Infectious and inflammatory processes
The clinical and imaging presentation of breast inflammation can be deceptive, as it is capable of masking a malignant process.
- Abscesses most commonly occur in young women during lactation. The standard treatment approach includes prescribing antibiotics and removing pus via aspiration, which is usually performed under ultrasound guidance.
- Non-lactational inflammation is a cause for clinical concern among physicians. Despite the existence of rare benign forms (e.g., granulomatous mastitis), such a symptom requires thorough investigation.
If the inflammatory process presents atypically, lacks clear causes, or does not respond to standard treatment, the patient is indicated for percutaneous biopsy to rule out malignancy.
Architectural distortion: scars
Breast tissue injuries form a specific imaging pattern that requires differential diagnosis.
- Surgical scar (Surgical scar): On mammograms, it may appear as a spiculated mass or a focal distortion of normal tissue architecture. It often contains radiolucent areas and coarse calcifications indicating associated fat necrosis. It is extremely crucial that radiologic technologists note the presence of all postoperative scars, as a tumor recurrence may be hidden next to them.
- Radial scars (Radial scars): These are complex sclerosing lesions that form spiculated structures visually indistinguishable from malignant neoplasms. They are often clinically asymptomatic and are found incidentally during screening. Due to their potential association with epithelial atypia, ductal carcinoma in situ (DCIS), and invasive cancer, excision or an extended biopsy is recommended upon their detection.
Benign microcalcifications
Microcalcifications are a frequent finding on routine mammography. Although they are benign in most cases, they sometimes serve as a marker of ductal carcinoma in situ. Due to the similarity of radiographic patterns, a biopsy is often required.
Examples of benign calcifications and their imaging symptoms:
- Vascular calcifications: Calcification of the walls of small blood vessels produces the "tramline appearance".
- Duct ectasia: Calcification of debris within dilated ducts. It manifests as coarse rod-like and branching structures (the "broken needle" sign). When debris extends into the parenchyma with the development of inflammation and fat necrosis, the calcifications take on a "stem-pipe" appearance.
- Fibrocystic change: When taking views with lateral magnification, one can see the sedimentation of calcified sludge within microcysts — the "teacup appearance" sign.
- Fat necrosis: Often occurs after trauma or surgery. The "eggshell" sign is characteristic—calcification of the walls of oleogranulomas (oil cysts).
- Fibroadenomas: Prone to calcification (especially in postmenopause), forming the classic "popcorn" sign.
Briefly: answers to topical questions
What rare benign forms of non-lactational breast inflammation exist?
Forms of non-lactational breast inflammation include granulomatous, periductal, and tuberculous mastitis.
- Granulomatous mastitis is a specific productive inflammation, including idiopathic granulomatous mastitis.
- Periductal mastitis is an inflammation typically characterized by duct dilation greater than 3 mm.
- Tuberculous mastitis is a form in which regional lymph nodes are evaluated and biopsy navigation is used.
What types of biopsy are used to verify radial scars and breast microcalcifications?
Percutaneous and surgical biopsy methods are used to verify radial scars and microcalcifications.
- Excision or extended biopsy is recommended for radial scars (radial scars), which are indistinguishable from malignant lesions on images.
- Percutaneous biopsy is necessary for the differential diagnosis of microcalcifications (microcalcifications).
- Stereotactic biopsy (stereotactic biopsy) is indicated when clusters of indeterminate microcalcifications are detected.
- Vacuum-assisted breast biopsy (VAB) makes it possible to obtain multiple samples and completely remove the pathological lesion with microcalcifications.
Class and exam questions
Why is increased oncological vigilance needed for non-lactational inflammation?
Non-lactational mastitis is less common and on ultrasound/mammography can completely visually mimic a malignant tumor, necessitating the exclusion of cancer.
How to distinguish a surgical scar from cancer recurrence?
The scar itself may look like a spiculated mass with fat necrosis calcifications. However, an ultrasound-guided biopsy is often required for precise differentiation of spiculated structures in or near the surgical zone.
When do benign microcalcifications require a biopsy?
A biopsy is necessary if the presentation does not have 100% classic features (e.g., the "teacup" sign is not obvious), the calcifications in a fibroadenoma are small and punctate, or if the lesion is unilateral or focal in duct ectasia.
What else to study on this topic
- Radiological signs of ductal carcinoma in situ (DCIS)
- Histological picture of fibroadenomatoid hyperplasia
- Techniques for ultrasound-guided breast biopsy
- Differential diagnosis of radial scar and invasive cancer
- Granulomatous mastitis: clinical presentation and diagnosis
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