Presentation
Right breast lump for 3 years. The patient had undergone a core biopsy locally, which showed invasive ductal carcinoma (IDC). She was referred for further treatment to our hospital. Other than right breast lumps and right axillary adenopathy, clinical breast and systemic examination was unremarkable. Blood investigations revealed anemia and eosinophilia.
Patient Data
Two irregular high-density masses with indistinct margins in the upper-inner quadrant of the right breast. These masses were associated with pleomorphic microcalcifications. Two other high-density round masses were seen in the outer quadrants on CC view. One of these was located in the subcutaneous location, other is not well appreciated on MLO view. Enlarged right axillary nodes were seen. Left breast showed a few scattered tiny round isodense lesions.
Two irregular hypoechoic solid masses with angular margins and posterior acoustic shadowing were seen at 12-1 o`clock position measuring about 1 cm each. These were hard on elastography and showed mild internal vascularity (images not shown). A well-defined hypoechoic taller than wider nodule with eccentric hyperechoic area within was seen at 8 o` clock position.This was one of the lesions seen in outer quadrants on mammogram and was thought to be enlarged intramammary lymph node due to presence of partly effaced fatty hilum. Right axillary nodes were seen with thickened cortex.
On left breast ultrasound, few 4-5 mm sized scattered hypoechoic/anechoic lesions were seen. These were assigned BIRADS category 3 and were suggested to be followed up with ultrasound at 6 months.
Also, a subcentimeter-sized cystic lesion was seen at the 9-10 o`clock position in the subcutaneous plane. It showed mobile echogenic linear structures. Doppler revealed non-rhythmic, rapidly changing mixed color signals.
The cystic lesion at 9-10 o`clock position in the subcutaneous plane showed mobile echogenic linear structures with vigorous twirling movements, suggesting filariasis.
Hence, two separate right breast pathologies were seen, i.e. breast mass (confirmed on review of outside slides) and filariasis (confirmed on excision).
Case Discussion
Lymphatic filariasis is caused by Wuchereria bancrofti (more common) and Brugia malayi. The breast is an uncommon site of involvement, but common in endemic areas of India 1. Imaging plays an important role in the diagnosis. Ultrasound is especially valuable in demonstrating the classical vigorous movement of worms called “filarial dance” 2.
Breast cancer is the most important cause of cancer-related morbidity and mortality in Indian women 3.
Filariasis is a tropical vector-borne disease, endemic in some areas. Adult parasite survives in the lymphatics of an infected person and produces microfilariae that circulate in the patient’s blood. Microfilariae are ingested by Culex mosquitoes where they form larvae, which are transmitted to another person’s skin via mosquito bites. The larvae develop into adult worm 1.
Patients with breast filariasis usually present with painless breast lumps. Upper-outer quadrant is most commonly involved. The common differential is malignancy clinically. It may also be mistaken for fibroadenoma in young patients on clinical examination. If there are associated skin changes(hyperemia or peau-d’orange appearance), there may be clinical confusion with inflammatory breast cancer or mastitis. If blocked lymphatics appear as prominent vessels, Mondor’s disease becomes a differential 1.
In acute and subacute phases, ultrasound is diagnostic. Amaral et al. reported visualization of adult worms in the scrotum of infected men on ultrasound. It was described as “filarial dance” due to the characteristic random movements of worms in lymphatic vessels. Worms are seen as echogenic structures in cystic lesions. Similar findings have been reported in breasts, first by Dreyer and colleagues 4. Rathi et al. described color motion artifact on Doppler, produced by swirling motion of parasite 5. Dilated lymphatic vessels are usually seen. But they were not seen in our case, possibly attributed to already involved lymph nodes by carcinoma.
In degenerating phase, there is dystrophic calcification of dead worms, seen as elongated tortuous calcifications which do not conform to a ductal pattern on mammogram1.
Filariasis may also be seen as noncalcified nodules which may be mistaken for fibroadenoma or intramammary lymph node on mammogram 1.
Diagnosis may be confirmed by fine needle aspiration of lesion 6. Treatment includes diethylcarbamazine and albendazole. The prognosis is good if uncomplicated 6.
Breast cancer is the most common cancer in women in India and accounts for 14% of all cancers in women 7.
For breast cancer and breast filariasis to occur in the same breast is not a common occurrence. There are no case reports of this in the literature.
Special thanks to Dr Purvi Haria and the rest of the breast imaging and entire radiology department of Tata Memorial Hospital.
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