AJR 2004; 182:1081-1083
© American Roentgen Ray Society
Breast MRI for Cancer Detection in a Patient with Diabetic Mastopathy
Helena A. Gabriel1,
Chun Feng,
Ellen B. Mendelson and
Stefanie Benjamin
1 All authors: Department of Radiology, Northwestern University Medical School,
676 North St. Clair St., Ste. 800, Chicago, IL 60611.
Received June 30, 2003;
accepted after revision August 22, 2003.
Address correspondence to H. A. Gabriel
(hgabriel{at}nmff.org).
Introduction
First described by Soler and Khardori in 1984
[1], diabetic mastopathy refers
to the formation of palpable fibrous nodules and asymmetries in the breasts of
women with long-standing type 1 diabetes mellitus. It can simulate a
malignancy and poses a diagnostic challenge. Conversely, patients with this
condition may also develop breast carcinomas hidden within areas of dense
fibrotic breast tissue. We report a case of inflammatory breast carcinoma in a
patient with insulin-dependent diabetic mastopathy to illustrate the
usefulness of MRI in evaluating possible malignant lesions and differentiating
diabetic fibrosis from malignancy.
Case Report
A 40-year-old woman who had insulin-dependent diabetes mellitus since
childhood presented to the breast specialist with questionable thickening in
the upper outer left breast. Physical examination by the breast surgeon showed
bilateral areas of nodularity. No discrete mass was perceived, and no skin or
nipple changes were present. Mammography at the time of initial presentation
consisted of routine and tangential compression images, which showed only
asymmetric density in the left breast superiorly and laterally
(Fig. 1A) with no discrete
masses, suspicious calcifications, or any other evidence of malignancy in
either breast. Sonography, performed using a 12-5–MHz linear array
transducer (Philips Medical Systems), showed areas of posterior acoustic
shadowing in the upper outer left quadrant
(Fig. 1B), with no masses seen
on orthogonal images. The sonographic examination was interpreted as
compatible with diabetic fibrosis, a probably benign assessment, and the
patient was then advised to follow up with clinical breast examination and a
short-interval imaging study in 6 months.
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Fig. 1A. —40-year-old woman with diabetic mastopathy. Bilateral
mediolateral oblique mammograms show dense fibroglandular tissue with
minimally increased density in superior aspect of left breast
(arrow).
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Fig. 1B. —40-year-old woman with diabetic mastopathy. Sonogram of
questionable palpable thickening of upper outer left quadrant shows
nonspecific areas of shadowing, thought to be related to diabetic mastopathy.
No cysts or solid masses are seen.
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Within 3 months, the patient returned with increased left-sided thickening
and breast tenderness in the upper outer quadrant. Physical examination by the
same breast surgeon now corroborated a thickening in the upper left breast
with no axillary, supraclavicular, or cervical lymphadenopathy.
Because of the additional symptoms, confusing clinical scenario, equivocal
mammographic and sonographic findings just 3 months earlier, and mammographic
limitation imposed by breast density, MRI (1.5-T Sonata scanner, Siemens) of
the breast was performed, seeking any focal areas that might represent a
malignant process. The attempt was to distinguish possible malignancy from
diabetic mastopathy by examining lesion morphology and enhancement kinetics.
We performed the following pulse sequences of our routine protocol:
T1-weighted MRI in the axial plane; STIR imaging in the axial, coronal, and
sagittal planes; and dynamic 3D T1-weighted gradient-echo MRI preceding and
after the IV administration of gadopentetate dimeglumine (Magnevist [0.1
mg/kg], Berlex Laboratories). Four contrast-enhanced sequences were performed.
Postprocessing manipulation included subtraction images and multiplanar
reconstruction in the axial plane and maximum-intensity-projection images. The
images were also reviewed on a 3D workstation.
The STIR images showed asymmetric high signal within the left breast and in
the skin, suggestive of edema. After contrast enhancement, a dominant, 2.1
x 2.3 x 1.8 cm, lobulated mass in the upper outer quadrant was
seen. The mass showed intense heterogeneous enhancement with enhancing septa.
The rapid rise and early washout of contrast material generated a suspicious
time–signal intensity enhancement curve. Additional small enhancing foci
were seen throughout the left breast, with suspicious enhancement curves. The
left breast was also marked by diffuse reticular enhancement suggestive of
infiltrative tumor. Skin thickening was seen especially within the inferior
portion of the left breast, with small nodular enhancing subcutaneous foci,
raising suspicion of inflammatory breast cancer (Figs.
1C,
1D,
1E,
1F).
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Fig. 1C. —40-year-old woman with diabetic mastopathy. STIR axial MR
image (TR/TE, 5,700/72) shows marked asymmetry in appearance of breasts. Left
breast has diffusely increased signal within parenchyma and skin, suggesting
diffuse breast edema and skin thickening (arrow).
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Fig. 1D. —40-year-old woman with diabetic mastopathy. Dynamic sagittal
T1-weighted 3D gradient-echo MR image obtained after contrast enhancement
reveals lobulated 2.4 x 1.9 cm mass in upper outer left quadrant. This
mass has heterogeneous contrast agent uptake with enhancing septa in
spiculated configuration (arrowhead) and enhancing thin peripheral
rim.
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Fig. 1E. —40-year-old woman with diabetic mastopathy. Subtraction
sagittal T1-weighted 3D gradient-echo MR image again shows dominant mass
(arrowhead) and other diffuse reticular areas of enhancement and
nodularity (straight arrows), suggesting diffuse tumor infiltration.
