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ECR 2010 / C-0453
Inflammatory breast disease: Radiologic findings, clinical manifestation and US-guided treatment
Congress: ECR 2010
Poster No.: C-0453
Type: Educational Exhibit
Topic: Breast - Miscellaneous
Keywords: Breast
Authors: S. H. Park1, E.-K. Kim2, M. J. Kim2, J. Y. Kwak2, S. J. Kim2; 1Incheon/KR, 2Seoul/KR
DOI:10.1594/ecr2010/C-0453

Imaging findings OR Procedure details

I. Pyogenic mastitis and abscess

 

Clinical manifestation: pain and erythema

 

Radiologic findings

 

Mammography: not useful (US: ideal imaging)

  • Mastitis: diffuse or focal skin and trabecular thickening from breast edema 
  • Abscess: Ill-defined noncalcified mass  

 

US findings of mastitis

  • Decreased parenchymal echogenicity or increased fat echogenicity 
  • Skin thickening 
  • Increased vascularity on color Doppler 
  • Reactive or enlarged axillary LNs 
  • Dilated lymphatics.

US findings of breast abscess

 

  • Round, oval, or irregular hypoechoic lesion (homogeneous or inhomogeneous)
  • Irregular hypoechoic or anechoic masses 
  • Sometimes with fluid/debris levels 
  • Usually with posterior acoustic enhancement

 

Fig.: 1. 28 years-old female with palpable mass in her left breast with tenderness and redness. US showed inhomegenous mixed-echoic mass in left subareolar area
References: Department of Radiology, Breast Division, Gachon University Gil Hospital - Incheon/KR

 

Fig.: 2. 30 years-old female with skin erythema for 3 months. US showed irregular shaped hypoechoic lesions with internal floating materials and diffuse skin thickening. Patient also had skin defect(thin arrows)with continuity to the abscess pocket.
References: Department of Radiology, Breast Division, Gachon University Gil Hospital - Incheon/KR

 

II. US-guided treatment of breast abscess

  • Breast abscesses have typically required treatment with surgical incision and drainage under general anesthesia.
  • When compared with surgical incision and drainage, the risk of damaging major ducts with catheter placement is negligible.  
  • The risk of a poor cosmetic result because of scar formation is also negligible. 
  • Ultrasonography is being used to diagnose breast abscesses. 
  • HR real-time US is unique means for diagnosis and evaluating the extent, size, site and internal characteristics of breast abscess  
  • A high rate of success (>90%) are reported with percutaneous aspiration and careful irrigation of breast abscesses. 
  • US guided aspiration of breast abscesses with placement of indwelling catheters has become the treatment of choice.
Fig.: 3. 37 years-old female with large abscess in her left breast. 10F pig-tail catheter(thin arrows) insertion was done under US guidance. 8 days later,on follow-up US, previous abscess(star) was markedly decreased after catheter insertion. After one month, previous abscess pocket near completely disappeared.
References: Department of Radiology, Breast Division, Gachon University Gil Hospital - Incheon/KR

 

III. Tuberculosis of breast

 

Clinical findings

  • Secondary in most patients -Primary breast Tb: rare as the primary manifestation
  • Exclusively in females, as many as 4.5% in males
  • Reproductive age group, especially during lactation
  • 50~70% patients with involvement of axillary nodes
  • Retrograde lymphatic spreadfrom axillary nodes or occasionally from cervical or mediastinal nodes
  • Insidious onset, painless lump
  • Most common in UOQ due to frequent extension from axillary LNs
  • Difficulty in its clinical manifestation from breast cancer

Radiological findings

  • Mammography:  nonspecific findings 
  • Mimicking carcinoma on mammogram -Nodular, Diffuse, Sclerosing form                                              
  • Often With axillary lymphadenopathy   
  • Suspected bony changes in the thorax
  • Hypoechoic fistulous tract on US
  • Confirmation by imaging-guided FNA biopsy and culture 

 

