Two cases of breast pseudoaneurysm following core biopsy: A very rare complication with different treatment options

Abstract

Introduction:

Breast pseudoaneurysm is a rare complication following breast interventional procedures such as core biopsies and vacuum-assisted biopsies. The occurrence of pseudoaneurysm increases with the conditions of increased breast vascularity like cancer, pregnancy and lactation.

Case Report:

We present two cases of pseudoaneurysm formation secondary to core biopsies of the breasts. The first patient was an 82-year-old female patient who presented with breast swelling and bruising after multiple clinical core biopsies of the left breast. Our second patient was a 47-year-old lady who presented with a palpable lump following ultrasound-guided core biopsies of the left breast. Ultrasound showed hypoechoic pulsating area with evidence of internal colour flow in connection with a vessel in both cases. Imaging appearances were in keeping with a pseudoaneurysm of the breast.

Discussion:

Most pseudoaneurysms are secondary to interventional procedures in the breast. Common clinical presentation is a pulsatile, palpable mass at the biopsy site soon after the biopsy or later. On B mode imaging, it presents as a well-circumscribed mass of mixed echogenicity. Typical waveform in spectral Doppler and ‘yin-yang’ sign in colour Doppler is demonstrated with a turbulent internal flow. There are different treatment options to manage pseudoaneurysms of the breast.

Conclusion:

Pseudoaneurysm of the breast should be considered if a patient presents with a breast mass/lump close to a recent biopsy site. On clinical examination, pulsatility of the mass should raise the suspicion and definite diagnosis can be made with spectral and colour Doppler US scan.

Introduction

Post-procedure complications due to core needle and vacuum-assisted biopsy of the breast are infrequent. ¹ Bleeding is the most common complication, followed by haematoma formation. Infection, fistulae and pseudoaneurysms are rarer.

A pseudoaneurysm is a contained trans-mural rupture of the arterial wall with subsequent direct leakage of blood forming a haematoma that communicates with the arterial wall. A pseudoaneurysm does not contain a three-layer wall and is contained by perivascular tissue. An increased risk of vessel injury is caused by advanced age, anticoagulant therapy, atherosclerosis and pregnancy.^2,3

We present two patients with breast symptoms who had breast pseudoaneurysm following core needle biopsies. None of these patients were on anticoagulants or had any predisposing factors for increased bleeding.

One patient was managed conservatively with periodic monitoring until the spontaneous thrombosis of the pseudoaneurysm occurred. The other patient was treated with ultrasound (US)-guided thrombin injection.

Case reports

Case 1

An 82-year-old patient presented to the one stop clinic with a P3 (indeterminate) lump in the upper central part of the left breast.

Bilateral mammogram and US of the left breast revealed no abnormality (M1 bilateral and U1 left breast). A clinical biopsy of the P3 lump was performed by the surgeon and the histopathology revealed fat necrosis (P2)

Two days following the clinical biopsy, the patient presented to the radiology department with a new lump and bruising of the left breast. Haematoma was suspected on this occasion.

US of the left breast revealed a lobulated avascular hypoechoic area measuring 20 mm × 26 mm with echogenic content in the upper outer quadrant (UOQ) and haematoma was included in the differential. In addition, a pulsating hypoechoic area measuring approximately 11 mm was observed medial to the large collection, connected to a vessel with internal colour flow leading to a diagnosis of pseudoaneurysm (Figure 1).

Figure 1.

An 82-year-old woman: pseudoaneurysm after core biopsy with 14-gauge needle. (a) Colour Doppler image showing well-defined mass and swirling flow typical of pseudoaneurysm. (b) Colour Doppler image shows ‘yin-yang’ sign (arrow). Spectral Doppler image shows ‘to and fro’ spectral waveform pattern.

Following discussion with the breast surgeon, this patient was managed conservatively with periodic monitoring until the spontaneous thrombosis occurred. Final follow-up scan 2 months later showed no evidence of pseudoaneurysm.

Case 2

A 47-year-old patient with left breast lump in the UOQ had an US-guided core biopsy in another hospital. She was diagnosed with invasive ductal carcinoma (IDC) grade 3 on biopsy histopathology results.

