Mammographic and sonographic spectrum of non-puerperal mastitis

Combining ultrasonography and mammography to improve diagnostic accuracy of plasma cell mastitis

OBJECTIVE

To evaluate the diagnostic value of ultrasonography and mammography for plasma cell mastitis.

METHODS

The ultrasonographic and mammographic images of 111 women with histopathologically confirmed plasma cell mastitis were retrospectively analyzed. The diagnostic accuracy of the two imaging methods was compared.

RESULTS

Ultrasonography identified 91 out of 111 (82.0%) patients with plasma cell mastitis, while the other twenty (18.0%) patients were misdiagnosed. Mammography identified 83 (74.8%) out of 111 patients with plasma cell mastitis. Nineteen (17.1%) patients were misdiagnosed. There was no significant difference between the diagnostic accuracy of using two imaging tests (P = 0.127). Mammography clouds identified 11 out of 20 patients who were not diagnosed by ultrasonography. Meanwhile, 19 of the 28 cases misdiagnosed with mammography were correctly identified by ultrasonography. Overall, 91.9% (102/111) of the patients were identified by the combination of ultrasonography and mammography, which yielded statistically significant higher accuracy than using each single test only (P < 0.05).

CONCLUSIONS

In diagnosis of plasma cell mastitis, high-frequency ultrasonography and mammography should be combined to improve the diagnostic accuracy.

Incidence of inflammatory breast cancer in patients with clinical inflammatory breast symptoms

BACKGROUND

To describe a large cohort of women with non-puerperal inflammatory breast and to identify characteristics of inflammatory breast cancer.

METHODS

All patients consulting for inflammatory breast syndrome in the breast unit of our tertiary University hospital between September 2013 and December 2015 were prospectively included. We excluded women who were pregnant or in the postpartum period. Patients underwent systematic clinical examination and imaging (breast ultrasonography and mammography). A biopsy was performed if the clinician suspected a malignant lesion of the breast. Clinicopathologic and radiologic data were registered. Statistics were performed using R (3.0.2 version) software.

RESULTS

Among the 76 patients screened and included, 38 (50%) had a malignant lesion at final diagnosis, 21 (27.6%) were diagnosed with infectious disease and 17 (22.4%) with inflammatory disease of the breast. When compared to patients with benign disease, patients with a malignant lesion were significantly older (p = 0.022, CI95% 1.78-14.7), had a significantly bigger palpable mass (p<0.001, CI 95% 22.8-58.9), were more likely to have skin thickening (p = 0.05) and had more suspicious lymph nodes at clinical examination (p<0.001, CI 95% 2.72-65.3). Precise limits on ultrasonography were significantly associated with benign lesions. The presence of a mass (p = 0.04), micro calcifications (p = 0.04) or of focal asymmetry (p<0.001, CI95% 1.3-618) on mammography was significantly associated with malignant disease.

CONCLUSION

Inflammatory breast cancer was common in our cohort of women consulting for inflammatory breast syndrome. Identifying these patients with high-risk malignancy is crucial in the management of an inflammatory breast.

Periductal Mastitis: An Inflammatory Disease Related to Bacterial Infection and Consequent Immune Responses?

Periductal mastitis (PDM) is a prolonged inflammatory disease, but the cause of PDM is poorly understood. In the present case control study, 87 PDM and 87 healthy controls were enrolled and the results were evaluated to identify the significant risk factors for PDM. To investigate the roles of bacterial infection and critical cytokines expression, 16S rRNA gene sequencing and bacterial culturing were conducted. We also measured the levels of interferon-γ, interleukin-12A, and interleukin-17A by semiquantitative immunohistochemistry method. In a multivariable logistic regression model, we identified overweight/obesity and late onset of menarche as independent risk factors for PDM. In contrast, age of first birth >27 years had a protective effect. With 16S rRNA gene sequencing, we confirmed bacterial infections were found in all PDM patients, but none of the control patients was positive on the gene expression of 16S rRNA. Our results also demonstrated significant increases of the IFN-γ and IL-12A expression in PDM, but there was no difference in IL-17A expression in these two groups. Taken together, this study suggests that reproductive factors and overweight/obesity are possible predisposing risk factors for PDM. Bacterial infection and the increased expression of some proinflammatory cytokines are associated with the pathogenesis of this disease.

