AJR 2003; 181:187-189
© American Roentgen Ray Society
Cancer Mimicked on Sonography: Lipomastia in an HIV-Positive Man Undergoing Antiretroviral Therapy
James M. Busch1,
Liron Pantanowitz2 and
Phyllis J. Kornguth1
1 Department of Radiology, Ansin 243, Beth Israel Deaconess Medical Center, 330
Brookline Ave., Boston, MA 02215.
2 Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA
02215.
Received September 13, 2002;
accepted after revision November 27, 2002.
Address correspondence to P. J. Kornguth.
Introduction
Breast enlargement in HIV-infected men was uncommon before the advent of
highly active antiretroviral therapy. Since that time, however, there has been
an increasing number of reports in the literature linking the use of
antiretroviral drugs with benign breast enlargement, both gynecomastia
(proliferation of normal fibroglandular tissue) and lipomastia (deposition of
fat tissue) [1]. Lipomastia is
a newly described feature of the highly active antiretroviral
therapy—associated fat maldistribution (lipodystrophy) syndrome, in
which there is wasting (lipoatrophy) of peripheral body fat in the face,
limbs, and buttocks and deposition of fat (lipohypertrophy) centrally in the
abdomen, the breasts, and the cervicodorsal fat pad
[2]. The exact mechanism
underlying the fat maldistribution is unknown but is postulated to be due to a
combination of mitochondrial dysfunction in fat tissue and altered glucose
metabolism induced by antiretroviral drugs
[1]. We report a case of
lipomastia that mimicked breast carcinoma on sonography.
Case Report
A 42-year-old HIV-positive man presented with a palpable left breast mass.
He first noticed this mass 1 month before the sonographic examination, and he
sought medical evaluation because the mass had been increasing. The patient
denied any pain or nipple discharge. His family history included a maternal
aunt with breast cancer. Medications included didanosine and stavudine
(nucleoside reverse transcriptase inhibitors), and efavirenz (a nonnucleoside
reverse transcriptase inhibitor). There was no other significant medical
history. On physical examination, there was a 4 x 2 cm tender left
breast mass located behind the nipple. The mass was firm and mobile. The right
breast was normal.
Sonographic examination of the left breast was performed with an ATL 5000
machine (Advanced Technology Laboratories, Both-ell, WA) using a
5-12—MHz linear transducer. This showed a 1.0 x 0.9 cm markedly
hypoechoic mass located in the retroareolar region and corresponding to the
palpable mass (Fig. 1A). The
margins of this mass were irregular and there was some posterior acoustic
shadowing. Care was taken to ensure that this was a true lesion rather than
shadowing from the nipple—areolar complex. Imaging was performed in
multiple obliquities, and scanning through the nipple—areolar complex
was avoided. On power Doppler sonography, the mass was hypervascular
(Fig. 1B). The lesion was
located in a background of a minimal amount of normal-appearing breast tissue.
Tissue sampling was recommended because of the strong likelihood of carcinoma.
Sonographically guided core biopsy in this patient was technically difficult
and hazardous; therefore, surgical excision was suggested.
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Fig. 1A. —42-year-old HIV-positive man with lipomastia undergoing
highly active antiretroviral therapy. Sagittal sonogram obtained in
periareolar position shows irregular and markedly hypoechoic mass
(arrow) and minimal posterior acoustic shadowing
(arrowheads).
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Fig. 1B. —42-year-old HIV-positive man with lipomastia undergoing
highly active antiretroviral therapy. Power Doppler sonogram obtained in same
area as A shows prominent vessel (arrow) near periphery of
mass.
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In the operating room, a 5.5 x 4.0 x 1.3 cm specimen was
excised that contained an approximately 2 x 3 cm retroareolar mass. The
nipple and areola were excluded. Macroscopic examination of the excised breast
tissue revealed uniformly large lobules of firm, indurated fat constituting
the entire specimen (Fig. 1C). Individual fat lobules measured up to 0.7 cm. No discrete mass was grossly
identified. Microscopically, the lobules of adipose tissue consisted of mature
adipocytes separated by fine fibrous septa with a fine vascular network
(Fig. 1D). Central areas of the
fat lobules contained adipocytes varying in size that were separated by a
delicate, paucicellular connective tissue stroma. Adjacent to this fat
deposition and located predominantly at the periphery of the specimen was
breast tissue consistent with gynecomastia. No malignancy or areas of fat
necrosis were identified.
