Presentation
A Western European patient was recalled from the screening programme for an asymptomatic multifocal left breast abnormality.
Patient Data
CASE OF THE MONTH: This case was selected as the Case of the Month for February 2024.
Mammograms show predominantly fatty breasts with scattered fibroglandular tissue (BI-RADS category B).
A comparison was made with screening mammograms from 6 years prior; see below.
Multiple new ill-defined (CC, MLO) are present in the left upper outer quadrant, measuring up to 12mm in diameter. No associated calcification. M4.
An implantable cardiac loop recorder device is seen posteriorly in the left breast.
Screening mammograms from 6 years prior.
Predominantly fatty density with no mass or sinister features. M1 bilaterally.
Further assessment with digital breast tomosynthesis (DBT) confirms four irregularly spiculated masses, some of which cause distortion of the adjacent tissue. These are graded as M5 (BSBR system).
Three of these are in the upper outer quadrant; however, the largest mass (16 mm) is located in the upper inner quadrant in close proximity to the nipple. This lesion was poorly seen on conventional mammograms.
Selected ultrasound images of the left breast.
The masses had a variable appearance on ultrasound;
Two appeared as irregular hyperechoic masses within fat lobules, similar to fat necrosis, U3 (BSBR).
Two had typical appearances for breast carcinoma, with an irregular hypoechoic mass with posterior acoustic shadowing and surrounding hyperechoic fat suggestive of edema. One of these masses extends to the overlying skin, U5.
Axillary ultrasound showed only morphologically normal nodes.
The three most suspicious lesions were biopsied (3 x 14G core to each lesion). Clip markers were placed in each biopsied lesion, with post-procedure mammograms showing the clips correlating to the spiculated masses.
Prior imaging included a CT of the thorax which was performed three years earlier due to recurrent anterior uveitis with bilateral hilar enlargement on chest radiography.
CT showed mediastinal and hilar lymphadenopathy with subcarinal, paratracheal and supraclavicular nodes, typical of sarcoidosis. No parenchymal lung abnormality.
A mediastinal node was biopsied shortly after the CT via EBUS (endobronchial ultrasound), confirming the diagnosis of sarcoidosis.
Case Discussion
Histology from the core biopsies of all three breast lesions showed a chronic granulomatous process, most likely sarcoid.
Review of the patient's history and imaging confirmed the patient had a known diagnosis of sarcoidosis (biopsy-proven).
The multifocal abnormality was categorized as M5, U5 (highly suggestive of malignancy), but ultimately was proven to be a benign granulomatous process from sarcoidosis.
Breast manifestations of sarcoidosis are extremely rare, with prevalence reported between <1% and 2% of women with sarcoid, normally presenting between the ages of 30 and 40 1.
When symptomatic, patients may present with a firm or hard breast mass and enlarged axillary nodes 1.
Radiologically, breast sarcoidosis mimics malignancy on both mammograms and ultrasounds, with irregular hypoechoic masses as well as enlarged axillary or intramammary lymph nodes 1.
When performed, breast MRI has not been shown to help differentiate between sarcoidosis and malignancy. Breast sarcoid lesions can rapidly enhance, wash out, or appear as an irregular mass with gradual enhancement 2.
E. Lower et al. reviewed 629 women with sarcoidosis for findings associated with breast disease and found that patients with sarcoid develop breast cancer at the expected frequency 3. In patients with breast disease, they were unable to identify any clinical or radiological findings to distinguish between breast sarcoidosis and malignancy.
In women with sarcoidosis, breast cancer remains a more common finding than breast granulomas. Given the overlapping clinical and radiological features, a biopsy of all suspicious lesions is recommended 3. Histological findings in breast sarcoidosis are those of non-caseating epithelioid granulomas.
Case courtesy of Dr. K. Paisley, University Hospitals Plymouth, UK.
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