Department of Surgery, Daejeon St. Necrotizing fasciitis NF is a rare and rapidly progressive disease involving the skin, subcutaneous tissue, and deep soft tissue. Although NF can occur any part of the body, the breast is an uncommon primary site for NF, and its occurrence in the breast during pregnancy has never previously been reported. Here, we report the case of a healthy year-old pregnant woman who presented with NF of the left breast that was successfully treated with breast-conserving debridement and secondary wound closure using negative-pressure wound therapy. NF can occur in any part of the body with or without injury.
Second, because of the rapid enhancement of lactating breast parenchyma with gadolinium, the detection of breast cancer is significantly limited [ 8 ]. She may seem to "adopt" a litter to fill the void, and those babies could be anything from a herd of stuffed toys to a group of smaller animals of another species to somebody else's puppies. Fat necrosis is a benign condition that is commonly the result of trauma of which the patient may or may not be aware. Some women find they have shooting pains deep in the breast that start after feeding and can last for a few hours. Katayune Kaeni, psychologist. Progesterone, a pregnancy hormone, Fat pregnant nipples the bowels Fat pregnant nipples less quickly. The patient delivered a Blood pouring out of pussy baby in her 39th week, while still undergoing NPWT treatment. Brent RL. Due to this overlap, distinguishing benign lesions from breast cancer can be difficult and biopsy may be Fat pregnant nipples.
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Current Obstetrics and Gynecology Reports. Nevertheless, the majority of breast disorders in pregnant patients are the same as those in nonpregnant patients, with a few unique exceptions.
Although many of the presenting symptoms are similar, the physiologic changes of pregnancy pose unique diagnostic challenges for the obstetrician, gynecologist, and radiologist, which may contribute to a delay in diagnosis of breast cancer. Awareness of benign and malignant breast disorders and a familiarity with current recommendations for the diagnostic imaging evaluation of breast symptoms in the pregnant patient may aid in earlier detection of pregnancy-associated breast cancer and improve outcomes for these women.
Thus, a diagnosis of breast disease in these patients is usually not made from a mammographic finding but rather a physical finding, such as a mass, skin changes, nipple discharge, or lymphadenopathy [ 2 , 3 ]. Although the majority of breast disorders diagnosed during pregnancy are benign, it is estimated that approximately 1 in 3, pregnancies are complicated by breast cancer [ 4 ].
Pregnancy-associated breast cancer PABC is defined as breast cancer found either during pregnancy or during the first year after pregnancy. During the past several decades, there has been an increase in the incidence of PABC [ 5 ].
With the trend toward advanced childbearing ages, the incidence of PABC is suspected to increase further [ 6 , 7 ]. A few other cancers have been reported but are significantly less frequent [ 3 , 8 , 9 , 10 ]. Understanding the effect of pregnancy on various breast disorders, the management of common presenting symptoms, and the diagnostic imaging algorithm for these symptoms during pregnancy may reduce the delay of diagnosis of PABC.
Physiologic changes of the breast, occurring in response to rising hormone levels during pregnancy, result in increased volume and firmness of the breast and diffusely increased parenchymal density. As a result, the physical examination of the gravid breast can be challenging. Nevertheless, physical examination of a symptom in this patient population is important and can direct the imaging evaluation.
The majority of breast masses exist before pregnancy but may present as an enlarging or newly painful mass as they respond to pregnancy-associated hormonal changes. Less frequently, breast cancer will present as breast erythema, breast swelling or enlargement, bloody nipple discharge, or local or distant metastasis.
Robbins et al. The remaining asymptomatic lesions included: a lesions classified as probably benign according to the American College of Radiology Breast Imaging Reporting and Data System BI-RADS , which were being followed after their initial detection on screening mammogram performed prior to pregnancy; b lesions called back from screening mammograms performed during lactation; or c lesions from routine surveillance imaging in patients with a prior history of breast cancer.
In another study, Ahn et al. Of those, Notably, Benign masses found in both pregnant and nonpregnant women include cysts, fibroadenomas, phyllodes tumors, papillomas, and fat necrosis.
Lactating adenomas and galactoceles are unique to the pregnant or lactating breast. They can produce a palpable lump, can be painful, and can grow and regress rapidly.
