الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
Regardless of the type of breast problem, the goal of the evaluation is to rule out cancer and address the patient’s symptoms.
Mastitis is inflammation of the breast irrespective of the cause. Breast inflammatory diseases occur more during the lactation period; otherwise it can occur in healthy, non-lactating women of all ages.
The aim of this work is to determine the diagnostic imaging approach of inflammatory breast lesions.
During the time period starting from the first of April 2013 till the end of March 2014, 1250 patients were referred to the breast imaging unit Alexandria university hospital, 41 patients were proved to have breast inflammatory lesions, with an incidence of 3.3%.
All patients (n=41) were subjected to full history taking, thorough clinical examination and high resolution US. Mammography was performed for the patients who were 30 years old or more at the time of examination (n=35) while MRI was performed for selected cases (n=7). All patients of infectious mastitis (n=11) and periductal mastitis (n=17) were subjected to short term follow up on repeated 10 days basis of proper medical treatment. Patients of non-lactational mastitis were recommended for long term follow up to exclude malignancy. All the examined breast lesions were subjected to pathological examination.
The patients of the current study were classified into 3 main groups of mastitis: infectious, non-infectious and malignant forms of mastitis.
This work showed the following results:
The age of the patients ranged from 21 to 73 years with a mean age of 41.26 ± 12.89 years. In group I patients (n=11) the age ranged from 22 to 42 with mean age of
33.64 ± 11.36 years, in group II (n=24) the age ranged from 21 to 59 with mean age of 40.21 ± 10.01 years and they were distributed among the different age groups while in group III (n=6) the age ranged from 36 to 73 with mean age of
54.33 ± 15.77 years and 66.7% of them (n=4/6) were above the age of 50.
Premenopausal patients comprised 73.2% of the cases while postmenopausal patients comprised 26.8% of the cases.
Lactating patients comprised 24.4% (n=10/41) of the cases with 6 of them being lactating for the first time and 4 patients experienced lactation before.
The most common presenting complaints in the patients of the current study were breast inflammatory manifestations (hotness, redness, tenderness, swollen breast) found in 61% (25/41) of the patients, nipple discharge in 36.6% (n=15/41) of the cases and breast lump in 19.5% (n=8/41) of the cases.
Mammography was performed for 35 patients where 31.4% (n=11) were described as negative mammography (BIRADS I), 28.6% (n=10) had mass density, 25.7% (n=9) had diffuse increase in breast density, focal asymmetrical density was described in 22.8% (n=8) while thick skin was described in 20% (n=7) of the mammographically examined patients.
US was performed to all the patients (n=41) where signs of active inflammation was represented as: 58.5% (n=24) of the patients showed echogenic fat lobules, 41.5% (n=17) showed thick skin while interstitial edema was described in 34.1% (n=14). Dilated duct 48.8% (n=20), mass lesions 26.8% (n=11), cyst/abscess 17% (n=7). Lymph nodes were found in 26.7% of the patients with 7 cases being with reactive LNs and 4 patients with malignant LNs.
Color Doppler US was performed to all patients by which 36.4% of patients of group I showed positive peri-lesional doppler signal while in group II patients only 4.2% of the patients showed positive intra-lesional doppler signal and regarding group III patients, all the masses (n=9) of inflammatory breast carcinoma were found to have positive intra-lesional doppler signal.
DCE-MRM was performed to only 7 patients who were either ranked as BIRADS 0 on mammographic and sonographic basis, with past history of cancer breast or cases of post irradiation mastitis. The results showed that thick skin was described in 71.4% (n=5) , enhancing mass lesions in 71.4% (n=5), 57.1% (n=4) of the cases showed subcutaneous and trabecular edema, while non-mass enhancement was in 14.3% (n=1) of the cases.
Comparison between different groups regarding categorical variables was tested using Chi-square test.
Mammography revealed that diffusely increased breast density and skin thickening were considered statistically differentiating signs between malignant mastitis and non-infectious mastitis while mass lesion considered statistically differentiating signs between infectious mastitis and malignant mastitis on one hand and non-infectious mastitis on the other hand.
The presence of acute inflammatory signs on ultrasound (thick skin > 2mm, echogenic fat lobules and interstitial edema) were considered statistically significant differentiating signs between infectious and malignant forms of mastitis on one hand and noninfectious form in the other hand. Nevertheless these signs could not differentiate infectious mastitis from malignant forms.
Mass lesions and malignant axillary nodes are significant differentiating signs between malignant mastitis and the other 2 forms of mastitis. Cysts/abscesses are significant differentiating signs between infective mastitis and the other 2 forms of mastitis.
Positive intra-lesional Doppler signal was a statistically significant sign for diagnosis of malignant mastitis, while peri-lesional doppler signal was a statistically significant sign for diagnosis of infectious mastitis.
DCE-MRM has limited role in differentiating between malignant and benign changes and in spite of sometimes MRI was able to differentiate between benign mastitis from malignant entities yet failure to achieve condition improvement had necessitated biopsy no matter what.
