Granulomatous mastitis: Radio-pathologic correlation and management Poster No.: C-1418 Congress: ECR 2014 Type: Educational Exhibit Authors: S. E. Song, B. K. Seo, K. R. Cho, O. H. Woo, Y.-S. Kim ; 1 1 1 2 2 1 2 Ansan/KR, Seoul/KR Keywords: Inflammation, Infection, Biopsy, MR, Ultrasound, Breast DOI: 10.1594/ecr2014/C-1418 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 17
Learning objectives 1. Pathogenesis and classifications of granulomatous mastitis 2.Radiological characteristics and pathological correlations of granulomatous mastitis with emphasis on idiopathic granulomatous lobular mastitis and tuberculous mastitis 3. Clues for diagnosing granulomatous mastitis and distinguishing from breast malignancies 4. Roles of radiologists for diagnosis and management of granulomatous mastitis Background <Granulomatous mastitis> Rare inflammatory breast disease Caused by both uncertain and certain pathogen Usually affecting women of childbearing age Should be managed differently according to various causes <Pathogenesis> Infectious: Tuberculosis mastitis (M/C), Gram-positive bacilli (Corynebacterium kroppenstedtii) Non-infectious: Idiopathic granulomatous mastitis, or lobular granulomatous mastitis, grabulomatous lobullitis Common Histological Finding: Epithelioid histiocytes, plasma cells, lymphocytes, eosinophils, neutrophils,multinucleated giant cells and necrosis < Treatment> Management of granulomatous mastitis depends on the causative factor. Page 2 of 17
TB granulomatous mastitis: TB medication Idiopathic granulomatous mastitis: Steroid therapy Findings and procedure details Idiopathic granulomatous mastitis Tuberculous mastitis Autoimmune disease Mycobacterium tuberculosis Immune response to Retrograde spread from axillary nodes local trauma, local irritants Undetected organisms Direct extension from contiguous structures such as the chest wall ( viruses, mycotic, and parasitic infections ) Hyperprolactinemia, alpha-1 antitrypsin diabetes mellitus, Direct inoculation of the nipple via the lactiferous ducts Use of oral contraceptives Hematogenous dissemination Pregnancy and lactation Etiology Idiopathic granulomatous Tuberculous mastitis mastitis Symptom Progressively #rm, enlarging Long-standing and substantially moderate mastalgia with masses, and tender and unilateral discharge breast lumps of variable size,nipple retraction, or #xed to underlying pectoralis muscle Age Women of childbearing age Pathology Premenopausal (predilection for who are lactating) women women Signi#cantly more plasma Signi#cantly more #brosis, cells eosinophils, and necrosis Page 3 of 17
Clinical and Pathologic Finding Idiopathic mastitis Mammography granulomatous Tuberculous mastitis Large focal asymmetric 1. Nodular (ill-defined density (44%) or irregular mass Lobulated or irregular mass that closely resembles (16%) carcinoma) Diffusely increased density 2. Diffuse (inflammatory (7%) carcinoma with skin Axillary adenopathy (18%) thickening) Skin thickening (7%) 3. Sclerosing (dense breast tissue,sometimes associated with areas of architectural Distortion) Ultrasonography Large, irregular hypoechoic Axillary adenopathy (50%) mass with multiple tubular Skin bulging and one or extensions (59%) more Lobulated or irregular sinus tracts hypoechoic mass (33%) Parenchymal distortion with US: internal cystic, acoustic shadowing and no solid, or complex structure discrete mass (7%) of the masses Axillary adenopathy (28%) Skin thickening (52%) Radiologic Finding <Radiologic Finding For Differential Diagnosis> Both Diseases: Diffuse skin thickening and edematous change of subcutaneous fat layer are common findings of both diseases. Page 4 of 17
TB granulomatous mastitis: multiple circumscribed complex echoic masses with LN enlargement Idiopathic granulomatous mastitis: Complex echoic masses with tubular extention and ductectasia with intraductal masses Images for this section: Fig. 1: Case 1. A 33-year-old woman with inflammation in right breast. Breast US showed irregular shaped, indistinct marginated, hypoechoic mass with extention to nipple in her right breast. Diffuse skin thickening and edematous change of subcutaneous fat layer were combined. US-guided core biopsy result was chronic noncaseating granulomatous mastitis and Mycobacterium tuberculosis was positive on Nested PCR. Page 5 of 17
Fig. 2: Case 2. A 59-year-old woman with palpable mass in right breast. Breast US showed irregular shaped, circumscribed and indistinct marginated, complex echoic masses in her right breast. Diffuse skin thickening and edematous change of subcutaneous fat layer were combined. Page 6 of 17
