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18 F-FDG PET in A Clinical Unsuspected Axillary Tuberculous Lymphadenitis Mimicking Malignancy

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Che-Ming Yang at Taipei Medical University
Che-Ming Yang
Chung-Huei Hsu at Taipei Medical University
Chung-Huei Hsu
Chia-Ming Hsieh at Taiwan Adventist Hospital
Chia-Ming Hsieh
Mao-Yuan Chen
Mao-Yuan Chen
Mao-Yuan Chen
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Isolated axillary tuberculous lymphadenitis is rare. We present a 33-year-old female who had palpable right axillary masses without remarkable clinical symptom. Ultrasound examination of breast and abdomen, mam- mography, and chest radiography were negative. 18 F- Fluorodeoxyglucose positron emission tomography (FDG-PET) study was misinterpreted as malignant dis- ease extensively involving right axillary and the sur- rounding lymph nodes, possibly metastatic occult breast cancer. Tuberculous lymphadenitis was finally proven by tissue biopsy. This potential pitfall should be kept in mind when FDG-PET images are interpreted in areas where the prevalence of granulomatous infection is high.
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18F-FDG PET in A Clinical Unsuspected Axillary Tuberculous
Lymphadenitis Mimicking Malignancy
Che-Ming Yang 1, Chung-Huei Hsu1, Chia-Ming Hsieh2, Mao-Yuan Chen3
1Department of Nuclear Medicine and PET Center, Taipei Medical University Hospital, Taipei, Taiwan
2Department of Surgery, Taiwan Adventist Hospital, Taipei, Taiwan
3Department of Pathology, Taiwan Adventist Hospital, Taipei, Taiwan
Received 01/28/2003; accepted 3/25/2003.
For correspondence or reprints contact: Chung-Huei Hsu, M.D., Department of
Nuclear Medicine, Taipei Medical University Hospital, 252 Wu-Hsing Street, Taipei
110, Taiwan. Tel: (886)2-27395748, Fax: (886)2-27395749,
E-mail: chhsu@tmu.edu.tw
Isolated axillary tuberculous lymphadenitis is rare. We
present a 33-year-old female who had palpable right
axillary masses without remarkable clinical symptom.
Ultrasound examination of breast and abdomen, mam-
mography, and chest radiography were negative. 18F-
Fluorodeoxyglucose positron emission tomography
(FDG-PET) study was misinterpreted as malignant dis-
ease extensively involving right axillary and the sur-
rounding lymph nodes, possibly metastatic occult
breast cancer. Tuberculous lymphadenitis was finally
proven by tissue biopsy. This potential pitfall should be
kept in mind when FDG-PET images are interpreted in
areas where the prevalence of granulomatous infection
is high.
Key words: FDG-PET, tuberculous lymphadenitis
Ann Nucl Med Sci 2003;16:107-110
Introduction
18F-Fluoro-2-deoxy-D-glucose (FDG) in conjunction
with positron emission tomography (PET) is a novel modali-
ty for tumor detection, staging, and therapeutic monitoring.
Its non-specificity remains a difficulty in differentiating
malignant from benign pathological variants which occasion-
ally mimic that of malignancy, especially in infectious and
non-infectious inflammatory foci with glucose hypermetabo-
lism [1-4]. The standard uptake value (SUV), 2.5 as cutoff
level, was commonly used as a supplementary tool for dis-
criminating benign from malignant [5]. However, various
intensities described as weak, intermediate, and strong FDG
uptake in tuberculosis (TB) infection had been reported pre-
viously [5-8].
Case Report
A 33-year-old female who had palpable right axillary
masses without clinical symptom was referred to our depart-
ment for a whole body FDG-PET study. Ultrasound examina-
tion of the breast and abdomen, mammography, chest radiog-
raphy, and physical examination of the breast were negative.
Occult breast cancer with lymph nodes metastases was clini-
cally suspected.
Whole body imaging was performed at 45 min and
additional focal delayed imaging was performed at 3 h after
intravenous injection of 259 MBq (7 mCi) of FDG on a
Siemens ACCEL PET scanner. Images were reconstructed
iteratively with attenuation correction.
