traumatic breast fat necrosis
Introduction
Introduction to traumatic breast fat necrosis Traumaticfatnecrosisofbreast refers to the damage of the adipose tissue of the breast due to violence and saponification under the action of fatty acid enzymes, which in turn leads to aseptic inflammation of the breast. The breast is composed of more fat and connective tissue and a small proportion of glands. The fat position is superficial (located under the skin), and the blood circulation is not abundant. Therefore, ischemic necrosis and scar tissue formation are likely to occur after trauma. basic knowledge The proportion of illness: 0.0002% Susceptible people: no special people Mode of infection: non-infectious Complications: nipple retraction
Cause
Causes of traumatic breast fat necrosis
(1) Causes of the disease
According to the cause of the disease, breast traumatic fat necrosis can be divided into two types: primary breast fat necrosis and secondary breast fat necrosis. Most of them are primary breast necrosis, which is caused by traumatic adipose tissue necrosis or bleeding. Necrosis, the tissue is gradually replaced by fibrous tissue, although half of the patients have no obvious history of trauma, but some lighter, inadvertent blunt trauma such as hitting the table, the horn, etc. can also cause the fat tissue in the breast to be squeezed. Necrosis, secondary breast fat necrosis, is due to secondary to certain diseases, such as plasma cell mastitis (breast ductal dilatation) when the expansion of the catheter contents can penetrate into the mammary gland through the wall, suppuration of the breast Sexual infections, breast surgery, hemorrhagic necrosis of breast tumors, partial breast resection and radiotherapy can cause breast fat necrosis.
(two) pathogenesis
It has been proved that the disease is aseptic fatty necrotic inflammation caused by trauma, which is caused by fatty acid enzymes in blood or tissues, which cause saponification of nodular fat, followed by pathological changes such as aseptic necroinflammation. According to its course of disease and inflammatory response, breast fat necrosis can be divided into early, middle and late stages.
1. Early 1 to 3 weeks after breast trauma, the skin of the wound may appear yellow, orange or dark brown ecchymosis, there may be bleeding in the lesion, and the fat tissue is slightly hardened. This is because the wound is small after the trauma of the breast. Blood vessel rupture and hemorrhage, the hemosiderin is released after the red blood cells are decomposed, resulting in yellowish brown ecchymosis on the skin of the breast injury. Under the microscope, the fat cells are turbid, that is, fat saponification and fat cell necrosis disintegration, and merge into larger lipid droplets. .
2. In the middle stage, about 4 to 6 weeks after the trauma, a round mass is formed in the adipose tissue, the diameter is about 2 to 4 cm, the boundary is unclear, the surface is slightly yellow, and the cut surface is formed by the oil sac. The capsules are of different sizes, which are full. Oily liquid or dark brown bloody liquid and necrotic substance. In this period, due to fat necrosis, cell lysis, lipid droplets are free, microscopically visible foamy phagocytic cells surround the lesion, and foreign bodies can be seen or wrapped with needles or Rhomboid fatty acid crystals and necrotic substances, accompanied by neutrophils, monocytes, lymphocytes and plasma cells infiltration; also due to stimulation of necrotic tissue lysates, so that fibroblasts, foreign body giant cells, epithelial cells surround Foreign body granulomatous structure.
3. In the late stage, about a few months after the trauma, the fibrous tissue of this stage is obviously hyperplasia, and the mass of the mass is grayish yellow. It is a hard solid body, cut into a radial scar-like tissue with hemoside and calcium deposits. This stage of the tumor can adhere to the skin, causing the skin to sag. When the tumor is large and the adhesion is heavier, the nipple will be invaginated or skewed. It should be distinguished from the breast cancer. The necrotic and inflammatory areas are seen by the fibrous tissue under the microscope. Substituted, there are residual granulated structures containing denatured fat cells and oily vacuoles and cholesterol crystals, calcium salts and residuals.
Although the pathological process can be divided into three phases, due to the inconspicuous trauma of the patient and the continuous development of the lesion, there is no strict clinical standard for accurate staging.
