Breast calcifications on mammography from systemic amyloidosis: A case report

Calcifications on mammography from systemic disease at times meet diagnostic criteria for histologic sampling to exclude malignancy. We present a case of bilateral groups of new calcifications on mammography that yielded amyloidosis on core biopsy. Awareness of our patient's known diagnosis of systemic light chain amyloidosis (AL) prompted use of Congo red staining to confirm the histologic diagnosis. Knowledge of systemic diseases with possible manifestations on mammography can facilitate cogent and clinically relevant radiology-pathology correlation.

Imaging enigma in mastitis: A comprehensive study of multifaceted causes, clinical and radiological presentations

BACKGROUND

Mastitis is an inflammatory condition of the breast which represents an array of underlying etiologies encompassing both infectious and non-infectious causes. Exacerbating factors include endemic infections, lack of awareness and suboptimal breastfeeding practices. Neglected cases lead to prolonged morbidity, recurrent episodes, and complications such as abscess or sinus formation, resulting in permanent breast disfigurement. Its overlapping clinical presentation with breast cancer necessitates an integrated multidisciplinary approach for diagnosis and treatment.

OBJECTIVES

The primary aim was to investigate demographic, radiological, and histopathological characteristics of mastitis. Objectives included correlating radiological and histopathological findings, classifying mastitis by etiology, identifying the clinical and imaging patterns across diverse clinical settings to enhance the understanding of mastitis.

MATERIAL AND METHOD

This is a retrospective observational study, analysing the clinical, radiological, and histopathological data from 65 patients with mastitis between February 2023 and February 2024.

RESULTS

The study included 65 patients, aged 18 to 65 years, with breast pain as the most prevalent clinical presentation. Cases were classified as infectious (47.6%) and non-infectious (52%). Acute puerperal mastitis (26.15%) and granulomatous mastitis (30%) were the most common subtypes. The commonest mammographic finding was focal asymmetry. On ultrasound, infectious mastitis showed oedema with other inflammatory changes, including diffuse skin thickening and collections; while non-infectious mastitis typically presented as solitary or multiple breast masses (p < 0.001). Surprisingly, idiopathic granulomatous mastitis constituted the largest percentage amongst various histopathological causes of mastitis in our study.

CONCLUSION

An integrated multidisciplinary approach with understanding of the pathogenesis is imperative for prompt diagnosis and optimizing treatment strategies, thereby improving patient outcome. Radiological imaging is critical for diagnosis, evaluating disease extent, conducting guided interventions, and monitoring treatment response.

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.

Unilateral primary breast edema: Can T2-weighted images meet the diagnostic challenge?

Background

Unilateral primary breast edema may pose a diagnostic challenge. Excluding malignant etiologies is of utmost importance and may require the use of dynamic MRI examination as a problem solver. Yet, the enhancement pattern of benign and malignant disorders associated with edematous breasts may overlap, and this may add to the dilemma. So, our aim in the current study was to assess the role of T2-weighted MR imaging as a problem-solving sequence in differentiating benign from malignant causes of the edematous breast.

Results

In the current prospective study, 65/96 cases were benign and 31/96 cases were malignant. By the individual analysis of the signal intensity in T2-weighted imaging of MRI examination, there was a significant correlation between low T2 signal intensity lesion and malignant etiology of breast edema with a resultant higher sensitivity of 83.87% and a higher specificity of 98.46% as compared to the contrast-enhanced series, which achieved a sensitivity of 80.65% and a specificity of 20.00%. The combined assessment of T2 WI and the contrast-enhanced series yielded a higher sensitivity of 100% and a specificity of 98.46%.

Conclusions

T2WI is a problem-solving sequence in the evaluation of the primary edematous breast, yielding a significant added value in the diagnostic approach and improving the overall diagnostic performance of dynamic contrast-enhanced MRI.