The studies demonstrated intense circular uptake of
FDG in the right axillary region (maximal SUV = 8.7), spot-
like increased uptake in the right supraclavicular (SUV = 1.6)
and infraclavicular regions (SUV = 3.2) (Figures 1A and B).
The findings suggested malignant disease involving the right
axillary, supraclavicular, interpectoral, and subclavian lymph
nodes, possibly metastases from occult breast cancer.
Yang CM et al
Ann Nucl Med Sci 2003;16:107-110 Vol. 16 No. 2 June 2003
108
Echo-guided core needle biopsy of the axillary lymph
node was performed which showed granulomatous inflam-
mation with caseating necrosis (Figure 2). Tuberculous lym-
phadenitis was diagnosed.
Discussion
Primary presenting peripheral lymphadenopathy (LAP)
without constitutional symptoms is not unusual. In the neck,
the commonest causes in adults are metastatic, lymphoma-
tous, tuberculous, and inflammation reactive node [9,10].
Although isolated axillary mass is uncommon and the inci-
dence of occult breast cancer presenting as axillary metasta-
sis was low, lymphomatous tumor and metastatic occult
breast cancer are the leading pathological features account-
ing for about 50-60% of the abnormalities [11-14]. The
usage of FDG-PET for detecting the origin of a quiescent
lymph node of unknown primary site has been established
clinically [4,15].
Mycobacterium TB infection is a high prevalence dis-
ease in developing country and patients with immunocom-
promised disorder. In extrapulmonary TB, single cervical
lymph node was the most frequently involved site [10,16-
18]. Positive chest radiographic finding was not frequently
seen [16-18]. Intense uptake of FDG in mediastinal, supra-
clavicular, and pare-aortic tuberculous lymphadenitis had
been previously reported [5-7]. Axillary tubercolous LAP
was found in 41% of mammary TB as previously reported
[19]. However, the frequency of isolated axillary tuberculous
LAP is low [11,13].
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Figure 1. FDG-PET images performed (A) at 45 min and
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Figure 2. Section of lymph node reveals caseating necrosis
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110 252 (02)-27395748 (02)-27395749 chhsu@tmu.edu.tw
... Isolated axillary TB lymphadenitis is extremely rare and is described in a patient with enlarged axillary lymph nodes without previous or active pulmonary TB or evidence of extrapulmonary TB elsewhere (7,10). In the case reported, systemic TB was immediately considered after diagnosis of tuberculous lymphadenitis was made. ...
... However, the absence of radiological features on chest X-ray excluded pulmonary TB. From the literature, only six such cases have been documented, affecting only women within the age of 21-69 years, with predilection for left axilla (3,4,7,8,10,11,12). This pattern of presentation is however poorly understood. ...
Case Report Open Access Isolated axillary tuberculous lymphadenitis in a Nigerian female: A case report with review of the literature Lymphadénite tuberculeuse axillaire isolée chez une femme Nigériane: à propos d'un cas avec revue de la littérature
Article
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  • Jan 2023
Tuberculosis (TB) is a chronic granulomatous infectious pulmonary and systemic disease caused mostly by members of the Mycobacterium tuberculosis complex (MTBC). It has variable clinical presentation and is a major cause of morbidity and mortality in the middle-and-low-income-countries (LMICs). Isolated axillary tuberculous lymphadenitis (ATL) is rare and is defined as the presence of axillary tuberculous lymphadenitis in the absence of previous or active pulmonary TB or evidence of extrapulmonary TB elsewhere. We present a case of isolated ATL in a 54-year-old HIV-negative Nigerian woman, whose diagnosis was made using histological evaluation that demonstrated typical Langhan's giant cells and caseous necrosis, with the detection of mycobacterial DNA by GeneXpert TB test. Isolated ATL is a diagnostic enigma but should be considered in young and middle-aged women in TB endemic regions presenting with enlarged axillary lymph nodes in the absence of foci of infections or malignancy. Sex difference in immunological response to infection may account for this unique presentation among the female gender. Résumé: La tuberculose (TB) est une maladie pulmonaire et systémique infectieuse granulomateuse chronique causée principalement par des membres du complexe Mycobacterium tuberculosis (MTBC). Il a une présentation clinique variable et est une cause majeure de morbidité et de mortalité dans les pays à revenu intermédiaire et faible (PRFI). La lymphadénite tuberculeuse axillaire (LTA) isolée est rare et se définit comme la présence d'une lymphadénite tuberculeuse axillaire en l'absence de tuberculose pulmonaire antérieure ou active ou de signes de tuberculose extrapulmonaire ailleurs. Nous présentons un cas d'ATL isolé chez une femme nigériane de 54 ans, séronégative, dont le diagnostic a été posé à l'aide d'une évaluation histologique qui a démontré des cellules géantes typiques de Langhan et une nécrose caséeuse, avec la détection d'ADN mycobactérien par le test GeneXpert TB. L'ATL isolée est une énigme diagnostique mais doit être envisagée chez les femmes jeunes et d'âge moyen dans les régions d'endémie tuberculeuse présentant des ganglions lymphatiques axillaires hypertrophiés en l'absence de foyers d'infection ou de malignité. La différence entre les sexes dans la réponse immunologique à l'infection peut expliquer cette présentation unique parmi le sexe féminin. Mots clés: tuberculose axillaire isolée; Mycobactérie; histopathologie; rapport de cas Isolated axillary tuberculous lymphadenitis Afr.
