Granulomatous mastitis can mimic breast cancer on clinical, radiological or cytological examination: a cautionary tale

In both women and men, breast lumps are the most common presentation of breast cancer. The following cases illustrate the pathological entity of granulomatous mastitis, which can present simulating breast cancer - including the first description of this condition in a male. These cases demonstrate the difficulty in clinical diagnosis and emphasizes that although there may be clues from the history, clinical awareness that this condition can mimic breast cancer in all aspects of the triple assessment process should arouse suspicion. The importance of histological diagnosis by core or excision biopsy is stressed, as with accurate diagnosis of granulomatous mastitis there is a mandate to avoid unnecessary surgery.

Experimentally Induced Teat Stenosis in Dairy Ewes: Clinical, Pathological and Ultrasonographic Features

A strain of Staphylococcus chromogenes was introduced into the teat cistern of five ewes, teat inflammation and stenosis being the primary consequences. Initially, the inoculated teats were swollen and warm; later, a hard structure was palpated running lengthwise inside the teat, with a thick ring above the tip of the teat, which interfered with expression of milk. Mastitis, confirmed by clinical, cytological, bacteriological and histological findings, was evident 4 days after infection. Ultrasonographically, a hyperechoic line under the mucosa of the teat cistern was observed. At necropsy, the duct wall of the inoculated teats was found to be thickened. Histopathological features included leucocytic infiltration, especially under the mucosa of the teat, and extensive fibrosis in the subcutaneous tissues. S. chromogenes was recovered from scrapings from the duct and the cistern of the inoculated teats.

18-Fluorodeoxyglucose-positron emission tomography in inflammatory breast cancer

Inflammatory breast cancer (IBC) is the most aggressive form of locally advanced breast cancer. It can be diagnosed based on a clinical or pathologic basis. We evaluated the usefulness of (18)F-fluorodeoxyglucose-positron emission tomography (FDG-PET) scans for diagnosing and staging IBC. We retrospectively reviewed the medical records of seven consecutive patients with IBC who underwent FDG-PET scanning for the initial staging. Four patients had follow-up PET scans after chemotherapy. All seven patients presented with diffuse breast enlargement, redness, and peau d'orange for 1 to 5 months' duration. In addition, four patients had a palpable breast mass, and three had axillary lymph node enlargement. Mammography showed diffuse, increased parenchymal density and skin thickening in 85% and parenchymal distortion in 43%. There was no evidence of distant metastasis on computed tomography of the chest or abdomen. Pathologic examination of breast biopsy specimens showed infiltrating ductal carcinoma in six patients, and one had lobular carcinoma. All patients had prechemotherapy whole-body PET scans that showed diffuse FDG uptake in the breast with superimposed intense foci in the primary tumor. Furthermore, there was skin enhancement in 100%, axillary lymph node in 85%, and skeletal metastases in 14% of the patients, confirmed by bone scintigraphy. Postchemotherapy FDG-PET scans performed in four patients showed response in the primary tumor, axillary lymph nodes, and skeletal metastases. The FDG-PET scan is thus useful for displaying the pattern of FDG breast uptake that reflects the extent of the pathologic involvement in IBC (i.e., diffuse breast involvement and dermal lymphatic spread). It can also detect the presence of lymph node and skeletal metastases, demarcating the extent of the disease locally as well as distally.

Case report: diabetic mastopathy

Diabetic mastopathy is a source of confusion with breast carcinoma. The association between mastopathy and Type I diabetes of long duration has been reported, but this clinical condition is poorly recognized since breast examination is not routinely performed in young diabetic patients. Radiologists' awareness of the constellation of findings in diabetic mastopathy may spare patients from undergoing unwarranted surgical biopsies.

Granulomatous mastitis: imaging findings with histopathologic correlation

OBJECTIVE

The purpose of this study is to evaluate the mammographic and ultrasonographic characteristics of granulomatous mastitis and to correlate the imaging features with the histologic findings.

