Imaging spectrum in tropical breast infections

While breast carcinoma is the most feared pathology in women with breast lumps, infections continue to be an important aetiology, especially in countries with low to middle socio-economic status. The breast infections or mastitis can present as acute painful breast or recurrent episodes of breast lumps with or without pain. The common causes include puerperal, non-puerperal, and idiopathic mastitis whereas uncommon causes like tuberculosis, filariasis, hydatid and other parasitic infections are still seen in developing countries. Imaging with digital mammography may be difficult due to pain or inadequate due to increased breast density. Ultrasound serves as the modality of choice for detailed assessment in these patients. Since the imaging features are often overlapping with malignancy, biopsy is almost always indicated. However, there are certain imaging findings that may point to the diagnosis of mastitis and can help in accurate radiologic-pathologic correlation. This article aims to illustrate the varied clinico-radiological features of patients with tropical breast infections.

A mimicker of inflammatory breast carcinoma: Lupus mastitis and evolving imaging features

Rare case of lupus mastitis in a 58-year-old female with discoid lupus erythematosus presented with fever, left breast swelling, and painful palpable lesion. Accurate imaging and histopathologic evaluation allowed for appropriate management and regression of breast findings with hydroxychloroquine treatment, emphasizing the need to avoid unnecessary biopsies and surgeries.

Percutaneouse ultrasound-guided needle aspiration for management of breast abscesses - a review

Breast abscesses are still a common cause of morbidity among lactational females. Over the years, there has been an increase in the incidence of non-lactational breast abscesses and a decrease in lactational breast abscesses. The management could be the use of the conventional method of surgical incision and drainage or the newer techniques of needle aspiration or suction drain or catheter in addition to the administration of antibiotics. The use of needle aspiration as the minimal-invasive conservative technique is generally recommended for abscesses less than 3-5 cm in diameter. However, recent studies have compared the two methods for abscesses larger than 3 cm and among patients with risk factors for breast abscesses. We aim to present the clinical evidence showing the comparison between needle aspiration and incision and drainage for breast abscesses irrespective of the size of the abscesses. There is a lack of comparative information on the two treatment modalities for breast abscesses larger than 3 cm in diameter; however, needle aspiration is being tried because of its advantages like cosmetic preference, short hospital stay and healing time, and no stoppage of breastfeeding.

Ultrasonic multimodality imaging features and the classification value of nonpuerperal mastitis

OBJECTIVE

To explore the value of ultrasonic multimodality imaging for characterizing nonpuerperal mastitis (NPM) lesions and feasibility of distinguishing different subtypes.

METHODS

Thirty-eight NPM lesions were assessed using conventional ultrasonography (US), strain elastography (SE), and contrast-enhanced ultrasound (CEUS). The lesions were confirmed pathologically and classified as granulomatous lobular mastitis (GLM), plasma cell mastitis (PCM), or nonspecific mastitis (NSM). Furthermore, diagnostic indicators were evaluated. The diagnostic performances of the modalities were compared using the area under the receiver operating characteristic curve (AUC).

RESULTS

The overall morphological features on US differed significantly between the GLM and PCM groups (p = 0.002). Lesion size (≤10 mm) (p = 0.003) and mean SE score (p = 0.001) differed significantly between the PCM and NSM groups. The frequent NPM characteristic on CEUS was hyperenhancement with (or without) increased lesion size; intergroup differences were not significant. Breast Imaging Reporting and Data System > 3 was considered to indicate malignancy; accordingly, the accuracy of US alone, US with CEUS, and US with SE was 10.5%, 21.1%, and 65.8%, respectively. Moreover, the AUC for US with SE for classifying GLM and PCM was 0.616.

CONCLUSION

CEUS cannot accurately classify NPM subtypes, while US and SE are valuable for classification.

Granulomatous Mastitis: What Radiologists Should Know With Imaging Examples of Biopsy Proven Cases

ABSTRACT

Granulomatous mastitis is a rare benign inflammatory disease of the breast, predominantly affecting women of childbearing age. Because of its low prevalence, the literature is limited, and its treatment algorithm is unclear. However, it is important to understand this disease for timely diagnosis and treatment. Our overview with imaging examples of biopsy-proven cases aims to improve our knowledge and to determine when it would be appropriate to include it in the differential diagnosis.

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.

The diagnostic value of MRI multi-parameter combination for breast lesions with ring enhancement

PURPOSE

To investigate the diagnostic value of MRI multi-parameter combination for breast lesions with ring enhancement (internal enhancement pattern) on dynamic contrast-enhanced (DCE)-MRI.

METHODS

149 patients with histologically confirmed breast lesions underwent DCE-MRI and diffusion-weighted imaging (DWI) examinations were analyzed. Sixty-seven lesions were found and were allocated into the benign group and the malignant group. The pathological results were used as dependent variables, indexes with statistical differences were used as independent variables, and logistic regression model was performed to construct the newly combined parameters and to evaluate the diagnostic efficacy of the stepwise combined parameters.

