Unusual.html
Unusual cause of breast lump: a CSF pseudocyst
Sandeep Gopal Jakhere, MD, DNB
Raju Kumbhar, MD
Harshal Dhongade, MD
Department of Radiology, B Y L Nair Charitable Hospital and Topiwala National Medical College, Mumbai, Maharashtra, India
Corresponding author: S Jakhere (drsandeepjakhere@gmail.com)
A
ventriculoperitoneal (VP) shunt is a fairly common and useful procedure
to reduce intracranial pressure in patients with hydrocephalus.
Complications associated with VP shunts are usually related to either
shunt obstruction or infection. A pseudocyst formation owing to leakage
of CSF into the breast tissue as a complication of VP shunting is a
rare entity, with few cases in the literature. Nonetheless, it is an
important cause of cystic breast lump and should be kept in mind in a
patient with an indwelling VP shunt. We describe the case of a
16-year-old girl patient with an indwelling VP shunt who presented with
a gradually increasing breast lump, and was diagnosed to have a CSF
pseudocyst based on characteristic imaging findings.
S Afr J Rad 2012;16(2):69-71.
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
Case report
A 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.
Discussion
Shunting of CSF into the peritoneal cavity in patients with hydrocephalus was advocated as far back as 1898 by Ferguson et al.12 However, it was only in 1905 that the first VP shunt was placed for CSF diversion.13
Although VP shunting has significantly improved outcomes in patients
with hydrocephalus, it has been estimated that 40 - 50% of children and
29% of adults will suffer a shunt failure within the first year of
placement.14
Complications associated with VP shunts are usually related to either
shunt infection or obstruction. Obstruction of a VP shunt usually
occurs at the proximal end, maybe caused by plugging of the catheter by
brain parenchyma, the choroid plexus or tumour cells. Patients usually
complain of headache, nausea, vomiting, lethargy, irritability and
sometimes increasing head size with bulging fontanelles. Distal
obstruction is usually caused by adhesions in the peritoneal cavity or
apposition of solid abdominal organs against the shunt tip, which may
lead to formation of abdominal pseudocysts that may present with
increasing abdominal size and pain. Migration of a VP shunt may occur
along the tract of its placement, and subsequent CSF drainage into the
soft tissues occurs, leading to formation of CSF collections. The
distal end of a VP shunt may migrate to unusual sites including the
anus, umbilicus, vagina, scrotum, pulmonary artery or even the oral
cavity.15
Thoracic complications associated with VP shunt
placement are not very common, although they can sometimes be
life-threatening. They are classified into 3 broad groups:15
1. complications occurring during shunt placement
2. complications related to catheter migration
3. pleural effusions.
Complications under the first group are infrequent,
with only 3 cases reported up to 2007. A typical example is lung apex
perforation while advancing the catheter during shunt placement,
leading to pneumothorax.
Thoracic migration of a VP shunt is also rather
uncommon, with 12 cases reported. The distal tip of the VP shunt may
migrate proximally along the chest wall, and may end up either in the
pleural cavity or the lung parenchyma, with a few cases of bronchial
perforation also being reported.
Pleural effusions are produced either due to supra
diaphragmatic or transdiaphragmatic migration of the VP shunt; the
treatment of choice is thoracocentesis.
Breast-related
complications of a VP shunt include formation of pseudocysts and CSF
galactorhea. CSF pseudocysts maybe formed in the breast either by
migration of the catheter tip into the breast tissue or by fracture of
the shunt followed by seepage of CSF and fluid accumulation. A few
cases of a VP shunt wrapped around a breast prosthesis with subsequent
CSF pseudocyst formation have also been reported.16 Spector et al.9
believed that migration of the VP shunt in their patient was related to
lifting heavy weights, compounded by adhesions between the pectoralis
major muscle and capsular tissues along the shunt tunnel, which caused
significant traction force on the VP shunt. However, in our patient,
there was no migration of the VP shunt tip, which remained in the
abdominal cavity, and the CSF pseudocyst formation was probably due to
inadequate CSF drainage, as evidenced by abdominal pseudocysts and
hydrocephalus, following a micro-fracture of the VP shunt in the region
of the breast, and subsequent slow seepage of CSF.
In conclusion: CSF pseudocyst formation is a rare
cause of a gradually enlarging breast lump, and should be borne in mind
in patients with an indwelling VP shunt catheter. Ultrasound and CT
evaluation would be diagnostic for this condition.
Acknowledgements. We thank Dr Bhakti Yeragi and Dr Vipul Chemburkar for evaluating the report for its content and accuracy.
1. Weinstein SP, Conant EF, Orel SG, Zuckerman JA, Bellah R. Spectrum
of US findings in pediatric and adolescent patients with palpable
breast masses. RadioGraphics 2000;20:1613-1621.
1. Weinstein SP, Conant EF, Orel SG, Zuckerman JA, Bellah R. Spectrum
of US findings in pediatric and adolescent patients with palpable
breast masses. RadioGraphics 2000;20:1613-1621.
2. Amshell CE, Sibley E. Multiple unilateral fibroadenomas. Breast J 2001;7:189-191.
2. Amshell CE, Sibley E. Multiple unilateral fibroadenomas. Breast J 2001;7:189-191.
3. Ries LA, Eisner MP, Kosary CL, et al., eds. SEER Cancer Statistics
Review, 1975-2002. Bethesda, MD: National Cancer Institute, 2005.
3. Ries LA, Eisner MP, Kosary CL, et al., eds. SEER Cancer Statistics
Review, 1975-2002. Bethesda, MD: National Cancer Institute, 2005.
