Screening mammography for diaylsis patients
Screening mammograms are not recommended as routine procedures for dialysis patients.
For indivisual patients,
the effectiveness of screening mammograms will depend on transplant status,
personal cancer risk factors,
and expected survival.
However,
incidences of malignancy-associated calcification and hence biopsy recommendation rate were slightly greater for dialysis patients.
Contents
Breast diseases occurring in patients with chronic renal failure are:
1.
Immunosuppressant drug (cyclosporin A) related breast disease
- Benign: fibroadenoma
- Malignant: invasive ductal carcinoma (IDC),
ductal carcinoma in situ (DCIS)
2.
Breast diseases related with hemodialysis.
- Collateral vessel engorgement
- Diffuse breast enlargement
- Post-traumatic hematoma or fat necrosis
3.
Diabetic mastopathy
1.
Immunosuppressant drug (cyclosporin A) related breast disease
- Benign
Cyclosporin A has been implicated in the development of benign breast lesions.
Breast fibroadenomas can developed in kidney-transplant recipients undergoing long-term cyclosporin A immunosuppressive therapy.
The mechanism of cyclosporin in the induction of fibroadenomas remains unclear.
The possible mechanisms include direct effect on fibroblasts,
hormonal action and,
less likely,
resolution of uremia.
Mammography showed multiple non-calcified well-circumscribed masses (fig.
1).
US showed hypoechoic,
well-circumscribed and solid masses (fig.
2).
They have a tendancy to be larger,
multiple,
and bilateral,
relative to those that develop in female who have not undergone organ transplantation or immunosuppressive therapy.
- Malignant
Increasing number of studies on the development of malignancies after organ transplantations show a correlation with immunosuppressive therapy.
The general incidence of all malignancies depends on the duration and intensity of immunosuppression.
The tumors manifests more aggressive in patients after transplantations with immunosuppressive therapy (fig.
3-7).
The factors causing the development of malignancies in renal tranplant patients include immune surveillance mechanism impairment,
chronic antigen stimulation of graft,
reactivation of latent oncoviruses and direct oncogenic impact of immunosuppressive substances.
Preventive evaluation should guarantee early detection of cancer.
Appropriate treatment,
without cessation of immunosuppressive therapy,
is needed.
2.
Breast diseases related with hemodialysis
- Diffuse breast enlargement
Breast enlargement is a rare complication of hemodialysis arteriovenous access that occurred as a consequence of supreior vena cava occlusions due to fibrosing mediastinits (fig.
8-10).
Unilateral breast edema may also be caused by increased hydrostatic pressure in arteriovenous dialysis complications or venous obstruction (fig.
11-12). The differential diagnosis includes inflammatory breast cancer.
Mammographic finding includes breast enlargement with increased parenchymal density,
trabecular thickening and skin thickening.
It may be treated with a percutaneous procedure.
- Collateral vessel engorgement
Bilateral venous engorgement occurs secondary to poor venous return to the heart,
as in superior vena cava obstruction or congestive heart failure.
Upper extremity hemodialysis shunts may result in unilateral venous engorgement of the breast due to hyperdynamic venous flow through the upper arm and chest.
At mammography and US,
engorged collateral vessels appears as thickened and tortous tubular structures,
usually in a superficial location (fig.
13).
- Post-traumatic hematoma or fat necrosis
In patients with chronic renal failure,
the procoagulant abnormalities persist,
but in addition patients start to exhibit platelet dysfunction that typically manifests with an increased risk of cutaneous,
mucosal,
or serosal bleeding.
Several factors are thought to contribute to platelet dysfunction in patients with chronic renal failure; impaired function of platelet gylcoprotein-like GPIIb/IIIa,
altered release of ADP and serotonin from platelet granules,
and faulty arachidonic acid and prostaglandin metabolism,
which all lead to impaired platelet adhesion and aggregation.
The breast manifestations of platelet dysfunction in patients include easy bruising of the skin or post-traumatic hematoma. The age of the blood products determines the specific appearance.
A hyperacute hematoma may appear as a simple cyst with internal echoes,
which rapidly becomes a complicated cyst (fig.
14-15).
3.
Diabetic mastopathy
Chronic renal failure is a serious complication of diabetes mellitus.
Diabetic mastopathy is a rare tumor-like fibrous proliferation of the breasts that occurs in patients who have a long history of type 1 diabetes mellitus.
It is uncommon form of lymphocytic mastitis and stromal fibrosis.
Physical examination reveals palpable discrete masses or diffuse nodularity,
both predominantly in the subareolar region.
At mammography,
the breasts usually appear diffusely dense,
making visualization of a discrete mass difficult.
US demonstrates irregular hypoechoic masses with marked posterior acoustic shadowing (fig.
16).
Given the nondiagnostic imaging features,
core-needle biopsy is usually warranted.
Diabetic mastopathy can be self-limited,
however,
recurrent masses are not uncommon.