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179 Case Report Recurrent Spontaneous Breast

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179 Case Report Recurrent Spontaneous Breast NOVEMBER-DECEMBER REV. HOSP. CLÍN. FAC. MED. S. PAULO 56(6):179-182, 2001 CASE REPORT RECURRENT SPONTANEOUS BREAST HEMATOMA: REPORT OF A CASE AND REVIEW OF THE LITERATURE Marilu Stimamiglio Kanegusuku, Dirceu Rodrigues, Linei Augusta B. Dellê Urban, Alexandre Bossmann Romanus, Rodrigo Peres Pimenta, Michelle Gusmão de Assis and Karla Alessandra Ferrari RHCFAP/3058 KANEGUSUKU MS et al. - Recurrent spontaneous breast hematoma: report of a case and review of the literature. Rev. Hosp. Clín. Fac. Med. S. Paulo 56(6):179-182, 2001. Background: Breast hematomas are common after traumas, surgeries, or contusions. They are rarely spontaneous, but they can occur spontaneously in patients with hematologic disease or with coagulation disorders. Material and methods: The authors report a clinical case of a 48-year-old female with a 27-year history of paroxysmal nocturnal hemoglobinuria who underwent mammography screening because of a painless palpable moveable node in the upper inner quadrant of the right breast. Results: Mammography showed a partially defined heterogeneous node of 35 mm without microcalcifications in the upper inner quadrant of the right breast which, associated with the clinical features, seemed to be an hematoma. Further mammography and ultrasound after 45 days showed retrocession of the lesion, and another mammography obtained after 60 days was normal. Seventy-five days after the first episode, the patient complained of another node with a skin bruise in the upper outer quadrant of the same breast, which seemed to be a recurrent hematoma. Two months later the mammography obtained was normal. Conclusion: Breast hematoma must be thought of as a differential diagnosis for a breast node, regardless of previous trauma or hematologic disorders. DESCRIPTORS: Breast. Hematoma. Hematologic disease. Paroxysmal nocturnal hemoglobinuria. Breast hematoma without a history CASE REPORT without nipple discharge or palpable of recent trauma is rare. It may be ob- axillary lymph node. Mammography served in patients having hematologic A female patient, 48 years old, was showed a dense node image of 35 mm disease or other condition that causes being treated. She had a history of re- in the upper inner quadrant of the right thrombocytopenia or coagulation disor- current episodes of hemoglobinuria breast with heterogeneous density, par- der, or it may occur in patients who take that needed blood transfusion since the tially defined, and without micro- anticoagulant medication. The resultant age of 20. On routine clinical exami- calcifications. This lesion, associated edema of hemorrhage causes a palpable nation, a palpable node was found in with her clinical history, suggested a mass or a located dense image. It can the junction of the upper quadrant of hematoma (Fig. 1). On that occasion, simulate or hide a carcinoma, necessi- the right breast, approximately 3.5 x the hemogram had granulocytopenia tating a complete investigation. The au- 3.0 cm in size, painless, moveable, and and thrombocytopenia (white cells = thors report a case of recurrent sponta- 3300/mm3 and platelets = 38 000/ neous breast hematoma in a 48-year-old mm3), and coagulation tests were nor- patient with paroxysmal nocturnal From the Discipline of Radiology of the mal. After 45 days the mammogram hemoglobinuria (PNH). Federal University of Paraná. image showed substantial lesion re- 179 REV. HOSP. CLÍN. FAC. MED. S. PAULO 56(6):179-182, 2001 NOVEMBER-DECEMBER Figure 1 - Craniocaudal (a) and mediolateral (b) mammograms reveal a Figure 2 - Follow-up craniocaudal (a) and mediolateral (b) mammograms partially defined dense node. after 45 days showing partial regression of the lesion. gression, indicating only a tenuous area tends to form a focal collection. It usu- of greater density in the upper inner ally occurs after trauma, contusion, quadrant of the right breast; ultrasound surgery, or fine needle aspiration punc- showed a solid hyperechoic area of ill- ture. Breast hematoma also occurs defined limits, 3.0 x 1.7 cm in size, lo- rarely after a hemopathy. Our patient cated in the parenchyma and progress- with a 27-year history of PHN had no ing to the subcutaneous fat (Fig. 2). history of spontaneous bleeding in After 60 days, a new mammographic other spots. image showed no lesion (Fig. 3). Sev- PHN is a rare acquired chronic enty-five days after the first episode of hemolytic disorder characterized by a hematoma, the patient returned, pre- defect in the membranes of erythro- senting a new node in the same breast, cytes that makes them sensitive to the palpable in the outer superior quadrant, action of complement. It usually ap- 2 x 2 cm in size, moveable, painless, pears in the third or fourth decade of and associated with a cutaneous hema- life, with the same incidence in both toma. The hemogram showed similar sexes. The beginning is insidious with values to the previous episode. Follow- progressive weakness and paleness, up mammograms