SMJ 2003: 48(2) 52-53
Tanju Acar, İsmail Gömceli, Kerim Güzel, Aylin Yazgan, Raci Aydın
From: Emergency Aid and Traumatology Hospital. Ankara -TURKEY
*Department of Surgery
**Department of Pathology
Correspondence adress
Dr Tanju Acar
Söğütözü sitesi.
Akasya apt.No=8
SöğütözüANKARA---TURKEY
e-mail = tanju _acar@ yahoo.com
INTRODUCTION
Hydatid cyst is a lesion caused by the larval form of
Echinococcus granulosus and encountered endemically in sheep breeding
communities . Humans are occasional intermediate hosts of this organism . The
oncospheres , which are ingested , penetrate the intestinal mucosa , enter the
blood stream and develop into hydatid cysts in various organ and tissue . 70% of
the cysts are detected in the liver , 20% in the lung , and the rest in other
organs ( 1 ) . The breast is a rare
primary site of hydatid cyst that accounts for only 0.27% of all cases ( 2 ) .
We describe the case of a 37 year-old woman who had a breast lump , which was
found to be a hydatid cyst on pathological examination .
CASE REPORT
A 37 year old woman presented at the Emergency department with a lump
and pain in the right breast . She had no history of injury , discharge from the nipple , fever or drug misuse ,
and no risk factors for breast cancer . On clinical examination the left breast
was normal . There was a 5x4x3 cm firm
, slightly mobile , mass with regular border ,
in the upper outer quadrant of the right breast . Both nipples were
normal and she had no axillary or supraclavicular lymphadenopathy . Initial
ultrasonography examination confirmed the presence of rounded mass with
a cystic area inside . (Fig
1 , 2 ) . A posteroanterior radiograph of the chest and abdominal ultrasound
scan showed no other abnormality . On needle aspiration of the lump , 4 ml of
clear fluid was obtained . Post-aspiration examination revealed a residual lump
, so an excisional biopsy was done . The mass appeared to be a cyst with
thickened membranes and dense surrounding fibrous tissue . Complete excision was
performed . On sectioning , it was realized that this mass could be a hydatid
cyst since a laminated membrane was seen . Post operative echinococcal
haemagglutination test was positive 1/800 , suggesting hydatid disease .
Pathologic examination confirmed a primary hydatid cyst of the breast with
laminated membranes and scoleces ( Fig
3 ) . Post-operative abdominal ultrasonography , chest radiography , and
bilateral mammography did not reveal any other hydatid cysts . With no further
treatment , she remains free of any recurrence 24 months after surgery .
DISCUSSION
Hydatid cysts are caused by larval tapeworm of the genus Echinococcus .
Echinococcus granulosus is the most common species , but Echinococcus
multilocularis and Echinococcus olgarthrus also infect man . The disease is a
serious problem in sheep and cattle rearing areas of the world , particularly
Australia , New Zealand , the Middle East , Mediterranean countries , and South
America . Hydatid disease of the breast is extremely rare . The breast can be
the only primary site or part of disseminated hydatidosis . Typically , the
patient presents with a painless breast lump that slowly increases in size and
when secondary infection exists the lesion is clinically indistinguishable from
breast abscess ( 3 ) . It generally affects women 30-50 years of age , although
a wider age range ( 26-74 ) has been reported ( 4 ) . Clinically , a hydatid
cyst in the breast might mimic fibroadenomas , cystic mastopathies , phylloides
tumors , chronic abscesses , or even carcinomas . No specific signs are found on
examination .
The diagnosis
of hydatid cyst of the breast based on results of fine-needle aspiration
cytology ( FNAC ) has previously been reported and no urticarial or anaphylactic
reactions have been reported as a complication of this procedure( 5 ) . The
laminated membrane or the diagnostic hooklets obtained by FNAC were sufficient
for preoperative diagnosis (6) .
Mammography shows a nonspecific , homogenous , smooth , circumscribed
lesion ( 7 ) . Differential diagnoses include cysts , fibroadenomas , phylloides
tumors , and rarely circumscribed carcinomas .Vega and associates were the first
to report the characteristic ring - shaped structures inside the mass in an
unintentional performed overpenetrated view ( 8 ) . They suggested that this
finding might be the result of the difference in the density of the walls and
the contents of the daughter cysts inside the fluid-filled hydatid cysts . Such
an overpenetrated view might be recommended in endemic areas if FNAC or breast
ultrasound results were suggestive of hydatid disease . The sonographic
appearance of mamary hydatid cysts is similar to those seen in other organs .
The fluid level seen in various intact daughter cysts is strongly due to
hydatid sand ,a mixture of infolded membranes , fragmented
hooklets , and debris , similar to earlier findings in hydatid lesions in
the liver ( 9 ) .
Immunologic tests such as intradermal and indirect hemagglutination
tests , may help to confirm the diagnosis .The positive serum reactions might
occur even in the absence of
associated liver and lung involvement ( 10 ) .
Hydatid cyst and breast abscess produces similar magnetic resonance
imaging findings ( 11 ) .A well-circumscribed cystic lesion with capsular
enhancement may suggest a hydatid cyst of the breast if the results of a
physical examination are not suggestive of a breast abscess .
In conclusion , despite its rareness , primary breast involvement might
constitute an important differential diagnosis of breast lumps in areas endemic
for hydatid disease .
REFERENCES:
Demirci
S , Eraslan S , Anadol E , Bozatlı L . Comparison of the results of
different surgical techniques in the management of hydatid cysts of the
liver. World J Surg 1989 ; 13 : 88 - 91.
Abi
F , Fares F , Khasis D , Bouzidi A . Unusual localization of hydatid cysts .
Aproposes of 40 cases . J Chir 1989 ; 26 : 307 - 312 .
Quedraogo
E G . Hydatid cyst of the breast.20 cases . J Gynecol Obstet Biol Reprod
1986 ; 15 : 187 -194 .
İloki
L H , Lefebvre G , Darbios Y , Tranbaloo P . Hydatid cyst of the breast .
Case report . Gynecol Obstet 1992 ; 87: 35 -38 .
Epstein
N A . Hydatid cyst of the breast:diagnosis using cytological techniques .
Acta Cytol 1969 ; 13 : 420 - 421 .
Sagin
H B , Kiroğlu Y , Aksoy F . Hydatid cyst of the breast diagnosed by
fine needle aspiration biopsy . A case report . Acta Cytol 1994 ; 38 : 965 -
967 .
Kurul
S , Tenekeci N , Topuzlu C . Case report:an unusual mass in the breast:the
hydatid cyst . Clin Radiol 1995 ; 50 : 869 - 870 .
Vega
A , Ortega E , Cavada A , Garijo F . Hydatid cyst of the breast :
Mammographic findings . Am J Roentgenol 1994 ; 162 : 825 - 826 .
Niron
E A , Ozer H .Ultrasound appearances of liver hydatid disease . Br J Radiol
1981 ; 54 : 335 338 .
Perez JA , Castillo P , Henning E , Perez A . Breast hydatid cyst . A case report . Rev Med Chil 1977 ; 125 : 66 - 70
11. Tukel S , Erden I , Koçak S M . Hydatid cyst of the breast : MR imaging findings . Am J Roentgenol 1997 ; 168 : 1386 -1387 .