AJR 2002; 178:1236-1238
© American Roentgen Ray Society
Aspergilloma of the Breast in a Woman with Acute Myeloid Leukemia
Stephan P. Kloska1,
Karl Ludwig1,
Michael Kreuter2,
Raihanatou Diallo3 and
Walter Heindel1
1 Department of Clinical Radiology, University of Muenster,
Albert-Schweitzer-Str. 33, 48149 Muenster, Germany.
2 Department of Medicine/Hematology and Oncology, University of Muenster, 48149
Muenster, Germany.
3 Gerhard-Domagk-Institute of Pathology, University of Muenster, Domagkstr. 17,
48149 Muenster, Germany.
Received July 30, 2001;
accepted after revision October 10, 2001.
Address correspondence to S. P. Kloska.
Introduction
Invasive aspergillosis is a common opportunistic infection in
immunocompromised patients
[1,2,3].
It usually affects the pulmonary system. Extrapulmonary manifestations are
rare. Invasive aspergillosis has been described in the brain, skin, heart,
kidney, and gastrointestinal tract
[4,
5].
This report presents a finding of invasive aspergilloma of the breast in a
patient with acute myeloid leukemia. Histologic findings and corresponding
radiologic features in mammography and sonography are described.
Case Report
A 40-year-old woman presented with a newly developed lump in the right
breast. She had a history of acute myeloid leukemia diagnosed 2 years
previously, with complete remission after chemotherapy. A relapse 1 year after
initial diagnosis had been treated by allogeneic stem cell transplantation. A
graft-versus-host disease of the skin and the intestine developed on day 17
after transplantation and was treated with high doses of corticosteroids and
cyclosporin A. Eight weeks later, still immunosuppressed, she had developed
pneumonia with a consolidating infiltrate of the right lower lobe.
Microbiology findings revealed aspergillus flavus in the specimen of a
bronchoalveolar lavage. Therefore, the patient received antimycotic therapy
with voriconazole (Vfend; Pfizer, New York, NY). Three months after stem cell
transplantation, she detected a newly developed breast lump in the right upper
lateral quadrant.
On physical examination, the lump was superficially located in the right
upper lateral quadrant. It was mobile against the surrounding tissue and had a
moderate resistance. The skin of the breast showed no signs of inflammation.
Three small cutaneous nodes were palpable in the right infraclavicular region,
as was one lesion at the right upper arm, none of which had been noted by the
patient.
Mammography revealed an inhomogeneous opaque lesion in the right upper
lateral quadrant (Figs. 1A and
1B) that had a lobulated shape
and an ill-defined border to the surrounding tissue without a halo sign. No
calcification was seen in the lesion.
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Fig. 1A. —40-year-old woman with newly developed lump in right breast
in underlying acute myeloid leukemia. Craniocaudal (A) and oblique
(B) mammograms show inhomogeneous opaque lesion in right upper lateral
quadrant. Lobulated shape and ill-defined border to surrounding tissue can be
seen. No calcification and no halo sign are evident.
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Fig. 1B. —40-year-old woman with newly developed lump in right breast
in underlying acute myeloid leukemia. Craniocaudal (A) and oblique
(B) mammograms show inhomogeneous opaque lesion in right upper lateral
quadrant. Lobulated shape and ill-defined border to surrounding tissue can be
seen. No calcification and no halo sign are evident.
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|
Sonography showed a lesion with a thin, distinct hypoechogenic border, a
moderate hypoechogenic center, and mild, irregular acoustic shadowing. The
lesion was 2 x 1.6 x 0.9 cm
(Fig. 1C).
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Fig. 1C. —40-year-old woman with newly developed lump in right breast
in underlying acute myeloid leukemia. Sonogram of right upper lateral
quadrant, obtained at 7.5 MHz, shows lesion (markers) with thin,
well-defined hypoechogenic border, moderately hypoechogenic center, and mild,
irregular acoustic shadowing.
