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Case Report |
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).
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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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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.
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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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  E. Christiaensen, Y. Jacquemyn, I. Verslegers, M. Van Goethem, and V. Van Marck Axillary lymphadenopathy as a first symptom of diabetic mastopathy BMJ Case Reports, June 11, 2009; 2008(jun09_1): bcr0320091703 - bcr0320091703. [Abstract] [Full Text]
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