[Exploration of breast inflammation excluding pregnancy and breastfeeding: Guidelines]

Breast inflammation, excluding breast-feeding and pregnancy, is a rare breast pathology. We conducted a PubMed database search of all studies focusing on mastitis or breast inflammation exploration. While the most frequent aetiologies are infectious and inflammatory, inflammatory breast cancer can be diagnosed (LE2). Aetiologic diagnostic is difficult due to the absence of any clinical and imaging specific signs (LE3). The presence of mass, suspect lymph nodes or skin thickening in a woman older than 40 years old should orient toward inflammatory breast cancer (LE3). A suspect lesion must lead to perform a biopsy under sonography (grade A). In the absence of evidence for a malignant pathology after initial evaluation, we recommend starting an antibiotic treatment (grade C) with a clinical follow-up at the end of the treatment (grade B). If the symptoms persist, we recommend a new imaging (± MRI) (grade C) and a biopsy (grade C). Benign inflammatory pathologies may require a biopsy to exclude an inflammatory breast cancer and precise the diagnosis. Their specific management and treatment are presented in detail in the following chapters and may involve steroids.

Clinical experience with aspiration of breast abscesses based on size and etiology at an academic medical center

PURPOSE

Our purpose was to review needle aspiration of breast abscesses and identify factors associated with treatment by aspiration alone versus aspiration with surgical incision and drainage (I/D).

METHODS

This Institutional Review Board-approved, retrospective review of the breast ultrasound database from 2008 to 2010 identified 40 patients (41 abscesses) who underwent aspiration, with or without I/D. Demographics, imaging, number of aspirations, and microbiology were reviewed.

RESULTS

Twenty-two abscesses underwent aspiration only, 16 > 3 cm, 6 ≤ 3 cm (mean 4.3 cm, range 0.9-10 cm). Known risk factors included lactational (11), 3 weeks post partum (1), pregnancy (1), recent biopsy/lumpectomy (5). Nineteen abscesses underwent aspiration and I/D, 15 > 3 cm, 4 ≤ 3 cm (mean 4.1 cm, range 2.2-7.5 cm). Known risk factors included lactational (4), recurrent subareolar abscess (4), diabetes (3), hydradenitis suppuritiva (1), nipple piercing (2), smoking (1), pregnancy (1), HIV (1), and lumpectomy (1). Identified reasons for I/D included lack of improvement/recurrence (12), fistula (3), and one electively after clinical improvement of a recurrent subareolar abscess.

CONCLUSIONS

Abscesses associated with pregnancy and lactation or breast biopsy are effectively managed with aspiration, even when large. Recurrence, chronicity, or fistula may require surgical intervention.

Nodular fasciitis in the axillary tail of the breast

Nodular fasciitis is a benign proliferation of myofibroblasts which presents clinically as a rapidly growing mass with nonspecific features on imaging and high cellular activity on histopathology. Nodular fasciitis can be mistaken for malignant fibrous lesions such as soft tissue sarcoma or breast carcinoma when located within breast tissue. This presents a problem for appropriate treatment planning as the natural history of nodular fasciitis is spontaneous regression. We present the mammographic, sonographic, computed tomography, and histopathologic characteristics of nodular fasciitis in a 68 year female initially presenting with a rapidly enlarging right axillary mass.

Breast ductal carcinoma in situ presenting as recurrent non-puerperal mastitis: case report and literature review

Breast ductal carcinoma in situ (DCIS) is a preinvasive form of breast cancer. It typically presents as microcalcifications which are picked up on screening mammogram. We report an atypical case of breast DCIS presenting with recurrent non-puerperal mastitis with a normal mammogram and perform a literature review.

