ARTICLE COVER SHEET
LWW—CONDENSED
FLA
Article : rct20513
Creator : scruz
Date : Friday July 20th 2007
Time : 09:57:03
Article Title :
Number of Pages (including this page) : 5
Template Version : 2.1
05/01/07
Notes:
02/01/06 - Modified template base from feedback I got (WTD)
05/10/06 - Extraction Script = "sc_Extract_Xml"
06/09/06 - Erratum Script = "sc_Load_Erratum"
06/29/06 - Announcement Script = "sc_LoadAnn"
03/01/07 - Multi-part Figure Marker Script = "sc_Multifig_Marker"
03/30/07 - Autopagination compliant
Copyright @ 2007 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
CASE REPORT
AQ1
Proton Magnetic Resonance Spectroscopy of Tubercular
Breast Abscess: Report of a Case
AQ2
Chandan Jyoti Das, MD, DNB,* and Kunjahari MedhiÞ
Abstract: In vivo proton magnetic resonance spectroscopy
(H-MRS) is a functional imaging modality. When magnetic resonance
imaging is coupled with H-MRS, it results in accurate metabolic
characterization of various lesions. Proton magnetic resonance
spectroscopy has an established role in evaluating malignant breast
lesions, and the increasing number of published literature supports the
role of H-MRS in patients with breast cancer. However, H-MRS can be
of help in evaluating benign breast disease. We present a case of
tubercular breast abscess, initial diagnosis of which was suggested
based on characteristic lipid pick on H-MRS and was subsequently
confirmed by fine needle aspiration biopsy of the breast lesion.
Key Words: proton magnetic resonance spectroscopy, tuberculosis,
abscess
(J Comput Assist Tomogr 2007;00:00Y00)
M
agnetic resonance imaging (MRI) coupled with in vivo
proton magnetic resonance spectroscopy (H-MRS) has
been useful in the evaluation of breast cancer.1 Proton
magnetic resonance spectroscopy has been demonstrated to
be successful in the differentiation of benign and malignant
breast lesions in a noninvasive manner by detecting increased
levels of composite choline (Cho) compounds.1 It plays an
important role in tumor detection, staging, long-term
prognosis, and demonstration of tumor response to chemotherapy during or after completion of the treatment in
patients with breast cancer.1,2 Proton magnetic resonance
spectroscopy has also been used successfully in the differentiation of cerebral tuberculoma.3Y6 Proton magnetic
resonance spectroscopy can be of help in evaluating benign
breast disease like tuberculosis because they are known to be
very useful in the evaluation of brain tuberculoma. We
describe herein a case of breast tuberculosis that was
suspected based on characteristic H-MRS finding and later
confirmed on histopathology.
CASE REPORT
AQ3
A 37-year-old woman presented with a 3-month history of left
breast lump. She also complained of early satiety and heaviness in
her abdomen for the last 1 month. Her medications included proton
pump inhibitor, antacid, and hematinics. Physical examination
From the *Departments of Radiology and †Medical Oncology, All India
Institute of Medical Sciences, New Delhi, India.
Received for publication May 29, 2007; accepted May 30, 2007.
Reprints: Chandan Jyoti Das, MD, DNB, Department of Radiology , All India
Institute of Medical Sciences, New DelhiY110029, India (e-mail: dascj@
yahoo.com).
Copyright * 2007 by Lippincott Williams & Wilkins
J Comput Assist Tomogr
revealed a 4 5-cm firm and mobile lump in the upper outer
quadrant of the left breast. A solitary left mobile axillary node
measuring 1 2 cm was also found. Her total leukocyte count was
5600/KL (reference range, 7000Y11000/KL), and polymorphs were
63%. Her erythrocyte sedimentation rate was 27 mm/first hour by
Westergren method. Chest and abdominal radiographs were
unremarkable. Ultrasonography of the left breast showed a
hypoechoic mass with an anechoic center in the upper and outer
quadrant. Mammography showed a high density mass without
microcalcification. Fine needle aspiration (FNA) cytology, done
from the breast mass, was inconclusive. Because the index of clinical
suspicion for malignancy was high, contrast-enhanced MRI coupled
with H-MRS was performed for further evaluation of the breast
mass. Magnetic resonance imaging showed a predominantly fluid
intensity mass with hypointense signal contents on T1-weighted
images and hyperintense signal contents with internal areas of
hypointense signal on T2-weighted (T2W) images (Figs. 1A, B).