MATERIALS-METHODS

15 patients with diagnosis of idiopathic granulomatous mastitis were examined with mammography and ultrasonography. The clinical, pathologic and imaging features were retrospectively reviewed and correlated in all patients.

RESULTS

Mammographic examination showed an asymmetric density with no distinct margins in 8 patients and an ill-defined mass in 3 patients. In 4 cases, no abnormal finding was detected on the mammography. Sonographic examination demonstrated an irregular mass with tubular connections in 5 patients, single or multiple hypoechoic tubular/nodular structures in 6, and focally or segmentally decreased parenchymal echogenity with acoustic shadowing in 4 patients. The imaging findings suggested a malignant tumor in 7 patients, while an inflammatory process or intraductal papilloma was considered in the differential diagnosis of the other patients.

CONCLUSION

Granulomatous mastitis usually presents with clinical findings mimicking a carcinoma. The most common mammographic appearance of the lesion is an asymmetrically increased density, which is not characteristic for this entity. Sonographic patterns of the disease are varied and appear to relate to the histologic features. Findings include a mass-like appearance, tubular/nodular hypoechoic structures and focal decreased parenchmal echogenicity with acoustic shadowing. With awareness of the findings granulomatous mastitis can be considered in the differential diagnosis.

Breast enhanced scintigraphy testing distinguishes between normal, inflammatory breast changes, and breast cancer: a prospective analysis and comparison with mammography

The detection of breast cancer has primarily focused on anatomic findings, whereas assessment of physiologic information using nuclear imaging has been used for the detection of heart disease. Using this approach, the authors developed a method (breast enhanced scintigraphy test [BEST]) for differentiation of breast tissue by enhancing the delivery of isotope. To determine if this technique could distinguish between normal (Nl), inflammatory changes of the breast (ICB), and breast cancer (CA), 100 women were prospectively studied using BEST imaging, and results were compared with mammography and pathology findings using either biopsy or ductoscopy approaches. Mammography demonstrated a sensitivity and specificity of 69% and 84%, respectively. Using BEST imaging, maximal count activity (MCA) was able to distinguish between Nl, ICB, and CA. The results of 2-tailed t test analysis demonstrated statistically significant differences between Nl and ICB MCA (P </=.001); ICB and CA MCA(P </=.001); and N1 and CA MCA(P </=.001). Using MCA results obtained via BEST imaging, breast tissue was able to be differentiated, whereas mammography was able to detect breast cancer in only 69% of cases and incorrectly identified cancer in 16% of cases.

Mammographic and sonographic findings in the diagnosis of idiopathic granulomatous mastitis

The aim of this study was to describe the mammographic and sonographic findings of idiopathic granulomatous mastitis which is a rare inflammatory disease of the breast of unknown etiology. The clinical, radiologic, and pathologic features of 12 cases with idiopathic granulomatous mastitis were retrospectively reviewed. Mammography was performed in all cases, 8 of which showed a focal asymmetric density, 3 had a mass with irregular margins, and 1 had no abnormality. Sonography was performed in 10 cases, and a focal area with inhomogeneous and hypoechoic pattern was depicted in 6 cases, 4 of which were associated with internal tubular hypoechoic structures. One case revealed a hypoechoic mass consistent with malignancy. In 1 case sonography showed an edematous pattern involving nearly the entire breast. Two patients had normal sonograms. If a focal asymmetric density is seen in mammography and inhomogeneous hypoechogenity with internal hypoechoic tubular structures accompany ultrasonographically, these findings should suggest the possibility of idiopathic granulomatous mastitis; however, very often idiopathic granulomatous mastitis mimics a breast carcinoma clinically and the final diagnosis should be reached histopathologically due to high false-positive and false-negative mammographic appearances.

[Breast scintigraphy using 99mTc-sestamibi--use and limitations]

AIM

Until now scintimammography did not achieve any definite role in the assessment of breast lesions. Purpose of this study was to elaborate its use as well as the limitations of scintimammography after 500 examinations completed.

