Granulomatous diseases of the breast and axilla: radiological findings with pathological correlation

The Spectrum of Non-neoplastic Changes Associated With Breast Implants: Histopathology, Imaging, and Clinical Significance

Breast implant-associated anaplastic large cell lymphoma has been recognized as a distinct entity in the World Health Organization classification of hematolymphoid neoplasms. These neoplasms are causally related to textured implants that were used worldwide until recently. Consequently, there is an increased demand for processing periprosthetic capsules, adding new challenges for surgeons, clinicians, and pathologists. In the literature, the focus has been on breast implant-associated anaplastic large cell lymphoma; however, benign complications related to the placement of breast implants occur in up to 20% to 30% of patients. Imaging studies are helpful in assessing patients with breast implants for evidence of implant rupture, changes in tissues surrounding the implants, or regional lymphadenopathy related to breast implants, but pathologic examination is often required. In this review, we couple our experience with a review of the literature to describe a range of benign lesions associated with breast implants that can be associated with different clinical presentations or pathogenesis and that may require different diagnostic approaches. We illustrate the spectrum of the most common of these benign disorders, highlighting their clinical, imaging, gross, and microscopic features. Finally, we propose a systematic approach for the diagnosis and handling of breast implant specimens in general.

Cat Scratch Disease of the Breast/Axilla: Recognition of a Rare Disease and Approaches for Differential Diagnosis

Cat scratch disease rarely presents as a breast or axillary mass mimicking carcinoma both clinically and radiologically. Diagnosing breast/axillary cat scratch disease is challenging due to its rarity and nonspecific findings. Here, we reported 2 patients with breast cat scratch disease and reviewed 14 patients with cat scratch disease involving breast/axilla from the past 30 years. It mainly affects women (median age: 48), consistently presenting as axillary lymphadenopathy, and demonstrates ipsilateral breast mass in half of patients (50%, 8/16). The breast mass was most commonly located in the upper outer quadrant (88%, 7/8), indicating the possibility of disease extension from axillary adenopathy. Around half of patients (56%, 9/16) reported cat exposure. Histologically, most patients (93%, 14/15) presented as necrotizing granulomas, with characteristic stellate-shaped necrosis in 5 patients. Although pathologic differential diagnoses between cat scratch disease and cancer are straightforward, distinguishing cat scratch disease from other granulomatous mastitis poses diagnostic challenges. Silver stains should be included in the diagnostic workup panel when highly suspecting cat scratch disease clinically. However, they were only able to highlight the causative microorganism in 54% (7/18) patients, and the gram stain was negative in all 12 tested patients. In contrast, polymerase chain reaction (PCR) for the causative microorganism was consistently positive in all 3 tested patients, while serologic test confirmed diagnosis in 85% (11/13) patients; 1 patient with negative serology showed a positive PCR result. Therefore, upfront PCR tests with or without serologic study should be considered to confirm the diagnosis of cat scratch disease in a timely manner.

Ultrasound imaging of the axilla

Axilla is a pyramidal-in-shape "virtual cavity" housing multiple anatomical structures and connecting the upper limb with the trunk. To the best of our knowledge, in the pertinent literature, a detailed sonographic protocol to comprehensively assess the axillary region in daily practice is lacking. In this sense, the authors have briefly described the anatomical architecture of the axilla-also using cadaveric specimens-to propose a layer-by-layer sonographic approach to this challenging district. The most common sonographic pathological findings-for each and every anatomical compartment of the axilla-have been accurately reported and compared with the corresponding histopathological features. This ultrasound approach could be considered a ready-to-use educational guidance for the assessment of the axillary region. CRITICAL RELEVANCE STATEMENT: Axilla is a pyramidal-in-shape "virtual cavity" housing multiple anatomical structures and connecting the upper limb with the trunk. The aim of this review article was to describe the anatomical architecture of the axilla, also using cadaveric specimens, in order to propose a layer-by-layer sonographic approach to this challenging district.

