Breast tuberculosis with bone destruction mimicking breast cancer with bone metastasis: a case report and literature review
Case Report

Breast tuberculosis with bone destruction mimicking breast cancer with bone metastasis: a case report and literature review

Li-Xin Li1#, Ya-Wen Wang1#, Yuan Lin1, Yan-Duo Chen1,2, Xu Chen3, Xin Li4, Xiao-Lin Zhou5, Liang Su6, Mei-Ying Lin7, Kai Zhang1

1Department of Breast Surgery, General Surgery, Qilu Hospital of Shandong University, Jinan, China; 2Department of Pediatric Surgery, Central Hospital Affiliated to Shandong First Medical University, Jinan, China; 3Department of Pathology, Qilu Hospital of Shandong University, Jinan, China; 4Department of Nuclear Medicine, Qilu Hospital, Shandong University, Jinan, China; 5Shandong Public Health Clinical Center, Jinan, China; 6Department of Medical Service, Shandong Public Health Clinical Center, Jinan, China; 7Department of Tuberculosis Medicine Three Wards, Shandong Public Health Clinical Center, Jinan, China

Contributions: (I) Conception and design: K Zhang, YW Wang; (II) Administrative support: K Zhang, YW Wang; (III) Provision of study materials or patients: K Zhang, X Chen, X Li, XL Zhou, L Su, MY Lin; (IV) Collection and assembly of data: LX Li, Y Lin, YD Chen; (V) Data analysis and interpretation: LX Li, K Zhang, YW Wang; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

#These authors contributed equally to this work.

Correspondence to: Kai Zhang, MD. Department of Breast Surgery, General Surgery, Qilu Hospital of Shandong University, 107 West Wenhua Road, Jinan 250012, China. Email: zhangkai@email.sdu.edu.cn.

Background: Tuberculosis (TB) poses a significant global health challenge. While the incidence of breast TB (BTB) is relatively low, it can easily be mistaken for breast cancer or breast granulomatous lobulitis, potentially delaying timely intervention. The gold standard for diagnosis consists of Mycobacterium TB culture and Ziehl-Neelsen staining. Treatment typically consists of a combination of anti-TB therapy and surgical intervention.

Case Description: Our research group recently reported a case of BTB accompanied by rib bone destruction. Initially, imaging examinations suggested breast cancer with bone metastasis. However, subsequent real-time ultrasound-guided biopsy revealed chronic inflammation with granulomatous inflammation and extensive necrosis, which led to the diagnosis of BTB. Further T cells spot test (T-SPOT) testing predicted the likelihood of the presence of TB infection, and magnetic resonance imaging (MRI) indicated a high likelihood of TB. A biopsy of the breast lesions was performed and subsequent polymerase chain reaction (PCR) analysis of the aspirated specimens confirmed the presence of DNA from the Mycobacterium TB complex, as well as genes associated with rifampicin resistance. These findings led to the definitive diagnosis of BTB complicated by bone destruction. The patient underwent a 4-month course of anti-TB medication, followed by surgical intervention and an additional regimen of anti-TB drugs. Nine months post-surgery, the patient exhibited no indications of recurrence.

Conclusions: The diagnosis of BTB with bone destruction is challenging, and clinicians need to be vigilant not to misdiagnose it as breast cancer or granulomatous lobulitis.

Keywords: Breast tuberculosis (BTB); bone destruction; breast cancer; diagnosis; case report

Submitted Jun 18, 2024. Accepted for publication Oct 11, 2024. Published online Oct 26, 2024.

doi: 10.21037/gs-24-185

Highlight box

Key findings

• We report a case of breast tuberculosis (BTB) with bone destruction mimicking breast cancer with bone metastasis.

What is known and what is new?

• The incidence of BTB is low and it is easy to be misdiagnosed. Especially, BTB accompanied by bone destruction is easily misdiagnosed as breast cancer. BTB is usually treated with anti-tuberculosis (TB) drugs, and surgery is only a small part of the treatment.

• The diagnosis and management of this case have been complex. Following 4 months of treatment with anti-TB medications, the patient underwent surgical intervention after a thorough professional assessment, subsequently continuing anti-TB therapy, yielding favorable outcomes without any indications of recurrence.

