ClinicalRadiology (1991)
44, 123 124
Case Report: Primary Systemic Amyloidosis Presenting as Breast Masses, Mammographically Simulating Carcinoma A. H. HECHT, A. TAN and J. F. SHEN
Department of Radiology, UHS/The Chicago Medical School, Mount Sinai Hospital Medical Center, Chicago, USA A case of primary systemic amyloidosis presenting as bilateral breast masses is described. The mammographic appearance was of multiple ill-defined masses associated with clustered microcalcifications simulating carcinoma. This is the first case of amyloid of breast reported in the radiological literature. Other available literature of breast involvement in systemic amyloidosis is reviewed. Hecht, A.H., Tan, A. & Shen, J.F. (1991). Clinical Radiology 44,
123-124. Case Report: Primary Systemic Amyloidosis Presenting as Breast Masses, Mammographically Simulating Carcinoma
To our knowledge, amyloid of breast has never been reported in the radiological literature, although there have been sporadic case reports elsewhere. N o preoperative diagnosis has ever been reported. Recently we encountered a case of primary systemic amyloidosis where the presenting feature was of breast masses with microcalcifications simulating carcinoma.
CASE R E P O R T A 68-year-old black nulliparous w o m a n presented with bilateral breast masses, which had gradually increased in size for more than a year. Past medical history was unremarkable except for hypertension. Physical examination revealed a partially mobile, non-tender mass of 6 x 5 cm in the right breast and 7 x 5 cm in the left breast. The rest o f the physical examination was non-contributory. M a m m o g r a p h y demonstrated bilateral multiple ill-defined densities of 1-4 cm in size with clusters of microcalcifications mixed with slightly coarser calcifications (Figs la, b). Multiple biopsies of the masses and calcifications were performed following m a m m o g r a p h i c needle localization, and histological examination showed chronic inflammatory cell infiltration and fibrosis with calcifications (Figs 2a, b). There was no evidence of malignancy but Congo red stains demonstrated amyloid which was deposited mainly in the periductal, perivascular and adipose tissue (Figs 2a, b). The patient was well until 1 year later, when she was readmitted for renal failure and ureteral obstruction. She also complained of dysphagia and dyspnoea. A chest radiograph revealed bilateral pleural effusions and a paratracheal mass which was due to a thyroid mass. Percutaneous biopsies revealed amyloid deposition in the thyroid, kidney, retroperitoneum, oesophagus and pleura. The patient subsequently developed bilateral retrobulbar orbital masses which were demonstrated on CT, and presumed due to tumoral amyloidosis, although no biopsy was done. Pertinent laboratory studies included serum protein a n d i m m u n o globulin electrophoresis, which demonstrated polyclonal i m m u n o globulins and K a p p a light chain in the serum and urine. There was no evidence of multiple myeloma, rheumatoid arthritis or other conditions known to be associated with amyloidosis.
Correspondence to: Dr Alan H. Hecht, Chairman, Department of Radiology, U H S / T h e Chicago Medical School, M o u n t Sinai Hospital Medical Center, 15th Street and California Avenue, Chicago, Illinois 60608, USA.
(a)
(b) Fig. 1 - (a) Craniocaudal view o f left breast shows ill-defined masses with micro- and macrocalcifications suggestive of carcinoma. (b) Obliquelateral view of right breast shows similar findings.