Prevention
Traumatic breast fat necrosis prevention
Trauma is the main cause of breast fat necrosis. Although the accidental injury of the breast can not be eliminated, it should avoid instilling drugs in the subcutaneous tissue of the breast, such as saline, hormone drugs, oil substances (liquid injected during breast plastic surgery). Paraffin or Vaseline, etc. In recent years, local injection of hormones in the breast has been used to treat mammary gland dysplasia, which has become one of the factors of traumatic breast fat necrosis. In addition, attention to hemostasis and avoid excessive tissue damage during breast surgery can be effective. Reduce the occurrence of breast fat necrosis.
Complication
Traumatic breast fat necrosis complications Complications nipple retraction
Late stage complicated fibrous tissue is obviously hyperplasia, and the mass of the mass is grayish yellow, which is a hard physical object. Cut into a radial scar-like tissue with hemosiderin and calcium deposits. This stage of the tumor can adhere to the skin, causing the skin to sag. When the tumor is larger and the adhesion is heavier, the nipple will be invaginated or skewed. It should be distinguished from breast cancer. Microscopically, the necrotic and inflammatory areas were replaced by fibrous tissue, and there were residual granulated structures containing oily vacuoles and cholesterol crystals, calcium salts and residuals.
Symptom
Traumatic breast fat necrosis symptoms Common symptoms Breast pain cysts Breast lumps nipples drooping breast abscess Lymph node enlargement Skin adhesion Breast tissue Mass necrosis Postpartum chest drooping
Patients often see a diagnosis of breast mass, the average symptom to treatment time is several months to several years, the disease occurs in the right breast, the main clinical symptoms are:
1. Breast skin changes
Post-traumatic blood stasis, often in the damaged breast localized with blood spots, local skin can be red, history of trauma and redness of the skin of the breast, which is very helpful for the diagnosis of this disease.
2. Suffering breast pain
Most patients have local pain in the breast, or no pain. This painless mass is one of the characteristics of this disease, most of which are forgotten due to long history.
3. Firm feeling and skin adhesion
When the injury is shallower, about 70% of the patients have local skin and mass adhesion. The adhesion of this solid mass to the skin is nipple depression, nipple retraction or orientation change, similar to breast malignant tumor (but no skin appears Edema and typical "orange peel sign" must be differentiated from breast cancer at the time of diagnosis.
4. Nipple depression
If the mass is located in the subcutaneous fat around the nipple, the nipple retraction may occur due to fibrosis of the lesion, which is one of the signs often confused with cancer.
5. Infection performance
Another manifestation of breast fat necrosis is like an abscess, with no obvious history of trauma and skin bruising. The initial manifestations are local redness, swelling, heat, and pain. Under the skin in or near the areola area. Touching a lump, and having a sense of undulation, after cutting the skin, there is a superficial cyst under the skin. The sac contains thick blood or gray-yellow thick necrotic tissue. When the biopsy is performed, the cyst wall is only fat necrosis. In the sagging breast of an obese woman, it is not related to breastfeeding, and is not a general acute breast abscess.
6. Axillary lymph node enlargement
Some patients may be accompanied by inflammation of the lateral axillary lymph nodes, which is very hard to touch, and even suspected of cancer metastasis.
Examine
Traumatic breast fat necrosis
Histopathological examination is the only method of diagnosis. There are common fats in the biopsy. The early lesions show fat saponification. The extensive fat necrosis is accompanied by inflammatory reactions. The lesions have foreign body giant cells and lymphocytes infiltrated. There are peripheral necrotic areas. Many foam macrophages and connective tissue grow, and finally the necrotic tissue is completely replaced by fibrous tissue.
1. Mammography target X-ray film
The dense shadow of the mass is shallower, the local skin is thicker, and the inward depression is seen. There are single or multiple lipid-containing cysts, which contain punctate or large irregular calcification.
2.B-ultrasound
Local fat necrosis is mostly irregular shape and low echo area, and the posterior acoustic shadow of the surrounding fibrous scar is formed. The single oil-like image of the oily cyst after trauma is typical. It has a circular or elliptical hypoechoic area with smooth and clear edges. Acoustic and enhanced, multi-image sonogram is not typical, the shape can be irregular, and there is a high echo shadow between the lesions.
