Iain Whitaker

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 Cronfa -  Swansea University Open Access Repository   _____________________________________________________________   This is an author produced version of a paper published in :JRSM                              Cronfa URL for this paper:http://cronfa.swan.ac.uk/Record/cronfa19920_____________________________________________________________ Paper:Hoey, R. & Russell, H. (2004).  Haemopneumothorax after fine needle aspiration of the breast. JRSM, 97(1), 50-50.http://dx.doi.org/10.1258/jrsm.97.1.50-a        _____________________________________________________________  This article is brought to you by Swansea University. Any person downloading material is agreeing to abide by theterms of the repository licence. Authors are personally responsible for adhering to publisher restrictions or conditions.When uploading content they are required to comply with their publisher agreement and the SHERPA RoMEOdatabase to judge whether or not it is copyright safe to add this version of the paper to this repository. http://www.swansea.ac.uk/iss/researchsupport/cronfa-support/  legs, face, feet, groin and pubic region. He had first noticeda lumpy scar after a minor shaving injury as a teenager. Hehad later developed bilateral axillary keloids as a result ofirritation from use of deodorants. At age 55 years, afterbilateral hernia repairs, keloid scars had appeared in thegroin. Some of the scars, particularly on the face and neck,had become smaller in his 80s. His father had had multiplelarge keloid scars in several anatomical locations. Three outof his four sons had keloid scars; three out of four daughterswere also affected and one granddaughter had a keloid.COMMENTThe pathogenesis of keloid scarring remains an enigma.1The three cases reported here illustrate the association ofsevere scarring with a positive family history and blackAfrican ethnic origin2–5 (though a similar condition can arisein Europeans).The special feature of the cases reported here is theirunusual extent and severity, reminiscent of neoplasticdisease. In such cases even an experienced clinician mayhave difficulty ruling out malignancy. However, in thepresent series and in a previous case from Kingston,Jamaica,6 the histology was typical of a keloid scar—i.e.nodular fibroblastic proliferation of the dermis. Severalfamilial syndromes have been associated with keloid scarsincluding Rubinstein–Taybi7 and Goeminne syndrome8 andconjunctivo-corneal dystrophy9 but none of these conditionswas found in any of our cases. Patient 2 had a uterinefibroid, a benign fibrous growth which like keloids seemsmost common in dark-skinned individuals and tends torecur after treatment.As regards treatment, all three patients had beenunresponsive to conventional strategies, with the recurrentlesions sometimes worse than the original. Two patients (1and 2) had experienced psychosocial difficulties requiringcounselling and are being considered for novel treatmentssuch as local or systemic chemotherapeutic agents. 5-fluorouracil and bleomycin have been previously used withvariable success.10Acknowledgments We thank the clinical and clerical staffat the Department of Plastic Surgery based at the KingstonChest and University of West Indies, Mona, for their helpand the Medical Research Council, UK, and the RoyalCollege of Surgeons of Edinburgh/Ethicon Travel Awardfor financial support.REFERENCES1 Bayat A, McGrouther DA, Ferguson MWJ. Clinical review article:medicine, science and future series: skin scarring. BMJ 2003;326:88–922 Marneros AG, Norris JE, Olsen BR, Reichenberger E. Clinical geneticsof familial keloids. Arch Dermatol 2001;137:1429–343 Bloom D. Heredity of keloids. Review of the literature and report of afamily with multiple keloids in five generations. N Y State Med J1956;56:511–194 Omo-Dare P. Genetic studies in keloids. J Nat Med Assoc1975;67:428–325 Datubo-Brown, DD. Keloids: A review of the literature. Br J Plast Surg1990;43:70–76 Raje D, Char G. Crippling giant keloid. Br J Surg 1980;67:452–37 Kurwa AR. Rubinstein–Taybi syndrome and spontaneous keloids. ClinExp Dermatol 1979;4:251–48 Goeminne L. A new probably X-linked inherited syndrome: congenitalmuscular torticollis, multiple keloids, cryptorchidism and renaldysplasia. Acta Genet Med Gemellol 1968;17:439–679 Haugen OH, Bertelsen T. A new hereditary conjunctivo-cornealdystrophy associated with dermal keloid formation. Acta OphthalmolScand 1998;76:461–510 Shaffer JJ, Taylor SC, Cook-Bolden F. Keloidal scars: a review witha critical look at therapeutic options. J Am Acad Dermatol2002;46:S63–97Haemopneumothorax afterfine needle aspiration of thebreastI S Whitaker MA MB B Elmiyeh MB MRCSM N Siddiqui FRCS1 T C Holme MD FRCS2J R Soc Med 2003;96:555–556Fine needle aspiration (FNA) of the breast is commonlyperformed without image guidance. Complications are rarebut can be serious.CASE HISTORYA woman of 54 was referred to the breast unit with arecurrent tender left upper outer quadrant mass. Mammo-graphy showed an asymmetrical density with no features ofcarcinoma. ‘Blind’ (non-image-guided) FNA yielded in-sufficient cells for diagnosis. Six weeks later she returnedfor a further blind FNA, subsequently reported as showingred blood cells and normal epithelial cells. 