Clinical History:
81 year old woman who presents for mammography complaining of increase in
size of the right breast over four weeks; now four times its normal size.
Radiographic Findings:
Bilateral MLO views (Figure 1) and bilateral CC views (Figure 2) show diffuse
increased density of the right breast. There is a prominent interstitial
or trabecular pattern throughout. There is diffuse skin thickening bilaterally,
on the right greater than the left. No masses or suspicious calcifications
and no adenopathy were noted. The pattern is that of bilateral breast edema,
right greater than left.
Discussion:
These findings should prompt clinical examination of the patient and
further details of her history. Bilateral edema is usually related to
a systemic etiology such as cardiac or renal failure, or diffuse metastatic
involvement of the skin of the thorax. With unilateral edema patterns,
abnormalities of the breast or ipsilateral axilla are more likely, such
as inflammatory breast cancer, acute mastitis, post radiation edema, diffuse
hemorrhage, lymphoma, or obstructed lymphatics secondary to axillary adenopathy
or post axillary node dissection. Without history to suggest iatrogenic
causes, inflammatory breast cancer must be excluded.
With the mammographic findings of an edema pattern, the patient typically
has thickened skin on clinical exam (peau d'orange) and an enlarged, heavy
breast. The compressed thickness of the affected breast may be significantly
greater than that of the opposite breast. With mastitis or inflammatory
breast cancer the breast is usually markedly reddened, tender, and hard.
The physiologic cause of an edema pattern is distention of dermal lymphatics
by fluid (i.e. in CHF or renal failure), infection (mastitis), or tumor
cells (inflammatory breast cancer).
In this particular patient, further clinical history included a recent
hospital admission for diverticulosis and lower GI bleeding requiring
blood transfusions and fluid replacement. She reported a history of two
prior cardiac angioplasties and is currently on 60 mg daily of furosemide. She
reports that she sleeps exclusively on the right side, thereby accounting
for the asymmetrical edema pattern. Clinical examination demonstrated
a markedly enlarged thickened right breast. The patient was also
noted to have 3+ pitting edema of both lower legs. She did not appear
dyspneic. Diagnosis:
Congestive heart failure with asymmetrical breast edema.
References
- Gold RH, Montgomery CK, Minagi H, Annes GP. The
significance of mammary skin thickening in disorders other than primary
carcinoma: a roentgenologic-pathologic correlation. Amer J Radiol
1971;112: 613-621.
- Droulias CA, Sewell CW, McSweeney MB, Powell RW. Inflammatory
carcinoma of the breast: a correlation of clinical, radiologic and pathologic
findings. Ann Surg 1976; 184: 217-222.
- Keller RJ, Herman G. Unilateral edema simulating inflammatory
carcinoma of the breast. Breast Dis 1990; 3: 61-74.
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