contents TIB Abstract Fibrous mastopathy is a condition seen mainly in premenopausal, insulin-depen- dent diabetics. The condition simulates breast cancer and is often poorly recog- nised. One of the main reasons for report- ing this well-described entity is to make radiologists and surgeons more aware of this condition, thereby reducing unneces- sary morbidity by establishing a correct diagnosis more efficiently, and differentiat- ing it from breast carcinoma. Case report Case 1 A premenopausal 49-year-old woman with no risks for breast cancer, no history of trauma, and with a history of previous biopsies of both breasts presented with a 6- month history of a lump in the left breast. The patient had been diabetic for more than 25 years, on insulin and oral hypogly- caemic agents (OHAs). There was a histo- ry of poor glycaemic control, with end- organ involvement, and renal impairment. Clinically rock-hard solid lesions were palpated in the lateral aspect of the left breast. The mammogram showed an increased ill-defined density in the left upper outer quadrant (Figs 1a,b). No focal lesion was identified at ultrasound. Fine needle aspi- ration cytology (FNAC), core needle biopsy (CNB), could not be undertaken because the tissue was too fibrotic to biopsy. The incision biopsy revealed diabetic mastopa- thy. Case 2 A 53-year-old nulliparous patient with no history of trauma who had been post- menopausal for 4 years presented with a history of a lump in the right breast for a period of 8 months. 26 SA JOURNAL OF RADIOLOGY • October 2005 CASE REPORT Diabetic mastopathy – clinical and mammographic findings I J Movson MB ChB, DMRD (UK) Department of Radiology Addington Hospital, Durban I Buccimazza MB ChB, FCS (SA) Department General Surgery Addington Hospital, Durban Fig.1a,b. Mediolateral and craniocaudal mammograms of case 1 demonstrate nonspecific increased density in the upper outer quadrant of the left breast. pg26-28 TIB 10/8/05 11:56 AM Page 26 The patient had been diabetic for more than 10 years on OHA and insulin. Clinically both breasts had a very dense fibroglandular pattern, making it difficult to identify the palpable lesion on the mam- mogram, although the right breast was denser than the left (Figs 2a,b). The patient had also had a breast abscess drained on the left side 4 years previously. The ultrasound examination revealed 2 poorly defined hypo-echoic masses 4.3 cm x 3.2 cm and 3 x 3 cm on the right side and similar masses at 5 o'clock and 12 o'clock on the left side (Fig. 2c). The incision biop- sy of both breasts revealed diabetic mastopathy. Case 3 A 60-year-old nulliparous, post- menopausal woman with no previous his- tory of breast problems presented with a lump in the right breast. The patient was also being treated with insulin and OHA. Clinically a 5 x 6 cm diameter lump was palpated at 12 o'clock on the right side, and a 2.7 cm x 2.7 cm diameter lump was pal- pated in the left upper outer quadrant. The mammogram demonstrated areas of increased density in both breasts requir- ing biopsy to exclude malignancy. The ultrasound examination revealed ill-defined lesions in both breasts with irregular margins and posterior acoustic shadowing suggesting non-benign lesions (Fig. 3). A Sestamibi scan was undertaken and there were no focal areas of increased uptake bilaterally. FNAC revealed fat necrosis on both sides. CNB revealed fat necrosis on the right side and hyalinised fibro-fatty connective tissue with no evi- dence of malignancy. Incision biopsies of both breasts revealed fat necrosis and extensive hyalinised fibrosis. Discussion According to the breast pathology text- book by Paul Peter Rosen1 most of all reported examples, with two exceptions of diabetic mastopathy, have been in females, and most patients were younger that 30 years of age. All the cases were type I insulin-dependent diabetics.1 Our 3 patients were aged 49, 53 and 60 years. There is no evidence to suggest that this condition predisposes to the development of breast cancer. Most patients with diabet- ic mastopathy also have complications such as retinopathy, neuropathy and nephropathy.2-4 According to Camuto et al. 5 approxi- mately 60% of diabetic mastopathy tends to be bilateral or to recur after surgical exci- sion. According to them recurrence tends to be in the same location and involves more breast tissue than the preceding lesion. They suggest that surgical biopsy should not be considered. CNB under ultrasound guidance avoids unnecessary surgical procedures. CASE REPORT 27 SA JOURNAL OF RADIOLOGY • October 2005 Fig. 2a,b. Craniocaudal and mediolateral mammograms of case 2 demonstrate diffusely dense breasts. The left marker outlines the scar from the abscess drainage site. pg26-28 TIB 10/8/05 11:58 AM Page 27 Summary of main points in relation to this relatively rare entity 1. This condition is seen mainly in pre- menopausal longstanding insulin-depen- dent female diabetics. 2. The condition presents as hard masses in one or both breasts simulating carcinoma of the breast. 3. The mammogram demonstrates areas of ill-defined increased density, diffi- cult to differentiate from carcinoma. 4. Sonography demonstrates a hypo- echoic solid mass with poor margins and well-marked acoustic shadowing. 5. MRI was seldom used in most reported cases of diabetic mastopathy. Wong and associates6 reported early and strong enhancement of contrast medium at the area of the palpable mass in a few cases when MRI was used. Yet others reported poor enhancement in the early phase. MR spectroscopy has been used to confirm benignity of lesions in recent cases reports.7 6. FNA is usually unsuccessful in diag- nosing the condition as resistance of the mass to the needle motion is very high. CNB can be useful in the diagnosis of recurrent lesions on follow-up, but the hard tissue often makes this procedure unsuccessful. A definite diagnosis was achieved in most cases by open surgical biopsy. The authors thank Cornelia Harmse for typing and setting out this manuscript. References 1. Rosen PP. Textbook of Breast Pathology. Lippincott, 1999: 347. 2. Soler NG, Khardori R. Fibrous disease of the breast, thyroiditis, and cheiroarthropathy in type I diabetes mellitus. Lancet 1984; 1: 193-195. 3. Ely KA, Tse G, Simpson JF, Clarefeld R, Page DL. Diabetic mastopathy, a clinicopathologic review. Am J Clin Pathol 2000; 113: 541-545. 4. Morgan MC, Weaver MG, Crowe JP, Abdul-Karim FW. Diabetic mastopathy; a clinicopathologic study in palpable and nonpalpable breast lesions. Mod Pathol 1995; 8: 349-354. 5. Camuto PM, Zetrenne B, Ponn T. Diabetic mastopathy; a report of 5 cases and a review of the literature. Arch Surg 2000; 135: 1190-1193. 6. Wong KT, Tse, G MK, Yang WT. Ultrasound and MR imaging of diabetic mastopathy. Clin Radiol, 2002; 57: 730-735. 7. Balan P, Turnbull LW. Dynamic contrast enhanced magnetic resonance imaging and magnetic reso- nance spectroscopy in diabetic mastopathy. Beast 2005; 14: 68-70. CASE REPORT 28 SA JOURNAL OF RADIOLOGY • October 2005 Fig. 2c. Ultrasound of the left breast demonstrates a 3 cm diameter hyperechoic mass (arrow) that was confirmed to be fibrous matopathy on biopsy. Fig. 3. Ultrasound of the left breast demonstrates an ill-defined irregular hyperechoic lesion suggesting malignancy (arrow). pg26-28 TIB 10/8/05 12:02 PM Page 28