Figure 1
Mammography
Oblique lateral (A) and craniocaudal incidences (B) revealed focal asymmetries in the upper-outer quadrant of the left breast and some round calcifications
Diabetic mastopathy: a diagnostic dilemma
SectionBreast imaging
Case TypeClinical Cases
Authors
Ines Alves1, José Carlos Marques2
1 Hospital Central do Funchal
2 Instituto Português de Oncologia de Lisboa Francisco Gentil
Connected authors
62 years, female
Clinical History
A 62-year-old female patient complains of painless left breast lumps found during self-examination. She has a 40-year history of type 1 diabetes, undergoing insulin therapy for more than 20 years.
No significant family or personal history of breast cancer is present.
No significant family or personal history of breast cancer is present.
Imaging Findings
Physical examination showed two stony hard, ill-defined and relatively immobile masses on the left breast.
Mammography revealed focal asymmetric densities in the upper-outer quadrant of the left breast and some round calcifications. No skin thickening, nipple retraction or enlarged lymph nodes were depicted (Fig. 1).
Ultrasound showed two areas of strong acoustic shadowing without definables masses in the left breast (Fig. 3).
Ultrasound-guided core biopsy was performed, revealing stromal fibrosis and moderate perilobular/periacinal lymphocytic infiltration (Fig. 6).
Contrast-enhanced MRI showed normal glandular tissue, without any abnormal intensity or enhancement (Fig. 5).
Diabetic mastopathy was diagnosed.
Currently, the patient remains well and is on both clinical and imaging follow-up.
The 7-year imaging follow-up studies revealed persistence of the mammographic findings, although ultrasound only depicted subtle mixed echogenic areas without posterior acoustical shadowing (Fig. 2 and 4).
Mammography revealed focal asymmetric densities in the upper-outer quadrant of the left breast and some round calcifications. No skin thickening, nipple retraction or enlarged lymph nodes were depicted (Fig. 1).
Ultrasound showed two areas of strong acoustic shadowing without definables masses in the left breast (Fig. 3).
Ultrasound-guided core biopsy was performed, revealing stromal fibrosis and moderate perilobular/periacinal lymphocytic infiltration (Fig. 6).
Contrast-enhanced MRI showed normal glandular tissue, without any abnormal intensity or enhancement (Fig. 5).
Diabetic mastopathy was diagnosed.
Currently, the patient remains well and is on both clinical and imaging follow-up.
The 7-year imaging follow-up studies revealed persistence of the mammographic findings, although ultrasound only depicted subtle mixed echogenic areas without posterior acoustical shadowing (Fig. 2 and 4).
Discussion
The breast is not usually included among organs involved in diabetes-related complications although it may infrequently occur, representing less than 1% of all benign breast diseases [1]. Diabetic mastopathy is a relatively recent discovery, firstly described in 1984 by Soler and Khardori [2]. It is a benign, self-limiting, fibroinflammatory condition, which does not incur an increased risk of malignancy, however, because of its clinical and imagiological appearance resembling carcinoma, it can constitute a diagnostic dilemma [3].
It typically affects women with long-standing type 1 diabetes (estimated to develop in about 0.6% to 13%), who manifest other complications of diabetes, particularly retinopathy and neuropathy. To a much lesser extent, it was reported in men and in patients with type 2 diabetes. Usually, this condition takes a long time to develop, approximately 20 years after the first onset of the disease [4, 5].
Its pathogenesis is not clearly understood. Some theories support a multifactorial aetiology, others suggest an inflammatory or immunologic reaction to exogenous insulin and some an autoimmune response to glycosides [3].
Clinical features include unilateral or bilateral, single or multiple masses, located predominately in the subareolar region, that are usually firm, mobile and painless, frequently indistinguishable from breast carcinoma [6].
Mammography most commonly depicts focal asymmetries or ill-defined masses without microcalcifications, both of them being highly nonspecific features [3].
Ultrasound usually reveals a solid, irregular and hypoechoic mass, often with ill-defined margins and moderate to strong posterior acoustic shadowing. Color Doppler examination shows no flow. The marked shadowing is associated with the amount of fibrous tissue, often being even greater than that seen in breast cancers [3].
