Pham Thi Ngoc A 20 Hong Bang 4541
5 Hoang Thi G 30 Kien An 2520
6 Do Thanh H 18 Ngo Quyen 2896
7 Pham Thi D 33 Le Chan 7660
8 Mac Thi Thanh X 19 Le Chan 7077
9 Pham Thuy Q 25 Ngo Quyen 6839
10 Tran Thanh M 48 Hong Bang 129
11 Bui Thi T 43 Hai An 18838
12 Vu Thi Thanh H 19 Kien An 20571
13 Vu Thi H 23 Le Chan 20509
14 Tran Thi M 50 Hai An 20421
15 Hoang Thuy M 42 Hong Bang 13982
16 Bui Thi K 26 Ngo Quyen 16562
17 Nguyen Thi Q 40 Ngo Quyen 15405
18 Nguyen Thi Bao T 23 Le Chan 13907
19 Vu Thi T 38 Ngo Quyen 3542
20 Tran Thi S 63 Ngo Quyen 3111
21 Tran Thi H 56 Le Chan 2614
22 Hoang Thi T 22 Hai An 17315
23 Nguyen Thi G 29 Hai An 19335
24 Tran Thanh H 43 Hong Bang 18802
25 Nguyen Thi H 23 Hong Bang 18556
26 Pham Thi L 43 Ngo Quyen 17916
27 Dinh Thi Bich H 44 Ngo Quyen 17471
28 Bui Thi T 43 Kien An 17348
29 Nguyen Thuy L 21 Kien An 17271
30 Nguyen Thi Thuy B 63 Hai An 6181
31 Dinh Thi H 27 An Duong 5703
32 Pham Thi H 30 An Duong 6348
33 To Thi Quynh T 28 Hong Bang 20553
34 Nguyen Thanh H 16 Ngo Quyen 23215
35 Pham Thi Minh Y 24 Ngo Quyen 23156
36 Nguyen Thi P 28 Le Chan 22732
37 Nguyen Thi H 33 Ngo Quyen 22512
38 Le Thi C 28 Ngo Quyen 22739
39 Do Hoai T 25 Ngo Quyen 22358
40 Luu Thi O 31 Kien An 21979
41 Nguyen Thi H 40 Kien An 21457
42 Pham Thi T 22 Hai An 21102
43 Vu Thi T 28 Hong Bang 21154
44 Mai Thuy L 15 Hong Bang 15106
45 Dam Thi N 37 Hai An 11896
46 Nguyen Thi L 28 Hai An 11862
47 Le Thi Thanh M 28 An Duong 14453
48 Do Thi H 40 An Duong 14132
49 Vu Thi Thuy D 35 Kien An 13465
50 Ngo Thi Da 43 Ngo Quyen 12243
51 Vu Thi D 45 Ngo Quyen 12265
52 Nguyen Thi T 42 Le Chan 12255
53 Pham Thi T 51 Le Chan 11523
54 Pham Thi Kim N 15 Hong Bang 12455
55 Ninh Thi M 27 Hong Bang 12046
56 Nguyen Thi H 38 Thuy Nguyen 11791
57 Nguyen Thi Tuyet N 43 Thuy Nguyen 11613
58 Nguyen Thi Q 46 Ngo Quyen 11754
59 Cao Thi Hoai T 21 Ngo Quyen 10775
60 Hoang Thi C 45 Kien An 10683
61 Vu Thi H 23 Kien An 10258
62 Tran Thi H 35 Kien An 9300
63 Pham Thi H 28 Le Chan 9704
64 Nguyen Thi H 24 Hai An 9738
65 To Thi Q 22 Hong Bang 7156
66 Mui Thi E 30 Hong Bang 6710
67 Le Thuy N 27 Ngo Quyen 23743
68 Pham Huyen T 23 Kien An 105
69 Ngo Thi T 40 An Duong 217
70 Pham Thi Thanh M 19 An Duong 1785
71 Nguyen Thi H 32 Ngo Quyen 1852
72 Nguyen Thi Anh T 46 Ngo Quyen 460
73 Nguyen Thi T 42 Kien An 3461