124
CLINICALRADIOLOGY DISCUSSION
(a)
The histology and current classification of amyloidosis have been described (Scott et aL, 1986). The association of amyloid with multiple myeloma, rheumatoid arthritis, chronic inflammatory disease and malignancy is well known. Amyloidosis of the breast is uncommon. A review of the literature reveals less than 20 reported cases, including both systemic and the more rare localized form. Breast involvement may be unilateral or bilateral with the deposits of amyloid diffuse or focal. Our patient represents a case of the primary systemic type of amyloidosis with K a p p a light chain polyclonal g a m m o p a t h y presenting as bilateral breast masses. To our knowledge the m a m m o g r a p h i c findings of only eight cases of amyloidosis have been reported, none of which was published in the radiology literature. Two reports described focal nodules with calcifications which were suggestive of carcinomas (Fernandez and Hernandez, 1973; Silverman et al., 1986). In one case the finding of diffuse increased breast density associated with skin thickening was interpreted as an inflammatory carcinoma (O'Connor et al., 1984). In the other five cases reported the m a m m o g r a p h i c findings simulated benign breast disease (Sadeghee and Moore, 1974; H a r d y et al., 1979; O ' C o n n o r et aL, 1984; Silverman et al., 1986). As in our case, in none of these eight cases was amyloid diagnosed pre-operativety. In our patient some coarse calcifications suggested benign disease, but the clustered microcalcifications associated with masses were highly suspicious of carcinoma and hence prompted biopsy. REFERENCES Fernandez, BB & Hernandez, FJ (1973). Amyloid tumor of the breast. Archives of Pathology, 95, 102-105. Hardy, TJ, Myerowitz, RL & Bender, BL (1979). Diffuse parenchymal amyloidosis of lungs and breast. Archives of Pathology and Laboratory Medicine, 103, 583-585. O'Connor, CR, Rubinow, A & Cohen, AS (1984). Breast disease in primary amyloidosis. American Journal of Medicine, 77, 980-986. Sadeghee, SA & Moore, SW (1974). Rheumatoid arthritis, bilateral amyloid tumors of the breast and multiple cutaneous amyloid nodules. American Journal of Clinical Pathology, 62, 472-476. Scott, PP, Scott, WW & Siegelmann, SS (1986). Amyloidosis: an overview. Seminars in Roentgenology, 2, 103 112. Silverman, JF, Dabbs, DJ & Norris, HT (1986). Localized primary amytoid tumor of the breast. American Journal of Surgical Pathology, 8, 539-545.
(b) Fig. 2 - (a) Low power view of breast biopsy specimen demonstrates chronic inflammatory changes. Eosinophilic material is deposited in perivascular area (large arrow), and scattered calcifications (small arrows) are seen. (b) Low power view of another biopsy specimen shows similar findings with deposition of eosinophilic material in adipose tissue and periductal area.
44, 123 124
Case Report: Primary Systemic Amyloidosis Presenting as Breast Masses, Mammographically Simulating Carcinoma A. H. HECHT, A. TAN and J. F. SHEN
Department of Radiology, UHS/The Chicago Medical School, Mount Sinai Hospital Medical Center, Chicago, USA A case of primary systemic amyloidosis presenting as bilateral breast masses is described. The mammographic appearance was of multiple ill-defined masses associated with clustered microcalcifications simulating carcinoma. This is the first case of amyloid of breast reported in the radiological literature. Other available literature of breast involvement in systemic amyloidosis is reviewed. Hecht, A.H., Tan, A. & Shen, J.F. (1991). Clinical Radiology 44,
123-124. Case Report: Primary Systemic Amyloidosis Presenting as Breast Masses, Mammographically Simulating Carcinoma
To our knowledge, amyloid of breast has never been reported in the radiological literature, although there have been sporadic case reports elsewhere. N o preoperative diagnosis has ever been reported. Recently we encountered a case of primary systemic amyloidosis where the presenting feature was of breast masses with microcalcifications simulating carcinoma.
CASE R E P O R T A 68-year-old black nulliparous w o m a n presented with bilateral breast masses, which had gradually increased in size for more than a year. Past medical history was unremarkable except for hypertension. Physical examination revealed a partially mobile, non-tender mass of 6 x 5 cm in the right breast and 7 x 5 cm in the left breast. The rest o f the physical examination was non-contributory. M a m m o g r a p h y demonstrated bilateral multiple ill-defined densities of 1-4 cm in size with clusters of microcalcifications mixed with slightly coarser calcifications (Figs la, b). Multiple biopsies of the masses and calcifications were performed following m a m m o g r a p h i c needle localization, and histological examination showed chronic inflammatory cell infiltration and fibrosis with calcifications (Figs 2a, b). There was no evidence of malignancy but Congo red stains demonstrated amyloid which was deposited mainly in the periductal, perivascular and adipose tissue (Figs 2a, b). The patient was well until 1 year later, when she was readmitted for renal failure and ureteral obstruction. She also complained of dysphagia and dyspnoea. A chest radiograph revealed bilateral pleural effusions and a paratracheal mass which was due to a thyroid mass. Percutaneous biopsies revealed amyloid deposition in the thyroid, kidney, retroperitoneum, oesophagus and pleura. The patient subsequently developed bilateral retrobulbar orbital masses which were demonstrated on CT, and presumed due to tumoral amyloidosis, although no biopsy was done. Pertinent laboratory studies included serum protein a n d i m m u n o globulin electrophoresis, which demonstrated polyclonal i m m u n o globulins and K a p p a light chain in the serum and urine. There was no evidence of multiple myeloma, rheumatoid arthritis or other conditions known to be associated with amyloidosis.
