DOI:10.2214/AJR.05.0517
AJR 2007; 188:1573-1576
© American Roentgen Ray Society
Nonnecrotizing Systemic Granulomatous Panniculitis Involving the Breast: Imaging Correlation of a Breast Cancer Mimicker
Marco C. Pinho1,
Felipe Souza1,
Erica Endo1,
Luciano F. Chala1,
Filomena M. Carvalho2 and
Nestor de Barros1
1 Instituto de Radiologia do Hospital das Clínicas da Faculdade de
Medicina da Universidade de São Paulo, Av. Dr. Enéas de Carvalho
Aguiar, 255-3o.andar – Cerqueira Cesar – São Paulo
05403-001, Brazil.
2 Departamento de Anatomia Patológica do Hospital das Clínicas da
Faculdade de Medicina da Universidade de São Paulo, São Paulo,
Brazil.
Received March 23, 2005;
accepted after revision July 12, 2005.
Address correspondence to L. F. Chala
(lucianochala{at}terra.com.br).
Keywords: breast • breast cancer • mammography • MRI • sonography
Introduction
Panniculitis is an inflammatory process of the subcutaneous tissue.
Immunologic, traumatic, metabolic, paraneoplastic, and infectious causes have
been implicated, and in some cases, the condition is idiopathic
[1]. Panniculitis typically
involves the subcutaneous tissue of the lower extremities but can affect fat
tissue in other locations, such as the viscera. Breast involvement is rare and
can be mistaken for cancer at clinical examination and on imaging studies.
Most of the cases of breast involvement described in the literature have been
reported as a component of Weber-Christian disease
[2,
3]. We report the clinical,
mammographic, sonographic, and MRI features and course of disease of a patient
with chronic nonnecrotizing systemic panniculitis affecting the breasts.
Case Report
A 57-year-old woman was referred to the breast imaging center because of
the presence of a rapidly growing, painfully indurated, fixed mass on the left
breast and inflammatory changes in the skin. She reported a 10-year history of
similar recurrent painful subcutaneous masses in both upper and lower
extremities, the abdominal wall, and the back. These lesions had been
clinically diagnosed as manifestations of chronic systemic panniculitis of
unknown cause. The results of investigations for infectious, neoplastic,
autoimmune, and metabolic disorders were normal. The patient had no
predisposing factors for panniculitis, and the masses usually underwent
involution without treatment. Mammography (Figs.
1A and
1B) and sonography
(Fig. 1C) were performed.
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Fig. 1A —57-year old woman with palpable breast masses. Craniocaudal
mammograms show subareolar and periareolar focal asymmetry associated with
skin thickening (arrows, A) of left breast. There are no
significant abnormalities on right breast (B).
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Fig. 1B —57-year old woman with palpable breast masses. Craniocaudal
mammograms show subareolar and periareolar focal asymmetry associated with
skin thickening (arrows, A) of left breast. There are no
significant abnormalities on right breast (B).
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Fig. 1C —57-year old woman with palpable breast masses. Radial
sonographic image obtained with 5–12-MHz transducer shows ill-defined
and homogeneous fat-tissue hyperechogenicity (arrows) involving left
breast and corresponding to focal asymmetry in A.
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Despite suspicion of breast involvement by systemic panniculitis,
sonographically guided biopsy with a 12-gauge core needle and an automated gun
(Bard Magnum, Bard Radiology) was performed because breast involvement in
panniculitis is unusual and because of the nonspecific imaging findings. Five
specimens were obtained. Histologic analysis revealed only fat necrosis
surrounded by fibrosis in the extralobular spaces. This result was not
sufficient for confirmation of a diagnosis. Repetition of the biopsy was
indicated, but for personal reasons, the patient did not participate in
follow-up.
Four months after the biopsy, the patient returned, reporting a new similar
lesion on the right breast. The lesion on the left breast had disappeared
without treatment. Mammography (Figs.
1D and
1E), sonography
(Fig. 1F), and MRI (Figs.
1G and
1H) were performed. Again,
despite clinical suspicion of new breast involvement by systemic panniculitis,
sonographically guided core biopsy was performed on the new lesion. Histologic
analysis showed features of panniculitis with nonnecrotizing granuloma and
fibrosis (Fig. 1I). Association
with the clinical findings confirmed the diagnosis of breast involvement by
systemic panniculitis. No treatment was prescribed, and the mass gradually
resolved.
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Fig. 1D —57-year old woman with palpable breast masses. Craniocaudal
mammograms obtained 4 months after biopsy reveal complete resolution of lesion
identified in A–C and appearance of new similar lesion
(arrows, E) on lateral portion of right breast.
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Fig. 1E —57-year old woman with palpable breast masses. Craniocaudal
mammograms obtained 4 months after biopsy reveal complete resolution of lesion
identified in A–C and appearance of new similar lesion
(arrows, E) on lateral portion of right breast.
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Fig. 1F —57-year old woman with palpable breast masses. Radial
sonographic image obtained with 5–12-MHz transducer shows ill-defined
and heterogenous fat-tissue hyperechogenicity with partial acoustic shadow
(arrows) involving right breast and corresponding to new lesion
identified in E.
