The radiologist should be familiar with the range of common inflammatory breast conditions and should also be aware of specific disease patterns such as Zuska's disease and diabetic mastopathy. Complications of breast infection, such as abscess formation or fistulas should also be sought after. For example, in a case of a lactating female, with signs of inflammation, benign mastitis is the most probable diagnosis and treatment can be initiated with follow-up imaging to look for resolution. In some cases, correlation with clinical history and risk factors may be useful. Imaging features of benign and malignant inflammatory conditions often overlap which may cause diagnostic confusion and possibly delay proper treatment. Inflammatory breast diseases consist of a wide array of conditions ranging from the benign simple infective mastitis to breast malignancy. Any non-lactating patient with mastitis that does not respond to antibiotic therapy should undergo biopsy to exclude presence of malignancy ( 3, 15) ( Fig. Lesions in benign mastitis also tend to occur in a subareolar location, whereas malignant lesions tend to occur either centrally or dorsally within the breast tissue ( 2). Lesions in benign mastitis tend to show a more persistent or plateaued enhancement pattern. Masses in inflammatory breast cancer tend to display greater initial enhancement and more frequent subsequent washout. Their differences, however, lie in their enhancement characteristics. On MR imaging, both inflammatory breast cancers and benign mastitis may exhibit similar morphological features such as skin thickening, edema and presence of mass lesions or non-mass like enhancement. However, inflammatory breast cancers are more likely to show solid mass lesions. On ultrasound, subareolar mastitis tends to show mixed solid-cystic lesions or collections. Mammographic findings include skin thickening, increased breast density and trabeculation ( 15). Some patients may present with breast pain. Clinical symptoms include palpable tumor, skin erythema, edema and warmth, breast enlargement and nipple retraction. Inflammatory breast cancer is an invasive aggressive disease with high rate of metastasis at diagnosis ( 1). If clinically suspected, biopsy should be conducted to exclude presence of malignancy. Radiological features of subareolar mastitis and inflammatory breast carcinoma may be similar ( 2). Subsequent recurring episodes of infection may be caused by mixed flora of bacteria, including anaerobes, and can be more complicated to treat with higher rates of recurrence. Initial infections are usually caused by Staphylococcus bacteria. They present as recurring abscesses, often with fistulous tracks extending to the skin near the periareolar region ( 1, 2, 10). This is caused by squamous metaplasia and proliferation of the epithelium in the lactiferious ducts, causing obstruction and secretory stasis leading to abscess formation. It frequently affects middle-age females in their 40s but may affect a wide range of ages (mid-teens-80s) and may even be observed in males ( 2) ( Fig. Non-puerperal subareolar mastitis and breast abscess, also known as Zuska's disease is an uncommon and recurring disease strongly linked to cigarette smoking ( 2, 9) ( Fig. Collections may fistulate into the skin or intra-mammary ducts ( 1). These commonly demonstrate hypoechoic and heterogeneous content and may show irregularly thickened walls. One should also notice possible fluid collections within the site of inflammation. Lactiferous duct abnormalities such as duct dilatation, thickened walls and presence of contents within the ducts should be investigated as some inflammatory conditions are related to lactiferous duct involvement. This can be evaluated using Doppler US, revealing increased arterial and venous structures ( 1) ( Fig. Hyperemia (increased vascularity) of the breast tissue is another sign of inflammation. Hyperemia of subcutaneous tissue surrounding collection is noted.Ĭlick for larger image Download as PowerPoint slide Ultrasound with color Doppler also reveals ill-defined hypoechoic fluid collection with heterogeneous content within site of inflammation. Fluid is observed as intervening hypoechoic lines (white arrows) in subcutaneous tissue. Ultrasound reveals features of subcutaneous edema with skin thickening with increase in echogenicity of subcutaneous tissue.
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