|Year : 2014 | Volume
| Issue : 1 | Page : 82-84
Scrofulous swelling of the bosom masquerading as cancer
VR Challa, A Srivastava, A Dhar
Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
|Date of Submission||25-Jul-2013|
|Date of Acceptance||27-Sep-2013|
|Date of Web Publication||4-Jan-2014|
Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi
Source of Support: None, Conflict of Interest: None
Tuberculosis of breast is very rare with an incidence of 0.1-0.5%. It can be primary or secondary. Except in patients presenting with sinuses, it is a challenge to diagnose it. A 40 year old premenopausal lady presented with breast lump increasing in size for 3 months. Mammogram showed a lesion suspicious of malignancy and trucut biopsy showed necrotic material only. Intraoperatively there was caseous necrosis and the tract from breast was extending to rib. It is a rare case with few case reports been reported where a rib tuberculosis presents as a breast lump rather than retromammary abscess.
Keywords: Breast tuberculosis, breast cancer, tuberculosis of rib
|How to cite this article:|
Challa V R, Srivastava A, Dhar A. Scrofulous swelling of the bosom masquerading as cancer. Indian J Med Microbiol 2014;32:82-4
|How to cite this URL:|
Challa V R, Srivastava A, Dhar A. Scrofulous swelling of the bosom masquerading as cancer. Indian J Med Microbiol [serial online] 2014 [cited 2019 Aug 20];32:82-4. Available from: http://www.ijmm.org/text.asp?2014/32/1/82/124331
| ~ Introduction|| |
Musculoskeletal tuberculosis constitutes 15% of extrapulmonary tuberculosis of which thoracic wall tuberculosis accounts for 1-5% of cases.  As cancer is a more common cause of breast lump, tuberculosis is not thought of initially in a case who presents with a breast lump. However, unlike malignancy, tuberculosis is a potentially curable disease and hence it is important to diagnose and manage accordingly. Because of the rarity of rib tuberculosis presenting as a breast lump, we would like to present this case. There are only a few cases reported in the literature with rib tuberculosis presenting as a breast lump. 
| ~ Case Report|| |
A 40-year, premenopausal lady presented with painless enlarging lump in left breast for 3 months, with no nipple discharge and no retraction. There was no family history of breast or ovarian cancer. Patient's body weight and appetite were constant and there was no personal history of tuberculosis or exposure to a person with tuberculosis. Physical examination revealed a firm, nontender lump in left breast measuring 5 × 5 cm size in the lower inner quadrant, with restricted mobility. The skin over the swelling was normal. Nipple, areola, mammary ducts and the contralateral breast were normal. There were no enlarged axillary and supraclavicular lymph nodes.
With a clinical diagnosis of breast cancer, patient underwent sonomammogram [Figure 1]a. There was a heterogeneous mass located in left breast in the lower inner quadrant with fine calcifications. The lesion measured 4.5 × 4 cms in diameter close to Pectoralis major muscle with few enlarged axillary lymph nodes. Chest X-ray was normal. A large core (trucut) biopsy was performed twice which showed only necrotic material and no opinion was possible. Hence the patient was planned for "excisional biopsy and proceed" further after frozen section.
|Figure 1: (a) Mammogram of left breast showing 4.5 × 4 cms dense lesion in left breast at 6'o clock position close to pectoralis major muscle (arrow) and few enlarged axillary nodes (arrow head). (b) Intraoperative picture showing curretted 4th rib after excision of the lesion. (c) Haemotoxylin and eosin staining Langerhan giant cells and epithelioid granulomas|
Click here to view
Peroperatively, firm mass was felt with a tract through Pectoralis major extending to 4 th rib. Twenty milliliters of caseous material was drained and the rib was curetted [Figure 1]b. Frozen section examination of tissue revealed granulomas with acid-fast bacilli within it. After excision of the lesion breast tissue was reconstructed by superior dermoglandular flap oncoplasty technique. Final histopathology confirmed the diagnosis of rib tuberculosis extending to breast tissue [Figure 1]c. Patient was started on Antituberculous therapy as per Revised National Antituberculous Control Programme (RNTCP) guidelines under category I. Patient had completed the treatment and she is free of disease with good cosmesis.