Mammographically, they appear as hypo- to isodense round or oval circumscribed masses. On ultrasound, they are anechoic masses with imperceptible walls and posterior acoustic enhancement.
Internal echogenicity can be interpreted as debris if visualized floating in real time. A complicated cyst, with internal proteinaceous material or blood, is difficult to distinguish from a solid mass and should be aspirated. Painful cysts also can be aspirated under ultrasound-guidance [ 11 ]. On mammogram, they appear as an isodense, oval, or lobulated mass that may or may not have associated course calcifications. A homogenous, hypoechoic, oval, or lobular solid mass, sometimes with posterior acoustic enhancement, is usually seen on ultrasound.
It is oriented parallel to the chest wall. Fibroadenomas may develop or markedly enlarge during pregnancy in response to increased estrogen and can regress in the postpartum period.
Their appearance in pregnant or lactating patients is no different than in nonpregnant patients, although a complex appearance with cystic spaces and prominent ducts can be seen.
Biopsy-proven fibroadenomas require only clinical follow-up to ensure stability or regression in patients who are not yet receiving annual screening mammography [ 8 , 11 ]. At our institution, biopsy-proven fibroadenomas that are considered radiographically concordant undergo 1-year follow-up in the over or screening population.
Several articles advocate that fibroadenomas may be managed with imaging surveillance as opposed to biopsy if there are only benign features on initial imaging and they are nonpalpable [ 12 , 13 , 14 ]. Lactating adenomas are benign stromal tumors that may represent a variant of fibroadenomas, tubular adenomas, or lobular hyperplasia. They are seen from the third trimester through lactation, and their natural course is regression following the cessation of breast feeding.
The sonographic appearance is typically a hypoechoic oval or lobulated mass that can be difficult to distinguish from the surrounding breast parenchyma. Spontaneous infarction may develop within fibroadenomas and lactating adenomas, usually during the third trimester or after delivery.
Clinically, this phenomenon presents as the sudden onset of pain in a previously painless fibroadenoma or lactating adenoma. Infarction can lead to a change in the radiographic appearance of the mass with suspicious findings that require core biopsy for definitive diagnosis [ 8 , 11 , 15 , 16 , 17 ].
Histologically similar to fibroadenoma, a phyllodes tumor usually presents as a rapidly enlarging mass. Although there does not appear to be evidence that phyllodes tumors are hormone receptive, they can rarely present as a rapidly enlarging mass in the pregnant, as well as the nonpregnant patient [ 18 ]. The mammographic and sonographic appearance is similar to a fibroadenoma, although a complex appearance and cystic spaces can also be seen. There is a low incidence of lung, bone, and liver metastasis.
Intraductal papillomas can occur as solitary or multiple lesions. If solitary, they are typically subareolar, and if multiple they are typically peripheral. The classic clinical symptom is bloody nipple discharge, but they also can cause spontaneous clear discharge. On mammogram, they are usually round or oval, circumscribed, isodense masses that can contain calcifications. On ultrasound, papillomas appear as solid, round or oval, hypoechoic masses, sometimes within a fluid-filled duct.
Papillomas produce an intraductal filling defect on MRI and ductography. Treatment is usually surgical excision to exclude the presence of malignancy, although follow-up for papillomas diagnosed by core biopsy is controversial. Based on our experience, benign intraductal papillomas diagnosed on core needle biopsy with radiology and pathology concordance may be managed with imaging follow-up rather than surgical excision.
Papillary lesions with atypia or classified as complex on core needle biopsy, however, should be surgically excised because of a 6. Fat necrosis is a benign condition that is commonly the result of trauma of which the patient may or may not be aware. An oil cyst associated with fat necrosis can present as a firm, palpable mass.
On mammogram, an oil cyst is characteristically a lucent round circumscribed mass that may exhibit a thin rim of calcification. Its appearance at ultrasound is characteristically an anechoic, circumscribed mass with through transmission at the palpable site and is considered benign. If there is rim calcification of the oil cyst, then there may be a conspicuous smooth curvilinear shadowing originating from the top of the mass, obscuring the inferior portion of the mass. Occasionally, fat necrosis can present as an irregular mass sonographically with indistinct margins with or without an echogenic halo.
