Mycoses of the Breast: Diagnosis by Fine-Needle Aspiration Charles Farmer, M.D., Michael W. Stanley, M.D., Ricardo H. Bardales, M.D., Sohelia Korourian, M.D., Hememdra Shah, M.D., Robert Bradsher, M.D., and Vicki S. Klimberg, M.D.

Fungal infections of the breast are unusual and may clinically mimic carcinoma. When studied by fine-needle aspiration (FNA), such masses may yield necrosis, granulomatous inflammation, reactive histiocytes, and atypical epithelial cells. Cohesive groups of atypical epithelial cells featured nuclear enlargement and over- lapping, as well as prominent nucleoli. The organisms may be widely scattered, so that careful evaluation was required for their identijicution. In concert with provocative clinical findings, these features may lead to an erroneous diagnosis of malignancy. We describe three women with mycotic masses of the breust initially studied by FNA. The first patient presented at age 31 with a large, firm breast mass, chest wall extension, and radiographic evidence of vertebral bone involvement. FNA was requested to confirm the clinical diagnosis of advanced breast carcinoma. In addition to the atypia described above, the smears showed yeast forms indicative of blastomycosis surrounded by neutrophils. She remains well, following antifungal treatment. The second case of Blastomycosis was diagnosed by FNA of a breast mass in a 64-yr-old woman, who also responded to treatment. The third patient 5 preoperative nee- dle aspiration showed granulomas, but no organisms were identi- fied, even with special stains: silver stains of surgically excised tissue showed histoplasmosis. Diagn Cytopathol 1995; 125 1-55. 0 1995 Wiley-Liss, Inc.

Key Words: Breast; Cytology; Fine-needle aspiration; Fungi; Mycoses; Blastomycosis; Histoplasmosis

Granulomatous lesions of the breast are uncommon. They may represent a reaction of the foreign body type, reaction to carcinoma, a lesion of unknown etiology (including sarcoidosis), or an infection (fungal or mycobacteria). It has been suggested that the otherwise idiopathic lesions known as lobular granulomatous mastitis may have an autoimmune pathogenesis.

Received January 17, 1994. Accepted July 7, 1994. From the Departments of Pathology, Medicine, Radiology, and Sur-

gery, University of Arkansas for Medical Sciences, Little Rock, AR. Address reprint requests to Michael W. Stanley, M.D., University of

Arkansas for Medical Sciences, Department of Pathology, Mail Slot 517, 4301 West Markham Street, Little Rock, AR 72205.

We describe our experience with three mycotic breast masses. Differential cytodiagnostic considerations are dis- cussed, as is the potential impact of cytologic diagnosis in the setting of planned neoadjuvant chemical therapy for presumed breast carcinoma.

Case Histories

Case 1 This 31-yr-old woman presented with a 4-cm right breast mass that had been enlarging over the preceding 2 months. At physical examination, the mass was tender, and most of the breast appeared indurated and erythematous. She had no other skin lesions. CT scan showed chest wall extension of the breast mass and involvement of vertebral bodies. Based on the working clinical diagnosis of ad- vanced breast carcinoma, the clinical team requested FNA for confirmation of the diagnosis, and for hormone receptor analysis. Following a cytologic diagnosis of blas- tomycosis, the patient was treated with fluconazole, and enjoyed complete resolution of palpable and radiographic disease. Culture of material from a repeat FNA showed Blastomyces derrnatitidis.

Case 2 This 64-yr-old woman was referred for evaluation of a 2-cm left breast mass that was clinically and mammo- graphically suspicious for carcinoma. Her chest radio- graph was clear, and she had no skin lesions. Fine-needle aspiration was performed. Following immediate initial ex- amination of the smears, a repeat aspiration was per- formed and submitted for fungal cultures. Following a cytologic diagnosis of blastomycosis (later shown by cul- ture to be Blustomyces dermatitidis), she was treated with itraconazole for 6 months. The lesion decreased rapidly in size and in mammographic density. The patient recovered fully.

