Tuberculosis of the breast

Fine-needle aspiration cytology-based accurate and rapid diagnosis of breast tuberculosis mimicking an abscess

A case of breast tuberculosis was initially misdiagnosed as a breast abscess and diagnosed definitively by minimally invasive fine-needle aspiration cytology. This definitive diagnosis enabled us to prevent widespread infection by early initiation of the standard anti-tuberculosis regimen. The patient recovered, and no disease recurrence was noted during follow-ups.

Can Fine Needle Aspiration Cytology be Used as a "Proxy Gold Standard" to Diagnose Tuberculous Mastitis?

Objective

To assess the performance of fine needle aspiration cytology (FNAC) in the diagnosis of tuberculosis mastitis.

Materials and Methods

Diagnostic test performance evaluation using two methods-as compared to an alloyed gold standard as well as in the absence of a gold standard. Alloyed gold standard combined the results of acid fast bacilli in cytology smears, histopathological confirmation, and response to treatment. Bayesian estimation of test parameters was done in the absence of the gold standard.

Results

FNAC was carried out in 6,496 consecutive cases of breast lump and 104 cases of granulomatous mastitis were detected. Both methods of test parameter estimation identified a high specificity of FNAC for the diagnosis of tuberculosis mastitis (98.9% and 98.4%, respectively). Estimation of sensitivity was falsely high (100%) using the alloyed gold standard because of a workup bias and falsely low (8.41%) using the Bayesian estimation because of low prevalence. Likelihood ratios by both methods suggested that FNAC has good discriminatory capability.

Conclusion

In situations where prevalence of tuberculosis is high and where facilities for histopathological evaluation do not exist, FNAC can offer an optional alternative to base the therapeutic decision for starting antitubercular treatment.

Multifocal Tubercular Osteomyelitis with Tubercular Breast Abscess: An Atypical Presentation of Tuberculosis

Tuberculosis of spine is common in a developing country like India. However, involvement of spine at multiple levels along with involvement of rib and tubercular breast abscess in an immunocompetent patient without any pulmonary involvement is extremely rare. Here we report a case of 53-year-old immunocompetent lady who presented with quadriparesis and MRI (magnetic resonance imaging) of spine revealed multiple lesions involving cervical, thoracic, lumbar, and sacral region without any involvement of intervertebral disc. On detailed examination she was found to have a lump in right breast. Fine needle aspiration cytology of both paravertebral collection and breast lump revealed presence of acid fast bacilli. She was put on antitubercular drug for one year and she responded well to therapy.

Duct Ectasia and Periductal Mastitis in Indian Women

There is very little awareness of the general physicians and surgeons about the benign breast conditions such as duct ectasia (DE) and periductal mastitis (PDM) causing nipple discharge. Not only that these benign breast diseases ring a false alarm of cancer, they are also the second most common cause of benign breast diseases. The objective was to study the clinical and microbiological profiles of duct ectasia and periductal mastitis in Indian women for better understanding of the disease process, in order to be able to treat them well. Forty-one consecutive patients presenting to the Surgical Out-Patient Department with non-bloody nipple discharge with clinical and radiological features suggestive of DE or PDM were included. Microbial culture and cytopathological study of the nipple discharge were done. Histopathological studies and culture of the ductal tissue taken intraoperatively were carried out. There is no significant difference in the age distribution among women with DE and PDM. Smoking is not associated with DE and PDM of Indian patients in contrast to the Western literature evidence. Infective etiology was present in nearly 46 % of the patients in the study population more so in the periductal mastitis cases. The most common isolated pathogens were Staphylococcus aureus and Staphylococcus epidermidis, unlike in Western population where nearly 50 % were anaerobes. Since the isolated organisms were resistant to the routinely used antibiotics in high proportion of cases, culture and sensitivity should be done in all possible cases for appropriately treating the subareolar sepsis before proceeding with the definitive treatment in the form of duct excision.

Tuberculosis of the breast in a patient undergoing hemodialysis

A 61-year-old female patient with diabetes undergoing maintenance hemodialysis presented with fever and swelling of her right breast. She had been unresponsive to nonspecific antimicrobial therapies. Breast tuberculosis and tuberculous lymphadenitis were diagnosed by excision biopsy and tissue culture. A combination antituberculous treatment including isoniazid, rifampin, ethambutol, and pyrazinamide was started and resulted in the remission of the lesions by the end of the first month of therapy.

[Mammary tuberculosis: a retrospective study of 65 cases]

OBJECTIVES

Remember the clinical, morphologic and histological particularities of mammary tuberculosis. Discuss clinical and radiological diagnostic problems caused by this localization, as far as breast cancer is concerned.

PATIENTS AND METHODS

This is a retrospective study concerning 65 women suffering from mammary tuberculosis, diagnosed at Salah Azaiez Institute between January 1980 and December 2001.

RESULTS

In this series, mammary tuberculosis represents 0.2% of the declared tubercular localizations and 0.3% of the mammary pathologies treated at the institute. The mean age of our patients was 36 years (19 to 79). Clinical findings were misleading. In 60% of cases the aspect was of a malignant tumor, in 24.6% of cases of a benign nodule and in 16.4% of cases of an abscess. The mammography concluded to a malignant lesion in 49% of cases. The fine needle aspiration achieved at 8 patients was negative in 6 cases and brought back the caseum in the 2 others. The diagnosis has been made, for all our patients, after histological study when we found typical tuberculosis lesions on pieces of tumorectomy, or biopsy. The diagnosis of tuberculosis was established; all patients had an anti-tuberculosis medical treatment in a department of infectious diseases out of the institute.

