The Diagnosis and Management of Diabetic Mastopathy

Diabetic Fibrous Mastopathy: Imaging Features With Histopathologic Correlation

Diabetic fibrous mastopathy (DFM) is a rare benign fibrotic disease of the breast that develops in patients with longstanding and often uncontrolled diabetes mellitus. Clinically, patients may present with an irregular, firm, palpable mass, which may be solitary or multiple, occurring in one or both breasts. Diabetic fibrous mastopathy occurs most often in premenopausal women with heterogeneously or extremely dense breasts; mammography may show focal asymmetry or, less often, a noncalcified mass with indistinct or obscured margins, but there are usually no discrete findings. On US, DFM may have marked hypoechogenicity and posterior shadowing secondary to extensive fibrosis. Diabetic fibrous mastopathy features on contrast-enhanced MRI are also nonspecific, with gradual persistent nonmass enhancement reported. Because the clinical presentation and US features of DFM overlap with those of breast cancer, histopathologic correlation is needed to confirm diagnosis and exclude malignancy. These findings include collagenous stroma often with keloidal features and chronic perilobular and perivascular inflammation. Histopathologic findings of lymphocytic lobulitis and perivascular inflammation are common to other autoimmune conditions.

Diabetic mastopathy: A rare clinicopathologic entity with considerable autoimmune potential

Introduction and importance

Diabetic mastopathy is a rare entity affecting diabetic patients. It has been previously linked to type 1 diabetes mellitus; however, due to the several accompanying conditions, a theory of autoimmune factors contributing to the origin of this condition has been on the rise. In this paper, we report a case of diabetic mastopathy associated with several autoimmune diseases to highlight the immunological potential of this condition.

Case presentation

A 25-year-old female, known to have type 1 diabetes mellitus, hypertension, hypothyroidism, adrenal insufficiency, dilated cardiomyopathy and end-stage renal disease, was referred to our clinic for a breast lump. Radiological investigations showed a dense mass with irregular borders in the retroareolar area of the left breast. A core biopsy was obtained which revealed keloid-like fibrosis along with lymphocytes infiltrated, suggestive of lymphocytic mastopathy.

Clinical discussion

Fibrous mastopathy has been merely attributed to a long-standing use of insulin therapy by diabetic patients; recent observations, however, proved the major contribution of immunity to etiopathogenesis. Even though human leukocyte antigen (HLA) association has not been supported in the literature, the histological changes of breast lymphocytic infiltrate are seen in patients who not only have T1DM, but also thyroiditis, systemic lupus erythematosus, Sjogren's syndrome, and Addison's disease. The frequent presence of several possible autoimmune conditions has promoted the theory of an autoimmune process affecting connective tissues, however, these claims are yet to be proven by future studies.

Conclusion

Recent observations have proved the major contribution of immunity to etiopathogenesis of diabetic mastopathy. We shed light on the role of the immune system in triggering the disease process by reporting a case of diabetic mastopathy with a cluster of autoimmune diseases. Future studies should explore the genetic background of the condition as it would potentially have several clinical implications. The discussed pathophysiologic explanations raise the possibility of autoimmunity as a key driver in pathogenesis and indicate the need to change the nomenclature of this condition.

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Recent observations proved the major contribution of immunity to etiopathogenesis of fibrous mastopathy.

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Fibrous mastopathy has some clinical and diagnostic features that resemble malignancy.

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The benign nature of diabetic mastopathy permits following a conservative approach for management.

Diabetic Mastopathy. Review of Diagnostic Methods and Therapeutic Options

Diabetic mastopathy is a rare breast condition that may occur in insulin-treated men and women of any age. The etiology is still unclear; however, the autoimmunological background of the disease is highly suspected. The changes in diabetic mastopathy may mimic breast cancer; therefore, its diagnostic process is demanding, and treatment options are not clear and limited. Lesions in DM are usually multiple; therefore, surgical removal is not fully effective. A well-done anamnesis with core-needle biopsy is essential and definitive in most cases. In this review, we summarize up-to-date knowledge of diagnostic methods and therapeutic options for diabetic mastopathy treatment and present three cases of diabetic mastopathy-type lesions in ultrasound and radiological examinations.