Biopsy was recommended for 14 cases which carried clinical suspicious (blood stained discharge) or those belonging to BIRADS 4 or 5 categories on mammographic, sonographic and/or MRM basis (a case of non-lactational mastitis, a case of chronic breast abscess, a case of granulomatous mastitis, a case of post irradiation mastitis.
Short term clinico-US follow up was recommended to cases of infectious mastitis (n=11) as well as periductal mastitis (n=17) to ensure complete resolution. Long term follow up was recommended to cases of non-lactational mastitis to exclude development of malignancy later on, none of these patients developed breast cancer for a period of one year.
The detectability of mammography, ultrasonography and MRM were calculated based on the ability of each imaging modality to reach the correct final BI-RADS that was confirmed by either biopsy or clinico-US follow to be: 14.3% for mammography, 92.7% for US and 71.4% for MRM.
from this study, we concluded that:
Mammography has a limited role in diagnosis of breast inflammatory conditions owing to its non-specific signs, increased mammographic density during pregnancy and lactation, inability to distinguish cystic from solid lesions, lack of characterization of the nature of the associated lymphadenopathy and finally, some inflammatory lesions may mimic malignant lesions (e.g: fat necrosis)
Ultrasound is a valuable diagnostic tool in breast inflammatory lesions due to its ability to detect signs of active inflammation in dense congested breast, can differentiate between cystic and solid lesions and characterize the nature of the associated lymphadenopathy. It is also valuable in monitoring treatment and guiding for interventional procedures. Nevertheless US may misinterpret some benign lesions as malignant owing to their unclassical morphological features (e.g: breast abscess, fat necrosis and granulomatous mastitis).
Doppler US has a valuable role due to its unique capability of demonstrating the pattern and flow characters of lesions vascularity.
MRM has limited value in verification of cases of active inflammatory conditions as it may be falsely diagnosed as a malignant condition.
Clinico-US Follow up of acute mastitis patients is mandatory on repeated 10 days basis of proper medical treatment (including antibiotics) in order to monitor treatment, ensure complete resolution and exclude re-collection in case of drained abscess, but if the symptoms persist in spite of proper medical treatment, malignancy must be excluded.
Pathological assessment (multiple punctures from multiple sites) remains the gold standard technique for the diagnosis of inflammatory lesions that appear suspicious on breast imaging basis (e.g: fat necrosis and granulomatous mastitis).
Regardless of the type of breast problem, the goal of the evaluation is to rule out cancer and address the patient’s symptoms.
Mastitis is inflammation of the breast irrespective of the cause. Breast inflammatory diseases occur more during the lactation period; otherwise it can occur in healthy, non-lactating women of all ages.
The aim of this work is to determine the diagnostic imaging approach of inflammatory breast lesions.
During the time period starting from the first of April 2013 till the end of March 2014, 1250 patients were referred to the breast imaging unit Alexandria university hospital, 41 patients were proved to have breast inflammatory lesions, with an incidence of 3.3%.
All patients (n=41) were subjected to full history taking, thorough clinical examination and high resolution US. Mammography was performed for the patients who were 30 years old or more at the time of examination (n=35) while MRI was performed for selected cases (n=7). All patients of infectious mastitis (n=11) and periductal mastitis (n=17) were subjected to short term follow up on repeated 10 days basis of proper medical treatment. Patients of non-lactational mastitis were recommended for long term follow up to exclude malignancy. All the examined breast lesions were subjected to pathological examination.
The patients of the current study were classified into 3 main groups of mastitis: infectious, non-infectious and malignant forms of mastitis.
This work showed the following results:
The age of the patients ranged from 21 to 73 years with a mean age of 41.26 ± 12.89 years. In group I patients (n=11) the age ranged from 22 to 42 with mean age of
33.64 ± 11.36 years, in group II (n=24) the age ranged from 21 to 59 with mean age of 40.21 ± 10.01 years and they were distributed among the different age groups while in group III (n=6) the age ranged from 36 to 73 with mean age of
54.33 ± 15.77 years and 66.7% of them (n=4/6) were above the age of 50.
Premenopausal patients comprised 73.2% of the cases while postmenopausal patients comprised 26.8% of the cases.
Lactating patients comprised 24.4% (n=10/41) of the cases with 6 of them being lactating for the first time and 4 patients experienced lactation before.
The most common presenting complaints in the patients of the current study were breast inflammatory manifestations (hotness, redness, tenderness, swollen breast) found in 61% (25/41) of the patients, nipple discharge in 36.6% (n=15/41) of the cases and breast lump in 19.5% (n=8/41) of the cases.
Mammography was performed for 35 patients where 31.4% (n=11) were described as negative mammography (BIRADS I), 28.6% (n=10) had mass density, 25.7% (n=9) had diffuse increase in breast density, focal asymmetrical density was described in 22.8% (n=8) while thick skin was described in 20% (n=7) of the mammographically examined patients.
