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Amyloid Deposition of the Breast

¹ Department of Radiology, Southampton Hospital, 240 Meeting House La., Southampton, NY 11968.
² Department of Pathology, Southampton Hospital, Southampton, NY 11968.
³ Department of Medicine, Southampton Hospital, Southampton, NY 11968.
⁴ Department of Surgery, Southampton Hospital, Southampton, NY 11968.

Received May 15, 2000; accepted after revision June 12, 2000.

 
Address correspondence to B. S. Gluck.

Introduction

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A 76 -year-old woman with a 15-year history of indolent multiple myeloma presented for annual screening mammography. Her myeloma had been diagnosed 15 years earlier by bone marrow biopsy and serum protein immunoelectrophoresis but was not treated because she remained asymptomatic. Annual screening mammography showed grouped, generally smooth branching rodlike calcifications in the upper outer quadrant of the right breast. These calcifications were new since the prior examination a year earlier (Figs. 1A and 1B). No correlative palpable abnormality was present on physical examination. Because of the short-interval appearance of calcium and the branched morphology, biopsy was recommended to exclude breast malignancy. The patient underwent needle localization and surgical excision.

View larger version (147K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A. —76-year-old woman with 15-year history of indolent multiple myeloma. Mediolateral oblique mammogram shows microcalcifications in upper outer quadrant of right breast.

View larger version (148K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B. —76-year-old woman with 15-year history of indolent multiple myeloma. Craniocaudal cone magnification mammogram reveals grouped, generally smooth branching rodlike calcifications.

Histology showed diffuse dense hyalinized material associated with fibrosis, chronic inflammation (including foreign body—like reaction), and microcalcifications. This was present in and around ducts, vessels, and stroma. The material exhibited exhibited apple-green birefringence with Congo red stain under polarized light, characteristic of amyloid deposition. No malignancy was identified at pathology (Fig. 1C).

View larger version (149K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1C. —76-year-old woman with 15-year history of indolent multiple myeloma. Photomicrograph shows dense interstitial hyaline material and chronic inflammation, suggestive of amyloid deposition. Note large microcalcification in lower left corner. (H and E,x100)

Amyloid deposition in the visceral organs may be seen in patients with primary amyloidosis (no preexisting or coexisting disease), multiple myeloma, chronic infectious disease, and chronic inflammatory disease (such as rheumatoid arthritis.) Amyloid tumor of the breast is rare and may present as a similar clinical appearance to mammary carcinoma, with a palpable breast mass and mammogram showing a mass or focal or diffuse density with or without calcifications [1,2,3,4,5,6]. Although there are sporadic case reports in the literature, amyloid deposition in the breast has been previously reported only once in the radiology literature to our knowledge [1]. Although it has been incidentally observed as breast nodules or infiltration at autopsy with negative mammograms [2], we are unaware of amyloid presenting as a nonpalpable mammographic abnormality consisting of only indeterminate calcifications on annual screening mammography. The mammographic appearance of nonpalpable amyloid has not been described and is not commonly thought of in the differential diagnosis of nonpalpable breast disease or, more specifically, indeterminate calcifications. In this case, the absence of ill-defined density or a nodule on mammogram may be related to the overall relative increased breast density; however, a discrete lesion was not present on gross pathologic examination either. Amyloid fibrils have an affinity for calcium and deposition around mammary ducts and in blood vessels [3, 6, 7]. In this case, perhaps the branched morphology of the calcium is related to deposition in or around vasculature or mammary ducts. When limited to the breast, primary amyloid tumor is benign. However, secondary amyloidosis may have an ominous significance and poor prognosis [8].

References

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1. Hecht AH, Tan A, Shen JF. Case report: primary systemic amyloidosis presenting as breast masses, mammographically simulating carcinoma. Clin Radiol 1991;44:123 -124[Medline]
2. O'Connor CR, Rubinow A, Cohen AS. Primary (AL) amyloidosis as a cause of breast masses. Am J Med 1984;77:981 -986[Medline]
3. Luo JH, Rotterdam H. Primary amyloid tumor of the breast: a case report and review of the literature. Mod Pathol 1997;10:735 -738[Medline]
4. Walker AN, Fechner RE, Callicott JH. Amyloid tumor of the breast. Diagn Gynecol Obstet 1982;4:339 -341[Medline]
5. Fernandez BB, Hernandez FJ. Amyloid tumor of the breast. Arch Pathol 1973;95:102 -105[Medline]
6. Silverman JF, Dabbs DJ, Norris HT, et al. Localized primary (AL) amyloid tumor of the breast: cytologic, histologic, immunocytochemical and ultrastructural observations. Am J Surg Pathol 1986;10:539 -545[Medline]
7. Levine E. Abdominal visceral calcification in secondary amyloidosis: CT findings. Abdom Imaging 1994;19:554 -555[Medline]
8. Scott PP, Scott WW, Siegelman SS. Amyloidosis: an overview. Semin Roentgenol 1986;22:103 -112

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