"What Do You Mean It's Not Cancer?" A Review of Autoimmune and Systemic Inflammatory Diseases Involving the Breast

Autoimmune and systemic inflammatory diseases represent a heterogeneous group of immune-mediated conditions with a wide range of clinical presentations and various affected organs. Autoimmune diseases can present in the breast as localized disease or as part of systemic involvement. Although breast involvement is uncommon, the spectrum of imaging findings can include breast masses, axillary adenopathy, calcifications, and skin changes, the appearance of which can mimic breast cancer. Common etiologies include diabetic mastopathy, systemic lupus erythematosus, scleroderma, rheumatoid arthritis, idiopathic granulomatous mastitis, sarcoidosis, and Immunoglobulin-G4 related mastopathy. This educational review will present multimodality imaging findings of breast manifestations of systemic inflammatory and autoimmune diseases and coexisting complications. It will also review how these disorders may affect breast cancer risk and breast cancer treatment options, including radiation therapy.

Mimickers of breast malignancy: imaging findings, pathologic concordance and clinical management

Many benign breast entities have a clinical and imaging presentation that can mimic breast cancer. The purpose of this review is to illustrate the wide spectrum of imaging features that can be associated with benign breast diseases with an emphasis on the suspicious imaging findings associated with these benign conditions that can mimic cancer. As radiologic-pathologic correlation can be particularly challenging in these cases, the radiologist’s familiarity with these benign entities and their imaging features is essential to ensure that a benign pathology result is accepted as concordant when appropriate and that a suitable management plan is formulated.

Systemic diseases affecting the breast: Imaging, diagnosis, and management

Various systemic diseases of benign or malignant etiologies can clinically manifest in the breast. Some imaging findings of breast lesions can be pathognomonic for a given condition, while others are non-specific, mimicking primary breast carcinoma and requiring tissue biopsy for definitive diagnosis. In addition to obtaining a detailed clinical history, radiologists should be familiar with the diverse clinical and imaging characteristics of these conditions to help exclude primary breast cancer and avoid unnecessary interventions. This review aims to discuss the clinical presentations, imaging features, pathologic findings, and management of systemic conditions that may affect the breast.

Diabetic Mastopathy in a Patient with High Risk of Breast Carcinoma: A Management Dilemma

Diabetic mastopathy is a rare benign breast condition. It is strongly associated with type I diabetes mellitus and commonly presents similar to malignancy. Here, we report a case of a 29-year-old Saudi female with a long history of type I diabetes mellitus (DM) who presented with a painless hard breast mass and had a strong family history of breast cancer. Further evaluation with ultrasound (US) imaging revealed a highly suspicious, ill-defined hypoechoic lesion. Mammographic examination revealed that both breasts were of normal shape with bilateral dense glandular parenchyma. US-guided true-cut biopsy was carried out, which showed acellular fibro-sclerotic tissues with normal-looking lobules and ducts surrounding by a dense lymphocytic infiltrate. Subsequently, a diagnosis of diabetic mastopathy was established. Results were discussed with the patient, and an agreement was reached to proceed with an excisional biopsy for further reassurance and exclusion of malignancy. Local surgical excision of the lesion was performed and histopathological examination revealed extensive fibrosis of the specimen with no cellular atypia. Awareness of such a condition, with its clinical, radiographical, and histopathological characteristics, is essential in order to alleviate the patient's anxiety and avoid unnecessary surgical interventions.

Mammary Extranodal Rosai-Dorfman Disease With and Without Associated Axillary Lymphadenopathy: Insights for Practitioners of Breast Pathology

Rosai-Dorfman disease is a rare proliferative histiocytic disorder of lymph nodes that is descriptively known as sinus histiocytosis with massive lymphadenopathy. Extranodal involvement of the parenchyma of the breast is uncommonly reported, with fewer than 50 cases of mammary extranodal disease detailed in the English-language literature. We characterize a retrospective series of adult female patients from a single institution with Rosai-Dorfman disease of the breast and axillary lymph nodes. Because Rosai-Dorfman disease of the breast and axillary lymph nodes may clinically, radiographically, and histologically mimic breast carcinoma and other conditions, we present an illustrated review of the disease and its relevant differential diagnoses in hopes of raising awareness and allowing for accurate management of affected patients.

Clinical, mammographic, and ultrasonographic characteristics of diabetic mastopathy: A case series

PURPOSE

Diabetic mastopathy (DMP) is a rare benign breast lesion that mimics breast cancer on ultrasound. Our aims were to identify patient characteristics and imaging features of the disease.

METHODS

We conducted retrospective searches of our database for DMP lesions that were pathologically confirmed between January 2004 and November 2015. Mammographic and ultrasound features were reviewed by two experienced radiologists.

