Postoperative breast oedema

Case contributed by Dr Giorgio M Baratelli

Presentation

A 35 year old patient underwent a wide quadrantectomy and axillary level II node dissection for two ductal carcinoma of the upper outer quadrant of the right breast. Both tumors, of 10 and 18 mm respectively, were high grade, estrogen, progesterone receptors and HER2/neu positive; the resection margins were clean; 8 out of 13 axillary lymph nodes removed were metastatic, with extension of tumor beyond the capsule in two. The postoperative period was uneventful, the suction drain was removed after 6 days and no wound infection occurred. Four months after surgery, during chemotherapy with AC regimen (cyclophosphamide, doxorubicin), an edema of the lower quadrants of the operated breast appeared, without lymphedema of the arm. The patient had not yet started radiotherapy.

Patient Data

Age: 35 years
Modality: Photo

Edema of the lower quadrants of the operated breast ( peau d'orange sign)

Modality: Mammography

Mammography shows thickening of the skin more than 3 mm of the lower quadrants of the right breast, without an increase of the density of parenchyma or a suspicious mass.

Modality: Ultrasound

Ultrasounds show the thickening of the skin and the dilated lymphatic channels (anechoic tubular images) in the subdermal fat.

Case Discussion

Since it was clinically suggestive of an inflammatory breast carcinoma, a biopsy of the involved skin was done, which showed chronic perivascular dermatitis without malignant tumor cells.

The cause of the edema is the interruption of the lymphatic flow from the breast, due to axillary lymphadenectomy.

Unilateral breast edema and peau d'orange sign of the breast skin are the common appearance of many diseases ranging from breast lesions to systemic entities, and from benign to malignant lesions. Schematically they are:

  • mechanical problems such as: 
    • obstruction of the lymphatic flow due to axillary lymphadenectomy or axillary lymph node enlargement (metastatic, lymphoma, tbc …)
    • venous stasis due to axillary or subclavian vein occlusion
    • heart failure (rare)
  • infection (mastitis)
  • inflammatory, post radiotherapy edema, that arise following completion of radiation therapy
  •  inflammatory breast carcinoma (IBC)

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Case Information

rID: 43353
Case created: 6th Mar 2016
Last edited: 14th Jun 2016
System: Breast
Inclusion in quiz mode: Excluded

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