Diagnosis
Diagnosis and diagnosis of traumatic breast fat necrosis
diagnosis
The disease occurs in the body, obesity, breast drooping, middle-aged women over 30 years old, generally have varying degrees of breast trauma, surgery and inflammation history, etc., the vast majority can touch the breast mass, the mass can be round or oval Shape, about 1 ~ 6cm, tough texture, smooth surface, some are fluctuating, there are irregular masses, unclear boundaries, some mild tenderness or limited skin surface depression, should pay attention to breast cancer identification, breast The mass is often painless or mildly painful, with no sustained growth, no metastasis, and the eccentric or retraction of the nipple is caused by the fibrosis of the lesion in the areola area. It should also be distinguished from breast cancer. Cases of axillary lymphadenopathy are chronic lymphadenitis or reactive hyperplasia of lymph nodes.
Differential diagnosis
Traumatic breast fat necrosis is more likely to be misdiagnosed. The rate of misdiagnosis is 82.9% in the literature. The main reason is that fat necrosis is rare in clinical practice, and doctors lack understanding. The fatty necrosis lacks characteristic clinical manifestations and different pathological changes. The clinical manifestations are complex and diverse. The pleomorphism of the mass and the relationship with the surrounding tissue are easily confused with the good breast and malignant tumors; there is a lack of valuable laboratory tests and auxiliary examinations, so it is necessary to strengthen the identification with the relevant lesions in order to make a diagnosis.
Breast cancer
The breast cancer mass is mostly irregular, the boundary is not clear, a few are spherical or oblate, and there may be nipple elevation, depression, pointing change, skin orange peel-like changes, axillary lymph nodes often enlarge, and breast fat necrosis mass boundary Relatively clear, the tumor is superficial, although it has adhesion to the skin, but it has nothing to do with the deep tissue, it will not be fixed on the chest wall, there will be no skin orange peel-like changes, the lymph nodes are occasionally swollen, and breast cancer has breast fat necrosis. The skin of the original breast cancer after traumatic skin and ecchymosis was misdiagnosed as fat necrosis. After detailed medical history, it was confirmed that the tumor occurred before the breast injury, and the breast skin was accompanied by orange-like edema, which was conducive to the diagnosis of breast cancer.
2. Breast abscess
Breast abscess manifested as redness and swelling of the breast, heat, pain, accompanied by systemic symptoms, fever, chills, deep abscess, pus out after incision, and breast fatty necrosis abscess is superficial, liquefied fat after excision or Old bloody liquid, or viscous, sticky necrosis, can have leukocytosis.
3. Breast duct dilatation
The disease has no history of breast trauma, the location of the disease is mostly in the areola area, there may be nipple discharge in the early stage, breast lumps may appear and adhesion to the surface skin, the mass has pain and tenderness, the patient may have fever, and the nipple may appear in the late stage with the enlargement of the tumor. Invagination or orange peel-like changes, the oil sac is not seen in the cut surface, the duct is dilated in pathology, the fibrosis is thickened in the wall, but there is no proliferation of ductal epithelial cells, and lymphocytes and plasma cells are infiltrated in the tissues surrounding the catheter.
4. Lactocyst cyst
Most occur in pregnancy, lactation or weaning, the milk may have inflammation, trauma or surgical history before the onset, the mass is oval or round, the boundary is clear, smooth and elastic, the activity is large, the tumor is mostly located in the areola Near the area, X-ray examination showed a clear outline, a low-density and uniform cyst, and ultrasound examination showed that the lesion was cystic, and the tumor was puncture to extract fresh milk or thick cheese-like substance to confirm the diagnosis.
5. Recurrent nodular non-suppurative panniculitis
The characteristic change of this disease is repeated induration under the skin. The induration often has fever. The induration can be isolated, or it can be fusion, and often has pain and tenderness. The lesion is usually located in the limbs and trunk, but it can also occur in Women's breasts, as the disease progresses, induration can occur liquefaction, the surface of the skin is blue-black, slightly raised on the body surface, there are fluctuations, puncture can extract brownish yellow oily liquid, then absorb and fibrosis, while pulling the skin, leaving a cup Depression, according to the history of the disease and the progress of the lesion, the two are not difficult to distinguish.
