British Journal of Radiology (2005) 78, 471-472
© 2005 British Institute of Radiology
doi: 10.1259/bjr/77108289
Breast or chest? A diagnostic conundrum
J C Lee, FRCR1,
S Banerjee, MRCP2 and
D M King, FRCR2
1 Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9NH and 2 Royal Marsden Hospital, Fulham Road, London SW3 6JJ, UK
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Introduction
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A 60-year-old female presented with a 3 week history of a painless swelling in the left breast. Risk factors for developing breast carcinoma were present including smoking, a 6 year history of hormone replacement therapy, and a positive family history in two second-degree relatives. The patient had a total abdominal hysterectomy and bilateral salpingo-oophorectomy 7 years earlier for fibroids. On clinical examination, a 2 cm by 2 cm soft, lobulated mass was palpated in the upper inner quadrant of the left breast. Screening mammography had been performed 2 months prior to attendance (Figure 1
). Following her clinical assessment, she was referred to the imaging department for ultrasound assessment and consideration for fine needle aspiration for cytology (Figure 2). A chest radiograph was obtained after the ultrasound (Figure 3).
What abnormalities are demonstrated? What possible pathologies are responsible?
The mammogram (Figure 1
) shows normal glandular architecture with several areas of benign calcification. No mass lesion is seen. The ultrasound image (Figure 2), demonstrates a well-defined, hypoechoic mass (M) deep to the pectoralis muscle (PM). The overlying breast tissue is sonographically normal. The chest radiograph (Figure 3) reveals a moderate-sized left pleural effusion with irregular pleural thickening superolaterally.
The differential diagnosis, at this point in the patient's management, included an atypical ductal/lobular carcinoma originating deep within the breast, an enlarged intramammary lymph node, or a chest wall mass such as an intramuscular lipoma, or rhabdomyosarcoma. To clarify the situation further, a CT was performed (Figure 4).
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Figure 4. Axial contrast enhanced CT of the thorax at the equivalent level as the ultrasound image seen in Figure 2.
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This demonstrates an infiltrating, soft-tissue density mass in the left anterior chest wall just lateral to the mid-sternum, associated with destruction of the costochondral junction. The mass arises deep to the pectoralis muscle and is associated with a large left pleural effusion. Note the enhancing thickened pleura adjacent to the descending thoracic aorta.
The initial fine needle aspirate for cytology was inadequate. Owing to the complex nature of the lesion, an excisional biopsy of the anterior chest wall mass was performed under general anaesthetic. Histopathlogy established a diagnosis of malignant pleural mesothelioma.
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Discussion
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90–95% of all breast masses are due to carcinoma, cysts or fibroadenomata [1]. The remaining 5–10% includes conditions arising from the ducts, e.g. papillomas; the glandular tissues, e.g. sclerosing adenosis; or from the supporting structures, e.g. lipomas. In a small subset of patients, breast masses may result from more unusual pathological processes. These include a variety of systemic diseases including diabetic fibrous mastopathy, amyloidosis and Wegener's granulomatosis, as well as rare primary tumours of the breast including hamartomas and haemangiomas, and malignant lesions such as lymphoma, leukaemia, and the sarcomas. Secondary haematogenous spread to the breast can occur from almost any primary malignancy of which the most common are melanoma and lung, but gastric, renal, cervical, and uterine tumours are known occasionally to metastasise [2].
However, it should be remembered that not all breast lumps represent breast disease and that tumours may arise from the chest wall beneath the breast. Primary chest wall tumours include sarcomas, fibromas, lipomas, desmoid tumours, lymphomas, osteochondromas and neurogenic tumours. Furthermore, bronchogenic carcinomas, intrathoracic lymphoma, and malignant pleural mesothelioma may involve the chest wall by direct spread from the thoracic cavity [3].
Malignant pleural mesothelioma (MPM) is a rare, aggressive tumour arising from the serosal lining of the chest and abdomen. In England and Scotland, the prevalence is 8 per 100 000 in the 40–74 year age group, with an overall incidence of 1–2 cases per million per year [4]. The link to asbestos exposure is well established. MPM principally spreads by the direct route and only rarely metastasises haematogenously. Direct spread typically results in circumferential nodular thickening of the pleural space and this process may involve the pericardium and mediastinum. Invasion by MPM through the chest wall is recognized and occurs in up to 16% of cases, although this usually occurs with advanced disease [5]. However, a review of the literature suggests that this is the first report of MPM presenting as a breast mass.
When surgical pleural resection is not possible, as in the illustrated case, recent advances in the medical management of MPM have, for the first time, demonstrated improved quality of life scores and prolonged survival in unresectable or recurrent cases [6].
From the radiologist's perspective, it is important to remember that not all breast masses arise from the breast itself. One should bear in mind that chest wall lesions and intrathoracic pathology can present as breast lesions.
Received for publication November 8, 2004.
Revision received February 3, 2005.
Accepted for publication February 7, 2005.
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References
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- Dixon JM, Mansel RE. Chapter 34 The Breast. In: Burnand KG, Young AE, editors. New Aird's companion in surgical studies. (1st edn). London, UK: Churchill Livingstone, 1994:811–44.
- Feder JM, de Paredes ES, Hogge JP, Wilken JJ. Unusual breast lesions: radiologic-pathologic correlation. Radiographics 1999;19:11–26.[Abstract/Free Full Text]
- Glazer HS, Duncan-Meyer J, Aronberg DJ, Moran JF, Levitt RG, Sagel SS. Pleural and chest wall invasion in bronchogenic carcinoma: CT evaluation. Radiology 1985;157:191–4.[Abstract/Free Full Text]
- Montanaro F, Bray F, Gennaro V, Merler E, Tyczynski JE, Parkin DM, et al. Pleural mesothelioma incidence in Europe: evidence of some deceleration in the increasing trends. Cancer Causes Control 2003;14:791–803.[CrossRef][Medline]
- Ng CS, Munden RF, Libshitz HI. Malignant pleural mesothelioma: the spectrum of manifestations on CT in 70 cases. Clin Radiol 1999;54:415–21.[CrossRef][Medline]
- Budde LS, Hanna NH. Pemetrexed (Alimta(R)): improving outcomes in malignant pleural mesothelioma. Expert Rev Anticancer Ther 2004;4:361–8.[CrossRef][Medline]
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Introduction
Discussion