Postgadolinium images show rim enhancement of the lesion and
nonenhancing center of the lesion (Fig. 1C). Enhancement of an
adjacent lymph node was also seen. We performed in vivo H-MRS
through the margin of the lesion using multivoxel MRS using the
following parameters: repetition time = 2000 milliseconds; time to
echo = 135 milliseconds; NS = 4; NEX = 256; and voxel size = 2 2 2 cm. Before the acquisition, localized shimming at the region of
interest was performed, followed by both water suppression and
simultaneous water and fat suppression. After zero-filling and
baseline correction, peak integrals were calculated by line fitting.
Proton magnetic resonance spectroscopy revealed prominent peak at
0.9 to 1.3 ppm representing lipid-lactate resonance suggestive of
necrotic lesion (Figs. 1D, E). All other metabolites including Cho
were suppressed. Water-suppressed spectra obtained from the lesion
also showed the presence of lipid peak without any choline
resonance. Based on the clinical presentation, contrast-enhanced
MRI features, and the H-MRS findings, a provisional diagnosis of
breast abscess was made possibly of tubercular etiology because
tuberculosis is endemic in this part of the world. The patient
underwent a repeat FNA cytology of the breast lesion. Acid-fast
staining of the left breast biopsy aspirates showed numerous acidfast bacilli. Based on the histopathologic findings and the results of
acid-fast staining, a final diagnosis of tubercular breast abscess was
made. The patient was treated with antitubercular therapy. She is
under follow-up for the last 2 months and has shown significant
clinical improvement.
DISCUSSION
Tuberculosis of the breast is extremely uncommon and
mostly seen in young multiparous lactating women.7
Mycobacterium tuberculosis infections are a serious clinical
problem in India, and its resurgence has been seen in
association with immunosuppression, especially in patients
infected with acquired immunodeficiency syndrome.8,9 The
usual mode of infection is retrograde spread from the
caseating axillary nodes, followed by direct extension from
cold abscess of the chest wall involving the rib.10 Retrograde
& Volume 00, Number 0, Month 2007
Copyright @ 2007 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
1
F1
J Comput Assist Tomogr
Das and Medhi
& Volume 00, Number 0, Month 2007
FIGURE 1. A, T2W axial image showing
hyperintense mass in left breast. B,
Fat-suppressed T2W sagittal image showing fluid
intensity contents with few hypointense areas
within it. C, Postcontrast fat-suppressed T1W
sagittal image showing peripheral enhancement
of the lesion with central necrosis. D and E, Proton
magnetic resonance spectroscopy shows
prominent peaks at 0.9 to 1.3 ppm representing
lipid-lactate resonance. All other peaks including
choline are suppressed.
spread from cervical or internal mammary lymph nodes is
possible. Hematogenous dissemination is seen in patients
with acquired immunodeficiency syndrome in the form of
miliary breast involvement. Direct inoculation via nipple has
also been reported.9,11
Most patients present with a hard painless lump in the
breast with or without ulceration that can masquerade
carcinoma.7,12 Up to 50% of patients have axillary node
enlargement. Premenopausal women are often affected, and
there may be a predilection for women who are lactating.11,13
The radiological manifestations of mammary tuberculosis can
be classified into 3 distinct patterns: nodular, diffuse, and
sclerosing patterns.10 Tuberculosis of the nodular type
manifests as an ill-defined or irregular mass that closely
resembles carcinoma. Findings of a diffuse type simulate
inflammatory carcinoma with skin thickening. The sclerosing
type, which usually affects elderly women, can manifest as
2
dense breast tissue.11,13Y15 The diagnosis of mammary
tuberculosis is often difficult and is usually based on
inflammatory and granulomatous findings at FNA cytological
analysis or biopsy.16 Acid-fast bacteria are not detected in most
cases; in addition, cultures develop slowly and are not always
demonstrative.9,11,17 Ultrasonography can be a useful investigation. Computed tomography and MRI can better depict direct
or contiguous involvement of adjacent anatomical regions such
as the chest wall.11,18 Magnetic resonance imaging may reveal a
smooth or irregular lesion with hyperintense or intermediate
signal intensity contents on T2-weighted images and T1
hyperintense/T2 hypointense periphery, suggesting a breast
abscess. After gadolinium injection, parenchymal asymmetry
with enhancement, microabscesses, and peripherally enhanced
masses can be seen.19 The T1 hyperintensity of the periphery of
the lesion is believed to represent epithelioid cell granulomas
and cellular infiltrates. The central fluid intensity contents are
* 2007 Lippincott Williams & Wilkins
Copyright @ 2007 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
J Comput Assist Tomogr
& Volume 00, Number 0, Month 2007
believed to contain necrotic material rich in lipids.3 These
findings are nonspecific, and reports on MRI of the breast
suggest its usefulness only in demonstrating the extramammary
extent of the lesion.20,21
Proton magnetic resonance spectroscopy is widely used
both as a clinical and research tool. Proton magnetic
resonance spectroscopy is now a well-established functional
imaging technique and is widely used in the evaluation of
malignant lesions of the brain.22Y24 Proton magnetic resonance spectroscopy has been used for assessment of various
inflammatory disorders and has shown encouraging results.