What is the implication, and what should change now?

• It is challenging to distinguish BTB from other diseases, such as breast cancer and granulomatous lobulitis. BTB is associated with bone destruction and is easily confused with breast cancer with bone metastasis. The clinicians should thoroughly inquire about the patient’s history of TB exposure. The BTB should be considered when the disease course is prolonged, nonresponsive to anti-inflammatory therapy, and associated with a long-term inflammation.

Introduction

Tuberculosis (TB) is a significant global health issue and ranks as the second leading cause of infectious disease mortality worldwide (1). Breast TB (BTB), accounts for a small proportion, ranging from 0.025% to 0.1%, of all TB cases (2). In elderly patients, BTB may present in a very similar way to breast cancer with bone metastasis. However, young patients typically present with suppurative abscesses, which can be challenging to differentiate from granulomatous lobulitis. The diagnosis of BTB is very important because it determines the appropriate follow-up treatment. We present a case of BTB with bone destruction, initially misdiagnosed as breast cancer with bone metastasis. We present this article in accordance with the CARE reporting checklist (available at https://gs.amegroups.com/article/view/10.21037/gs-24-185/rc).

Case presentation

A 52-year-old woman in menopause was admitted with painful “left breast lump for 20 days”. The skin on the surface of the mass was not red, swollen, or ruptured, and there was no discharge of the left nipple. The patient then went to a township hospital and was diagnosed with a left breast tumor, suggesting further examination. Later, the patient was admitted to Qilu Hospital of Shandong University, and ultrasound showed a mixed-echo mass with an irregular shape and unclear boundaries, measuring 4.1 cm × 1.4 cm, located deep in the subcutaneous tissue of the left breast at the 6 o’clock position (Figure 1A). Additionally, mammography showed scattered calcifications below the left breast (Figure 1B). It was recommended that the patient be admitted to Qilu Hospital of Shandong University with left mammary duct ectasia. The patient had recently had good diet and sleep, normal stool and urine, and no significant change in weight. The patient denied a history of chronic diseases such as hypertension. The patient denied the history of TB infection and any history of TB exposure. The patient denied the history of blood transfusion, trauma, surgery, and allergies.

Figure 1 The imaging and pathological examinations of the patient. (A) The first ultrasound suggested a mixed echo mass with an irregular shape and unclear boundary. Chaotic internal echoes and detectable blood flow signals were observed at the edge of the mass. (B) No signs of malignancy were found on the mammogram. (C) The image depicts the patient following the biopsy procedure, showcasing the presence of lumps marked by a dotted line and a circle. The mass was situated at the 6 o’clock position below the left breast, approximately 3 cm away from the areola. The nodules exhibited an irregular shape, unclear borders, rough surfaces, and limited mobility. (D) The CT suggested a soft tissue density mass lesion at the lower margin of the left mammary gland, measuring approximately 3.6 cm in length, accompanied by bone destruction near the ribs. Arrows indicate mass lesions and rib bone destruction. (E) ECT (whole-body bone imaging) suggested enhancement of the 6th anterior rib strip and uneven distribution of the imaging agent in the third and fourth lumbar vertebra, bilateral sternoclavicular joint, and bilateral shoulder joint. The arrow indicates that the developer is concentrated on the left sixth rib. (F,G) Puncture pathology HE staining suggested presence of chronic inflammation with granulomatous inflammation and extensive necrosis, indicating a potential diagnosis of TB (F: ×200, scale bar =50 μm; G: ×400, scale bar =20 μm). (H) Acid-fast staining did not detect any specific pathogens (H: ×100, scale bar =100 μm). (I) The second ultrasound suggested an inhomogeneous echo was observed in the left chest wall, extending towards the 5–6 points of the breast, measuring approximately 4.2 cm × 1.8 cm. The boundaries were unclear, and there was slight peristalsis of flock-like hypoecho, with no evident internal blood flow. (J) MRI suggested irregular lesions deep within the glands in the left outer lower quadrant of the breast, displaying uneven signals and isometric T1 and T2 signals. The lesion boundaries were indistinct, with a size of approximately 3.2 cm × 2.5 cm. Enhanced MRI demonstrated annular enhancement, with the lesions extending into the chest wall, causing rib destruction and thickening of the adjacent pleura. Arrows indicate mass lesions and rib bone destruction. (K) The patient’s chest CT at 9 months after surgery did not show signs of BTB recurrence. L, left breast; R, right breast; ML, medial and lateral oblique position; CC, cephalocaudal position; ANT, anteposition; POST, posterior position; A, anteposition; P, posterior position; CT, computed tomography; ECT, emission computed tomography; HE, hematoxylin-eosin; TB, tuberculosis; MRI, magnetic resonance imaging; BTB, breast tuberculosis.

