CASE 16952 Published on 06.08.2020

Unilateral breast oedema due to congestive heart failure

Section

Breast imaging

Case Type

Clinical Cases

Authors

Andreas Markou1,George Sapourids2

¹ Dept of Radiology, General Hospital of Florina, Greece

²Dept of Radiology, General hospital of Thessaloniki-IPPOKRATEIO, Greece

Patient

60 years, female

Categories
Area of Interest Breast, Cardiac, CNS ; Imaging Technique CT, Mammography, Ultrasound-Power Doppler
Clinical History

A 60-year-old woman was admitted because of a gradual enlargement of right breast with peau d’orange appearance and dyspnea. On clinical examination, there was no nipple discharge, nipple retraction, palpable breast mass or palpable axillary lymphadenopathy. Patient had not fevered. She had a past medical history of congestive heart failure (EF 25%) and she was suffering from an acute exacerbation of chronic dyspnea.

Imaging Findings

She was referred for a CT pulmonary angiogram (CTPA) in order to exclude Pulmonary Embolism (PE) and a mammography in order to exclude breast cancer. Mammography of the right breast showed skin and trabecular thickening without any apparent mass or calcifications. Left breast appeared mammographically normal. In addition, ultrasound showed skin thickening and increased echogenicity of the whole breast tissue due to oedema without any apparent mass. CTPA and Chest X-ray showed cardiac enlargement, bilateral pleural effusion, interstitial thickening and peripheral consolidation in keeping with pulmonary oedema on a degree of heart failure. CTPA showed no evidence of PE, but demonstrated breast skin thickening and edematous changes within the right breast.  2 week after the treatment, chest x-ray demonstrated significant improvement. She was treated with diuretics and 1 week after the treatment breast size, peau d'orange skin appearance, and breast oedema all decreased. She underwent skin punch biopsy for ruling out inflammatory breast cancer. Her follow-up ultrasounds also did not show any mass and proved decrease of edema and skin thickening.

Discussion

Oedema of the breast is characterised by an increased skin thickness and breast parenchymal density with prominent interstitial markings and may present in either unilateral or bilateral manner. Bilateral breast oedema occurs in patients with systemic illnesses like renal failure, heart failure, connective tissue disease, liver disease and superior vena cava syndrome. Unilateral breast oedema occurs usually in patients with mastitis, malignancy or treatment changes after surgery or irradiation. Congestive heart failure usually causes bilateral breast oedema, but can rarely cause unilateral breast oedema, which should resolve when the underlying condition is appropriately treated. Breast oedema due to heart failure could be unilateral due to patient position during sleep. Atrophic breast of elderly women is more susceptible to oedema rather than young women. Many diseases can present with mammographic or physical signs of breast tissue inflammation. Heart failure is considered as a differential diagnosis for more important inflammatory breast cancer (IBC) despite.  Diagnosis of IBC should be based on the clinical manifestations, consisting of increased warmth, erythema, and the classic peau d'orange (skin of an orange) appearance of the thickened skin. [1, 2]                                    

Mammographic findings of both diseases include skin thickening, trabecular thickening and increased breast density. In mammography, the absence of a breast mass, microcalcifications or axillary lymphadenopathy is more compatible with oedema due to congestive heart failure. In the case of IBC, ultrasound may show a hypoechoic shadowing mass, or a demarcated abscess, which can be obscured on mammography by diffusely increased breast density, and axillary involvement. No underlying masses or lymphadenopathy are detected on ultrasound examination in patients with congestive heart failure. [1, 2, 3]

Imaging features of heart failure and malignant inflammatory conditions often overlap which may cause diagnostic confusion and possibly delay proper treatment.  The medical history and physical exam are critical to the diagnostic process. Oedema that does not resolve or respond to treatment (antibiotic or diuretic) should always be further evaluated with biopsy to rule out presence of malignancy. [2, 3]

Differential Diagnosis List
Unilateral breast oedema due to congestive heart failure
Inflammatory breast carcinoma
Mastitis
Leukemia-lymphoma
Progressive systemic sclerosis
Skin diseases
Venous obstruction
Poor lymphatic drainage due the axillary adenopathy
Post treatment changes after surgery/irradiation
Final Diagnosis
Unilateral breast oedema due to congestive heart failure
Case information
URL: https://www.eurorad.org/case/16952
ISSN: 1563-4086
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