Wo m e n ’s I m a g i n g • R ev i ew Mahoney and Ingram Breast Emergencies
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Women’s Imaging Review
Breast Emergencies: Types, Imaging Features, and Management Mary C. Mahoney 1 Amanda D. Ingram 2 Mahoney MC, Ingram AD
OBJECTIVE. The objective of this article is to describe the types of breast emergencies that can be encountered in a breast imaging practice, discuss the characteristic imaging features of these emergencies, and explain the most common methods and interventions used for the treatment of breast emergencies and complications. CONCLUSION. Breast emergencies are uncommon but require prompt identification and management when they do occur. Patients with mastitis or a breast abscess may be seen for either diagnosis or treatment. Most complications are the result of interventional procedures. Pseudoaneurysms, postbiopsy hematoma, and localization wire migration are the most common situations encountered. A milk fistula resulting from a core biopsy is uncommon. Fortunately, seat-belt injuries to the breast are rare. Knowledge of these entities—of the usual presentation, management, and appropriate follow-up protocols—is essential for breast imagers.
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Keywords: abscess, breast emergencies, hematoma, mastitis, pseudoaneurysm DOI:10.2214/AJR.13.11758 Received August 20, 2013; accepted after revision November 7, 2013. 1 Department of Radiology, Breast Imaging Section, University of Cincinnati Medical Center, 234 Goodman St, ML 0772, Cincinnati, OH 45219-0772. Address correspondence to M. C. Mahoney ([email protected]). 2 Department of Radiology, University of Tennessee Medical Center, Knoxville, TN.
This article is available for credit. WEB This is a web exclusive article. AJR 2014; 202:W390–W399 0361–803X/14/2024–W390 © American Roentgen Ray Society
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reast-specific emergencies are infrequent but can be encountered in a busy breast imaging practice. Breast emergencies include acute situations that require urgent treatment and complications from percutaneous biopsy or trauma that potentially require interventional techniques to resolve. It is important for the practicing breast imager to recognize the clinical and imaging findings of breast emergencies and complications to make a timely diagnosis. Knowledge about the management, treatment, and appropriate referral of patients with breast emergencies and complications is essential for all breast imagers. Breast emergencies and complications include those related to infection and inflammation; those related to interventional procedures such as prolonged bleeding after a percutaneous biopsy, a postbiopsy hematoma, a milk fistula, a pseudoaneurysm, and lost or migrated localization wires; and trauma-specific issues such as seat-belt injuries. Mastitis and Abscess Mastitis is an inflammation of the breast that can be infectious or noninfectious. When it is due to an infection, the most frequent cause is Staphylococcus aureus bacteria [1, 2]. Clinically, mastitis typically presents as unilateral localized inflammation causing pain, redness, and warmth of the involved breast. Patients
also experience flulike symptoms, including fever, malaise, fatigue, headache, and generalized body aches [1]. An abscess occurs primarily as a complication of mastitis [2]. It is defined as a collection of infected fluid or pus within the breast. Clinically, an abscess presents with many of the same symptoms as mastitis but is associated with a palpable mass [2]. Abscesses are not related to breast cysts [3]. A breast abscess occurs when the infected area of the breast due to mastitis becomes walled off. On the other hand, a breast cyst develops when an overgrowth of glands and of connective tissue obstructs the ducts, causing them to dilate and fill with fluid. Cysts are associated with fibrocystic changes in the breast and are related to hormone levels, not infection. Both mastitis and abscesses can be classified as “puerperal” or “lactational” (related to childbirth) or as nonpuerperal. The puerperal types of inflammation and infection generally occur in lactating women within 3 months of childbirth [1]. Puerperal mastitis affects 1–9% of nursing mothers [3]. Significant predictors for puerperal or lactation mastitis include blocked ducts, fatigue, high stress levels, breast restriction from tight bras, attachment difficulty, and sore nipples [4–6]. Although the cause of puerperal mastitis can be unclear, in some cases, it is caused by lactation difficulties and
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Breast Emergencies suboptimal nursing technique, causing sore and cracked nipples, leading to retrograde bacterial or yeast infections. However, although the milk is an excellent culture medium and frequently becomes infected by retrograde travel of bacteria, the constant and regular flow of milk through the ducts to a nursing infant flushes out infecting organisms and prevents more severe complications, such as an abscess, in most cases. Furthermore, nursing dilates the mammary blood vessels, improving the flow of blood to the involved area, helping to clear infections. This explains the fact that puerperal mastitis often resolves without antibiotic therapy. Women with puerperal mastitis are advised to nurse as frequently as possible and to consult a lactation specialist to aid in complete emptying of the breast [3]. Nonpuerperal infections, including both mastitis and an abscess, are classified by the location within the breast and are described as either subareolar or peripheral. Risk factors for nonpuerperal infections include diabetes, smoking, obesity, and black race [2]. The subareolar inflammation cases are usually due to ductal ectasia and squamous metaplasia, which cause ductal obstruction, ductal rupture, and chronic granulomatous changes. The term “Zuska disease” has been used to describe patients who present with nipple retraction; a painful lump; and, frequently, a draining sinus. These infections are difficult to treat. With repeated failures to resolve with antibiotic therapy, most cases require surgical excision for definitive resolution [7–9]. Having mastitis does not increase a woman’s risk of developing breast cancer. Howev-
Fig. 1—Ultrasound image of 26-year-old woman with mastitis shows significant skin thickening and heterogeneous tissue.
Imaging Mastitis is often empirically treated without any imaging. However, if the patient does not completely respond to antibiotic treatment, imaging is indicated, and ultrasound is the first imaging modality that should be used. Typical findings include dilated ducts,
heterogeneous tissue related to diffuse inflammation and edema, and no focal discrete fluid collection to suggest an abscess (Fig. 1). Imaging is pursued for evaluation of an abscess in cases of long-standing symptoms, no resolution with antibiotics, or a palpable mass. An abscess presents as a hypoechoic collection of variable size and shape with mobile internal debris and some acoustic enhancement (Fig. 2). Abscesses are often multiloculated but lack internal flow on Doppler imaging. On the other hand, the periphery of an abscess is usually thick, echogenic, and hypervascular, reflecting the inflamed, hyperemic tissue surrounding the abscess [2, 10–13]. Published recommendations for mammography vary, primarily reflecting the young age of most women presenting with mastitis or an abscess. Some researchers recommend mammography in all women older than 30 years old, whereas others recommend mammography only in nonpuerperal cases of inflammation [2, 10–13]. In either case, delaying the imaging examination until the acute phase has resolved is strongly recommended. Imaging after the acute phase allows patients to better withstand compression, resulting in better images that can provide more diagnostic information about potential underlying abnormalities [2]. Mammographic findings in patients with mastitis and in those with an abscess usually include asymmetric density and skin thickening; a mass may be seen in the case of an abscess [2]. The presence of microcalcifications is unusual for mastitis and for an abscess and should prompt further evaluation
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er, it is important to note that the differential diagnosis of mastitis includes inflammatory carcinoma. Inflammatory carcinoma may be difficult, if not impossible, to differentiate from mastitis—both clinically and by imaging. In general, inflammatory cancer is less painful than mastitis and the skin thickening is more generalized. Mammography is difficult to perform and interpret in both conditions, with increased density due to edema and poor compression related to pain. Deferring mammography until the acute symptoms have resolved is recommended. In the case of inflammatory cancer, suspicious microcalcifications or masses may be seen. Lymphadenopathy is usually present in both entities, but hilar thickening is usually more marked in cases of cancer [2, 10–12]. Other differential considerations include trauma (with hematoma formation); postradiation change; various dermatologic conditions such as cellulitis or psoriasis; vascular abnormalities including venous hypertension or lymphatic obstruction; and immunologic diseases such as amyloidosis, Wegener granulomatosis, sarcoidosis, or diabetic mastopathy. In many of these differential considerations, the patient will have additional symptoms not related to the breast.
Fig. 2—Ultrasound images of breast abscess in 32-year-old woman. A, Image shows breast abscess with large, multiloculated, hypoechoic collection with internal debris. B, Image shows fluid collection extends into breast parenchyma.
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Mahoney and Ingram
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Fig. 3—Mammographic image of 40-year-old woman shows diffuse edema with increased tissue density, coarsened trabeculae, and skin thickening.
Fig. 4—Percutaneous drainage catheter placement for treatment of abscess in 33-year-old woman. A, Ultrasound image shows abscess. B, Corresponding angiographic image shows drainage catheter in place.
and biopsy to exclude an underlying malignancy. Similarly, unresolved findings after treatment should also undergo histologic evaluation [2, 13] (Fig. 3). Breast MRI has been proposed as another imaging tool to differentiate infection from malignancy. However, because of substantial overlap in findings, MRI has not proved useful in most cases [2].
Nonpuerperal mastitis and abscess—Oral antibiotics are the mainstay of treatment of nonpuerperal mastitis and abscesses. Antibiotics are often chosen empirically. However, better results are achieved in the case of abscesses by culturing the abscess contents [2]. Along with antibiotic therapy, aspiration is performed as the first-line treatment of abscesses. The best results occur in abscesses smaller than 3 cm, but aspiration should be attempted for the treatment of abscesses of all sizes [2, 11]. Lidocaine is used for local anesthesia before aspiration, but applying ice packs to the breast is also very helpful [2]. Under ultrasound guidance, an 18-gauge needle is inserted into the collection, and the fluid is completely aspirated. Viscous collections may require a larger-gauge needle to completely drain the cavity [11, 12]. In all cases, the aspirate should be sent for microbiologic analysis to help direct antibiotic therapy [2, 10–12]. Once emptied, the cavity is
flushed with saline two to three times until the aspirate appears clear. In abscesses larger than 3 cm, direct instillation of antibiotics into the abscess cavity yields higher success rates [2]. Using an oblique tract to approach the cavity helps reduce the incidence of fistula formation [11]. This process of aspiration and flushing can be repeated if the abscess persists on follow-up ultrasound [2, 11, 12]. Reported success rates for percutaneous drainage range from 54% to 100% [2]. Although abscess aspiration is the first line of treatment, placement of an indwelling catheter should be considered after five recurrences. A 6- to 8-French catheter is placed, and the collection is aspirated and irrigated with saline similar to simple aspiration. The process of irrigation is repeated over several days of follow-up, until a minimal cavity remains and the patient is asymptomatic. At this point, the catheter is removed [12]. The success rate of catheter placement is similar to that of repeat
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Treatment Lactational mastitis—Conservative treatment is generally all that is needed for the treatment of lactational mastitis. Treatment includes analgesics for pain, gentle massage, warm compresses before nursing, and ice packs after nursing. Lactation consultants can help to improve breast-feeding technique, with measures directed toward complete breast emptying. If symptoms persist, antibiotics can be given. The milk can be cultured to direct antibiotic choice [1].