Atypical sonographic presentation of diabetic mastopathy: A case report and literature review

Diabetic fibrous mastopathy (DFM) is a relatively rare condition that most often occurs in insulin-dependent diabetics with a characteristic hypoechoic appearance on ultrasound (US). DFM frequently poses a diagnostic challenge in radiology due to malignant imaging similarities, and core needle biopsy is often required. If DFM is in the differential, fine-needle aspiration should not be considered as it will likely be non-diagnostic due to insufficient sampling and excisional biopsy should be avoided as it may worsen the disease process. Therefore, high clinical suspicion of DFM is important for diagnostic intervention consideration. We report the case of a 57-year-old who presented with a firm breast lump which on mammography was seen as a new 5.8 by 5.3 cm global asymmetry. US was performed and a diffuse area of increased echogenicity without posterior shadowing was identified. Given the appearance and patient history, DFM was considered unlikely. However, core needle biopsy revealed diabetic lymphocytic mastopathy consistent with DFM. Even though DFM is uncommon and has been reported to have a specific US appearance, it should be included in the differential for a palpable breast lump in any diabetic patient regardless of glucose control or atypical imaging findings.

"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.

Skin Nodules as a First Presentation of Synchronous Bilateral Invasive Lobular Breast Carcinoma: A Case Report

The most common cause of skin metastases in adult women is primary breast carcinoma, which comprises about 70% of cases [1]. Skin metastases have non-specific clinical appearances, making it challenging to differentiate them from other benign conditions [1]. We present a case of a 52-year-old female with type II diabetes and a three-month history of refractory skin lesions who did not respond to anti-inflammatory treatment. The patient subsequently complained of a right breast lump, evaluation of which led to the diagnosis of bilateral synchronous invasive lobular carcinoma.

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.

Breast tuberculosis: a diagnosis not to be forgotten

Objective:

To study the clinical characteristics and imaging features of breast tuberculosis (TB) and to describe treatment.

Material and Methods:

A retrospective study including all patients hospitalized in the infectious diseases department for breast TB between 1997 and 2018.

Results:

Twenty-two women, with a mean age of 39±12 years, were identified. In total, 18 patients were multiparous (81.8%). Both lump and mastalgia were the presenting symptoms in 19 cases (86.3%). Ipsilateral axillary lymphadenopathy was noted in 14 cases (63.6%). The most common finding on ultrasound was a well or poorly defined mass lesion, noted in 17 cases (77.2%), followed by fistulous tracts in seven cases (31.8%). Mammography showed focal, asymmetric breast density in 17 cases (89.5%) and diffuse in two cases (10.5%). The diagnosis was confirmed based on the presence of epithelioid cell granulomas and caseous necrosis in 13 cases (59.1%). Patients received antitubercular therapy for a mean duration of 11±5 months. The disease evolution was favorable in 20 cases (91%). There were two relapsing cases (9%).

Conclusion:

Breast TB should be considered in the differential diagnosis of young patients presenting with palpable lump with axillary lymphadenopathy, especially in endemic regions. The diagnosis confirmation usually requires an excision biopsy providing histological or bacteriological evidence.

Continuous postoperative negative pressure irrigation assisted mammaplasty in treating chronic refractory plasma cell mastitis

Background

Chronic refractory plasma cell mastitis (CRPCM) is an aseptic inflammation of the breast with a chronic course of the disease, extended treatment cycle (months to years), with a high recurrence rate. The objective of this study was to evaluate the efficacy of continuous postoperative negative pressure irrigation assisted mammaplasty (CPNPIAM) in treating CRPCM.

Methods

Between 2016 and 2018, 36 CRPCM patients receiving CPNPIAM were enrolled in this study. CPNPIAM mainly involved complete lesion removal, immediate breast mammaplasty, and continuous postoperative negative pressure irrigation. The age of the patients, local symptoms, history of treatment, the duration of the disease before surgery, hospitalization period, related risk factors, the success rate, the recurrence rate and patients' overall satisfaction ratings were analyzed in the article.

Results

Patients were aged between 22 and 53 years (mean 34.64 years). All patients had a history of conservative treatment or simple drainage. Local symptoms included inflammatory mass (n=36, 100%), abscess (n=33, 92%), nipple discharge (n=7, 19%), inflammatory plaque (n=34, 94%), and sinus tract formation (n=19, 53%). The lesion sizes ranged from 3 to 10 cm (mean 5.13 cm) in diameter. The mean hospitalization period was 8.42 days. The success rate was 100% (36/36) and the recurrence rate was 0% (0/36) at a 3-month follow-up. The patients' overall satisfaction ratings were "very good" (n=22, 61%), "good" (n=12, 33%), and "moderate" (n=2, 6%) with no poor or unsatisfactory ratings.

