History

Fact Explanation
Breast Lump Fat necrosis is a sterile, inflammatory process which results from aseptic saponification of fat by means of blood and tissue lipase.[1] Saponification is a process by which triglycerides react with sodium or potassium hydroxide to produce glycerol and a fatty acid salt, producing 'soap'. This saponified fat tissue clinically presents as a palpable mass. Most often seen in women between fourth and fifth decades, frequently as a stony hard tumor firmly fixed to the skin[3]
Ecchymosis, erythema or pain Acute inflammatory process due to cell damage.[2]
History of trauma to breast Physical trauma, radiotherapy, cyst aspiration, biopsy, lumpectomy, reduction mammoplasty, implant removal, breast reconstruction with tissue transfer, duct ectasia and breast infection acan lead to fat necrosis. However even when a clear history of previous trauma is present, the possibility of a malignancy should not be overlooked, as a patient's attention may only be drawn to the lump by an episode of trauma.[1]
References
  1. TAN, P. H., L. M. Lai, E. V. Carrington, A. S. Opaluwa, K. H. Ravikumar, N. Chetty, V. Kaplan, C. J. Kelley, and E. D. Babu. Fat necrosis of the breast—a review. The Breast, 2006, 3, 313-318.
  2. KUMAR Vinay, Abul K. ABBAS, Nelson FAUSTO, Richard MITCHELL. Robbins Basic Pathology. 8th ed. Philadelphia: Saunders Elsevier, 2007
  3. BROWSE Norman L. The Breast. In: Browse, Norman L, Browse's Introduction to the Symptoms and Signs of Surgical Disease. 4th ed.London, Bookpower: 2005, 312-330

Examination

Fact Explanation
Breast lump A painless, Irregular lump which is hard in consistency and often fixed to the skin.[3]
Skin tethering After tissue damage following trauma the inflammatory process subsides and there is healing of the damaged tissues by fibrosis.[2] This lead to formation of bridging fibrous bands between necrotic fat tissue(saponified fat) and the skin.[1]
Nipple retraction Once the inflammatory process subsides, healing of the damaged tissues occur by fibrosis. When the formation of fibrous bands occur just beneath the nipple, it will result in nipple retraction due to contraction of the fibrous bands.[2]
References
  1. TAN, P. H., L. M. Lai, E. V. Carrington, A. S. Opaluwa, K. H. Ravikumar, N. Chetty, V. Kaplan, C. J. Kelley, and E. D. Babu. Fat necrosis of the breast—a review. The Breast, 2006, 3, 313-318.
  2. KUMAR Vinay, Abul K. ABBAS, Nelson FAUSTO, Richard MITCHELL. Robbins Basic Pathology. 8th ed. Philadelphia: Saunders Elsevier, 2007
  3. BROWSE, Norman L. The Breast. In: Browse, Norman L, Browse's Introduction to the Symptoms and Signs of Surgical Disease. 4th ed.London, Bookpower: 2005, 312-330