RESULTS

There were significant differences in the number of cases with different wall shapes concerning "enhanced ring" and the number of cases with wall nodules between the benign and the malignant group. Significant differences were found in the number of cases with different distribution locations of limited diffusion on DWI between the benign and the malignant group. There were significant differences in the semi-quantitative parameters including early enhancement ratio (EER) and maximum enhancement time (Tmax) between the benign group and the malignant group. There were significant differences in apparent diffusion coefficient (ADC) ring inner and ADC ring wall between the benign and the malignant group. The maximum Youden index of a newly-constructed parameter combination: morphological indexes of "enhanced ring" + distribution locations of limited diffusion on DWI + Tmax + ADC ring inner was 0.732 for combined diagnosis, the area under the ROC curve (Az) was 0.887, and the diagnostic sensitivity and specificity were 85.78 and 87.37%, respectively.

CONCLUSIONS

MRI multi-parameter combination can improve the diagnostic efficacy of breast lesions with ring enhancement.

Sonography of Palpable Breast Lumps in a Tertiary Health Care Centre in Nepal

BACKGROUND

With a palpable lesion in the breast, the goal is to diagnose malignancy at the earliest. Ultrasonography is used for evaluating symptomatic patients especially those with dense breasts where mammography gives limited information. The objective of this study was to evaluate the sonographic pattern of the palpable breast lumps and correlate with the final pathological diagnosis.

METHODS

This was a retrospective study done at our tertiary health care center, from July 2016 to March 2017, including 121 patients presenting to the ultrasound department with complaint of palpable breast lump and whose pathological reports could be followed up. Various sonographic features were studied, sonography and final diagnosis compared.

RESULTS

On sonography, about 46% of the cases were benign, 35 % malignant and 18 % indeterminate while tissue diagnosis revealed 63% to be benign, 34% malignant. The most common lesions in each group and sonographic characteristics were evaluated. Of the benign lesions, fibroadenoma was the most common. Most of the indeterminate lesions on sonography were histologically mastitis. We found nearly 58% of the malignant lesions had microlobulated margins. The sensitivity of sonography was 92.9% and specificity 97.5% with diagnostic accuracy 94.8%.

CONCLUSIONS

Most of the palpable lumps were benign in our study, most common being fibroadenoma. We had a relatively higher percentage of malignancy which may be due to patients with obviously benign lesions not undergoing tissue diagnosis in our setting. The sonographic features and diagnosis correlated well with the histological diagnosis.

[Breast tuberculosis is a rare cause of breast abscess]

Isolated secondary breast tuberculosis (TB) is an uncommon entity. This is a case report of a 27-year-old female who presented with a tumour in the breast. After four months with tedious examinations a positive polymerase chain reaction for TB was finally found, and the patient recovered after ten months of TB therapy and drainage of the abscess. One year later, a recurrence was seen after the patient had been breast feeding. Therapy was repeated, and more extensive surgery was performed with surgical excision of the abscess cavity, the fibrous tract to the pleura and resection of a pleural section. The patient achieved a full recovery afterwards.

Infectious and Inflammatory Breast Disease

Breast inflammation can signal an array of breast conditions, from difficulties with breastfeeding to a rare and aggressive type of breast cancer. In some cases, these diseases resemble each other clinically and on imaging examinations. This article explains the inflammatory process and discusses a variety of localized benign inflammatory breast diseases, including lactational and nonlactational mastitis, ductal ectasia, idiopathic granulomatous mastitis, fat necrosis, and diabetic mastopathy. Inflammatory breast cancer also is presented, with an emphasis on its signs and symptoms, diagnosis, staging, multimodality treatment, and prognosis.

