An unusual cause of breast lump: CSF pseudocyst

Abstract

A breast lump is an uncommon occurrence in the paediatric and adolescent patient; 1 a majority of cases are either related to endocrine function or benign masses. 2 The common benign causes are gynaecomastia, simple cyst, fibroadenoma, lymphnode, galactocoele, duct ectasia and infection.1 Malignant lesions are extremely rare in the paediatric and adolescent population, with an age-specific incidence of less than 25 cases per 100 000 per year among patients younger than 19 years.3 Cystic lesions account for approximately 7.2% of breast lesions on ultrasound; an overwhelming majority are of benign aetiology (approximately 88%). 4 The common causes of cystic breast lesion include simple cyst, abscess, galactocoele and papilloma. A CSF pseudocyst of the breast has rarely been described in the literature, with only a few cases to date. 5-11 Case reportA 16-year-old girl presented with pain in the right breast and a gradually increasing breast lump over the last 15 days. There was no history of fever. She was mentally retarded and had a history of tuberculous meningitis with multiple intraparenchymal tuberculomas at the age of 6 months. She had developed moderate hydrocephalus with thinning of the neuroparenchyma at that time, which was treated with a ventriculoperitoneal (VP) shunt.She was referred for ultrasound study of the breast which showed a well-defined, thin-walled cystic lesion in the right breast. Moving internal echoes were seen within it. The VP shunt was seen passing through the cystic lesion. Since the cystic lesion was seen surrounding the VP shunt, a possibility of CSF leakage with resultant cyst formation was considered, and the patient was referred for CT scan of the brain, chest and abdomen to look for any other sites of CSF leakage. The brain CT revealed moderate hydrocephalus with several areas of encephalomalacia. The VP shunt was seen traversing the frontal horn of the right lateral ventricle, with its tip in the region of the suprasellar cistern. The chest CT showed a well-defined fluid collection in the right breast, measuring approximately 4.9 x 2.9 cm with the VP shunt passing through it. Similar collections were also seen along the tract of the VP shunt in the right supraclavicular region and the lower anterior chest wall.The abdominal CT showed an intraperitoneal fluid collection adjacent to the tip of the VP shunt measuring 7.9 x 3.9 cm. The collection appeared thin-walled and localised and displaced the adjacent bowel loops. In view of several fluid collections along the tract of the VP shunt, intraperitoneal collection adjacent to the tip of VP shunt and moderate hydrocephalus, a diagnosis of a CSF pseudocyst of the breast was made.

Complications of Cerebrospinal Fluid Diversion (Shunt) Catheters: A Pictorial Essay

“…Wandering or recoiling of catheter into subcutaneous soft tissues of thorax, abdominal wall, or behind breast 12 (►Fig. 25).…”

Treatment Strategies of Complications of Breast Implants Associated With Ventriculoperitoneal Shunts

“…Literature review returned 34 articles, one of which described two separate patients, bringing cases to a total of 35 breast-related VPS complications (Table 1). 4–37 Seventeen included migration and coiling of the distal catheter inside the breast. Of these 17 patients, 13 had breast implants at the time of migration.…”

“…Smooth implants, which have been shown to rotate more, 40 may therefore theoretically increase the risk of this complication; unfortunately, the case reports found did not comment on implant texture. If the VPS distal catheter is still in place on imaging, the presence of a breast pseudocyst can be confirmed with ultrasound (US), CT, or contrast shuntogram 5,8,12,26 …”

“…If the VPS distal catheter is still in place on imaging, the presence of a breast pseudocyst can be confirmed with ultrasound (US), CT, or contrast shuntogram. 5,8,12,26 Once pseudocyst and/or shunt migration is confirmed, the level of the plastic surgery team's involvement in management can be guided by the presence or absence of signs of infection or implant rupture (Fig. 4).…”