Breast Hematoma

A breast hematoma is basically a collection of blood inside the breast tissue. This usually occurs as a result of bleeding somewhere inside the breast tissue.

Hematomas can happen due to many factors, such as

• Trauma: Sports injury, car accident, in fact, any hard bump to the breast
• Weak blood vessels: Sometimes blood vessels can leak and cause bleeding
• Breast Biopsy: This can cause a hematoma or may cause bruising under the skin.
• Breast surgery: Both for breast surgery and for cosmetic changes like breast reduction or augmentation surgery with implants

Blood that leaks into the tissue, will usually clot, but sometimes it can remain liquid.

 

 
 

Diagnosis of a Breast Hematoma

Hematomas are usually very obvious because they are visible. They tend to be a dark red/purple color that fades to greens, grey and yellows. In other words, they look like a typical bruise. In addition, hematomas are often palpable. That is, you can feel them under the skin as a lump.

In the breast, a small hematoma might be the size of a cherry. A medium sized breast hematoma could be the size of a plum. A ‘large’ breast hematoma might grow to the size of a grapefruit, except they tend to elongate to the shape of a banana.

Sometimes, a hematoma can occur without any obvious symptoms, but still show up on a mammogram. For example, see the mammogram on the right for example.

Mammographic Characteristics

On the mammogram, a hematoma can appear similar to a mass. This can cause some concern for most patients, but especially for those that have breast cancer and treatment.

When this is the case, an ultrasound may be necessary to make the diagnosis and rule out local recurrence of breast cancer.

In general, hematomas are usually quite obvious and predictable on a mammogram. Furthermore, they are even more obvious on corresponding ultrasound, so they do not usually require biopsy.

A very small breast hematoma may not even be detectable on a mammogram. However, when you have a large enough one to be seen, it will typically appear as a well-defined oval mass.

Less frequently, a breast hematoma may appear on an x-ray as a nodular image (a nodule usually refers to something with solid elements) with well-circumscribed margins. In addition, there may be edema (a build-up of fluid, basically water) around the periphery.

Hematomas often occur in combination with a breast seroma (a collection of clear ‘blood-serum’). This can cause a little bit of ambiguity on a mammogram, but usually, an ultrasound will quickly and easily confirm the diagnosis.

A Breast hematoma may leave scar tissue when it resolves

As hematomas tend to resolve on their own, the mass will likely not show up on a follow-up mammogram. However, as they dissipate, fibrous tissue (scar tissue) can grow in the area of the former hematoma. This can give an appearance of a ‘proliferative’ growth which could possibly indicate breast cancer cell growth.

This is not unexpected, but will still require the screening doctors to take a closer look. Usually, this residual fibrous-scar tissue will appear as architectural distortion on the mammogram. What is this? Well, it is an oddly arranged segment of breast tissue with a ‘spikey’ outline.

 
 

These sorts of ‘focal asymmetries’ are very common and occur in about 60% of all breast hematomas, and an ultrasound will usually be sufficient to make the situation clear. But sometimes even the ultrasound can be inconclusive.

The transitional nature of hematomas can present as a strange combination of liquid and solid elements. Because, if you imagine a bruise, they change appearance over time. If there is any uncertainty, (perhaps a finding of irregular margins and a non-homogeneous hypoechoic nodule) a biopsy may be necessary.

A Breast hematoma may produce calcifications

Calcifications may develop in later stages of the dispersal of a hematoma. However, these are quite easily distinguishable from the common microcalcification patterns that occur with ductal carcinoma.

What is the Treatment?

Hematomas usually resolve on their own, but that can take quite a while (4-6 six weeks, sometimes longer). Very large hematomas may need surgical drainage. That is usually the end of the issue, but there are cases of ‘spontaneous recurrence’. This is where the issue just happens again.

Breast hematomas present some risks for secondary health complications

Physicians and specialists need to keep a very close eye on hematomas because they can be a risk for secondary health complications.

Whilst hematomas have nothing to do with cancer or anything of that nature they do pose a risk for infection. Bacteria can sometimes infect the blood underneath the tissue. Symptoms of infection include swelling, pain and fever.

Skin discoloration is also a common side-effect. A special concern is for women with any medical history of hemopathy and coagulation disorders, or those taking anticoagulant drugs.

Some doctors might even suggest a patient keep away from certain pain killers (such as aspirin) which have been known to hinder the ‘blood-clotting’ process.

Are hematomas of any concern for breast cancer?

Hematomas are not related to breast cancer. However, damage to blood vessels due to surgery is a common cause. But, it is quite important to get a clear differential diagnosis of hematoma if a patient is undergoing treatment for breast cancer.