A case report of a bullet in the breast of a woman for four years without any complications

INTRODUCTION AND IMPORTANCE

A bullet stabilized in a breast for more than 4 years without causing any complication due to its presence is not a common case. Sometimes breast isolated injury could be seen without symptoms like pain, or palpable mass, or it could present with abscess formation and fistula. In addition, the bullet - if it's small - could mimic calcifications seen in malignancy when performing mammography.

CASE PRESENTATION

We report a case of a 46-year-old well-being female who came to resect a superficial gunshot she got in her left breast in one of the armed conflict areas in Syria. The bullet has been settled there for more than 4 years without causing any inflammation-related signs at the wound's site and without causing any symptoms or complications.

CLINICAL DISCUSSION

The tissue damage caused by the gunshot is associated with several factors such as the bullet caliber, speed, range of shooting, and energy flux. Frequently, gunshot injuries are most serious in friable solid organs like the liver and brain, whereas dense tissues such as bones and loose tissues like subcutaneous fat are more tolerant and resistant to that kind of insult. When a foreign body (bullet) enters the body without causing tremendous tissue damage and settles there for enough period of time we expect seeing signs of inflammation (heat, swelling, pain, tenderness, and redness).

CONCLUSION

Such cases must be taken into consideration and not be neglected without intervention due to the increased risk of many fearful complications including Squamous Cell Carcinoma.

Breast imaging of infectious disease

Infectious diseases of the breast can demonstrate a wide variety of clinical presentations and imaging appearances. Breast abscesses are often a complication of infectious mastitis of the breast. Puerperal mastitis is the most common cause of breast abscess, typically affecting postpartum females. Often diagnosed clinically, it is usually treated with antibiotics without need for imaging. Non-puerperal mastitis is relatively uncommon and typically subareolar in location. Patients can present with asymmetric breast thickening, a palpable lump, nipple discharge, or axillary adenopathy. These presentations can mimic malignancy. Herein, this pictorial review demonstrates imaging findings of common and uncommon infectious processes of the breast and clinically important mimickers of breast infection.

The role of diffusion-weighted MR imaging in discrimination between benign and malignant axillary lymph nodes in breast cancer patients

Background

Noninvasive preoperative evaluation of axillary lymph nodes proved to have a significant role not only on the protocol of treatment of breast cancer but also impact the whole life of the patient. Complications of lymph node biopsy or axillary clearance increase the need for noninvasive reliable diagnostic tool. We aimed in the current study to evaluate the role of diffusion-weighted magnetic resonance imaging (DW-MRI) and apparent diffusion coefficient (ADC) in discrimination between benign and malignant axillary lymph nodes. We included 44 suspicious lymph nodes from 29 patients. Qualitative DW-MRI was analyzed into restricted or not; ADC maps and cut-off value were calculated, and they were correlated with histopathological results, which were the gold standard tool of the current study.

Results

The cut-off value of ADC-differentiated between malignant and benign lymph nodes was 0.89 × 10−3 mm2/s. The statistical indices including the sensitivity, specificity, PPV, NPV and accuracy were 89.66%, 86.67%, 93.9, 81.2% and 87.8%, respectively, with P value < 0.001, while DW-MRI results were classified into restricted or not restricted with qualitative statistical indices of 96.6%, 80%, 90.3%, 92.3% and 90.9% for sensitivity, specificity, PPV, NPV and accuracy, respectively, with P value < 0.001.

Conclusion

DW-MRI and ADC both have significant role in discrimination between benign and malignant axillary lymph nodes increasing the accuracy of MRI examination in breast cancer patients.

Calcified Axillary Lesions on Mammography: Review and Management

When interpreting mammography, breast radiologists may identify radiopaque densities in the axilla on the mediolateral oblique or lateral projections. When such densities are encountered, true calcifications must be differentiated from pseudocalcifications (artifact). Using imaging, breast radiologists should be able to localize the finding as being dermal, within the soft tissues, within a lymph node, or intramuscular. By combining the anatomic location with the clinical presentation and any other imaging findings, breast radiologists will be able to determine the most appropriate management.

Mammary schistosomiasis: A rare case

Schistosomiasis is prevalent in some developing countries; however, it does not commonly affect the breast. Mammary schistosomiasis may present as suspicious microcalcification or a mass on mammography. Image-guided biopsy is necessary to exclude malignancy and identify calcified Schistosoma ova on histology. We report a case of a patient born in the Philippines who was diagnosed with mammary schistosomiasis from incidental microcalcifications seen on mammography.

