ORIGINAL ARTICLE

Mastitis, a Radiographic, Clinical, and Histopathologic

Review
Lin Cheng, MD, PhD, Vijaya Reddy, MD, Gene Solmos, MD,
Latanja Watkins, MD, David Cimbaluk, MD, Pincas Bitterman, MD,
Ritu Ghai, MD, and Paolo Gattuso, MD
Department of Pathology, Rush University Medical Center, Chicago, Illinois

n Abstract: Mastitis is a benign inflammatory process of the breast with heterogeneous histopathological findings, which
clinically and radiographically may mimic a mammary carcinoma. We undertook a retrospective study on 37 cases of mastitis in our institution to correlate the radiographic imaging features and the clinical presentation with the histopathological
findings. Histologically, there were 21 granulomatous, 7 fibrous, 3 plasma cell, 3 lupus, 2 lymphocytic, and 1 case of acute
mastitis. Radiographically, 16/25 (64%) patients with ultrasound studies showed irregular hypoechoic masses suspicious for
malignancy. Clinically, 38% of patients had an associated systemic disease. n
Key Words: fibrous mastitis, granulomatous mastitis, lupus mastitis, lymphocytic mastitis, plasma cell mastitis

astitis is a benign inflammatory process of the

breast with heterogeneous histopathological findings. The most common type of mastitis is the acute
mastitis caused by bacterial infections in breastfeeding
women (1). In surgical pathology practice, acute mastitis is less challenging than other types of mastitis. Its
clinical presentation is usually classic enough to render
a diagnosis, and surgical intervention is only applied
when an abscess forms and drainage is necessary (2).
Other types of mastitis such as granulomatous mastitis,
however, are more worrisome since they may clinically
and radiographically mimic a mammary carcinoma
and lead to either tissue biopsy or surgical excision of
the lesion (3). Therefore, to define mastitis, we undertook a retrospective study to describe and correlate the
radiographic imaging and the clinical presentation with
the histopathological findings.

MATERIALS AND METHODS

The computerized surgical pathology archives at
our institution were searched by the key word masti-

Address correspondence and reprint requests to: Lin Cheng, Department of Pathology, Rush University Medical Center, 1750 W Harrison St
570 Jelke, Chicago, IL 60612, USA, or e-mail: lin_cheng@rush.edu
DOI: 10.1111/tbj.12430
2015 Wiley Periodicals, Inc., 1075-122X/15
The Breast Journal, Volume 21 Number 4, 2015 403409

tis. A total of 37 cases were retrieved from 1994 to

2012 and studied retrospectively.
All patients medical records were reviewed. Demographic information, significant past medical history,
and family history of breast cancer were recorded.
The location, number, and size of the breast
lesions, type of the radiological examination, and the
available radiographic results were analyzed.
The surgical procedures and pathology reports were
reviewed. When granuloma formation was noted, GMS,
PAS, Fite, and Gram stains were performed. All available H&E and special stain slides were reviewed by two
pathologists independently to confirm the diagnosis.
RESULTS
Clinical Features
All 37 patients were female. The mean age at presentation of mastitis was 46 years, ranging from 27 to 78
with a standard deviation of 12. Patients were from
three different ethnic groups, including 22 AfricanAmerican, 11 Caucasian, and 4 Hispanic/Latino.
Thirty-five patients had unilateral lesions, and two
patients had bilateral lesions. Three patients presented
with recurrent disease. Thirty-eight percent of patients
had an associated systemic disease, such as sarcoidosis
and rheumatoid arthritis, and will be discussed in the
following section.

404 cheng et al.

Histopathological Features
There are 23 patients who underwent surgical excision (lumpectomy) and 14 patients who had core needle biopsies. According to the main histopathological
features, we divided our mastitis cases into six categories. As shown in Figure 1, there were 21 cases of
granulomatous mastitis, 7 cases of fibrous mastitis, 3
cases of lupus mastitis, 3 cases of plasma cell mastitis,
2 cases of lymphocytic mastitis, and 1 case of acute
mastitis.
1. Granulomatous mastitis: This type was characterized by the formation of noncaseating granulomas
composed of epithelioid histiocytes and multinucleated
giant cells (Fig. 2A). Lymphocytic infiltration was also
commonly present in these cases. Although all our
cases showed noncaseating granulomas, GMS, PAS,
Fite and Gram stains were still performed and they
were negative in all cases, excluding the possibility of
an infectious process. Seven out of 21 cases were previously diagnosed with systemic sarcoidosis, two of
which had granulomatous mastitis as the primary presentation for the systemic sarcoidosis. The remaining
14 patients had idiopathic granulomatous mastitis.