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Fig. 1C. —42-year-old HIV-positive man with lipomastia undergoing
highly active antiretroviral therapy. Photograph of sectioned biopsy specimen
shows large lobules of fat composing entire specimen.
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Fig. 1D. —42-year-old HIV-positive man with lipomastia undergoing
highly active antiretroviral therapy. Photomicrograph of specimen shows breast
parenchyma entirely replaced with lobules of fat composed of uniform mature
adipocytes. (H and E, x 40)
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Discussion
Breast enlargement in the HIV-infected population was first described in
1987 as a rare association of HIV infection
[3]. Breast enlargement in an
HIV-positive man presents a unique list of differential diagnostic
considerations. Although malignancy is a wellknown complication of HIV
infection, it is controversial whether HIV-infected individuals are at an
increased risk for primary breast carcinoma
[4,
5]. Malignant diseases in
addition to breast carcinoma include Kaposi's sarcoma, plasmacytoma, and
lymphoma. Benign causes of breast enlargement in the setting of HIV are
opportunistic infections, gynecomastia, lipomastia, and pseudoangiomatous
stromal hyperplasia [6].
Gynecomastia and pseudoangiomatous stromal hyperplasia are proliferative
processes that appear to have a hormonal cause, whereas lipomastia does not.
Although gynecomastia in this patient population may be related to
antiretroviral drugs, it also may be due to other medications, marijuana use,
testicular tumors, liver failure, and kidney failure.
Breast sonography is a proven modality for the detection of a palpable
breast abnormality. Gynecomastia appears as normal breast tissue on
sonographic examination. No sonographic characteristics are reported regarding
the appearance of lipomastia. In a recent publication, sonographic findings
similar to those reported here were described in 13 patients receiving highly
active antiretroviral therapy
[7]. No pathologic correlation
was provided in this published report. The sonographic findings in our patient
were worrisome for malignancy. Thus, tissue sampling was recommended.
Mammography was not performed because it was believed that it would not alter
our recommendation for biopsy. However, in retrospect, a mammogram would have
been helpful to show the radiographic density of the palpable mass, to
identify calcifications outside or within the mass, and to reveal other
lesions not seen sonographically.
No focal abnormality was identified on histopathologic inspection. The
focal area of sonographic abnormality was confidently resected because the
excisional specimen was large and included the palpable mass. After learning
of the histologic diagnosis, we considered that this lesion could represent a
focal area of fat necrosis in this patient's lipomastia.
A number of sonographic findings are associated with fat necrosis
[8], one of which is a
hypoechoic irregular nodule with some posterior acoustic shadowing, similar to
the findings in this patient. However, the entire surgical specimen was
examined histologically, and no areas of fat necrosis were seen. We are at a
loss to explain the sonographic—pathologic discrepancy and can only
speculate as to its cause. It is possible that a globule of fat had different
impedance characteristics than its neighbors, therefore causing this
sonographic appearance. The pathologic specimen did show central areas of
adipocytes of various sizes surrounded by areas of the more typical
uniformity, but it is unclear if these areas were responsible for the
sonographic finding.
Little information exists in the imaging literature regarding breast
disease in HIV-positive patients. As aggressive treatment of HIV infection
with highly active antiretroviral therapy becomes more prevalent, lipomastia
is expected to become more common in the HIV-positive community. Studies
suggest that approximately half of the patients treated with highly active
antiretroviral therapy regimens will develop lipodystrophy
[1]. We report this case to
bring attention to lipomastia as a benign cause of unilateral breast
enlargement in an HIV-infected patient undergoing highly active antiretroviral
therapy, which for unknown reasons mimics the sonographic appearance of breast
cancer. Lastly, had mammography been performed and sonographically guided core
biopsy been possible, surgical excision could have been averted.
Acknowledgments
We thank Donald W. Moorman, James L. Connolly, and Bruce J. Dezube for
sharing their knowledge and expertise.
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Introduction
Case Report
