sarcoid is most common between the ages of 20 - 40 years and is more common in african americans . involvement of the breast is rare , but when it occurs , it can be confused with malignancy . the diagnosis of sarcoid does not exclude malignancy . because malignancy is far more common than sarcoid of the breast , malignancy a 64-year - old african american female was referred to our center with a complaint of new bilateral palpable breast masses and a reported history of diffuse increasing bilateral breast densities on the mammogram taken at another center . the patient denied family history of breast or ovarian cancer and had no history of trauma to her breasts . physical exam was remarkable for multiple palpable masses throughout both breasts with no overlying skin or nipple changes . the patient presented to our breast imaging department with printed copies of her digital bilateral mammogram images which were taken at an outside facility on 11/11/2011 . bilateral mediolateral oblique ( mlo ) and craniocaudal ( cc ) views were reviewed and demonstrated multiple new irregular spiculated masses within all quadrants of both breasts most prominent in the right upper outer quadrant and the left lower inner quadrant [ figure 1 ] . there were triangle skin markers denoting the areas of palpable abnormality in the patient and these corresponded to the areas of greatest increase in density . these mammograms were compared to her prior images which were dated 06/01/2010 , also from an outside facility [ figure 2 ] . additional compression views of the irregular masses in the right lower outer quadrant and the left lower central breast demonstrated that the irregular masses persisted . bilateral diagnostic mammogram with ( a ) mlo and ( b ) cc views demonstrates new spiculated masses throughout both breasts ( arrows ) which were all initially suspicious for carcinoma . comparison mammogram ( a ) mlo and ( b ) cc views 1 year prior shows only normal scattered fibroglandular breast tissue with no abnormal masses present . ultrasound examination of both breasts was performed utilizing a 12 mhz transducer ( toshiba alplio mx , japan ) . ultrasound of the bilateral breasts demonstrated multiple hypoechoic , taller than wide irregular masses with angular margins throughout both breasts at nearly every clock position [ figure 3 ] . gray - scale sonograhic image of the right breast demonstrates an irregular hypoechoic mass with angular margins ( arrow ) . similar masses were present in the bilateral breasts at nearly every clock position by ultrasound . the mammographic and ultrasound findings were suggestive of malignancy , and the patient subsequently underwent bilateral ultrasound guided core biopsy using a 14 gauge achieve biopsy device ( cardinal health , mcgraw park , il ) of the most suspicious appearing masses bilaterally at 6:00 and 11:00 oclock position in the left breast and at 6:00 and 12:00 oclock positions in the right breast . pathology results of the left breast lesion at the 6:00 oclock position showed invasive lobular carcinoma nottingham combined histologic grade ii / iii moderately differentiated [ figure 4 ] . pathology results of the left breast at the 11:00 oclock and right breast at 6:00 and 12:00 oclock positions all showed granulomatous inflammation consistent with sarcoid . auramine rhodamine and grocott 's methenamine silver stains were negative for acid - fast bacteria and fungus at all four biopsy sites . gray - scale sonographic image of the left breast at the 6:00 oclock position at the site of known lobular carcinoma also demonstrates an irregular hypoechoic mass ( arrow ) . breast mri ( magnetom verio 3 t , in vivo breast coil , siemens , germany ) was performed with intravenous contrast to evaluate the extent of disease . the mri demonstrated patchy areas of non - mass enhancement throughout all quadrants of both breasts [ figure 5a ] . the patient 's known invasive lobular carcinoma in the left breast at the 6:00 oclock position was indistinguishable from the known sarcoid lesions [ figure 5b ] . axial mri t1wi post contrast fat saturation subtracted images of the bilateral breasts ( a ) breast sarcoidosis presents as multiple patchy bilateral areas of non - mass enhancement ( arrows ) ( b ) known left breast lobular carcinoma at 6:00 oclock position ( arrow ) with susceptibility artifact from biopsy clip is indistinguishable from the surrounding sarcoid lesions . the patient underwent ct ( lightspeed , ge healthcare , uk ) of the chest to evaluate for sequela of sarcoid which revealed