Differential Diagnoses

Fact Explanation
Breast carcinoma A common presenting feature of breast carcinoma is a painless lump found most commonly in the upper outer quadrant. Will give rise to a painless and hard breast lump with tethering of the skin, skin ulceration, peau du orange appearance,nipple retraction, bloody nipple discharge and co-existent axillary and/or cervical lymphadenopathy. Nipple retraction and skin tethering is also seen in fat necrosis. However features of malignancy that are described above are not seen [2].
Tuberculosis of breast May be seen in parts of the developing world where incidence of tuberculosis is high
Fibroadenoma Benign neoplasm of breast usually occurs in young women.A slow growing lesion. The lump is mobile,very discrete, spherical in shape with a smooth surface and a firm rubbery consistency.[2]
Phylloides tumor This is a rare lesion. Presents as a slow growing smooth swelling in middle aged women[3]. It can be big enough to cause skin necrosis.[2]
Breast cyst Peak incidence is in the forties and fifties. May develop suddenly. It is smooth,spherical and of variable consistency which ranges from soft and cystic to a hardness equal to cancer or fat necrosis.[1]
References
  1. TAN, P. H., L. M. Lai, E. V. Carrington, A. S. Opaluwa, K. H. Ravikumar, N. Chetty, V. Kaplan, C. J. Kelley, and E. D. Babu. Fat necrosis of the breast—a review. The Breast, 2006, 3, 313-318.
  2. BROWSE Norman L. The Breast. In: Browse, Norman L, Browse's Introduction to the Symptoms and Signs of Surgical Disease. 4th ed.London, Bookpower: 2005, 312-330
  3. KUMAR Vinay, Abul K. ABBAS, Nelson FAUSTO, Richard MITCHELL. Robbins Basic Pathology. 8th ed. Philadelphia: Saunders Elsevier, 2007

Investigations - for Diagnosis

Fact Explanation
Fine needle aspiration cytology (FNAC) Will allow for cytological diagnosis.Using FNAC as a diagnostic tool enables rapid results[2]
Core biopsy Core biopsy of breast lesions has been shown to be more sensitive than FNAC as it allows for histological diagnosis.[2]
Surgical excision biopsy Core biopsy can result in false negatives. Hence surgical excision biopsy is indicated where there is still suspicion of malignancy following negative core biopsy.[2]
Mammography Imaging features of fat necrosis can vary depending on the stage of evolution and may mimic malignancy in late stages. Imaging may suffice to differentiate fat necrosis in the early stages from malignancy, thus avoiding unnecessary biopsy. In the appropriate clinical setting, no mammographic features suspicious for malignancy should be present.[1]
Ultrasonography (USG) When the typical mammographic features are not present, USG can aid with the diagnosis and a follow up USG will confirm the findings.[1]
References
  1. UPADHYAYA VS, R. Uppoor , L. Shetty, et al. Mammographic and sonographic features of fat necrosis of the breast.Indian Journal of Radiology and Imaging[online].Indian Radiological and Imaging Association. Octomber 2013, vol. 23(4). 366-72[ viewed 18 March 2014]. Available from: doi: 10.4103/0971-3026.125619.
  2. TAN, P. H., L. M. Lai, E. V. Carrington, A. S. Opaluwa, K. H. Ravikumar, N. Chetty, V. Kaplan, C. J. Kelley, and E. D. Babu. Fat necrosis of the breast—a review. The Breast, 2006, 3, 313-318.

Management - General Measures

Fact Explanation
Short-term follow-up with imaging and physical examination To reduce the number of unnecessary biopsies[1]
Reassure Only if the diagnosis is confirmed by several means.
References
  1. TAN, P. H., L. M. Lai, E. V. Carrington, A. S. Opaluwa, K. H. Ravikumar, N. Chetty, V. Kaplan, C. J. Kelley, and E. D. Babu. Fat necrosis of the breast—a review. The Breast, 2006, 3, 313-318.

Management - Specific Treatments

Fact Explanation
No specific management protocol The management of fat necrosis continues to be challenging in practice.[1] If the diagnosis is confirmed no specific management is necessary unless patient is symptomatic, since this is a entirely benign condition[2]
Surgical excision As a method of symptom relief and to obtain a histological diagnosis[1]
Aspiration Only for lesions where imaging shows oil cysts
References
  1. TAN, P. H., L. M. Lai, E. V. Carrington, A. S. Opaluwa, K. H. Ravikumar, N. Chetty, V. Kaplan, C. J. Kelley, and E. D. Babu. Fat necrosis of the breast—a review. The Breast, 2006, 3, 313-318.
  2. BROWSE Norman L. The Breast. In: Browse, Norman L, Browse's Introduction to the Symptoms and Signs of Surgical Disease. 4th ed.London, Bookpower: 2005, 312-330