2. Fibrous mastitis: This type of mastitis shows a

dense stromal fibrosis. Variable amounts of perilobular, periductal, and perivascular lymphocytic infiltrations were also present (Fig. 2B). One of the 7
patients in this group had type I diabetes and received
exogenous insulin treatment for 17 years. Another
patient had Graves disease. Other 5 patients did not
have systemic diseases.
3. Lupus mastitis: Lobular panniculitis and hyaline
fat necrosis were the distinctive histopathological features of this group (Fig. 2C). As we previously
reported, two patients had diagnosed systemic lupus
erythematosus/discoid lupus erythematosus (SLE/
DLE), and 1 patient had abnormal serology and was
closely followed up for SLE (4).
4. Plasma cell mastitis: Marked plasma cells infiltration was present (Fig. 2D). Lymphocytes in the background were seen as well, but at a much lower
frequency compared to plasma cells. The ductal or
lobular structure was often veiled or distorted.
5. Lymphocytic mastitis: Lymphocytic infiltration
was intralobular, periductal, and/or perivascular. The
lymphocytic vasculitis involves small and medium
sizes vessels. Lymphocytic mastitis was a diagnosis of
exclusion in our study. This category consists of cases
without other concurrent pathologic changes
(Fig. 2E). Of the two cases we encountered, one
patient had a history of rheumatoid arthritis.
6. Acute mastitis: The microscopic picture is intensive neutrophil infiltration, necrosis, and abscess formation (Fig. 2F). Depending on the clinical courses,
chronic inflammation may be present as well.
Radiographic Features

acute (n=1, 3%)

fibrous (n=7, 19%)
granulomatous (n=21, 57%)
lymphocytic (n=2, 5%)
plasma cell (n=3, 8%)
lupus (n=3, 8%)
Figure 1. Summary of the histopathologic subtypes of mastitis
Histologically, there were 21 granulomatous (57%), 7 fibrous
(19%), 3 plasma cell (8%), 3 lupus (8%), 2 lymphocytic (5%), and
1 case of acute mastitis (3%).

Twenty-six patients had their radiographic studies

done in our institution and were available for
review, including 25 ultrasound studies and 1 MRI.
The size of the lesions on ultrasound examination
ranged from 0.5 to 3.9 cm, with a mean of 1.8 cm.
There were 14 granulomatous mastitis cases, 1 lupus
mastitis case, and 1 plasma cell mastitis case (64%
in total) which all showed irregular, hypoechoic
masses indicating possible malignancy on ultrasound
images. The remaining cases cases showed nonspecific/well-circumscribed masses, favoring benign
lesions. One case of the lymphocytic mastitis had an
MRI study showing increased blood supply and
thickened skin suggestive of a possible malignant
process (Fig. 3).

Mastitis Analysis 405

Figure 2. Histopathological characteristics of

different types of mastitis (a) High power
view (4009) of granulomatous mastitis showing well formed noncaseating granulomas
with associated multinucleated giant cells. (b)
Low power view (1009) of fibrous mastitis
showing dense stromal fibrosis and perilobular lymphocytic infiltration. (c) Lupus mastitis
is characterized with lobular panniculitis and
hyaline fat necrosis. (d) High power view
(4009) of plasma cell mastitis showing a
dense infiltrate of plasma cells with sparse
lymphoid cells in the background. (e) High
power view (400 9) of lymphocytic mastitis
shows periductal lymphoid infiltrate. (f) High
power view (400 9) of acute mastitis showing a marked neutrophiltic infiltrate within the
breast parenchyma and intraductal lumen.
Eosinophils also are appreciated.

(a)

(b)

(c)

(d)

(e)

(f)

DISCUSSION
Granulomatous mastitis was the most common type
of mastitis encountered in our surgical pathology
practice. It can occur in both female and male patients
(5). The etiology of this entity includes infectious and
noninfectious processes as well as unknown factors.
Infections such as histoplasmosis capsulatum (6),
mycobacteria tuberculosis (7), corynebacterium species
(8,9), brucellosis (10), and filariasis (11) can lead to
caseating granuloma, and/or abscesses formation with
neutrophil infiltration. Clinically, the patients may
present with painful breast masses, breast swelling,
draining sinuses, and scarring (12). Treatment with
antimicrobial agents usually results in improvement
(7). However, incision and drainage may be required.
Systematic diseases such as sarcoidosis (13,14), Wegeners granulomatosis (15), and necrobiotic xanthogranulomatosis (3), can affect the breast and form
irregular, hypoechoic masses on the radiologic images.
Clinically the mass can be painful or painless. Histologically, the sarcoidosis related mastitis presents with

small well-circumscribed noncaseating granulomas;

