British Journal of Radiology (2003) 76, 192-194
© 2003 British Institute of Radiology
doi: 10.1259/bjr/51145312
Diabetic mastopathy
C W Mak, MD1,
C K Chou, MD1,
S Y Chen, MD2,
P S Lee, MD, MS3 and
J M Chang, MD1
1 Department of Diagnostic Radiology, 2 Endocrinology and 3 Pathology, Chi-Mei Foundation Medical Center, Tainan, Taiwan, Republic of China
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Abstract
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Diabetic mastopathy is a source of confusion with breast carcinoma. The association between mastopathy and Type I diabetes of long duration has been reported, but this clinical condition is poorly recognized since breast examination is not routinely performed in young diabetic patients. Radiologists' awareness of the constellation of findings in diabetic mastopathy may spare patients from undergoing unwarranted surgical biopsies.
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Introduction
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Diabetic mastopathy (DMP) is a collection of radiological and histological features found in dense fibrous masses of the breast in long standing Type I diabetes. Since Soler and Khadori first described this disease in 1984 [1], several reports have been published in radiology, pathology and surgical literature [2–4]. These patients present with rocky, hard, painless, irregular mass of the breast. Mammography usually discloses only dense glandular tissue, and ultrasound shows irregular, hypoechoic masses indistinguishable from breast cancer.
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Case report
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The patient described was a 27-year-old female, affected by Type I diabetes from the age of 15 years. She received insulin injection once daily with poor diet control, had previously suffered from diabetic retinopathy requiring photocoagulation therapy and also had diabetic nephropathy. Her free thyroxine (T4), thyroid stimulating hormone (TSH), antimicrosomal antibody titre and antithyroglobulin titre were all within normal limits.
Physical examination disclosed a hard, irregular, painless and mobile mass measuring approximately 2 cm on the left breast. No axillary lymphadenopathy was present and there was no nipple discharge.
Mammography showed that the breasts consisted of dense glandular tissue, no discrete nodules were found. Neither microcalcification nor architectural distortion were detected (Figure 1
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Figure 1. Mammography showed dense fibroglandular tissue without focal mass, microcalcification or architectural distortion.
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An irregular mass with acoustic shadowing was demonstrated on ultrasound (Figure 2), indistinguishable from that of a breast carcinoma and biopsy under ultrasound guidance was performed. Pathology demonstrated the lesion to consist of dense fibrous stroma with infiltrating lymphocytes surrounding the ductules, suggestive of DMP (Figure 3). At follow-up 1 year later, ultrasound demonstrated another impalpable hypoechoic lesion with acoustic shadowing (Figure 4) in the right breast and biopsy again confirmed DMP.
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Figure 2. Ultrasound showed an irregular hypoechoic mass with posterior shadowing seen in left breast.
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Figure 3. Pathology showed stromal fibrosis and periductal lymphocytic infiltration, suggesting diabetic mastopathy.
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Figure 4. Ultrasound showed another hypoechoic irregular mass with posterior shadowing developed in the right breast.
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Discussion
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DMP is an uncommon tumour like fibrous proliferation of the breast. Histologically, it consists of lymphocytic mastitis and stromal fibrosis [4]. Most published reports of DMP are of pre-menopausal women with long standing Type I diabetes mellitus [1, 2, 4]. Most patients with DMP also have complications arising from diabetes such as retinopathy, neuropathy and nephropathy [1, 3–5]. This condition has also been described in Type II diabetes and in patients with other endocrine disease, especially thyroid diseases [3, 6, 7], though with a lower incidence compared with Type I diabetes mellitus.
In 1989, Logan and Hoffman [2] mentioned several criteria for the clinical and radiographical diagnosis of DMP, i.e. a long-term history of insulin dependent diabetes mellitus radiographically demonstrated dense glandular tissue, one or more hard, irregular, easily movable, discrete, painless, palpable masses, and strong ultrasound acoustic shadowing.
Seidmen et al [7] reported a mean duration of greater than 13 years (range 4–27 years) for DMP to develop. Although the pathogenesis is still obscure and could be multifactorial, it is generally believed that these lesions are attributable to extracellular matrix expansion secondary to increased collagen production and decreased degradation, in part related to the hyperglycemic state [6].
As DMP can feel like breast cancer upon physical examination and can be difficult for the radiologist and referring physician to diagnose, this little-known benign process can lead to multiple, unnecessary surgical biopsies. Logan and Hoffman [2] have advocated the use of fine needle aspiration cytology in the diagnosis of DMP. They mentioned that the firm resistance experienced during the back-and-forth motion of the needle are stronger than that of other benign and malignant breast conditions, hence this could be a clue to the diagnosis of DMP. Unfortunately, DMP contains little cellular material, making cytological diagnosis difficult.
In 2000, Camuto [4] reported that approximately 60% of DMP tends to be bilateral or recur after surgical excision. According to his description, recurrence tends to be in the same location and involves more breast tissue than the preceding lesion, therefore surgical biopsy should not be considered. Core needle biopsy under ultrasound guidance avoids unnecessary surgical procedures that may exacerbate the condition.
DMP may be confused with breast carcinoma; it is difficult to distinguish these two entities both physically and by imaging. The clinical characteristics of this disease, i.e. it tends to be recurrent and bilateral in 63% of cases [4], enable it to be followed closely with ultrasound, avoiding unnecessary surgical biopsies.
In conclusion, recognizing DMP requires an awareness that this entity exists, a careful correlation of the patient's clinical history with the physical, radiological and pathological examinations of the breasts, and the presence of significant acoustic shadowing on ultrasound of the mass or masses, which may be multiple and bilateral.
Received for publication May 20, 2002.
Revision received August 9, 2002.
Accepted for publication September 16, 2002.
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References
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- Soler NG, Khardori R. Fibrous disease of the breast, thyroiditis, and cheiroarthropathy in type I diabetes mellitus. Lancet 1984;1:193–5.[Medline]
- Logan WW, Hoffman NY. Diabetic fibrous breast disease. Radiology 1989;172:667–70.[Abstract/Free Full Text]
- Ely KA, Tse G, Simpson JF, Clarfeld R, Page DL. Diabetic mastopathy: a clinicopathologic review. Am J Clin Pathol 2000;113:541–5.[CrossRef][Medline]
- Camuto PM, Zetrenne E, Ponn T. Diabetic mastopathy: a report of 5 cases and a review of literature. Arch Surg 2000;135:1190–3.[Abstract/Free Full Text]
- Morgan MC, Weaver MG, Crowe JP, Abdul-Karim FW. Diabetic mastopathy: a clinicopathologic study in palpable and nonpalpable breast lesions. Mod Pathol 1995;8:349–54.[Medline]
- Tomaszewski JE, Brooks JS, Hick D, Livolsi VA. Diabetic mastopathy: a distinctive clinicopathological entity. Hum Pathol 1992;23:780–6.[CrossRef][Medline]
- Seidman JD, Schnaper LA, Phillips LE. Mastopathy in insulin requiring diabetes mellitus. Hum Pathol 1994;25:819–24.[CrossRef][Medline]
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Abstract
Introduction