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... Isolated axillary TB lymphadenitis is extremely rare and is described in a patient with enlarged axillary lymph nodes without previous or active pulmonary TB or evidence of extrapulmonary TB elsewhere (7,10). In the case reported, systemic TB was immediately considered after diagnosis of tuberculous lymphadenitis was made. ...
... However, the absence of radiological features on chest X-ray excluded pulmonary TB. From the literature, only six such cases have been documented, affecting only women within the age of 21-69 years, with predilection for left axilla (3,4,7,8,10,11,12). This pattern of presentation is however poorly understood. ...
Isolated axillary tuberculous lymphadenitis in a Nigerian female: A case report with review of the literature
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Full-text available
  • Jul 2023
Tuberculosis (TB) is a chronic granulomatous infectious pulmonary and systemic disease caused mostly by members of the Mycobacterium tuberculosis complex (MTBC). It has variable clinical presentation and is a major cause of morbidity and mortality in the middle-and-low-income-countries (LMICs). Isolated axillary tuberculous lymphadenitis (ATL) is rare and is defined as the presence of axillary tuberculous lymphadenitis in the absence of previous or active pulmonary TB or evidence of extrapulmonary TB elsewhere. We present a case of isolated ATL in a 54-year-old HIV-negative Nigerian woman, whose diagnosis was made using histological evaluation that demonstrated typical Langhan’s giant cells and caseous necrosis, with the detection of mycobacterial DNA by GeneXpert TB test. Isolated ATL is a diagnostic enigma but should be considered in young and middle-aged women in TB endemic regions presenting with enlarged axillary lymph nodes in the absence of foci of infections or malignancy. Sex difference in immunological response to infection may account for this unique presentation among the female gender.
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... Similar ndings were observed by Fujii T et al and Nwagbara 20.3% cases of tuberculous lymphadenitis . Isolated axillary tuberculous lymphadenitis is rare and described in patients without previous or active pulmonary TB and no evidence of the origin of TB 15,16 detected elsewhere . Tuberculous lymphadenitis presents as a painless, slowly progressive swelling of a single group of nodes and in 17 85% of cases involvement is unilateral . ...
“TUBERCULOSIS – A COMMON GRANULOMATOUS DISEASE AT UNCOMMON SITES: A COMPREHENSIVE HISTOCYTOLOGICAL STUDY IN A TERTIARY CARE HOSPITAL OF CENTRAL INDIA”
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Background: Tuberculosis (TB) is a common granulomatous disease caused by Mycobacterium tuberculosis, which primarily affects lungs in about 80 % of cases. Extrapulmonary tuberculosis (EPTB) is dened according to WHO classication criteria as an infection by M. tuberculosis which affects tissues and organs outside the pulmonary parenchyma. Among EPTB the most common location is cervical lymphadenopathy (63- 77%). Involvement of other organs or location is extremely rare, even in countries in which tuberculosis is endemic. Aim:To study the common granulomatous lesion, tuberculosis at uncommon sites on histological and cytological preparations. Materials and methods: A retrospective study of 76 cases (presented during two years), of extrapulmonary tuberculosis excluding lung, pleura and cervical lymph nodes was undertaken. Cases were selected according to the inclusion and exclusion criteria. After morphological diagnosis, cases were subjected to modied ZN staining. This was correlated with ultrasonography and Cartridge Based Nucleic Acid Amplication Test (CBNAAT) wherever available. Results: Majority of cases (63.2%) were females. Most of the cases (28/60) belonged to the age group between 21 and 30 years. Most common of the uncommon sites were axilla followed by breast and submandibular region. Conclusions: Extrapulmonary tuberculosis is quite common and keeping a high index of suspicion helps in early diagnosis and hence early treatment of this disease.
