Non-Puerperal Inflammatory Breast Pathology: Ultrasound Diagnosis and Keys to Differential Diagnosis
- Dr. Segnini
- Jan 15
- 3 min read
Beyond Puerperal Mastitis
Inflammatory breast disease outside of the lactation period presents a diagnostic challenge. Its symptoms (pain, erythema, palpable mass) can mimic inflammatory cancer , an oncological emergency. Breast ultrasound, complemented by Doppler , is the first-line tool for characterizing these lesions, guiding procedures, and establishing a rapid and accurate differential diagnosis.
The Crucial Role of Ultrasound in Inflammatory Triage
Objectify the Clinic: Transform physical findings into evaluable images, determining the true extent of inflammation.
Inflammation vs. Tumor Difference: This is key to distinguishing between acute mastitis, an abscess, and the diffuse skin/dermal thickening of inflammatory cancer.
Detects Collections: Accurately identifies and locates abscesses that require drainage.
Characterize Vascularization: Doppler differentiates reactive hyperemia from benign inflammation from the anarchic vascularization of a tumor.
Guide Interventions: Directs puncture-aspirations for culture, percutaneous drainage of abscesses and biopsies of suspicious areas.
Ultrasound Findings and Key Differential Diagnosis
A) Acute Non-Puerperal Mastitis:
Findings: Diffuse thickening of glandular tissue, which becomes hypoechoic (darker) and heterogeneous. Subcutaneous fat may show an edematous pattern ("orange peel" appearance on ultrasound). Doppler : Diffuse and reactive hypervascularization in the affected area.
Common Causes: Bacterial infection (S. aureus ), diabetes, immunosuppression, ductal ectasia.
B) Breast Abscess:
Findings: A fluid-filled, rounded or oval lesion with echogenic content (pus/ debris ) that may present fluid- debris levels . The wall is usually thick, irregular, and vascularized on Doppler . It may show posterior acoustic enhancement (increased brightness behind) due to its fluid content.
Dynamic Characteristic: Upon compression with the transducer, the contents may show internal movement (sign of "flow" or " swirling ").
Management: Accurate ultrasound diagnosis allows guided percutaneous drainage, avoiding surgery in many cases.
C) Inflammatory Cancer (Diagnostic Urgency):
Key Findings That Raise Maximum Alert:
Diffuse Dermal Thickening: The skin appears abnormally thickened (>2-3 mm) and hypoechoic .
Subcutaneous Tissue Edema ("Orange Peel" Ultrasound): Linear anechoic / hypoechoic tracts in the fat due to lymphedema .
Underlying Mass: Presence of a solid, irregular, hypoechoic lesion with spiculated or microlobulated margins .
Doppler : Anarchic, chaotic vascularization, with straight, high-flow vessels within the mass and thickened skin.
Critical Differentiator: In benign mastitis, thickening and vascularization are more diffuse and reactive; in inflammatory cancer, there is an underlying destructive solid mass with secondary skin changes.
D) Other Entities ( Periductal Mastitis / Zuska 's Disease ):
Findings: Dilated ducts with echogenic content , surrounded by a hypoechoic inflammatory halo ( periductal inflammation ). May progress to recurrent abscess and fistula, typically in the areola.
Practical Ultrasound Algorithm and Limitations
Algorithm: Pain + Erythema → Ultrasound. If there is a fluid collection → Guided drainage. If there is a solid mass + dermal edema → Urgent ultrasound -guided biopsy . If there are only diffuse inflammatory changes → Medical treatment and ultrasound follow-up in 2-3 weeks.
Limitations: Ultrasound cannot detect microcalcifications associated with some cancers. Breast MRI may be complementary in complex cases. Biopsy is always necessary . mandatory if there is the slightest doubt of malignancy.
Conclusion:
In non-puerperal inflammatory breast disease, ultrasound is the guiding light for diagnosis. Its main value lies in its ability to effectively distinguish between a medically treatable infectious process and an aggressive neoplasm requiring immediate action, thus optimizing the therapeutic approach from the outset.
breast ultrasound
Dr. Jose Segnini, Radiologist / Diagnostic Medical Sonographer
MD Radiologist (Venezuela – Chile)
Board Certified Diagnostic Medical Sonographer (ARDMS, USA)
Mobile Ultrasound & Medical Supplies – Orlando, Florida
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