MRI can be useful to differentiate diabetic mastopathy from malignant lesions. Findings are variable, including decreased diffuse contrast material enhancement and rapid, intense enhancement similar to breast cancer. Further studies are needed to assess the role of MRI in this condition [3].
As imaging findings are nonspecific and cannot exclude malignancy, biopsy (core needle or excisional) is required for a definitive diagnosis. Histologically, it consists of a combination of stromal dense fibrosis and lymphocytic infiltrate of mature B cells surrounding the ducts, lobules and vessels [6].
The diagnosis is complex, requiring an appropriate clinical history combined with a high index of suspicion. As this is usually a self-limited disease with no required treatment, an appropriate diagnosis can avoid unnecessary surgeries. Reported recurrence rates are substantial and can be multiple, ipsilateral, or contralateral. Annual clinical and imaging follow-up is advised [1, 6].
It typically affects women with long-standing type 1 diabetes (estimated to develop in about 0.6% to 13%), who manifest other complications of diabetes, particularly retinopathy and neuropathy. To a much lesser extent, it was reported in men and in patients with type 2 diabetes. Usually, this condition takes a long time to develop, approximately 20 years after the first onset of the disease [4, 5].
Its pathogenesis is not clearly understood. Some theories support a multifactorial aetiology, others suggest an inflammatory or immunologic reaction to exogenous insulin and some an autoimmune response to glycosides [3].
Clinical features include unilateral or bilateral, single or multiple masses, located predominately in the subareolar region, that are usually firm, mobile and painless, frequently indistinguishable from breast carcinoma [6].
Mammography most commonly depicts focal asymmetries or ill-defined masses without microcalcifications, both of them being highly nonspecific features [3].
Ultrasound usually reveals a solid, irregular and hypoechoic mass, often with ill-defined margins and moderate to strong posterior acoustic shadowing. Color Doppler examination shows no flow. The marked shadowing is associated with the amount of fibrous tissue, often being even greater than that seen in breast cancers [3].
MRI can be useful to differentiate diabetic mastopathy from malignant lesions. Findings are variable, including decreased diffuse contrast material enhancement and rapid, intense enhancement similar to breast cancer. Further studies are needed to assess the role of MRI in this condition [3].
As imaging findings are nonspecific and cannot exclude malignancy, biopsy (core needle or excisional) is required for a definitive diagnosis. Histologically, it consists of a combination of stromal dense fibrosis and lymphocytic infiltrate of mature B cells surrounding the ducts, lobules and vessels [6].
The diagnosis is complex, requiring an appropriate clinical history combined with a high index of suspicion. As this is usually a self-limited disease with no required treatment, an appropriate diagnosis can avoid unnecessary surgeries. Reported recurrence rates are substantial and can be multiple, ipsilateral, or contralateral. Annual clinical and imaging follow-up is advised [1, 6].
Differential Diagnosis List
Diabetic Mastopathy
Breast Carcinoma
Breast Fibrosis
Final Diagnosis
Diabetic Mastopathy
References
[1] Sankaye S, Kachewar S (2012) Diabetic mastopathy. Australas Med J 5(6): 296–299 (PMID: 3395289)
[2] Soler NG, Khardori R (1984) Fibrous disease of the breast, thyroiditis, and cheiroarthropathy in type I diabetes mellitus. Lancet 1(8370):193-5 (PMID: 6141337)
[3] Neetu G, Pathmanathan R, Weng NK (2010) Diabetic Mastopathy: A Case Report and Literature Review. Case Rep Oncol 16;3(2):245-251 (PMID: 20740205)
[4] Sabaté JM, Clotet M, Gómez A, De Las Heras P, Torrubia S, Salinas T (2005) Radiologic evaluation of uncommon inflammatory and reactive breast disorders. Radiographics 25(2):411-24 (PMID: 15798059)
[5] Stavros AT (2004) Diabetic Mastopathy (Diabetic Fibrosis). Breast Ultrasound 1st ed.Lippincott Williams & Wilkins 578–581
[6] Francisco C, Júlio C, Fontes AL, et al. (2012) Diabetic mastopathy: a case report. Clin Imaging 36(6):829-32 (PMID: 23154017)
Case information
| URL: | https://www.eurorad.org/case/14178 |
| DOI: | 10.1594/EURORAD/CASE.14178 |
| ISSN: | 1563-4086 |
License
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
Figure 2
7-year follow-up mammography
Oblique lateral (A) and craniocaudal incidences (B) show lower breast density due to age, with persistence of the focal asymmetries
Figure 3
Left breast ultrasound
Strong acoustic shadowing without a definable mass.