32 hours afterthe second FNA she was seen in the emergency departmentwith left-sided pleuritic chest pain and dyspnoea. She wascyanosed, with a respiratory rate of 22 per minute andoxygen saturation 88% on air. Her trachea was deviated tothe right. There was reduced expansion and air entry on the555J O U R N A L O F T H E R O Y A L S O C I E T Y O F M E D I C I N E V o l u m e 9 6 N o v e m b e r 2 0 0 3Department of Anatomy, University of Cambridge; 1Queen Elizabeth Hospital,London; 2Lister Hospital, Stevenage, UKCorrespondence to: Dr I S Whitaker, 8 Avonlea Road, Sale,Cheshire M33 4HZ, UKE-mail: iain_Whitaker@yahoo.comleft, associated with ipsilateral chest wall tenderness. Pulserate was 110 per minute and blood pressure 88/58 mmHg.Haemoglobin was 12.1 g/dL, coagulation normal; whitecell count 16.16109/L; platelet count 3826109/L.Needle thoracocentesis in the second intercostal spaceyielded 800 mL of air. A chest X-ray subsequently showeda large left-sided haemothorax without residual pneu-mothorax. She remained breathless and a size 26 chest drainwas inserted with immediate drainage of 1200 mL blood.Over the next 2 hours the chest drain produced a further1200 mL. Despite 2 units of blood, 1 L colloid and 2 Lcrystalloid via a central line she remained hypotensive andthe thoracic surgeons recommended urgent thoracotomy.At operation the source of bleeding was located at the apexof the lung. A vascular adhesion had become disrupted bythe development of the pneumothorax that followed theFNA. Postoperatively she spent 4 days in intensive care,requiring a total of 14 units of blood and 8 units of freshfrozen plasma.COMMENTFNA is the fastest and easiest method of breast biopsy, andthe results are rapidly available. Pneumothorax is arecognized complication, with an incidence ranging from0.01% to 3%.2 Risk factors are deep breast lumps, thinbody build and breath-holding during the procedure. Thecomplication has been associated with FNA in any of thefour quadrants of the breast but especially with aspiration inthe outer upper quadrant. In 50–80% of cases no specifictreatment is needed; the remainder require insertion of achest drain.3,4 Haemopneumothorax following FNA of abreast lump has not to our knowledge been previouslyreported. In the present case the bleeding was life-threatening and required open thoracotomy, althoughthoracoscopy5 might have been an alternative.The risk of pneumothorax can be lessened by technique:the patient should breathe normally4 and the needle shouldbe inserted into the mass parallel rather than perpendicularto the chest wall whenever possible2,3 especially in thinpatients2 with small breasts. In addition, blind aspiration isgiving way to image-guided methods, the simplest of whichis ultrasound.6 If the lesion is visible ultrasonically, theneedle can be followed in real time to its destination. Othermethods of image guidance are CT,6,7 stereotacticmammography8 and MR.9 MR-guided biopsy is not yetwidespread but is likely to be used increasingly by hospitalsand diagnostic centres.REFERENCES1 Kaufman Z, Shpitz B, Shapiro M, Rona R, Lew S, Dinbar A. Tripleapproach in the diagnosis of dominant breast masses: combinedexamination, mammography and fine needle aspiration. J Surg Oncol1994;56:254–72 Bates T, Davidson T, Mansel RE, Litigation for pneumothorax as acomplication of fine needle aspiration of the breast. Br J Surg2002;89:134–73 Gateley CA, Maddox PR, Mansel RE. Pneumothorax: a complication offine needle aspiration of the breast. BMJ 1991;303:627–84 Kaufman Z, Shpitz B, Shapiro M, Dinbar A. Pneumothorax: acomplication of fine needle aspiration of breast tumours. Acta Cytol1994;38:737–85 Liu HP, Yim AP, Izzat MB, Lin PJ, Chang CH. Thoracoscopic surgeryfor spontaneous pneumothorax. World J Surg 1999;23:1133–66 Broderick LS, Kopecky KK, Cramer H. Image-guided coaxial fineneedle aspiration biopsy with a side-exiting guide. J Comput Assist Tomogr2002;26:292–77 Sack MJ, Weber RS, Weinstein GS, Chalian AA, Nisenbaum HL,Yousem DM. Image-guided fine-needle aspiration of the head and neck:five years’ experience. Arch Otolaryngol Head Neck Surg 1998;124:1155–618 Jackman RJ, Marzoni FA Jr. Stereotactic histologic biopsy with patientsprone: technical feasibility in 98% of mammographically detectedlesions. Am J Roentgenol 2003;180:785–949 Orel SG, Schnall MD, Newman RW, Powell CM, Torosian MH,Rosato EF. MR imaging-guided localization and biopsy of breast lesions:initial experience. Radiology 1994;193:97–102Periprosthetic tuberculousbreast infectionG Miles MB BSc T K Walters MD FRCSC D Shee MD FRCPJ R Soc Med 2003;96:556–557If persistent exudates occur in association with breastimplants it is important to think of mycobacteria.CASE HISTORYA woman of 31 was referred to the chest clinic in January2001 with weight loss and sweats. She had not lived ortravelled abroad and had been well in the past apart frommild migraine and asthma. In 1997 she had had bilateralsilicone breast augmentation prostheses inserted. ChestX-ray showed left apical shadowing. Physical examinationand blood tests were normal. She was unable to producesputum for culture and would not agree to bronchoscopiclavage for suspected tuberculosis. CT-guided lung biopsyshowed some caseating necrosis with occasional multi-nucleated giant cells. Although stains and culture formycobacteria were negative, tuberculosis was thought the556J O U R N A L O F T H E R O Y A L S O C I E T Y O F M E D I C I N E V o l u m e 9 6 N o v e m b e r 2 0 0 3Departments of Medicine and Surgery, Queen Mary’s Sidcup NHS Trust,Sidcup DA14 6LT, UKCorrespondence to: Dr C D SheeE-mail: charles.shee@qms.nhs.uk

Haemopneumothorax after Fine Needle Aspiration of the Breast

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