upper lobe predominant perihilar ground glass opacities with mild bronchiectasis consistent with sarcoidosis . on ct of the abdomen and pelvis , multiple soft tissue nodules of the omentum , left flank , and gluteal regions were noted which were all subsequently biopsy - proven to be granulomas consistent with sarcoid . the patient initially desired breast conserving therapy and was treated with left partial mastectomy and sentinel lymph node biopsy . surgical pathology revealed the presence of a 4.5 cm invasive lobular carcinoma of the left breast with ductal carcinoma in situ nuclear grade ii / iii ( intermediate ) and lobular carcinoma in situ . given the margin positivity , extent of the cancer , the complexity of the mammographic , sonographic , and mri imaging , and the need for treatment with steroids as well as adjuvant chemotherapy , the patient ultimately underwent a completion mastectomy with complete axillary lymph node dissection on the left side . the patient 's treatment plan for adjuvant therapy included cytotoxic chemotherapy , post mastectomy radiation , and endocrine therapy . sarcoidosis primarily involves the lungs , lymph nodes , spleen , liver , skin , eyes , muscles , myocardium , bones , cns , and salivary glands . sarcoid involvement of the breasts is rare , and occurs in less than 1% of sarcoidosis patients . it is also very rare for breast involvement to be the primary manifestation of sarcoid . most cases of breast sarcoid occur in patients who already have a known sarcoid diagnosis elsewhere in the body . in an article by ojeda et al . , 35 cases of sarcoidosis of the breast published between 1921 and 1997 were reviewed . only 20% ( seven cases ) had a breast mass as the initial manifestation , and only one patient ( 3% ) had bilateral breast masses . other findings may include enlarged axillary or intramammary lymph nodes ; however , in our case there was no abnormal lymphadenopathy present . these imaging appearances are all suspicious for malignancy and should be evaluated by core biopsy . the differential diagnosis of new irregular spiculated masses include malignancy , fibrosis , radial scar , prior surgery , granulomatous mastitis , diabetic mastopathy , and fungal or mycobacterial infections such as tuberculosis . particular note should be made that even mri is unhelpful for excluding malignancy in cases of breast sarcoidosis . on mri , sarcoid of the breast often presents as irregular enhancing masses making it difficult to distinguish from carcinoma as in the other imaging modalities . ishimaru et al . , reported a case of breast sarcoid presenting as an irregular mass which demonstrated slow progressive enhancement on serial post contrast mri imaging . however , other authors have reported breast sarcoid lesions demonstrating rapid enhancement with wash - out phenomenon which is commonly seen in breast carcinoma , making sarcoid lesions very difficult to distinguish from cancer . in our case , both the bilateral sarcoid lesions and the invasive lobular carcinoma of the left breast at the 6:00 oclock position demonstrated progressive enhancement on post contrast mri images . there was also a large area of sarcoidosis surrounding the area of known invasive lobular carcinoma seen at surgical pathology , making the extent of the cancer difficult to determine on any imaging modality . the possible association of sarcoidosis with a higher rate of malignancy remains controversial and unproven with conflicting results among various studies . many authors theorize that patients with sarcoidosis are predisposed to malignancy , although others believe that malignancy may lead to sarcodosis . in very rare cases such as ours as in this case , breast sarcoidosis often has imaging features mimicking malignancy on all imaging modalities and carcinoma must always be excluded by core biopsy . one possible management strategy is a baseline mammogram at the time of diagnosis of sarcoid or age 40 . our case was exceptional and presented a particular diagnostic and management challenge with both malignancy and primary sarcoidosis involving the breasts .
breast sarcoidosis is rare and usually presents in patients with known sarcoid involving other organ systems . in the breast 
 , sarcoidosis may mimic malignancy which must be excluded by core biopsy . 
 we report a very unusual case of primary breast sarcoidosis with incidentally discovered breast carcinoma . 
 the roles of mammography , ultrasound , and mri in the diagnosis as well as other potential differential diagnosis are discussed .