Superficial phlebitis of the breast

Superficial Phlebitis of the Breast MITCHELL KARLAN, M .D . AND DONALD W . TRAPHAGEN, M .D .,

from The Obio State University Department of Surgery and University Hospital, Columbus, Obio .

approximately 4 mm . by 6 cm . It was superficial and adherent to the skin . By retracting the breast medially (Fig . I), a cord of tissue could be made to stand out like a bowstring . The left breast and regional lymphatic areas, bilaterally, were normal .

phlebitis of the breast, or Mender's disease, is an unusual condition which apparently occurs more frequently than is reported because of its self-limitation and minimal symptomatology . In the past, patients have probably disregarded the cord-like lesion which usually occurs in the breast area, but with the layman's present day awareness of cancer, more of these patients are seeking medical consultation . The presence of a lump or cord in the breast with skin fixation, a characteristic feature of this disease, demands that malignancy be ruled out. This case presents some of the interesting facets of this disease and is reported to add to the number already collected in the literature. The fre uency with which this lesion is coming to attention justifies that every physician examining a breast be aware of it.

S

Columbus, Ohio

uPERFICIAL

CASE REPORT

G. N ., a thirty-four year old Negro housewife, was first seen in The Ohio State University Cancer Clinic on October 1, 1956 . She had been in apparent good health until two weeks prior to her initial visit when, while bathing, she noticed a lump in her right breast . The lump allegedly increased in size during the ensuing two weeks, and was slightly tender and painful. She had menstruated one week before the lesion was found ; this was the first such lump noted by the patient . There was no recent history of trauma, infection, febrile episode or malaise . Her appetite was good, weight stable, and her general well-being and activity were excellent. General physical examination revealed no abnormalities, except for positive findings confined to the right breast . On its lateral aspect, a firm, tender mass was felt which measured

When the patient's left hand retracts the breast medially, a cord of tissue appearing as a bowstring comes into prominence on its lateral aspect . Fic . L

A preoperative diagnosis of Mondor's disease was made and no biopsy thought necessary . However, because of our interest in this lesion, the patient's anxiety and to be absolutely certain that it was not malignant, a portion of the lesion was excised under local anesthesia . The pathologic report confirmed our preoperative 981

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Karlan and Traphagen

Fm . 2 . A high power magnification showing the marked fibrous perivascular inflammation in the subcutaneous tissue of the breast . (Department of Photography, Ohio State University .)

diagnosis of superficial phlebitis of the breast . Her postoperative course was uneventful, and the incision healed with no complication .

Histologic sections of the lesion confirm that it is a sclerosing endophlebitis . Differentiation between an arteritis and phlebitis is difficult at times, but the paucity of elastic fibers and the small, thin ring of smooth muscle cells surrounded by a perivascular cuff of thick, fibrous, inflammatory tissue (Fig . 2) suggest that it is venous in origin . Mender's disease has occasionally been mistaken for a malignant lesion in the breast . The cord was interpreted as consisting of a lymphatic permeation of neoplastic cells [16] . The reason for its consideration in differentiating it from a malignancy in the breast is its fre uent fixation to the skin . Atkins [r7] has stated that the most important sign in differentiating a benign from a malignant lesion in the breast is to note whether skin fixation has occurred . Adair [14] reports that the following lesions in the breast may produce skin attachment : pyogenic infection, cysts, traumatic fat necrosis, plasma cell mastitis, intradermal tumors such as neurofbromas and sebaceous cysts, and an occasional intracanalicular fibroadenoma in contrast to a periductal fibroadenoma, which is freely movable and without skin attachment . Finally, he included thrombosis of the superficial veins of the breast, the majority of which occurred following operative procedures on the breast . The characteristic physical finding of this condition is a round 3 to 5 mm . in diameter,