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Fig. 1G —57-year old woman with palpable breast masses. Sagittal
contrast-enhanced fat-suppressed 3D dynamic T1-weighted fast spoiled
gradient-recalled MR image (G) (TR/TE, 6.2/1.4; flip angle, 15°)
and subtraction image (H) show irregular heterogeneous regional
enhancement (arrows) in lateral portion of right breast corresponding
to area previously identified in D and E. Enhancement foci
(arrowheads) are evident on periphery of lesion. Kinetic analysis
(not shown) showed continuous enhancement.
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Fig. 1H —57-year old woman with palpable breast masses. Sagittal
contrast-enhanced fat-suppressed 3D dynamic T1-weighted fast spoiled
gradient-recalled MR image (G) (TR/TE, 6.2/1.4; flip angle, 15°)
and subtraction image (H) show irregular heterogeneous regional
enhancement (arrows) in lateral portion of right breast corresponding
to area previously identified in D and E. Enhancement foci
(arrowheads) are evident on periphery of lesion. Kinetic analysis
(not shown) showed continuous enhancement.
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Fig. 1I —57-year old woman with palpable breast masses.
Photomicrograph of histologic section shows granuloma in extralobular space
with central area of fibrosis and no necrosis surrounded by epithelioid
histiocytes and giant cells. Intralobular lymphocytic infiltrate is present in
border of lesion. (H and E, x100)
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Discussion
Panniculitis is a heterogeneous group of benign inflammatory diseases that
affect the subcutaneous fat
[4]. Although there is no
universally accepted classification, these diseases can be grouped into
categories on the basis of etiologic factor, primary site of involvement, and
microscopic pattern [1].
Classification based on etiologic factors involves immunologic and autoimmune
diseases (erythema nodosum, systemic lupus erythematous, scleroderma),
metabolic disorders (
1-antitrypsin deficiency, pancreatic
fat necrosis), physical panniculitis (trauma, cold, reaction to foreign
bodies), and neoplastic processes (histiocytic cytophagic panniculitis). On
the basis of microscopic findings, panniculitis is classified as lobular
(predominant involvement of fat lobules) or septal (predominant involvement of
interlobular septa). Other possible associated features are the presence of
granulomas, necrosis, and vasculitic changes
[4]. These patterns have a
great degree of overlap, so diagnosis usually is confirmed with a combination
of clinical findings, histologic features, and exclusion of associated
diseases through a search for infectious agents and immunologic markers, among
other features. When no diagnostic criteria are met for defining the etiologic
factor, as in this case, panniculitis is termed idiopathic and traditionally
has been called Weber-Christian disease. Some authors
[2,
5] suggest that the term
Weber-Christian disease be abandoned because in most cases a specific
diagnosis can be determined.
The usual clinical manifestation in all subtypes of panniculitis is the
presence of multiple tender subcutaneous nodules or plaques. These lesions
most commonly involve the extremities but can be widespread. Specific patterns
of distribution of the lesions can be suggestive of specific pathologic
conditions (e.g., lower limb involvement in erythema nodosum). In the acute
stages, fever and other systemic symptoms may be present. Besides the
subcutaneous fat, body fat tissue such as that in viscera, the mediastinum,
mesentery, and retroperitoneum may be involved
[3]. Despite the presence of a
large amount of subcutaneous tissue in the breasts, involvement of the breasts
is rare and usually is a component of a systemic disease.
Breast involvement can be mistaken for cancer at clinical examination and
on imaging studies [3,
6]. Rapid growth, hard
consistency, lack of mobility on palpation, and inflammatory signs, as found
in this case, are all suspicious findings for breast carcinoma, especially of
the inflammatory type. On mammograms and sonograms, the two episodes of breast
involvement had nonspecific features that can be found in several inflammatory
or infectious processes and in malignant disease. Focal asymmetry on
mammograms and ill-defined, heterogeneous fat-tissue hyperechogenicity with
partial acoustic shadows on sonograms can be explained by edema and fat
necrosis. These sonographic and mammographic features are similar to those
previously reported [7]. An
important feature observed in this case was the tendency of the lesions to
regress spontaneously and gradually. The first clinical signs of involution
were present after 1–4 weeks. This evolution is not expected for
untreated malignant disease of the breast or infectious mastitis.
The breast lesions in this patient underwent complete clinical and
mammographic regression with no residual changes. Curvilinear, branching, and
punctate microcalcifications have been described in the literature as residual
changes after episodes of breast panniculitis. These lesions probably
represent calcification of the fat necrosis component commonly found in the
acute stages [3].
To our knowledge, the MRI features of breast panniculitis have not been
described in the literature. In this case, MRI showed a large irregular
heterogeneous area with high signal intensity on T2-weighted images, medium
signal intensity on T1-weighted images, and regional enhancement. Enhancement
foci were identified in the periphery of the lesion. These features are
nonspecific and can be explained by the inflammatory process and edema.
Kinetic analysis showed continuous enhancement, which suggested benignity
[8].
The key feature in this case was the correlation between imaging findings
and clinical data. The imaging features on mammography, sonography, and MRI
were nonspecific but were suggestive of an inflammatory process. In adequate
clinical context, such as a history of a chronic systemic panniculitis, as in
this case, a conservative approach can be considered, and selected patients
can undergo a short period of observation without biopsy. This approach can
avoid unnecessary multiple biopsies of these patients, who can have repetitive
episodes of breast involvement because of the chronic remitting course of this
disease.
Acknowledgments
We thank Anderson Ferreira Rodrigues for help in the preparation of this
article.
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Introduction
Case Report