Idiopathic granulomatous mastitis: experience at a New York hospital

INTRODUCTION

Idiopathic granulomatous mastitis (IGM) often mimics breast cancer. Presentation includes pain, palpable mass, suppuration or suspicious imaging. Widely reported in Asia and the Middle East, IGM is diagnosed after excluding specific granulomatous mastitis (SGM). Aetiology remains unknown. Lactation, prolactinaemia, ethnicity, autoimmune disease and Corynebacteria are associated. Treatment is controversial and the prevalence rising. Surgery and non-operative treatments including antibiotics, non-steroidal anti-inflammatory drugs (NSAIDs), steroids, methotrexate and observation have advocates.

METHODS

A retrospective chart review of 63 patients with IGM from 2008 to 2018 was undertaken focusing on birthplace, age, clinical presentation, wound cultures, imaging, treatments and outcomes.

RESULTS

Sixty-one of 63 patients were Hispanic; 53 were Mexican-born women aged 23-46. Clinical presentation included pain, painful mass, painless mass, suppuration and abnormal imaging. Some 31/61 ultrasound examinations and 17/33 mammograms were deemed Breast Imaging Reporting and Data System (BI-RADS) score 4 or 5. Management included antibiotics (43), incision and drainage (24), NSAIDs (29), steroids (8), lumpectomy (18) and observation (12). Some 12/20 patients with painless masses resolved with observation, 3 received NSAIDs, 2 received steroids and 3 underwent lumpectomies. Antibiotics resolved 8/43 cases, 5 needed incision and drainage, 26 received NSAIDs, 6 received steroids and 5 underwent lumpectomies. Nineteen patients had indolent disease or recurrence.

CONCLUSIONS

Excluding malignancy is critical, treatment challenging and recurrence common in IGM. A preponderance of patients were Mexican-born, similar to other reports from the USA. Over 50% of IGM cases had suspicious BI-RADS scores. Best management remains a challenge and ranges from observation to lumpectomy.

Idiopathic granulomatous mastitis: case series and clinical review

Idiopathic granulomatous mastitis is a chronic inflammatory breast disorder that typically affects young, parous women, often following lactation. Patients present with tender, erythematous breast lesions with histological evidence of non-caseating granulomata and an inflammatory cell infiltrate. An immune-mediated pathophysiology is hypothesised and an association with lipophilic Corynebacterium species is observed. Initial diagnosis is often delayed due to lack of awareness of the condition and management of refractory disease can be challenging. We present an extensive case series of patients collaboratively managed by subspecialty physicians and surgeons at a single centre in Sydney, Australia. The accompanying review expands on features of this condition and supports the utility of a multidisciplinary approach.

Management of Granulomatous Mastitis Following Aesthetic Breast Surgery

BACKGROUND

Granulomatous mastitis (GM) is not among the well-known diseases in the field of aesthetic breast surgery (ABS). The clinical presentation of GM resembles infectious diseases or malignancies, but the management of these diseases is quite different. In this study, we aimed to present the management of GM in patients who underwent ABS.

METHODS

In this study, patients with GM (n = 65) and patients who underwent ABS (n = 531) were evaluated. A total of six GM patients with a history of ABS were included in the study between January 1, 2010, and January 1, 2019. The data were collected retrospectively. The quantitative variables are shown as medians (minimum-maximum), and categorical variables are shown as numbers and percentages (%).

RESULTS

Median duration of disease onset after the ABS was 16 (8-38) months. After the diagnosis of GM was obtained, all patients received steroid treatment. Median steroid treatment duration was 10 (8-20) weeks. Methotrexate was administered in two patients due to persistent breast mass and steroid side effect. Surgical excision was performed in three patients with wide excision. No patient needed further surgery such as mastectomy. Median follow-up period was 37.5 (18-70) months.

