Role of ultrasound in the management of Mastitis: when to re-assure, when to follow up and when to interfere? Poster No.: C-0324 Congress: ECR 2012 Type: Scientific Paper Authors: R. M. K. E. Fouad, S. T. Hamed, D. Salem, S. A. Mansour, L. Adel; Cairo/EG Keywords: Education, Breast, Genital / Reproductive system female, Mammography, Ultrasound, CAD, Abscess delineation, Abscess, Inflammation DOI: 10.1594/ecr2012/C-0324 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 36
Purpose To identify the fundamental role of ultrasound in the diagnosis and management of mastitis patients and in guiding various interventional diagnostic and therapeutic procedures. Methods and Materials The study population included 197 female patients with clinical and ultrasound signs suggestive of mastitis. According to kamal, et al, 2009, they were classified into 3 Groups (fig. 1) and (fig. 2): Group 1: Infectious mastitis Group 2: Non infectious mastitis Group 3: Malignant mastitis Infectious mastitis (IM): specific and non specific forms of infections whether primary or complicating already present breast pathologies. Patients usually present with fulminant inflammatory signs that frequently accompany lactation. Non infectious forms of mastitis (NIM): aseptic or chemical inflammatory breast disorders that do not necessarily occur during lactation, are not necessarily accompanied by microbial infections and thus do not usually present with fulminant inflammatory signs and do not necessarily resolve with antibiotics. Malignant mastitis (MM): it is the most serious form of mastitis and includes inflammatory breast carcinoma or the very rare form of malignant breast abscess. US Examination: Ultrasound examination was performed using a linear array (7-13 MHz) transducer. The recorded ultrasound findings of mastitis included: echogenic fat lobules, interstitial edema lines, ill defined collections, skin thickening, prominent subdermal lymphatics, and axillary lymphnode status. The ultrasound report should also include the presence or abscence of associated mass lesions, dilated ducts and draining sinus tracts. Reported findings of Page 2 of 36
the performed ultrasound examination were tabulated and compared by the Pearson Chi Square test using the Statistical Package of Social Sciences (SPSS). US guided interventional procedures: Ultrasound guided biopsy was performed to evaluate suspicious mass lesions when present. Skin punch biopsies, axillary lymphnode biopsy and aspiration from the dilated subdermal lymphatic layer were performed to confirm the diagnosis of inflammatory breast carcinoma. Abscess cavities, infected cysts and post operative collections were drained. Ultrasound " Diagnostic Workup' of mastitis cases: When diagnosing mastitis cases we should pass through several sequential steps (fig. 3): 1. 2. 3. 4. 5. Mastitis is diagnosed on ultrasound examination when the following signs are encountered: interstitial edema lines that delineate the echogenic and edematous fat lobules with overlying focal or diffuse skin thickening. Look for other associated signs. If no other associated signs are seen, simple mastitis is diagnosed. The patient is assured and is asked to come for a short term follow up study after completing an antibiotic course. Complete resolution should be the rule. Non resolution should raise the possibility of development of complications, infection by atypical organisms or inflammatory breast carcinoma. A biopsy should then be considered. If abscess cavities, infected cysts or post operative collections are encountered they should be drained and followed up to ensure no recollection. If pathological lymphnodes, dilated subdermal lymphatics or mass lesions are encountered we should directly resort to biopsy. US guided management: Mastitis patients were managed according to their ultrasound findings into 3 categories: Category 1: were re-assured and were given a short course of antibiotics and hot fomentations. Category 2: were asked to come for a short term follow up study after completion of medical therapy or after performing ultra sound or operative intervention Category 3: were subjected to immediate interventional procedures Page 3 of 36
Images for this section: Fig. 1: Classification of mastitis cases. Color code (green: infectious m., red: non infectious m.,blue: malignant m.) Page 4 of 36