74 Vu Thi Thuy L 34 Le Chan 3862
75 Nguyen Thi V 64 Le Chan 3342
76 Vu Thi Thanh N 38 Le Chan 5485
77 Trinh Thi Minh N 21 Hai An 5993
78 Nguyen Thi T 68 Hai An 6622
79 Pham Thi Ngoc D 27 Hong Bang 6625
80 Nguyen Thi M 59 Ngo Quyen 6404
81 Vu Thi Kim L 49 Ngo Quyen 7129
82 Nguyen Thi S 56 Le Chan 5166
83 Dao Thi N 25 An Duong 6747
84 Dang Thi Hong H 38 An Duong 5453
85 Doan Thi H 39 Hong Bang 5487
86 Luong Thi C 62 Ngo Quyen 7640
87 Tran Thi C 74 Ngo Quyen 6821
88 Vu Thi Tuyet N 34 Hai An 8973
89 Pham Thi M 35 Hai An 9202
90 Tran Bich L 75 Le Chan 3691
91 Pham Thi Hong B 36 Kien An 6403
92 Nguyen Mai A 22 Hai An 10555
93 Do Thi Thuy D 33 Ngo Quyen 9685
94 Bui Thi Kim P 54 Hong Bang 9193
95 Dang Thi N 24 An Duong 9146
96 Phi Thi Thuy T 15 Thuy Nguyen 10336
97 Nguyen Thi X 62 Ngo Quyen 10242
98 Pham Thi Mai T 40 Ngo Quyen 11873
99 Tran Thi H 51 Ngo Quyen 12855
100 Ngo Thi H 25 Ngo Quyen 11105
101 Do Thi T 60 Le Chan 11946
102 Do Thi Ng 43 Le Chan 11870
103 Dang Thi T 29 Hong Bang 13292
104 Vu Thi Huyen T 27 Hai An 13432
105 Pham Thi D 49 Kien An 11107
106 Pham Thi T 46 Hai An 11645
107 Nguyen Thi P 28 An Duong 13781
108 Truong Thi L 26 Thuy Nguyen 11797
109 Ngo Thi C 29 Ngo Quyen 14021
110 Tran Thi H 24 Le Chan 11850
111 Tran Thi T 35 Ngo Quyen 11993
112 Tran Thi Thu N 17 Kien An 19423
113 Trinh Thi Minh H 86 An Duong 15785
114 Nguyen Thi H 56 Hai An 15848
115 Tran Thi B 48 Ngo Quyen 15894
116 Nguyen Thi U 27 Le Chan 19176
117 Pham Thi T 46 Hai An 19636
118 Nguyen Thi T 24 Hong Bang 17893
119 Dao Phuong T 19 Hong Bang 18863
120 Vu Thi T 37 Hai An 18819
121 Nguyen Thi Thanh V 30 Le Chan 14031
122 Nguyen Thi Thu H 44 Le Chan 6168
123 Hoang Thi T 37 Ngo Quyen 9739
124 Pham Thi D 38 Thuy Nguyen 9312
125 Le Thi H 28 Thuy Nguyen 8981
126 Nguyen Thi H 42 Ngo Quyen 8085
127 Duong Thi X 30 Hai An 8088
128 Vu Thi T 29 Ngo Quyen 18734
129 Nguyen Thi P 38 Hong Bang 17211
130 Bui Thi Kim L 43 Kien An 15942
131 Vu Thi T 19 Kien An 15926
132 Nguyen Thi Hong C 33 Hai An 15939
133 Hoang Thi M 40 Le Chan 15985
134 Pham Thi H 41 Ngo Quyen 17294
135 Pham Thi P 47 Hai An 15295
136 Doan Thi T 32 Hong Bang 15567
137 Bui Thi N 51 An Duong 15508
138 Bui Bich H 61 Hai An 15061
139 Do Thi Mai N 32 Ngo Quyen 11945
140 Dinh Thi N 58 Le Chan 18383
141 Bui Thi T 48 Hong Bang 19827
142 Pham Thi N 26 Thuy Nguyen 19383