Fig. 3: Case 2. A 59-year-old woman with palpable mass in right breast. Right axillary LN enlargement was also seen. Excision was performed due to long standing inflammation and the pathologic result was chronic noncaseating granulomatous mastitis and AFB stain for Mycobacterium tuberculosis was positive. Page 7 of 17
Fig. 4: Case 3. A 27-year-old woman with swelling and heating sensation in left axilla Breast US showed irregular shaped, indistinct marginated, complex echoic mass in her left axilla. Page 8 of 17
Fig. 5: Case 3. A 27-year-old woman with swelling and heating sensation in left axilla Necrotic lymph nodes w.ere also seen at left axilla level II. Excision was performed due to long standing inflammation and the pathologic result was chronic noncaseating granulomatous mastitis and AFB stain for Mycobacterium tuberculosis was positive. Page 9 of 17
Fig. 6: Case 4. A 15-year-old woman with palpable mass in right axilla. Breast US showed multiple enlarged hypoechoic lymph nodes witt absent or displaced hila in her right axilla level I,II. US-guided core biopsy result was chronic caseating granulomatous lymphadenitis and Mycobacterium tuberculosis was positive on Nested PCR. Page 10 of 17
Fig. 7: Case 5. A 36-year-old woman with palpable mass in UOQ of right breast. Breast US showed indistinct irregular shaped hypoechoic mass in her entire breast. Overlying skin thickening with subcutaneous fat edema and ipsilateral lymph node enlargement were also seen, suggesting inflammatory breast cancer. US-guided core biopsy result was chronic granulomatous mastitis and multiple masses in right breast showed improving process after medication and incision and drainage. Page 11 of 17
Fig. 8: Case 5. A 36-year-old woman with palpable mass in UOQ of right breast. Breast US showed indistinct irregular shaped hypoechoic mass in her entire breast. Overlying skin thickening with subcutaneous fat edema and ipsilateral lymph node enlargement were also seen, suggesting inflammatory breast cancer. US-guided core biopsy result was chronic granulomatous mastitis and multiple masses in right breast showed improving process after medication and incision and drainage. Page 12 of 17
Fig. 9: Case 6. A 34-year-old woman with multiple masses in right breast. Breast US showed multiple hypoechoic masses with tubular extention connecting masses in her right breast inner quadrant. Inflammations such as idiopathic granulomatous lobular mastitis or chronic pyogenic abscess were suggested and the pathologic result by USguided core biopsy was chronic granulomatous mastitis. Mycobacterium tuberculosis was negative on Nested PCR. Page 13 of 17
Fig. 10: Case 7. A 24-year-old woman with multiple masses in right breast. Breast US showed multiple hypoechoic masses with tubular extention connecting masses in her right breast inner quadrant. Inflammations such as idiopathic granulomatous lobular mastitis or chronic pyogenic abscess were suggested and the pathologic result by USguided core biopsy was chronic granulomatous mastitis. Mycobacterium tuberculosis was negative on Nested PCR. Page 14 of 17
Fig. 11: Case 8. A 36-year-old woman with previous history of inflammation in left breast. Breast US showed dilated duct with internal hypoechoic debri in her left subareolar area. The pathologic result by US-guided core biopsy was chronic granulomatous mastitis. Mycobacterium tuberculosis was negative on Nested PCR. Page 15 of 17
Conclusion Diffuse skin thickening and edematous change of subcutaneous fat layer are common findings of both diseases. Complex echoic masses with tubular extention and ductectasia with intraductal masses are more typical finding of idiopathic chronic granulomatous mastitis and multiple circumscribed complex echoic masses with LN enlargement are typical finding of TB granulomatous mastitis. Dilatation of subdermal lymphatics are common finding of inflammatory breast cancer but are not usual in both of idiopathic and TB granulomatous mastitis. Personal information Presenting author: Bo Kyoung Seo, MD, PhD Department of Radiology, Korea University Ansan Hospital, Korea University College of Medicine, 516, Gosan-dong, Danwon-gu, Ansan city, Kyungki-do, 425-707, Korea. Tel: +82-31-412-5228 Fax: +82-31-412-5224 E-mail: seoboky@korea.ac.kr References 1. Lacambra M, Thai TA. Granulomatous mastitis: the histological differentials J Clin Pathol 2011;64:405-411 2.Hovanessian Larsen LJ, Peyvandi B. Granulomatous lobular mastitis: imaging, diagnosis, and treatment. AJR Am J Roentgenol 2009 Aug;193(2):574-81. 3. Sabate JM, Clotet M. Radiologic evaluation of uncommon inflammatory and reactive breast disorders. Radiographics 2005 Mar-Apr;25(2):411-24. Page 16 of 17
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