CONCLUSION

This is the first study to declare GM in patients who underwent ABS. Atypical clinical presentation such as breast abscess, mass or fistula after ABS should alert the surgeon about GM. Unlike other mastitis, the primary treatment of this rare disease is steroid and immunosuppressive treatment. Insufficient knowledge about GM can lead to unnecessary surgeries or breast loss.

LEVEL OF EVIDENCE IV

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Palpable Lumps after Mastectomy: Radiologic-Pathologic Review of Benign and Malignant Masses

Patients who have undergone mastectomy, with or without reconstruction, are not universally screened with mammography or US. Therefore, clinical breast examination by the physician and patient-detected palpable abnormalities are crucial for detecting breast cancer or recurrence. Diagnostic US is the first-line modality for evaluation of postmastectomy palpable masses, with occasional adjunct use of diagnostic mammography for confirming certain benign masses. In the setting of a negative initial imaging evaluation with continued clinical concern, diagnostic MRI may aid in improving sensitivity. Knowledge of the typical multimodality imaging appearances and locations of malignant palpable abnormalities-such as invasive carcinoma recurrence, cancer in residual breast tissue, radiation-induced sarcoma, and metastatic disease-is crucial in diagnosis and treatment of these entities. In addition, familiarity with the range of benign palpable postmastectomy processes-including fat necrosis, fat graft, seroma, granuloma, neuroma, fibrosis, and infection-may help avoid unnecessary biopsies and reassure patients. The authors review common and rare benign and malignant palpable masses in mastectomy patients, describe multimodality diagnostic imaging evaluation of each entity, review radiologic and pathologic correlation, and acquaint the radiologist with management when these findings are encountered. ^©RSNA, 2021.

Granulomatous mastitis caused by Rickettsia species

Granulomatous mastitis is a rare inflammatory disease of varying etiology. Tuberculosis and cystic neutrophilic granulomatous mastitis caused by Corynebacterium are the best-established infectious examples. Despite the increasing incidence of Rickettsia-related diseases worldwide, granulomatous inflammation of breast parenchyma caused by Rickettsia has not yet been reported. We present a unique case of bilateral granulomatous mastitis documented with mammography, magnetic resonance imaging and core-needle biopsy. The rickettsial etiology of the disease was proved with specific immunohistochemistry and confirmed with DNA extraction, PCR and serology. The lesions completely resolved after a full-course tetracycline treatment. This case report widens the knowledge about the possible clinical manifestations of Rickettsia infection and adds a new bacterium to the list of etiological factors causing granulomatous mastitis.

A very rare case of mycobacterium gordonae infection of the breast

Mastitis is a common disease in women with both infectious and noninfectious causes. Most cases occur during lactation and are caused by Staphylococcus aureus and Streptococcus species; parasites and Mycobacteria have rarely been reported to cause breast infections (Mandell, Douglas, and Bennett's principles and practice of infectious diseases (9th edn);2019, Am J Respir Crit Care Med. 2007;175:367). Nontuberculous mycobacteria (NTM) which are also referred to as atypical mycobacteria, mycobacteria other than tuberculosis (MOTT), or environmental mycobacteria are a large group of Mycobacteria which are becoming increasingly common cause of infection all over the world (Arch Dermatol. 2006;142:1287). NTM can cause infection diseases especially in immunocompromised patients, such as HIV-positive hosts, most commonly in the lungs, skin and soft tissue, lymph nodes or rarely spread with multiorgan dissemination (Arch Plast Surg. 2014;41:759). Mycobacterium gordonae (M. gordonae) is a slow-growing atypical mycobacterium that is considered the least pathogenic NTM. The organism is ubiquitous, and mostly isolated from soil and water. Despite its nonvirulent nature, clinically significant infections have been reported also in some immunocompetent patients (J Formosan Med Assoc. 2020, Clin Infect Dis. 1992;1229). We report the first documented case of breast infection in a young immunocompetent woman sustained by Mycobacterium Gordonae.

Cystic neutrophilic granulomatous mastitis during chemotherapy treatment for invasive breast carcinoma – a rare lesion that simulates tumor progression

Background

Cystic neutrophilic granulomatous mastitis (CNGM) is an uncommon and recently described pattern of granulomatous mastitis. To our knowledge, no cases have been described during chemotherapy for invasive breast cancer.

