Milk fistula

Case contributed by Dr Garth Kruger

Presentation

A 35 year old lactating woman presents with a palpable mass left breast.

Patient Data

Age: 35
Gender: Female

The lesion indicated by the patient is palpbale with no redness or pain on clinical exam.

Modality: Ultrasound

In the two o'clock radian of the left breast a heterogenous mixed echogenicty lesion is seen. The initial diagnosis was a galactocele and follow up was suggested. The patient insisted on biopsy.

Modality: Ultrasound

Ultrasound guided core biopsy was performed two days later .....

Modality: Ultrasound

Two weeks after the biopsy the patient is back with a discharging lesion at the cutaneous puncture site. The discharge is lactiferous. Conservative managemenbt was suggested. The tract of the biopsy needle is visible as well as the cutaneous connection.

Modality: Ultrasound

There weeks after biospsy the fisulous connection is still visible ..........

Modality: Ultrasound

6 weeks after biopsy the puncture site has healed and this is the residual galactocoel.

Case Discussion

Galactoceles (and the lactating breast in general) can be nightmare lesions for senologists. The wide variation in appearance can be very confusing and to further complicate issues, no one wants to consrvatively manage or downplay an enlarging breast lesion in a lactating patient..

As a general rule, very careful follow up imaging should be used almost without exception and this is one place in radiology where I even say in the report that follow up should be done at the same site and even on the same ultrasound machine if possible. Without exception the radiologist should view these images in real time.

Most of these lesions clear up with conservative management, as in this case. The fistula is messy, but otherwise the lesions are rarely difficult to manage.

The teaching point is this is a complication of intervention on a galactocele, but its very rare. I have seen 2 in more than 2 decades of breast imaging.

Don't assume that lesions that develop in the lactating breast are all galactoceles. If the lesion enlarges, stick a needle in it. Meticulous careful follow up is mandatory.

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Case Information

rID: 25206
Case created: 12th Oct 2013
Last edited: 24th Dec 2016
System: Breast
Inclusion in quiz mode: Included

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