What to do in case of an active bleeding breast mass?

Management of Active Bleeding Breast Mass

In case of an active bleeding breast mass, immediate diagnostic imaging with ultrasound followed by appropriate intervention based on the underlying cause is essential, with surgical consultation recommended for uncontrolled bleeding.

Initial Assessment and Imaging

• Ultrasound is the preferred initial imaging modality for evaluation of a bleeding breast mass, especially in women younger than 30 years 1
• For women 30 years or older, diagnostic mammography should be performed along with ultrasound to fully characterize the mass 1
• Imaging helps determine if the bleeding is from a benign condition (hematoma, abscess) or potentially malignant mass 1

Management Algorithm Based on Imaging Findings

If Imaging Suggests Breast Abscess:

• For abscesses with intact skin, repeated aspiration is recommended as first-line treatment with a success rate of 80-90% 2
• Appropriate antibiotic therapy should accompany aspiration 2
• Incision and drainage may be necessary for larger abscesses (>5cm) or those that fail aspiration 2

If Imaging Suggests Hematoma:

• Conservative management is appropriate for most breast hematomas, especially those related to anticoagulant use 3, 4
• Manual compression should be applied to control active bleeding 5
• Serial imaging follow-up is required until complete resolution to exclude underlying malignancy 4
• Discontinuation or adjustment of anticoagulant therapy may be necessary in consultation with the prescribing physician 3

If Imaging Suggests Malignancy with Active Bleeding:

• Tissue sampling via core needle biopsy should be performed if bleeding can be controlled 1
• For severe uncontrolled bleeding from suspected malignancy, consider:
  • Surgical consultation for potential excision or control of bleeding 1
  • Interventional radiology consultation for potential transcatheter arterial embolization (TAE) 6, 5

Hemostatic Interventions for Active Bleeding

• Direct pressure should be applied as first-line management 7, 5
• For persistent bleeding despite pressure:
  • Consider topical hemostatic agents 7
  • Interventional radiology consultation for embolization is preferred before surgical intervention for severe bleeding, especially in locally advanced or recurrent breast cancer 6, 5
  • Surgical intervention may be necessary for uncontrolled bleeding despite conservative measures 5

Follow-up After Bleeding Control

• If the bleeding mass is determined to be benign and concordant with imaging:
  • Physical examination with or without ultrasound every 6-12 months for 1-2 years 1
  • Return to routine screening if the lesion remains stable 1, 8
• If the bleeding mass is determined to be malignant or indeterminate:
  • Management according to NCCN Guidelines for Breast Cancer 1
  • Surgical excision is recommended for indeterminate lesions or benign lesions not concordant with imaging 1

Important Considerations and Pitfalls

• Never delay imaging for a bleeding breast mass, as it may mask an underlying malignancy 1, 4
• Repeat imaging is mandatory until complete resolution of hematoma to exclude underlying pathology 4
• Bleeding complications from percutaneous breast biopsies are rare (1.1%) but may require intervention 5
• For patients on anticoagulants with spontaneous breast bleeding, consider temporary adjustment of anticoagulation in consultation with the prescribing physician 3, 4