RESULTS

Twelve women were identified with 16 lesions. Most patients (83%) had type 2 diabetes mellitus (DM) and over half were insulin-dependent (58.3%), with a mean time of 16.9 years between the diagnosis of DM and that of DMP. There were negative findings on mammography for 46.7% of the lesions, including larger-sized lesions. Ultrasound revealed various features, including irregular shape (81.3%), indistinct margins (100%), parallel orientation to the chest wall (93.8%), marked hypoechogenicity (87.5%), and posterior shadowing (62.5%).

CONCLUSIONS

DMP was more common in patients with longstanding DM; in particular, type 2 DM and insulin-dependent patients. DMP lesions were usually occult on mammography, despite the relatively large size of DMP, which may help distinguish DMP from invasive cancer. Ultrasound detected several features that are also present in invasive cancer, making tissue sampling necessary to distinguish these.

Image analysis of immune cell patterns in the human mammary gland during the menstrual cycle refines lymphocytic lobulitis

PURPOSE

To improve microscopic evaluation of immune cells relevant in breast cancer oncoimmunology, we aim at distinguishing normal infiltration patterns from lymphocytic lobulitis by advanced image analysis. We consider potential immune cell variations due to the menstrual cycle and oral contraceptives in non-neoplastic mammary gland tissue.

METHODS

Lymphocyte and macrophage distributions were analyzed in the anatomical context of the resting mammary gland in immunohistochemically stained digital whole slide images obtained from 53 reduction mammoplasty specimens. Our image analysis workflow included automated regions of interest detection, immune cell recognition, and co-registration of regions of interest.

RESULTS

In normal lobular epithelium, seven CD8[Formula: see text] lymphocytes per 100 epithelial cells were present on average and about 70% of this T-lymphocyte population was lined up along the basal cell layer in close proximity to the epithelium. The density of CD8[Formula: see text] T-cell was 1.6 fold higher in the luteal than in the follicular phase in spontaneous menstrual cycles and 1.4 fold increased under the influence of oral contraceptives, and not co-localized with epithelial proliferation. CD4[Formula: see text] T-cells were infrequent. Abundant CD163[Formula: see text] macrophages were widely spread, including the interstitial compartment, with minor variation during the menstrual cycle.

CONCLUSIONS

Spatial patterns of different immune cell subtypes determine the range of normal, as opposed to inflammatory conditions of the breast tissue microenvironment. Advanced image analysis enables quantification of hormonal effects, refines lymphocytic lobulitis, and shows potential for comprehensive biopsy evaluation in oncoimmunology.

Sclerosing Lymphocytic Lobulitis Mimicking a Tumor Relapse in a Young Woman with a History of Breast Cancer

Sclerosing lymphocytic lobulitis or diabetic mastopathy is a benign entity with non-specific imaging features which can mimic breast carcinoma. It is a condition commonly associated with long standing diabetes and has also been linked with various auto-immune diseases. We present the case of a 27-year-old woman with a history of carcinoma of the left breast and otherwise unremarkable medical history, who developed sclerosing lymphocytic lobulitis in the right breast during follow-up.

Diabetic mastopathy: a diagnostic challenge in breast sonography

PURPOSE

Our purpose was to retrospectively evaluate the incidence and morphologic features of diabetic mastopathy in a group of patients with diabetes, searching for specific sonographic characteristics of diabetic mastopathy.

METHODS

One hundred twenty diabetic patients underwent breast clinical examination, mammography, and sonography. All detected breast lesions were confirmed histopathologically.

RESULTS

Breast lesions were found in 11 of the 120 patients (9%), including two cases of invasive ductal carcinomas and nine cases of diabetic mastopathy. In seven of those nine cases (77%), diabetic mastopathy appeared as a hypoechoic solid mass with irregular margins, inhomogeneous echotexture, and marked posterior shadowing. In the other two cases (23%), it appeared as a mildly inhomogeneous, hypoechoic solid mass.

CONCLUSIONS

Diabetic mastopathy is a diagnostic challenge and needs to be suspected in all patients with diabetes mellitus. Imaging features are nonspecific and highly susggestive on breast sonography in most cases. Core-needle biopsy confirmation remains mandatory for a definitive diagnosis.

Unusual breast lesion mimicking cancer: diabetic mastopathy

Diabetic mastopathy represents an uncommon tumor-like proliferation of fibrous tissue of the breast that usually occurs in patients who suffered from type 1 diabetes mellitus for a long time. We report an uncommon case of diabetic mastopathy presenting in a type 2 non-insulin dependent diabetes mellitus 61-year-old postmenopausal woman. Physical examination revealed a hard, low movable mass in the upper outer quadrant of the right breast. Mammography and ultrasonography showed typical features of breast cancer. Ultrasound-guided fine-needle aspiration cytology (US-FNAC) was performed showing inflammatory infiltrate, suggesting excisional biopsy. Histological findings demonstrated typical diabetic mastopathy with fibrosis, histiocytic and limphocytic infiltration without evidence of malignancy.