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Case 3 This 74-yr-old woman had a history of rectal adenocarci- noma (moderately differentiated, transmural, with nega- tive regional lymph nodes). She was in her fourth month of treatment with 5-fluorouracil(5-FU), when a firm, ten- der, 4-cm left breast mass was noted. A mammogram showed suspicious skin thickening, but no dominant mass or suspicious calcifications. A recent chest radiograph was clear, and she had no skin lesions. FNA showed granu- lomatous inflammation. (This specimen was initially inter- preted as suspicious for malignancy. Our review of this archival case shows it to be of relatively poor quality and to have definite areas of granulomatous inflammation.) Following FNA, a core needle biopsy was obtained and showed granulomatous mastitis with necrosis. Silver- stained sections showed histoplasmosis. Culture of addi- tional aspirated material was negative. Itraconazole treat- ment led to complete resolution of the breast mass and tenderness.

Materials and Methods All FNAs were performed by cytopathologists, using 25- gauge (0.5-mm) needles. The aspirated material was smeared onto uncoated glass slides, and either air-dried or spray-fixed, for a Diff-QuikO or a Papanicolaou stain, respectively. Surgically excised tissue in case 3 was forma- lin-fixed, paraffin-embedded, sectioned at 4 pm, and stained with both hematoxylin and eosin, and Gomori methenamine silver (GMS).

Results Cases 1 and 2 were cytologically identical. There was a background of acute inflammation and fibrin, through which were scattered fragments of duct epithelium and histiocytes (Fig. C-1). The fibrinous exudate was much more apparent in the air-dried than in the fixed material. Cohesive groups of atypical epithelial cells featured nu- clear enlargement and overlapping, as well as prominent nucleoli (Figs. C-2, C-3). The organisms were widely scat- tered, so that careful evaluation was required for their identification. Individual yeast organisms, some of which showed broad-based buds, were enclosed in a corona of degenerating neutrophils. These Splendor-Hoppeli-like bodies greatly aided in locating the organisms at low mag- nification. The characteristic features of blastomycosis were noted in the Papanicolaou-stained smears. These in- cluded a thick, refractile outer wall, a clear cytoplasmic contraction zone, and punctate central nuclear material (Figs. C-4-C-6). Spherical yeast surrounded by neutro- phils was seen in the air-dried slides, but the morphologic details were less apparent in these preparations. Decrease in size of this lesion over the 6 weeks following diagnosis was documented radiographically (Fig. 1).

Case 3 showed cytologically and histologically typical granulomas. Central necrosis was appreciated in the sec- tions. No organisms were seen in the smears, or in the hematoxylin and eosin-stained sections. Based on the find- ing of necrotizing granulomatous inflammation, a GMS stain was applied to histologic sections, and showed the small yeast of histoplasmosis.

Discussion Granulomatous lesions of the breast are not common but include several entities. Extravasated secretory material and keratin produced by metaplastic ductal epithelium can elicit a foreign body reaction, as can iatrogenically placed substances such as silicon and sutures. Sarcoidosis can present in the breast or may be a manifestation of widespread disease. ’ A granulomatous reaction to infil- trating carcinoma is not common, but has been de- scribed.

The distinctive lesion usually designated “granuloma- tous mastitis” is a noninfectious, lobulocentric process that often bears a temporal relationship to pregnancy. Some have suggested an autoimmune pathogenesis for this lesion. It has been described in histologic, 3,4 and rarely, in cytologic material.

Granulomatous breast masses of infectious etiology in- clude those due to either mycobacteria or fungi. Tubercu- lous mastitis has been studied by fine-needle aspiration (FNA) and in nipple discharge specimens. Fungal lesions have been attributed to Candida, Blastomyces, Histo- plasma, Cryptococcus neoformans, and Coccidioides im- mitis. ’-” Actinomycosis and parasitic infestations such as Wuchereria bancrofi can also lead to granulomatous mas- titis. Primary diagnosis of mammary mycoses by cytologic means appears to be extremely uncommon.

