Radiol Oncol 2003; 37(1): 1-3.
Primary breast tuberculosis. A case report
Dimitrios C. Filippou, Spiros Rizos, Athanasios Nissiotis
Department of Surgical Oncology, Kiffisias Anticancer Hospital »Agii Anargiri«, Athens, Greece
Background. The differential diagnosis of primary breast tuberculosis with other benign or malignant con-ditions can be difficult with the current imaging techniques that used to recognize breast pathologies. In many cases mammographic and ultrasound characteristics of breast tuberculosis are similar to those of breast cancer.
Case report. We present a case of primary breast tuberculosis, with no previous history of the disease, which was diagnosed during the operation.
Conclusions. Primary breast tuberculosis can be misdiagnosed. In these cases a tuberculosis infection his-tory is negative, the mammographic and radiological findings obscure and the mass can be misdiagnosed as carcinoma. The diagnosis is achieved after the surgical removal of the mass and histological examination of the specimen.
Key words: breast diseases; tuberculosis; female genital
Introduction
Breast tuberculosis is a rare pathology, with a very low incidence ranging from 0.1-0.5%. Breast, spleen and skeletal muscles seem to be relatively immune to tuberculous infec-tion. In non-endemic countries breast tuber-culosis is 3-4.5% of all breast pathologies. In non-endemic countries breast tuberculosis is rare, and usually is secondary through haematogenous spreading from other infect-ed organ.1-3
Primary breast tuberculosis in non-endem-Received 3 December 2002 Accepted 9 January 2003
Correspondence to: Dimitrios C. Filippou, M.D., 17is Noembriou 20 str., GR-11562 Holargos, Athens, Greece; Phone: +30.944.287125, +30.10.6563789; Fax: +30.10.2220892; E-mail: d_filippou@hotmail.com
ic countries is so rare that only a few cases had been reported till now. The clinical and radiological (mammographic, ultrasound) characteristics of breast tuberculosis are sim-ilar to those of other breast pathologies; in young masquerades as abscess and in elderly ones as cancer. So, if there is no history known, then, the diagnosis is very difficult to
be established.4-6
Case report
A 65-year-old woman admitted to our surgical department complaining of a mass in the up-per quadrant of the right breast. The patient discovered the palpable mass 12 days ago. The patient’s and family history were clear, except of a mild hypertension pharmaceuti-cally treated. The findings at physical exami-
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Filippou DC et al. / Primary breast tuberculosis
nation were a non-tender, palpable, mobile mass extending from the skin to the chest wall. No skin or nipple alterations observed. Auxiliary lymph nodes were present consist-ing block. The examination of the other breast showed no findings. We performed mammography (craniocaudal and lateral view), which showed a mass in the upper quadrant of the right breast, with mild skin retraction, with malignant characteristics (Figure 1). Breast ultrasound showed a well-defined nodular lesion with heterogeneous echo pattern posterior to acoustic enhancement. The lesion considered being malignant, and no fine needle aspiration cytology re-ceived. The resection of the tumour and aux-iliary lymph nodes dissection decided to be performed therapeutically.
At operation tumour was excised in healthy tissue and sent to cryobiopsy, which showed no malignant cell, but tyroid necrosis
Figure 1. Mammography of primary breast tuberculo-sis mimics breast cancer. The findings were obscure and the diagnosis set by cold biopsy.
of the tissue, compatible with the inflamma-tory disease. No lymph nodes were removed. The pathological examination of the speci-men showed that the mass was tuberculous. Mantoux test was positive. The full examina-tion (x-ray, CT, etc) showed that tuberculosis was nowhere else; that means that breast tu-berculosis was primary. The patient received anti-tuberculosis therapy (3 drugs combined therapy) for 9 months. There has not been re-currence for 4 years of the follow-up.