Conclusions

CPNPIAM is an effective way of treating CRPCM, and showed a high success rate, a low recurrence rate, and high patient satisfaction.

"The unusual suspects"-Mammographic, sonographic, and histopathologic appearance of atypical breast masses

Breast malignancy is the second most common cause of cancer death in women. However, less common breast masses can mimic carcinoma and can pose diagnostic challenges. This case-based review describes a spectrum of rare breast neoplastic and non-neoplastic masses ranging from malignant to benign entities. Malignant masses in this review include adenoid cystic carcinoma, spindle cell lipoma, granular cell tumor, angiosarcoma, glomus tumor, adenosquamous carcinoma, and myofibroblastoma. Benign masses include sarcoidosis, diabetic mastopathy, and cat scratch disease. Demographics and, when relevant, clinical presentation are summarized. Breast imaging appearance on mammography and ultrasound are highlighted along with radiology-pathology correlation with the appearance and characteristics of the histopathological specimen of these rare masses.

[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.

Differentiation between idiopathic granulomatous mastitis and invasive breast carcinoma, both presenting with non-mass enhancement without rim-enhanced masses: The value of whole-lesion histogram and texture analysis using apparent diffusion coefficient

PURPOSE

The aim of this study was to investigate whether whole-lesion histogram and texture analysis using apparent diffusion coefficient can discriminate between idiopathic granulomatous mastitis (IGM) and invasive breast carcinoma (IBC), both of which appeared as non-mass enhancement lesions without rim-enhanced masses.

METHOD

This retrospective study included 58 pathology-proven female patients at two independent study sites (27 IGM patients and 31 IBC patients). Diffusion-weighted imaging (3b values, 50, 400 or 500, and 800 s/mm²) was performed using 1.5 T or 3 T MR scanners from the same vendor. Whole-lesions were segmented and 11 features were extracted. Univariate analysis and multivariate logistic regression analysis were performed to identify significant variables for differentiating IGM from IBC. Receiver operating characteristic curve was assessed. The interobserver reliability between two observers for the histogram and texture measurement was also reported.

RESULTS

The 5th percentile, difference entropy and entropy of apparent diffusion coefficient showed significant differences between the two groups. An area under the curve of 0.778 (95 % CI: 0.648, 0.908), accuracy of 79.3 %, and sensitivity of 87.1 % was achieved using these three significant features. No significant feature was found with the multivariate analysis. For the interobserver reliability, all apparent diffusion coefficient parameters except skewness and kurtosis indicated good or excellent agreement, while these two features showed moderate agreement.

CONCLUSIONS

Whole-lesion histogram and texture analysis using apparent diffusion coefficient provide a non-invasive analytical approach to the differentiation between IGM and IBC, both presenting with non-mass enhancement without rim-enhanced masses.

Radiological evaluation of primary breast sarcoidosis presenting as bilateral breast lesions

Sarcoidosis is an idiopathic multisystemic inflammatory disease that may exceptionally involve the breast and can have imaging features suspicious for benign or malignant lesions. Biopsy should be required to distinguish between breast sarcoidosis and malignancy, because clinical, mammographic and sonographic findings can be ambiguous or inconclusive. This case discusses the radiological manifestations and the value of different diagnostic features, and names the most relevant differential diagnosis.

