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Beth Israel Deaconess Medical Center and Harvard Medical School Boston, MA 02215
Venta et al. [1] describe the primary diagnosis of focal fibrosis in 8.2% (50/610) of consecutive core needle biopsies of the breast. Presumably this percentage would have been even higher if the denominator had included only biopsies performed for masses.
As addressed by Venta et al. [1], knowledge of this entity is important because it challenges the traditional belief that a nonspecific diagnosis of fibrosis with needle biopsy usually necessitates a second biopsy or surgical excision. However, cognizance of the potential diagnosis of focal fibrosis rarely changes the need to biopsy an indeterminate breast mass.
Venta et al. [1] fail to mention diabetes as one of the few known predisposing factors for focal fibrosis of the breast [2,3,4]. Diabetic fibrous mastopathy occurs in insulin-dependent women, most of whom have had the disease for many years with complications such as retinopathy [2]. These individuals are young, with a mean age of 34-47 years [2,3,4]. In the study by Venta et al. the average patient age was only 50 years.
In our practice, considerably fewer than 8.2% of core needle breast biopsies reveal focal fibrosis as the primary diagnosis. However, probably because our practice is associated with the Joslin Diabetic Center, diabetic mastopathy is the cause of a substantial minority of breast masses caused by focal fibrosis. Pathologic changes may be relatively specific in diabetic fibrous mastopathy [4].
The mammographic presence of a breast mass in association with vasculopathy, as manifest by arterial breast calcifications in a young woman, should suggest the possibility of diabetic fibrous mastopathy. In such cases, there is often a history of either previous benign breast biopsies or multiple masses, particularly small lesions often seen during sonography. Recognition of this constellation of findings is important because if a previous biopsy has revealed focal fibrosis, we often elect imaging follow-up rather than biopsy.
References
Northwestern University Medical School Chicago, IL 60611
We thank Dr. Hall for his interest and comments regarding our recent paper on focal breast fibrosis [1]. Dr. Hall mentions diabetes as a predisposing factor for breast fibrosis, an entity that he encounters in his practice as "the cause of a substantial minority of breast masses." Although none of our patients exhibited the symptoms of diabetic mastopathy, Dr. Hall's comments prompted us to research this entity, which we rarely encounter in our practice.
In the late 1980s, diabetic fibrous breast disease, or diabetic mastopathy, was described in the medical [2], surgical [3], and radiology literature [4]. These reports described benign hard palpable breast masses in long-term (average, 12 years) insulin-dependent diabetic patients. The series reported by Logan and Hoffman [4] included 36 patients and defined criteria for the diagnosis of diabetic fibrous breast disease. The criteria included the history of long-standing insulin-dependent diabetes mellitus, rock-hard mobile irregular painless palpable breast masses, sometimes bilateral dense tissue, and intense acoustic shadowing on sonography. Histology from biopsy specimens revealed stromal fibrosis with perivascular and periductal lymphocytic opacities [2,3,4]. Subsequent reports on diabetic fibrous mastopathy described similar clinical, radiographic, and histologic findings [5,6] with the presence of epithelioid fibroblasts added to the histologic description of abnormalities [7,8]. More recently, diabetic mastopathy was reported in the breasts of male diabetic patients with similar clinical and histologic findings [9], and in eight patients with long-standing insulin-dependent diabetes with clinically palpable breast masses [10]. In this last series, as in others, the presence of microvascular complications (such as retinopathy, nephropathy, or polyneuropathy) was common.
Although the cause of diabetic fibrous mastopathy is unknown, the presence of lymphocytic opacities, described by some as the histologic hallmark of this disease [7], suggests the possibility of an autoimmune reaction against components of the extracellular matrix.
Diabetic mastopathy is a rare clinical entity, with a reported prevalence of 0.06% or less, even in busy practices [3,4]. However, physicians specializing in the treatment of diabetic patients report a prevalence of 13% among premenopausal women less than 40 years old who are suffering from chronic insulin-dependent diabetes [2].
None of our patients met the clinical, radiographic, or histologic criteria for diabetic fibrous breast disease. Clinically, our patients presented with impalpable or barely palpable breast masses, thus necessitating sonographic guidance for histologic sampling. This is in marked contrast to the patients diagnosed with diabetic mastopathy in the previously mentioned publications [2,3,4,5,6,7,8,9,10], who usually presented with rock-hard palpable masses. Findings on imaging studies in cases of diabetic mastopathy were described by Logan and Hoffman [4] and Garstin et al. [5] and consisted of dense tissue or asymmetric density associated with acoustic shadowing. In contrast, we found that round (18%), oval (50%), or lobulated (32%) mammographic masses were the most common finding of focal fibrosis. Sonographically, only 18% of hypoechoic masses had posterior acoustic shadowing, a nonspecific finding itself, reported in benign and malignant lesions [11]. Finally, histologic review of the biopsy specimens in our series found no evidence of lymphocytic opacities or epithelioid fibroblasts. Although we do not specifically inquire about the presence of diabetes in our patients, in no case was the presence of diabetes or diabetic microvascular complications noted as part of the clinical history provided by the patient at the time of mammography or core biopsy.
In conclusion, the diagnosis of diabetic fibrous breast disease is usually made in the setting of long-standing insulin-dependent diabetes in patients with hard palpable masses that exhibit acoustic shadowing on sonograms, and in patients with histologic findings of lymphocytic infiltration and epithelioid fibroblast formation. None of our patients fit these criteria. Our series of noncalcified lesions representing focal breast fibrosis typically presented as hypoechoic masses with circumscribed or partially obscured margins. Awareness of this presentation should facilitate concordance assessment after core biopsy procedures, and avoid unnecessary anxiety and possible reexcision.
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