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Original Report |
1
Department of Radiology, The Woman's Hospital of Texas, 7600 Fannin St.,
Houston, TX 77054.
2
Department of Radiology, Baylor College of Medicine, One Baylor Plaza,
Houston, TX 77030.
Received January 23, 2001;
accepted after revision March 28, 2001.
Address correspondence to M. K. Shetty.
Abstract
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CONCLUSION. The combination of a sonographic finding of a superficial vessel—with or without an intraluminal thrombus and without flow on Doppler imaging—and a mammographic finding of a tubular density is the typical sign of Mondor's disease of the breast. Women present with a palpable cordlike structure, which is often painful, especially in the acute phase of thrombophlebitis. An understanding of such an entity and knowledge of the imaging findings will help breast imagers avoid the pitfall of mistaking this finding for a dilated duct.
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Sonography was performed with a 7-MHz (or higher) transducer using Logic 700MR (General Electric Medical Systems), 128 XP (Acuson, Mountain View, CA), SSD-5000 (Aloka, Mitaka-shi, Tokyo, Japan), and SSD-1700 (Aloka). Sonographic examinations included real-time as well as spectral and color Doppler imaging of the area of concern.
The following information was documented for each of the patients: age, sex, clinical presentation, and type of treatment and clinical follow-up, where appropriate. For each patient, the presence of known associated risk factors—a history of breast surgery, breast biopsy, breast inflammation or infection, or trauma—was documented.
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The mammograms revealed a superficially located tubular density corresponding to the marker placed on a palpable mass in all patients. The density was seen in the upper outer breast, indicating involvement of the lateral thoracic veins, in four patients (Figs. 1A and 1B). In the remaining patient, the thrombosed vein was periareolar, coursing deep to the nipple toward the lower outer quadrant of the breast.
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Sonograms showed a markedly dilated superficial vessel distended with a thrombus in one patient (Fig. 2). In the remaining four patients, a tubular anechoic structure with multiple areas of narrowing was seen, giving a beaded appearance to the vessel (Fig. 1C). No flow was present in these structures on color or spectral Doppler studies (Fig. 3B).
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Of the five women, two had palpable findings without pain and did not require treatment. The three other patients were treated conservatively to relieve pain; one of these patients is scheduled to have prophylactic bilateral mastectomy because of a strong family history of breast cancer. This woman had an acute episode of thrombophlebitis with a severely painful and enlarged breast and had experienced a similar episode affecting the opposite breast in 1996. At 6-month follow-up, a complete clinical resolution of the superficial thrombophlebitis was noted. Two of the other treated women also were found to have had a complete resolution of symptoms at follow-up (1 and 5 months, respectively).
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The reported association of breast cancer with Mondor's disease is of
particular interest to mammographers. Catania et al.
[2] reported that eight of
their 63 patients with Mondor's disease had breast cancer and strongly
recommended mammography in all cases, even when the findings at the patient's
physical examination were otherwise negative. They reported that mammography
alone identified two of the eight breast cancers. In the series reported by
Hou et al. [6], two of the 64
women with Mondor's disease had associated breast cancer. The infrequency of
Mondor's disease and the fact that these studies included patients presenting
for breast evaluation make its association with breast cancer difficult to
assess.
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Mondor's disease of the breast may present clinically as a palpable cord or a mass usually associated with pain. Mammographic evaluation is, therefore, indicated in patients with suspected Mondor's disease primarily for the evaluation of a palpable finding in the breast. At mammography, the finding of a dilated tubular density may potentially be mistaken for a dilated duct, a finding that may lead to biopsy. Huynh et al. [9] reported that at mammography, an asymmetrically dilated duct not situated beneath the areola that is associated with an interval change, suspicious microcalcifications, or both warrant biopsy. The researchers in that study found that 24% of the patients with such findings had breast cancer [9]. Tubular or branching structures in the subareolar region, however, represent dilated ducts, and, if unassociated with other suspicious or clinical or mammographic findings, are of minor importance [10]. Miller et al. [11] reported a case in which a patient had both Mondor's disease and a metastatic lymph node; at mammography, the thrombosed vessel was mistaken for a dilated duct.
At sonography, the thrombosed vessel appears as a superficially located, long, tubular, anechoic structure with a beaded appearance that does not show any flow on color or spectral Doppler studies. We found that sonography enables us to identify the entire course of the thrombosed vessel, which may not be visible in a mammographically dense breast. In patients with acute cases, a thrombus distending the vein may be seen, as in one patient in our series. Bilaterality is rare; one patient in our series had bilateral superficial thrombophlebitis occurring in each breast at different times. A thrombosed vein tends to be longer than a duct, have a beaded appearance, and is seen most commonly in the upper outer aspect of the breast. When in a periareolar location, a thrombosed vein does not terminate at the areola, unlike a lactiferous duct. Dilated interstitial fluid collections do not have a beaded or tubular appearance like thrombosed veins seen in patients with Mondor's disease.
Mondor's disease is a benign and self-limiting condition; patients are conservatively treated for pain with antiinflammatory and analgesic drugs. Antibiotics and anticoagulants are not indicated. We believe that, after a mammographic and sonographic work-up has been performed, a Breast Imaging Reporting and Data System (BI-RADS) [10] category 3 assessment, with a recommendation for a short-interval follow-up in 6 months, is appropriate.
Our series was small; however, Mondor's disease is a rare entity. Breast imagers should have an awareness of this condition and its imaging findings to avoid potentially misdiagnosing the palpable thrombosed vessel as a dilated duct and to exclude an associated breast cancer.
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