Diagnostic techniques and multidisciplinary approach in idiopathic granulomatous mastitis: a revision of the literature

Idiopathic granulomatous mastitis (IGM) is a chronic benign inflammatory disease of the breast that may mimic breast cancer. It is most common in parous young fertile women, although it can occur in nulliparous women and in men. IGM is an idiopathic disease due to the influence of some environmental factors in genetically predisposed subjects. Several pathogenic hypothesis have been proposed in the last years (autoimmune, hormonal, infective genesis). IGM presents as a painful palpable mass located in one of the two udders. The skin is usually normal but could present signs of inflammation with or without lymph nodes involvement. Ultrasonography, mammography, magnetic resonance can be diagnosed an IGM, but pathognomonic radiological signs has not yet reported in literature. Biopsy findings show granulomatous lesion centered on the breast lobule, as in granulomatous mastitis induced by tuberculosis or sarcoidosis. The aim of this review of literature is to verify the development of new advanced diagnostic techniques and multidisciplinary approach for this condition. In the last years innovative approaches have modified IGM diagnosis and therapy, avoiding surgery in most of cases, introducing a more conservative medical approach based on recent etiopathological hypothesis. (www.actabiomedica.it)

Recurrent Mondor's breast disease -- Hormonal contraceptive involvement

Mondor's disease can be a challenging diagnosis. The case we present is of a 29 year-old Brazilian woman, under combined hormonal contraception, who consulted for a painful lump on her right breast. She presented a complete resolution after a local treatment of heparinoid cream and a non-steroidal anti-inflammatory oral treatment, but relapsed 18 months later. Oral combined hormonal contraception was the only "risk factor" found, in this case, and the modification of the latter helped resolve the relapse clinical symptoms.

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.

Localized Breast Amyloidosis

Localized amyloidosis in the breast is a very rare disease and may mimic malignant lesions. A 60-year-old woman who had a history of breast-conserving surgery presents with a new a well-defined oval opacity accompanied by many round tight clustered micro- and macrocalcifications on mammograms. It could not be visualized sonographically due to the intense posterior acoustic shadowing of the fat necrosis areas and contrast enhancement was not detected in this area on the dynamic contrast enhanced magnetic resonance images. At pathological examination breast amyloidosis was detected. Amyloidosis of the breast is a rare disease, but it can mimic malignancy and should be included in the differential diagnosis.

Tuberculosis mastitis presenting as bilateral breast masses

Tuberculosis mastitis can be a challenging diagnosis, often presenting with clinical and imaging findings that are suspicious for malignancy. We present a case of a 49-year-old female with a breast mass initially diagnosed as idiopathic granulomatous mastitis. Failure to respond to standard treatments, development of new breast masses, and discovery of a concurrent ulcerating thigh rash with similar histologic findings as the breast masses prompted further investigation, which ultimately lead to the diagnosis of tuberculosis mastitis. There was rapid resolution of both breast and skin symptoms after initiation of empiric drug therapy.

Idiopathic Granulomatous Mastitis: Manifestations at Multimodality Imaging and Pitfalls

Idiopathic granulomatous mastitis (IGM) is a rare benign inflammatory breast entity characterized by lobulocentric granulomas. IGM has a persistent or recurrent disease course and affects parous premenopausal women with a history of lactation. It has also been associated with hyperprolactinemia. The most common clinical sign is a palpable tender mass. However, the nonspecific manifestations and varied demographic features of this condition, as well as the other similar-appearing and superimposed breast entities, pose substantial diagnostic challenges. Entities with similar manifestations include inflammatory breast cancer (IBC), infective mastitis, foreign body injection granulomas, mammary duct ectasia, diabetic fibrous mastopathy, and systemic granulomatous processes. The strategy for imaging IGM depends on patient age, clinical manifestations, and risk factors. Targeted ultrasonography, mammography, and less commonly, magnetic resonance imaging have proven to be useful for imaging evaluation. Core-needle biopsy, with or without fine-needle aspiration for cytopathologic examination, and culture analysis are usually required to exclude IBC and other benign inflammatory breast processes. Patients with IGM have an excellent prognosis when they are appropriately treated with oral steroids or second-line immunosuppressive and prolactin-lowering medications. However, surgical excision may be an option for patients in whom medication therapy is unsuccessful. Imaging surveillance can be offered to patients with incidentally encountered IGM or mild symptoms. Clinical suspicion for this rare disease and the breast imager's prompt diagnosis can lead to an improved patient outcome. The purpose of this article is to review the imaging manifestations of IGM in a multimodality case-based format and to describe relevant clinical and imaging-based differential diagnoses. The associated pitfalls, epidemiologic and histopathologic factors, clinical manifestations, natural course, and management of IGM also are discussed. ©RSNA, 2018.