Hyperechoic lesions of the breast: radiologic-histopathologic correlation

OBJECTIVE

Breast ultrasound is helpful in the characterization of masses to differentiate benign from malignant disease. The internal echotexture of a mass is an important ultra-sound feature in breast diagnostic workup. This article reviews the imaging and histopathology findings of benign and malignant hyperechoic masses to better recognize these conditions.

CONCLUSION

Hyperechoic masses are frequently benign, including hematoma, fat necrosis, abscess, and benign neoplasm. Malignant hyperechoic lesions include invasive ductal and invasive lobular carcinoma, lymphoma, and sarcoma. Understanding lesion echotexture in the context of clinical and mammographic findings will help establish appropriate diagnoses for hyperechoic masses.

Radiological and clinical features of adult non-puerperal mastitis

OBJECTIVE

To describe the radiological and clinical features of adult non-puerperal mastitis and to determine the most accurate method of preventing unnecessary surgical procedures.

METHODS

Clinical and imaging findings were retrospectively reviewed in 51 females with non-puerperal mastitis, which was confirmed by biopsy/surgical pathology. All 51 patients had pre-operative MRI; 45 patients also had sonograms and 25 also had mammograms, pre-operatively.

RESULTS

Of the 51 cases with non-puerperal mastitis, 94.1% (48/51) were confirmed as having acute or chronic inflammation, and the other 3 had plasma cell mastitis; areola papillaris inflammation was found in 39.2% (20/51) of the cases. Overall, 6 of the 25 cases that were examined with mammography and 2 of the 45 cases that were examined with sonography appeared normal, but all 51 lesions were positively identified on MRI. Asymmetrical density (12/25) on mammograms and solitary or separated/contiguous, clustered, hypoechoic mass-like lesions (31/45) on ultrasound were the most common signs of non-puerperal mastitis. On enhanced MRI, 90.2% (46/51) of patients showed non-mass-like enhanced lesions. Multiple regional enhancements in the pattern of distribution (32/46) and separated or contiguous, clustered, rim-like enhancements in the pattern of internal enhancement (29/46) were the most common manifestations in non-mass-like enhanced lesions. Of the 51 patients, mastitis Type 1 and Type 2 in the time-signal intensity curve were detected in 47.1% and 51.0% of the patients, respectively. The breast imaging reporting and data system categories with the highest number of patients were Category 0 (9/25) on mammography, Category 4a on sonography (18/45) and Category 4a on MRI (29/51).

CONCLUSION

The findings from mammography and ultrasound are non-specific; therefore, using MR can be helpful in the diagnosis, especially in the presence of non-mass-like enhancements that are multiple, regional, separated, or contiguous, clustered and rim-like.

ADVANCES IN KNOWLEDGE

Mastitis is often neglected because of the lack of typical clinical signs and symptoms. This study has assessed and described the clinical features and imaging findings of adult non-puerperal mastitis on mammograms, sonograms and MRI and found that MRI is more specific in the diagnosis of disease.

Breast abscess, an early indicator for diabetes mellitus in non-lactating women: a retrospective study from rural India

INTRODUCTION

Breast abscess is commonly seen in lactating and non-lactating women. Diabetes mellitus (DM) frequently predisposes to soft tissue infections and has many different presentations. But DM presenting in the form of breast abscess is yet to be studied, and we believe our study is the first to explore this connection.

METHODS

We collected 30 cases of breast abscess in women who presented to our hospital from May 2010 to June 2011 retrospectively. They were classified into lactating and non-lactating women, and their glycemic status was evaluated, together with length of hospital stay, management, recurrence, and follow-up status after 6 months.

RESULTS

We found that of the 30 patients in our study, 20% had high blood sugar levels. And 37.5% of the non-lactating women were diagnosed newly with DM.

CONCLUSIONS

This study shows that DM can present as breast abscess in non-lactating women. Therefore, non-lactating women with a breast abscess should be evaluated for DM.

Morphological manifestations of nonpuerperal mastitis on magnetic resonance imaging

PURPOSE

To investigate the morphological features of nonpuerperal mastitis on magnetic resonance imaging (MRI).