US was performed to all the patients (n=41) where signs of active inflammation was represented as: 58.5% (n=24) of the patients showed echogenic fat lobules, 41.5% (n=17) showed thick skin while interstitial edema was described in 34.1% (n=14). Dilated duct 48.8% (n=20), mass lesions 26.8% (n=11), cyst/abscess 17% (n=7). Lymph nodes were found in 26.7% of the patients with 7 cases being with reactive LNs and 4 patients with malignant LNs.
Color Doppler US was performed to all patients by which 36.4% of patients of group I showed positive peri-lesional doppler signal while in group II patients only 4.2% of the patients showed positive intra-lesional doppler signal and regarding group III patients, all the masses (n=9) of inflammatory breast carcinoma were found to have positive intra-lesional doppler signal.
DCE-MRM was performed to only 7 patients who were either ranked as BIRADS 0 on mammographic and sonographic basis, with past history of cancer breast or cases of post irradiation mastitis. The results showed that thick skin was described in 71.4% (n=5) , enhancing mass lesions in 71.4% (n=5), 57.1% (n=4) of the cases showed subcutaneous and trabecular edema, while non-mass enhancement was in 14.3% (n=1) of the cases.
Comparison between different groups regarding categorical variables was tested using Chi-square test.
Mammography revealed that diffusely increased breast density and skin thickening were considered statistically differentiating signs between malignant mastitis and non-infectious mastitis while mass lesion considered statistically differentiating signs between infectious mastitis and malignant mastitis on one hand and non-infectious mastitis on the other hand.
The presence of acute inflammatory signs on ultrasound (thick skin > 2mm, echogenic fat lobules and interstitial edema) were considered statistically significant differentiating signs between infectious and malignant forms of mastitis on one hand and noninfectious form in the other hand. Nevertheless these signs could not differentiate infectious mastitis from malignant forms.
Mass lesions and malignant axillary nodes are significant differentiating signs between malignant mastitis and the other 2 forms of mastitis. Cysts/abscesses are significant differentiating signs between infective mastitis and the other 2 forms of mastitis.
Positive intra-lesional Doppler signal was a statistically significant sign for diagnosis of malignant mastitis, while peri-lesional doppler signal was a statistically significant sign for diagnosis of infectious mastitis.
DCE-MRM has limited role in differentiating between malignant and benign changes and in spite of sometimes MRI was able to differentiate between benign mastitis from malignant entities yet failure to achieve condition improvement had necessitated biopsy no matter what.
Biopsy was recommended for 14 cases which carried clinical suspicious (blood stained discharge) or those belonging to BIRADS 4 or 5 categories on mammographic, sonographic and/or MRM basis (a case of non-lactational mastitis, a case of chronic breast abscess, a case of granulomatous mastitis, a case of post irradiation mastitis.
Short term clinico-US follow up was recommended to cases of infectious mastitis (n=11) as well as periductal mastitis (n=17) to ensure complete resolution. Long term follow up was recommended to cases of non-lactational mastitis to exclude development of malignancy later on, none of these patients developed breast cancer for a period of one year.
The detectability of mammography, ultrasonography and MRM were calculated based on the ability of each imaging modality to reach the correct final BI-RADS that was confirmed by either biopsy or clinico-US follow to be: 14.3% for mammography, 92.7% for US and 71.4% for MRM.
from this study, we concluded that:
Mammography has a limited role in diagnosis of breast inflammatory conditions owing to its non-specific signs, increased mammographic density during pregnancy and lactation, inability to distinguish cystic from solid lesions, lack of characterization of the nature of the associated lymphadenopathy and finally, some inflammatory lesions may mimic malignant lesions (e.g: fat necrosis)
Ultrasound is a valuable diagnostic tool in breast inflammatory lesions due to its ability to detect signs of active inflammation in dense congested breast, can differentiate between cystic and solid lesions and characterize the nature of the associated lymphadenopathy. It is also valuable in monitoring treatment and guiding for interventional procedures. Nevertheless US may misinterpret some benign lesions as malignant owing to their unclassical morphological features (e.g: breast abscess, fat necrosis and granulomatous mastitis).
Doppler US has a valuable role due to its unique capability of demonstrating the pattern and flow characters of lesions vascularity.
MRM has limited value in verification of cases of active inflammatory conditions as it may be falsely diagnosed as a malignant condition.
Clinico-US Follow up of acute mastitis patients is mandatory on repeated 10 days basis of proper medical treatment (including antibiotics) in order to monitor treatment, ensure complete resolution and exclude re-collection in case of drained abscess, but if the symptoms persist in spite of proper medical treatment, malignancy must be excluded.
Pathological assessment (multiple punctures from multiple sites) remains the gold standard technique for the diagnosis of inflammatory lesions that appear suspicious on breast imaging basis (e.g: fat necrosis and granulomatous mastitis).