The overriding significance of these disorders is that they can mammographically and clinically simulate carci- noma very closely. A mass that is very suspicious may be accompanied by cutaneous breakdown, sinus tracts, or skin changes similar to those seen with inflammatory car- cinoma. If an infection also features distant disease, this can easily be assumed to represent metastatic carcinoma superimposed on locally advanced malignancy.

We report three cases of fungal mastitis. Two were diagnosed as such by FNA, while the third was granulom- atous without an apparent etiology on smear material. The small yeast forms of histoplasmosis are difficult to visual- ize without special stains, unless large numbers are aggre- gated within macrophage cytoplasm in the pattern typical of disseminated disease. This explains the need for GMS stain in our case 3. The larger yeast of blastomycosis are more readily identified in routine preparations, as exem- plified by cases 1 and 2.

As in granulomatous mastitis of many types, each of our cases was clinically suspicious for carcinoma. The

52 Diagnostic Cytopathology, Yo1 12, No I

Fig. C-I Fig. C-2

Fig. C-3 Fig. C-4

Fig. C-5 Fig. C-6

Figs. C-1-C-6. Fig. C-1. Case I : This smear shows the background of blastomycosis. Red cells, neutrophils, and fibrin are abundant. This fragment of ductal epithelium is cohesive and features mild nuclear enlargement and overlapping (Diff-QuikB stain, X 100). Fig. C-2. Case 1: This group of epithelial cells show marked enlargement and nuclear overlapping with loss of orientation. The background shows a fibrinopurulent exudate similar to that in Figure C-l (Diff-Quikm stain, X600). Fig. (2-3. Case 1: This group of epithelial cells shows marked enlargement and nuclear overlapping. Chromatin clearing and nucleoli are present. The background fibrinous exudate is much less conspicuous than in the air-dried material illustrated in Fig. C-2 (Papanicolaou stain, x 600). Figs. C-4-C-5. Case 1: The characteristic features of blastomycosis, including a thick, refractile outer wall, a clear cytoplasmic contraction zone, and punctate central nuclear material, are seen in these smears. One of these shows a broad-based bud (Papanicolaou stain, ~ 6 0 0 ) . Fig. (2-6. Case 1: In the air-dried material the yeast forms of blastomycosis were spherical, deeply basophilic, and surrounded by neutrophils. Other details of their internal structure were less apparent than in the Papanicolaou-stained slides (Diff-QuikB stain, x 600).

FARMER ET AL.

Fig. 1. Case 2: Serial mammagraphs showed marked decrease in the size of the mass between the time of original diagnosis (A) and 6 weeks later (B). The metallic marker in B shows the initial size of the mass.

atypical epithelial cells seen in FNA material make the danger of false-positive diagnosis particularly great. If the clinical team plans neoadjuvant chemotherapy based on a cytologic diagnosis of malignancy, the patient may be placed at grave risk by such an error.

In addition to direct identification of infectious orga- nisms or granulomas, one should be very conservative when a fibrinopurulent exudate is seen in breast FNA material. Striking epithelial and stromal atypia may be present as a reactive or reparative process. Blastomycosis usually incites formation of granulomas with purulent in- flammation. The latter component should override any concern over cytologic atypia, and a diagnosis of malig- nancy should be withheld. Furthermore, the striking nu- clear abnormalities that we observed occurred in cohesive cells groups. The cytology of breast carcinoma usually features single, free-lying malignant cells rather that only

groups of abnormal cells. Such inflammatory breast masses should be reaspirated and the material sent for appropriate cultures and sensitivity testing. Our observa- tions emphasize the need to include fungi and acid fast bacilli in this evaluation.

The physical findings and the radiographs may be very striking in such cases, and the clinicians may be confident in diagnosing malignancy. However, if significant inflam- mation is present, or if organisms are suspected, one must resist the insistent urging of anxious clinicians to render such a diagnosis.

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