A 54-year-old woman who was a dialysis patient presented for a screening mammogram. Her physical breast examination was normal. She had no unusual risk factors for developing breast cancer.
Prepared by Lisa F. Baron, MD, Associate Professor of
Radiology, and Susan J. Ackerman, MD, Assistant Professor of
Radiology, Department of Radiology, Medical University of South
Carolina, Charleston, SC.
A 54-year-old woman who was a dialysis patient presented for a
screening mammogram. Her physical breast examination was normal.
She had no unusual risk factors for developing breast cancer.
Extensive vascular collaterals within the breasts of a dialysis
Medialateral film screen mammograms of both breasts demonstrate
abnormal torturous blood vessels within the upper breast. In the
right axilla, there is a large serpiginous vein and associated
venous collaterals (Figure 1). Extensive vascularity was found in
the upper and middle portions of the left breast, and arterial
calcifications, or tram tracking, was noted (Figure 2). Duplex
Doppler examination of the right subclavian vein (Figure 3)
demonstrated the vein to be occluded. Chest computed tomography
(CT) depicted collateral blood flow along the anterior right chest
wall (Figure 4). Finally, the left arm fistulogram revealed a
patent dialysis graft (Figure 5).
This case illustrates the importance of correlating a patient's
medical history with findings noted on the mammogram. The pattern
of vascularity in this patient is abnormal. Usually, the arterial
and venous vessels of the breast are generally symmetric in size
and in distribution. However, in this case, there were excessive
tortuous vessels in the upper breasts. Clinical correlation
determined the cause for this observation. The right subclavian
vein was occluded from a prior dialysis catheter, resulting in
collateral blood flow through the upper portions of the right
breast. This observation was noted on both the mammogram and the
chest CT. In addition, a dialysis fistula was present in the left
arm, accounting for the elaborate vascularity in the left upper
Prominent asymmetric or symmetric venous en-gorgement is usually
benign. However, dilated prominent vessels may be observed in those
patients with congestive heart failure. Infrequently, dilated or
collateral veins can be noticed when there is an obstruction to
flow within the axilla or mediastinum resulting in collateral blood
Rarely, a single dilated vessel may be associated with a later
stage breast cancer.
This case also demonstrated bilateral arterial calci-fications
(tram tracking). Bilateral or unilateral arterial calcifications
are seen in 9% of all women and are an independent risk factor for
cardiovascular mortality in women over 50 years of age.
In diabetic women, the presence of breast arterial calcification is
associated with a 90% increase in cardiovascular mortality.
Correlating the mammographic findings with the patient's medical
history is important. The abnormality vascularity on the mammogram
indicates the systemic effects of the patient's chronic renal