METHODS

Scintigraphic findings were correlated with the histopathologic outcome of 219 patients, who underwent surgery or biopsy for histopathological confirmation. The results were determined with respect to palpability of the lesion and tumour size. Additionally, a distinct analysis was performed for the patient subpopulation with indeterminate results of previously performed physical examination, mammography, and sonography.

RESULTS

Overall sensitivity for scintimammography was 82.1% at a specificity of 87.5%. For palpable lesions sensitivity was 91.7% which was evidently higher as compared to 64.9% for non palpable lesions. For palpable lesions specificity was 81.1% and 88.6% for non palpable lesions. According to tumour size sensitivity ranged between 65.2% for carcinoma with a diameter < 1 cm and 93.7% for carcinoma > 1 cm. In the patients subgroup with indeterminate preliminary diagnosis (n = 143) sensitivity decreased to 71.7% at a specificity of 87.8%. Patients undergoing neoadjuvant chemotherapy showed decreasing sestamibi uptake as early as 8 days after therapy if tumour response was evident. However, small residual invasive tumours in patients with complete remission could not be visualised.

CONCLUSION

Scintimammography is neither suited for screening, nor early diagnosis of breast cancer, nor for the further evaluation of small and unclear mammographic findings. Scintimammography should not be used whenever histopathological clarification of a suspicious lesion is necessary. It is useful to further investigate patients with unclear or probably benign findings in physical examination and/or mammography and to monitor tumour response to neoadjuvant chemotherapy.

Ultrasonographic appearance of the superficial supramammary lymph nodes in lactating dairy cattle

The superficial supramammary lymph nodes of 54 lactating dairy cows were examined ultrasonographically with a 7.5 MHz linear transducer; each node was measured in two planes within 24 hours of recording the milk somatic cell count. In most cows, the nodes were well demarcated from the surrounding tissue. The parenchyma of the nodes ranged from hypoechoic to anechoic, with a central bright hyperechoic area, and a thin hyperechoic line surrounded the nodes. The size of the nodes varied, but their internal architecture remained relatively consistent. Their mean length was 7.4 cm (range 3.5 to 15 cm) and their mean depth was 2.5 cm (range 1.2 to 5.7 cm). They were significantly larger in cows with more lactations (P<0.05), but there were no correlations between their size and either the time calved or the milk somatic cell count. The lymph nodes on sides which were positive in a California milk test were significantly larger than those on sides which were negative (P<0.05).

F-18 FDG uptake in breast infection and inflammation

PURPOSE

Whole-body fluorine-18 fluorodeoxyglucose (F-18 FDG) positron emission tomography (PET) scanning has been useful in the management of breast cancer. However, F-18 FDG uptake sometimes has been associated with benign breast disease. Four cases are reported of F-18 FDG breast uptake caused by infectious or inflammatory mastitis that mimics malignant disease.

METHODS AND RESULTS

Two women had F-18 FDG whole-body scans for the evaluation of a large breast mass after inconclusive results of ultrasonography. In both cases, intense focal F-18 FDG breast uptake was noted that mimicked breast cancer. Histologic examination showed, in one patient, chronic granulomatous infiltration that likely represented tuberculous mastitis, because she showed a good clinical response to empirical anti-tuberculous treatment. The second patient had lactational changes associated with acute inflammation, and the culture grew Staphylococcus aureus. The breast mass completely disappeared 3 weeks after a course of antibiotic treatment. The other two patients had staging F-18 FDG PET scans 1 and 12 months after lumpectomy for breast carcinoma to detect residual, recurrent, or metastatic disease. Both scans showed a ring-like uptake in the involved breast, with superimposed intense focal uptake suggesting tumor necrosis centrally and malignant foci peripherally. In both cases, histologic examination revealed hemorrhagic inflammation secondary to postsurgical hematomas and no evidence of malignancy.

CONCLUSION

Acute or chronic infectious mastitis and postsurgical hemorrhagic inflammatory mastitis should be considered in patients who have a breast mass, especially those with a history of tenderness or surgery.

