Presentation
A 35 year old lactating woman presents with a palpable mass left breast.
Patient Data
The lesion indicated by the patient is palpable with no redness or pain on clinical exam.
In the two o'clock radian of the left breast, a heterogenous mixed echogenicity lesion is seen. The initial diagnosis was a galactocele and follow-up was suggested. The patient insisted on biopsy.
Ultrasound-guided core biopsy was performed two days later .....
Two weeks after the biopsy the patient is back with a discharging lesion at the cutaneous puncture site. The discharge is lactiferous. Conservative management was suggested. The tract of the biopsy needle is visible as well as the cutaneous connection.
There weeks after biopsy the fistulous connection is still visible ..........
6 weeks after biopsy, the puncture site has healed and this is the residual galactocele.
Case Discussion
Galactoceles (and the lactating breast in general) can be nightmare lesions for sonologists. The wide variation in appearance can be very confusing and to further complicate issues, no one wants to conservatively 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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