Mimickers of breast malignancy on breast sonography

The aim of this article is to review benign breast lesions that can mimic carcinoma on sonography. Cases of benign lesions mimicking carcinoma on sonography were collected among lesions that were initially assessed as suspicious on sonography according to the American College of Radiology Breast Imaging Reporting and Data System category. Sonographically guided core needle biopsy was performed, and the pathologic types were confirmed to be benign. Cases of benign lesions mimicking carcinoma on sonography were shown to include fat necrosis, diabetic mastopathy, fibrocystic changes, sclerosing adenosis, ruptured inflammatory cysts, inflammatory abscesses, granulomatous mastitis, fibroadenomas, fibroadenomatous mastopathy, and apocrine metaplasia. Benign breast lesions may present with malignant features on imaging. A clear understanding of the range of appearances of benign breast lesions that mimic malignancy is important in radiologic-pathologic correlation to ensure that benign results are accepted when concordant with imaging and clinical features but, when discordant, there is no delay in further evaluation up to and including excisional biopsy.

Characteristics of systemic diseases in the breast: clinical, imaging and pathologic features

Despite tremendous efforts placed on advances in diagnosis and treatment of the spectrum of breast disease, the impact of systemic diseases on the breast has remained under recognized. Distinction between a variety of benign breast diseases versus those that are manifestations of a systemic disease is critically important for appropriate treatment planning and follow-up of patients. This article is designed to provide an overview of different systemic diseases that can present as a breast lesion. Attempts are made to highlight the significance of the distinction between benign breast disease versus benign conditions that present as the result of a systemic disease. Naturally, distinction between any benign condition versus breast carcinoma is a part of the evaluation process.

Idiopathic granulomatous lobular mastitis

Idiopathic granulomatous lobular mastitis (IGLM) is a rare breast condition with prominent skin findings. It is typically seen in young parous women. Painful breast masses, draining sinuses, scarring, and breast atrophy are the main clinical manifestations. IGLM can resemble a variety of other inflammatory and neoplastic processes of the breast. It is thought to result from obstruction and rupture of breast lobules. Extravasated breast secretions then induce an inflammatory reaction. Corynebacteria have also been implicated in the pathogenesis. Treatment is surgical, but systemic corticosteroids, methotrexate, and antibiotics also play a role.

Mammographic signs of systemic disease

Although mammography is primarily used for the detection of breast cancer, it can occasionally reveal breast abnormalities related to extramammary disease. Cardiovascular diseases such as congestive heart failure and central venous obstruction may manifest as venous engorgement and breast edema at mammography. Pathologic arterial calcifications seen at mammography can indicate an underlying risk factor for accelerated atherosclerosis such as chronic renal failure. Connective tissue diseases including rheumatoid arthritis, systemic lupus erythematosus, dermatomyositis-polymyositis, and systemic scleroderma typically manifest with bilateral axillary lymphadenopathy, and stromal calcifications are also seen in the latter three disease processes. Some diseases such as neurofibromatosis type 1 and filariasis may manifest with pathognomonic findings at mammography, whereas other systemic diseases such as Wegener granulomatosis, sarcoidosis, and amyloidosis can manifest as nonspecific breast masses that are indistinguishable from breast cancer and usually require tissue biopsy for confirmation. Knowledge of the imaging characteristics of various systemic diseases affecting the breast will aid the radiologist in differentiating systemic disease from suspect breast lesions, thereby helping ensure appropriate follow-up. Furthermore, recognition of systemic diseases such as Cowden syndrome that are associated with an increased risk of breast cancer will allow the radiologist to recommend appropriate surveillance.

Percutaneous biopsies: indications and techniques

Breast inflammation is a difficult clinical problem as it can result from a variety of causes: specific or non-specific infectious mastitis, which may or may not be complicated, primary or secondary inflammatory mastitis or inflammatory cancer. The main objective of radiology is to eliminate an inflammatory cancer. Other objectives are to characterise an inflammatory condition (where the clinical context is valuable in guiding diagnosis but which often requires a micro- or macrobiopsy) or to obtain a microorganism in cases of complicated infectious mastitis (a diagnostic procedure but also comprising the first stage of treatment). Whether for bacteriological or histological purposes, percutaneous samples therefore play a large part in the diagnostic procedure, other than in the clinical context of pregnancy where mastitis is more easily diagnosed because of its frequency. The guidance method is usually ultrasound, and the needle chosen will depend on the radiological or ultrasound signal: puncture with an 18G needle will be used for a bacteriological sample, microbiopsy of a mass or lymph nodes, or macrobiopsy in the case of microcalcifications.