Upon admission, the patient exhibited stable vital signs and did not present with cough, fever, night sweats, weight loss, or any other systemic symptoms. A pliant nodule was palpated below the left breast, approximately 3 cm from the areola at the 6 o’clock position (Figure 1C), with an irregular shape, unclear boundary, rough surface, and limited mobility. No notable abnormalities were detected in the lymph nodes. Blood tests showed the patient’s inflammatory marker, erythrocyte sedimentation rate (ESR), was elevated (39.00 mm/h). The proportion of white blood cells in the patient’s blood routine was normal. Chest and abdominal computed tomography (CT) revealed a soft tissue density mass lesion at the lower margin of the left mammary gland, measuring approximately 3.6 cm in length, accompanied by bone destruction near the ribs, and CT showed no sign of pulmonary TB (Figure 1D). Emission CT (ECT; whole-body bone imaging) demonstrated enhancement of the sixth anterior rib strip, suggesting the possibility of bone metastasis (Figure 1E). Therefore, the patient was clinically diagnosed with breast cancer accompanied by bone metastasis. Subsequently, a core needle biopsy of the left breast mass was performed with real-time ultrasound guidance and a rapid paraffin section examination was conducted. The hematoxylin-eosin (HE) staining showed chronic inflammation with granulomatous inflammation and extensive necrosis, suggesting a possible diagnosis of TB (Figure 1F,1G). Acid-fast staining did not detect any specific pathogens (Figure 1H). Considering the likelihood of BTB, an anti-TB antibody (TB-Ab) test yielded a negative result. However, T cells spot test (T-SPOT) yielded positive results. Breast ultrasound suggested an inflammatory mass with possible abscess formation on the left chest wall (Figure 1I). Breast magnetic resonance imaging (MRI) showed irregular lesions in the deepest part of the glands in the lower outer quadrant of the left breast. Enhanced MRI revealed annular enhancement, with the lesions extending into the chest wall, causing rib destruction and thickening of the adjacent pleura (Figure 1J). Based on the above physical examination, test results, and imaging studies, the patient was diagnosed with BTB combined with bone destruction. Therefore, the patient was admitted to Shandong Public Health Clinical Center. Upon admission, breast lesions were subjected to biopsy, and subsequent polymerase chain reaction (PCR) analysis of the aspirated specimens confirmed the presence of DNA from the Mycobacterium TB complex group, along with genes associated with rifampicin resistance. No malignant tumor cells were detected in the needle aspiration cytology smear of the breast lesion. Consequently, she was formally diagnosed with BTB accompanied by rib bone destruction and received first-line anti-TB treatment with HRZE (H: isoniazid, R: rifampicin, Z: pyrazinamide, E: ethambutol) for 4 months. Later, in March 2023, the patient underwent surgical intervention, which included excision of the left breast lesion, resection of the tuberculous lesion in the left chest wall, partial rib resection, and breast reconstruction utilizing a left latissimus dorsi flap. The patient’s intraoperative frozen-section examination showed that the left breast mass was an inflammatory lesion, and necrotizing granuloma was found. The patient’s postoperative routine paraffin pathology revealed necrotizing granulomatous inflammation of the left breast mass and positive acid-fast staining. The fibrous connective tissue on the surface of the diseased rib showed chronic inflammation. She received first-line anti-TB treatment with HRZE. Nine months after surgery, the patient’s breast ultrasound, chest CT (Figure 1K), breast MRI, and blood tests showed no signs of BTB recurrence.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

TB is a significant global health concern and ranks as the second leading cause of death from infectious diseases (1). TB most often occurs in the lungs, and various sequelae and complications of intrapulmonary tissue or extrapulmonary tissue threaten human health (3,4). BTB accounts for a small proportion, ranging from 0.025% to 0.1%, of all TB cases (2,5), occurs in women of childbearing age, with an average age of 32.2 to 40 years (6).