Imaging Features of Inflammatory Breast Disorders: A Pictorial Essay

Inflammatory breast disorders include a wide array of underlying causes, ranging from common benign infection, non-infectious inflammation and inflammation resulting from underlying breast malignancy. Because it is at times difficult to distinguish mastitis and breast cancer based on clinical features, awareness of detailed imaging features may be helpful for better management of inflammatory breast disorders. Therefore, this pictorial essay intends to demonstrate radiologic findings of a variety of inflammatory breast disorders, using selected cases with mammography, ultrasound and magnetic resonance images.

Diagnosis of sarcoidosis from a biopsy of a dilated mammary duct

Sarcoidosis is an immunologic disease of unknown etiology that manifests most frequently within the lungs or associated lymph nodes. Sarcoidosis involving the breast is seen in <1% of cases and usually is diagnosed in patients with multisystem disease. The clinical and imaging presentations of sarcoidosis of the breast can be variable. Though uncommon, sarcoidosis should be considered in the differential diagnosis of a breast lesion, and given that imaging characteristics cannot distinguish between sarcoidosis and malignancy, all breast lesions in patients with sarcoidosis should be biopsied. Our case study demonstrates a diagnosis of sarcoidosis in an asymptomatic patient presenting with a single dilated duct and associated filling defect within the right breast.

Imaging Findings in Patients with Granulomatous Mastitis

BACKGROUND

Granulomatous mastitis (GM) is a rare inflammatory breast disease that may mimic the clinical characteristics and radiologic imaging findings of breast carcinoma. Considering the importance of making a correct diagnosis, careful radiologic evaluations and recognition of imaging features are necessary.

OBJECTIVES

The aim of this study was to review the radiological findings and diagnostic value of the imaging in GM.

PATIENTS AND METHODS

This retrospective study involved a total of 29 patients who were diagnosed with GM between 2009 and 2013 and who underwent mammography (MG) and/or ultrasound (US) examination in addition to magnetic resonance imaging (MRI) before diagnosis.

RESULTS

Among 14 patients over 35 years of age who underwent MG imaging, focal asymmetric, ill-defined nodular, or diffusely increased densities were detected in nine (64.3%), two (14.3%), and one (7.1%) subjects, respectively, while there were no pathological findings in two (14.3%) patients. In the overall group of 29 patients, US showed heterogeneous hypoechoic lesions with tubular extensions in 16 (55.2%), well-demarcated heterogeneous hypoechoic lesions in eight (27.6%), parenchymal heterogeneous appearance in three (10.3%), and a heterogeneous hypoechoic lesion with irregular margins in one (3.4%), with another (3.4%) patient having normal US findings. MRI findings included lesions consistent with solitary or multiple separate or confluent abscesses with marked peripheral ring enhancement in 25 (86.2%) patients, accompanied by intensity changes suggesting edematous inflammation in the peripheral parenchyma, as well as non-mass-like heterogeneous segmental and regional contrast enhancement. Four (13.8%) patients had non-mass-like segmental and regional contrast enhancement only. A histopathological diagnosis of GM was established in all patients with biopsy.

CONCLUSION

GM presents with a wide range of conventional radiological findings, hampering the diagnosis. In patients with inconclusive conventional findings, MRI may assist in the differential diagnosis and assessment of the extent of disease. However, a definitive diagnosis and relevant treatment require histopathological confirmation.

Infiltrating ductal carcinoma of the breast with coexisting lymphocytic mastitis in a non-diabetic adult female