Fig. 5—Two cases of extensive postbiopsy hematoma. A, Photograph shows hematoma extends from breast to flank of 70-year-old woman. B, Photograph shows hematoma involves entire inferior breast of 68-year-old woman.
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Breast Emergencies Fig. 6—Mammographic images of postbiopsy hematomas. A, Ill-defined density is large hematoma in 62-yearold woman. B, Hematoma tracks along pectoral muscle in 48-year-old woman.
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Fig. 7—Ultrasound images of postbiopsy hematoma in 40-year-old woman. A, Hypoechoic blood (arrows) extends along needle and follows tissue planes during biopsy. B, Large heterogeneous hematoma is seen after biopsy.
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Fig. 8—Magnified mammographic images. A, Small circumscribed mass adjacent to blood vessel is pseudoaneurysm in 45-year-old woman. B, Small circumscribed mass adjacent to blood vessel is intramammary lymph node in 43-year-old woman.
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Mahoney and Ingram
Fig. 9—Ultrasound images. A, 50-year-old woman. Pseudoaneurysm (short arrows) is centrally hypoechoic lesion with echogenic rim. Linear echogenicity adjacent to pseudoaneurysm is tissue marker (long arrow). B, 65-year-old woman. Cancer lesion (arrows) shows echogenic rim.
ultrasound-guided aspirations. However, the risk of cutaneous fistula formation is higher, and there is more discomfort associated with catheter placement [2] (Fig. 4). Breast-feeding can be continued after catheter placement unless the abscess aspirate is milky. Milky aspirate implies duct injury, and breast-feeding is discontinued in these cases to prevent reinfection [12]. Surgical incision and drainage was the first line of treatment in the past but is now used only after three to five failed aspiration attempts. In general, aspiration failure is higher in patients who have been symptomatic for more than 6 days and in those with larger abscesses [2]. Lactational (puerperal) abscesses are more easily treated and rarely require catheter placement or surgical incision and drainage. When incision and drainage is performed, an incision is made over the site of maximum tenderness, the abscess septa are disrupted under anesthesia, and the wound is left open with gauze packing for approximately 6 weeks [10]. The disadvantages of surgical incision and drainage are the need for general anesthesia, greater scarring in the breast, and a relatively high recurrence rate of 28% [2]. Follow-Up Mastitis—Patients with mastitis should be followed clinically until complete resolution occurs [13]. If symptoms do not fully resolve with supportive treatment and antibiotics, imaging should be pursued to exclude an underlying malignancy or a developing abscess [1, 13]. Abscess—As previously described, lactational abscesses respond better to treatment than nonpuerperal abscesses, and clinical follow-up after aspiration is usually sufficient [2]. In the case of nonpuerperal abscesses, if there is good clinical response to aspiration and antibiotics, clinical follow-up and imaging followup with ultrasound are continued every 7–14 days until complete resolution occurs [2]. As with mastitis, if symptoms related to either type of abscess fail to fully resolve, biopsy should be performed to exclude malignancy [13].
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Postbiopsy Hemorrhage and Hematoma After percutaneous biopsy, manual compression is applied to the biopsy site for 5–10 minutes to achieve hemostasis. Excessive bleeding is defined as bleeding that continues after this time and is often associated with a large area of bruising of the breast, particularly 1–2 days after the biopsy. The bruising can extend to the contralateral breast, up the chest wall, around to the back, and down the flank [14] (Fig. 5). The incidence of bruising complications is higher in patients who are taking anticoagulants [15]. Interestingly, the incidence of postbiopsy hematoma is not affected by the patient’s coagulation status [15]. In one recent study, the probability of developing a hemato-
ma was 22% for patients taking antithrombotics compared with 13% for patients not taking antithrombotics [16]. Despite this difference in incidence, no clinically significant bleeding complications have been reported [15, 16]. The overall incidence of postbiopsy hematoma is very low, reported to be less than 1% in multiple studies [17]. The routine use of lidocaine with epinephrine during the biopsy and significant localized compression after the biopsy certainly aid in achieving hemostasis with few complications. If extra precautions, such as prolonged compression and pressure dressing, are used in patients taking anticoagulants, the complication rate may remain low. On mammography, a hematoma presents as a new mass at the biopsy site [9]. It may
Fig. 10—Color-flow Doppler ultrasound image shows swirling “yin-yang” appearance of pseudoaneurysm in 50-year-old woman. Dashed line = 8-mm width of pseudoaneurysm.
Fig. 11—Mammographic image of left breast of 47-year-old woman after wire localization and surgery. Arrow shows retained localization wire. Arrowheads correspond to skin marker over site of surgical incision.
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Breast Emergencies be ill-defined or circumscribed in appearance and a gas-fluid level may be present if the biopsy was performed with a vacuum-assisted biopsy device. Hemorrhage within the breast is identified as a new focal asymmetry in and around the biopsy site. The blood can also be seen tracking along the connective tissue planes of the pectoralis muscle (Fig. 6). On occasion, it may be difficult to differentiate hemorrhage within the breast tissues from local anesthetic injected at the time of biopsy. On ultrasound, hemorrhage appears as an area of hypoechogenicity that can be seen to track along the shaft of the needle and to follow the tissue planes. A hematoma may appear as a hypoechoic fluid collection or as a complex, heterogeneous cystic and solid mass. The appearance reflects the amount of clotted-versusfree blood within the cavity [14] (Fig. 7). Angiography can be helpful in detecting active extravasation by showing a blush of free contrast material [18]. Pseudoaneurysm formation is also well documented by angiography. There are several issues to consider when heavy bleeding is encountered at the time of percutaneous biopsy. First, it is important to quickly obtain tissue samples. As brisk bleeding continues, subsequent biopsy passes will yield less diagnostic tissue and, eventually, only clotted blood. Injection of additional lidocaine with epinephrine will restrict blood vessels and can help slow the rate of bleeding [15, 19]. Finally, if using a vacuum-assisted biopsy device, aggressive vacuum suctioning can help slow bleeding and should be performed before removing the biopsy needle and beginning manual compression. Vacuum suctioning can help restrict the vessels and thereby decrease bleeding. Consistent steady manual compression against a firm surface and in the plane of the needle insertion for 10–20 minutes will usu-
ally result in hemostasis [15, 20]. However, the necessity for extended compression of more than 1 hour has been reported [20]. In these cases, a pressure bandage, such as an elastic chest wrap, can be used to maintain hemostasis [15]. In cases in which prolonged compression has been necessary to achieve hemostasis, it is advisable to observe the patient for at least 30 minutes before discharge to ensure stability [21]. If bleeding cannot be controlled, surgical consultation is warranted [20]. Surgical ligation of the bleeding vessel or evacuation of a hematoma interfering with adequate compression can be performed [18, 19]. Most severe bleeding complications occur when the vessel is sliced by the biopsy needle in the longitudinal plane, allowing continuous bleeding. Vessels transected in the cross-sectional plane usually retract, constrict, and do not cause prolonged bleeding. When an artery is completely divided, the circular muscular fibers of the vessel wall contract so that the lumen of the cut end is diminished and the vessel contracts and collapses over the cut ends, ceasing the bleeding. On the other hand, if an artery is only partly cut across or sliced along the long axis of the vessel, the same muscular fibers of the vessel wall retract, with the result that a more or less circular hole is formed in the wall of the vessel, from which free bleeding takes place. Even if a clot does form, when the blood pressure rises, the clot is readily displaced, leading to more bleeding and an increased risk of aneurysm. In cases in which prolonged bleeding results from friable vessels contained within an advanced breast cancer lesion rather than from vessel injury, particle embolization may be an excellent alternative to surgical repair [18]. The primary blood supply to the breast is from the internal thoracic artery via the
subclavian artery and the lateral thoracic artery via the axillary artery. Additional blood supply is also provided from the thoracoacromial artery and branches of the serratus anterior and intercostal arteries [18]. Selective angiography of these vessels can identify the source of bleeding, and embolization can be performed with gelatin particles (Gelfoam, Upjohn), glue, particles, or coil. In general, Gelfoam is favored because recanalization is possible, which is important if neoadjuvant chemotherapy is to be delivered [18]. It is important to realize that although anticoagulants are routinely discontinued before breast biopsy, discontinuing anticoagulation therapy is associated with risk and that risk is increased in certain patient populations. These populations include patients with atrial fibrillation, especially those with a history of an embolic event; patients with a mechanical heart valve; patients with any recent thromboembolic event; or, finally, patients with a naked stent placed in the past 3 months or a drug-eluting stent placed within the past 12 months [22]. In these higher-risk patient groups (atrial fibrillation, mechanical valve, recent thromboembolic event, or stent placement), discontinuing anticoagulation medications should be done judiciously and in consultation with the physician managing anticoagulation. In some clinical settings, discontinuing anticoagulation medications may be too risky. In these cases, patients may be better managed in a hospital setting with surgical excision and bridging anticoagulation therapy with subcutaneous lowmolecular-weight heparin or IV unfractionated heparin [22]. Alternatively, recent reports in the literature support performing the biopsy while maintaining anticoagulation therapy [15, 16]. After careful consideration, this treatment plan may be attempted.