COMMENTS

The eponym, Mondor's disease, became popular after Henry Mondor published his report of four cases in 1939 [r] . He called this condition a "string phlebitis of the breast" [2,3] . Farrow's review on the subject [4] in 1955 noted that only fifty-eight cases had been reported in the world literature, and that twenty-four of these occurred in males . Kaufman [51 added seven more cases in 1956, and mentioned that the appellation, Mondor's disease, was not accurate because there were prior descriptions of the syndrome [6-9] . The first report of superficial phlebitis of the chest was probably the case described by Fagge [rol in 1869, who believed that the cord-like thickenings with skin fixation were scleroderma bands . Since that time occasional reports have appeared in the literature. The etiology has been ascribed to various causes, including scleroderma, inflammation in an embryonic milkridge (vestigial mastitis) [rr], trauma and effort [12,13], and idiopathic and postoperative phlebitis [r41 . Previous investigators have believed that this lesion represents a sclerosing periangiitis [r5] or phlebitis, which usually affects the lateral thoracic vein or thoracoepigastric vein . 982

Superficial Phlebitis of Breast 3 . MONDOR, H . and BERTRAND, 1 . Thrombophlebitis et periphlebites de In paroi thoraei ue anterienre . Presse med ., 59 : 1533. 1951 4 . FARROw, J . H . Thrombophlebitis of the superficial veins of the breast and anterior chest wall (Mondor's disease) . Surg ., Gynec . e" Obst ., tot : 63, 1955 . 5 . KAUFMAN, P . A . Subcutaneous phlebitis of the breast and chest wall. Ann . Surg ., 144 :847, i956 . 6 . FIESSINGER, N . and MATn1EU, P . Thrombophlebites des veines de Is paroi thoraco-abdominale . Bull . et mem . Soc . med d. hop . de Paris ., 46 : 352, 1922 . 7 . FAVRE, M . J . de med . d e Lyon, 1929. Quoted in communication to Presse med ., 6o : 79, 1952 . 8 . 1Vn .uAnts, G . A . Thoraco-epigastric phlebites producing dyspnea, J. A . M. A ., 96 : 2196, 1931 . 9 . DANIELS, W . B . Superficial thrombophlebites ; a new cause of chest pain . Am . J . M. Se, 183 : 398, 1932 . 1o . FACCn, C . H . Remarks on certain cutaneous affections . Guv's Hosp. Rep ., 15 : 302, 1870 . 11 . MoscocowiTZ, A ., V . Vestigial mastitis . Ann . Surg., 98 : 855, 193312 . Roa1NsoN, R . H . 0 . Thrombosis following strain . Brit . J. Sure ., 23 : 296, 1 935 . 13 . WERNER, M . Un cas de phlebite en cordon postcontusionelle du bras, a rapprocher de to maladie de Mondor . Presse med., 57 : 166, 1949 . 14 . ADAIR, F . E . Cancer of the breast . Practitioner, 165 : 473, 193-15 . HucmEs, E . S . R . Sclerosing peri-angiitis of the lateral thoracic wall. Australian ee New Zealand J. Surg., 22 : 17, 1952 . 16 . LUNN, G . M . and POTTER, J . M . Mender's disease (subcutaneous phlebitis of the breast) . Brit . W. J ., 1 : 1074, 1954 . 17 . ATKINS, 11, J . B . Painful nodular breast . Prac . titioner, 165 :482, 1950 .

tender, painful sinuous cord of variable length in the subcutaneous tissue and fixed to the skin . By elevating or retracting the breast, the cord can be made to stand out like a bowstring . Axillary lymphadenopathy is not a common finding, but may occur as a reactive hyperplasia to the localized inflammatory process . The disease occurs in an otherwise healthy person who suddenly notices a tender, painful mass or cord, usually somewhere along a line from the anterior axillary fold to the epigastrium . There may be a history of recent trauma, muscular strain or pre-existing respiratory infection [6] . Antibiotics and anticoagulants are not indicated, inasmuch as the disease tends to be self-limited and resolved without treatment within several months . SUMMARY

r . A case report of superficial phlebitis of the breast, or Meador's disease, is presented . z . This lesion may occasionally be mistaken for a malignancy because of the' fre uency of skin fixation . It is self-limited and resolves without treatment . REFERENCES

MoNOOR, H . Tronculite sous-cutanee subaigue de laa paroi thoraci uc antero laterale . Mem . Acad . de cbir ., 65 : 1271, 1 9392 . MONDoR, H . Phlebite en cordon de la parai thoraci ue . Mem . Acad . de ebir ., 70 : 96, 1944 . 1.

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