Case presentation

A 42-year-old female patient had a diagnosis of invasive breast carcinoma (3-cm nodule). During neoadjuvant chemotherapy, she presented with an enlargement of the breast nodule that measured 7.0-cm on palpation. The lesion did not show typical inflammatory clinical findings and simulated tumor progression. A core biopsy showed granulomas with pseudocystic spaces with gram-positive bacilli (Corynebacterium sp.), and numerous circumjacent neutrophils. She was treated with antibiotics and resumed chemotherapy. Surgical specimen showed a 1.0-cm residual carcinoma and extensive xanthogranulomatous inflammation with no evidence of residual CNGM.

Conclusion

CNGM is usually associated with typical clinical presentation of mastitis. It is an important pattern of granulomatous inflammation to be recognized in the breast since it directly impacts treatment. The present case highlights its potential occurrence during chemotherapy treatment of breast cancer mimicking progression of breast malignancy.

Cat Scratch Disease Is an Entity Often Diagnosed in Breast Imaging Department During Axillary Lymph Node Assessment

Cat scratch disease (CSD) is an infectious disease process of generally immunocompetent children and young adults. This infection can be introduced through skin trauma by direct exposure to the saliva of an infected kitten or cat. CSD is typically associated with constitutional symptoms and self-limited regional lymphadenopathy. In the sole presence of swollen lymph nodes, however, the differential diagnosis for CSD is relatively broad, including an active infection, an ongoing inflammatory process, and a metastatic process. CSD can present as axillary lymphadenopathy without typical constitutional symptoms. With proper clinical and laboratory investigation, CSD can be accurately identified and correctly diagnosed, as demonstrated in this case series featuring five symptomatic young adults with axillary lymphadenopathy. Breast imaging clinic specializes in lymph node assessment because metastatic lymphadenopathy is one of the most common presenting signs of breast cancer. Most isolated axillary lymphadenopathy without breast mass is benign reactive lymphadenopathy, but biopsy is necessary to exclude malignancies, such as metastatic lymphadenopathy or lymphoma.

Clinical and imaging features of idiopathic granulomatous mastitis - The diagnostic challenges and a brief review

Idiopathic granulomatous mastitis (IGM), or granulomatous lobular mastitis is a rare, benign, inflammatory condition of the breast, without an identifiable underlying etiology. The clinical and imaging diagnosis of this entity is challenging with the presentation frequently mimicking inflammatory breast carcinoma (IBC). Mammography and breast ultrasound (US) have an important role in its detection, however, biopsy is imperative for histopathological confirmation. We present three cases of biopsy proven IGM, highlighting the variability of the clinical and imaging features,brieflyreview the relevant literature and discuss the challenges associated with its diagnosis and management.

Mastitis in Autoimmune Diseases: Review of the Literature, Diagnostic Pathway, and Pathophysiological Key Players

Mastitis frequently affects women of childbearing age. Of all the pathological breast conditions requiring specific management, autoimmune mastitis is in the third position after infection and breast cancer. The aim of this literature review was to make a comprehensive description of autoimmune diseases targeting the mammary gland. Four main histological patterns of autoimmune mastitis are described: (i) lymphocytic infiltrates; (ii) ductal ectasia; (iii) granulomatous mastitis; and (iv) vasculitis. Our literature search found that all types of autoimmune disease may target the mammary gland: organ-specific diseases (diabetes, thyroiditis); connective tissue diseases (such as systemic erythematosus lupus or Sjögren’s syndrome); vasculitides (granulomatosis with polyangiitis, eosinophilic granulomatosis with polyangiitis, giant cell arteritis, polyarteritis nodosa, Behçet’s disease); granulomatous diseases (sarcoidosis, Crohn’s disease); and IgG4-related disease. Cases of breast-specific autoimmune diseases have also been reported, including idiopathic granulomatous mastitis. These breast-limited inflammatory diseases are sometimes the first symptom of a systemic autoimmune disease. Although autoimmune mastitis is rare, it is probably underdiagnosed or misdiagnosed. Early diagnosis may allow us to detect systemic diseases at an earlier stage, which could help to initiate a prompt, appropriate therapeutic strategy. In case of suspected autoimmune mastitis, we hereby propose a diagnostic pathway and discuss the potential pathophysiological pathways leading to autoimmune breast damage.