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Fig. 12—CT images of 60-year-old female passenger who presented with seat-belt injuries after motor vehicle crash. A, Right breast hematoma with active extravasation (arrow) caused by harness part of seat belt. B, Abdominal wall injury caused by lap belt.
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Mahoney and Ingram Milk Fistula A milk fistula is a tract that forms between a lactiferous duct and the skin. These fistulas are most commonly seen in lactating women after a surgical procedure but have also been reported after a large-core biopsy of a breast mass. Although most breast masses that occur during pregnancy and lactation are benign, breast cancers that do develop at these times carry a worse prognosis [23]. Therefore, biopsy must not be deferred in cases of indeterminate or suspicious lesions. With open surgical biopsy, a milk fistula is more likely to occur if the lesion is close to the nipple than if the lesion is in the periphery of the breast. A fine-needle aspiration biopsy carries less risk of formation of a milk fistula but presents interpretation difficulties for the cytopathologist because of the increased cellularity and frequent mitoses that can be seen accompanying pregnancy and lactation. Therefore, core biopsy may be necessary to provide histologic material for analysis. Using an oblique approach from the skin to the lesion can decrease the incidence of milk fistula, and certainly, core biopsy is a better al-
Fig. 13—Photograph of 80-year-old woman 1 month after motor vehicle crash shows severe diffuse skin bruising. Patient was driver and bruising is most severe along lower inner right breast and upper inner and central left breast.
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Pseudoaneurysm A pseudoaneurysm is a hematoma that communicates with the arterial lumen and contains flowing blood [24–26]. It lacks the three layers of the arterial wall, differentiating it from a true aneurysm [24, 26]. Most pseudoaneurysms in the breast occur secondary to trauma or biopsy. However, the spontaneous occurrence of a pseudoaneurysm has been reported and is more likely to occur in patients with underlying atherosclerotic disease and those taking anticoagulation medication [25, 26].
Patients with a pseudoaneurysm of the breast usually present with a recent history of trauma or a biopsy. In particular, excessive bleeding or formation of a large hematoma is often noted at the time of the biopsy [25–27]. On physical examination, a palpable pulsatile mass is present, generally ranging from 1 to 3 cm [3, 5]. There may be considerable cutaneous bruising in the overlying area as well [26]. Mammography can show a circumscribed mass adjacent to a blood vessel [27]. A lack of internal fat density can help differentiate the pseudoaneurysm from an intramammary lymph node (Fig. 8). Ultrasound is the imaging procedure of choice for identifying and diagnosing a pseudoaneurysm in the breast. Pseudoaneurysms present as anechoic lesions with an echogenic rim [26, 27]. Clotting occurs at the periphery of the hematoma, which appears hyperechoic at sonographic evaluation, whereas the center of the aneurysm remains anechoic (Fig. 9). Ultrasound imaging allows identification of the neck of the pseudoaneurysm connecting to the adjacent artery [24–26,
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ternative than open surgical biopsy. Nevertheless, a milk fistula is a known, although infrequent, complication of core biopsy. Treatment of a milk fistula primarily involves supportive measures. In most cases, the fistula resolves spontaneously over several weeks. However, in some cases, it may be necessary for the patient to discontinue nursing with eventual cessation of milk production to close the fistula tract. In severe cases, bromocriptine may be used to chemically suppress milk production.
Fig. 14—Mammographic images of left breast of 67-year-old woman with seat-belt injury show bandlike density representing hematoma and furrow in skin along path of seat belt. A, Mediolateral oblique projection. B, Craniocaudal projection.
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Breast Emergencies
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Fig. 15—Ultrasound image of 51-year-old woman shows that hematoma from motor vehicle crash appears as complex nonspecific fluid collection.
28]. Color Doppler imaging will show the swirling or “yin-yang” pattern of blood flow in the pseudoaneurysm [26, 28] (Fig. 10). Spectral Doppler imaging will show a “to and fro” waveform [25, 26]. Several options exist for the treatment of pseudoaneurysms of the breast. Ultrasoundguided manual compression is considered to be the first line of treatment [26–28]. Under ultrasound visualization, manual compression is applied at the neck of the pseudoaneurysm for 30–60 minutes. Doppler imaging is used to assess resolution of flow [24, 28]. Once the pseudoaneurysm has thrombosed, follow-up ultrasound imaging is performed in 2–7 days to ensure continued thrombosis. Higher success rates are reported when the pseudoaneurysm is treated early [28]. Because breast pseudoaneurysms are infrequent, most reports of treatment are case reports based on very few patients. Therefore, accurate success rates of these treatments in the breast are hard to determine. Compared with pseudoaneurysms located in other areas, lower success rates are reported in the breast. This lower success rate is possi-
bly because of the presence of wider-neck pseudoaneurysms in the breast from the large-gauge core needle biopsy devices used in the breast and the potential for considerable mobility of breast tissue, disrupting early thrombus formation and allowing recanalization of the pseudoaneurysm neck [27]. Injections and embolizations have also been used to successfully treat pseudoaneurysms in the breast. These treatment options are generally used in cases in which ultrasound compression has failed. Under ultrasound guidance, the pseudoaneurysm is accessed with a small (18- to 27-gauge) needle, and 0.2–1.0 mL of thrombin is slowly injected into the pseudoaneurysm until thrombosis is confirmed with ultrasound color-flow imaging. Alternatively, ultrasound can be used to identify the feeding and draining arteries of the pseudoaneurysm. These vessels are compressed, and the pseudoaneurysm is accessed with a small (18- to 27-gauge) needle. Under direct ultrasound visualization, 1 mL of 95% alcohol is slowly injected. Compression is continued for an additional 30 minutes, which is generally sufficient to achieve
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thrombosis [24]. A third ultrasound-guided interventional option involves embolization. Access of the pseudoaneurysm is achieved with ultrasound guidance and a 3-French micropuncture kit. A microcoil is then released directly into the lumen of the pseudoaneurysm to induce thrombosis [27]. In some circumstances, surgical repair of a pseudoaneurysm of the breast may be a reasonable treatment option. In cases in which a percutaneous biopsy led to the formation of a pseudoaneurysm and also to the diagnosis of a lesion requiring surgical excision, both the index lesion and the pseudoaneurysm can be managed with surgical excisional biopsy [26]. Last, spontaneous resolution of breast pseudoaneurysms has been reported [24– 27]. In fact, small pseudoaneurysms may be more common than previously reported, with the majority spontaneously resolving. There is a greater chance of spontaneous resolution when the pseudoaneurysm is small and has a small neck and the patient is not taking anticoagulation medication. Complications of Localization Wires Presurgical localization of nonpalpable masses is performed with a variety of needle and wire apparatuses to guide surgical excision. In some cases, the needle is removed and the wire is left in place to mark the index lesion. Complications of these localization wires include migration into other areas of the breast or body and retention of wire fragments after surgery. Reports of wire migration cover many areas of the body, some quite distant from the breast. Wires have migrated into the pericardium, pleural spaces, lung, mediastinum, neck muscles, gluteal region, axilla, abdominal cavity, and other locations in the breast [29–32].
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Fig. 16—MR images of 51-year-old woman show linear band of fibrosis and fat necrosis related to seat-belt injury. A, T1-weighted non–fat-saturated image. B, T2-weighted fat-saturated image.
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There are several postulated mechanisms for wire migration, with movement of the breast as the primary mechanism before surgery. Movement of the breast tissues, particularly in large pendulous breasts, can cause retraction and inward pulling of the wire. As the wire advances deeper into the breast tissues, other mechanisms can cause continued migration of the wire [29, 32]. Negative intrathoracic pressure and contraction of the pectoralis muscle [29, 30] are associated with continued migration of localization wires within the breast tissue and to locations outside the breast. Another major cause of wire migration, distinct from those mentioned, occurs during the surgical procedure rather than before it. Wires cut during surgery, particularly those cut using an electric-thermal cutting device, have a propensity for migration. In fact, the energy transferred to the wire during cautery transection can actually propel the wire a substantial distance [29]. In a typical wire localization, the excised tissue is sent for specimen radiography. If the surgeon is not already aware of the missing wire, he or she is notified at the time of the specimen radiograph that the wire or needle was not identified as expected in the specimen radiograph. The surgeon must then search for the missing wire or wire fragments [29, 31]. The surgeon can explore the breast tissues for the missing wire, but wire migration out of the breast can occur quickly and the wire may not be found [32]. Wire migration to pericardial and pleural locations presents higher risks to the patient, and wires that have migrated to these areas must be identified [29, 31]. Imaging is used to find the wires and may involve mammography, chest radiography, chest CT, or fluoroscopy. For cases in which the wire has migrated to subcu-
Fig. 17—Mammographic images of 64-year-old woman show hematoma caused by harness part of seat belt. A, Initial mediolateral oblique mammographic image of right breast shows irregular mass in anterior breast. BB denotes palpable mass corresponding to hematoma. B, Follow-up mediolateral oblique mammographic image obtained 3 months after A shows significant decrease in size of hematoma.