Discussion
Breast tuberculosis identified as primary and secondary. In the primary, breast is the only site of the disease in patients with no history of tuberculosis. In the secondary, mainly haematogenous spreading or direct extension infects breast after a contact with an infected material. The mycobacterium can infect breast haematogenous from auxilla, lungs, ribs and articular lesions, or can be infected by a direct contact through nipple, abrasions of the skin or lactiferous duct.1,4,5,7
Three types of breast tuberculosis have been described. The most common type is nodular disease, which is growing slowly and masquerades carcinoma on mammography. The second type, which also mimics carcino-ma, is the diffuse type, which presents multiple foci. The third type is the sclerosing, which is painful and more common in the
elderly.3,4,8,9
The differential diagnosis is quite difficult, and includes cancer, mastitis, sarcoma, actin-omycosis, granulomatous mastitis, etc., al-though it’s not uncommon that more than one pathologies in the same breast coexist.9,10
The most common symptoms are a palpa-ble breast with or with no auxiliary lymph nodes, usually painful with sometimes nipple
discharge.5,7
Mammographic findings are not always specific for breast tuberculosis, which can be
Radiol Oncol 2003; 37(1): 1-3.
Filippou DC et al. / Primary breast tuberculosis
3
misdiagnosed as fibroadenoma or adenocar-cinoma (inflammatory or scirrous). The two mammographic findings that are specific for breast tuberculosis are »skin bulge« and the »sinus tract site«. Ultrasonography may re-semble cystic lesion, or indicates a hypoe-choic heterogeneous mass with irregular borders. CT is useful in the diagnosis, particular-ly between primary and secondary tuberculo-sis as can indicate lesions in other sites.4,6,8-10
More accurate information can be achieved by fine needle aspiration biopsy, which can demonstrate a granulomatous in-flammatory lesion with central cessation.7
Many cases can be misdiagnosed and the diagnosis achieved after the surgical removal of the mass and histological examination of the specimen. In these cases a tuberculosis infection history is negative, the mammo-graphic and radiological findings obscure and the mass misdiagnosed as carcinoma.3,7,9
In primary breast tuberculosis the indicat-ed treatment consists of the surgical removal of the mass and the anti-tuberculosis therapy with isoniazide, pyrazimanide, ethamboutole and rifampikin for the period from 9 months
to 2 years.2,10
The increasing tuberculosis incidence in Western countries may also increase the inci-dence of breast tuberculosis.
In conclusion, primary breast tuberculosis is an uncommon breast pathology, which can mimic adenoma or carcinoma and can be mis-diagnosed especially in patients with no pre-vious history of the disease. The fine needle aspiration biopsy can lead to a correct diag-nosis, which is finally achieved with the his-tological examination of the specimen. Patients with breast tuberculosis should un-dergo a surgical removal of the tumour and a long time anti-tuberculosis therapy.
References
1.   Gupta R, Gupta AS, Duggal N. Tubercular mastitis, Int Surg 1982; 67: 422-4.
2.   Zandrino F, Monetti F, Gandolo N. Primary tuber-culosis of the breast. A case report. Acta Radiol 2000; 41: 61-3.
3.   D’Orsi CJ, Feldhaus L, Sonnenfeld M. Unusual lesions of the breast. Radiol Clin North Am 1983; 21: 67-80.
4.   McKeown KC, Wilkinson KA. Tuberculosis of the breast. J Surg 1962; 103: 424-7.
5.   Raven RW. Tuberculosis of the breast. Br Med J 1949; 2: 734-7.
6.   Gilbert AI, McCough EC, Farell JJ. Tuberculosis of the breast. Am J Surg 1962; 103: 424-7.
7.   Wilson TS, MacGregor JW. The diagnosis and treatment of tuberculosis of the breast. Can Med Assoc J 1963; 89: 1118-24.
8.   Estrin J, Bernstein M. Tuberculous mastitis. South Med J 1994; 87: 1151-2.
9.   Alagaratnam TT, Ong GB. Tubereculosis of the breast. Br J Surg 1980; 67: 125-6.
10. Wilson JP, Chapman SW. Tuberculous mastitis. Chest 1990; 98: 1505-9.
Radiol Oncol 2003; 37(1): 1-3.