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... Cervical lymph nodes constitute the most common site of involvement with axillary nodes affected in 3.8-20.3% of tuberculous lymphadenitis [1,2]. Isolated axillary tuberculous lymphadenitis is rare and described in patients without previous or active pulmonary TB and no evidence of the origin of TB detected elsewhere [3,4]. Tuberculous lymphadenitis presents as a painless, slowly progressive swelling of a single group of nodes and in 85% of cases involvement is unilateral [5]. ...
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Tuberculosis (TB) still accounts for a high burden disease. It has been estimated that one third of the world population is infected with Mycobacterium tuberculosis, the most residing in developing countries. Separated axillary tuberculous lymphadenopathy is rare and described in patients without proof of previous or outstanding tuberculosis anywhere in the body. TB was supposed to be considered in the differential diagnosis of patients who present with axillary lymphadenopathy, especially in the endemic areas of Tuberculosis. Ultrasonography features of the axillary lymph node in our patient were not as helpful in diagnosis as the biopsy of the lymph node. Axillary tuberculous lymphadenitis diagnosis depends on the complete pathological examination. It remains both diagnostic and therapeutic challenge because it mimics other pathologic processes and yields inconsistent physical and laboratory findings. Diagnosis is difficult often requiring biopsy.
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... Both cases had no evidence of mammary TB or other sites of lymph node involvement and had no prior history or exposure to TB. Lymph node TB should be suspected when lymph node swelling is noted and x-ray shows clustered calcifications in axillary lymph nodes [9]. In spite of that, malignant and inflammatory lymph nodes cannot often be definitely distinguished based on mammographic criteria, Computerized Tomography [CT], or Positron Emission Tomography [PET] scans [15,16]. In most of the reported cases tuberculous lymph nodes were incidentally discovered after the patient had undergone axillary dissection for breast cancer especially that a calcified tuberculous lymph node is not a common phenomenon. ...
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Objective: To review the challenges in treating patients with breast cancer and history of or co-existing tuberculosis [TB]. Method: A review of the data base of the breast unit at King Fahd General Hospital performed from 1998 till end of July, 2012. Records of all breast cancer patients seen in that period [221 patients] were reviewed for clinical, radiologic, pathologic data and disease outcome. Results: In the study period, there were 7 cases with concurrent or past history of tuberculosis. Two cases had concurrent tuberculosis of axillary lymph nodes, one had contralateral calcified tuberculous axillary lymph nodes that were radiologically suspicious for malignancy and the other one had ipsi-lateral tuberculous axillary lymph nodes discovered during axillary dissection. Both were reluctant to receive the lengthy anti-tuberculous treatment for an asymptomatic disease. Three cases had past history of pulmonary tuberculosis, 2 of them presented with multiple lung nodules that were radiologically indistinguishable [whether tuberculous or metastatic nodules] and eventually they died of lung metastases. They had no radiologic evidence of skeletal or other metastatic sites. One case had past history of treated synovial [knee] and cerebral tuberculosis presented with lung metastases. She also had a thigh lesion that was suspicious for tuberculosis but proved histologically to be metastatic in nature. The last case had a past history of treated ovarian tuberculosis; she had multiple calcified pelvic nodules on computerized tomography. The last 2 cases received chemotherapy with no evidence of reactivation of tuberculosis. Conclusion: The presence of tuberculosis with breast cancer cause clinical and radiologic diagnostic difficulties and requires extra invasive diagnostic procedures for differentiation. Fear of tuberculosis reactivation with chemotherapy may force clinicians to prescribe prophylactic anti tuberculous treatment unnecessarily. A well planned management with psycho-social support is mandatory to maximize patient compliance.
