Bilateral Breast Swelling due to Central Venous Occlusion

History:

A 47-year-old female with long stand history of hemodialysis and hypertension. No family history of breast cancer. No personal history of diabetes or smoking.

Findings:

Figure 1: Craniocaudal and MLO views of both breasts demonstrated prominent venous vasculature bilaterally. Scattered arterial vascular calcifications with train track like appearance and with normal vessel size. The breast parenchyma is heterogeneously dense. There is no evidence of suspicious clustered microcalcifications, architectural distortion or dominant mass.

Figure 2: Coronal reformatted CT image of the chest at the level of the origin of aortic arch demonstrated a long and complete obliteration of the left innominate vein. Also, multiples collateral vessels are noted in the axillary region and breasts bilaterally.

What is your diagnosis?

Continue to the next page for the diagnosis and conclusion.

Diagnosis:

Bilateral innominate vein and SVC occlusion in this patient with long-standing history of renal failure that subsequently developed multiple collaterals throughout the chest wall and axillary regions. Most likely this was developed after multiple central vein cannulations due to a repeatedly re-occlusion of the left arteriovenous fistula.

Arterial vascular calcifications were also seen, which are usually secondary to medial atherosclerosis. Arterial calcification in the breasts is highly associated with kidney failure. 

Conclusion:

Mammography is primarily used for the detection of suspicious abnormalities that can represent breast cancer. However, mammography sometimes exposes breast abnormalities that are suggestive of extrammamary pathologies. Venous engorgement and breast edema are findings sometimes seen in the setting of congestive heart failure or central vein stenosis. Also, venous engorgement has been reported in pregnancy and breast augmentation.¹ Central vein stenosis is a well-recognized complication due to previous and multiple cannulations of the subclavian and the internal jugular veins for intravenous access.² Multiples factors are involved when analyzing the pathophysiology of stenosis due to intravenous cannulation, such as: local injury, pericatheter thrombosis, uremic state and others.³

Ipsilateral central vein occlusion may be asymptomatic or may be manifested with arm and breast swelling due to collaterization.^2,4 Breast swelling is a rare complication of central venous stenosis was initially reported by Topf et al. in 1977.^2,5 In our case, patient demonstrated bilateral central vein occlusion which makes even worst the blood return leaving as the only pathway throughout collaterals.

Usually management of central vein stenosis includes angioplasty with balloon dilatation and stent placement. New techniques such as coil embolization of the long thoracic vein are being reported for unilateral breast edema and varicose veins.⁶

Arterial vascular calcification in chronic renal failure and dialysis patients is well-documented and generally considered to be a consequence of decreased phosphorus excretion, secondary hyperparathyroidism, and increased calcium-phosphorus product.

Dr. Sergio Dromi and Dr. Erini Makariou, Georgetown University Hospital, Washington, DC

References:

1. Cao MM, Hoyt AC, Bassett LW. Mammographic signs of systemic disease. Radiographics. 2011 Jul-Aug;31(4):1085-100.
2. Yalavarthy U, Agrawal VK, Showkat A. Unilateral breast swelling as a complication of innominate vein stenosis in a hemodialysis patient. Clin Nephrol. 2011; 75 Suppl 1:56-9.
3. Kommareddy A, Zaroukian MH, Hassouna HI. Upper extremity deep venous thrombosis. Semin Thromb Hemost. 2002; 28(1):89-99.
4. Molhem A, Sabry A, et. al. Superior vena cava syndrome in hemodialysis patient. Saudi J Kidney Dis Transpl. 2011; 22(2):381-6.
5. Topf G, Jenkins P, Gutmann FD, et. al. Unilateral breast enlargement. A complication of an arteriovenous fistula and coincidental subclavian vein occlusion. JAMA. 1977 7; 237(6):571-2.
6. Miller GA, Friedman A, et. al. Long thoracic vein embolization for the treatment of breast edema associated with central venous occlusion and venous hypertension. J Vasc Access. 2010; 11(2):115-21.