4. Berg WA, Campassi CI, Ioffe OB. Cystic lesions of the breast: sonographic-pathologic correlation. Radiology 2003;227:183-191.
4. Berg WA, Campassi CI, Ioffe OB. Cystic lesions of the breast: sonographic-pathologic correlation. Radiology 2003;227:183-191.
5. Kalra N, Mani NB, Jain M, et al. Cerebrospinal fluid pseudocyst of the breast. Australas Radiol 2002;46:76-79.
5. Kalra N, Mani NB, Jain M, et al. Cerebrospinal fluid pseudocyst of the breast. Australas Radiol 2002;46:76-79.
6. Lazarus E, Nebres M, Spencer P, et al. Iatrogenic breast mass
associated with a malfunctioning ventriculoperitoneal shunt in a
patient with neurosarcoidosis. Am J Roentgenol 1998;171:529-530.
6. Lazarus E, Nebres M, Spencer P, et al. Iatrogenic breast mass
associated with a malfunctioning ventriculoperitoneal shunt in a
patient with neurosarcoidosis. Am J Roentgenol 1998;171:529-530.
7. Vimalachandran D, Martin L, Lafi M, et al. Cerebrospinal fluid pseudocyst of the breast. Breast 2003;12:215-216.
7. Vimalachandran D, Martin L, Lafi M, et al. Cerebrospinal fluid pseudocyst of the breast. Breast 2003;12:215-216.
8. Iyer HP, Jacob LP, Chaudhry NA. Breast cerebrospinal fluid pseudocyst. Plast Reconstr Surg 2006;118:87e–89e.
8. Iyer HP, Jacob LP, Chaudhry NA. Breast cerebrospinal fluid pseudocyst. Plast Reconstr Surg 2006;118:87e–89e.
9. Spector JA, Culliford AT, Post NH, et al. An unusual case of
cerebrospinal fluid pseudocyst in a previously augmented breast. Ann
Plast Surg 2005;54:85-87.
9. Spector JA, Culliford AT, Post NH, et al. An unusual case of
cerebrospinal fluid pseudocyst in a previously augmented breast. Ann
Plast Surg 2005;54:85-87.
10. Spector JA, Culliford IV AT, Levine JP. Breast cerebrospinal fluid pseudocyst. Plast Reconstr Surg 2007;120:357-358.
10. Spector JA, Culliford IV AT, Levine JP. Breast cerebrospinal fluid pseudocyst. Plast Reconstr Surg 2007;120:357-358.
11. Torres AN, Barraquer EL, Salvador Sanz JF, et al. Late complication
of a ventriculoperitoneal shunt in a patient with mammary prosthesis. J
Plast Reconstr Aesthet Surg 2008;61:212-214.
11. Torres AN, Barraquer EL, Salvador Sanz JF, et al. Late complication
of a ventriculoperitoneal shunt in a patient with mammary prosthesis. J
Plast Reconstr Aesthet Surg 2008;61:212-214.
12. Ferguson AH. Intraperitoneal diversion of the cerebrospinal fluid in cases of hydrocephalus. NY Med J 1898;67:902.
12. Ferguson AH. Intraperitoneal diversion of the cerebrospinal fluid in cases of hydrocephalus. NY Med J 1898;67:902.
13. Harsh GR. Peritoneal shunt for hydrocephalus utilizing the fimbria
of the fallopian tube for entrance to the peritoneal cavity.
Neurosurgery 1954;11:284-294.
13. Harsh GR. Peritoneal shunt for hydrocephalus utilizing the fimbria
of the fallopian tube for entrance to the peritoneal cavity.
Neurosurgery 1954;11:284-294.
14. Kupeli E, Yilmaz C, Akcay S. Pleural effusion following
ventriculo-pleural shunt: Case reports and review of the literature.
Ann Thorac Med 2010;5:166-170.
14. Kupeli E, Yilmaz C, Akcay S. Pleural effusion following
ventriculo-pleural shunt: Case reports and review of the literature.
Ann Thorac Med 2010;5:166-170.
15. Taub E, Lavyne MH. Thoracic complications of ventriculoperitoneal
shunts: case report and review of the literature. Neurosurgery
1994;34:181-183.
15. Taub E, Lavyne MH. Thoracic complications of ventriculoperitoneal
shunts: case report and review of the literature. Neurosurgery
1994;34:181-183.
16. Chu YT, Chuang HC, Lee HC, Cho DY. A ventriculoperitoneal shunt
catheter wrapped around a right mammary prosthesis forming a
pseudocyst. J Clin Neurosci 2010;17(6):801-803.
16. Chu YT, Chuang HC, Lee HC, Cho DY. A ventriculoperitoneal shunt
catheter wrapped around a right mammary prosthesis forming a
pseudocyst. J Clin Neurosci 2010;17(6):801-803.
Fig. 1. Axial CT scan image of brain showing encephalomalacic changes in the right temporal lobe. Ex vacuo dilatation of the left frontal horn is seen. The VP shunt traverses the temporal lobe neuroparenchyma.
Fig.
2. Contrast-enhanced axial CT scan of the thorax showing a cystic
lesion in the right breast (thick arrow) with the VP shunt (thin arrow)
passing through it.
Fig. 3. A similar cystic lesion (arrow) surrounding the VP shunt is also seen in the right supra-clavicular region.
Fig.
4. Axial contrast-enhanced CT scan of the abdomen shows a well-defined
thick-walled intra-peritoneal fluid collection (thick arrow) with the
VP shunt (thin arrow) traversing it.
Fig. 5. Sagittal reformatted image showing the
cystic lesion in the breast (thin arrow) and the intraperitoneal fluid
collection (thick arrow).