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Fig. 2: frequencies and relative frequencies of mastitis cases Fig. 3: Diagnostic workup of mastitis cases Color code (yellow: US exam and intervention, green: infectious m., red: non infectious m.,blue: malignant m.) Page 6 of 36
Results One hundred and ninety seven female patients with clinical or ultrasound findings of mastitis were enrolled in the study. We classified them into 3 main groups of mastitis according to the classification previously proposed by the authors (kamal,et al, 2009) (fig. 1). Fig. 1: Classification of mastitis cases. Color code (green: infectious m., red: non infectious m.,blue: malignant m.) References: R. M. K. E. Fouad; Radiology, Cairo University, Cairo, EGYPT The frequency and relative frequencies (percentage) of cases included under each pathological entity is shown in fig. 2. Page 7 of 36
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Fig. 2: frequencies and relative frequencies of mastitis cases References: R. M. K. E. Fouad; Radiology, Cairo University, Cairo, EGYPT Group I comprised the higher frequency of mastitis cases (n: 132, 67%) showing predominance of complicated forms of mastitis comprising 79 (40.1 %) patients. Fifty (37.9%) of group I patients were lactating (fig. 4, 5, 6). Group 2 included 54 cases (27.4%) with predominance of periductal mastitis/duct ectasia comprising 32 (16.3%) cases (fig. 7). Group III included 11 (5.6%) cases of malignant mastitis (fig. 8, 9). Table 1 shows the correlation of the ultrasound findings in the 3 study groups stressing on the significance of each sign in differentiating between the different pathological entities of mastitis. Table 1: Ultrasound findings in the 3 study groups References: R. M. K. E. Fouad; Radiology, Cairo University, Cairo, EGYPT Page 9 of 36
The presence of acute inflammatory signs on ultrasound (edematous, echogenic fat lobules and interstitial edema) could significantly differentiate infectious and malignant forms of mastitis (p<0.001) from non infectious forms but could not differentiate infectious from malignant forms (fig. 10). The presence of ill defined collections and abscess cavities in infectious mastitis (p: 0.001 and 0.026) and the absence of malignant axillary nodes (p: 0.05) are significant differentiating signs between infectious and malignant mastitis (fig. 11, 12). Mass lesions favor noninfectious and malignant forms of mastitis (p: 0.038 and p: 0.023) over infectious forms. Thickened skin was significantly higher in malignant than infectious and non infectious mastitis (p: 0.01 and p: <0.05 respectively) but no definite cutoff values could be calculated due to the paucity of cases included in the study. Thick skin was also significantly higher in infectious than non infectious mastitis (p:< 0.05) (fig. 10). Dilated ducts are significantly higher in non infectious than infectious and malignant mastitis (p: <0.05). Nine fistulous tracts with draining skin sinuses could be traced on ultrasound examination. Seven were seen draining neglected abscess cavities. Multiple discharging fistulous tracts were traced in a tuberculous patient and another one was seen draining a malignant abscess (fig. 13). According to their ultrasound findings, 83 (42.2%) cases were re-assured and were given a short course of antibiotic therapy and hot fomentations. These included 46 (23.3.%) cases of simple mastitis, 32 (16.3%) cases of periductal mastitis and 5 (2.6%) cases of plasma cell mastitis. They were asked to come for a short term follow up study to ensure complete resolution (fig. 14). Complicated mastitis cases (77 cases, 39.1%) were drained, given a course of antibiotic therapy and were asked to come for a short term follow up ultrasound study to ensure complete resolution (fig. 15). Specific forms of infection (9 cases, 4.6%) were biopsied. They received appropriate therapy according to their culture and sensitivity results. They were followed up along the course of treatment (fig 16). Non infectious mastitis cases, including granulomatous mastitis (3 cases, 1.5%), diabetic mastopathy (2 cases, 1%) and secondary forms of mastitis (12 cases, 6%) were biopsied (fig. 17). Each entity was managed according to the clinical condition. they were asked to come on an annual check up basis. Malignant mastitis cases (11 cases, 5.6%) were biopsied. After mastectomy they were asked to come for a follow up study every 6 months for one and a half year to exclude any possibility of recurrence. Page 10 of 36
Images for this section: Page 11 of 36