Hardness and Painful Lesion of the Breast

Dear Editor, Lupus panniculitis or lupus profundus is a rare inflammatory complication found in patients with systemic lupus erythematosus (SLE), or discoid lupus erythematosus (DLE) (1). When the breast is involved, the term lupus mastitis (LM) is used. This disease involving the breast is rare, and the lesions may precede, coincide with, or occur later than the onset of other lupus lesions. Tissue biopsy is required to confirm the suspected diagnoses of LM. We report a case of a patient with lupus mastitis due to the important differential diagnosis. A 60-year-old woman presented with a painful nodular lesion in her left breast that had appeared 15 days ago (Figure 1, a). She had been previously diagnosed with discoid lupus erythematosus 3 years ago. Physical examination revealed a deep and firm erythematous subcutaneous nodule without overlying skin involvement in the lower-central portion of the left breast. Laboratory findings were positive for antinuclear antibodies (1:80) and double-stranded deoxynucleic acid antibodies (1:10). Mammography and ultrasounds showed an area of increased density and irregular breast tissue along with an important thickening of the overlying skin (Figure 1, b). On suspicion of malignancy, a needle biopsy of the breast lesion was performed and showed vacuolar alteration and lymphocytic infiltrate in the basal layer. Subcutaneous fat showed a lobular panniculitis with a prominent lymphocytic infiltrate and hyalinization of the fat lobules (hyaline fat necrosis). Direct immunofluorescence of the face biopsy revealed IgA, IgG, IgM, and C3 granular deposition. Based on these results, a diagnosis of lupus mastitis associated with DLE was established. Antimalarial therapy resulted in complete resolution of the clinical features. Three years later, the patient presented with a disfiguring atrophy with retraction in the damaged areas of the breast (Figure 2). Lupus mastitis is a very unusual disease that most commonly affects middle-aged women. The first case of LM was described by Tuffanelli in 1971. The lesions usually present following the diagnosis of SLE/DLE; however, on rare occasions they may be observed earlier (2). The histophysiology of this disease remains unclear, but the predominant theory suggests an autoimmune-related etiology. Corroborating evidence for this theory includes the finding of immune complexes, both at the basement membrane of the dermal-epidermal junction and in the blood vessels in the areas of panniculitis (3). Lupus mastitis may be present in the breast as single or multiple subcutaneous nodules that may be tender or painful and can progress to chronic ulcers over time or resolve, leaving atrophic scars. The overlying skin can be normal, erythematous, poikilodermic or ulcerated. When skin changes are prominent, the lesion may clinically and radiologically mimic inflammatory breast carcinoma. Mammographic and ultrasounds findings include an ill-defined breast density with or without associated microcalcifications (4). Histologically, this disease is characterized by lobular lymphocytic panniculitis and predominantly involves the fat lobule and the presence of anucleated adipocytes in a background of a glassy-appearing collagenous stroma (hyaline fat necrosis). Fibrinoid necrosis of the vessel wall has also been reported, but is usually absent (5). Differential diagnosis of lupus mastitis includes inflammatory breast carcinoma, primary medullary carcinoma, and other immune-mediated inflammatory conditions such as diabetic mastopathy. The first line of treatment the use of antimalarial drugs such as hydroxychloroquine. Systemic steroids and cyclophosphamide have also been used. Surgical treatment should be considered only in patients who do not respond to management with medications. In summary, we reported a case of lupus mastitis in a patient with discoid lupus erythematosus. This dermatosis should be considered in the differential diagnosis of breast lesions in lupus patients, and a biopsy of the breast lesion is essential to reject suspected malignancy. If the disease is left untreated, unsightly atrophy will appear; it is thus important to diagnose early on. The course of the disease tends to be chronic with remission and flares, so patients should be followed-up regularly due to the risk of recurrences in the same area or in a different location.

Sonographic Elastography of Mastitis

Sonographic elastography has been shown to be a useful imaging modality in characterizing breast lesions as benign or malignant. However, in preliminary research, mastitis has given false-positive findings on both strain and shear wave elastography. In this article, we review the findings in mastitis with and without abscess formation on both strain and shear wave elastography. The elastographic findings in all cases were suggestive of a malignancy according to published thresholds. In cases of mastitis with abscess formation, there is a characteristic appearance, with a central very soft area (abscess cavity) and a very stiff outer rim (edema and inflammation). This appearance should raise the suspicion of mastitis with abscess formation, since these findings are rare in breast cancers.

Mitochondrial Uptake of Sestamibi Distinguishes Between Normal, Inflammatory Breast Changes, Pre-Cancers, and Infiltrating Breast Cancer

The evaluation of breast tissue using nuclear imaging is dependent upon the delivery and uptake of the isotope by breast tissue. This is dependent upon blood flow to the breast and functioning mitochondria. This 2-part study investigated (1) differences in uptake of sestamibi when blood flow is enhanced (breast enhanced scintigraphy test [BEST]), and (2) differences in isotope uptake in normal (Nl) breast tissue, inflammatory changes in breast tissue (ICB), and breast cancer (CA). In the first part of the study, 10 women were compared using both Miraluma and BEST imaging; in the second part, 195 people were studied using BEST imaging only. The results were compared with histopathologic specimens. Little difference was noted between Miraluma and BEST imaging in the first part. Women with ICB showed a statistically significant ( P< .05) increase in isotope uptake using BEST imaging. This difference was even more significant ( P< .005) in women with CA. During the second part of the study, BEST imaging demonstrated an exponential increase in tracer uptake. When maximal count activity was compared, there was a statistically significant ( P<.001) difference between Nl and ICB, between ICB and atypia (A), and between A and CA. BEST imaging demonstrated significant increases in isotope delivery when compared with Miraluma imaging. These differences allowed differentiation of breast tissue, including the detection of early changes in breast tissue.

Breast imaging after dark: patient outcomes following evaluation for breast abscess in the emergency department after hours

In our study, we sought to report the management, clinical outcomes, and follow-up rates of patients who presented for evaluation of breast abscess in the Emergency Department (ED) after hours. A retrospective search of ultrasound reports at our institution identified all patients from January 1, 2009 to June 30, 2013 who were scanned in the ED after hours to evaluate for breast abscess. Patient demographics, clinical information, imaging findings, follow-up rates, and outcomes were reviewed. One hundred eighty-five patients were included in the study. Forty-four percent (86/185) of the patients were diagnosed with abscess based on ultrasound findings in the ED. Twenty-seven percent (23/86) were recently post-operative, and 12 % (10/86) were postpartum/breastfeeding. Mastitis was the diagnosis in the remaining 54 % (99/185). Only 1/86 cases were associated with breast cancer. Seventy-seven percent (66/86) of patients were treated with an invasive procedure; 39 % (26/66) had surgical evacuation, 30 % (20/66) image-guided drainage, 23 % (15/66) bedside or clinic incision and drainage, and 8 % (5/66) palpation-guided fine needle aspiration (FNA). Seventy-seven percent (143/185) of patients had clinical and/or imaging follow-up. Forty-four percent (63/143) had long-term follow-up (≥ 3 months). Almost 50 % of the patients who presented to the ED for evaluation of abscess were diagnosed with abscess while the remaining patients were diagnosed with mastitis. Appropriate clinical and/or imaging follow-up occurred in 77 %. Long-term follow-up (≥ 3 months) occurred more frequently in patients older than 30 years of age. Appropriate follow-up does not occur in approximately one fourth of cases, suggesting that additional clinician and patient education is warranted.