Lymphocytic mastitis, also known as diabetic mastopathy or sclerosing lymphocytic lobulitis, is a benign clinicopathological entity that, in earlier studies, has been described as an uncommon cause of breast mass in adult females with long-standing insulin-dependent diabetes mellitus. Further studies have suggested an autoimmune aetiology owing to its association with other autoimmune diseases such as Hashimoto's thyroiditis. On clinical examination, mammography and ultrasound, this lesion may mimic breast carcinoma. The most common mammographic findings are ill-defined masses or asymmetric densities. Such lesions are often masked by dense glandular tissue, making mammographic evaluation difficult. Ultrasound often reveals the characteristic finding of an irregular, hypoechoic mass with marked posterior acoustic shadowing. We present a case of infiltrating ductal carcinoma with coexisting lymphocytic mastitis involving the right breast of a non-diabetic adult female who presented with complaints of a painless, hard palpable lump in her right breast for 2 months. Mammography and ultrasonography showed features of a malignant lesion that was subjected to fine needle aspiration cytology and tru-cut biopsy examination. Cytology revealed features suggestive of infiltrating ductal carcinoma in a background of severe inflammation and necrosis. Tru-cut biopsy showed features suggestive of lymphocytic mastitis. The patient underwent modified radical mastectomy of the right breast. Histopathological examination of right breast tissue revealed multifocal infiltrating ductal carcinoma, metastatic ipsilateral axillary lymph nodes, lymphovascular tumour emboli and tumour-free margins. The patient underwent adjuvant chemotherapy and radiotherapy. She is on hormone therapy with a selective oestrogen receptor modulator and is disease-free now.

Granulomatous Mastitis: Imaging of Temporal Evolution

Aim. To assess the temporal imaging evolution of granulomatous mastitis and to review imaging findings. Material and Methods. Retrospective review of imaging data of 10 patients with biopsy proven granulomatous mastitis. The patients were divided into 3 groups according to their initial imaging presentation. Temporal evolution of imaging findings was observed separately for each group. Ratios, proportions, and percentages were used for data analysis. Results. Upon initial presentation, 75% of women who underwent mammogram showed an area of mass like architectural distortion. 25% demonstrated focal asymmetry. Complex cystic lesion was seen 40%. Multiple abscesses with sinus tract formation tracking into surrounding tissues were seen in 2 cases. Four out of 10 patients presented as edematous changes. Three out of this group progressed to develop complex cystic lesions/abscess formation. 25% presenting with complex cystic lesions or abscess at presentation showed spontaneous resolution. The remainder needed surgical treatment. The patients with abscess formation and sinus tract formation needed surgical management. Conclusion. Initial imaging findings in granulomatous mastitis can be variable but the eventual course and outcome is similar in most patients with surgical management required in most cases.

Unusual Benign Tumors of the Breast

The purpose of this article is to describe the imaging characteristics of a variety of benign breast tumors that may be encountered in daily practice, in order to formulate an appropriate differential diagnosis and to establish concordance between the imaging and the pathologic findings, and to assist the clinician with appropriate management.

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.

Systemic granulomatous diseases associated with multiple palpable masses that may involve the breast: case presentation and an approach to the differential diagnosis

Palpable mass is a common complaint presented to the breast surgeon. It is very uncommon for patients to report breast mass associated with palpable masses in other superficial structures. When these masses are related to systemic granulomatous diseases, the diagnosis and initiation of specific therapy can be challenging. The purpose of this paper is to report a case initially assessed by the breast surgeon and ultimately diagnosed as granulomatous variant of T-cell lymphoma, and discuss the main systemic granulomatous diseases associated with palpable masses involving the breast.

Tuberculous mastitis presenting as a lump: a mimicking disease in a pregnant woman case report and review of literature

Tuberculosis (TB) of the breast is a rare entity, and can be confused with many other breast disorders, like mamma carcinoma or inflammatory breast cancer. When finding granulomatous mastitis (GM) on histology, it is important to make a differential diagnosis and seek actively for clues on the presence of tuberculosis, sarcoidosis, Wegener's granulomatosis, or idiopathic granulomatous mastitis, since treatment strategies differ and maltreatment has major implications on morbidity and mortality. An extensive clinical evaluation, laboratory work up, and imaging will lead in most cases to the right diagnosis. Anti-tuberculous therapy is the core treatment for breast TB, and surgery is indicated for extensive or persistent residual disease. Here we present a case of tuberculous mastitis and a review of literature on GM.

