Tuberculosis of the breast: US, mammographic, and CT findings

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

Objectives

This article reviews our experience and describes the literature findings of granulomatous diseases of the breast and axilla.

Methods

After approval of the Institutional Review Board was obtained, the surgical pathological records from January 2000 to January 2017 were searched for the keyword granulomatous. Clinical, imaging and histology findings were reviewed by both a fellowship-trained radiologist and a breast-imaging consultant radiologist, reviewing 127 patients (age range, 32–86 years; 126 women and 1 man).

Results

Most common causes of granulomatous lesions of the breast and axilla included silicone granulomas 33% (n = 42), fat necrosis 29% (n = 37) and suture granulomas 11% (n = 14). In 16% (n = 20), no cause could be found and clinical history was consistent with idiopathic granulomatous mastitis. Other granulomatous aetiologies included granulomatous infections, sarcoidosis and Sjögren’s syndrome. Causes of axillary granulomatous disease were similar to the breast; however, a case of cat-scratch disease was found that only involved the axillary lymph nodes. They can have a variable appearance on imaging and may mimic malignancy with irregular masses seen on mammography, ultrasound and magnetic resonance imaging. Fistulas to the skin and nipple retraction can suggest chronicity and a granulomatous aetiology. Combination of clinical history, laboratory and imaging findings can be diagnostic.

Conclusions

Granulomatous processes of the breast are rare. The diagnosis can, however, be made if there is relevant history (prior trauma, silicone breast implants, lactation), laboratory (systemic or infectious processes) and imaging findings (fistula, nipple retraction). Recognising these entities is important for establishing pathological concordance after biopsy and for preventing unnecessary treatment.

Teaching points

Breast granulomatous are rare but can mimic breast carcinoma on imaging

Imaging with clinical and laboratory findings can correctly diagnosis specific granulomatous breast diseases

Recognition of the imaging findings allows appropriate pathological concordance and treatment

Breast Tuberculosis

Tuberculosis affects over a billion people worldwide. There is a raise in incidence of extrapulmonary tuberculosis in recent years. Mammary tuberculosis has been estimated to be 0.1 % of breast lesions examined histologically, and it constitutes about 3-4.5 % of surgically treated breast diseases in developing countries. Breast tuberculosis is paucibacillary and routine diagnostic tests such as microscopy, culture, and nucleic acid amplification tests such as polymerase chain reaction techniques do not have the same diagnostic utility as they do in pulmonary tuberculosis. Also, the histology resembles various other granulomatous mastitis. The coexistence of carcinoma and breast tuberculosis adds challenge to diagnosis. Correct diagnosis of tuberculous mastitis is important as the treatment of differential disease varies from steroid to surgery which can have devastating consequences in patients suffering from breast tuberculosis.

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.

Primary breast tuberculosis presenting as a lump: a rare modern disease

Breast tuberculosis is an uncommon form of entity especially in the infra-mammary area. A 25- year-old female, presented with a lump in the breast and infra-mammary area. She was having off and on fever without any other complaints. There was no positive family history. Primary breast tuberculosis was diagnosed on fine needle aspiration cytology wherein ZN stain for acid fast bacilli was positive. The patient received antitubercular drugs and at 3 month follow up the swelling had resolved and the patient was asymptomatic. Breast tuberculosis is a rare disease with non-specific clinical, radiological, and histological findings. Misdiagnosis is common as biopsy specimens are pauci-bacillary and investigations such as microscopy and culture are frequently negative.

[Tuberculosis of the breast: imaging findings in two patients]

Diagnosis of breast tuberculosis is difficult and rare in western countries. We describe two cases of mammary tuberculosis, with mastitis as clinical feature that fail to heal despite antibiotic therapy. Mammographic findings showed a large opacity involving the entire breast in case 1, and a focal asymmetric density with irregular margins in case 2. Sonographic findings revealed in both cases hypoechoic nodules with fistulous tracks and axillary lymph nodes. Magnetic resonance was performed in one case, which showed parenchymal asymmetry with heterogeneous enhancement including irregular internal ring enhancement. Fine needle aspiration cytology revealed inflammatory cells in first case and atypical cells in second case. Core needle biopsy was performed in both cases to rule out malignant lesions. Acid-fast bacilli were negative in both patients while polymerase chain reaction was positive in one case. There was a good clinical response to antituberculosis therapy.

Proton magnetic resonance spectroscopy of tubercular breast abscess: report of a case

In vivo proton magnetic resonance spectroscopy (H-MRS) is a functional imaging modality. When magnetic resonance imaging is coupled with H-MRS, it results in accurate metabolic characterization of various lesions. Proton magnetic resonance spectroscopy has an established role in evaluating malignant breast lesions, and the increasing number of published literature supports the role of H-MRS in patients with breast cancer. However, H-MRS can be of help in evaluating benign breast disease. We present a case of tubercular breast abscess, initial diagnosis of which was suggested based on characteristic lipid pick on H-MRS and was subsequently confirmed by fine needle aspiration biopsy of the breast lesion.

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 tuberculosis

Breast tuberculosis is a rare form of tuberculosis. Of all the breast diseases treated surgically, tuberculosis is seen in the range between 0.025% and 0.1%. This ratio is higher in undeveloped countries. We presented five cases with breast tuberculosis. Their ages were between 20 and 63 years. All of them had children and were breastfeeding. The cause of admission to the hospital was swelling in four of them and pain in the remainder. All of the lesions were unilateral. One case had received antituberculosis treatment for pulmonary tuberculosis 10 years ago. AAFB was not detected in sputum, breast discharge, urine and tissue culture in all the cases. Diagnosis was made histopathologically from the excisional biopsy material. Caseating granulomatosis was also found in axillary lymph nodes in three cases. Antituberculosis therapy was planned as 2HRZE/4HR for all of the cases. Three of them completed the therapy without any complaints. One case left the hospital without permission. The last one is now undergoing resistant tuberculosis treatment for pulmonary disease without any complaint of her breast. As a conclusion, although tuberculosis of breast is extremely rare, it should be kept in mind particularly in developing and undeveloped countries.

Chest wall tuberculosis simulating breast carcinoma: imaging appearance

Tuberculosis of the breast is a rare disease. Tubercular abscesses predominantly affecting the soft tissues are also very infrequent. A case of chest wall tuberculosis secondarily involving the breast presenting as a hard, fixed lump simulating mammary carcinoma is presented here. There was no evidence of pleural or pulmonary tuberculosis.

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.