Traumatic neuroma as a rare cause of intractable neuropathic breast pain following cancer surgery: Management and review of the literature

Abstract

Traumatic neuroma of the breast after cancer surgery is a very rare clinical entity with only a few cases having been reported to date. We herein present a very rare case of traumatic breast neuroma in a postmenopausal patient with a history of breast-conserving surgery, who presented with a four-month history of intractable neuropathic breast pain. Diagnostic evaluation and management are discussed along with a review of the literature. Traumatic breast neuromas are very rare benign lesions that have been reported mainly after mastectomy. Our literature review yielded only 35 cases of traumatic breast neuromas in 28 patients, reported so far. Although imaging features may be indicative of a benign lesion, surgical excision is necessary to obtain a definitive diagnosis and to rule out a recurrent breast cancer. Conservative treatment is feasible in properly selected cases with asymptomatic neuromas after an accurate tissue sampling. The case presented herein underlines the necessity to consider traumatic neuroma in the differential diagnosis in patients with a history of breast surgery presenting with refractory neuropathic breast pain. A high index of suspicion is required because the lesion may be too small and can be missed on imaging investigations.

Traumatic neuroma in mastectomy scar

“…Patients were either asymptomatic or complained of pain, tenderness, or extreme pain during aspiration. [7,11] The mechanisms of neuroma-associated pain are not fully understood. Some research has indicated that increasing levels of nerve growth factor, alpha-smooth muscle actin, cannabinoid CB2 receptor, and unmyelinated fiber, as well as changes in peripheral and central sensitization, may be related to neuroma-associated pain.…”

“…However, 4 lesions exhibited indistinct margin and irregular shape, [3,10] 2 lesions in 1 patient demonstrated inner vascularity, [10] and one 0.2-cm lesion was unremarkable in a surgical scar after breast-conserving surgery. [11] The tail sign was described in 2 reports with an incidence of 33.3% to 50%. [7,10] Nonetheless, this sign was absent in our cases.…”

“…Six lesions were investigated by mammography. [7,8,11,12] However, 3 of these 6 nodules were not detected after breast-conserving surgery. Among the 3 remaining lesions, 1 demonstrated clustered heterogeneous calcification in the surgical site after nodule resection surgery; 1 showed clustered microcalcifications with architectural distortion after breast-conserving surgery; and the other comprised a small, oval, well-circumscribed, equal-density nodule in the mastectomy site.…”

Neuropathic pain: new mechanisms of action of old drugs

“…Moreover, this process can expand and intensify. If the axons are unable to grow into existing nerve sheaths or if they encounter obstacles on their path, such as a scar or an amputated end of a nerve, they grow chaotically as a small tumour -a neuroma -which is very sensitive to mechanical damage and can cause increased pain [10,11].…”

“…Co więcej, proces ten może się rozszerzać i być coraz bardziej intensywny. Jeżeli aksony nie są w stanie wrosnąć w istniejące osłonki nerwowe albo na swojej drodze napotykają przeszkody, takie jak blizna lub koniec nerwu jest amputowany, aksony rosną chaotycznie w postaci niewielkiego guzka -nerwiaka (neuroma), który jest bardzo wrażliwy na uraz mechaniczny i może być przyczyną nasilonego bólu [10,11].…”