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Fig. 4: 30-year-old female with history of left breast cyst that has recently became tender and has increased in size. Her mammogram (A) showed a well defined rounded lesion. On ultrasound examination (B) the contents of the cyst are turbid with floating internal particles. It was surrounded by a minimal inflammatory reaction denoting secondary infection Fig. 5: An immune compromised patient with Systemic Lupus Erythematosis under corticosteroid therapy. She developed a huge right breast mass lesion associated with fulminant inflammatory signs. Ultrasound examination performed using a 3.5MHz probe showed a huge abscess cavity occupying most of the right breast parenchyma. Ultrasound guided drainage was performed. Page 13 of 36
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Fig. 6: Two galactoceles in two different lactating females who developed retro-areolar rod shaped, severely tender mass lesions associated with inflammatory signs. Their ultrasound examination revealed two remarkably dilated retro-areolar ducts with retained milk that were surrounded by a focal inflammatory reaction. Page 15 of 36
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Fig. 7: A case of peri ductal mastitis showing a dilated, thick walled retroareolar duct with retained secretions (A). A peri ductal inflammatory reaction is noted with ill defined collections denoting impending abscess formation (B). Fig. 8: Malignant breast abscess showing a thickened irregular wall (arrow). Diagnosis was confirmed after biopsy. Page 17 of 36
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Fig. 9: A case of inflammatory breast carcinoma. Her mammogram (A) showed a diffuse edema pattern with apparent pathological axillary lymphnodes. Diagnosis was confirmed on ultrasound (B) which showed diffuse inflammatory reaction with remarkable skin thickening and dilated subdermal lymphatics. Her axillary lymphnodes were enlarged with eccentric and infiltrated hila (C). No mass lesions were identified. Page 19 of 36
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Fig. 10: Two different cases showing the full blown picture of mastitis. Fig. (A) is a case of simple mastitis and Fig (B) is a case of early inflammatory breast carcinoma. Fig. 11: A case of simple lactational mastitis. Ill defined collections are signs of impending abscess formation. Page 21 of 36
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Fig. 12: A young female patient who developed a left retro areolar mass lesion. Her mammogram (A) showed a suspicious retro areolar mass lesion which was assigned BIRADS 4 category. Complementary ultrasound examination showed an avascular retroareolar abscess cavity with benign looking non specific enlarged axillary lymph nodes. Page 23 of 36
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Fig. 13: A 40-year-old female complaining of inflammatory changes of her right breast that were resistant to antibiotic therapy. She recently developed multiple discharging skin sinuses. Her mammogram (A)showed a markedly distorted parenchyma. On ultrasound examination multiple intercommunicating abscess cavities were identified (B) and multiple discharging skin sinuses could be traced (C). Tuberculous mastitis was diagnosed after ultrasound guided biopsy and culture sensitivity of the discharge. Page 25 of 36
Conclusion Mastitis is a frequently encountered clinical complaint, yet, there remains a paucity of scientific research discussing inflammatory breast disorders. A common misconception is using the terms mastitis and breast infection as synonymous terms, but strictly speaking mastitis means inflammation of the breast irrespective of the cause. Described mammography signs of mastitis are vague and non specific (2). Adding to this, patients with mastitis have a painful, swollen and dense breasts and thus they cannot withstand adequate mammography compression. Therefore, mastitis patients are usually referred for an early ultrasound examination. Ultrasound plays a fundamental role in the diagnostic work up of mastitis patients. An ideal ultrasound should ensure an accurate diagnosis, guide for interventional procedures whenever necessary and should be used to monitor adequate management by short term follow up studies along the course of therapy. To ensure an adequate diagnosis, the breast ultrasound specialists should bear some tips in mind: Ultrasound inflammatory signs are the same in all mastitis