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Seat-Belt Injury Injuries from three-point harness seat belts lead to a characteristic pattern of findings termed the “seat-belt syndrome.” This syndrome includes chest wall soft-tissue injury, including the breasts; clavicle, sternum, rib, and spine fractures; mesenteric tears; and
hollow organ perforation [33]. The mechanism of injury to the breasts is most often a crush or compression, but cases of shear injury and even breast avulsion have been reported [33]. Injury to the breasts is dependent on multiple variables, including the presence of air bags in the vehicle, the vehicle velocity, the age and habitus of the patient, and the position of the passenger and the seat belt [33]. In a motor vehicle crash involving a left-hand drive vehicle, the passenger injures the upper inner right breast and the lower inner left breast. The driver usually injures the upper inner or central left breast and the lower inner right breast [34] (Fig. 12). Clinically, these patients present with a lump due to a hematoma or a furrow or indentation along the seat-belt line, which may lead to a large, prominent scar of the overlying skin and breast parenchyma [33]. Blistering and ulceration of the skin can occur as a result of the friction of the seat belt against the breast skin. The most common scenario involves very prominent bruising associated with a painful swollen breast. These findings may persist for many months after injury [33, 35] (Fig. 13). Characteristic mammographic findings include a linear or bandlike density, hematoma, skin thickening, and eventually fat necrosis [33, 34, 36] (Fig. 14). Ultrasound is less specific than mammography in imaging seat-belt injuries of the breast. Nonspecific hypoechoic or anechoic fluid collections containing lowlevel debris are common sonographic features related to hematoma formation [34, 36] (Fig. 15). The MRI findings mimic those of mammography. Bandlike enhancement, corresponding to the course of the seat belt, that is usually hyperintense on STIR and T2-weighted images may be identified. Rim-enhancing nodules with central fat signal intensity are
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taneous or soft tissue, a small incision may Mahoney and Ingram be used to remove the wire [32]. In the event of wire migration to the pleura, thoracotomy may be needed [30, 31]. In the situation of wire migration to the pericardium, videoassisted thorascopic surgery or open surgery may be necessary to remove the wire fragment and prevent further complications [29]. Perhaps the best solution to wire migration is to prevent it from happening altogether. Placing the localization needle and wire apparatus parallel to the chest wall prevents wire penetration into the pectoralis muscle and subsequent contraction of the pectoralis muscle pulling the wire further into the breast and possibly into the intrathoracic cavity [30]. It is advisable to bend or secure localization wires to the skin so as to secure the contact outside the breast and thoracic cavity. Wires should not be cut short even to distinguish between different locations of multiple localization wires [32]. Because large pendulous breasts are associated with a greater risk of wire migration, measures to decrease breast movement can be helpful in ensuring proper wire location. In addition, efforts to decrease the time between wire localization and surgery can also be helpful in reducing the incidence of wire migration [32]. In all cases, the entire wire and needle apparatus should be identified and verified in its entirety at the time of surgery and specimen radiography (Fig. 11).
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consistent with oil cysts and fat necrosis [36] (Fig. 16). Management of these patients usually consists of nonsteroidal medications or narcotics for pain relief and a professionally fitted bra to aid in breast support. Breast reconstruction can be considered for treatment of a resultant breast deformity. In the rare event of breast avulsion, emergent surgical treatment is needed because of accompanying massive hemorrhage [33]. Follow-up of nonemergent cases should occur with physical breast examination and mammography 3–6 months after the injury primarily to establish a new baseline [33]. The presence of a spiculated mass or architectural distortion is usually related to hematoma and scarring and should be followed at 6-month intervals until stability, similar to the protocol for postoperative scarring. In addition, calcifications and distortion related to fat necrosis are followed in the same manner (Fig. 17). Summary Breast emergencies are uncommon but require prompt identification and management when they do occur. Patients with mastitis or a breast abscess may be seen for either diagnosis or treatment. Most complications are the result of interventional procedures. Pseudoaneurysms, postbiopsy hematoma, and localization wire migration are the most common situations encountered. A milk fistula resulting from a core biopsy is uncommon. Fortunately, seat-belt injuries to the breast are rare. Knowledge of these entities—of the usual presentation, management, and appropriate follow-up protocols—is essential for breast imagers. References 1. Spencer JP. Management of mastitis in breastfeeding women. Am Fam Physician 2008; 78:727–731 2. Trop I, Dugas A, David J, et al. Breast abscesses: evidence-based algorithms for diagnosis, management, and follow-up. RadioGraphics 2011; 31:1683–1699 3. Cantlie HB. Treatment of acute puerperal mastitis and breast abscess. Can Fam Physician 1988; 34:2221–2226 4. Fetherston C. Risk factors for lactation mastitis. J Hum Lact 1998; 14:101–109 5. Riordan JM, Nichols FH. A descriptive study of lactation mastitis in long-term breast feeding women. J Hum Lact 1990; 6:53–58
6. Vogel A, Hutchinson BL, Mitchell EA. Mastitis in Breast Emergencies the first year postpartum. Birth 1999; 26:218–225 7. Guadagni M, Nazzari G. Zuska’s disease. G Ital Dermatol Venereol 2008; 143:157–160 8. Meguid MM, Oler A, Numann PJ, Khan S. Pathogenesis-based treatment of recurring subareolar breast abscesses. Surgery 1995; 118:775–782 9. Dixon JM. Periductal mastitis/duct ectasia. World J Surg 1989; 13:715–720 10. Hook GW, Ikeda DM. Treatment of breast abscesses with US-guided percutaneous needle drainage without indwelling catheter placement. Radiology 1999; 213:579–582 11. Ozseker B, Ozcan UA, Rasa K, Cizmeli OM. Treatment of breast abscesses with ultrasoundguided aspiration and irrigation in the emergency setting. Emerg Radiol 2008; 15:105–108 12. Ulitzsch D, Nyman MKG, Carlson RA. Breast abscess in lactating women: US-guided treatment. Radiology 2004; 232:904–909 13. Froman J, Landercasper J, Ellis R, De Maiffe B, Theede L. Red breast as a presenting complaint at a breast center: an institutional review. Surgery 2011; 149:813–819 14. Yap LP, Rouse H, Cawson J. An extensive breast hematoma following stereotactic 9 gauge vacuum assisted large-core biopsy. Breast J 2010; 16:199–200 15. Somerville P, Seifert PJ, Destounis SV, Murphy PF, Young W. Anticoagulation and bleeding risk after core needle biopsy. AJR 2008; 191:1194–1197 16. Chetlen AL, Kasales C, Mack J, Schetter S, Zhu J. Hematoma formation during breast core needle biopsy in women taking antithrombotic therapy. AJR 2013; 201:215–222 17. Parker SH, Burbank F, Jackman RJ, et al. Percutaneous large-core breast biopsy: a multi-institutional study. Radiology 1994; 193:359–364 18. Fischman AM, Epelboym Y, Siegelbaum RH, et al. Emergent embolization of arterial bleeding after vacuum-assisted breast biopsy. Cardiovasc Intervent Radiol 2012; 35:194–197 19. Salem C, Sakr R, Chopier J, Antoine M, Uzan S, Darai E. Pain and complications of directional vacuum-assisted stereotactic biopsy: comparison of the Mammotome and Vacora techniques. Eur J Radiol 2009; 72:295–299 20. Simon JR, Kalbhen CL, Cooper RA, Flisak ME. Accuracy and complication rates of US-guided vacuum-assisted core breast biopsy: initial results. Radiology 2000; 215:694–697 21. Lai JTW, Burrowes P, MacGregor JH. Vacuumassisted large-core breast biopsy: complications and their incidence. Can Assoc Radiol J 2000; 51:232–236
22. Douketis JD, Berger PB, Dunn AS, et al. The perioperative management of antithrombotic therapy. Chest 2008; 133:299S–339S 23. Ishida T, Yokoe T, Kasuni F, et al. Clinicopathologic characteristics and prognosis of breast cancer patients associated with pregnancy and lactation: analysis of case control study in Japan. Jpn J Cancer Res 1992; 83:1143–1149 24. Bazzocchi M, Francescutti GE, Zuiani C, Del Frate C, Londero V. Breast pseudoaneurysm in a woman after core biopsy: percutaneous treatment with alcohol. AJR 2002; 179:696–698 25. Bitencourt AGV, Cohen MP, Graziano L, et al. Pseudoaneurysm after ultrasound-guided vacuum-assisted core breast biopsy. Breast J 2012; 18:177–178 26. El Khoury M, Mesurolle B, Kao E, Mujoomdar A, Tremblay F. Spontaneous thrombosis of pseudoaneurysm of the breast related to core biopsy. AJR 2007; 189:[web]W309–W311 27. Beres RA, Harrington DG, Wenzel MS. Percutaneous repair of breast pseudoaneurysm: sonographically guided embolization. AJR 1997; 169:425–427 28. Sohn Y, Kim MJ, Kim EK, et al. Pseudoaneurysm of the breast during vacuum-assisted removal. J Ultrasound Med 2009; 28:967–971 29. Azoury F, Sayad P, Rizk A. Thoracoscopic management of a pericardial migration of a breast biopsy localization wire. Ann Thorac Surg 2009; 87:1937–1939 30. Banitalebi H, Skaane P. Migration of the breast biopsy localization wire to the pulmonary hilus. Acta Radiol 2005; 46:28–31 31. Mituś J, Kolodziejski L, Dyczek S, Wysocki WM, Komorowski AL. Localization wire migrating into the hilum of the lung during wire-guided breast biopsy. Breast J 2004; 10:165–166 32. Owen AW, Kumar EN. Migration of localizing wires used in guided biopsy of the breast. Clin Radiol 1991; 43:251 33. Paddle AM, Morrison WA. Seat belt injury to the female breast: review and discussion of its surgical management. ANZ J Surg 2010; 80:71–74 34. DiPiro PJ, Meyer JE, Frenna TH, Denison CM. Seat belt injuries of the breast: findings on mammography and sonography. AJR 1995; 164:317–320 35. Sircar T, Mistry P, Harries S, Clarke D, Jones L. Seat-belt trauma of the breast in a pregnant woman causing milk-duct injury: a case report and review of the literature. Ann R Coll Surg Engl 2010; 92:W14–W15 36. Kinoshita T, Yashiro N, Ihara N, Yokogawa M. MR findings of seat belt injury in the breast. J Comput Assist Tomogr 2002; 26:1054–1056
F O R YO U R I N F O R M AT I O N
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Women’s Imaging Review
Breast Emergencies: Types, Imaging Features, and Management Mary C. Mahoney 1 Amanda D. Ingram 2 Mahoney MC, Ingram AD
OBJECTIVE. The objective of this article is to describe the types of breast emergencies that can be encountered in a breast imaging practice, discuss the characteristic imaging features of these emergencies, and explain the most common methods and interventions used for the treatment of breast emergencies and complications. CONCLUSION. Breast emergencies are uncommon but require prompt identification and management when they do occur. Patients with mastitis or a breast abscess may be seen for either diagnosis or treatment. Most complications are the result of interventional procedures. Pseudoaneurysms, postbiopsy hematoma, and localization wire migration are the most common situations encountered. A milk fistula resulting from a core biopsy is uncommon. Fortunately, seat-belt injuries to the breast are rare. Knowledge of these entities—of the usual presentation, management, and appropriate follow-up protocols—is essential for breast imagers.