Wegners granulomatosis related mastitis shows granulomas with prominent vasculitis; while necrobiotic
xanthogranulomatosis has degeneration of the collagen fibers and foam cells besides the granulomas (3).
Treatment of the systemic conditions can relieve the
local symptoms (16). Surgical resection may be needed
for definitive treatment of the mass. However, recurrence is common.
Breast implant-related silicone can also cause
chronic granulomatous inflammation (17). The clinical
history is very important for the diagnosis, and the
foreign-body giant cells should be seen histologically.
Rarely, nodular deposition of amyloid can cause
prominent granulomatous reaction in the breast (18).
Congo red stain or immunostain for amyloid-p will
confirm the diagnosis.
A large group of granulomatous mastitis cases have
an unknown etiology. These are also described as idiopathic granulomatous mastitis or granulomatous lobular mastitis. This entity was first reported by Kessler

406 cheng et al.

(a)

(b)

(c)

(d)

(e)

(f)

and Wolloch in 1972 (19). Since then, multiple studies

have shown that idiopathic granulomatous mastitis
mainly affects childbearing age women. It can mimic
breast malignancy clinically, radiographically and even
cytologically upon fine-needle aspiration (20,21).
Therefore, tissue biopsy and careful histologic evaluation is required to avoid unnecessary mastectomy. The
current hypotheses on the etiology include oral contraceptive pills usage, response to the extravasated secretion of milk, and underlying autoimmune or infectious
process that cannot be detected by current technique
(20). It is still controversial whether idiopathic granulomatous mastitis can increase the incidence of breast
carcinoma. Treatment of idiopathic granulomatous
mastitis includes corticosteroids or methotrexate for
refractory cases, and wide local excision for extensive
cases (22,23). Steroids can be used before surgical
removal to shrink the mass (24). Clinical follow-up is
recommended to look for systemic diseases that could
cause mastitis. Clinical follow-up is also needed in
case of sampling of the granulomatous reaction near
an underlying breast cancer (13).
Fibrous mastitis was the second most common type
of mastitis encountered in our surgical pathology

Figure 3. Radiographic characteristics of different types of mastitis. (a) An irregular hypoechoic nodule is noticed in the ultrasound
image of a granulomatous mastitis. (b) Ultrasound of a patient with fibrous mastitis
reveals an irregularly marginated hypoechoic
mass with significant posterior acoustical
shadowing. (c) Lupus mastitis shows a single
multi-lobulated iso-tohyperechoic lesion. (d)
Ultrasound of a patient with plasma cell mastitis shows an irregular hypoechoic nodule
with an echogenic rim and vascularity. (e and
f) These are MRI images from a patient with
lymphocytic mastitis. (e) This is the subtraction image showing increased vascularity and
skin thickening. (f) This is the T2 STIR image
showing stromal edema and skin thickening.

practice. We designate the term fibrous mastitis for

both the diabetic mastopathy and the sclerosing lymphocytic lobulitis, due to their similar histopathologic
pictures. The etiology of fibrous mastitis is not thoroughly understood. The related systemic conditions
include diabetes mellitus and other autoimmune
diseases.
In 1984, Soler and Khardori first described the correlation between diabetes type I and fibrous breast disease (25). Later, Tomaszewski et al. proposed that the
presence of keloid-like fibrosis with epithelioid fibroblasts is the diagnostic histologic feature for diabetic
mastitis (26). Lymphocytic ductitis, lobulitis, and perivasculitis are also commonly present. More studies
have shown that diabetic mastopathy can occur in
both male and female patients with either diabetes
type I or type II who have received long-standing
exogenous insulin treatment (27). Presumably the
exogenous insulin or the abnormal protein glycosylation of the breast tissue causes local immune response
(28).
Other autoimmune diseases such as Harshimoto
thyroiditis (29), Graves disease (30), and Sjogrens
syndrome (31)are also associated with breast stromal