Primary BTB is uncommon (7), with the bacteria entering the breast through the opening of the duct or via damage to the breast skin (8). The secondary BTB is more frequently encountered through three modes of infection: neighboring tissues and organs, lymphatic dissemination and hematogenous dissemination. Among these, lymphatic transmission is the most common (9). There are five types of BTB: nodular, disseminated, sclerosis, obliterated, and acute miliary (9). Elderly patients often present with the nodular type, which shares similarities with breast cancer according to physical and imaging examinations, leading to potential misdiagnosis of BTB as breast cancer (2,10-14) (Table 1, only the literatures published after 2020 are presented in Table 1 and subsequent tables). It should be noted that the coexistence of breast cancer and the BTB is also possible (15-17) (Table 2). Conversely, young patients tend to exhibit suppurative abscesses, which can be challenging to distinguish from granulomatous lobulitis (18).

Table 1

BTB mimicking breast cancer

Age (years old)/sex Type of BTB Clinical picture Auxiliary inspection Prediagnosis treatment Diagnostic method Treatment Follow-up visit Cite
Local expression System expression
56/F P There is a lump and a superficial ulceration of the skin over the upper outer quadrant of the breast Weight loss and loss of appetite The preliminary diagnosis was breast cancer. A core-needle biopsy and histopathological examination of the lump revealed caseating granulomas with multinucleate giant cells; ZN staining (+); AFB (+) N/A Histopathological examination + ZN staining + AFB 6HRZE Relapse-free (11)
29/F N/A Two discrete and tender masses were palpable in the upper outer quadrant of the left breast N/A Physical examination and ultrasound made a preliminary diagnosis of breast cancer Take antibiotics and pain relievers An excision biopsy and pathological examination: numerous granulomas with central caseous necrosis; Mantoux test (+) 6HRZE Loss to follow-up (12)
31/F N/A A palpable, tender mass in her left breast, with pain, swelling and purulent discharge N/A Mammography: lobulated heterogeneously hypoechoic lesion suggesting inflammatory/infective. Ultrasound-guided FNAC: ductal malignancy with abscess Take antibiotics + mastectomy + abscess drainage Histopathological examination: granulomatous mastitis. Tumor excision biopsy: chronic granulomatous inflammation and there was no evidence of carcinoma 6HRZE Relapse-free (13)
37/F P A palpable mass in left breast, with retraction and ulceration of the skin, pain and redness N/A Both ultrasound and mammography suspect breast cancer N/A Excise the diseased tissue and the histopathological examination: granulomatous caseating tuberculous mastitis After 1HRZE, the patient did not adhere to treatment, so relapsed 3 months later. We performed another lumpectomy + 9HRZE Relapse-free (14)

BTB, breast tuberculosis; F, female; P, primary; ZN, Ziehl-Neelsen; AFB, acid fast bacilli; (+), positive; 6HRZE, 6 months of HRZE treatment; H, isoniazid; R, rifampicin; Z, pyrazinamide; E, ethambutol; N/A, not applicable; FNAC, fine needle aspiration cytology; 1HRZE, 1 month of HRZE treatment; 9HRZE, 9 months of HRZE treatment.

Table 2

BTB co-existing with breast cancer

Age (years old)/sex Type of BTB Clinical picture Auxiliary inspection Prediagnosis treatment Diagnostic method Treatment Follow-up visit Cite
Local expression System expression
70/F N/A Right breast mass with pain N/A Mammography: skin thickening of the areola and the nipple N/A A tru-cut biopsy: an invasive ductal carcinoma of no special type along with evidence of non-necrotizing granulomatous inflammation. AFB (+) ATT + radical mastectomy with lymphadenectomy Not mentioned (16)
45/F N/A Left breast mass with pain A history of incomplete ATT for tubercular lymphadenitis Mammography: a small opacity with few micro calcifications in the upper outer quadrant of the left breast suggestive of breast carcinoma N/A FNAC: clusters of malignant duct epithelial cells and many epithelioid cell granulomas and caseous necrosis ATT + modified radical mastectomy Not mentioned (17)

BTB, breast tuberculosis; F, female; N/A, not applicable; AFB, acid fast bacilli; (+), positive; ATT, antitubercular therapy; FNAC, fine needle aspiration cytology.