Idiopathic granulomatous mastitis. Report of a case diagnosed with fine needle aspiration cytology

BACKGROUND

Idiopathic granulomatous mastitis (IGM) is a benign, inflammatory breast disease of unknown etiology. Although it is rare, it frequently presents in a manner similar to that of breast carcinoma.

CASE

A 41-year-old female developed unilateral idiopathic granulomatous mastitis, diagnosed by fine needle aspiration cytology. The clinical presentation and mammographic findings were suspicious for carcinoma. Fine needle aspiration cytology showed granulomatous inflammation. Histopathologic examination revealed a noncaseating, granulomatous lesion. Further clinical, radiologic and laboratory investigations disclosed no etiology. Therefore, we considered the case to be idiopathic granulomatous mastitis.

CONCLUSION

Cytologically it may be difficult to distinguish IGM from carcinoma of the breast. Typical cytologic findings of the lesion are helpful to rule out cancer. In the differential diagnosis, all known causes of granulomatous changes have to be excluded before a diagnosis of idiopathic granulomatous mastitis is made.

Mammographic appearances of male breast disease

Various male breast diseases have characteristic mammographic appearances that can be correlated with their pathologic diagnoses. Male breast cancer is usually subareolar and eccentric to the nipple. Margins of the lesions are more frequently well defined, and calcifications are rarer and coarser than those occurring in female breast cancer. Gynecomastia usually appears as a fan-shaped density emanating from the nipple, gradually blending into surrounding fat. It may have prominent extensions into surrounding fat and, in some cases, an appearance similar to that of a heterogeneously dense female breast. Although there are characteristic mammographic features that allow breast cancer in men to be recognized, there is substantial overlap between these features and the mammographic appearance of benign nodular lesions. The mammographic appearance of gynecomastia is not similar to that of male breast cancer, but in rare cases, it can mask malignancy. Gynecomastia can be mimicked by chronic inflammation. All mammographically lucent lesions of the male breast appear to be benign, similar to such lesions in the female breast.

Granulomatous mastitis: gray-scale and color Doppler sonographic findings

PURPOSE

We examined the roles of gray-scale and color Doppler sonography in the diagnosis of granulomatous mastitis.

METHODS

We retrospectively studied the clinical, mammographic, and sonographic findings in 10 women 24-57 years old (mean age, 35.9+/-13.9 years) who had a histopathologic diagnosis of granulomatous mastitis. All patients underwent gray-scale sonographic examination, and 8 patients were further examined with color Doppler imaging. Seven patients had previously undergone mammography.

RESULTS

Mammographic findings were nonspecific in all 7 patients. Gray-scale sonographic findings were compatible with mastitis in 6 (60%) of 10 patients. Doppler examination showed increased arterial and venous vascularization within and around the lesion in 5 of 8 patients, but the spectral analysis findings were not specific for granulomatous mastitis.

CONCLUSIONS

Neither mammography nor Doppler sonography plays a significant role in the differential diagnosis of granulomatous mastitis versus fibroadenoma or carcinoma. Gray-scale sonography shows findings specific for granulomatous mastitis in some cases, but all cases require histopathologic confirmation for final diagnosis.

[Significance of resistance index and pulsatility index in differential diagnosis of breast neoplasm]

OBJECTIVE

To investigate the significance of the resistance index (RI) and pulsatility index (PI) in differential diagnosis between the benign and malignant breast neoplasms.

METHODS

Forty-seven cases of malignant breast tumors, sixty-nine cases of fibroadenomas, seven cases of inflammatory masses and twenty-two cases of mammiplasia were demonstrated on color Doppler flow imaging (CDFI). The measurements of RI and PI of the four groups were recorded respectively and the comparison between benign and malignant neoplasms was made by applying Doppler quantitative analysis.

RESULTS

The color flow was detected in 59.4% of benign breast neoplasms and in 89% of malignant ones respectively (chi 2-test, P < 0.001). There were significant difference between benign and malignant neoplasms on the RI and PI. The malignant neoplasms were characteristic of higher RI (> or = 0.70) and PI (> or = 1.30), which were of satisfactory value for differential diagnosis, amounting to 95.5% of accuracy.