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Keywords: abscess, breast emergencies, hematoma, mastitis, pseudoaneurysm DOI:10.2214/AJR.13.11758 Received August 20, 2013; accepted after revision November 7, 2013. 1 Department of Radiology, Breast Imaging Section, University of Cincinnati Medical Center, 234 Goodman St, ML 0772, Cincinnati, OH 45219-0772. Address correspondence to M. C. Mahoney ([email protected]). 2 Department of Radiology, University of Tennessee Medical Center, Knoxville, TN.
This article is available for credit. WEB This is a web exclusive article. AJR 2014; 202:W390–W399 0361–803X/14/2024–W390 © American Roentgen Ray Society
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reast-specific emergencies are infrequent but can be encountered in a busy breast imaging practice. Breast emergencies include acute situations that require urgent treatment and complications from percutaneous biopsy or trauma that potentially require interventional techniques to resolve. It is important for the practicing breast imager to recognize the clinical and imaging findings of breast emergencies and complications to make a timely diagnosis. Knowledge about the management, treatment, and appropriate referral of patients with breast emergencies and complications is essential for all breast imagers. Breast emergencies and complications include those related to infection and inflammation; those related to interventional procedures such as prolonged bleeding after a percutaneous biopsy, a postbiopsy hematoma, a milk fistula, a pseudoaneurysm, and lost or migrated localization wires; and trauma-specific issues such as seat-belt injuries. Mastitis and Abscess Mastitis is an inflammation of the breast that can be infectious or noninfectious. When it is due to an infection, the most frequent cause is Staphylococcus aureus bacteria [1, 2]. Clinically, mastitis typically presents as unilateral localized inflammation causing pain, redness, and warmth of the involved breast. Patients
also experience flulike symptoms, including fever, malaise, fatigue, headache, and generalized body aches [1]. An abscess occurs primarily as a complication of mastitis [2]. It is defined as a collection of infected fluid or pus within the breast. Clinically, an abscess presents with many of the same symptoms as mastitis but is associated with a palpable mass [2]. Abscesses are not related to breast cysts [3]. A breast abscess occurs when the infected area of the breast due to mastitis becomes walled off. On the other hand, a breast cyst develops when an overgrowth of glands and of connective tissue obstructs the ducts, causing them to dilate and fill with fluid. Cysts are associated with fibrocystic changes in the breast and are related to hormone levels, not infection. Both mastitis and abscesses can be classified as “puerperal” or “lactational” (related to childbirth) or as nonpuerperal. The puerperal types of inflammation and infection generally occur in lactating women within 3 months of childbirth [1]. Puerperal mastitis affects 1–9% of nursing mothers [3]. Significant predictors for puerperal or lactation mastitis include blocked ducts, fatigue, high stress levels, breast restriction from tight bras, attachment difficulty, and sore nipples [4–6]. Although the cause of puerperal mastitis can be unclear, in some cases, it is caused by lactation difficulties and
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Breast Emergencies suboptimal nursing technique, causing sore and cracked nipples, leading to retrograde bacterial or yeast infections. However, although the milk is an excellent culture medium and frequently becomes infected by retrograde travel of bacteria, the constant and regular flow of milk through the ducts to a nursing infant flushes out infecting organisms and prevents more severe complications, such as an abscess, in most cases. Furthermore, nursing dilates the mammary blood vessels, improving the flow of blood to the involved area, helping to clear infections. This explains the fact that puerperal mastitis often resolves without antibiotic therapy. Women with puerperal mastitis are advised to nurse as frequently as possible and to consult a lactation specialist to aid in complete emptying of the breast [3]. Nonpuerperal infections, including both mastitis and an abscess, are classified by the location within the breast and are described as either subareolar or peripheral. Risk factors for nonpuerperal infections include diabetes, smoking, obesity, and black race [2]. The subareolar inflammation cases are usually due to ductal ectasia and squamous metaplasia, which cause ductal obstruction, ductal rupture, and chronic granulomatous changes. The term “Zuska disease” has been used to describe patients who present with nipple retraction; a painful lump; and, frequently, a draining sinus. These infections are difficult to treat. With repeated failures to resolve with antibiotic therapy, most cases require surgical excision for definitive resolution [7–9]. Having mastitis does not increase a woman’s risk of developing breast cancer. Howev-
Fig. 1—Ultrasound image of 26-year-old woman with mastitis shows significant skin thickening and heterogeneous tissue.
Imaging Mastitis is often empirically treated without any imaging. However, if the patient does not completely respond to antibiotic treatment, imaging is indicated, and ultrasound is the first imaging modality that should be used. Typical findings include dilated ducts,
heterogeneous tissue related to diffuse inflammation and edema, and no focal discrete fluid collection to suggest an abscess (Fig. 1). Imaging is pursued for evaluation of an abscess in cases of long-standing symptoms, no resolution with antibiotics, or a palpable mass. An abscess presents as a hypoechoic collection of variable size and shape with mobile internal debris and some acoustic enhancement (Fig. 2). Abscesses are often multiloculated but lack internal flow on Doppler imaging. On the other hand, the periphery of an abscess is usually thick, echogenic, and hypervascular, reflecting the inflamed, hyperemic tissue surrounding the abscess [2, 10–13]. Published recommendations for mammography vary, primarily reflecting the young age of most women presenting with mastitis or an abscess. Some researchers recommend mammography in all women older than 30 years old, whereas others recommend mammography only in nonpuerperal cases of inflammation [2, 10–13]. In either case, delaying the imaging examination until the acute phase has resolved is strongly recommended. Imaging after the acute phase allows patients to better withstand compression, resulting in better images that can provide more diagnostic information about potential underlying abnormalities [2]. Mammographic findings in patients with mastitis and in those with an abscess usually include asymmetric density and skin thickening; a mass may be seen in the case of an abscess [2]. The presence of microcalcifications is unusual for mastitis and for an abscess and should prompt further evaluation
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er, it is important to note that the differential diagnosis of mastitis includes inflammatory carcinoma. Inflammatory carcinoma may be difficult, if not impossible, to differentiate from mastitis—both clinically and by imaging. In general, inflammatory cancer is less painful than mastitis and the skin thickening is more generalized. Mammography is difficult to perform and interpret in both conditions, with increased density due to edema and poor compression related to pain. Deferring mammography until the acute symptoms have resolved is recommended. In the case of inflammatory cancer, suspicious microcalcifications or masses may be seen. Lymphadenopathy is usually present in both entities, but hilar thickening is usually more marked in cases of cancer [2, 10–12]. Other differential considerations include trauma (with hematoma formation); postradiation change; various dermatologic conditions such as cellulitis or psoriasis; vascular abnormalities including venous hypertension or lymphatic obstruction; and immunologic diseases such as amyloidosis, Wegener granulomatosis, sarcoidosis, or diabetic mastopathy. In many of these differential considerations, the patient will have additional symptoms not related to the breast.
Fig. 2—Ultrasound images of breast abscess in 32-year-old woman. A, Image shows breast abscess with large, multiloculated, hypoechoic collection with internal debris. B, Image shows fluid collection extends into breast parenchyma.
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Mahoney and Ingram
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Fig. 3—Mammographic image of 40-year-old woman shows diffuse edema with increased tissue density, coarsened trabeculae, and skin thickening.
Fig. 4—Percutaneous drainage catheter placement for treatment of abscess in 33-year-old woman. A, Ultrasound image shows abscess. B, Corresponding angiographic image shows drainage catheter in place.
and biopsy to exclude an underlying malignancy. Similarly, unresolved findings after treatment should also undergo histologic evaluation [2, 13] (Fig. 3). Breast MRI has been proposed as another imaging tool to differentiate infection from malignancy. However, because of substantial overlap in findings, MRI has not proved useful in most cases [2].
Nonpuerperal mastitis and abscess—Oral antibiotics are the mainstay of treatment of nonpuerperal mastitis and abscesses. Antibiotics are often chosen empirically. However, better results are achieved in the case of abscesses by culturing the abscess contents [2]. Along with antibiotic therapy, aspiration is performed as the first-line treatment of abscesses. The best results occur in abscesses smaller than 3 cm, but aspiration should be attempted for the treatment of abscesses of all sizes [2, 11]. Lidocaine is used for local anesthesia before aspiration, but applying ice packs to the breast is also very helpful [2]. Under ultrasound guidance, an 18-gauge needle is inserted into the collection, and the fluid is completely aspirated. Viscous collections may require a larger-gauge needle to completely drain the cavity [11, 12]. In all cases, the aspirate should be sent for microbiologic analysis to help direct antibiotic therapy [2, 10–12]. Once emptied, the cavity is
flushed with saline two to three times until the aspirate appears clear. In abscesses larger than 3 cm, direct instillation of antibiotics into the abscess cavity yields higher success rates [2]. Using an oblique tract to approach the cavity helps reduce the incidence of fistula formation [11]. This process of aspiration and flushing can be repeated if the abscess persists on follow-up ultrasound [2, 11, 12]. Reported success rates for percutaneous drainage range from 54% to 100% [2]. Although abscess aspiration is the first line of treatment, placement of an indwelling catheter should be considered after five recurrences. A 6- to 8-French catheter is placed, and the collection is aspirated and irrigated with saline similar to simple aspiration. The process of irrigation is repeated over several days of follow-up, until a minimal cavity remains and the patient is asymptomatic. At this point, the catheter is removed [12]. The success rate of catheter placement is similar to that of repeat
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Treatment Lactational mastitis—Conservative treatment is generally all that is needed for the treatment of lactational mastitis. Treatment includes analgesics for pain, gentle massage, warm compresses before nursing, and ice packs after nursing. Lactation consultants can help to improve breast-feeding technique, with measures directed toward complete breast emptying. If symptoms persist, antibiotics can be given. The milk can be cultured to direct antibiotic choice [1].