obtained 2 months progressing to asymptomatic hemoglo- after the second episode revealed no binuria, or accompanied by lumbar lesions in either breast. pain during intense crises. The diagno- sis is conducted by the presence of hepatolysin acid demonstrated by the Figure 3 - Craniocaudal mammogram after 60 days showing complete regression of the lesion. DISCUSSION HAM test or by a positive test of sugar water. There is no efficient treatment; Breast hematoma is the result of a therapy is directed only at the compli- thrombocytopenia and bone marrow hematic extravasation that diffusely in- cations. Hemorrhagic disorders are rare hypoplasia, which is usually fatal. No filtrates the mammary parenchyma and and usually related to secondary report was found of the association of 180 NOVEMBER-DECEMBER REV. HOSP. CLÍN. FAC. MED. S. PAULO 56(6):179-182, 2001 breast hematoma and PHN in searches and solid compounds can be observed. tient has an organized hematoma that of MEDLINE (between 1976 and The most important differential di- will always show mammographically as 2001) and LILACS (between 1982 and agnosis of breast hematoma is with car- a mass of high density. Our patient, af- 2001) using the key words, breast cinoma, because the mammographic ter 2 months of follow up, did not hematoma, hematologic disease, and appearance of asymmetric density and present any mammographic alterations, paroxysmal nocturnal hemoglobinuria. skin thickness is similar. Hemorrhage confirming the benign nature of the le- On mammography, the hematoma caused by an intracystic tumor also sion, even though recurrent bleeding in appears as an asymmetric density asso- should be considered. Occult breast the same breast occurred. ciated with cutaneous thickness, or less tumors were also reported as the cause frequently, as a nodular image with cir- of spontaneous bleeding in patients cumscribed margins. Sometimes the pe- presenting coagulation disorders. CONCLUSION ripheral edema around the hematoma The majority of hematomas are partially defines the lesion margins. Cal- monitored 4 to 6 weeks after initial ob- The diagnosis of hematoma must cifications and spiculated margins are servation until there is only a small fo- be considered in all patients who not present, even though in later stages, cal distortion; it is necessary to keep the present a mammary node of sudden some hematomas may calcify. In 40% patient in observation until complete re- appearance and recent history of of the cases, no focal abnormality can gression. In two situations, a biopsy is trauma. In patients with hemopathy or be identified. Ultrasound is useful necessary for complete elucidation of who are undergoing treatment with an- mainly in an early phase, when it dem- the case: when there is absorption and ticoagulant drugs, hematoma must be onstrates a very defined anechoic cyst. the residual area presents a focal distor- considered in the differential diagnosis Ultrasound can also be used to monitor tion of the parenchyma, or when there of mammary nodes, even in the ab- regression, where a mixture of cystic is not any absorption, in which the pa- sence of a history of trauma. RESUMO RHCFAP/3058 KANEGUSUKU MS e col. - Hemato- xística noturna há 27 anos, submetida primeiro episódio, a paciente apresen- ma espontâneo recorrente de mama: a mamografia por apresentar em con- tou outro nódulo, agora associado a revisão da literatura e relato de caso. sulta de rotina nódulo palpável em hematoma cutâneo, em quadrante su- Rev. Hosp. Clín. Fac. Med. S. Pau- quadrante superior interno (QSI ) da perior externo da mesma mama, inter- lo 56(6):179-182, 2001. mama direita, móvel e indolor. pretado como novo hematoma. O con- Resultados: A mamografia evi- trole clínico após dois meses do segun- Objetivo: Os hematomas de mama denciou nódulo heterogêneo, de 35 do episódio foi normal. são comuns após traumatismo, cirurgi- mm, em QSI da mama direita, de con- Conclusões: A hipótese de hema- as ou contusões. Raramente são espon- torno parcialmente delimitado, sem toma deve ser considerada no diagnós- tâneos, podendo ocorrer em pacientes microcalcificações, que correlacionado tico diferencial de nódulo mamário, com doença hematológica ou outras do- com a história clínica, sugeria o diag- com ou sem história de trauma ou do- enças associadas a distúrbios da coagu- nóstico de hematoma. O controle ença sistêmica associada. lação sangüínea. evolutivo com mamografia e ecografia, Material e métodos: Os autores após 45 dias mostrou substancial re- DESCRITORES: Mama. Hemato- relatam o caso de paciente feminina, gressão da lesão e novo exame após 60 ma. Doença hematológica. Hemoglo- 48 anos, com diagnóstico e acompa- dias foi normal. Decorridos 75 dias do binúria paroxística noturna. nhamento de Hemoglobinúria paro- 181 REV. HOSP. CLÍN. FAC. MED. S. PAULO 56(6):179-182, 2001 NOVEMBER-DECEMBER REFERENCES 1. SHROTRIA S & GHILCHIK MW - Breast haematomas: same 5. PACKMAN CH - Pathogenesis and management of paroxysmal appearance, different diagnosis. Br J Clin Pract 1994; 48:214- nocturnal hemoglobinuria. Blood Reviews 1998; 12:1-11. 215. 6.
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