Proton magnetic resonance spectroscopy is useful in the
differential diagnosis of tubercular lesions, especially those
found in the brain.3Y6 Intracranial tuberculomas usually seem
hypointense on T2-weighted images and on H-MRS; they
show lipid resonance at 1.3, 2.02, and 3.7 ppm without any
change in other resonances.3,5,25 Caseation necrosis is
believed to cause the raised lipid-lactate resonance in these
lesions on H-MRS because of high lipid content in the
mycobacterial cell wall.3 In our patient, H-MRS acquired
from the breast lesion showed similar lipid-lactate peak
without any presence of Cho resonance, thus raising the
possibility of a tubercular lesion.
The H-MRS of the present case shows that relatively
specific spectra may be present in cases of tubercular abscess
of the breast. In vivo H-MRS may be used as an adjunct in the
diagnosis of tuberculosis of breast when index of suspicion is
very high.
ACKNOWLEDGMENTS
The authors thank Dr NR Jaganathan, Danishad, and
Dr Sandeep Kawlra for help and sincere advice in the
preparation of the manuscript.
REFERENCES
1. Tse GM, Yeung DK, King AD, et al. In vivo proton magnetic resonance
spectroscopy of breast lesions: an update. Breast Cancer Res Treat. 2006
Oct 19; [Epub ahead of print].
2. Kumar M, Jagannathan NR, Seenu V, et al. Monitoring the therapeutic
response of locally advanced breast cancer patients: sequential in vivo
proton MR spectroscopy study. J Magn Reson Imaging.
2006;24:325Y332.
3. Gupta RK, Roy R, Dev R, et al. Finger printing of Mycobacterium
tuberculosis in patients with intracranial tuberculomas by using in vivo,
ex vivo, and in vitro magnetic resonance spectroscopy. Magn Reson
Med. 1996;36:829Y833.
H-MRS of Tubercular Breast Abscess
4. Gupta RK, Vatsal DK, Husain N, et al. Differentiation of tuberculous
from pyogenic brain abscesses with in vivo proton MR spectroscopy and
magnetization transfer MR imaging. AJNR Am J Neuroradiol.
2001;22:1503Y1509.
5. Gupta RK, Roy R. MR imaging and spectroscopy of intracranial
tuberculomas. Curr Sci. 1999;76:783Y788.
6. Gupta RK, Husain M, Vatsal DK, et al. Comparative evaluation of
magnetization transfer MR imaging and in-vivo proton MR spectroscopy
in brain tuberculomas. Magn Reson Imaging. 2002;20:375Y381.
7. Gilbert AI, McGough EC, Farrel JJ. Tuberculosis of the breast. Am J
Surg. 1962;103:424Y427.
8. Banerjee SN, Ananthakrishnan N, Mehta RB, et al. Tuberculous mastitis:
a continuing problem. World J Surg. 1987;11:105Y109.
9. Hartstein M, Leaf HL. Tuberculosis of the breast as a presenting
manifestation of AIDS. Clin Infect Dis. 1992;15:692Y693.
10. Sabate JM, Clotet M, Gomez A, et al. Radiologic evaluation of
uncommon inflammatory and reactive breast disorders. Radiographics.
2005;25:411Y424.
11. Oh KK, Kim JH, Kook SH. Imaging of tuberculous disease involving the
breast. Eur Radiol. 1998;8:1475Y1480.
12. Tewari M, Shukla HS. Breast tuberculosis: diagnosis, clinical features
and management. Indian J Med Res. 2005;122:103Y110.
13. Tabar L, Kelt K, Nemeth A. Tuberculosis of the breast. Radiology.
1976;118:587Y589.
14. Aguirrezabalaga J, Sogo C, Parajo A, et al. Mammary tuberculosis: three
case reports. Breast Dis. 1994;7:377Y382.
15. Greenberg D, Hingston G, Harman J. Chest wall tuberculosis. Breast J.
1999;5:60Y62.
