ClinicalRadiology (1991) 44, 89-91

Fibrous Mastopathy in Insulin Dependent Diabetics

W. I. H . G A R S T I N , Z. K A U F M A N , M . J. M I C H E L L * and M. BAUM

Department of Surgery, The Rayne Institute and * The Breast Assessment Clinic, King's College Hospital, London

The cases of two poorly controlled insulin dependent diabetic women, presenting with hard
discrete breast lumps clinically suspicious of carcinoma are presented. Mammography revealed
dense dysplastic parenchymal changes with no specific features of carcinoma and ultrasound
showed acoustic shadowing but no discrete mass.
Excision biopsy of these lumps was performed. Histologically they were benign, and were
composed of fibrous tissue with a chronicinflammatory cell infiltrate.
With better awareness of fibrous mastopathy which can occur in this group of diabetic
patients, and with the absence of specific radiologicai features of malignancy, some of these
women may be observed and spared excision biopsy. Garstin, W.I.H., K a u f m a n , Z . , M i c h e l l ,
M . J . & B a u m , M . (1991). Clinical Radiology 44, 89-91. F i b r o u s M a s t o p a t h y in I n s u l i n
Dependent Diabetics

F i b r o u s b r e a s t disease in i n s u l i n d e p e n d e n t d i a b e t e s Nine months later she presented with a 3 week history of a similar
sized hard lump behind the nipple of the left breast. The mammogram
mellitus ( 1 D D M ) is u n c o m m o n a n d w a s first r e p o r t e d in
revealed dysplastic changes but no evidence of malignancy, and was
the m e d i c a l l i t e r a t u r e in 1984 ( S o l a r a n d K h a r d o r i , 1984). similar to the mammogram performed 9 months previously (Fig. 2b).
T h e p a t h o l o g i c a l c h a n g e s c a n c a u s e a l u m p in t h e b r e a s t Ultrasound again only demonstrated acoustic shadowing in the region
which clinically m a y be i n d i s t i n g u i s h a b l e f r o m a carci- of the mass. A watch policy was adopted and to date the lump has not
n o m a . D i a b e t i c f i b r o u s m a s t o p a t h y is a b e n i g n disease, changed appreciably in size or consistency.
and c a n be t r e a t e d c o n s e r v a t i v e l y if c e r t a i n d i a g n o s t i c
criteria a r e satisfied. A w a r e n e s s o f this disease b y the
DISCUSSION
surgeon, e n d o c r i n o l o g i s t a n d r a d i o l o g i s t c a n s p a r e
patients with IDDM from undergoing unnecessary biop-
F i b r o u s disease o f t h e b r e a s t o c c u r r i n g in insulin
sies.
d e p e n d e n t d i a b e t i c s is a n u n c o m m o n c o n d i t i o n , initially
Two patients with IDDM are reported, both of whom
d e s c r i b e d b y S o l a r a n d K h a r d o r i (1984). T h e f i b r o u s
had f i b r o u s b r e a s t disease a n d p r e s e n t e d w i t h l u m p s in
c h a n g e s t h e y r e p o r t e d a f f e c t e d t h e b r e a s t as well as t h e
b o t h breasts.
t h y r o i d , eyes a n d j o i n t s o f s u c h p a t i e n t s . S i m i l a r f i n d i n g s
w e r e r e p o r t e d b y B y r d et al. (1987), a n d L o g a n a n d
CASE REPORTS H o f f m a n (1989). S o l a r a n d K h a r d o r i (1984) e s t i m a t e d t h e
p r e v a l e n c e o f f i b r o u s m a s t o p a t h y t o be 13% in pre-
Case 1. A 35-year-old insulin dependent diabetic lady was referred to m e n o p a u s a l insulin d e p e n d e n t d i a b e t i c s less t h a n 40 y e a r s
the breast clinic with a 1 month history of a lump in her right breast. Her
diabetes was poorly controlled and she developed proliferative retino- o f age a t t e n d i n g their d i a b e t i c clinics. B y r d et al. (1987)
pathy requiring laser treatment. She also had a past medical history of
sero-negative arthropathy affecting the joints of her lower limbs.
On examination she had a discrete lump measuring 2 x 4 cm in the
upper outer quadrant of the right breast which was hard and mobile.
Clinically the lump was suspicious of a carcinoma. The mammograms
revealed an asymmetrical area of increased density corresponding to the
palpable mass, but no specific features of malignancy (Fig. I). The lesion
was subsequently excised and histology showed mammary dysplasia
and a periductal infiltrate of lymphocytes.
She was again referred to our breast clinic 6 months later with a 5 cm
diameter hard lump in the upper outer quadrant of the left breast. The
mammogram showed no discrete mass and there were no other features
to suggest malignancy. The lump was excised and histologically a mass 5
cm in diameter with prominent stromal fibrosis and patchy chronic
inflammatory changes was seen.
Case 2. A 37-year-old insulin dependent diabetic was referred to the
breast clinic with a non-tender lump in her right breast. Her diabetes was
poorly controlled and she had developed hypertensive nephropathy. She
had also received photocoagulation for proliferative retinopathy.
On examination she had a 3.5 cm diameter hard, mobile lump behind
the nipple. The mammogram showed an area of dense tissue corres-
ponding to the mass, but no specific features of malignancy (Fig. 2a).
The only abnormality demonstrated by ultrasound was acoustic
shadowing in the region of the palpable mass (Fig. 3). Excision biopsy
was performed and histology revealed fibrotic tissue with periductal and
perilobular chronic inflammatory changes. There was no evidence of
malignancy.

