Recurrent breast lesion in a patient with systemic lupus erythematosus – A radiological review and case report

Clinical History

A 42-year-old female patient with SLE presented bilateral painless breast lumps. The patient refused a core needle biopsy and a bilateral surgical excision was thus performed. In the 18 month follow-up she presented with a recurrent lump on the right side. A mammography and ultrasound-guided biopsy were performed.

Imaging Findings

The patient was initially referred to our department for a breast MRI. A mammography and ultrasound were also performed. The mammography revealed a partially spiculated, hyperdense mass with a diameter of 4 cm and multifocal calcifications in the right upper quadrant (Fig. 1) as well as an additional lesion on the left cranial midline with 1.6 cm. There were widespread bilateral calcifications. The breast was classified as Grade II according to ACR. In the ultrasound a diffuse, ill-defined hypoechogenicity on both lesions was seen (Fig. 2). The lesions revealed an inhomogeneous hyper- to isointense signal on T2w (Fig. 3) and showed rim-like contrast enhancement on fat-saturated T1w images following Gadolinium administration. There was no axillary lymph node enlargement. After surgical excision, the 18 month follow-up mammography revealed an inhomogeneous spiculated nodule on the right upper quadrant (Fig. 4). An ultrasound-guided biopsy was performed and revealed a fibrosing mastitis.

Discussion

Systemic lupus erythematosus is a chronic autoimmune disease affecting mostly women in the childbearing age, it can affect any organ system and its presentation and course is highly variable. The involvement of soft tissue was firstly described by Kaposi in 1883 and is now believed to occur in 2-3% of the cases of SLE [1]. A subcategory of lupus erythematosus panniculitis is the lupus mastitis, in which the breast tissue is involved. Less than 30 cases were described in the literature, however, the exact incidence of LM is not known. Although the aetiology is not entirely clear it is believed to follow the linear deposition of immunoglobulin M and C3 along the dermoepidermal junction and vessel basement membrane [2]. The involvement may be uni-or bilateral as well as focal or multifocal. Diagnostic workup includes thorough family and personal history, biochemical studies for the presence of antibodies, tumour markers and infection parameters, as well as radiological studies. Mammography reveals mostly dense breast tissue with an irregular mass [1] and coarse or curvilinear calcifications due to fat necrosis [3, 4]. In breast ultrasound the lesions are often hypo- [4] or hyperechoic, heterogeneous, ill-defined masses located in the subcutaneous fat without evidence of perfusion on colour Doppler [5, 1, 6]. Sabot et al. were the first to describe a lupus mastitis lesion on the pre-contrast MRI as a heterogeneous mass with high signal intensity on both T1w and T2w and after contrast administration presenting with irregular margins and rim enhancement [7]. Rosier et al. described a continuous, irregular, thick rim of enhancement after contrast administration, which in response to appropriate therapy gradually thins, discontinues and eventually resolves in certain areas [8]. MRI can be valuable in accessing the skin and lymph node involvement as well as in monitoring the response to therapy [8]. However, it fails to differentiate between benign and malignant inflammatory masses. The definite diagnosis is made histologically and a core needle biopsy is required in most cases. However, it is important to note that the traumatic injury of needle biopsies and surgical interventions may exacerbate the course of the event as well as cause recurrence [9]. Therefore contrast-enhanced MRI represents an effective, non-invasive method to monitor disease evolution and further response to therapy. In summary, lupus mastitis should be considered as a differential diagnosis when managing a breast mass with calcifications in patients with a history of SLE.

Differential Diagnosis List

Final Diagnosis

Lupus mastopathy with fibrosing mastitis, fat necrosis and secondary calcification.

URL:	https://www.eurorad.org/case/13799
DOI:	10.1594/EURORAD/CASE.13799
ISSN:	1563-4086