Mastitis Analysis 407

fibrosis, in addition to lymphocytic ductitis, lobulitis,

and perivasculitis. Sclerosing lymphocytic lobulitis is
sometimes used to describe this condition. IgG 4 is
believed to play a role in the pathogenesis (32,33).
Association of human leukocyte antigen (HLA) DR3
with fibrous mastitis is also noted (34). Additionally,
increased expression of HLA type II molecules on the
infiltrating lymphocytes is observed (35). However,
there is no monoclonal gene rearrangement detected
in the infiltrating lymphocytes, and previous reports
failed to show increased incidence of lymphoma in
these patients (36). Therefore, patients should be followed similarly to other benign breast conditions.
Another autoimmune disease, SLE/DLE, can cause
an unusual complication in the breast (37). On histologic examination, the lymphocytes infiltrate the subcutaneous fat and form lobular panniculitis. Germinal
center formation and vasculitis are commonly seen.
More importantly, fat necrosis present in this condition is the hyaline type, which is diagnostic for lupus
mastitis (4). This is also the reason that we separate
lupus mastitis from the nonspecific lymphocytic mastitis. The differential diagnoses of lupus mastitis had
been discussed in detail in our previous case report
(4). As we suggested previously, if a patient does not
have clinical diagnosis of lupus, our diagnostic report
will be more generic, such as lobular pannuculitis
and hyaline fat necrosis, suggestive of lupus mastitis,
clinical correlation, and serology testing are advised.
As early as 1933, plasma cell mastitis was reported
by Adair for clinically mimicking a breast carcinoma
(38). Unfortunately, the etiology is still unknown after
years of study. The proposed risk factors include
smoking and nipple retraction (39). Clinically, this
type of mastitis can present with breast swelling, painful masses, skin redness or peau dorange appearance,
and nipple discharges, which needs to be differentiated
with acute mastitis or inflammatory breast cancer
(38). Histologically, significant periductal plasma cells
infiltration and mammary duct ectasia are present
(40). Gray, thick discharge may be seen within the
affected ducts, leading to mastitis obliterans (41). Current treatment for plasma cell mastitis is antibiotic
therapy and supportive care in the absence of abscess,
incision and drainage when abscess forms. For
patients with nipple retraction, early excision of
affected major ducts and correction of nipple retraction can decrease the likelihood of recurrence (39).
Although extremely rare, plasma cell neoplasm
involving the breast should be included in the differen-

tial diagnosis (42). The plasma cells should have cytologic atypia suggestive of malignancy, and light chain
restriction and/or abnormal expression of surface marker CD56 should be detected. Interestingly, a mouse
model of plasma cell mastitis has been established
(43). The study of the model system may shed light
into the pathogenesis and treatment of this disease in
humans.
Lymphocytic mastitis is a chronic inflammation of
the breast. The etiology is unknown. One of our
patients had rheumatoid arthritis, which leads us to
suspect that this entity may have an autoimmune
basis. In our cases, the lymphocytes are small mature
looking, with intralobular, periductal, and/or perivascular distribution. The name lymphocytic mastitis was
occasionally used for the diabetic mastopathy. However, in our study, diabetic mastopathy is classified as
fibrous mastitis due to the significant stromal fibrosis.
The term lymphocytic mastitis is only used when there
are no coexistent pathologic changes in addition to
the lymphocytic infiltration. The differential diagnosis
should include primary breast lymphomas (44). Clinical history of hematological malignancies, aberrant
expression of surface markers, and detection of a
monoclonal population of lymphocytes will support
the diagnosis of lymphoma. Similar to the fibrous
mastitis, currently there is no evidence that the
patients with lymphocytic mastitis have a higher incidence of developing lymphoma (36).
The incidence of acute mastitis could be as high as
33% in the breastfeeding women (1). Presumably bacteria can get into the mammary tissue through cracked
skin, and cause acute inflammation and abscess formation (45). Squamous metaplasia in the lactiferous
ducts may predispose the breast to infection. The most
common causative microorganism is Staphylococcus
aureus. Other species of Staphylococcus, Streptococcus, Enterococcus, Mycobacteria, Salmonella, and
Brucella (46) are also reported. Acute mastitis can
have a similar clinical presentation as plasma cell mastitis, with skin redness, painful sub-areolar mass, and
sometimes fistula formation. In nonlactating elder
patients, inflammatory breast cancer should be at the
top of the differential list. MRI can be used to separate these two conditions. Inflammatory breast cancer
has rapid enhancement, often with a washout pattern
and also diffuse prepectoral edema on the T2weighted images due to the lymphocytic infiltration.
Acute mastitis usually has sub-areolar edema and
rarely shows a washout pattern (47). Histologic

408 cheng et al.

evaluation is required when the clinical picture is confusing. Antibiotics are commonly used, although its
efficacy needs further study (1). Percutaneous drainage
with urokinase irrigation can be used for large
abscesses (48).
In summary, mastitis includes a group of acute and
chronic inflammatory conditions of the breast. The
etiology is partially understood. Autoimmune diseases
play a role in the pathogenesis and can cause multiple
types of mastitis. Radiographic studies show that 64%
patients had abnormal findings suggesting a neoplastic
process. Tissue biopsy and histologic examination are
required to establish a definitive diagnosis. Six categories of mastitis can be seen with distinct histopathological features. Granulomatous and fibrous mastitis
are the most often encountered histologic subtypes in
our surgical pathology. Thirty-eight percent of
patients in our study had an associated systemic disease. Treatment of mastitis depends on the histopathological subtype. Recurrence is common, and routine
follow-up is recommended.
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