| ~ Discussion|| |
Tuberculosis of breast was first described by Astley Cooper in 1829 as 'scrofulous swelling of the bosom'.  It is very rare with an incidence varying from 0.1% in developed countries to 0.3-0.5% in developing countries where it is endemic.  It can be primary or secondary in the breast. The incidence is low because of resistance offered by breast tissue to the growth of bacilli.  There is an increase in incidence of extrapulmonary tuberculosis in immunocompromised patients. Primary breast tuberculosis is diagnosed when there is no source of infection elsewhere in the body and the mode of spread to breast is by haematogenous or direct inoculation through the ducts. Secondary breast tuberculosis occurs due to retrograde spread from axillary/cervical or intercostal lymph nodes, ruptured intramammary lymph nodes, ruptured rib/pleural and parenchymal tuberculosis involving breast tissue directly.  Most commonly secondary tuberculosis due to underlying condition presents as retromammary abscess and sometimes they may present as breast lump. The present case had no history of tuberculosis or disease elsewhere at the time of presentation.
Breast tuberculosis can be categorized into three types based on radiological and clinical presentation as nodular, diffuse and sclerosing variants.  Diffuse type is also called "disseminated tubercular mastitis" and can present with multiple pus discharging sinuses. Nodular form presents as a well circumscribed dense lesion which cannot be differentiated with malignancy. The tubercular lesion usually does not have microcalcification. In this case, mammogram showed a nodular type of lesion with microcalcifications which is a very rare finding. Sclerosing variant is usually seen in elderly females and occurs due to excessive desmoplastic reaction and is difficult to differentiate from malignancy.
Ultrasonography can show hypoechoic or heterogenous lesion with internal echoes and irregular borders or thick cystic wall. FNAC and biopsy were used for diagnosis but the success rate to detect AFB in smear or tubercle bacilli in culture is only about 25%.  Recently presence of epitheloid granulomas and necrosis has been considered as diagnostic criteria and has helped to diagnose breast tuberculosis in 73% of cases accurately.  In absence of caseation necrosis in FNAC we need further investigations like nucleic acid amplification tests like polymerase chain reaction if culture is not diagnostic.  An algorithm for work-up for suspected breast tuberculosis is described in [Figure 2].
|Figure 2: A proposed algorithm to work up a case of suspected breast tuberculosis|
Click here to view
Excisional biopsy of the lump is required in most cases. Excision proves to be both diagnostic as well therapeutic in controlling abscess and sinus tracts. Before development of ATT, mastectomy was recommended for breast tuberculosis because of risk of recurrence.  Nowadays mastectomy is very rarely performed, except in presence of painful and ulcerated infection.
| ~ Conclusions|| |
of breast is a diagnostic challenge especially if it presents with lump, no sinuses or constitutional symptoms. Most of the patients need excision for diagnosis and antituberculous treatment. In experienced hands, a good cosmetic result can be obtained by oncoplastic technique.
| ~ References|| |
|1.||Mathlouthi A, Ben M'Rad S, Merai S, Friaa T, Mestiri I, Ben Miled K, et al. Tuberculosis of the thoracic wall. Presentation of 4 personal cases and review of the literature. Rev Pneumol Clin 1998;54:182-6. |
|2.||Jain S, Shrivastava A, Chandra D. Breast lump, a rare presentation of costochondral junction tuberculosis: A case report. Cases J 2009;2:7039. |
|3.||Cooper A. Illustrations of the Diseases of the Breast, Part 1. London: Brown and Green; 1829. p. 73. |
|4.||Sriram K, Moffatt D, Stapledon R. Tuberculosis infection of the breast mistaken for granulomatous mastitis: A case report. Cases J 2008;1:273. |
|5.||Mukerjee P, George M, Maheshwari HB, Rao CP. Tuberculosis of the breast. J Indian Med Assoc 1974;62:410-2. |
|6.||Mallika T, Shukla HS. Breast tuberculosis: Diagnosis, clinical features and management. Indian J Med Res 2005;122:103-10. |
|7.||Kervancioðlu S, Kervancioðlu R, Ozkur A, Sirikçi A. Primary tuberculosis of the breast. Diagn Interv Radiol 2005;11:210-2. |
|8.||Kakkar S, Kapila K, Singh MK, Verma K. Tuberculosis of the breast: A cytomorphologic study. Acta Cytol 2000;44:292-6. |
|9.||Luh SP, Hsu JD, Lai YS, Chen SW. Primary tuberculous infection of breast: Experiences of surgical resection for aged patients and review of literature. J Zhejiang Univ Sci B 2007;8:580-3. |
|10.||Wilson TS, Macgregor JW. The diagnosis and treatment of tuberculosis of the breast. Can Med Assoc J 1963;89:1118-24. |
[Figure 1], [Figure 2]