patients. That is why; more effort should be spent to look for supplementary signs. Abscess cavities, ill defined collections in the presence of reactionary nodes should favor an infectious etiology. Remarkable skin thickening with prominent sub-dermal lymphatics, pathological lymphnodes with or without mass lesions should favor a malignant pathology. Dilated ducts associated with inflammatory signs may be in favor of ductal pathology; mainly periductal mastitis. We should never ignore the clinical background of the patient to exclude secondary forms of mastitis. Complete resolution is the rule after a short course of antibiotics if simple mastitis is the case. The second job of the breast ultrasound specialist starts when a patient is resistant to treatment. One of three conditions should be considered: The patient might have an unusual form of infection (e.g. TB). She might have developed complications e.g. abscess cavity. She might have early malignant signs. Page 26 of 36
It should be strictly specified in this context that most women with inflammatory breast carcinoma are originally diagnosed as having simple mastitis (3). Most physicians will prescribe antibiotics, If after one week symptoms do not dissipate, a biopsy should be considered (4). Ultrasound guided diagnostic and therapeutic interventional procedures should then play a role. Under all conditions, mastitis patients should be asked to come for a follow up ultrasound study to monitor treatment, ensure complete resolution and exclude recurrence. To sum up, ultrasound examination should replace mammography as the gold standard breast imaging technique in the perspective of inflammatory breast disorders. It should be considered the mainstay in making an accurate diagnosis, in monitoring treatment and in guiding interventional procedures. Images for this section: Page 27 of 36
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Fig. 14: A case of simple lactational mastitis with inflammatory signs seen on her US image (A). The patient was re-assured, given a short course of antibiotic therapy and was asked to come for a short term follow up ultrasound examination. One week later, ultrasound showed complete resolution of all inflammatory signs (B). Page 29 of 36
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Fig. 15: A lactating female who developed a right lower inner quadrant tender and hard mass lesion. She was referred for a biopsy. Her mammogram (A) showed a suspicious lower inner quadrant ill defined mass lesion with overlying focal skin thickening that was categorized as BIRADS4. Her ultrasound examination (B) showed an underlying huge abscess cavity with a surrounding focal inflammatory reaction. The abscess cavity was drained and she came for a post operative follow up ultrasound examination (C) to ensure complete resolution. Page 31 of 36
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Fig. 16: A case of axillary tuberculous lymphadenitis that was only diagnosed by a lymphnode biopsy. Page 33 of 36
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Fig. 17: A 34-year-old lactating female who developed a hard right breast lump. Her mammogram (A) showed a non specific diffuse edema pattern of the right breast with increased density, coarsened trabeculae and overlying skin thickening. On ultrasound examination (B and C) an underlying huge irregular suspicious mas lesion was seen associated with pathological right axillary lymphadenopathy. Granulomatous mastitis was diagnosed after revision of her biopsy specimens. Page 35 of 36
References 1. 2. 3. 4. Kamal, R. M., Hamed, S. T. and Salem, D. S. (2009), Classification of Inflammatory Breast Disorders and Step by Step Diagnosis.The Breast Journal, Volume 15, Issue 4, pages 367-380. Gupta R, Behbehani A, Chisti F, Alsaleh M. The role of ultrasound in the management of inflammatory disorders of the breast. Medical Principles and Practice 1999; 8: 51-57. Guray MS. Benign breast diseases: classification, diagnosis and management. Oncologist 2006; 11:435-449. Dahlbeck SW, Donnelly JF, Theriault RL. Differentiating inflammatory breast cancer from acute mastitis. American Family Physician 1995. Personal Information R. K. Fouad, S.T. Hamed, D. Salem, S.A. Mansour, L.Adel Women Imaging Unit - Radiology Department- Cairo University The Egyptian National Breast Screening Program: 'The Women Health Outreach Program' e-mail: rashaakamal@hotmail.com tel: 002-0122 - 7457992 Page 36 of 36