Note skin enhancement (curved arrow), suggesting dermal lymphatic
invasion.
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Fig. 1F. —40-year-old woman with diabetic mastopathy. Graph of MRI
time–signal intensity curves from MR image with mean enhancement plotted
on y-axis against time on x-axis shows distinctive
enhancement kinetics of mass. Curve of dominant lobulated mass shows washout
of contrast agent, which is suspicious for malignancy.
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After the suspicious mass was identified on MRI, sonography was again
performed to locate the lesion so that sonographic guidance could be used for
biopsy. A hypoechoic mass was observed in the 2-o'clock position of the left
breast; its size and location were consistent with the dominant mass seen on
MRI. Areas of shadowing were seen throughout the left breast, with small
irregular hypoechoic lesions posterior to the nipple. As seen on MRI, the skin
of the lower left breast was thickened, measuring 0.6 cm, and edema was
present. Repeated mammography showed further increase in left breast density
compared with that in the previous study.
Sonographically guided core biopsy of the mass was performed using a
14-gauge core biopsy needle with a 22-mm throw. A skin punch biopsy in an area
of skin thickening was also performed. Histopathology of the core biopsy
specimen revealed poorly differentiated grade 3 infiltrating ductal carcinoma
and ductal carcinoma in situ. Dermal lymphatic invasion was present in the
skin-punch biopsy, signifying inflammatory carcinoma.
The patient was treated with chemotherapy for inflammatory breast carcinoma
and underwent repeated MRI, which showed marked reduction in the size of the
mass in the upper outer quadrant and significant resolution of abnormal
enhancement, although small enhancing foci were seen within the breast.
Mastectomy was performed after four cycles of chemotherapy, and histopathology
of the specimen revealed areas of fibrosis consistent with diabetic mastopathy
and residual infiltrating poorly differentiated ductal carcinoma, grade 3 of
three, in four quadrants, as scattered nests and single cells, with nodules of
infiltrating carcinoma. Focal residual ductal carcinoma in situ was also
present. Three of eight axillary lymph nodes harbored metastatic
carcinoma.
Discussion
Associated with long-standing type 1 (insulin-dependent) diabetes mellitus,
diabetic mastopathy is an unusual fibroinflammatory breast lesion that often
presents in premenopausal women and is associated with other multiple
microvascular complications. The cause of diabetic mastopathy is unknown but
is thought to be related to an autoimmune reaction to diabetogenic abnormal
matrix accumulation [2].
Histologically, diabetic mastopathy consists of focal, dense, keloid-like
areas of fibrosis, which show B cell–predominant lymphocytic lobulitis,
ductitis, and vasculitis [3,
4]. Our patient had both the
clinical and histopathologic features of diabetic mastopathy.
The differentiation of mastopathy from cancer is imperative but difficult
both at clinical examination and by conventional imaging. In our patient, the
mammographic and sonographic studies were difficult to interpret and equivocal
at best because of the dense tissue and posterior acoustic shadowing from the
diabetic mastopathy [5]. In
contrast, MRI was helpful in differentiating the similar-appearing benign and
malignant processes and confirming malignancy.
In our patient, the MR image depicted masses and enhancement that had both
suspicious morphologic features and contrast kinetics
[6,
7]. The dominant mass had
lobulated margins with enhancing septa and a time–signal intensity curve
that showed rapid uptake and washout of contrast material, all worrisome
features. Reticular enhancement was also seen, consistent with diffuse
malignancy, and dermal invasion was suggested by the nodular enhancement of
the skin. In this case, breast MRI was the one technique to reveal a highly
suspicious lesion requiring biopsy. MRI enhancement kinetics and
postprocessing image subtraction techniques helped to differentiate the benign
diabetic mastopathy and breast cancer and to depict the wide extent of disease
in this patient, thus aiding in staging the cancer. MRI also showed the
diffuse nature of the patient's inflammatory carcinoma, represented by the
reticular breast and skin enhancement.
The patient underwent adjuvant chemotherapy with repeated MRI, which showed
a strong response to the therapy, although MRI findings of residual disease
were present. The MRI examination underestimated the amount of disease found
in the mastectomy specimen; this phenomenon has been previously reported in
patients who exhibit a strong response to chemotherapy
[8].
Recently, a case report described the use of MRI in a patient with diabetic
mastopathy, in whom a focal area of asymmetry had continuous enhancement
[9]. The authors concluded,
however, that MRI may not be useful in differentiating diabetic mastopathy
from breast cancer. In their patient, MRI showed a benign type of enhancement,
potentially differentiating the two. In our patient, MRI was extremely helpful
in detecting the malignancy and was the best technique for diagnosing the
tumor and assessing its extent. Thus, MRI may have an important application in
evaluating breast abnormalities in exactly this patient population, in which
mammography and sonography are limited by breast density and cancer-mimicking
breast lesions. More studies need to be performed, however, to evaluate the
utility of breast MRI in diabetic mastopathy.
In conclusion, this case emphasizes the diagnostic ambiguity of breast
cancer in patients with diabetic mastopathy, which is a confusing
clinicopathologic and radiographic entity that can confound the detection of
breast carcinoma in affected patients. The value of breast MRI lies in its
ability to detect possible malignant lesions in highly dense breast tissue.
When used in combination with conventional breast imaging techniques, breast
MRI can be an effective aid in the diagnostic evaluation of suspected breast
malignancy in patients with diabetic mastopathy.
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Introduction
Case Report
