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.

CASE SUMMARY

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.

DIAGNOSIS

Extensive vascular collaterals within the breasts of a dialysis patient

IMAGING FINDINGS

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).

DISCUSSION

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 breast.

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 supply. ¹ 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. ² In diabetic women, the presence of breast arterial calcification is associated with a 90% increase in cardiovascular mortality. ²

CONCLUSION

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 disease.