Fig. 5—Two cases of extensive postbiopsy hematoma. A, Photograph shows hematoma extends from breast to flank of 70-year-old woman. B, Photograph shows hematoma involves entire inferior breast of 68-year-old woman.
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Breast Emergencies Fig. 6—Mammographic images of postbiopsy hematomas. A, Ill-defined density is large hematoma in 62-yearold woman. B, Hematoma tracks along pectoral muscle in 48-year-old woman.
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Fig. 7—Ultrasound images of postbiopsy hematoma in 40-year-old woman. A, Hypoechoic blood (arrows) extends along needle and follows tissue planes during biopsy. B, Large heterogeneous hematoma is seen after biopsy.
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Fig. 8—Magnified mammographic images. A, Small circumscribed mass adjacent to blood vessel is pseudoaneurysm in 45-year-old woman. B, Small circumscribed mass adjacent to blood vessel is intramammary lymph node in 43-year-old woman.
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Mahoney and Ingram
Fig. 9—Ultrasound images. A, 50-year-old woman. Pseudoaneurysm (short arrows) is centrally hypoechoic lesion with echogenic rim. Linear echogenicity adjacent to pseudoaneurysm is tissue marker (long arrow). B, 65-year-old woman. Cancer lesion (arrows) shows echogenic rim.
ultrasound-guided aspirations. However, the risk of cutaneous fistula formation is higher, and there is more discomfort associated with catheter placement [2] (Fig. 4). Breast-feeding can be continued after catheter placement unless the abscess aspirate is milky. Milky aspirate implies duct injury, and breast-feeding is discontinued in these cases to prevent reinfection [12]. Surgical incision and drainage was the first line of treatment in the past but is now used only after three to five failed aspiration attempts. In general, aspiration failure is higher in patients who have been symptomatic for more than 6 days and in those with larger abscesses [2]. Lactational (puerperal) abscesses are more easily treated and rarely require catheter placement or surgical incision and drainage. When incision and drainage is performed, an incision is made over the site of maximum tenderness, the abscess septa are disrupted under anesthesia, and the wound is left open with gauze packing for approximately 6 weeks [10]. The disadvantages of surgical incision and drainage are the need for general anesthesia, greater scarring in the breast, and a relatively high recurrence rate of 28% [2]. Follow-Up Mastitis—Patients with mastitis should be followed clinically until complete resolution occurs [13]. If symptoms do not fully resolve with supportive treatment and antibiotics, imaging should be pursued to exclude an underlying malignancy or a developing abscess [1, 13]. Abscess—As previously described, lactational abscesses respond better to treatment than nonpuerperal abscesses, and clinical follow-up after aspiration is usually sufficient [2]. In the case of nonpuerperal abscesses, if there is good clinical response to aspiration and antibiotics, clinical follow-up and imaging followup with ultrasound are continued every 7–14 days until complete resolution occurs [2]. As with mastitis, if symptoms related to either type of abscess fail to fully resolve, biopsy should be performed to exclude malignancy [13].
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Postbiopsy Hemorrhage and Hematoma After percutaneous biopsy, manual compression is applied to the biopsy site for 5–10 minutes to achieve hemostasis. Excessive bleeding is defined as bleeding that continues after this time and is often associated with a large area of bruising of the breast, particularly 1–2 days after the biopsy. The bruising can extend to the contralateral breast, up the chest wall, around to the back, and down the flank [14] (Fig. 5). The incidence of bruising complications is higher in patients who are taking anticoagulants [15]. Interestingly, the incidence of postbiopsy hematoma is not affected by the patient’s coagulation status [15]. In one recent study, the probability of developing a hemato-
ma was 22% for patients taking antithrombotics compared with 13% for patients not taking antithrombotics [16]. Despite this difference in incidence, no clinically significant bleeding complications have been reported [15, 16]. The overall incidence of postbiopsy hematoma is very low, reported to be less than 1% in multiple studies [17]. The routine use of lidocaine with epinephrine during the biopsy and significant localized compression after the biopsy certainly aid in achieving hemostasis with few complications. If extra precautions, such as prolonged compression and pressure dressing, are used in patients taking anticoagulants, the complication rate may remain low. On mammography, a hematoma presents as a new mass at the biopsy site [9]. It may
Fig. 10—Color-flow Doppler ultrasound image shows swirling “yin-yang” appearance of pseudoaneurysm in 50-year-old woman. Dashed line = 8-mm width of pseudoaneurysm.
Fig. 11—Mammographic image of left breast of 47-year-old woman after wire localization and surgery. Arrow shows retained localization wire. Arrowheads correspond to skin marker over site of surgical incision.
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Breast Emergencies be ill-defined or circumscribed in appearance and a gas-fluid level may be present if the biopsy was performed with a vacuum-assisted biopsy device. Hemorrhage within the breast is identified as a new focal asymmetry in and around the biopsy site. The blood can also be seen tracking along the connective tissue planes of the pectoralis muscle (Fig. 6). On occasion, it may be difficult to differentiate hemorrhage within the breast tissues from local anesthetic injected at the time of biopsy. On ultrasound, hemorrhage appears as an area of hypoechogenicity that can be seen to track along the shaft of the needle and to follow the tissue planes. A hematoma may appear as a hypoechoic fluid collection or as a complex, heterogeneous cystic and solid mass. The appearance reflects the amount of clotted-versusfree blood within the cavity [14] (Fig. 7). Angiography can be helpful in detecting active extravasation by showing a blush of free contrast material [18]. Pseudoaneurysm formation is also well documented by angiography. There are several issues to consider when heavy bleeding is encountered at the time of percutaneous biopsy. First, it is important to quickly obtain tissue samples. As brisk bleeding continues, subsequent biopsy passes will yield less diagnostic tissue and, eventually, only clotted blood. Injection of additional lidocaine with epinephrine will restrict blood vessels and can help slow the rate of bleeding [15, 19]. Finally, if using a vacuum-assisted biopsy device, aggressive vacuum suctioning can help slow bleeding and should be performed before removing the biopsy needle and beginning manual compression. Vacuum suctioning can help restrict the vessels and thereby decrease bleeding. Consistent steady manual compression against a firm surface and in the plane of the needle insertion for 10–20 minutes will usu-
ally result in hemostasis [15, 20]. However, the necessity for extended compression of more than 1 hour has been reported [20]. In these cases, a pressure bandage, such as an elastic chest wrap, can be used to maintain hemostasis [15]. In cases in which prolonged compression has been necessary to achieve hemostasis, it is advisable to observe the patient for at least 30 minutes before discharge to ensure stability [21]. If bleeding cannot be controlled, surgical consultation is warranted [20]. Surgical ligation of the bleeding vessel or evacuation of a hematoma interfering with adequate compression can be performed [18, 19]. Most severe bleeding complications occur when the vessel is sliced by the biopsy needle in the longitudinal plane, allowing continuous bleeding. Vessels transected in the cross-sectional plane usually retract, constrict, and do not cause prolonged bleeding. When an artery is completely divided, the circular muscular fibers of the vessel wall contract so that the lumen of the cut end is diminished and the vessel contracts and collapses over the cut ends, ceasing the bleeding. On the other hand, if an artery is only partly cut across or sliced along the long axis of the vessel, the same muscular fibers of the vessel wall retract, with the result that a more or less circular hole is formed in the wall of the vessel, from which free bleeding takes place. Even if a clot does form, when the blood pressure rises, the clot is readily displaced, leading to more bleeding and an increased risk of aneurysm. In cases in which prolonged bleeding results from friable vessels contained within an advanced breast cancer lesion rather than from vessel injury, particle embolization may be an excellent alternative to surgical repair [18]. The primary blood supply to the breast is from the internal thoracic artery via the
subclavian artery and the lateral thoracic artery via the axillary artery. Additional blood supply is also provided from the thoracoacromial artery and branches of the serratus anterior and intercostal arteries [18]. Selective angiography of these vessels can identify the source of bleeding, and embolization can be performed with gelatin particles (Gelfoam, Upjohn), glue, particles, or coil. In general, Gelfoam is favored because recanalization is possible, which is important if neoadjuvant chemotherapy is to be delivered [18]. It is important to realize that although anticoagulants are routinely discontinued before breast biopsy, discontinuing anticoagulation therapy is associated with risk and that risk is increased in certain patient populations. These populations include patients with atrial fibrillation, especially those with a history of an embolic event; patients with a mechanical heart valve; patients with any recent thromboembolic event; or, finally, patients with a naked stent placed in the past 3 months or a drug-eluting stent placed within the past 12 months [22]. In these higher-risk patient groups (atrial fibrillation, mechanical valve, recent thromboembolic event, or stent placement), discontinuing anticoagulation medications should be done judiciously and in consultation with the physician managing anticoagulation. In some clinical settings, discontinuing anticoagulation medications may be too risky. In these cases, patients may be better managed in a hospital setting with surgical excision and bridging anticoagulation therapy with subcutaneous lowmolecular-weight heparin or IV unfractionated heparin [22]. Alternatively, recent reports in the literature support performing the biopsy while maintaining anticoagulation therapy [15, 16]. After careful consideration, this treatment plan may be attempted.
