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A 28-year-old woman presented with tenderness and redness in her right breast. She denied fever and recent illness or injury, and she had been in good general health. The woman (gravida 1, para 1) had given birth 28 months earlier, and she had not breast-fed the infant. She was not currently pregnant. On examination, the woman had a hard, irregular, and tender 2-cm mass in the right breast. Mammography revealed irregular calcifications that were interpreted as a benign pattern. Excisional biopsy was planned. |
The most critical diagnosis that must be considered in a patient with a breast mass and local inflammation is inflammatory carcinoma. However, it is unusual for the presentation of carcinoma to include inflammatory changes; more typical symptoms are a mass or an abnormal mammogram in an otherwise asymptomatic patient. Inflammatory carcinoma is an invasive carcinoma that causes inflammatory changes in the overlying skin, resulting in warmth and erythema. It usually is caused by a poorly differentiated infiltrating ductal carcinoma, which results in a skin reaction because of the lymphatic obstruction/invasion by tumour. A peau d’orange (thickened, dimpled) appearance may be present, as may a palpable mass, which may or may not be painful.
Mastitis, an infection of the mammary ducts and glands, is a common cause of localized redness and tenderness, often accompanied by fever and local induration. Although the infection can occur in nonlactating women, it most commonly occurs 1 to 3 months after delivery in women who are nursing. In postmenopausal women, subareolar infections can develop. Most cases of mastitis are caused by Staphylococcus and Streptococcus species, though Escherichia coli or anaerobes also may be present in postmenopausal women. This condition can look the same as inflammatory carcinoma.
Patients with fat necrosis may present with a hard, irregular mass that is tender. Skin retraction also may occur. This condition is often, but not always, caused by trauma (including trauma from surgery). Local haemorrhage may occur in some cases, and abscesses may form. Because the condition is difficult to differentiate on the basis of the clinical presentation alone, diagnosis requires a biopsy.
Other conditions to consider include superficial thrombosis of the thoracoepigastric vein, duct ectasia, granulomatous disease (idiopathic or infectious), foreign body reaction, and cellulitis or abscess of the skin overlying the breast. Thrombophlebitis is distinguished by the presence of a palpable cord. Duct ectasia develops as a result of dilated, obstructed terminal collecting ducts in the mammary gland; patients present with a lesion adjacent to the areola, discoloured nipple discharge, and possibly an abscess. Cellulitis is usually not associated with a mass, and a mass caused by an abscess is typically fluctuant. Granulomatous disease or foreign body reaction may be distinguished only on biopsy.
For the patient presented, the findings on excisional biopsy demonstrated fat necrosis with a small amount of coagulated blood, consistent with a diagnosis of fat necrosis. The finding of calcium deposits is also common with fat necrosis.
For many of these conditions, the presentation and physical findings overlap, and biopsy is necessary to make the diagnosis. The diagnosis of mastitis is supported by the history of lactation. Cellulitis and thrombophlebitis are usually apparent from the clinical presentation.
The treatment for inflammatory carcinoma is aggressive systemic chemotherapy; this lesion is considered too advanced to be amenable to surgical treatment.
Mastitis is typically treated with antibiotics and warm compresses, but incision and drainage may be necessary. Mastitis that does not respond to conservative therapy should be biopsied, as this condition mimics inflammatory carcinoma. Cellulitis would also be treated with antibiotics and warm compresses, and any abscesses should be drained.
Fat necrosis is cured with the excisional biopsy that is done as part of the diagnostic process. Duct ectasia also is treated with excisional biopsy.
Thrombophlebitis usually responds well to symptomatic care (analgesics) and warm compresses.
The treatment of granulomatous disease depends on the cause, as treatment of the underlying disease is the primary treatment for the breast lesion as well. Granulomatous disease due to tuberculosis requires antitubercular therapy. The cause of idiopathic granulomatous disease is not known, but it is usually treated with systemic corticosteroids and has a high rate of recurrence.
In this patient, excisional biopsy confirmed the diagnosis of fat necrosis and cured the symptoms. She had no prior history of trauma, but only about half of patients report surgery or trauma before the onset of the symptoms.