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Because the patient had undergone mammography 4 months earlier with
unremarkable findings, carcinoma of the breast seemed unlikely. Our main
differential diagnosis was the rare leukemic infiltration of the breast tissue
known as granulocytic sarcoma
[6].
A biopsy of the breast lesion performed because of the unspecific
radiologic findings revealed an extrapulmonary infiltration of aspergillus
flavus. The small skin lesions proved to be extrapulmonary manifestations of
aspergillosis as well.
Pulmonary aspergillosis proceeded despite antimycotic therapy; therefore,
the patient underwent surgery with resection of the right lower lobe as well
as the extrapulmonary lesions. A thin-walled, centrally necrotic lesion with a
size of 2 x 1.7 x 1.2 cm was found in the resected breast tissue
(Fig. 1D). Histologic
examination showed this lesion to be a central abscess with a rim of
organizing granulation tissue. A high-power view of the specimen revealed
multiple branching hyphae with the typical appearance of aspergillus (Figs.
1E and
1F).
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Fig. 1D. —40-year-old woman with newly developed lump in right breast
in underlying acute myeloid leukemia. Photograph of gross specimen that is 2
x 1.7 x 1.2 cm shows paracentrally located yellow—green
necrotic area.
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Fig. 1E. —40-year-old woman with newly developed lump in right breast
in underlying acute myeloid leukemia. Photomicrograph of histologic section
reveals mammary abscess with surrounding inflammatory infiltrate and some
breast ducts (arrow). (H and E, x25)
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Fig. 1F. —40-year-old woman with newly developed lump in right breast
in underlying acute myeloid leukemia. High-power photomicrograph of histologic
section shows multiple branching hyphae with typical appearance of
aspergillus. (H and E, x400)
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Discussion
In an indolent, growing breast lump without signs of inflammation, primary
carcinoma of the breast is the most likely diagnosis. Metastases to the breast
from an extramammary tumor are rare
[7]. The mammographic
appearance of the mass in our patient contained both soft tissue and fat
elements. Therefore, hamartoma would have been another differential diagnosis,
had it appeared on the previous mammograms.
In patients with an underlying hematologic malignancy, granulocytic sarcoma
(chloroma) has been reported as a rare breast tumor
[6]. Granulocytic carcinoma is
an extramedullary tissue mass of blasts and immature myeloid cells. The
surface of a freshly cut of granulocytic carcinoma turns light green (hence
the name chloroma) upon exposure to air, when large amounts of peroxidase are
oxidized. Granulocytic sarcoma may represent the initial manifestation of
acute leukemia or signal relapse. The mammographic and sonographic findings in
our patient were indistinguishable from those seen in carcinoma of the breast
and granulocytic sarcoma.
Aspergillosis is an opportunistic infection having several risk factors
affecting the immune system [2,
3,
8]. Aspergillus infection leads
to hyphal growth and invasion of the blood vessels, hemorrhagic necrosis,
infarction, and potential dissemination to any other organ in susceptible
patients. It most commonly affects the lungs and paranasal sinuses; less
frequently, extrapulmonary sites such as the brain, skin, gastrointestinal
tract, heart, or kindney are involved
[4,
5]. In our patient, risk
factors for opportunistic infections were chemotherapy-induced
granulocytopenia and the treatment with high doses of cyclosporin A and
corticosteroids for graft-versus-host disease
[8]. In some rare cases,
aspergillus colonization of the breast tissue associated with silicone mammary
implants has been reported [9];
those patients had no clinical evidence of infection or inflammation and were
not immunosuppressed. Because of the unspecific radiographic findings in our
patient, only biopsy could reveal the diagnosis.
Extrapulmonary aspergilloma has to be considered as a rare differential
diagnosis in a newly developed breast tumor in immunocompromised patients,
especially in patients with known pulmonary aspergillosis.
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Introduction
Case Report