There are a couple of reasons for this. The asymmetric density and increased skin thickness that sometimes develops as the hematoma retreats often has a mammographic appearance that can mimic some breast carcinomas, so that has to be ruled out.

Also, it is possible that an occult (hidden) breast tumor could be causing the internal bleeding. A hemorrhage caused by an intracystic tumor (a breast-cancer growth growing in the middle of a cyst, surrounded by fluid) might also be a possibility, though rare.

Hematomas can actually be helpful in removing breast tumors in some cases

Though hematomas following core biopsy procedures (for a suspected breast carcinoma) are quite rare, when they do develop it presents a certain pragmatic opportunity for subsequent surgical treatment.

If surgeons perform a lumpectomy, they can sometimes use a ‘sonographically visible hematoma’ (induced accidentally by the biopsy) as a localizing device and get very accurate surgical margins. This is always a desirable outcome when treating DCIS and breast cancer.

How to prevent hematoma from a biopsy

 
 

For the first minute after a core biopsy, I use my own hand and put pressure on the breast. Still wearing a surgical glove, pressing on a thin piece of gauze on the skin puncture site, but also pressing over the biopsy site.

Then we put on a bandaid and ask the patient to place her own bare hand on her breast and apply pressure by herself for another 5 minutes. My secret is to use a bare hand on the skin NOT pressing on a thick sterile folded-up towel and not pressing on a cold-pack or warm-compress. I believe bare-hand pressing on the skin is the only way to achieve enough pressure.

Conversely, I believe cold and warm packs lead to insufficient pressure. The fact that my thousands of breast biopsies have never caused a hematoma, validates my belief.

Hematoma versus Seroma

When leaking blood accumulates in a fluid collection, at first it clots. Then, later it separates into a yellow fluid (which is the “serum” component of blood), and the solid-fibrin component of a blood clot.

On ultrasound, the seroma fluid looks clear, without any echos floating in the fluid. Fresh blood, on the other hand, has red blood cells in the fluid, which cause echos that give ultrasound some texture of speckles visible in the fluid. Seeing echos in the fluid is how ultrasound decides whether something is called a hematoma or a seroma.

When you drain a breast fluid collection with a needle, if the fluid looks clear yellow we call it a seroma, if it looks dark red, like old blood, we call it a hematoma.

Why drain hematomas and seromas?

In the breast after surgery, the tissue that was cut by the scalpel will normally heal itself and join back together. But it can’t heal if the cut surfaces aren’t touching each other. If there is fluid filling the gap between tissue surfaces, then they can’t join together and heal. So this is a good reason to have a needle drainage procedure.

Another good reason is that a breast hematoma that is large can stretch the skin, stretching the skin incision. That makes the incision heal slower and end up looking like a wider scar. Another reason is simply to reduce pain. A hematoma stretches the tissues around it and nerve endings don’t like being stretched or pushed around so they send pain signals to the brain. If you remove the hematoma the nerve endings no longer complain about it.

When I try to drain breast hematomas with a needle, if the ultrasound shows the fluid is fairly clear, then usually I can drain it completely. But if the fluid is a hematoma that still has echogenic speckles in the fluid, that means there are lots of blood cells floating around in the fluid, like a slurry of tiny blood clots. These tend to plug up a needle. So there is a tendency for some hematomas to be not completely drainable, at a given moment in time.

BUT, if you wait a week or two, the hematoma changes into seroma and fibrin-clot, and fluid becomes drainable again. This is why it may take several drainage procedures, spread out over time, to get rid of them.

Did I miss any questions?

• What does a hematoma feel like and how does it resolve? It hurts quite a lot and makes your skin feel tight and your breast feels hard and swollen. Small hematomas can resolve completely. Medium sized ones can take a long time to resolve completely, like many many months. Large ones should be drained.
• Can infection happen? Yes, but it’s hard to tell, so often the doctor gives antibiotics just to be safer.
• So hematomas last a long time? Hopefully not months, but I’ve seen a few that stayed around for a few years. I remember one patient, who would deliberately ask each doctor, so she could humiliate them when they said months, and she’s say, wrong, this one has been here for two years.
• What is evacuation of a hematoma? If you have a syringe on a needle, put the needle through the skin, into the hematoma (but freeze the skin first with local anaesthetic), when you suck out fluid into the sryinge, that’s called evacuation. There are other ways to create suction besides syringes.

Further Reading

• Breast Seroma
• Core Biopsy of the Breast
• Post Biopsy Changes on Mammogram
• Breast Cancer Surgery
• Full List of ALL Articles on Benign Breast Conditions

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References

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