In these instances, malignancy cannot be excluded. If fat necrosis is suspected based on a history of trauma or ecchymosis at the site, a mammogram may be helpful to confirm the presence of fat or oil cysts to avoid a core needle biopsy.
If there is any uncertainty about the precise site of the inciting trauma, biopsy should be performed to exclude malignancy. Galactoceles are the result of an obstructed milk duct and occur both during and after cessation of lactation. Although the mammographic and sonographic appearance is dependent on fat and water content, a fat-fluid level is a diagnostic sign that can be seen on a degree true lateral mammogram, as well as ultrasound. Additional sonographic features include a round or oval, smooth-walled structure with variable internal echogenicity.
Mastitis for which treatment is delayed or inadequate can progress to abscess formation. Mammogram is not usually needed unless malignancy is suspected. A breast abscess usually appears as a round or irregular hypoechoic homogenous or heterogeneous fluid collection, often with fluid-debris levels or mobile debris on real-time imaging.
There may be posterior acoustic enhancement and increased peripheral vascularity. If breast ultrasound demonstrates findings consistent with breast abscess, ultrasound-guided needle aspiration can be performed, both for therapeutic and diagnostic measures to obtain an aspirate for culture and sensitivity.
If the abscess persists on follow-up ultrasound imaging, the procedure can be repeated until the abscess is no longer visible and the patient is asymptomatic. If the abscess is not amenable to needle aspiration, surgical incision and drainage may be necessary to treat the patient [ 8 , 11 , 17 , 20 , 21 , 22 ].
Granulomatous mastitis is an uncommon inflammatory disease closely associated with pregnancy and lactation. Clinically, it can present as a firm or hard mass typically sparing the subareolar breast and can have associated reactive lymphadenopathy.
Corticotherapy is usually effective. Because of an association with Corynebacterium, penicillin and tetracycline should be effective if the bacteria are isolated in microbiology or pathology [ 8 , 11 ]. Disorders of the nipple areolar complex can occur during pregnancy, lactation, or after breastfeeding.
Benign processes that may affect the nipple-areolar complex include nipple inversion related to scarring or constriction of the milk ducts after breastfeeding, eczema, duct ectasia, subareolar abscess, nipple adenomas, and papillomas. Patients may present with nipple inversion, retraction or enlargement, a palpable mass, nipple discharge, skin changes in and around the nipple, infection with resultant nipple changes or a subareolar mass, or abnormal findings at routine mammographic screening.
The evaluation and management of these symptoms is the same as in the nonpregnant patient. Disorders of the nipple-areolar complex require a diagnostically specific imaging evaluation beginning with high-frequency transducer sonography. Knowledge of what constitutes abnormal nipple discharge is critical in the appropriate management of this frequent symptom.
Spontaneous, clear, bloody, or serous nipple discharge is considered pathologic. In the lactating patient, true bloody nipple discharge should be distinguished from cracked or bleeding nipples related to nursing. Bilateral nipple discharge, discharge arising from multiple duct orifices, or discharge of white or green color is less suspicious.
This type of discharge should be managed clinically and imaging often has no significant role. First-line management in the pregnant patient with bloody nipple discharge is a high-frequency ultrasound of the subareolar region to search for an intraductal mass.
Doppler can be helpful to detect vascularity within an intraductal mass, but the lack of vascularity does not exclude malignancy. Mammography should be considered for further evaluation, but its definitive role in the pregnant patient is not known. MR ductography uses a heavily weighted T2 sequences, does not require contrast, is noninvasive, and does not use any radiation.
MR ductography will demonstrate dilated ducts and show ductal masses as signal defects [ 28 ]. In general, for persistent pathologic nipple discharge, if an intraductal mass is not identified on ultrasound or at mammography, the patient should be referred to a breast surgeon for possible surgical duct excision.
Radiation is an important consideration in the pregnant patient because of concerns about exposure to both the mother and fetus. With current digital mammography techniques, the mean average glandular dose from a bilateral two-view digital mammogram is 3. Many of the articles reporting on the radiation dose of mammography to the fetus have estimated fetal dose ranging from 0. Based on this information, the authors conclude that mammography during pregnancy is safe, yet should be avoided during the first trimester when organogenesis occurs [ 2 , 8 ].