Correspondence to: M. Baum, Department of Surgery, Royal Fig. 1 - Oblique mammograms showing asymmetrical increased
Marsden Hospital, Fulham Road, London SW3. density on the right.
 90 CLINICAL RADIOLOGY

reported only eight biopsies showing typical fibrous

: i .................
(a)
(b)
Fig. 2 - (a) Oblique m a m m o g r a m s showing increased density in the
retroareolar area bilaterally. (b) Oblique m a m m o g r a m s showing an
area of increased density behind the left nipple, unchanged com-
pared to the previous examination, and an area of distortion behind
the right nipple consistent with a history of previous biopsy.
Fig. 3 - Ultrasound of retroareolar area of left breast (longitudinal
scan).
changes in I D D M patients, from a series of several
thousand breast biopsies performed for all causes. Logan
and Hoffman (1989) estimated the prevalence of fibrous
mastopathy to be one out of 1700 women attending their
breast clinic. It would appear that although the preva-
lence reported by Solar and Khardori (1984) was 13% in
patients with I D D M the disease is an u n c o m m o n prob-
lem and is not well recognized in breast clinics.
The exact aetiology of the condition is unknown. Solar
and Khardori (1984) postulated that auto-immunity may
be a factor producing fibrous changes seen in the breast
and other organs. H L A histocompatibility would, how-
ever, indicate that these patients do not form a distinct
subgroup of insulin dependent diabetics. Abnormalities
in collagen formation (Chang et al., 1980; Brownlee et al.,
1986) and microvascular changes have been postulated in
the pathogenesis of the disease (Rosenbloom et al., 1981).
A correlation between Hgb A L C and fibrous changes in
patients with I D D M has been reported (Byrd et al., 1987).
Fibrous mastopathy typically presents in pre-menopausal
women with poorly controlled insulin dependent dia-
betes. In most of the patients the diabetes will be juvenile
onset with a period of at least 6 years between the onset of
diabetes and the development of a breast lump (Solar and
Khardori, 1984; Byrd et al., 1987).
Clinically the disease usually presents as diffuse nodu-
larity in the breast with dense dysplastic changes seen on
m a m m o g r a p h y . Presentation as an isolated hard, mobile
lump is even more u n c o m m o n and differentiation from a
carcinoma on clinical grounds alone is difficult. Twelve of
the 36 patients reported by Logan and Hoffman (1989)
had a solitary mass. In a mean follow-up of 6 years none
of these patients developed malignant disease. M a m m o -
graphy for an isolated lump in these patients usually does
not reveal a distinct mass but more commonly a dense
glandular pattern. The striking abnormality shown on
ultrasound is acoustic shadowing in the absence of a
discrete mass. Fine needle aspiration does not appear to
be helpful in making a diagnosis. In 50% of aspirates,
insufficient material for evaluation was reported (Logan
and Hoffman, 1989). Repeated attempts at aspiration are
therefore unrewarding.
Although fibrous mastopathy presenting as an isolated
lump is rare, unnecessary surgery may be avoided if the
clinician has an understanding of the criteria which
indicate the benign nature of this lesion. The condition
typically presents in long-standing insulin dependent
diabetics whose disease may be complicated by eye, renal,
joint and other organ involvement. The breast lump is
usually painless, hard and mobile and clinically m a y be
suspicious of malignancy. M a m m o g r a p h y usually does
not demonstrate an isolated mass with spiculation or
calcifications. More commonly an ill-defined area of
dense breast tissue (or D Y pattern according to Wolfe's
criteria) is seen. The absence of a discrete mass on
ultrasonography is a further indicator.
In the two patients presented, most of the criteria
described were present. Both patients had poorly con-
trolled, juvenile onset I D D M complicated by renal, joint
and eye involvement. In Case 1 two biopsies and in Case 2
one biopsy were performed. However, with typical clini-
cal findings, negative m a m m o g r a m and ultrasound some
of these women may be observed and thus spared excision
biopsy which may be hazardous in insulin dependent
diabetics subjected to a general anaesthetic.
 FIBROUS MASTOPATHY IN INSULIN DEPENDENT DIABETICS
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