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We present two examples of Liesegang rings occurring in association with duct ectasia. Liesegang rings are a rare phenomenon usually found in association with cystic or inflammatory lesions, and may be mistaken for parasites.
The first patient, a 52 year old woman, had a radiological code 4 mass lesion on screening mammography. Needle core biopsy (NCB) showed breast tissue infiltrated by sheets of single cells, with abundant foamy cytoplasm and slightly eccentric nuclei. Cytological atypia was minimal and there was no significant mitotic activity. The cells were admixed with lymphocytes, plasma cells, and neutrophil polymorphs. Immunohistochemical studies showed that the lesional cells were strongly CD68 positive and cytokeratin negative, confirming the haematoxylin and eosin impression of an inflammatory process, and excluding histiocytoid carcinoma. The aetiology of the inflammatory process was not apparent on NCB and, in view of the radiological suspicion of malignancy, the patient proceeded to excisional biopsy. This revealed a 1 cm slightly irregular lesion with a white cut surface and yellow foci centrally, bordered by fatty breast tissue. Microscopically, the lesion was composed of an irregular dense aggregate of histiocytes, lymphocytes, plasma cells, and neutrophil polymorphs, as seen on NCB. Within the aggregate of inflammatory cells, foreign body type giant cells were identified, some of which were associated with round acellular structures. These structures typically comprised a double layered outer wall containing evenly spaced radial cross striations, surrounding dense amorphous non-refractile orangophilic material, interpreted as Liesegang rings (fig 1). There was evidence of fat necrosis and florid duct ectasia in the immediate vicinity. The overall histological appearances were thought to represent a predominantly histiocytic inflammatory process incorporating Liesegang rings, secondary to a ruptured ectatic duct. There was no evidence of malignancy.
The second patient, a 54 year old woman, had a radiological code 5 mass lesion in the upper inner quadrant of her right breast on screening mammography. After a needle core biopsy diagnosis of invasive ductal carcinoma with associated ductal carcinoma in situ, she underwent therapeutic wire guided breast wide local excision and sentinel lymph node biopsy. The breast specimen showed a 15 mm, grade 3, invasive ductal carcinoma, with extensive high grade ductal carcinoma in situ. Three sentinel lymph nodes were negative for metastatic carcinoma. The tissue lateral to the tumour showed features of duct ectasia. Liesegang rings were present in the lumen of one of the ectatic ducts and in the adjacent tissue with an associated foreign body type giant cell reaction.
Liesegang rings are laminated spherical ring-like structures that develop usually in relation to cystic or inflammatory lesions. The rings are typically composed of a mixture of calcium, iron, silicone, and sulfur and form by periodic precipitation from a supersaturated colloidal solution.1 Liesegang rings are rare and have been described primarily in the setting of renal cysts,2 but have also been observed occasionally in association with breast cysts, endometriotic lesions, and cysts at other sites.3–5 In the above two cases, the Liesegang rings were related to duct ectasia and in the first case were an integral part of the mammographic lesion. Liesegang rings may be mistaken for psammoma bodies or parasites. Liesegang rings lack the internal organs of true parasites and have a characteristic histological configuration, as described above. Accurate identification of Liesegang rings supports the diagnosis of a cystic or inflammatory process, and decreases the possibility of erroneous misdiagnosis as another type of pathological process.
Full consent was given for the publication of these cases.