[Modern diagnosis-treatment approaches for inflammatory changes of mammary glands]

There were examined 567 women, in whom inflammatory changes of mammary glands (MG), not connected with a child borning, were revealed. There was established, that "nonlactational mastitis" of various structure: the cyst--in 36.5% of observations, periductal mastitis--in 32.1%, abscess--11.3%, purulent galactophoritis--12.9%, mastitis-like mammary gland cancer--7.2%. In the diagnosis of inflammatory changes of MG the ultrasonographic investigation is the main, which permit to determine the disease, to study the abscesses topography, to control miniinvasive diagnostic-treatment interventions, in cluding, for abscess and cyst. Purulent-inflammatory processes in MG while extralactational period demand individual differentiated treatment-diagnostic approach regarding khowledge of ultrasonographic (echographic) semiotics of pathological process.

Breast inflammation in type 1 diabetes

BACKGROUND

Lymphocytic mastitis is an uncommon fibroinflammatory disease of the breast which occurs in patients with longstanding diabetes. Various imaging patterns in mammography, ultrasound and magnetic resonance imaging (MRI) have been widely described. This communication wishes to provide some explanation to the variation of imaging findings by a study of follow-up cases and present young nonlactating women who had abscess as the first clinical manifestation of type 1 diabetes.

METHODS

Five women with pathologically confirmed lymphocytic mastopathy and 8 women with type 1 diabetes who presented with breast abscess at National Guard Hospital, Riyadh were studied. The ultrasound, mammographic and MRI features were analyzed. Follow-up of 2 to 4 years was done. The clinical findings were analyzed in a descriptive way.

RESULTS

A total of 13 women were studied. Age ranged from 22-54 years. The clinical presentation was a painless hard breast mass in the 5 cases with lymphocytic mastitis and painful mass in 8 women with breast abscess, 3 of which were non-lactating young women. The common imaging finding at mammography was diffuse or focal stromal distortion unilaterally or bilaterally in 4 cases (80%). Complete clinical and mammographic resolution occurred in 2 (40%) of the cases while it was only partial in the rest with lymphocytic mastopathy. Initial ultrasound showed stromal changes in 3 (60%), mass-like lesion in 1 (20%) and normal in 1 (20%). At follow-up ultrasound examination, all had interval development of dense acoustic shadowing representing the previous lesions between 1-2 years.

CONCLUSION

Lymphocytic mastitis can have various patterns at the initial presentation at ultrasound. However, the chronic change at follow-up in this study was intense acoustic shadowing without any mass in all. Type 1 diabetes is suggested in young non-lactating females presenting with breast abscess.

Tuberculosis of the breast

BACKGROUND

Tuberculosis of the breast is a rare disease with non specific manifestations. It should be included in the differential diagnosis of breast lesions in immune compromised patients especially in tuberculosis endemic areas of the world.

CASE REPORT

We report a case of a 31 year old HIV positive lady who presented with an ulcerated mass on the left breast of 3 months' duration. Incision biopsy of the lesion confirmed tuberculosis of the breast. Treatment with standard anti tuberculous drugs resulted In complete resolution.

CONCLUSION

A high index of suspicion is required to make a diagnosis of breast tuberculosis. The disease can be treated conservatively with standard anti tuberculous drugs while surgery is reserved for rare cases.

Tuberculosis of the breast: medical treatment

Two patients with breast tuberculosis (BT) were discussed. In the presentation of each of the patients were a breast lump without pain and purulent discharge. There was associated axillary lymphadenopathy in one patient. Diagnoses were done by open biopsy and only antitubercular therapy was given to the patients. After two months of therapy, the breast lumps disappeared completely from both patients. Treatment was continued for 9 months. In breast tuberculosis, medical therapy can be used without further surgical intervention.

[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.

Treatment of breast abscesses with ultrasound-guided aspiration and irrigation in the emergency setting

The purpose of our study was to describe the efficacy of ultrasound (US)-guided aspiration and intracavitary irrigation of breast abscesses in the emergency setting. Ten cases of mastitis clinically suspected of having a breast abscess were referred from the emergency department for breast ultrasound. Eleven abscesses depicted at US were treated with US-guided aspiration and intracavitary irrigation. All patients were given antibiotics, and the success of US-guided treatment was determined. Three abscesses that were smaller than 3 cm were treated with single aspiration and irrigation. Ninety-one percent of patients were cured with US-guided aspiration and irrigation requiring no further surgical intervention. One case of chronic mastitis fistulized to the skin and was drained surgically. No recurrences were observed in the follow-up period. US-guided percutaneous aspiration and irrigation is a successful method for treatment of breast abscesses in the emergency setting. This method is more successful in abscesses with a maximum dimension smaller than 3 cm and should be preferred to the surgical drainage.

