JBRBTR, 2008, 91: 126-127.

FIBROUS DISEASE OF THE BREAST

K.A. Vanwambeke1, F Vanhoenacker1, A. Snoeckx1, P Berteloot2, H. Van Dijck3 .M. . Key-word: Breast, diseases

Background: A 38-year-old premenopausal woman with a past medical history of long-standing insulin-dependent diabetes mellitus (type 1), presented with a painless, hard, palpable lump located in the retro- to supra-areolar aspect of the left breast. No axillary adenopathy was found on clinical examination.

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Departments of 1. Radiology, 2. Gynecology and 3. Pathology, Sint-Maartenziekenhuis, campus Duffel, Duffel, Belgium

FIBROUS DISEASE OF THE BREAST VANWAMBEKE et al

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Work-up Mammography of both breasts in craniocaudal direction (Fig. 1) shows dysplastic aspect of both breasts, with a firm asymmetric density within the left breast. There is no significant distortion or spiculation, nor intralesional microcalcification. Ultrasonography of the left breast (Fig. 2) reveals an irregularly delineated, hypoechoic mass with acoustic shadowing. Thereis absence of power Doppler signal. MRI of the breasts (Fig. 3), coronal STIR-image (A) shows hypointense glandular tissue. Axial subtraction image of 3D gradient echo T1-weighted MR-images before and after intravenous gadolinium contrast administration (B) demonstrates poor patchy enhancement of the lesion, while the rest of the breast contains almost no proliferative tissue. Figure 4 is the photomicrograph. Hematoxylineosin stain The normal stroma is completely replaced by extensive collagenous stromal fibrosis and the remaining acini in the center are surrounded by a lymphocytic infiltrate (arrow). Radiological diagnosis Based on the combination of clinical history, imaging and histopathological findings, the diagnosis of diabetic (fibrous) mastopathy was made. Discussion Diabetic (fibrous) mastopathy, firstly described in 1984, is a rare but well-known complication in patients with long-standing (more than 20 years after the onset of the disease) insulin-dependent diabetes mellitus (DM). It typically affects premenopausal women, whereas men are only very rarely affected. Clinically, patients present with a painless, hard palpable breast lump that is indistinguishable from breast cancer. The size of the mass may vary considerably from 5 mm to 6 cm. Multi-centric or bilateral involvement is relatively frequent (but not necessarily synchronous), often occurring in late stages of the disease. The most common mammographic finding consists of an ill-defined mass or an asymmetric density. The lesion is often masked by dense glandular tissue, making mammographic evaluation very difficult. Calcifications are absent. US often reveals an irregular delineated worrisome hypoechoic mass with marked posterior acoustic shadowing.

MRI-findings are rather nonspecific. There may be a slight diffuse enhancement after intravenous injection of gadolinium contrast. Dynamic contrast enhanced MRI demonstrates a gradual contrast uptake, with a slow slope, different from malignant lesions. The most characteristic finding however is the low signal intensity of the glandular tissue on T2-weighted images, reflecting the presence of fibrosis. At microscopic analysis, the lesions of diabetic mastopathy are characterized by a dense collagenous stroma that contains a varying amount of fibroblasts, related to the age of the lesion. Pronounced lobular atrophy, periductal and perivascular lymphocytic infiltration are other typical findings. This lymphocytic infiltrate contains predominantly mature B cells rather than the usual T cells seen in other types of mastitis. There is always a fibrotic and an inflammatory component. The condition is thought to result from an underlying autoimmune reaction. Although in the past surgical excision was usually performed to exclude malignancy, core biopsy is currently accepted as appropriate for confirmation of the diagnosis. As the condition is not associated with an increased risk for breast cancer, local resection is not advocated. However, these patients will often develop other foci of palpable fibrous mastopathy in the ipsilateral or contralateral breast. Therefore, regular senological follow-up is mandatory in every premenopausal woman with DM type 1 and several additional biopsies over time may be required in some patients. It is important that the radiologist is aware of this rare complication of DM, mimicking breast carcinoma, both clinically and radiologically. Bibliography 1. Goel N.B., Knight T.E., Pandey S., et al.: Fibrous lesions of the breast: Imaging-Pathologic Correlation. Radiographics, 2005, 25: 1547-1559. 2. Sabat J.M., Clotet M., Gomez A., et al.: Radiologic evaluation of uncommon inflammatory and reactive breast disorders. Radiographics, 2005, 25: 411-424. 3. Soler N.G., Khardori R.: Fibrous disease of the breast, thyroiditis, and cheiroarthropathy in type 1 diabetes mellitus. Lancet, 1984, 1: 193-194. 4. Wong K.T., Tse G.M., Yang W.T.: Ultrasound and MR-imaging of diabetic mastopathy. Clin Radiol, 2002, 57: 730-735.