Figure 5
MRI
(A) Axial T1 and (B) Axial T2 Fat-suppressed weighted images depicted no lesions.
(C) Axial Postcontrast Fat-suppressed T1W image showing no abnormal enhancement.
(A) Axial T1 and (B) Axial T2 Fat-suppressed weighted images depicted no lesions.
(C) Axial Postcontrast Fat-suppressed T1W image showing no abnormal enhancement.
(A) Axial T1 and (B) Axial T2 Fat-suppressed weighted images depicted no lesions.
(C) Axial Postcontrast Fat-suppressed T1W image showing no abnormal enhancement.
Figure 6
Pathology
Photomicrographs of the histological specimen of left breast core biopsy showing stromal fibrosis and periductal/perivascular lymphocytic infiltration (Hematoxylin-eosin, X10 [A] and X20 [B]).
Photomicrographs of the histological specimen of left breast core biopsy showing stromal fibrosis and periductal/perivascular lymphocytic infiltration (Hematoxylin-eosin, X10 [A] and X20 [B]).
Mammography
Oblique lateral (A) and craniocaudal incidences (B) revealed focal asymmetries in the upper-outer quadrant of the left breast and some round calcifications
Instituto Português de Oncologia de Lisboa Francisco Gentil
Instituto Português de Oncologia de Lisboa Francisco Gentil
7-year follow-up mammography
Oblique lateral (A) and craniocaudal incidences (B) show lower breast density due to age, with persistence of the focal asymmetries
Instituto Português de Oncologia de Lisboa Francisco Gentil
Instituto Português de Oncologia de Lisboa Francisco Gentil
Left breast ultrasound
Strong acoustic shadowing without a definable mass.
Instituto Português de Oncologia de Lisboa Francisco Gentil
Instituto Português de Oncologia de Lisboa Francisco Gentil
MRI
(A) Axial T1 and (B) Axial T2 Fat-suppressed weighted images depicted no lesions.
(C) Axial Postcontrast Fat-suppressed T1W image showing no abnormal enhancement.
Instituto Português de Oncologia de Lisboa Francisco Gentil
Instituto Português de Oncologia de Lisboa Francisco Gentil
(A) Axial T1 and (B) Axial T2 Fat-suppressed weighted images depicted no lesions.
(C) Axial Postcontrast Fat-suppressed T1W image showing no abnormal enhancement.
Instituto Português de Oncologia de Lisboa Francisco Gentil
Instituto Português de Oncologia de Lisboa Francisco Gentil
(A) Axial T1 and (B) Axial T2 Fat-suppressed weighted images depicted no lesions.
(C) Axial Postcontrast Fat-suppressed T1W image showing no abnormal enhancement.
Instituto Português de Oncologia de Lisboa Francisco Gentil
Instituto Português de Oncologia de Lisboa Francisco Gentil
Pathology
Photomicrographs of the histological specimen of left breast core biopsy showing stromal fibrosis and periductal/perivascular lymphocytic infiltration (Hematoxylin-eosin, X10 [A] and X20 [B]).
Instituto Português de Oncologia de Lisboa Francisco Gentil
Instituto Português de Oncologia de Lisboa Francisco Gentil
Photomicrographs of the histological specimen of left breast core biopsy showing stromal fibrosis and periductal/perivascular lymphocytic infiltration (Hematoxylin-eosin, X10 [A] and X20 [B]).
Instituto Português de Oncologia de Lisboa Francisco Gentil
Instituto Português de Oncologia de Lisboa Francisco Gentil