[Image quality and characterisation of sonographically detected breast lesions: comparison of tissue harmonic imaging alone and in combination with frequency compounding]

PURPOSE

To determine the accuracy of frequency compounding (FC) in detection and characterisation of breast lesions by ultrasound (US) and to assess the image quality in direct comparison with tissue harmonic imaging (THI).

MATERIALS AND METHODS

A total of 60 breast lesions were examined; these were malignant in 39 cases and benign in 21 as confirmed by histology of core biopsy specimens (Aplio 80, Toshiba, Otawara, Japan). A total of 120 freeze frames, 60 B-mode scans with THI and 60 scans with FC were assessed by three independent examiners, who determined the presence of pathology on a scale of 1 to 5 using established criteria (BI-RADS classification). Image quality of each technique was rated on a ranking scale of - 2 (FC clearly superior to THI), - 1 (FC slightly superior to THI), 0 (identical), + 1 (THI slightly superior to FC), to + 2 (THI clearly superior to FC). The different US techniques were compared in terms of image quality and diagnostic accuracy using Mann Whitney U test and ROC analysis.

RESULTS

The results for image quality were as follows: - 0.56 +/- 0.71. In 56 % of the images FC was superior to THI, both techniques were identical in 37 % of cases, and in only 7 % THI was superior to FC. The following AUCs (Area under Curve, presence of pathology) were calculated: 0.945 and 0.969 for THI and FC, respectively (not significant). The two US techniques had comparable sensitivity (FC/THI 100/98 %) and specificity (FC/THI 76/74 %).

CONCLUSION

Altogether, the diagnostic value of FC was comparable to that of THI with only slight differences. For ultrasound examinations of breast lesions, FC improves the image quality and conspicuity of pathology.

An unusual bilateral mastitis in a postmenopausal woman caused by brucellosis

Breast involvement of brucella can be frequently detected in animals, however, it is extremely rare in humans. Clinical findings and complications may cause difficulties in diagnosis. We report the case of a 52-year old woman with bilateral brucella mastitis, which is difficult to differentiate from inflammatory breast carcinoma.

Granulomatous lobular mastitis: two case reports with focus on radiologic and histopathologic features

Granulomatous lobular mastitis (GLM) is a rare, benign condition with an unknown etiology that can appear as cancer on mammogram, ultrasound, and magnetic resonance imaging. The terminology of GLM was first named by Going et al (J Clin Pathol 1987;40:535-540) in 1987 after he noted the lobule centered distribution on histologic exam. We present 2 case reports of GLM that clinically and radiographically appeared as malignant lesions. The first case was a 31-year-old woman with a 1-month history of breast mass, and the second case was a 33-year-old woman with a 2-week history of breast mass. Both cases were histologically diagnosed as GLM. Retrospectively, we identified ultrasound and magnetic resonance imaging characteristics that may be used in the future to classify the breast mass before biopsy.

[Granulomatous mastitis: diagnostic and therapeutic problems. Case report and review of the literature]

The granulomatous mastitis is uncommon inflammatory disease of the breast of unknown etiology. The diagnosis is obtained only through hystopathology. We report a case of woman, 41 years old, showing lesions of the breast, that caused strong pain with ulcerations sero-haematic secretion and axillary omolateral lymphadenopathy. The diagnostic workup (sonography, mammography, multiples FNAB of single lesions, the culture of cells and hormonal profile) showed an inflammatory aspecific lesions with presence of atipic cells in nipple's secretion and in FNAB of periareola lesion. We performed an excisional biopsy. The hystopathologic diagnosis showed a granulomatous mastitis, confirming the validity of our diagnostic and therapeutic choices. The excisional biopsy has allowed to avoid an overtreatment and obtain a good aesthetic result.

Mammary tuberculosis: analysis of thirty-eight patients

Thirty-eight patients with mammary gland tuberculosis were evaluated over a 5-year period presenting to the surgical unit of our institution. Unilateral involvement of the breast in a woman presenting at an average age of 29 years was the commonest observation. A lump in the breast with or without discharging sinuses was the most common clinical presentation. Ten (26%) of these patients had breast pain with or without increased breast nodularity. Axillary lymph nodal involvement was evident in 14 (36%) of our patients. Only five patients had associated pulmonary tuberculosis, the rest having an isolated involvement of the breast. Fine-needle aspiration cytology was the most reliable diagnostic modality. Medical therapy with antitubercular drugs ranging from 6 to 9 months was the mainstay of treatment. Surgical intervention was reserved for selected refractory cases.

Lupus mastitis

We report a case of a 28-year-old female with the diagnosis of systemic lupus erythematosus (SLE) referred to our breast pathology consultancy in 2002 due to a left breast nodule. Further investigation revealed bilateral coarse calcifications. Biopsy was consistent with a diagnosis of lupus mastitis.