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Fig. 12—CT images of 60-year-old female passenger who presented with seat-belt injuries after motor vehicle crash. A, Right breast hematoma with active extravasation (arrow) caused by harness part of seat belt. B, Abdominal wall injury caused by lap belt.
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Mahoney and Ingram Milk Fistula A milk fistula is a tract that forms between a lactiferous duct and the skin. These fistulas are most commonly seen in lactating women after a surgical procedure but have also been reported after a large-core biopsy of a breast mass. Although most breast masses that occur during pregnancy and lactation are benign, breast cancers that do develop at these times carry a worse prognosis [23]. Therefore, biopsy must not be deferred in cases of indeterminate or suspicious lesions. With open surgical biopsy, a milk fistula is more likely to occur if the lesion is close to the nipple than if the lesion is in the periphery of the breast. A fine-needle aspiration biopsy carries less risk of formation of a milk fistula but presents interpretation difficulties for the cytopathologist because of the increased cellularity and frequent mitoses that can be seen accompanying pregnancy and lactation. Therefore, core biopsy may be necessary to provide histologic material for analysis. Using an oblique approach from the skin to the lesion can decrease the incidence of milk fistula, and certainly, core biopsy is a better al-
Fig. 13—Photograph of 80-year-old woman 1 month after motor vehicle crash shows severe diffuse skin bruising. Patient was driver and bruising is most severe along lower inner right breast and upper inner and central left breast.
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Pseudoaneurysm A pseudoaneurysm is a hematoma that communicates with the arterial lumen and contains flowing blood [24–26]. It lacks the three layers of the arterial wall, differentiating it from a true aneurysm [24, 26]. Most pseudoaneurysms in the breast occur secondary to trauma or biopsy. However, the spontaneous occurrence of a pseudoaneurysm has been reported and is more likely to occur in patients with underlying atherosclerotic disease and those taking anticoagulation medication [25, 26].
Patients with a pseudoaneurysm of the breast usually present with a recent history of trauma or a biopsy. In particular, excessive bleeding or formation of a large hematoma is often noted at the time of the biopsy [25–27]. On physical examination, a palpable pulsatile mass is present, generally ranging from 1 to 3 cm [3, 5]. There may be considerable cutaneous bruising in the overlying area as well [26]. Mammography can show a circumscribed mass adjacent to a blood vessel [27]. A lack of internal fat density can help differentiate the pseudoaneurysm from an intramammary lymph node (Fig. 8). Ultrasound is the imaging procedure of choice for identifying and diagnosing a pseudoaneurysm in the breast. Pseudoaneurysms present as anechoic lesions with an echogenic rim [26, 27]. Clotting occurs at the periphery of the hematoma, which appears hyperechoic at sonographic evaluation, whereas the center of the aneurysm remains anechoic (Fig. 9). Ultrasound imaging allows identification of the neck of the pseudoaneurysm connecting to the adjacent artery [24–26,
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ternative than open surgical biopsy. Nevertheless, a milk fistula is a known, although infrequent, complication of core biopsy. Treatment of a milk fistula primarily involves supportive measures. In most cases, the fistula resolves spontaneously over several weeks. However, in some cases, it may be necessary for the patient to discontinue nursing with eventual cessation of milk production to close the fistula tract. In severe cases, bromocriptine may be used to chemically suppress milk production.
Fig. 14—Mammographic images of left breast of 67-year-old woman with seat-belt injury show bandlike density representing hematoma and furrow in skin along path of seat belt. A, Mediolateral oblique projection. B, Craniocaudal projection.
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Breast Emergencies
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Fig. 15—Ultrasound image of 51-year-old woman shows that hematoma from motor vehicle crash appears as complex nonspecific fluid collection.
28]. Color Doppler imaging will show the swirling or “yin-yang” pattern of blood flow in the pseudoaneurysm [26, 28] (Fig. 10). Spectral Doppler imaging will show a “to and fro” waveform [25, 26]. Several options exist for the treatment of pseudoaneurysms of the breast. Ultrasoundguided manual compression is considered to be the first line of treatment [26–28]. Under ultrasound visualization, manual compression is applied at the neck of the pseudoaneurysm for 30–60 minutes. Doppler imaging is used to assess resolution of flow [24, 28]. Once the pseudoaneurysm has thrombosed, follow-up ultrasound imaging is performed in 2–7 days to ensure continued thrombosis. Higher success rates are reported when the pseudoaneurysm is treated early [28]. Because breast pseudoaneurysms are infrequent, most reports of treatment are case reports based on very few patients. Therefore, accurate success rates of these treatments in the breast are hard to determine. Compared with pseudoaneurysms located in other areas, lower success rates are reported in the breast. This lower success rate is possi-
bly because of the presence of wider-neck pseudoaneurysms in the breast from the large-gauge core needle biopsy devices used in the breast and the potential for considerable mobility of breast tissue, disrupting early thrombus formation and allowing recanalization of the pseudoaneurysm neck [27]. Injections and embolizations have also been used to successfully treat pseudoaneurysms in the breast. These treatment options are generally used in cases in which ultrasound compression has failed. Under ultrasound guidance, the pseudoaneurysm is accessed with a small (18- to 27-gauge) needle, and 0.2–1.0 mL of thrombin is slowly injected into the pseudoaneurysm until thrombosis is confirmed with ultrasound color-flow imaging. Alternatively, ultrasound can be used to identify the feeding and draining arteries of the pseudoaneurysm. These vessels are compressed, and the pseudoaneurysm is accessed with a small (18- to 27-gauge) needle. Under direct ultrasound visualization, 1 mL of 95% alcohol is slowly injected. Compression is continued for an additional 30 minutes, which is generally sufficient to achieve
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thrombosis [24]. A third ultrasound-guided interventional option involves embolization. Access of the pseudoaneurysm is achieved with ultrasound guidance and a 3-French micropuncture kit. A microcoil is then released directly into the lumen of the pseudoaneurysm to induce thrombosis [27]. In some circumstances, surgical repair of a pseudoaneurysm of the breast may be a reasonable treatment option. In cases in which a percutaneous biopsy led to the formation of a pseudoaneurysm and also to the diagnosis of a lesion requiring surgical excision, both the index lesion and the pseudoaneurysm can be managed with surgical excisional biopsy [26]. Last, spontaneous resolution of breast pseudoaneurysms has been reported [24– 27]. In fact, small pseudoaneurysms may be more common than previously reported, with the majority spontaneously resolving. There is a greater chance of spontaneous resolution when the pseudoaneurysm is small and has a small neck and the patient is not taking anticoagulation medication. Complications of Localization Wires Presurgical localization of nonpalpable masses is performed with a variety of needle and wire apparatuses to guide surgical excision. In some cases, the needle is removed and the wire is left in place to mark the index lesion. Complications of these localization wires include migration into other areas of the breast or body and retention of wire fragments after surgery. Reports of wire migration cover many areas of the body, some quite distant from the breast. Wires have migrated into the pericardium, pleural spaces, lung, mediastinum, neck muscles, gluteal region, axilla, abdominal cavity, and other locations in the breast [29–32].
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Fig. 16—MR images of 51-year-old woman show linear band of fibrosis and fat necrosis related to seat-belt injury. A, T1-weighted non–fat-saturated image. B, T2-weighted fat-saturated image.
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There are several postulated mechanisms for wire migration, with movement of the breast as the primary mechanism before surgery. Movement of the breast tissues, particularly in large pendulous breasts, can cause retraction and inward pulling of the wire. As the wire advances deeper into the breast tissues, other mechanisms can cause continued migration of the wire [29, 32]. Negative intrathoracic pressure and contraction of the pectoralis muscle [29, 30] are associated with continued migration of localization wires within the breast tissue and to locations outside the breast. Another major cause of wire migration, distinct from those mentioned, occurs during the surgical procedure rather than before it. Wires cut during surgery, particularly those cut using an electric-thermal cutting device, have a propensity for migration. In fact, the energy transferred to the wire during cautery transection can actually propel the wire a substantial distance [29]. In a typical wire localization, the excised tissue is sent for specimen radiography. If the surgeon is not already aware of the missing wire, he or she is notified at the time of the specimen radiograph that the wire or needle was not identified as expected in the specimen radiograph. The surgeon must then search for the missing wire or wire fragments [29, 31]. The surgeon can explore the breast tissues for the missing wire, but wire migration out of the breast can occur quickly and the wire may not be found [32]. Wire migration to pericardial and pleural locations presents higher risks to the patient, and wires that have migrated to these areas must be identified [29, 31]. Imaging is used to find the wires and may involve mammography, chest radiography, chest CT, or fluoroscopy. For cases in which the wire has migrated to subcu-
Fig. 17—Mammographic images of 64-year-old woman show hematoma caused by harness part of seat belt. A, Initial mediolateral oblique mammographic image of right breast shows irregular mass in anterior breast. BB denotes palpable mass corresponding to hematoma. B, Follow-up mediolateral oblique mammographic image obtained 3 months after A shows significant decrease in size of hematoma.
