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Case Report |
1 All authors: Institute of Radiology, University of Udine, Italy, via Colugna 50, 33100 Udine, Italy.
Received December 12, 2001;
accepted after revision February 13, 2002.
Address correspondence to C. Del Frate.
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Pseudoaneurysm after core biopsy has been described in the literature [3,4,5], and most patients with this condition required surgical treatment. We describe a patient whose breast pseudoaneurysm that developed after core needle biopsy was treated with sonographically guided percutaneous alcohol injection. This therapy has been used since 1981 in the treatment of renal cysts but, to the best of our knowledge, has not previously been used in the treatment of a breast pseudoaneurysm.
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The lesion was classified as category 3, probably benign, on the basis of the Breast Imaging Reporting and Data System [6]. Nevertheless, core biopsy was performed with the patient's consent to obtain a definitive diagnosis and to avoid further short-term follow-up.
Sonographically guided biopsy was performed using a 14-gauge cutting needle. During the biopsy, slight bleeding occurred. It resolved after 5 min of focused compression. A cold pack was placed on the breast immediately after the procedure to prevent the development of a hematoma. The finding on histopathologic diagnosis of the core biopsy specimen was fibroadenoma, which did not require surgical excision.
After 2 weeks, the patient returned with a visible and palpable throbbing mass in the biopsy area. Sonographic examination revealed the presence of a 1.6 x 1.2 cm round, hypo- to anechoic structure with well-defined borders (Fig. 1A). Color Doppler sonography, performed because of the pulsatile nature of the mass, revealed the presence of blood flow inside the mass. An associated adjacent artery was connected to the cavity by a track (Fig. 1B). Sonographically guided focused compression that was performed for 30 min five times at weekly intervals failed to result in spontaneous thrombosis. The patient refused surgery and was then offered percutaneous treatment of the lesion using 95% alcohol.
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Both feeding and draining arteries were identified on sonography and were compressed. Slow injection of 1 mL of 95% alcohol into the throbbing mass was performed using a 27-gauge needle (N.V. 3001; Terumo Europe, Leuven, Belgium) without anesthesia. After alcohol injection, both draining artery and pseudoaneurysm were kept compressed, while the compression on the feeding artery was released to induce reflux of alcohol into the feeding artery.
The treatment caused modest immediate pain along the artery, but the pain disappeared after a few minutes. The vessels and the pseudoaneurysm were compressed for 30 min after the procedure until the flow inside the lesion disappeared.
The complete thrombosis of the pseudoaneurysm was confirmed by sonography after 1 week. The mass caused by the pseudoaneurysm progressively decreased in size. After 2 months of follow-up, the pseudoaneurysm and the feeding artery were still thrombosed and present as a nonpalpable 5-mm mass (Fig. 1C).
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Pseudoaneurysm of the breast is uncommon, and its natural history is not well known. Many pseudoaneurysms spontaneously thrombose and never come to the attention of clinicians.
To our knowledge, six cases of breast pseudoaneurysm have been reported in the literature: three cases after core biopsy, one case after surgical biopsy, one case in a patient with a history of controlled hypertension, and one case in a patient undergoing anticoagulant therapy for arterial disease [3,4,5, 7,8,9]. In the three cases related to the core biopsy, a 14-gauge needle had been used.
One thousand eight hundred fifty core biopsies of the breast were performed at our institution in 1100 women and 15 men with 75% of the biopsies sonographically guided. In our experience, pseudoaneurysm is the only complication of clinical significance encountered.
The diagnosis of pseudoaneurysm is easily performed by color-flow Doppler sonography [7] with an accuracy of more than 95% [9]. Color Doppler sonography shows the presence of a swirling flow in the mass, which is connected by a track to an adjacent vessel.
All patients described in the literature underwent surgical treatment except one patient described by Beres et al. [4] for whom the authors proposed a new treatment of percutaneous embolization with the introduction of a microcoil into the lesion, resulting in its immediate thrombosis.
Compression of the neck of the pseudoaneurysm to obtain a thrombosis may not be successful because the neck may be too wide, especially after laceration of the vessel from the use of a large core needle (14 gauge).
In our patient, simple focused compression, performed both under sonographic guidance and manually, resulted in a reduction of the lesion after 1 month of treatment for progressive thickening of the pseudoaneurysm wall. Nevertheless, simple treatment based on compression was only partially successful, and a further treatment was needed.
We chose alcohol injection because alcohol produces apoptosis of the endothelial cells, resulting in a cicatrization reaction, stenosis, and thrombosis of the afferent artery.
A similar effect can be obtained using thrombin injection, which is valuable in the treatment of pseudoaneurysm [10]. Our preference for alcohol-based treatment is related to its availability and the minor cost to our institute. The procedure in our patient was completely successful.
Alcohol injection has many advantages: it does not require hospitalization or anesthesia, does not cause scarring of the skin, and takes just 1 hr to perform. Because alcohol is absorbed by the peripheral tissue, no residual foreign bodies such as coils or surgical clips are in the breast to interfere with visualization of the breast tissue in future diagnostic examinations, particularly MR imaging.
Breast pseudoaneurysm is uncommon in clinical practice but may occur and resolve without treatment, particularly during a long interval (6-24 months) between biopsy and subsequent sonographic follow-up. During this period, a small nonpalpable pseudoaneurysm may thrombose, be absorbed, and vanish. We believe that because these kinds of complications are rare and are not a risk to the patient's health, a more frequent follow-up should not be recommended. Nevertheless, a clinically evident pseudoaneurysm must be treated because its evolution is still unknown.
Several factors, such as the invasiveness and the cost, should be considered in choosing treatment. Alcohol sclerotherapy is economic, simple, without complications, and, as shown in our patient, efficient.
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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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