Fig.: 4-a. 51 years-old female with palpable mass in RLOQ(a:mammogram). Mammography(Rt.MLO view) showed enlarged lymph nodes with multiple dense calcifications in right axilla.
References: Department of Radiology, Breast Division, Gachon University Gil Hospital - Incheon/KR

 

Fig.: 4-b. 51 years-old female with palpable mass in RLOQ area.(b: US and chest CT) US revealed large anechoic mass(star) posterior to retroglandular tissue. In chest CT, necrotic mass with well-enhancing wall seen at right anterior chest wall and pleural space, around the right 5th anterior rib. Adjacent linear pleural calcification is seen.
References: Department of Radiology, Breast Division, Gachon University Gil Hospital - Incheon/KR

 

IV. Granulomatous mastitis

 

Clinical findings 

  • Very rare  inflammatory disease of unknown origin that can clinically mimic carcinoma
  • Etiology: unknown
  • Possible cause:  immunologic factors, oral contraseptives, reaction to childbirth

Diagnosis

  • Depend on the demonstration of a particular histologic pattern with  exclusion of other granulomatous reactions such as sarcoidosis, Wegener’s granulomatosis, Tb and fungal infection etc.

Clinical manifestation

  • Breast lump: distinct, firm to hard mass
  • Typically affects younger women(4th decades), <6yrs of pregnancy 
  • Relationship to pregnancy or lactation has been strongly emphasized
  • Reactive axillary lymphadenopathy : up to 15% of patients

 

Radiologic findings

 

Mammography

  • Focal asymmetry : m/c finding
  • Mass with irregular margins
  • Normal findings

US

  • Inhomogeneous hypoechogenicity with internal hypoechoic tubular structures

 

Fig.: 5. 21 years-old female with left palpable mass for 5 months. US showed irregular shaped, heterogeneously hypoechoic lesions. US-guided 14G core needle biopsy was done. Pathology was confirmed to be granulomatous mastitis.
References: Department of Radiology, Breast Division, Gachon University Gil Hospital - Incheon/KR

 

Fig.: 6-a. 50 years-old female with two palpable mass in her left breast. Mammography was heterogeneously dense breasts with negative findings.
References: Department of Radiology, Breast Division, Gachon University Gil Hospital - Incheon/KR

 

Fig.: 6-b. 50 years-old female with two palpable mass in her left breast. US showed one isoechoic(5H dierction) and the other hypoechoic(2H) well-circumscribed oval shaped nodules. With biopsy, the nodules were confirmed to be granulomatous mastitis.(6-a:mammography. 6-b:US)
References: Department of Radiology, Breast Division, Gachon University Gil Hospital - Incheon/KR

 

V. Parasitic infection - Sparganosis of breast

 

Incidence 

  • Sparganosis >> cysticercosis, norcadiasis

Sparganosis of breast 

  • Sparganosis of breast 
  •  Few cases reported

Mammography of sparganosis in breast

  • Amorphous, lobular, marginated solid mass
  • Usually located in subcutaneous tissue
  • Mimic mastitis or cancer  

 

US findings of sparganosis in breast

  • Heterogeneously hyperechoic masses → granuloma containing living worm
  • Internal hypoechoic tubular lesion → empty tract of migrating larval worm
  • Tunnel formation is quite distinguishable from cysticercosis and other disease   

 

Fig.: 7-a. 62 years-old female with movable soft palpable mass in LUOQ. Mammography showed lobular shaped, circumscribed marginated, hyperdense solid mass in LUOQ.
References: Department of Radiology, Breast Division, Gachon University Gil Hospital - Incheon/KR

 

Fig.: 7-b. 62 years-old female with movable soft palpable mass in LUOQ. US showed heterogenous, hyperechoic mass with internal tunnel-like hypoechoic tracts. A living larval worm was extracted through excisional biopsy (color figure in 7-a).
References: Department of Radiology, Breast Division, Gachon University Gil Hospital - Incheon/KR
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