Innominate vein stenosis mimicking locally advanced breast cancer in a dialysis patient

Reduction mammoplasty as a treatment for symptomatic central venous stenosis

Central venous stenosis is a rare cause of unilateral breast edema occurring in hemodialysis patients that needs to be differentiated from other differential diagnoses, including, but not limited to, inflammatory breast carcinoma, mastitis, lymphedema, and congestive heart failure. All reports of similar cases in the available literature have described improvement or resolution of the edema after treatment. Herein, we report and discuss the pathophysiology of breast edema formation in a patient who presented with massive left-sided breast edema 7 years after being diagnosed with central venous stenosis. Medical and minimally invasive therapy had not been successful, so she underwent reduction mammoplasty to relieve the symptoms.

Long Thoracic Vein Embolization for the Treatment of Breast Edema Associated with Central Venous Occlusion and Venous Hypertension

Purpose

Breast edema is a rare complication in hemodialysis patients with central venous occlusions. The present study sought to determine whether coil embolization of the long thoracic vein is an effective long-term treatment for this pathology.

Methods

The study patients were 6 female hemodialysis patients whose primary clinical manifestation of central vein occlusion was breast edema. When conservative treatment (allowing collaterals to dilate over time), as well as recanalization of occlusions through angioplasty with or without stent placement, failed to alleviate symptoms, patients underwent coil embolization of the long (lateral) thoracic vein.

Results

In 4 of the 6 cases, the breast edema was completely resolved without recurrence, while the other 2 patients experienced durable symptomatic improvement with only mild residual swelling. Average follow-up was 22 months. There were no adverse sequelae and none of the patients experienced increased swelling elsewhere following the coil embolization procedure.

Conclusions

Coil embolization of the long thoracic vein effectively alleviates breast edema in hemodialysis patients with elevated venous hydrostatic pressure due to central venous occlusions.

Lymphedema of the breast as a symptom of internal diseases or side effect of mTor inhibitors

A common situation presented in any clinical facility is a woman with swelling and redness of the breast. Diagnosis upon suspicion is often mastitis or inflammatory breast cancer, which are popular and well-known diseases of the breast. However, there is one main differential diagnosis which has to be taken into consideration: lymphedema of the breast. Twenty patients with internal diseases presented in our Breast Care Unit over a 4-year period with breast-affecting lymphedema. The patients suffered from cardiac failure, nephrotic syndrome, liver failure, lymphadenopathy, and central vein occlusion. Additionally, we identified 5 patients with a history of organ transplantation and under immunosupressive medication with sirolimus or everolimus. These mTor inhibitors are known to have unwanted side effects such as unilateral or bilateral upper/lower extremity peripheral edema or facial/eyelid edema, but as we know, isolated lymphedema of the breast represents a previously unreported complication.

Mammographic signs of systemic disease

Although mammography is primarily used for the detection of breast cancer, it can occasionally reveal breast abnormalities related to extramammary disease. Cardiovascular diseases such as congestive heart failure and central venous obstruction may manifest as venous engorgement and breast edema at mammography. Pathologic arterial calcifications seen at mammography can indicate an underlying risk factor for accelerated atherosclerosis such as chronic renal failure. Connective tissue diseases including rheumatoid arthritis, systemic lupus erythematosus, dermatomyositis-polymyositis, and systemic scleroderma typically manifest with bilateral axillary lymphadenopathy, and stromal calcifications are also seen in the latter three disease processes. Some diseases such as neurofibromatosis type 1 and filariasis may manifest with pathognomonic findings at mammography, whereas other systemic diseases such as Wegener granulomatosis, sarcoidosis, and amyloidosis can manifest as nonspecific breast masses that are indistinguishable from breast cancer and usually require tissue biopsy for confirmation. Knowledge of the imaging characteristics of various systemic diseases affecting the breast will aid the radiologist in differentiating systemic disease from suspect breast lesions, thereby helping ensure appropriate follow-up. Furthermore, recognition of systemic diseases such as Cowden syndrome that are associated with an increased risk of breast cancer will allow the radiologist to recommend appropriate surveillance.

Is unilateral breast enlargement always a sign of cancer?

Breast swelling is caused by many etiological factors, but should alert central vein occlusion in hemodialysis patients when the permanent vascular access is in the same arm. The swelling of the breast is caused by venous hypertension in the venous plexus draining the breast. Endovascular treatment relieves venous hypertension and related clinical signs. Additional diagnostic workup or invasive interventions such as a biopsy should be avoided in such patients, as diagnosis is straightforward with the presence of a functioning arteriovenous fistula in the same arm.

Red breast as a presenting complaint at a breast center: an institutional review

BACKGROUND

The differential diagnosis of a red breast is extensive and includes both benign and malignant diseases. The literature documents patients who present with a red breast with delays in diagnosis of inflammatory cancer. We recorded our institutional experience prospectively in the evaluation, diagnosis, and treatment of a red breast.

METHODS

Data were collected prospectively on patients who presented with a red breast during a 14-month period. A retrospective review of final diagnosis and outcome was then conducted. A PubMed and Ovid Medline literature search were performed.

RESULTS

Twenty-two patients presented with a red breast. This number accounted for only 0.6% (22/3,762) of patients evaluated in our breast center during this time period. Final diagnoses were as follows: mastitis in 31.8%, breast abscess in 13.6%, erythematous changes secondary to radiation therapy in 13.6%, cellulitis in 9.1%, and venous hypertension in 9.1%. Other diagnoses included postradiation morphea, benign dermatologic inflammation, Paget disease of the breast, inflammatory breast cancer, and psoriasis (1 patient each). After treatment, 67% (17/22) patients had resolution of their symptoms and 18% (4/22) were improved. Only 1 (4.5%) of 22 patients had a change in diagnosis in a median follow-up of 8.8 months.

CONCLUSION

A red breast is an uncommon presenting complaint in patients evaluated at a breast center; however, the differential diagnosis is extensive. With appropriate diagnosis and treatment, most patients will have improvement or resolution of their symptoms. The diagnostic algorithm used by our breast center identified the cause of the red breast correctly in >95% of patients at presentation, and it can serve as a guide to evaluate patients with a red breast. This algorithm is in agreement with National Comprehensive Cancer Network guidelines.