16. Kakkar S, Kapila K, Singh MK, et al. Tuberculosis of the breast. A
cytomorphologic study. Acta Cytol. 2000;44:292Y296.
17. Rosen PP. Inflammatory and reactive tumors. In: Rosen PP ed. Rosen’s
Breast Pathology, 2nd ed. Philadelphia, PA: Lippincott-Raven;
2001:29Y63.
18. Schnarkowski P, Schmidt D, Kessler M, et al. Tuberculosis of the breast:
US, mammographic and CT findingsVcase report. J Comput Assist
Tomogr. 1994;18:970Y971.
19. Engin G, Acunas B, Acunas G, et al. Imaging of extrapulmonary
tuberculosis. Radiographics. 2000;20:471Y488.
20. Oh KK, Kim JH, Kook SH. Imaging of tuberculous disease involving
breast. Eur Radiol. 1998;8:1475Y1480.
21. Chung SY, Yang I, Bae SH, et al. Tuberculous abscess in retromammary
region: CT findings. J Comput Assist Tomogr. 1996;20:766Y769.
22. Moller-Hartmann W, Herminghaus S, Krings T, et al. Clinical
application of proton magnetic resonance spectroscopy in the diagnosis
of intracranial mass lesions. Neuroradiology. 2002;44:371Y381.
23. Tosi MR, Ricci R, Bottura G, et al. In vivo and in vitro nuclear magnetic
resonance spectroscopy investigation of an intracranial mass. Oncol Rep.
2001;8:1337Y1339.
24. Kumar A, Kaushik S, Tripathi RP, et al. Role of in vivo proton MR
spectroscopy in the evaluation of adult brain lesions: our preliminary
experience. Neurol India. 2003;51:474Y478.
25. Jinkins JR, Gupta R, Chang KH, et al. MR imaging of central nervous
tuberculosis. Radiol Clin North Am. 1995;33:771Y786.
* 2007 Lippincott Williams & Wilkins
Copyright @ 2007 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
3
AUTHOR QUERIES
AUTHOR PLEASE ANSWER ALL QUERIES
AQ1 = Please check article title.
AQ2 = Please provide academic degree of this author.
AQ3 = FFHematenic__ was changed to FFhematinic.__ Please check.
END OF AUTHOR QUERIES
Copyright @ 2007 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Author Reprints
For
Rapid Ordering
go to: www.lww.com/periodicals/author-reprints
Journal of Computer
Assisted Tomography
Order
Author(s) Name
Title of Article
*Article #
______
*Publication Mo/Yr
*Fields may be left blank if order is placed before article number and publication
month are assigned.
Quantity of Reprints ____ $
Reprint Pricing
Shipping
100 copies = $375.00
Covers (Optional)
$
200 copies = $441.00
$5.00 per 100 for
orders shipping
within the U.S.
Shipping Cost
$
Reprint Color Cost
$
Tax
$
Total
$
300 copies = $510.00
500 copies = $654.00
$20.00 per 100 for
orders shipping
outside the U.S.
Covers
Tax
400 copies = $585.00
$108.00 for first 100
copies
U.S. and Canadian
residents add the
appropriate tax or
submit a tax exempt
form.
$18.00 each add’l 100
copies
Reprint Color
($70.00/100 reprints)
You may have included color figures in your article. The costs to publish those will
be invoiced separately. If your article contains color figures, use Rapid Ordering
www.lww.com/periodicals/author-reprints.
VISA
Account #
Payment must be
received before
reprints can be
shipped. Payment is
accepted in the form
of a check or credit
card; purchase orders
are accepted for
orders billed to a
U.S. address.
Prices are subject to
change without
notice.
Quantities over 500
copies: contact our
Pharma Solutions
Department at
Payment
MC
Use this form to
order reprints.
Publication fees,
including color
separation charges
and page charges will
be billed separately,
if applicable.
Discover
/
/
American
Express
Exp. Date
Name
410.528.4077
Outside the U.S. call
4420.7981.0700
MAIL
Address
Dept/Rm
City
State
Zip
Country
Telephone
your order to:
Lippincott Williams &
Wilkins
Author Reprints Dept.
351 W. Camden St.
Baltimore, MD 21201
FAX:
Signature
410.528.4434
For questions
regarding reprints or
publication fees,
Ship to
E-MAIL:
[email protected]
Name
Address
Dept/Rm
City
State
Zip
OR PHONE:
1.800.341.2258
Country
Telephone
For
Rapid Ordering
go to: www.lww.com/periodicals/author-reprints
Copyright @ 2007 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.