She presented to our hospital 3 weeks after the biopsy with severe bruising of the left breast. Two different areas of the left breast had been subjected to multiple biopsies. Only one area came back as cancer, and a marker clip was inserted in that. According to the patient, there had been significant bleeding during the biopsy.

The US of the left breast was performed. On grey-scale US scan, an oval hypoechoic lesion in the UOQ was seen measuring 8 mm. Typical diastolic flow reversal in Doppler spectral waveform was noted, and ‘yin-yang’ sign in colour Doppler demonstrated with a turbulent internal flow. Diagnosis of a pseudoaneurysm measuring 8 mm was made (Figure 2(a) and 2(b)).

Figure 2.

A 47-year-old woman with pseudo aneurysm after core biopsy. (a) Colour Doppler image showing the feeding artery to the pseudo aneurysm (arrow), (b) Colour Doppler image after the core biopsy showing hypoechoic mass with internal colour flow, (c) MRI reconstructed images of the left breast showing the pseudoaneurysm with feeding vessel and (d) CT three-dimensional images demonstrating the pseudoaneurysm with the feeding vessel.

The site of the pseudoaneurysm was away from the malignant mass, but it probably was in the path of the biopsy needle.

Following the diagnosis of breast pseudoaneurysm, the Interventional Radiologist who was consulted, discussed the treatment options (follow-up vs thrombin injection) with the patient. The lady was supposed to start on chemotherapy soon. Therefore, it was agreed that thrombin injection was probably the safest option in view of the chemotherapy.

A total of 400 units of thrombin were injected. The pseudoaneurysm was occluded immediately after the thrombin injection. Follow-up US a week later confirmed complete occlusion of the pseudoaneurysm.

This patient also had magnetic resonance imaging (MRI) scan of the breast (Figure 2(c)) and computed tomography (CT) of thorax abdomen and pelvis for staging purposes (Figure 2(d)).

Discussion

Most breast pseudoaneurysms are secondary to biopsy. However, a spontaneous pseudoaneurysm secondary to a coughing spell has been reported. ⁴ There have been two other cases of spontaneous pseudoaneurysms secondary to hypertension. ⁴

Cases of breast pseudoaneurysm following vacuum assisted biopsy have also been reported. ⁵ Clinically, these present as pulsatile, throbbing masses at the biopsy site, either immediately after the procedure or weeks, even months later.

On B mode imaging, a pseudoaneurysm presents as a mixed echogenicity, well-circumscribed mass. Typical waveform in spectral Doppler and ‘yin-yang’ sign in colour Doppler is demonstrated with a turbulent internal flow. ²

The differential diagnoses are mainly true aneurysms, which present as slow growing masses and haematomas. The latter does not have internal vascularity. Other imaging modalities are not usually required, and confident diagnosis can be made with US alone.

Pseudoaneurysm can be treated with various methods. No standard management protocol has been established. ⁶ Observation, external pressure dressing, US-guided focused compression, thrombin injection, ⁷ intravascular embolisation and open surgical repair are recognised treatment options. ³ Conservative treatment is first attempted with US-guided focused mass compression for 20–30 minutes which may be repeated during periodic monitoring. Many undergo spontaneous thrombosis.

However, there is a risk of rupture. It is difficult to predict which pseudoaneurysm ⁸ will thrombose spontaneously. In cases with significant haemorrhage, endovascular treatment is performed with thrombosis with gel foam particles, glue, coil or alcohol injection. Open surgical repair is the final option when other methods have failed. ⁹

Conclusion

With the widespread use of US-guided core biopsies and vacuum-assisted biopsies, due to expansion of screening programmes, the risk of iatrogenic complications such as pseudoaneurysm formation is higher.

Therefore, careful colour flow evaluation to identify vessels adjacent to the targeted lesion is important before the biopsy. In addition, if the patient presents with a lump, immediately or subsequently after an interventional procedure, US colour Doppler examination should be a first-line investigation as this differentiates hematoma from pseudoaneurysm.

Treatment options vary from observation to open surgical treatment. In our cases, one patient was managed conservatively while the other patient was managed by US-guided thrombin injection.