143 Tran Thi N 44 Thuy Nguyen 18188
144 Le Thi N 63 Hong Bang 18814
145 Tran Thi Mai H 47 Ngo Quyen 21977
146 Do Thi Thuy L 23 Ngo Quyen 15814
147 Bui Thi T 38 Le Chan 20853
148 Phuong Thi N 29 Tien Lang 19957
149 Nguyen Thi N 60 Tien Lang 15847
150 Dang Lan P 35 Vinh Bao 15506
151 Vu Thi P 28 Vinh Bao 15446
152 Nguyen Thi Th 47 Do Son 15512
153 Hoang Thu H 17 Tien Lang 18236
154 Nguyen Thi V 36 Ngo Quyen 17203
155 Nguyen Thi L 39 Do Son 17292
156 Nguyen Thi Hong P 53 Vinh Bao 19942
157 Khoa Thi T 64 Le Chan 6851
158 Truong Thuy A 23 Tien Lang 19273
159 Ha Thi Kim C 22 Ngo Quyen 19341
160 Nguyen Thi T 36 Ngo Quyen 15900
161 Nguyen Thi Khanh L 35 Do Son 15322
162 Nguyen Thi Hong S 33 Do Son 21817
163 Pham Thi Tra M 13 An Duong 21423
164 Nguyen Thi Thanh H 26 Hai An 20712
165 Nguyen Bich H 24 Hong Bang 3980
166 Hoang Thu L 43 Do Son 4002
167 Tran Thi H 21 Ngo Quyen 13409
168 Tran Thi H 44 Le Chan 13191
169 Tran Thi H 35 Vinh Bao 4003
170 Hoang Thi L 26 Vinh Bao 3477
171 Tran Thi H 40 Thuy Nguyen 2960
172 Nguyen Thi Nhu T 32 Ngo Quyen 20104
173 Doan Thi Ngoc H 25 Le Chan 17264
174 Vu Thi H 34 Vinh Bao 16941
175 Vu Thi D 24 Do Son 6180
176 Pham Thi Thu H 25 Duong Kinh 6076
177 Le Thi N 24 Duong Kinh 21448
178 Vu Thuy T 20 Vinh Bao 21081
179 Le Thi Thu H 39 Hai An 20641
180 Doan Thi T 50 Duong Kinh 21003
181 Doan Thi N 41 Thuy Nguyen 13472
182 Ngo Thi E 38 Ngo Quyen 13968
183 Mai Khanh L 21 Le Chan 11051
184 Vu Thi Thuy H 35 Duong Kinh 12253
185 Tu Thi Hong B 50 Duong Kinh 16420
186 Nguyen Thi Lien H 41 Le Chan 12115
187 Ngo Thuy D 20 Hong Bang 11577
188 Vu Thi Thu H 20 Hai An 11279
189 Tran Thi Le T 26 Kien An 3835
190 Ho Thi Minh H 21 Duong Kinh 4971
191 Nguyen Thi P 32 Ngo Quyen 5335
192 Vu Thi L 35 Thuy Nguyen 15850
193 Vu Thi Mai A 33 Le Chan 18251
194 Nguyen Thi Hong N 25 Duong Kinh 8577
195 Giang Khanh C 39 Kien An 15976
196 Nguyen Thi Ngoc D 28 Vinh Bao 18861
197 Nguyen Thi C 47 Hai An 14902
198 Khuc Thi Thanh H 21 Ngo Quyen 15927
199 Bui Thi T 58 Le Chan 19701
200 Do Thi H 37 Ngo Quyen 18385
201 Pham Thi A 25 Thuy Nguyen 17953
202 Hoang Thi H 45 Duong Kinh 8000
203 Do Thi P 34 Duong Kinh 7584
204 Vu Thi T 38 Hai An 15812
205 Cao Thi D 27 Kien An 19967
206 Dao Thi T 34 Vinh Bao 18240

Supervisor General Planning department of

Haiphong hospital of
Obstetrics and Gynecology