Quiz case. Breast sarcoidosis presenting as a metastatic breast cancer

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.

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.

Chronic granulomatous inflammation of the breast as a first clinical manifestation of primary sarcoidosis

BACKGROUND

Sarcoidosis is an idiopathic multisystemic disease that affects young to middle aged adults, with higher incidence in women. Although it may involve the breast parenchyma, primary sarcoidosis of the breast is very rare. It occurs in less than 1% of cases. In a differential diagnosis it may potentially be considered a malignancy.

CASE REPORT

We report a case in which breast sarcoidosis was the first clinical manifestation of systemic disease in a 54-year-old woman who presented with wide erythematous skin changes associated with palpable induration. Considering the fact that physical examination and the results of mammography, ultrasound and magnetic resonance imaging were inconclusive and unable to rule out malignancy, biopsy was performed. Pathohistological diagnosis showed a non-necrotizing granulomatous inflammation without elements of breast cancer. Sarcoidosis was confirmed with elevated level of angiotensin-converting enzyme in the sera and characteristic chest multislice computed tomography findings. The bronchoalveolar lavage was infiltrated with lymphocytes.

CONCLUSION

Breast sarcoidosis has diverse and nonspecific imaging characteristics. Carcinoma must always be excluded by core needle biopsy. Achieving correct diagnosis is mandatory so that adequate corticosteroid therapy can be applied as early as possible. A multidisciplinary approach is of utmost importance in the diagnostic workup.