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Iatrogenic lymphatic malformation of the breast
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  1. Clement Wenhao Chan and
  2. Haiyuan Shi
  1. Department of Radiology, Changi General Hospital, Singapore
  1. Correspondence to Dr Clement Wenhao Chan; clemchan24{at}gmail.com

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Description

A female in her 60s who underwent left breast excision biopsies for histology-proven benign nodules presented a few months later with a new multiloculated cystic lesion in the ipsilateral breast (figure 1). The cystic lesion was recurrent and aspirated multiple times over the next 10 years, each time yielding straw-coloured fluid containing lymphocytic and degenerate epithelial cells but no malignant cells. A lymphoscintigraphy study was performed, demonstrating intense accumulation of radiocolloid in the upper outer quadrant of the left breast, corresponding to the cystic lesion, highly suspicious for a lymphatic malformation (figure 2). It was treated with alcohol sclerotherapy and there was no further recurrence.

Figure 1

Ultrasound scan showing a large multiloculated cystic lesion in the left upper outer breast.

Figure 2

Lymphoscintigraphy showing intense radiocolloid uptake in the left breast.

Lymphatic malformation of the breast is extremely rare and forms when there is underlying blockage or weakness in the lymphatic channels resulting in lymph leak and accumulation.1 While typically congenital in the paediatric population, those that occur in adults are commonly associated with a precipitating event such as trauma or infection1 or, in this case, likely iatrogenic from the repeated excision biopsies. Lymphatic malformation of the breast is a benign entity, though malignant degeneration into squamous cell carcinoma has been reported in long-standing cases.1 2 They present as slow-growing lesions in the breast with a cystic appearance on ultrasound. On MRI, lymphatic malformations are T1W hypointense and T2W hyperintense with enhancing internal septa.3 They may hence be mistaken for complicated or complex breast cysts, resulting in delayed diagnosis. A lymphoscintigraphy study was helpful in this case by demonstrating the intense focal uptake of radiocolloid in the left breast, thereby confirming its lymphatic origin.

Fine needle aspiration yields serous or haemoserous fluid and are often non-diagnostic.1 Surgical excision remains the treatment of choice with the lowest rate of recurrence.3 Injection sclerotherapy, steroid injection and carbon dioxide laser treatment are alternative modalities of treatment in poor surgical candidates.2

Patient’s perspective

Thank you for finding the root of the problem and treating me once and for all.

Learning points

  • Lymphatic malformation of the adult breast is a rare entity that is commonly associated with a precipitating event (ie, trauma, infection or iatrogenic).

  • It may be mistaken for complicated or complex breast cysts on ultrasound and MRI, resulting in delayed diagnosis.

  • Lymphoscintigraphy is able to confirm the lesion’s lymphatic origin and is a useful tool in the diagnostic work-up.

Ethics statements

Patient consent for publication

References

Footnotes

  • Contributors CWC wrote the manuscript. HS conceptualised, reviewed and edited the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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