Tuberculosis--the great mimicker

Tuberculosis is an immense health problem in the developing world, and it remains a health care challenge in the developed world. It can affect virtually any organ system in the body. Diagnosis of tuberculosis is often difficult. Many patients with tuberculosis present with nonspecific symptoms, negative purified protein derivative skin test result, and negative findings on culture specimens. Cross-sectional imaging with ultrasound, multidetector computed tomography, and magnetic resonance imaging plays an important role in the diagnosis of tuberculosis. Tuberculosis demonstrates a variety of radiologic features depending on the organ involved and can mimic a number of other disease entities. Cross-sectional imaging alone is insufficient in reaching a conclusive diagnosis. Tuberculosis is a great mimicker as its radiologic manifestations can simulate numerous other diseases across the body systems. However, recognition and understanding of the common and uncommon radiologic manifestations of tuberculosis should alert considering tuberculosis in the high-risk population and correct clinical setting to enable appropriate treatment.

Diabetic mastopathy

Diabetic mastopathy is an uncommon condition found in patients with long-standing diabetic mellitus (DM). Although benign in nature, it can sometimes not be distinguishable from breast carcinoma, and may lead to unnecessary anxiety or intervention. Clinicopathologic features of 10 patients were reviewed in detail. Only three of the 10 patients had type I DM. All patients had over a 10-year history of DM, and presented with unilateral, solitary, palpable breast mass, ranging in size from 1.5 to 5 cm. Radiologic and pathologic features of each patient were described. None of the patients in our series developed malignancy during the follow-up period. Diabetic mastopathy is a benign condition and not unique to type I DM. Surgeons should be aware of this distinct fibroinflammatory breast condition and its association with long-standing DM.

Amyloidosis of the Breast with Multicentric DCIS and Pleomorphic Invasive Lobular Carcinoma in a Patient with Underlying Extranodal Castleman's Disease

We present an interesting case of focal amyloidosis of the left breast which was intermixed with ductal carcinoma in situ (DCIS). On subsequent staging bilateral breast magnetic resonance imaging (MRI), the patient was found to have an additional suspicious enhancing mass with spiculated borders within the left breast. This mass was biopsy proven to represent pleomorphic invasive lobular carcinoma. A pulmonary nodule within the lingula was also noted on the staging bilateral breast MRI and was biopsy proven to represent extranodal Castleman's disease. Therefore, it is believed that our patient had secondary amyloidosis due to Castleman's disease.

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.

Primary sarcoid of the breast with incidental malignancy

Breast sarcoidosis is rare and usually presents in patients with known sarcoid involving other organ systems. In the breast, sarcoidosis may mimic malignancy which must be excluded by core biopsy. We report a very unusual case of primary breast sarcoidosis with incidentally discovered breast carcinoma. The roles of mammography, ultrasound, and MRI in the diagnosis as well as other potential differential diagnosis are discussed.

Idiopathic granulomatous mastitis: a report of twenty cases

INTRODUCTION

Idiopathic granulomatous mastitis is a benign lesion of the mammary gland characterised by the presence of non-infectious inflammatory breast lesions limited to the lobules.

OBJECTIVE

We report twenty cases of idiopathic granulomatous mastitis (IGM) with a discussion of epidemiology, clinical and diagnostic features, treatment and progress of this pathological entity.

MATERIALS AND METHODS

A retrospective study of twenty cases compiled from a ten-year period, from 952 pathological anatomy examinations carried out to investigate various breast pathologies.

RESULTS

The patients had a mean age of 45.5 years. Clinical examinations revealed a tumefaction measuring between 2.5 and 18 cm in diameter. The mean size was 5.5 cm. Mammography showed nodular lesions and sonography demonstrated hypoechoic nodules. On histological examination there was a granulomatous inflammatory infiltrate of epithelioid and giant cells, without caseation necrosis, made up of lymphocytes, plasma cells and neutrophils. Microbiology investigations were negative. Lesion involvement was principally lobulocentric. Surgical excision of the lesions was combined with corticosteroid therapy in twelve cases, with non-steroidal anti-inflammatory drugs in another four and with antibiotic therapy in four cases. The patients made good progress in the short-term.

DISCUSSION AND CONCLUSION

IGM is a rare entity. It poses a problem of differential diagnosis because it clinically resembles other forms of mastitis. The diagnosis can be made with certainty on histological studies. The treatment is medical alongside surgical excision. The prognosis of this disease remains favourable.

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.