DISCUSSION AND CONCLUSION

Clinical and radiological features of mammary tuberculosis are very confusing and cause a diagnostic problem with breast cancers. In front of symptoms evoking tuberculosis, biopsies must be done to eliminate an eventual cancer.

Dermatologic diseases of the breast and nipple

Breast and nipple skin is commonly affected by various inflammatory and neoplastic processes. Despite this fact, many physicians are unaware of the spectrum of diseases that can involve this area. Because breast and nipple skin represents a cosmetically, sexually, and functionally important entity to most patients, awareness of these disease entities is invaluable. This article reviews the normal anatomy of the breast, cutaneous manifestations of neoplastic processes that can present in these areas, and common inflammatory diseases of the breast and nipple skin.

Utility of fine-needle aspiration in the diagnosis of granulomatous lesions of the breast

Fourteen cases of granulomatous mastitis (GM) studied by fine-needle aspiration (FNA) are reviewed and nine cytologic features (necrosis, neutrophil granulocytes, foamy cells, plasma cells, granulomas, epitheloid cells, multinucleated giant cells of foreign body type and Langhans' type, duct cells, and the presence of acid-fast bacilli) are reappraised in a semiquantitative manner. The main objective of this study was to find out if one or more of these features would permit the various granulomatous entities identified in surgical pathology to be separated cytologically. The results suggest that FNA does not permit the various granulomatous lesions identified in surgical pathology to be differentiated, since in this series different entities share a common cytologic pattern. Only the presence of acid fast bacilli in smears would enable a tuberculous etiology to be diagnosed. The opinion is put forward that the term GM should be avoided in the cytologic report and substituted by the noncommitted term "granulomatous lesion of the breast.

Tuberculous abscess in retromammary region: CT findings

PURPOSE

Our goal was to evaluate CT findings of tuberculous abscess in the retromammary region of the breast.

METHOD

Four patients with tuberculosis extending from the retromammary region to the pleura were examined by CT and the findings were evaluated. All cases were also examined with mammography and two cases were evaluated with sonography. Diagnosis was confirmed by acid-fast bacillus stain, culture, and histologic examination.

RESULTS

Mammography showed relatively smoothly marginated, round mass density in two cases, nodular density in one, and focal bulging of the pectoral wall in one. A sonogram demonstrated in two cases a fistulous connection from the heterogeneous, fluid-containing lesion with floating internal debris in the retromammary region to the thoracic cavity. In all four cases, CT showed relatively smoothly marginated, inhomogeneous, hypodense lesions with surrounding rims of the cold abscess type. A direct fistulous connection from the retromammary lesion through the thoracic wall into the pleura was seen in two cases. Destroyed rib fragments within the abscess were noted in two cases.

CONCLUSION

A tuberculous abscess in the retromammary region usually showed on CT a focal, smoothly marginated, inhomogeneous, hypodense lesion with a surrounding enhancing rim. A direct fistulous connection with the pleura or a destroyed rib fragment in the abscess as revealed by CT can be helpful in the differential diagnosis of other infectious types of retromammary abscess.

Paraffinomas of the breast: an oriental curiosity

BACKGROUND

The injection of liquid paraffin wax was a form of breast augmentation practised in Hong Kong 30-40 years ago. Patients may present many years later with complications of this treatment.

METHODS

The records of 43 patients diagnosed with paraffinomas of the breast at a teaching hospital in Hong Kong were reviewed. These patients had received paraffin injections 3-41 years (median 17) previously.

RESULTS

Patients presented with hard masses in the breast 4-18 cm (median 17) diameter. Ulceration or infection occurred in 10 patients. Mammography revealed a honeycomb appearance in the affected breast. Treatment included biopsy only (7), excision of masses (3) and total mastectomy (30, bilateral in 27). Histology demonstrated hyalinized and densely sclerotic fibrous tissue with cystic spaces of various sizes.

CONCLUSIONS

Awareness of this condition facilitates the differentiation from tuberculosis and carcinoma of the breast which often present late in this population of patients. Adequate treatment usually require total mastectomy.

Tubercular mastitis: a pragmatic approach to its management

Six cases of tubercular granulomatous mastitis were studied retrospectively. Three of these six cases posed diagnostic difficulties because of a lack of caseation in granuloma on fine needle aspiration cytology. A pragmatic approach is described here that is based on the correlation of the clinical features with the cytological findings. All six cases improved on therapeutic trial of antitubercular treatment.

Diseases of the breast in Nigeria

For the purpose of defining the distribution of breast diseases in Nigeria, a review of 671 cases seen in Ife over a 10 year period was undertaken. Twenty-six (3.9 per cent) of the patients were males. The frequency of breast diseases in this population was fibro-adenoma, 48 per cent; carcinoma, 21 per cent; breast abscess, 8.6 per cent; fibrocystic disease, 5.5 per cent; sclerosing adenosis, 5.4 per cent and gynaecomastia, 2.7 per cent. The other breast lesions were the same type of disease as documented in white patients. The most striking difference was the relatively high incidence of fibro-adenoma, especially in nulliparous adolescent females, while carcinoma and fibrocystic disease were fewer than expected. Breast carcinoma presented a decade earlier in Nigerian women and was usually advanced at presentation and of aggressive histological type. Of the breast carcinomas, 4.3 per cent were associated with pregnancy.