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Case report |
1 Division of Radiography, University of Bradford, Bradford BD5 0BB and 2 Blackburn Royal Infirmary, Bolton Road, Blackburn BB2 3LR, UK
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Abstract |
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Introduction |
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Case history |
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Clinical examination revealed bilateral lumpy breasts with a 15 mm non-tender discrete mobile nodule in the upper outer quadrant on the right.
Bilateral mammography showed dense glandular breasts in keeping with lactation and multiple well-defined soft tissue densities throughout. Prominent discrete focal lesions were noted in each upper outer quadrant (Figure 1
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At the site of the discrete mammographic lesion in the left upper outer quadrant, ultrasound demonstrated a 9 mm well-defined hyporeflective solid mass of indeterminate nature (Figure 2). This was subjected to needle core biopsy to obtain a definitive diagnosis.
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Histological analysis of the sampled core showed only fibro-fatty tissue; the patient was clinically discharged for review in 3 months. The patient re-presented during this interval with extensive bruising and an enlarging palpable mass at the biopsy site.
At re-presentation ultrasound revealed a well-defined 30 mm diameter focal lesion with heterogeneous overall reflectivity and anechoic centre, adjacent to the previously noted small solid lesion (Figure 3). Use of colour flow and pulsed Doppler demonstrated chaotic blood flow within the centre of the mass and high velocity antegrade and retrograde flow through a narrow vascular channel connecting it to an adjacent arterial vessel (Figures 4 and 5).
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Discussion |
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TopAbstractIntroductionCase historyDiscussionReferences |
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Following localized rupture of all three layers of an arterial wall, extravasation of blood and haematoma formation, a potential cavity is created by the development of encasing periarterial connective tissue [5]. Colour Doppler ultrasound can be employed to demonstrate arterial blood filling and draining from the cavity in phase with the cardiac cycle, through a small communicating channel at the site of initial vessel trauma [6].
Risk of pseudoaneurysm formation is greater in patients with known atherosclerosis, in the elderly and in females and increased risk is also associated with anticoagulation therapies such as warfarin, heparin and aspirin [6].
There are few previous reports of pseudoaneurysm in the breast. Spontaneous lesions have been reported both in patients with hypertensive disease [7] and in those where no such pre-disposing risk factors or history of natural trauma are present [8].
An earlier reported case [9] presenting for mammographic evaluation of a palpable breast mass 8 years after surgical biopsy, raised a potential association with surgical trauma although this patient also had several other predisposing risk factors. The presence of degenerative arterial disease and anticoagulation following mitral valve replacement would both be consistent with spontaneous pseudoaneurysm formation although delayed procedure-related complication at an arterial site previously weakened by biopsy may also have been a contributory factor.
The differential ultrasound features of breast pseudoaneurysm have been described for a patient presenting with a palpable lump underlying a surgical scar 3 months following wide local excision of breast carcinoma [10].
There are four reports in the literature to date of breast pseudoaneurysm formation following image-guided needle core biopsy.
Smith [11] and Beres et al [12] report development of such lesions following stereotactic procedures, Chorny et al [13] and McNamara and Boden [14] report cases following ultrasound guided procedures. The most recent report [14] documents pseudoaneurysm formation following 18 G needle biopsy, previous reports all involved 14 G needle procedures.
The use of percutaneous needle core biopsy of the breast has increased in recent years and is likely to continue to rise as asymptomatic surveillance programmes are expanded and guidelines for investigation of symptomatic breast disease are implemented. Both regimens have an inherent requirement for high pre-operative diagnosis rates. Reported complications after image guided needle core biopsy of the breast are rare, the most common being haematoma and infection [1, 2, 15, 16]. The majority of procedural complications are minor and of no clinical consequence, resolving spontaneously under observation or medical management. Major complications requiring surgical intervention are exceptional. Refractory mammillary fistulae have been reported following surgical biopsy [17–19], although there is no evidence to suggest that lactating women are at any increased risk [19].
In radiological practice, pseudoaneurysm formation is a well-recognised complication of vascular catheterization and percutaneous needle core biopsy of solid organs [20, 21]. Enlarging lesions are more susceptible to infection or rupture, making them more likely to be associated with surgical repair [6].
Superficial lesions developing after femoral artery puncture have been successfully occluded in the early post-procedure period using a colour Doppler ultrasound guided external compression technique, and more recently by endovascular embolisation [22–24].
Interventional management was attempted in all the four previously reported cases of pseudoaneurysm following image guided NCB of the breast. In the first three reported cases [11–13] the aneurysm was not detected until patients re-presented 6 to 9 months after initial biopsy. In two of these cases [11, 13] arterial trauma was apparent at the time of biopsy, however patients had been discharged once immediate post-procedure haemostasis was achieved. Attempts to obtain external compression induced repair both immediately [14] and after a delay [11–13] were unsuccessful. Whilst one small lesion was managed conservatively [11], surgery was successfully avoided in two further lesions; complete intra-aneurysm coagulation being achieved by Beres et al using a percutaneous microcoil embolisation technique [12] and by McNamara and Boden with direct percutaneous thrombin injection [14].
As the use of image guided needle core biopsy for pre-operative breast diagnosis increases, the incidence of procedure related pseudoaneurysm is also likely to increase. Recognition of the clinical signs during the procedure and extended use of colour Doppler ultrasound monitoring in the early post-procedure period might offer a realistic chance of successful non-surgical occlusion. Published reports to date suggest that ultrasound guided external compression is unlikely to be successful and that mechanical and pharmaceutical embolisation agents are to be preferred.
In view of the expansion of breast imaging services and increased use of minimally invasive diagnostic interventions in evaluation of breast disease, this case report is an addition to the literature illustrating a potentially serious complication that might no longer be considered a rare occurrence.
Received for publication July 28, 2003. Revision received October 22, 2003. Accepted for publication March 30, 2004.
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This article has been cited by other articles:
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  Y.-M. Sohn, M. J. Kim, E.-K. Kim, S. H. Chung, J. Y. Kwak, H. J. Moon, and S. J. Kim Pseudoaneurysm of the Breast During Vacuum-Assisted Removal J. Ultrasound Med., July 1, 2009; 28(7): 967 - 971. [Full Text] [PDF]
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K. H. Lee, E. Y. Ko, B.-K. Han, J. H. Shin, S. S. Kang, and S. Y. Hahn Thrombosed Pseudoaneurysm of the Breast After Blunt Trauma J. Ultrasound Med., February 1, 2009; 28(2): 233 - 238. [Full Text] [PDF]
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 M. El Khoury, B. Mesurolle, E. Kao, A. Mujoomdar, and F. Tremblay Spontaneous Thrombosis of Pseudoaneurysm of the Breast Related to Core Biopsy Am. J. Roentgenol., December 1, 2007; 189(6): W309 - W311. [Full Text] [PDF]
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 J Cox, B Kaye, D Burn, and R Bliss Multiple aneurysms in the female breast: a case report Br. J. Radiol., November 1, 2007; 80(959): e275 - e277. [Abstract] [Full Text] [PDF]
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