Correspondence to: Dr Alan H. Hecht, Chairman, Department of Radiology, U H S / T h e Chicago Medical School, M o u n t Sinai Hospital Medical Center, 15th Street and California Avenue, Chicago, Illinois 60608, USA.
(a)
(b) Fig. 1 - (a) Craniocaudal view o f left breast shows ill-defined masses with micro- and macrocalcifications suggestive of carcinoma. (b) Obliquelateral view of right breast shows similar findings.
124
CLINICALRADIOLOGY DISCUSSION
(a)
The histology and current classification of amyloidosis have been described (Scott et aL, 1986). The association of amyloid with multiple myeloma, rheumatoid arthritis, chronic inflammatory disease and malignancy is well known. Amyloidosis of the breast is uncommon. A review of the literature reveals less than 20 reported cases, including both systemic and the more rare localized form. Breast involvement may be unilateral or bilateral with the deposits of amyloid diffuse or focal. Our patient represents a case of the primary systemic type of amyloidosis with K a p p a light chain polyclonal g a m m o p a t h y presenting as bilateral breast masses. To our knowledge the m a m m o g r a p h i c findings of only eight cases of amyloidosis have been reported, none of which was published in the radiology literature. Two reports described focal nodules with calcifications which were suggestive of carcinomas (Fernandez and Hernandez, 1973; Silverman et al., 1986). In one case the finding of diffuse increased breast density associated with skin thickening was interpreted as an inflammatory carcinoma (O'Connor et al., 1984). In the other five cases reported the m a m m o g r a p h i c findings simulated benign breast disease (Sadeghee and Moore, 1974; H a r d y et al., 1979; O ' C o n n o r et aL, 1984; Silverman et al., 1986). As in our case, in none of these eight cases was amyloid diagnosed pre-operativety. In our patient some coarse calcifications suggested benign disease, but the clustered microcalcifications associated with masses were highly suspicious of carcinoma and hence prompted biopsy. REFERENCES Fernandez, BB & Hernandez, FJ (1973). Amyloid tumor of the breast. Archives of Pathology, 95, 102-105. Hardy, TJ, Myerowitz, RL & Bender, BL (1979). Diffuse parenchymal amyloidosis of lungs and breast. Archives of Pathology and Laboratory Medicine, 103, 583-585. O'Connor, CR, Rubinow, A & Cohen, AS (1984). Breast disease in primary amyloidosis. American Journal of Medicine, 77, 980-986. Sadeghee, SA & Moore, SW (1974). Rheumatoid arthritis, bilateral amyloid tumors of the breast and multiple cutaneous amyloid nodules. American Journal of Clinical Pathology, 62, 472-476. Scott, PP, Scott, WW & Siegelmann, SS (1986). Amyloidosis: an overview. Seminars in Roentgenology, 2, 103 112. Silverman, JF, Dabbs, DJ & Norris, HT (1986). Localized primary amytoid tumor of the breast. American Journal of Surgical Pathology, 8, 539-545.
(b) Fig. 2 - (a) Low power view of breast biopsy specimen demonstrates chronic inflammatory changes. Eosinophilic material is deposited in perivascular area (large arrow), and scattered calcifications (small arrows) are seen. (b) Low power view of another biopsy specimen shows similar findings with deposition of eosinophilic material in adipose tissue and periductal area.