Breast manifestations of systemic diseases

Although much emphasis has been placed on the primary presentations of breast cancer, little focus has been placed on how systemic illnesses may affect the breast. In this article, we discuss systemic illnesses that can manifest in the breast. We summarize the clinical features, imaging, histopathology, and treatment recommendations for endocrine, vascular, systemic inflammatory, infectious, and hematologic diseases, as well as for the extramammary malignancies that can present in the breast. Despite the rarity of these manifestations of systemic disease, knowledge of these conditions is critical to the appropriate evaluation and treatment of patients presenting with breast symptoms.

Diabetic mastopathy as a radiographically occult palpable breast mass

Diabetic mastopathy is an uncommon, benign disease of the breast that can occur in women with diabetes and clinically mimic breast cancer. We describe a patient with long-standing type 1 diabetes who presented with a palpable breast mass with negative imaging findings on mammography, ultrasonography, and breast MRI. Surgical biopsy and histopathology confirmed diabetic mastopathy. We use this case to highlight the recognition, radiographic features, pathology, and management of this benign breast condition and emphasize that, in diabetic patients, the differential diagnosis of a new breast mass should include diabetic mastopathy.

Benign breast lesions: Ultrasound

Benign breast diseases constitute a heterogeneous group of lesions arising in the mammary epithelium or in other mammary tissues, and they may also be linked to vascular, inflammatory or traumatic pathologies. Most lesions found in women consulting a physician are benign. Ultrasound (US) diagnostic criteria indicating a benign lesion are described as well as US findings in the most frequent benign breast lesions.

Calcifying fibrous pseudotumor of the breast

Calcifying fibrous pseudotumor (CFP) is classified as a benign fibrous lesion, and is a rare pathologic entity. Previous reports have described CFPs in the extremities, chest wall, pleura, scrotum, mediastinum, neck, and visceral peritoneum. We present the first reported case of a CFP in the breast. CFP should be considered in the differential diagnosis for patients presenting with coarse indeterminate calcifications of the breast.

An uncommon case of T1b breast cancer with diabetic mastopathy in type II diabetes mellitus

A 64-year-old postmenopausal female had been treated with insulin therapy for type 2 diabetes mellitus for 18 years, but her diabetes mellitus was not well controlled and she developed retinopathy. Her screening mammography showed abnormal findings, and thus she consulted a hospital. A physical examination showed her mammary glands to be hard on both sides and no palpable mass was observed. Mammography revealed an amorphous calcification in the middle outer portion of the left breast. Ultrasonography showed an irregular hypoechoic mass measuring about 11 mm in size in the upper outer portion of the left breast. Although a core-needle biopsy specimen of the hypoechoic mass showed hyalinizing fibrosis without any evidence of malignancy, a stereotactic guided vacuum-assisted biopsy was performed because magnetic resonance imaging revealed an enhanced area in the region of the amorphous calcification that could not be distinguished from breast cancer. The histological findings indicated noninvasive ductal carcinoma, and therefore a quardrantectomy with a sentinel lymph node biopsy was performed. The pathological diagnosis was invasive ductal carcinoma (0.7 × 0.3 cm) with a predominant intraductal component accompanying diabetic mastopathy. The sentinel lymph nodes demonstrated no metastasis. The surgical margin was positive for carcinoma and the patient later underwent a mastectomy. No malignant cells were observed in the specimen. The patient has so far experienced no recurrence after surgery.

Axillary lymphadenopathy as a first symptom of diabetic mastopathy

Diabetic mastopathy is an unusual fibroinflammatory breast lesion that characteristically presents in premenopausal women with long-standing type 1 diabetes mellitus.Patients present with clinically suspicious breast masses or axillary lymph nodes with imaging characteristics indistinguishable from malignancy. Fine needle aspiration is often inadequate and a core biopsy should be performed. Excisional biopsy is not necessary, and annual follow-up is recommended. Recognition of diabetic mastopathy should lead to better care of patients with breast nodules or axillary masses who are diabetic, avoiding surgery for this benign condition.