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Seat-Belt Injury Injuries from three-point harness seat belts lead to a characteristic pattern of findings termed the “seat-belt syndrome.” This syndrome includes chest wall soft-tissue injury, including the breasts; clavicle, sternum, rib, and spine fractures; mesenteric tears; and
hollow organ perforation [33]. The mechanism of injury to the breasts is most often a crush or compression, but cases of shear injury and even breast avulsion have been reported [33]. Injury to the breasts is dependent on multiple variables, including the presence of air bags in the vehicle, the vehicle velocity, the age and habitus of the patient, and the position of the passenger and the seat belt [33]. In a motor vehicle crash involving a left-hand drive vehicle, the passenger injures the upper inner right breast and the lower inner left breast. The driver usually injures the upper inner or central left breast and the lower inner right breast [34] (Fig. 12). Clinically, these patients present with a lump due to a hematoma or a furrow or indentation along the seat-belt line, which may lead to a large, prominent scar of the overlying skin and breast parenchyma [33]. Blistering and ulceration of the skin can occur as a result of the friction of the seat belt against the breast skin. The most common scenario involves very prominent bruising associated with a painful swollen breast. These findings may persist for many months after injury [33, 35] (Fig. 13). Characteristic mammographic findings include a linear or bandlike density, hematoma, skin thickening, and eventually fat necrosis [33, 34, 36] (Fig. 14). Ultrasound is less specific than mammography in imaging seat-belt injuries of the breast. Nonspecific hypoechoic or anechoic fluid collections containing lowlevel debris are common sonographic features related to hematoma formation [34, 36] (Fig. 15). The MRI findings mimic those of mammography. Bandlike enhancement, corresponding to the course of the seat belt, that is usually hyperintense on STIR and T2-weighted images may be identified. Rim-enhancing nodules with central fat signal intensity are
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taneous or soft tissue, a small incision may Mahoney and Ingram be used to remove the wire [32]. In the event of wire migration to the pleura, thoracotomy may be needed [30, 31]. In the situation of wire migration to the pericardium, videoassisted thorascopic surgery or open surgery may be necessary to remove the wire fragment and prevent further complications [29]. Perhaps the best solution to wire migration is to prevent it from happening altogether. Placing the localization needle and wire apparatus parallel to the chest wall prevents wire penetration into the pectoralis muscle and subsequent contraction of the pectoralis muscle pulling the wire further into the breast and possibly into the intrathoracic cavity [30]. It is advisable to bend or secure localization wires to the skin so as to secure the contact outside the breast and thoracic cavity. Wires should not be cut short even to distinguish between different locations of multiple localization wires [32]. Because large pendulous breasts are associated with a greater risk of wire migration, measures to decrease breast movement can be helpful in ensuring proper wire location. In addition, efforts to decrease the time between wire localization and surgery can also be helpful in reducing the incidence of wire migration [32]. In all cases, the entire wire and needle apparatus should be identified and verified in its entirety at the time of surgery and specimen radiography (Fig. 11).
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consistent with oil cysts and fat necrosis [36] (Fig. 16). Management of these patients usually consists of nonsteroidal medications or narcotics for pain relief and a professionally fitted bra to aid in breast support. Breast reconstruction can be considered for treatment of a resultant breast deformity. In the rare event of breast avulsion, emergent surgical treatment is needed because of accompanying massive hemorrhage [33]. Follow-up of nonemergent cases should occur with physical breast examination and mammography 3–6 months after the injury primarily to establish a new baseline [33]. The presence of a spiculated mass or architectural distortion is usually related to hematoma and scarring and should be followed at 6-month intervals until stability, similar to the protocol for postoperative scarring. In addition, calcifications and distortion related to fat necrosis are followed in the same manner (Fig. 17). Summary Breast emergencies are uncommon but require prompt identification and management when they do occur. Patients with mastitis or a breast abscess may be seen for either diagnosis or treatment. Most complications are the result of interventional procedures. Pseudoaneurysms, postbiopsy hematoma, and localization wire migration are the most common situations encountered. A milk fistula resulting from a core biopsy is uncommon. Fortunately, seat-belt injuries to the breast are rare. Knowledge of these entities—of the usual presentation, management, and appropriate follow-up protocols—is essential for breast imagers. References 1. Spencer JP. Management of mastitis in breastfeeding women. Am Fam Physician 2008; 78:727–731 2. Trop I, Dugas A, David J, et al. Breast abscesses: evidence-based algorithms for diagnosis, management, and follow-up. RadioGraphics 2011; 31:1683–1699 3. Cantlie HB. Treatment of acute puerperal mastitis and breast abscess. Can Fam Physician 1988; 34:2221–2226 4. Fetherston C. Risk factors for lactation mastitis. J Hum Lact 1998; 14:101–109 5. Riordan JM, Nichols FH. A descriptive study of lactation mastitis in long-term breast feeding women. J Hum Lact 1990; 6:53–58
6. Vogel A, Hutchinson BL, Mitchell EA. Mastitis in Breast Emergencies the first year postpartum. Birth 1999; 26:218–225 7. Guadagni M, Nazzari G. Zuska’s disease. G Ital Dermatol Venereol 2008; 143:157–160 8. Meguid MM, Oler A, Numann PJ, Khan S. Pathogenesis-based treatment of recurring subareolar breast abscesses. Surgery 1995; 118:775–782 9. Dixon JM. Periductal mastitis/duct ectasia. World J Surg 1989; 13:715–720 10. Hook GW, Ikeda DM. Treatment of breast abscesses with US-guided percutaneous needle drainage without indwelling catheter placement. Radiology 1999; 213:579–582 11. Ozseker B, Ozcan UA, Rasa K, Cizmeli OM. Treatment of breast abscesses with ultrasoundguided aspiration and irrigation in the emergency setting. Emerg Radiol 2008; 15:105–108 12. Ulitzsch D, Nyman MKG, Carlson RA. Breast abscess in lactating women: US-guided treatment. Radiology 2004; 232:904–909 13. Froman J, Landercasper J, Ellis R, De Maiffe B, Theede L. Red breast as a presenting complaint at a breast center: an institutional review. Surgery 2011; 149:813–819 14. Yap LP, Rouse H, Cawson J. An extensive breast hematoma following stereotactic 9 gauge vacuum assisted large-core biopsy. Breast J 2010; 16:199–200 15. Somerville P, Seifert PJ, Destounis SV, Murphy PF, Young W. Anticoagulation and bleeding risk after core needle biopsy. AJR 2008; 191:1194–1197 16. Chetlen AL, Kasales C, Mack J, Schetter S, Zhu J. Hematoma formation during breast core needle biopsy in women taking antithrombotic therapy. AJR 2013; 201:215–222 17. Parker SH, Burbank F, Jackman RJ, et al. Percutaneous large-core breast biopsy: a multi-institutional study. Radiology 1994; 193:359–364 18. Fischman AM, Epelboym Y, Siegelbaum RH, et al. Emergent embolization of arterial bleeding after vacuum-assisted breast biopsy. Cardiovasc Intervent Radiol 2012; 35:194–197 19. Salem C, Sakr R, Chopier J, Antoine M, Uzan S, Darai E. Pain and complications of directional vacuum-assisted stereotactic biopsy: comparison of the Mammotome and Vacora techniques. Eur J Radiol 2009; 72:295–299 20. Simon JR, Kalbhen CL, Cooper RA, Flisak ME. Accuracy and complication rates of US-guided vacuum-assisted core breast biopsy: initial results. Radiology 2000; 215:694–697 21. Lai JTW, Burrowes P, MacGregor JH. Vacuumassisted large-core breast biopsy: complications and their incidence. Can Assoc Radiol J 2000; 51:232–236
22. Douketis JD, Berger PB, Dunn AS, et al. The perioperative management of antithrombotic therapy. Chest 2008; 133:299S–339S 23. Ishida T, Yokoe T, Kasuni F, et al. Clinicopathologic characteristics and prognosis of breast cancer patients associated with pregnancy and lactation: analysis of case control study in Japan. Jpn J Cancer Res 1992; 83:1143–1149 24. Bazzocchi M, Francescutti GE, Zuiani C, Del Frate C, Londero V. Breast pseudoaneurysm in a woman after core biopsy: percutaneous treatment with alcohol. AJR 2002; 179:696–698 25. Bitencourt AGV, Cohen MP, Graziano L, et al. Pseudoaneurysm after ultrasound-guided vacuum-assisted core breast biopsy. Breast J 2012; 18:177–178 26. El Khoury M, Mesurolle B, Kao E, Mujoomdar A, Tremblay F. Spontaneous thrombosis of pseudoaneurysm of the breast related to core biopsy. AJR 2007; 189:[web]W309–W311 27. Beres RA, Harrington DG, Wenzel MS. Percutaneous repair of breast pseudoaneurysm: sonographically guided embolization. AJR 1997; 169:425–427 28. Sohn Y, Kim MJ, Kim EK, et al. Pseudoaneurysm of the breast during vacuum-assisted removal. J Ultrasound Med 2009; 28:967–971 29. Azoury F, Sayad P, Rizk A. Thoracoscopic management of a pericardial migration of a breast biopsy localization wire. Ann Thorac Surg 2009; 87:1937–1939 30. Banitalebi H, Skaane P. Migration of the breast biopsy localization wire to the pulmonary hilus. Acta Radiol 2005; 46:28–31 31. Mituś J, Kolodziejski L, Dyczek S, Wysocki WM, Komorowski AL. Localization wire migrating into the hilum of the lung during wire-guided breast biopsy. Breast J 2004; 10:165–166 32. Owen AW, Kumar EN. Migration of localizing wires used in guided biopsy of the breast. Clin Radiol 1991; 43:251 33. Paddle AM, Morrison WA. Seat belt injury to the female breast: review and discussion of its surgical management. ANZ J Surg 2010; 80:71–74 34. DiPiro PJ, Meyer JE, Frenna TH, Denison CM. Seat belt injuries of the breast: findings on mammography and sonography. AJR 1995; 164:317–320 35. Sircar T, Mistry P, Harries S, Clarke D, Jones L. Seat-belt trauma of the breast in a pregnant woman causing milk-duct injury: a case report and review of the literature. Ann R Coll Surg Engl 2010; 92:W14–W15 36. Kinoshita T, Yashiro N, Ihara N, Yokogawa M. MR findings of seat belt injury in the breast. J Comput Assist Tomogr 2002; 26:1054–1056
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