CONCLUSIONS

Combination of both color Doppler analysis and 2D-US might remarkably increase the sensitivity and specificity of differential diagnosis of breast neoplasms. Our results confirmed the significance of color Doppler flow imaging and Doppler quantitative analysis on the differential diagnosis of breast neoplasms.

Cytologic features of granulomatous mastitis. Report of a case with fine needle aspiration cytology and immunocytochemical findings

BACKGROUND

Granulomatous mastitis, a rare condition of unknown etiology, affects women of childbearing age and clinically simulates breast carcinoma.

CASE

Granulomatous mastitis of the breast in a 32-year-old female was studied by fine needle aspiration cytology. Aspirated material was quite cellular and consisted of epithelioid histiocytes, lymphocytes, plasma cells, neutrophils and multinucleated Langhans-type giant cells. However, no cheesy, necrotic material in the background was noted.

CONCLUSION

Granulomatous mastitis, although infrequently reported, appears to have rather characteristic cellular features that may allow its recognition.

Radioimmunolocalization of primary and metastatic breast cancer

The appropriate therapy for breast cancer depends mainly upon early and reliable tumor detection, correct tumor staging and accurate re-staging after therapy. Current radiological imaging methods are based primarily on morphology resulting in high sensitivity but lacking specificity. Established nuclear medicine techniques are sensitive but not very specific. To improve specificity, a number of monoclonal antibodies, selected against a particular tumor-associated antigen expressed on the surface of breast cancer cells, have been radiolabeled for imaging in vivo tumor localizations. In theory, radioimmunodetection offers the potential to demonstrate cancer cells even in subradiological disease, or when anatomy-based imaging methods may be unable to distinguish the nature of an evident mass, making the differential diagnosis between an inflammatory reaction, a postsurgical fibrosis, or a truly viable tumor impossible. Suspected tumor recurrence indicated by increasing tumor marker levels could be another clinical indication for radioimmunolocalization, even if standard imaging modalities are negative. A large number of antibodies against different epitopes of human neoplastic breast tissue have been investigated previously. However, a highly specific and sensitive monoclonal antibody for immunoscintigraphy and radioimmunotherapy has not yet been found. This review addresses tumor-biological considerations, radioisotopes and radiolabeling methods, tumor targets and different monoclonal antibodies used for immunoscintigraphy (incl. SPECT amd PET) of breast cancer.

Idiopathic granulomatous mastitis

A case of idiopathic granulomatous mastitis mimicking breast carcinoma clinically and radiographically is reported with mammography, sonography and MR images.

99Tcm-tetrofosmin scintigraphy in the evaluation of palpable breast masses

201Tl and 99Tcm-MIBI have been used to evaluate palpable breast masses. The aim of this study was to evaluate the potential of 99Tcm-tetrofosmin as a new tumour localizing agent in patients with palpable breast masses. Nineteen palpable breast masses were evaluated in 18 patients. Each patient received 740 MBq 99Tcm-tetrofosmin intravenously. Ten minutes after the injection, planar breast images in the anterior, right lateral and left lateral views were obtained with the patient in the supine position. Mammography and ultrasonography were performed in all patients. Biopsy or mastectomy with axillary dissection was performed in all patients. Thirteen of 14 primary breast tumours were detected (9 invasive ductal carcinomas, 3 invasive lobular carcinomas, 1 papillary carcinoma). One patient with mucinous carcinoma did not demonstrate 99Tcm-tetrofosmin accumulation. Four of five patients with histopathologically proven benign lesions did not demonstrate 99Tcm-tetrofosmin accumulation (2 fibrocystic diseases, 2 fibroadenomas). 99Tcm-tetrofosmin accumulation was seen in a patient with chronic mastitis. The sensitivity and specificity of 99Tcm-tetrofosmin for malignant breast lesions was 92 and 80% respectively. Four of seven (57%) axillary lymph node metastases showed 99Tcm-tetrofosmin uptake. In conclusion, 99Tcm-tetrofosmin shows real promise for use in evaluating patients with palpable breast masses.