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... Cervical lymph nodes constitute the most common site of involvement with axillary nodes affected in 3.8-20.3% of tuberculous lymphadenitis [1,2]. Isolated axillary tuberculous lymphadenitis is rare and described in patients without previous or active pulmonary TB and no evidence of the origin of TB detected elsewhere [3,4]. Tuberculous lymphadenitis presents as a painless, slowly progressive swelling of a single group of nodes and in 85% of cases involvement is unilateral [5]. ...
View
... High FDG uptake is also seen in other pulmonary abnormalities like pneumonia, aspergillosis, histoplasmosis, Cryptococcus, lung abscess, Wegener granuloma, sarcoidosis, inflammatory pseudo tumor, Schwannoma, and mesothelioma. 6,7 The exact role of FDG PET and PET-CT in TB and other inflammatory diseases is evolving, and there is early evidence to show that they could be used for evaluating treatment response of some granulomatous diseases. [8][9][10] The intense FDG uptake in the pleural lesions, lymph nodes, lung nodules, and skeletal lesions is a pattern that is common to both TB and lung adenocarcinoma 11 (as was seen in our report). ...
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... Moreover, breast MRI did not exclude malignant right axillary lymph nodes. Yang et al. reported a case of tuberculous axillary lymph node that was misinterpreted by 18 F-fluorodeoxyglucose positron emission tomography (FDG-PET) as a malignant metastatic disease from a possibly occult breast cancer [10]. ...
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Full-text available
  • Feb 2013
  • World J Surg Oncol
Background Breast cancer coexisting with tuberculous axillary lymph nodes is rare. Case report We report a 69 years old Yemeni patient with a left breast invasive ductal carcinoma associated with contralateral tuberculous axillary lymph nodes containing microcalcifications mimicking malignancy. The patient had to be investigated for the possibility of bilateral breast cancer since she had no history of previous exposure to tuberculosis. Conclusion Tuberculosis involving lymph nodes can create a diagnostic dilemma in the presence of a malignant process. The presence of calcifications in lymph nodes should raise the possibility of tuberculosis even in the absence of contact history with tuberculosis.
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... [3] TB of the hip joint accounts for about 15% of cases of tubercular osteomyelitis. [4] Although the PET/CT appearances of pulmonary and extrapulmonary TB have been described in the past, [3,5,6,7] there are limited reports on the role of PET/ CT in the evaluation of TB of the hip joint. [8] Increased FDG uptake has been visualized in regions of active granulomatous inflammation in musculoskeletal TB, with cold areas in necrosed tissue containing pus. [9] The same findings were noted in our case too, with highest uptake (SUV 6.7) noted at the hip joint, and relatively low uptake in the region of cold abscess. ...
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  • Jan 2011
Tuberculosis (TB) has become a global health concern. Cross-sectional imaging modalities like ultrasound, computed tomography and magnetic resonance imaging play an important role in the diagnosis, assessment of disease extent and response to treatment. PET/CT, a unique molecular imaging technique, allows the most accurate correlation of anatomic and metabolic information. We report a case wherein PET/CT played a significant role and contributed valuable information in the evaluation of a patient with TB of the hip. A brief review of the existing literature on the role of PET/CT in musculoskeletal TB is also discussed.
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FDG-PET in infectious lesions: The detection and assessment of lesion activity
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  • Jun 1996
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Yamada S, Kubota K, Kubota R, Ido T, Tamahashi NHigh accumulation of fluorine-18-fluorodeoxyglucose in turpentine-induced inflammatory tissue. J Nucl Med 36: 1301-1306
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Full-text available
  • Aug 1995
Fluorine-18-2-deoxy-2-fluoro-D-glucose ([18F]FDG) uptake and distribution in an experimentally induced inflammatory tissue were investigated. Rats were subcutaneously inoculated with turpentine oil to induce inflammation and used for tissue distribution studies and autoradiography. Time course study of [18F]FDG tissue distribution showed that the uptake in inflammatory tissue increased gradually until 60 min and then decreased. A longitudinal study of [18F]FDG tissue distribution showed that the uptake increased progressively to a peak 4 days after inoculation and then decreased. On the fourth day postinoculation, a section of inflammatory tissue showed characteristic changes of chronic inflammation. Macro- and micro-autoradiography showed a high density of silver grains in the abscess wall consisting of an inflammatory cell layer and granulation tissue. Grain counting on micro-autoradiography of the abscess wall showed that the highest grain density was found in the marginal zone of young fibroblasts, endothelial cells of vessels and phagocytes of neutrophils and macrophages, followed by that in the neutrophil layer and granulation tissue. Our results indicate that [18F]FDG PET may be useful in detecting and monitoring chronic inflammatory processes.