[Lobular idiopathic granulomatos mastitis. About 10 cases]

Our retrospective study was performed on 10 cases of granulomatous mastitis registered in Obstetric Gynaecology Department and Pathology Department of CHU F. Hached, Sousse, during 8 years period. The mean age was 36.4 years (range 32-59). Among these 10 cases. 8 were observed in reproductive-age women and 2 were noted in menopausal women. Clinical findings showed unilateral breast nodule associated with inflammatory signs in 4 cases, mammelonary retraction in 2 cases and serous or sero-purulent mamelonnary flow in 4 cases. Mamnmographic examination suggested a malignant tumor in 5 patients. In all cases, the diagnosis is made by histopathology. Surgical treatment consisted in wide excision with drainage or radical mastectomy, eventually with combination with antibiotic therapy and non steroid anti-inflammatory drugs. Prognostic features showed a good cicatrization in 4 cases, local recurrence and cutaneous fistulization in one patient. Granulomatous mastitis aetiology is still unclear, auto-immune aetio-pathogenesis appears more interesting and should be clarified.

Ultrasonographic and gross pathological findings in the mammary glands of weaned sows having suffered recidiving mastitis metritis agalactia

In a large pig breeding herd with high prevalence of post-parturient diseases of the sows, weaned sows of different parity groups with (n = 663) or without (n = 1125) recidiving mastitis metritis agalactia (MMA) in their previous history were subjected to ultrasonography. A total of 114 of 663 sows with recidiving MMA in their previous history and with ultrasonographic visible mammary gland changes, and 157 of sows without recidiving MMA in their previous history were culled and subjected to gross pathological and bacteriological examination of their mammary glands. The sows having suffered MMA had more (p < 0.001) hyperechogenic images in their mammary glands compared with the sow having suffered no recidiving MMA. Abdominal glands were more (p < 0.01) prone to pathological changes compared with the pectoral ones. Sows of high parity had more hyperechogenic images and gross pathological changes in their mammary glands compared with the sows of low parity.

[Non-lactational mastitis: our experience]

The most frequent breast inflammatory diseases are lactational and non-lactational mastitis. The diagnosis of these lesions is always difficult, as they often mimic breast cancer. The Authors report on their experience about 830 clinical cases of non-lactational mastitis, 804 were superficial abscesses and 24 were phlegmons. In 379 cases an infectious cause was found: in 249 by Streptococcus/Pseudomonas and in 30 by Staphylococcus Aureus. All patients underwent surgical treatment. Diagnosis was obtained by clinical examination, routine investigations (ultrasound, mammography and cytology) and post-operatively by histological evaluation. The non-lactational mastitis are more frequent in the postmenopausal and the menopausal period, but MDAIDS (Mammary Ducts Associated Inflammatory Diseases Sequence) are particularly interesting. MDAIDS was observed in 178 cases, these are very peculiar lesions characterized by ducts ectasia, squamous metaplasia, lymphoid infiltration and strictly correlated with heavy smoking. Sometimes, only surgical treatment clarifies the nature of these lesions. Patients with inflammatory diseases of the breast present with mastalgia and secretions, symptoms which alert patients to consult quickly a specialist. Instrumental investigations often don't clarify the diagnosis and surgical treatment by incision and drainage or excision is definitive.

Radiologic and clinical features of idiopathic granulomatous lobular mastitis mimicking advanced breast cancer

Idiopathic granulomatous lobular mastitis (IGLM), also known as idiopathic granulomatous mastitis, is a rare chronic inflammatory lesion of the breast that can clinically and radiographically mimic breast carcinoma. The aim of this study was to describe the radiological imaging and clinical features of IGLM in order to better differentiate this disorder from breast cancer. We performed a retrospective analysis of the clinical and radiographic features of 11 women with a total of 12 IGLM lesions. The ages of these women ranged between 29 and 42 years, with a mean age of 34.8 years. Ten patients were examined by both mammography and sonography and one by sonography alone. The sites that were the most frequently involved were the peripheral (6/12), diffuse, (3/12), and subareolar (3/12) regions of the breast. The patient mammograms showed irregular ill-defined masses (7/11), diffuse increased densities (3/11), and one oval obscured mass. In addition, patient sonograms showed irregular tubular lesions (7/12) or lobulated masses with minimal parenchymal distortion (2/12), parenchymal distortion without definite mass lesions (2/12), and one oval mass. Subcutaneous fat obliteration (12/12) and skin thickening (11/12) were also observed in these patients. Contrary to previous reports, skin changes and subareolar involvement were not rare occurrences in IGLM. In conclusion, the sonographic features of IGLM show irregular or tubular hypoechoic masses with minimal parenchymal distortion. Both clinical information and the description of radiographic features of IGLM may aid in the differentiation between IGLM and breast cancer, however histological confirmation is still required for the proper diagnosis and treatment of the disorder.