Only a small proportion of patients with BTB exhibit symptoms of systemic TB (19), such as low-grade fever, night sweats, and weight loss. This patient had no systemic symptoms, as described above. The most common presentation is unilateral, solitary, and indistinct hard mass in the breast, primarily located in the central or outer upper quadrant (20). The nodules in this patient were located below the left breast and were irregular in shape, with unclear borders, rough surfaces, and limited movement. Axillary lymph node enlargement can be observed in 50% to 75% of patients (14). No axillary or supraclavicular lymphadenopathy was detected in this patient. As the disease progresses, it may extend to the skin, resulting in edema adhesion, and leading to ulcers, fistulas, or sinus tracts (21-23). The BTB can invade bone and cause bone destruction (Table 3) (24-27). This patient had primary BTB with bone destruction and was initially misdiagnosed with breast cancer with bone metastasis.

Table 3

BTB accompanied by bone destruction

Age (years old)/sex Type of BTB Clinical picture Auxiliary inspection Prediagnosis treatment Diagnostic method Treatment Follow-up visit Cite
Local expression System expression
21/F S Two sinuses in the right breast, spontaneous discharge of pus N/A Mantoux test (+); X-ray chest: an osteolytic lesion in anterior part of fifth rib; breast ultrasound: ill-defined sinus tract and opening Irregularly ATT Histopathology of specimen: chronic inflammatory cell infiltrate, with areas of caseous necrosis, giant cells 9HRZE + resection of lesions and ribs Relapse-free (24)
40/F P A soft fluctuant swelling in the upper inner quadrant of left breast Associated low-grade fever with night sweats and evening rise of temperature FNAC of the swelling: tubercular cold abscess; ZN staining of pus (+); AFB (+); after ATT of 1 month, patient has swelling and sinuses above the sternum. X-ray chest with contrast injected through the sinus: osteomyelitic changes in the sternum with a cavity N/A FNAC + AFB 3HERZ + 9HR + debridement and curettage of osteomyetic bone Relapse-free (25)
11/M P Gradual left breast enlargement for 1 year duration, a firm swelling involving left anterior chest wall elevating the nipple and areolar region N/A Ultrasound examination: a thick wall cystic lesion with internal debris and bone erosion. Ultrasound examination: a thick wall cystic lesion with internal debris and bone erosion with a similar cystic lesion in the substernal area through a hole in the fifth rib N/A Excise the diseased tissue and ribs and the histopathological examination: multiple granuloma with caseating material 3ATT + excise the diseased tissue and ribs Relapse-free (26)
42/F N/A Palpable cord-like induration with mild tenderness from the right margin of the sternum to the skin around the right nipple. A fistula near the right nipple, and it showed slightly cloudy and yellowish exudates Miliary TB at the age of 25 years Mammography: regional microcalcifications. MRI: a fistula formation between the parasternal area and skin of the right breast. T2 imaging: enhanced high signal intensity lesions in the sternum, suggesting sternal osteomyelitis Broad-spectrum antibiotic treatment + incisional drainage of the lesion PCR of the pus for M. TB (+) and the M. TB isolate was cultured from the pus specimen 2HRZE + 7HR Relapse-free (27)

BTB, breast tuberculosis; F, female; M, male; S, secondary; P, primary; N/A, not applicable; (+), positive; ATT, antitubercular therapy; 9HRZE, 9 months of HRZE treatment; H, isoniazid; R, rifampicin; Z, pyrazinamide; E, ethambutol; FNAC, fine needle aspiration cytology; ZN, Ziehl-Neelsen; AFB, acid fast bacilli; 3HRZE, 3 months of HRZE treatment; 9HR, 9 months of HR treatment; 3ATT, 3 months of antitubercular therapy; TB, tuberculosis; MRI, magnetic resonance imaging; PCR, polymerase chain reaction; M. TB, Mycobacterium tuberculosis; 2HRZE, 2 months of HRZE treatment; 7HR, 7 months of HR treatment.