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F-18-FDG uptake in tuberculosis
Article
  • Nov 1998
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Evaluation of pulmonary lesions with FDG-PET - Comparison of findings in patients with and without a history of prior malignancy
Article
  • May 1996
The purpose of this study was to evaluate the accuracy of positron emission tomography (PET) using F-18 fluorodeoxyglucose (FDG) in differentiating benign from malignant pulmonary lesions both in patients with and without a history of prior malignancy. Forty-eight consecutive patients with pulmonary lesions suspicious for malignancy underwent FDG-PET scanning. Group 1 included 27 patients without and group 2 included 21 patients with a history of malignancy. Pathologic proof of diagnosis was obtained for 32 patients and 16 patients were followed up clinically and radiographically for at least 6 month. The standard uptake ratio (SUR) and the lesion to background (L/B) ratio were determined in 45 patients. Vanderbilt University Medical Center. In group 1, the average SUR and L/B ratio for malignant lesions (n=14) were 8.9 +/- 4.9 and 20.6 +/- 14.2, respectively. For benign lesions (n=12), the average SUR was 3.3 +/- 3.2 and L/B ratio was 5.2 +/- 5.5. In group 2, the average SUR and L/B ratio for malignant lesions were not significantly different from group 1. Using either a SUR greater than 2.5 or L/B ratio greater than 5 as an cutoff level to differentiate benign and malignant lesions, the sensitivity and negative predictive value in both groups were 100%. There were five false-positive studies in group 1 and one in group 2, including tuberculosis (n=2), a granulomatous lesion (n=1), an inflammatory lesion (n=1), a schwannoma (n=1), and a fibrous mesothelioma (n=1). The overall accuracy was 88%, 81% in group 1, and 95% in group 2. FDG-PET can identify malignant pulmonary lesions both in patients without and with a history of prior malignancy with a high sensitivity and negative predictive value for lesions greater than 1 cm (100% in this study). High FDG uptake by some inflammatory processes and benign tumors may cause false-positive results. Semiquantitative evaluation using SUR or L/B ratio provides similar accuracy.
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Normal physiological and benign pathological variants of 18-fluoro-2-deoxyglucose positron-emission tomography scanning: Potential for error in interpretation
Article
  • Nov 1996
  • SEMIN NUCL MED
The use of positron-emission tomography in clinical practice is increasing, particularly with the use of 18-fluoro-2-deoxyglucose (FDG) for oncological studies. As in other imaging modalities, it is important to be aware of normal variants and benign diseases that may mimic more serious pathology. Uptake of FDG in a number of sites may be variable. Uptake of FDG may be seen normally in the skeletal muscle after exercise or under tension, in the myocardium, in parts of the gastrointestinal tract, especially the stomach and cecum, and in the urinary tract. Some causes of increased physiological uptake are avoidable, and measures can be taken to minimize accumulation, thus aiding study interpretation. Inflammatory lesions may cause an increase in FDG uptake, but not usually to the same degree as malignancy. Benign disease such as Paget's disease of bone, sarcoidosis, and tuberculosis may cause uptake that occasionally mimics that of malignancy. Typical examples of a number of physiological and benign variants are described and illustrated.
