Dear Patricia,

I have copied the article from the Lancet below. It is not about the
lactating breast, but I was wondering if it could be a possiblility in a
lactating woman in which the more common causes of breast lumps had been
ruled out, in which case, testing to rule out diabetes might be suggested?
Just something that came to mind when I read it.

Kathy

A diabetic breast lump
Lukas Zimmerli, Hueseyin Yurtsever, Dieter Conen, Kaspar Truninger

Lancet 2000; 357: 1670

Department of Medicine (L Zimmerli MD, D Conen MD, K Truninger MD) and
Pathology (H Yurtsever MD), Cantonal Hospital Aarau, CH-5001 Aarau,
SwitzerlandCorrespondence to: Dr K Truninger, St Mark's Hospital, ICRF
Colorectal Cancer Unit, Northwick Park, Harrow HA1 3UJ, UK(e-
mail:[log in to unmask])

A 36-year-old Turkish woman was referred to our hospital in April, 1999,
for the surgical excision of a left-sided breast lump. She had a 1-year
history of a painless mass increasing in size. Her medical history included
surgical therapy of varicose veins and a leiomyoma of the uterus. The
family history was unremarkable. Clinical examination confirmed a 5 cm
painless, hard, well-defined mobile mass, with no discharge from the
nipple, and no enlarged axillary lymph nodes. The mammogramm showed a
single mass within dense mammary tissue with no evidence of carcinoma, and
ultrasonography showed acoustic attenuation behind the nodules. Fine needle
aspiration contained insufficient cellular material for diagnosis.
Preoperative laboratory tests showed hyperglycaemia of 15·6 mmol/L.
Additional postoperative tests found antibodies to islet-cell and raised
antibodies to glutamic acid decarboxylase (1170 KU/L, normal <70 KU/L).
Macroscopic examination of the excised specimen showed a firm node, 5 cm
maximum diameter with a greyish-white and rather homogenous cut surface.
Microscopic examination showed a lymphocytic infiltrate in both the
intraobular and perilobular areas of the mammary gland with perivascular
distribution in places, but no signs of neoplasm (figure).
Immunohistochemical findings showed a mixture of B and T lymphocytes with a
slight preponderance of B cells in a majority of the lobules. Based on
these findings, the diagnosis of type 1 diabetes mellitus with diabetic
mastopathy was made. When last seen in March, 2001, she was on insulin
therapy.
[]

Hematoxylin-eosin stained section of excised breast tissue
Two lobules of the mammary gland with intra- and perilobular lymphocytic
infiltrates, lobular and stromal fibrosis (magnificationx110).

Lesions in most organs have been described inlong-standing diabetes but the
breast is not usually included among these organs. In 1984 Soler & Khardori
reported the first cases of breast lesions in women with type 1 diabetes
mellitus.1 Subsequently, the association between breast disease and long-
standing insulin-dependent diabetes mellitus, designated as diabetic
fibrous breast disease (DFBD), diabetic fibrous mastopathy or diabetic
mastopathy, has been described in few publications.2-5 However, this
clinical disorder is poorly recognised since the breast is not routinely
examined in young diabetic patients, Diagnosis is based on the clinical
context as well as radiological and histopathological findings.2 DFBD
occurs in premenopausal women with early-onset, long-standing insulin-
dependent diabetes mellitus. On physical examination, one or more painless,
rock-hard, irregularly outlined, freely movable masses are found. These
lesions are equally distributed in all four quadrants. Mammograms show
dense breasts without features of malignancy. A typical pattern including
marked acoustic shadowing of sound waves is found on ultrasonography. Fine-
needle aspiration cytology is characteristically difficult in patients with
DFBD with 50% of aspirates reported as having insufficient cellular
material for diagnosis. Microscopic examination shows predominantly dense
stromal fibrosis, and the presence of intralobular and perilobular
lymphocytic infiltrates has been described as the hallmark of this disease.
In a recent study, the histopathologic features of DFBD were confirmed,
however, the specificity of these features have been questioned because
identical findings were occasionally seen in nondiabetic patients.4 The
lymphocytic infiltrate in DFBD is composed predominantly of B-cells.5 In
contrast, the infiltrating lymphocytes in non-diabetic mastitis are mostly
T cells. Based on these results and the coexistence of autoimmune
disorders, particularly thyroid disease and elevated antiparietal cell
antibodies, it is believed that autoimmunity is a central factor in this
benign breast disease.1,5 In a 6-year follow-up by Logan et al2 no breast
carcinoma developed. Our case is unusual in its presentation. In previous
series, patients with DFBD suffered from longstanding type 1 diabetes with
microvascular complications. In contrast to these cases, our patient had
newly diagnosed type 1 diabetes without retinopathy, nephropathy
(microalbuminuria 5 mg/L, normal <30), or neuropathy. No thyroid and
parietal cell antibodies were detectable in our patient. Our clinical
observation shows the need to examine the breast in young diabetic patients
without longstanding type 1 diabetes. Physicians of different specialities
need to be aware of the constellation of DFBD to spare young patients from
undergoing repeated biopsies and mutilating surgery.
References


1 Soler NG. Khardori R. Fibrous disease of the breast, thyroiditis,and
cheiroarthropathy in type 1 diabetes mellitus. Lancet 1984; 1: 193-95.
[PubMed]

2 Logan WW, Hoffman NY. Diabetic fibrous breast disease. Radiology 1989;
172: 667-70. [PubMed]

3 Rode S, Favre C, Thivolet C. Diabetic mastopathy. Diabetes Care 1998; 21:
322.

4 Ely KA, Tse G, Simpson JF, Clarfeld R, Page DL. Diabetic mastopathy: a
clinicopathologic review.  Am J Clin Pathol 2000; 113: 541-45. [PubMed]

5 Tomaszewski JE, Brooks JSJ, Hicks D, Livolsi VA. Diabetic mastopathy: a
distinctive clinicopathologic entity.  Hum Pathol 1992; 23: 780-86. [PubMed]
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