The Role of Establishing a Multidisciplinary Team for Idiopathic Granulomatous Mastitis in Improving Patient Outcomes and Spreading Awareness about Recent Disease Trends

Background

Iidiopathic granulomatous mastitis (IGM) is stereotypically described as a mysterious entity that mimics breast carcinoma imposing management challenges. In 2002, we established a multidisciplinary team to treat patients with IGM. This study aimed to evaluate the role of this team in improving patient outcomes. Also, a review of literature is provided to highlight recent disease trends. Patients and Methods. Pertinent data for 44 patients treated for IGM from 2002 to 2018 were analyzed and compared to data prior to 2002.

Results

Mean age at diagnosis was 37.9 years ± 6.4. The diagnosis of IGM was confirmed by True-cut biopsy (TCB), Frozen section (FS), and surgical biopsy in 70.5%, 25%, and 4.5% of patients, respectively. FS was used to assess the resection margins in three patients. Suspicion for malignancy was raised in one out of 39 ultrasound reports, and one out of 20 mammography reports. Wide local excision was the main treatment modality (95.5%). 19 patients (43.2%) received corticosteroids. Prior to 2002, IGM was only recognized after surgical resection with a 71% initial false impression of carcinoma. After 2002, the initial false clinical impression of carcinoma dropped to 29.5%. Recurrence rate was 31.82%. Younger age at diagnosis was significantly associated with recurrence (χ ² = 5.598; p = 0.018). Chi-square analysis showed no significant association between BMI and recurrence (χ ² = 0.776; p = 0.678).

Conclusion

The establishment of a multidisciplinary team for IGM was associated with a reduced erroneous impression of breast cancer, and a reduced false positive radiological diagnosis of breast carcinoma. FS was a useful confirmatory procedure. Our series included the first case of a diffuse papular rash as a systemic manifestation of IGM. Recent literature indicates that IGM is changing its face. IGM is being reported in all age groups, and even in males. The clinical manifestations have markedly expanded. Diagnosis by TCB has replaced blind surgical excision. More data regarding predictors of recurrence is accumulating.

[Rare Forms of Mastitis]

Rare Forms of Mastitis Abstract. Inflammatory breast diseases caused by bacterial infections represent the main cause for mastitis in breastfeeding and non-breastfeeding women. The clinical appearance and a standardized evaluation can indicate rare inflammatory breast diseases. An underlying comorbidity or the evidence of rare pathogens could be suggestive. However, core needle biopsy is the main step in diagnostics. Malignancy, e.g. an inflammatory breast cancer must consistently be excluded. This mini review outlines a few rare inflammatory breast diseases, their initial presentation, and how to diagnose them accurately.

Granulomatous Mastitis: A Therapeutic and Diagnostic Challenge

Granulomatous mastitis (GM) is a rare benign inflammatory breast disease that affects mostly women of childbearing age with a history of breastfeeding. The etiopathogenesis is still unknown; however, inflammation as the result of a reaction to trauma, metabolic or hormonal processes, autoimmunity, and an infection with Corynebacterium kroppenstedtii have all been implicated. Clinical findings are pain, mass, hyperemia, and inflammation. Because the clinical presentation can mimic infectious mastitis or inflammatory carcinoma, the disease course is often protracted. The diagnosis is made by histopathology. Biopsies show a granulomatous formation in combination with a localized infiltration of multi-nucleated giant cells, epithelioid histiocytes, and plasma cells. Ultrasound, mammography, and magnetic resonance imaging are not specific; however, ultrasound and mammography should be done to exclude other pathologies. Due to the lack of data including randomized controlled studies, the management of GM is controversial. In Western industrialized countries, most authors use a therapy regimen starting with antibiotics and corticosteroids, followed by continuous steroid therapy and surgery in patients with persisting symptoms. More data are needed to define the best therapy. The role of immunotherapy has not yet been ascertained. The implementation of a registry to collect more information on this rare disease is highly recommended.