Elsevier

The Breast

Volume 15, Issue 3, June 2006, Pages 313-318
The Breast

REVIEW
Fat necrosis of the breast—A review

https://doi.org/10.1016/j.breast.2005.07.003Get rights and content

Summary

Fat necrosis of the breast is a benign condition that most frequently affects peri-menopausal women. It can mimic breast cancer clinically or radiologically. In other cases it can obscure malignant lesions.

The core of this review is derived from a MEDLINE database literature search from 1966–2004. Further references were from lateral search.

In this paper, we review the pathogenesis and pathology clinical and radiological features of fat necrosis of the breast. The implication of fat necrosis in the management of patients with breast lump is also discussed.

Fat necrosis of breast is a complex process. Therefore, a systematic review of this condition will enable surgeons, radiologists and oncologists working in the field of breast disease to understand it better and improve its management.

Introduction

Fat necrosis is a benign non-suppurative inflammatory process of adipose tissue which was initially described in the breast in 1920.1, 2 Hadfield described it as “an innocent lesion of the breast presenting itself most often in women between the fourth and fifth decades, frequently as a stony-hard tumour firmly fixed to the skin, often resembling an early cancer so closely that a wide resection of the breast has been performed”.3

It is important to diagnose fat necrosis because it often mimics carcinoma of the breast. The aim of this paper is to review the clinical, pathological and radiological features of fat necrosis of the breast which distinguishes it from breast cancer.

Section snippets

Epidemiology

The incidence of the disease is estimated to be 0.6% in the breast, representing 2.75% of all benign lesions.1, 2, 3, 4 Fat necrosis is found in 0.8% of breast tumours and 1% of breast reduction surgery cases.5 The average age of patients is 50 years.1, 2, 3, 4

Aetiology

The aetiological factors include trauma (21–70%),1, 2, 3, 4 radiotherapy,6, 7, 8 anticoagulation (warfarin),9 cyst aspiration, biopsy, lumpectomy, reduction mammoplasty, implant removal, breast reconstruction with tissue transfer,10 duct ectasia and breast infection. Other rare causes include polyarteritis nodosa, Weber-Christian disease and granulomatous angiopanniculitis. In some patients, the cause is unknown.11

Pathogenesis

Fat necrosis is a sterile, inflammatory process which results from aseptic saponification of fat by means of blood and tissue lipase.12 It varies in appearance depending on the stage of the process. It is recognised histologically as fat-filled macrophages and foreign body giant cells surrounded by interstitial infiltration of plasma cells.13

After trauma to the breast, haemorrhage occurs within a surgical cavity, or extravasate into the parenchyma. Blood dissects along the fibrous planes of

Clinical features

Clinical presentation of fat necrosis can range from an incidental benign finding to a lump highly suggestive of cancer.16, 18 In most cases it is clinically occult; however, it can present as single or multiple smooth, round, firm nodules or irregular masses. It may be associated with ecchymosis, erythema, inflammation, pain, skin retraction or thickening, nipple retraction and lymphadenopathy simulating carcinoma.10, 16, 19, 20

Hadfield3 described 66% of lesions as being stony hard. Up to 52%

Fine needle aspiration cytology (FNAC)

FNAC is reported to have a high sensitivity and specificity—87% and 99%, respectively.22, 23

Using FNAC as a diagnostic tool enables rapid results particularly in a ‘one-stop’ clinic setting. FNAC can decrease the number of excision biopsies.22, 23 However, the diagnosis of fat necrosis using FNAC is limited by inadequate samples24 and repeated attempts may be necessary to achieve a confident result. FNAC is reliable in collaboration with a good history of trauma and close follow-up in

Mammography

The mammographic appearance of fat necrosis include normal appearance (9%), discrete round or oval radiolucent oil cyst with thin capsule (27%), thickening and deformity of skin and subcutaneous tissue (16%), focal mass (13%), and ill-defined spiculated mass (4%).5 Oil cysts may be associated with uniform continuous eggshell calcification (27%). There may also be multiple clustered pleomorphic microcalcifications (4%) suspicious of malignancy.10, 19, 28 The most common mammographic findings are

Discussion

The management of fat necrosis continues to be challenging in practice. Even with modern diagnostic modalities, fat necrosis of the female breast can still be difficult to diagnose. In patients who have undergone breast conservation surgery or reconstruction for breast cancer, fat necrosis must be distinguished from cancer recurrence. Hence in specific cases, needle core biopsy is required to confirm diagnosis.

Although there is a definite association with trauma, surgery or biopsy of the

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