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No Breast Growth During Early Pregnancy
Department of Surgery, Daejeon St. Necrotizing fasciitis NF is a rare and rapidly progressive disease involving the skin, subcutaneous tissue, and deep soft tissue. Although NF can occur any part of the body, the breast is an uncommon primary site for NF, and its occurrence in the breast during pregnancy has never previously been reported. Here, we report the case of a healthy year-old pregnant woman who presented with NF of the left breast that was successfully treated with breast-conserving debridement and secondary wound closure using negative-pressure wound therapy.
NF can occur in any part of the body with or without injury. In this report, we present the first case of NF of the breast in a pregnant woman successfully treated using negative-pressure wound therapy.
A year-old woman in 33 weeks of pregnancy presented to the Emergency Department with a 2-day history of pain in the left breast and fever. The patient had previously given birth vaginally to a single child with no complications. On physical examination, the patient had a fever temperature, The whole left breast was swollen, and the skin over the left breast, especially the outer-central area, was reddish.
There was no fluctuation, but the breast was extremely painful. No palpable masses could be felt in the left breast, and the axillary lymph nodes were not palpable. On initial admission, laboratory evaluation revealed leukocytosis Ultrasound of the breasts showed marked subcutaneous edema, diffuse edema of the glandular tissue, intraglandular fluid collection, bright echo, and decreased superficial blood flow Fig.
The initial impression was acute mastitis. The patient was resuscitated with intravenous fluids, and empiric treatment was begun with cefazolin 1. Physical examination one day later revealed skin discoloration Fig. Hence, necrotizing fasciitis NF was suspected, and emergency operation excision of necrotic skin and debridement with sparing of the nipple-areolar complex as it was nonnecrotic was performed. The intraoperative findings were highly suggestive of NF because the deep and superficial fat layers showed liquefied necrosis, and there was loss of normal resistance of the fascia to finger dissection positive "finger test".
Microscopic examination of the surgical specimen revealed coagulative and liquefactive necrosis involving the skin, subcutaneous fat, and breast tissue, and the patient was ultimately diagnosed with NF.
There was no growth in blood cultures, and Streptococcus pyogenes grew in the necrotic tissue culture. Seven days after the initial operation, the nipple-areolar complex turned necrotic and was subsequently excised under local anesthesia. Primary closure of the wound was not possible due to the large skin defect Fig. The NPWT dressing was changed two or three times a week for 1 month. The patient delivered a healthy baby in her 39th week, while still undergoing NPWT treatment. After the NPWT dressings had been applied for 4 weeks, the open wound had shrunk in size significantly.
Then, a silicon adhesive foam dressing was applied twice a week. At the follow-up visit 2 months after her initial presentation with symptoms, the patient had no local or systemic signs of infection, and her healed state was demonstrated by progressive re-epithelialization Fig.
NF is a rare disease but is associated with systemic toxicity and a high death rate despite aggressive treatment. Skin changes will become evident only with resulting skin ischemia, usually a late feature of the disease. In our case, acute mastitis was first suspected due to the presence of no signs of skin discoloration, and the rapidly exacerbating pain and bluish discoloration subsequently led us to perform an emergency operation under the diagnosis of NF.
Gram staining and culture may be helpful, but these procedures can delay appropriate therapy. Standard NF risk factors include: chronic debilitating comorbidities diabetes mellitus, peripheral vascular disease, smoking, alcohol abuse, liver disease, obesity, and immunosuppression and conditions compromising skin integrity surgery, trauma, burn, intravenous drug use, biopsy, pressure ulcers, and chronic skin disease [ 3 , 4 ]. Breast cancer, operation, wound dehiscence, and previous biopsies are other possible risk factors that could facilitate the development of NF in breast [ 2 , 5 ].
Though pregnancy can induce a mildly immunosuppressive state, there had been no previous reported cases of NF during pregnancy. In our case, the patient was previously healthy and had no other risk factors for NF.
Depending on the pathogen, NF may be categorized into three types. Type 2 comprises monomicrobial infections caused by group A beta-hemolytic streptococci.