[Neonatale mastitis in a 4-week-old infant]

This is a case report of a four week old newborn, presenting with a red and swollen right breast gland. Clinical examination and ultrasound confirmed the diagnosis of a suppurative mastitis. The abcess was incised and drained and systemic antibiotic therapy started. Staphylococcus aureus was isolated from the culture. The important aspects of aetiology, pathogenesis, diagnosis and therapy of suppurative mastitis in the newborn are discussed in a short literature review.

[Diagnosis of plasma cell mastitis with multi-slice spiral CT]

OBJECTIVE

To evaluate the diagnostic value of multi-slice spiral CT (MSCT) for plasma cell mastitis.

METHODS

Radiographs of MSCT for forty-six patients with plasma cell mastitis diagnosed by pathological examination were reviewed.

RESULTS

The findings of MSCT of plasma cell mastitis could be divided into four types, including the inflammation type, the abscess type, the sinus and fistula type, and the mixed type, and each type had its radiographic characteristics.

CONCLUSION

MSCT is helpful for diagnosing plasma cell mastitis and should be used as an examination of first choice for the patients.

Occult inflammatory breast cancer: review of clinical, mammographic, US and pathologic signs

PURPOSE

To examine the clinical, radiologic and pathologic findings of occult inflammatory breast cancer (OIBC) in order to identify features useful for diagnosis.

MATERIALS AND METHODS

We retrospectively reviewed the records of 19 women with OIBC observed at our Department between 1992 and 2001. We analysed the clinical history, mammographic, ultrasonographic, and pathologic findings and investigated overall survival (OS), prognostic variables and radio-pathologic correlations.

RESULTS

The most common mammographic findings were: diffusely increased density (52.63%), trabecular thickening (42.1%), mass (36.84%). The most common US findings were axillary lymphadenopathy (68.75%), skin thickening (43.75%) and mass (56.25%). At least one inflammatory sign was found in 14 women (74%) at mammography (subcutaneous thickening, trabecular thickening, diffuse increase in density) or at US (subcutaneous thickening, diffuse increase in echogenicity due to oedema, lymph vessel dilatation). Estrogen receptors (ER) were present in 63.2% and Progesterone receptors (PgR) in 36.8%. Significant prognostic variables were ER and Ki 67.

CONCLUSIONS

The typical radiological pattern of clinical inflammatory breast carcinoma is less frequently present in OIBC; nevertheless the radiologist must pay attention because frequently OIBC presents just one radiological sign and this should be enough for a diagnostic suspicion. Moreover, the absence of clinical and radiological inflammatory signs does not exclude inflammatory breast cancer because OIBC can manifest at imaging as a mass or isolated calcifications. ER and PgR are positive in a high percentage of patients and confirm that OIBC has a better prognosis than clinical inflammatory breast cancer.

Mammographic features of isolated tuberculous mastitis

OBJECTIVE

To present the mammography findings in 8 patients with tuberculosis (TB) of the breast, with a review of the literature.

METHODS

This study is a retrospective data collection. Each chart with confirmed breast TB based on bacteriology or pathologic findings was analyzed for clinical presentation, gender, nationality, demographic data, prior history of TB, investigation, management, mammographic findings and ultrasound, when available. Mammograms were reviewed by 2 consultant radiologists without knowing the previous diagnosis or the nature of the study. The study was carried out at The State Tuberculosis Registry and Radiology Department, Hamad General Hospital, State of Qatar, from 1990 to 2002.

RESULTS

Out of 13 females with TB mastitis, only 8 cases had mammograms preoperatively. The incidence of breast TB in Qatar is rare (1/1000 mammograms per year). Three types of TB mastitis were identified in our study; the nodular (50%), the diffuse (37.5%) of which 77% were limited to one sector of the breast and the sclerosing (12.5%) mastitis. Three patients (43%) were reported as carcinoma.

CONCLUSION

Although mammography identified 3 types of TB, it was not helpful in differentiating TB from carcinoma of the breast. However, the careful evaluation of the degree of density and trabecular thickening of the mass in relation to it size might reduce the number of false positive cases of carcinoma diagnosed with mammograms. Biopsy specimen remains the best diagnostic tool in TB mastitis.

Imaging of granulomatous mastitis: assessment of three cases

Granulomatous mastitis is a benign, inflammatory breast disease of unknown aetiology, which can mimic breast carcinoma in its clinical manifestations. Imaging features of three cases of granulomatous mastitis mimicking breast carcinoma on both clinical and radiographic examination are presented, with special emphasis on the role of dynamic contrast-enhanced-magnetic resonance mammography in the differential diagnosis.

[Conservative treatment of puerperal breast abscesses with repeated sonographically guided aspirations and oral antibiotic administrations]

BACKGROUND

Breast abscesses have usually been treated by incision and drainage. During the past 10 years conservative treatment with repeated ultrasound-guided drainage to evacuate the abscess combined with antibiotic treatment has become a valuable alternative.

PATIENTS AND METHODS

From 1991 to 2003 the authors treated 17 patients with puerperal abscess with this method. Under local anesthesia with ultrasound guidance a thick needle (preferably a Venflon) is introduced into the cavity. The procedure is repeated every two or three days until the ultrasound image demonstrates a diameter of the cavity of 1.5 cm or less. The oral antibiotic treatment lasts for 6 to 10 days.

