What are the management and evaluation steps for breast bruising?

Management and Evaluation of Breast Bruising

For breast bruising in adults, obtain a bilateral diagnostic mammogram with or without ultrasound as the initial imaging evaluation, followed by clinical reassessment and consideration of underlying bleeding disorders or trauma history based on the imaging findings. 1

Initial Clinical Assessment

Obtain a detailed history focusing on:

• Specific trauma history, including timing and mechanism of injury 2
• Personal history of bleeding symptoms (excessive bleeding after surgery, dental procedures, or easy bruising elsewhere) 1
• Family history of bleeding disorders 1
• Current medications, including anticoagulants or antiplatelet agents 1
• Associated symptoms such as pain, palpable mass, skin changes, or nipple discharge 1

Physical examination should document:

• Exact location, size, and pattern of bruising 1
• Presence of palpable mass or asymmetric thickening 1
• Skin changes including erythema, edema (peau d'orange), or dimpling 1
• Nipple changes such as excoriation, scaling, or discharge 1

Diagnostic Imaging Algorithm

For patients ≥30 years old:

• Obtain bilateral diagnostic mammogram with or without ultrasound as the initial study 1
• Mammography characterizes the lesion, screens the remainder of both breasts, provides baseline documentation, and detects calcifications or architectural distortions 3

For patients <30 years old:

• Start with ultrasound evaluation, followed by consideration of diagnostic mammography 1
• Diagnostic mammograms have lower yield in this age group due to breast density 1

Management Based on Imaging Results

BI-RADS Category 1-3 (Negative, Benign, or Probably Benign):

• Re-examine in 3-6 months 1
• If stable, resume annual screening 1
• If progression occurs, investigate as a dominant mass with tissue biopsy 1

BI-RADS Category 4-5 (Suspicious or Highly Suggestive of Malignancy):

• Perform tissue biopsy immediately 1
• Core needle biopsy is preferred over fine needle aspiration 3
• Ultrasound-guided biopsy is preferred when the lesion is visible on ultrasound 3

Evaluation for Bleeding Disorders

Consider laboratory evaluation when:

• Bruising occurs without adequate trauma history 1
• Personal or family history suggests bleeding disorder 1
• Bruising is recurrent or in unusual locations 1, 4

Initial screening tests should include:

• Complete blood count with platelet count 5
• Prothrombin time (PT) 5
• Activated partial thromboplastin time (aPTT) 5
• Fibrinogen level 5

Important caveat: The aPTT can be falsely prolonged with lupus anticoagulant or factor XII deficiency, which may not indicate a true bleeding disorder 1

Special Considerations

Trauma-related hematomas:

• Breast hematomas can occur spontaneously in patients with coagulation disorders or hematologic disease 4
• Follow-up imaging at 45-60 days should show resolution of traumatic hematomas 4
• Persistent or enlarging lesions require tissue diagnosis 4, 2

Red flags requiring immediate evaluation:

• Skin erythema and edema involving one-third or more of the breast (concerning for inflammatory breast cancer) 1
• Nipple excoriation, scaling, or eczema (concerning for Paget's disease) 1
• Palpable mass with overlying skin changes 1

Common Pitfalls to Avoid

• Do not assume benign etiology based solely on trauma history - breast cancer can coexist with trauma, and trauma may draw attention to an underlying malignancy 2
• Do not delay imaging evaluation - clinical findings of breast trauma can mimic malignancy, and imaging is essential to differentiate 2
• Do not rely on single imaging modality - mammography and ultrasound provide complementary information 3
• Do not attribute all bruising to bleeding disorders without considering malignancy - both conditions can coexist 5
• Ensure concordance between clinical findings, imaging, and pathology - discordance requires further investigation 3