Type 3 NF is less common and involves skin wounds with infections caused by marine insects hosting Vibrio vulnificus [ 3 ]. We dealt with a type 2 infection without any underlying disease, although type 1 infection has been reported in over half of the cases in breast [ 2 ]. The Laboratory Risk Indicator for Necrotizing Fasciitis score can be utilized to stratify patients presenting with signs of mastitis to determine the likelihood of NF. Wong et al.
In the case described here, a score of 8 was obtained. However, currently, the Laboratory Risk Indicator for Necrotizing Fasciitis score remains unvalidated in larger, prospective studies. Yen et al. Hanif and Bradley [ 9 ] reported that focal bright echoes can be seen due to microbubbles of gas in advanced cases. In our case, a diffuse brighter echo was observed in the affected breast compared to that in the contralateral healthy breast on the initial admission.
Limited data on the diffuse brighter echo exist. However, providers should include NF in the differential diagnosis, and consider the possible consequence of necrosis, when ultrasound shows a brighter echo in the diseased breast. MRI may not be readily available in an emergent setting and can be time-consuming. Few data exist on the optimal method of wound management following debridement.
As with all infected wounds, the wound should be left open and treated with wet-to-dry dressings initially. NPWT has become a common method of treating large wounds once infection is controlled, although there have been no well-designed studies evaluating the role of NPWT in patients with large wounds following infection [ 1 ]. NPWT increases local oxygenation by enhancement of dermal perfusion and accelerates formation of granulation tissue by stimulating fibroblasts [ 10 ].
NPWT has been used for lesions in the breast such as chest wall defects following bilateral NF and salvage of infected breast implants [ 2 ]. There was a case report describing NF of the breast following a core needle biopsy, in which surgical debridement and NPWT allowed breast conservation after split thickness skin graft [ 5 ].
Skin graft requires considerable skill and donor-site surgery. In our case, split thickness skin graft was also considered, but we decided to allow the wound to heal by secondary closure to avoid a second operation because the patient was pregnant.
About 2 months were required for full recovery of the open wound, which might be comparable to the length of time required for healing following a second graft operation. To the best of our knowledge, this is the first case of NF of the breast in a pregnant woman, whose wound defect was successfully managed by secondary closure using NPWT.
It is reasonable to assume that this case demonstrates the benefits of secondary wound closure using NPWT. These benefits are enhanced by the fact that providers can avoid a second skin graft operation, including donor-site surgery, for wound closure.
Secondary wound closure using NPWT can be a viable option in the management of huge wound defects. National Center for Biotechnology Information , U.
Ann Surg Treat Res. Published online Jul 9. Find articles by Jina Lee. Find articles by Kwan Ju Lee. Find articles by Woo Young Sun. Author information Article notes Copyright and License information Disclaimer. Corresponding author. Corresponding Author: Woo Young Sun. This article has been cited by other articles in PMC. Abstract Necrotizing fasciitis NF is a rare and rapidly progressive disease involving the skin, subcutaneous tissue, and deep soft tissue.
Keywords: Necrotizing fasciitis, Breast, Pregnancy, Negative-pressure wound therapy. Open in a separate window. Ultrasound image of necrotizing fasciitis. Ultrasound revealing marked subcutaneous and glandular edema, intraglandular fluid collection, brighter echo A , and decreased superficial blood flow in Doppler sonogram B compared to that in the contralateral normal breast C, D.
A Necrotizing fasciitis of the left breast demonstrating edema, inflammation, and an area of necrosis. B Postoperative photograph demonstrating open wound after removal of the nipple-areolar complex. References 1. Necrotizing fasciitis: current concepts and review of the literature. J Am Coll Surg. Bilateral necrotizing fasciitis of the breast following quadrantectomy. Breast Cancer. Salcido RS. Necrotizing fasciitis: reviewing the causes and treatment strategies.
Adv Skin Wound Care. Necrotizing fasciitis following a small burn. J Korean Surg Soc. First report of a necrotising fasciitis of the breast following a core needle biopsy. Breast J. The microbiology of necrotizing soft tissue infections. Am J Surg. Crit Care Med. Ultrasonographic screening of clinically-suspected necrotizing fasciitis. Acad Emerg Med. Sonographic findings of necrotizing fasciitis in the breast.
J Clin Ultrasound.