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Axillary lymph nodes: Mammographic, pathologic, and clinical correlation
Article
  • Feb 1997
The purpose of this study was to determine the cause and frequency of axillary abnormalities seen mammographically and to evaluate the imaging characteristics of lymphadenopathy that are associated with malignancy. Ninety-six axillary abnormalities seen mammographically in 94 patients were retrospectively reviewed and correlated with the clinical diagnoses and pathologic results found in the medical records. For each abnormality, the length, margins, and presence of microcalcifications were noted. Logistic regression was used to determine an association between these findings and status (benign or malignant). Seventy-six of 94 patients had lymphadenopathy. Eighteen of 94 patients had an abnormality other than lymphadenopathy. Because two of these 94 patients had more than one abnormality, a total of 96 abnormalities occurred, 20 of which were due to an abnormality other than lymphadenopathy. Regarding the 76 cases of lymphadenopathy, the most frequent diagnosis was nonspecific benign lymphadenopathy in 29% (n = 22) of cases, followed by metastatic breast cancer in 26% (n = 20) and chronic lymphocytic leukemia or well-differentiated lymphocytic lymphoma in 17% (n = 13). Other causes (n = 21) included collagen vascular disease, lymphomas other than well-differentiated lymphocytic lymphoma, metastatic disease from nonbreast primary site, metastatic disease from unknown primary site, sarcoidosis. HIV-related lymphadenopathy, and reactive lymphadenopathy associated with a breast abscess. An association between length of nonfatty lymph nodes and malignant status was statistically significant at the .001 level. When a length greater than 33 mm was used as a predictor of malignancy, the specificity and sensitivity were 97% and 31%, respectively. We found an association between malignancy and nonfatty lymph nodes with ill-defined or spiculated margins (p = .053). Regarding the 20 abnormalities other than lymphadenopathy, epidermal cysts (n = 7) were most prevalent. The most common axillary abnormality revealed on mammography was abnormal lymph nodes. Homogeneously dense (nonfatty) axillary lymph nodes were strongly associated with malignancy when the lymph nodes were longer than 33 mm, had ill-defined or spiculated margins, or contained intranodal microcalcifications. However, our study confirmed that in most cases benign and malignant lymph nodes cannot be distinguished from each other mammographically.
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The clinical importance of axillary lymphadenopathy detected on screening mammography
Article
  • Jul 1997
  • CLIN RADIOL
The aim of this study was to determine the incidence and cause of axillary lymphadenopathy detected by screening mammography and to devise a management protocol for this pathology. In a retrospective study of 95,806 consecutive screening mammograms, 37 cases of 'pathological' axillary nodes were identified using two or more of the following criteria: size > 2 cm, replacement of fatty hilum, rounded shape and generalized increased density. In 16 cases with an additional mammographic abnormality, 12 had a mass (10 malignant and two benign) and four had suspicious calcification (all malignant). In 12 of these cases, the lymph nodes showed malignancy (75%). In 21 patients with lymphadenopathy alone on screening, six patients had a known underlying diagnosis and were not recalled from screening. The remaining 15 patients were recalled for further assessment including fine needle aspiration cytology (FNAC). The ultimate diagnosis was benign in 10 cases (48%)--six reactive changes, one healed granulomatous disease, one rheumatoid arthritis, one amyloid and one acute infection--and malignant in 11 cases (52%)--six non-Hodgkin's lymphoma, four metastatic carcinoma and one leukaemia. In conclusion, there is a high incidence of malignant nodal involvement in cases of screen detected lymphadenopathy (62% of cases in our series). We would advise that patients with lymphadenopathy as the sole finding on screening mammography and in whom there is no known underlying cause should undergo FNAC followed by excision biopsy. Fifty per cent of such patients in this study had underlying malignancy.
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Positron emission tomography in diagnosis of occult adenocarcinoma of the breast
Article
  • Oct 1998
  • AM SURGEON
Occult adenocarcinoma with clinically apparent axillary lymphadenopathy represents a challenging surgical problem. Mammography is frequently unable to identify a primary breast carcinoma, and extramammary sources are common and equally difficult to identify. This may leave the clinician and patient with a conundrum of whether to proceed with "blind" mastectomy. A 35-year-old white female presented with axillary adenopathy and a normal breast physical exam. Mammography was unable to demonstrate a specific tumor. Excisional biopsy of the axillary lymph node demonstrated metastatic adenocarcinoma. Positron emission tomography showed increased uptake in the breast and the axilla, consistent with breast carcinoma and axillary metastases. The patient underwent modified radical mastectomy and pathologic review of the specimen proved infiltrating ductal carcinoma in the breast with metastatic nodes. Positron emission tomography may be helpful in localizing occult carcinoma of the breast that presents with metastatic lymph nodes and in excluding other potential primaries.
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