RESULTS

In 7 cases only one puncture was needed, 5 cases needed 2 punctures while 4 women needed 3 or more punctures (up to 5). In 16 cases an open drainage could be avoided. One patient wanted to discontinue the conservative treatment after the first puncture and requested the surgical drainage.

CONCLUSIONS

Conservative therapy with ultrasound-guided drainage of puerperal breast abscesses can therefore be recommended as a standard treatment.

Imaging Findings in Idiopathic Granulomatous Mastitis

OBJECTIVE

To describe magnetic resonance (MR) imaging features of patients with a histologic diagnosis of idiopathic granulomatous mastitis (IGM).

METHODS

Dynamic contrast-enhanced MR imaging was performed with a 1.5-T MR unit. Postprocessing of images included subtraction and calculation of time-intensity curves of the enhancing regions at several points in all patients.

RESULTS

In addition to granulomatous inflammation, biopsy slides of 5 patients demonstrated abscess formation without a specific organism (aseptic abscess). One patient had a fibrotic tissue component. Magnetic resonance imaging findings were heterogeneously enhancing areas with (n = 5) and without (n = 1) multiple ring-like enhanced abscesses and a circumscribed lesion with heterogeneous contrast enhancement (n = 1). Time-intensity curves showed a benign pattern in all but 1 patient.

CONCLUSION

Idiopathic granulomatous mastitis has a number of appearances on MR imaging. Magnetic resonance imaging with measurement of time-signal intensity curves may support the findings of ultrasonography and mammography in distinguishing benign inflammatory breast disorders from malignant ones; however, biopsy still remains the only method of definite diagnosis.

Mammographic and sonographic features of tuberculous mastitis

From December 1999 to April 2001, 10 cases of tuberculous mastitis were presented to the Radiology Unit at the Medical Research Institute of Alexandria University for mammographic and sonographic evaluation. Sixty percent presented with masses, 50% mastalgia, 40% discharge, and 10% complained of skin sinus. In 30% of the patients the complaint was bilateral. All cases underwent full mammographic and ultrasonographic (US) studies, and US-guided fine needle aspiration. Also pathological, bacteriological analysis, and polymerase chain reaction (PCR) were done to all patients to prove the tuberculous nature of their lesions. Thirty percent of the cases had surgical excision on their masses. On mammography 30% were found to have mass lesion mimicking malignant tumors, 40% smooth bordered masses, 40% axillary or intramammary adenopathy, 30% asymmetric density, 30% duct ectasia, 20% with skin thickening and nipple retraction, 20% with macrocalcification, and 10% with skin sinus. On US 60% had hypoechoic masses, 40% focal or sectorial duct ectasia, and 50% axillary adenopathy. History of tuberculosis was found in 30% of the cases. Chest X-ray was positive in 20% and breast magnetic resonance imaging was done to one patient who had skin sinus.

[3D ultrasound in core breast biopsy]

AIM

To evaluate the potential of three-dimensional ultrasound (3D US) in core biopsy of suspicious breast lesions.

METHOD

3D US controlled core biopsy was performed in 107 breast masses in 100 women by using an automated biopsy system (11G coaxial needle, 12 G biopsy needle). Mean diameter of the lesions was 1.55 cm (0.5 - 3.5 cm). A linear 3D US volume scanner was used for the procedure. Localization of the lesion and placement of the needle were initially done under 2D US guidance. After core needle stroke a 3D US volume acquisition was performed to correlate lesion and needle position. In the case of eccentric needle position the needle was repositioned under 3D control. 5 specimens were taken from each lesion. The histological results from the specimens were correlated with the results from surgery or clinical follow-up (> 2.5 years).

RESULTS

Biopsy was taken from 59 probably benign (BI-RADS 3 - 4) and 48 malignant (BI-RADS 5) lesions. 3D US revealed 61 central, 44 eccentric and 2 marginal needle positions after the initial 2D guidance. Central repositioning of the needle was achievable under 3D guidance in all patients. Histological examination of the specimens revealed 41 invasive carcinomas and one in-situ carcinoma (DCIS). In one lesion, the carcinoma was missed in the core biopsy, despite central hits of the biopsy needle. This led to a sensitivity of 98 %, specificity of 100 %, PPV of 100 %, NPV of 98.5 % and accuracy of 99 % for the diagnosis of a malignant lesion.

CONCLUSION

3D US improves needle positioning as well as the depiction of correct needle placement in freehand core biopsy.

Granulomatous mastitis can mimic breast cancer on clinical, radiological or cytological examination: a cautionary tale

In both women and men, breast lumps are the most common presentation of breast cancer. The following cases illustrate the pathological entity of granulomatous mastitis, which can present simulating breast cancer - including the first description of this condition in a male. These cases demonstrate the difficulty in clinical diagnosis and emphasizes that although there may be clues from the history, clinical awareness that this condition can mimic breast cancer in all aspects of the triple assessment process should arouse suspicion. The importance of histological diagnosis by core or excision biopsy is stressed, as with accurate diagnosis of granulomatous mastitis there is a mandate to avoid unnecessary surgery.