MATERIALS AND METHODS

MRI results of 27 patients diagnosed with nonpuerperal mastitis were retrospectively analyzed according to the Breast Imaging Reporting and Data System (BI-RADS).

RESULTS

According to the enhanced MRI results, 22 cases presented as nonmass-like enhancements and five cases presented as masses. For the 22 nonmass-like enhancement lesions, one case showed as a homogeneous enhancement and 21 cases showed as heterogeneous enhancements. In the 21 heterogeneous enhancement cases, 13 contained lesions of rim-like enhancement. With regard to the number of lesions with rim-like enhancement, 11 presented as multiple and two as single. In the five mass lesions, three presented as rim enhancements. Indications of rim or rim-like enhancement accounted for 59% (16/27) of all cases. For the 16 cases that presented with signs of rim or rim-like enhancement, the central hypointensity area surrounded by enhanced rim or rim-like entity showed as hyperintensity in 14 cases and hypointensity or heterointensity in two cases on T2-weighted imaging.

CONCLUSION

On contrast-enhanced MRI, most nonpuerperal mastitis presented as nonmass-like lesion with heterogeneous signal intensity. The observation of signs of rim or rim-like enhancement on contrast-enhanced MRI with central hypointensity areas showing as hyperintensity on T2-weighted imaging is suggestive of the possibility of nonpuerperal mastitis.

Spectrum of sonographic findings in superficial breast masses

OBJECTIVE

The purpose of this presentation is to show the sonographic findings of breast masses, which can occur in subcutaneous fat or in the cutaneous layer of the breast.

METHODS

We reviewed the sonographic findings of superficial breast masses, including the epidermal inclusion cyst, steatocystoma multiplex, fat necrosis, accessory breast, Mondor disease, sparganosis, neurofibroma, tuberculosis, mastitis, and breast malignancy.

RESULTS

Specific sonographic features of superficial breast masses have been illustrated.

CONCLUSIONS

Radiologists must be familiar with the sonographic findings of various diseases involving the superficial layer of the breast to avoid further patient workup.

Breast Abscess in Lactating Women: US-guided Treatment

PURPOSE

To retrospectively evaluate the use of ultrasonography (US)-guided treatment of breast abscesses in lactating women.

MATERIALS AND METHODS

One hundred eight consecutive lactating women who were clinically suspected of having a breast abscess were examined with US. Abscesses depicted at US were treated with US guidance, and the success of US-guided treatment was retrospectively determined.

RESULTS

Fifty-six abscesses were identified at US in 43 women; all abscesses were treated with US guidance: 23 with needle aspiration and 33 with catheter drainage. Treatment method was determined according to the size of the abscess. Abscesses that were smaller than 3 cm in maximum diameter were treated with needle aspiration, and abscesses that were 3 cm or larger in maximum diameter were treated with catheter insertion. One patient who was treated with needle aspiration subsequently underwent surgical intervention; all others were successfully treated with US intervention. Catheter placement was well tolerated (mean pain score 2.3 in 22 women by using a subjective pain scale of 0-10).

CONCLUSION

US-guided needle aspiration of abscesses smaller than 3 cm and US-guided catheter drainage of abscesses 3 cm or larger are successful means of treating breast abscesses.

Interstitial fluid and hypoechoic wall: two sonographic signs of breast abscess

PURPOSE

Many mammographic and sonographic features of breast abscess overlap with those of carcinoma. We reviewed the usefulness of interstitial fluid and hypoechoic walls in the sonographic diagnosis of breast abscess.

METHODS

The sonograms and records of 65 patients with breast infection and 60 contemporaneous patients with breast cancer were retrospectively reviewed.

RESULTS

Of 49 abscesses identified in patients with breast infection, 14 (29%) had adjacent interstitial fluid that was sonographically visible, and 15 (31%) had a hypoechoic wall. No patients with breast cancer had either sign. The overall sensitivity of the presence of either sign was 55%, and the specificity was 100%.

CONCLUSIONS

Two sonographic findings, interstitial fluid and a hypoechoic wall, are relatively specific for breast abscess and may aid in the diagnosis of breast disease.