Auxiliary examinations for the BTB include bacteriology, imaging, pathology, immunology, and molecular biology (28,29). Among these methods, Mycobacterium TB culture and Ziehl-Neelsen staining serve as the gold standards for diagnosing TB infection, offering high specificity but limited sensitivity. Acid-fast staining was negative in this patient. Conventional ultrasound allows for observation of the lesion’s location, shape, boundary, internal echo, calcification, and blood supply. Additionally, ultrasound provides clear visualization of sinus tract formation (30). Breast MRI aids in visualizing mass sinus formation and assessing the extent of lesion involvement in surrounding tissues. MRI of this case not only revealed deep irregular lesions of the gland, involving the chest wall and ribs backwards, but the enhanced scan also showed annular enhancement. Granulomatous lesions with caseous necrosis are the characteristic pathological features of BTB and can be distinguished from granulomatous lobulitis. The purified protein derivative (PPD) skin test, T-SPOT TB test for TB infection, and TB-Ab test have been utilized as primary screening tests for TB patients. TB-Ab test is not universally acknowledged due to insufficient sensitivity and specificity. This is because there are false negatives and false positives (31). People vaccinated with Bacillus Calmette-Guerin Vaccine will show false positive results for TB-Ab, while immunocompromised TB patients will show false negative results for TB-Ab. The T-SPOT test has emerged as a valuable tool for diagnosing extrapulmonary TB (32). It is primarily utilized to differentiate the BTB from other forms of granulomatous mastitis (7).

There are no specific guidelines for the treatment of BTB, and some publications report the application of standard TB treatment, a four-drug strategy of rifampicin, isoniazid, ethambutol, and pyrazinamide for 2 months, followed by a two-drug rifampicin and isoniazid for 6 to 7 months (1). Some cases have also been reported that require extension up to 18 months due to poor clinical response (19). Mastectomy has been performed in 4% of cases, representing 4.5% of all breast surgeries in developing countries (1).

Conclusions

Here, the patient, a middle-aged woman, presented with a breast mass. Imaging revealed bone destruction, leading to an initial diagnosis of breast cancer with bone metastasis. After the biopsy at Shandong Public Health Clinical Center, the PCR of the lesion detected TB DNA, which confirmed the diagnosis of BTB. Subsequent surgical intervention and anti-TB therapy were performed, resulting in effective symptom control without recurrence. BTB is characterized by a low incidence, nonspecific imaging findings, and laboratory examinations that can be influenced by various factors. This can make it challenging to differentiate BTB from other conditions such as breast cancer, granulomatous lobulitis, or breast fibroadenoma. Needle biopsy and empirical anti-TB therapy are valuable diagnostic approaches for the BTB, and clinicians should thoroughly inquire about the patient’s history of TB exposure. The BTB should be considered when the disease course is prolonged, nonresponsive to anti-inflammatory therapy, and associated with a long-term inflammation.

Acknowledgments

We would like to thank Dr. Michael N. Routledge (University of Leicester) and Prof. Yun Yun Gong (University of Leeds) for language editing and valuable comments.

Funding: This work was supported by the National Natural Science Foundation of China (No. 81802406), the Shandong Provincial Natural Science Foundation (Nos. ZR2021MH045, ZR2020LZL009, and ZR2019BH061), and the Special Funds for Scientific Research on Breast Diseases of Shandong Medical Association (No. YXH2021ZX058).

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://gs.amegroups.com/article/view/10.21037/gs-24-185/rc

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Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gs.amegroups.com/article/view/10.21037/gs-24-185/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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Cite this article as: Li LX, Wang YW, Lin Y, Chen YD, Chen X, Li X, Zhou XL, Su L, Lin MY, Zhang K. Breast tuberculosis with bone destruction mimicking breast cancer with bone metastasis: a case report and literature review. Gland Surg 2024;13(10):1853-1862. doi: 10.21037/gs-24-185

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