Dr. Saroj K. Suwal, OncoSurgery Department, BCH
People generally come the hospital with complain of breast lump over thinking that they have carcinoma of breast but it’s not always true and while investigation is done for breast screening, tubercular breast is also encountered. Breast Tuberculosis is one of the rare types of tuberculosis all over the world. In Western Communities, it is found as less than 0.1 % but in the developing countries the incidence increases as other different types of tuberculosis. In context of Nepal also , the breast tuberculosis is diagnosed increasingly day by day as comparison to past days It might be due the misdiagnosis as Breast cancer and abscess as they appear similar symptoms and findings
Atypical Mycobacterium Verfaillie is found to be dominant in breast tuberculosis.
Route of infection:
Major route of infection can be point out as: Hematogenus, through vascular systems; Lymphatic, through lymph nodes; Ductal infection, mammary duct infections and due to tuberculosis on Surrounding structures like chest wall, skeleton. Whereas breast tissue is considered as the resistant to tuberculosis.
As mentioned before also, the most of the symptoms appear as those similar to the Breast Cancer. Generally it present as the breast lump in central or upper outer quadrant which is found to have most command frequent extension of Tubercular bacteria from axillary nodes to breast. As the disease advances, there might be the abscess formation and skin indurations with or without sinus formation may occur. With the treatment with antibiotics as for the breast abscess, it might subside for time being but later recurrent abscess formation is also one of the major findings in the tubercular breast. Tubercular ulcer over the breast tissue and breast abscess with or without discharging sinus is most common form of Tubercular breast. In case of Breast Cancer , there will be hard , irregular breast lump fixed to either skin or chest wall. In tubercular mass is mostly mobile in nature till it advances to secondary and surrounding structures like axilla, chest wall. Nipple might also be retracted also. Pau de Orange, nipple discharge with purulent nature is mostly seen in secondary extension.
According to the Meckewon and Wilkinson, Breast Tuberculosis can be classified into
- Nodular Tubular mastitis
There will be well circumscribed, slow growing painless mass/es over the breast. It may ulcerate and form sinus with painful in nature. At early stage, it’s more likely as fibroadenoma where as in later stages, it mimics Carcinomas
- Disseminated Tubercular Mastitis
In dominated type, there will be multiple foci seen over the breast. Later it advances to the formation of the sinus. The overlying skin will be thickened. The skin may or may not be ulcerative. Breast will be tensed and tender. Axillary Lymph nodes enlarged and palpable with matted nature
- Sclerosing Tubercular Mastitis
In this type, excessive fibrosis of breast tissue occurs which is most common dominating feature. Hard painless slow growing lump with nipple retraction are other features. This might resembles to Scirrhotic Ca due to dense fibrosis
- Tubercular mastitis obliterans
This is generally occurred due the duct infection with proliferation of lining epithelium. Marked epithelial and periducatal fibrosis is found. The ducts are occluded and cystic formation occur resulting cystic mastitis
- Acute Millary tubercular mastitis
It is the rarest mastitis among all the types. It will be one of the parts of the Millary tuberculosis.
To diagnose tubercular mastitis we generally have to access the patient clinically with the history. There might or might not be Koch’s History like evening fever, night sweating, past history of Tuberculosis to self or in family. For laboratory assessment we performed following examinations
- CBC, ESR
- AFB Sputum, AFB of nipple or wound discharge
- Monteux test
- Sputum culture, Discharge Culture, PCR,
- Radiological Investigation : Chest X-Ray, USG , Mammogram, CT
- Histopathology (FNAC, Biopsies)
In Past days mastectomy used to be recommended for breast tuberculosis but now-a-days conservative surgery followed by anti-tuberculosis chemotherapy is the treatment of choice. In the early stages anti- tuberculosis chemotherapy and in late cases lumpectomy or excision of the sinus tract along with anti-tuberculosis chemotherapy gives good results.
Published on the souviner of NCRS Bhatkapur chapter on 2069