Mondor Disease


Article Author:
Kaitlyn Rountree
Hassana Barazi


Article Editor:
Neal Aulick


Editors In Chief:
Ahmad Al Aboud
Jayakar Thomas
Pramod Nigam


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes


Updated:
5/5/2019 11:02:08 PM

Introduction

Initially described in 1939 by Henri Mondor, Mondor Disease classically describes a syndrome of sclerosing superficial thrombophlebitis of the veins of the anterior thoracic wall. The most commonly involved vessel is the superior epigastric vein producing a palpable cord in the inferior outer quadrant of the breast [1]. Also known as Mondor's Cord, this rare clinical entity has also been reported as affecting the superficial penile veins [2]. Fage is credited with first describing cording as a sign of superficial thrombophlebitis in 1870. 

Etiology

Mondor Disease is a rare clinical entity with a poorly understood etiology. Many case reports have linked sclerosing superficial thrombophlebitis and the resulting palpable cord to local trauma including such repetition injury as a tight brassier, strenuous exercise in the case of bodybuilders or direct injury associated with surgery [3]. Other causes include direct damage to the veins, stagnation of blood, or extrinsic pressure on veins. Cases of Mondor Disease have been reported after cosmetic mammoplasty, mastectomy and breast-conserving surgery for breast cancer and after core needle biopsy [4]. Prior authors have highlighted an association between Mondor's Cord as a sign of underlying breast pathology and recommend ruling out breast cancer through appropriate imaging before expectant management, however, no direct correlation has been proven. 

Mondor Disease can affect several different veinous drainage systems. However, it never involves in the inner, upper portion of the breast. Symptoms may be found in the groin, abdomen, arm or axilla. Axillary disease, also known as axillary web syndrome, has been well documented following axillary lymph node dissection and sentinel lymph node biopsy for breast cancer [5]. Penile Mondor Disease has also been described, while its pathogenesis is incompletely understood, this rare entity involves near-painless cords on the dorsal aspect of the penis [6].   

Epidemiology

There are less than 400 reported cases of Mondor Disease in medical literature [7]. This may be due to the generally self-limited nature of the condition. However, the potential link with underlying malignancy, hypercoagulable state or systemic vasculitis warrants a greater vigilance on the part of providers when affected patients are encountered. Women are three times more likely to be affected than men. No racial or ethnic propensity has been reported. While cases have present in all ages, most are between the ages of 30 and 60 years old. A recent literature review by Amano et al. revealed 45% of cases to be idiopathic, 20% iatrogenic, 22% traumatic and 5% about breast cancer [1]

Pathophysiology

The pathophysiology of Mondor Disease is incompletely understood. Inciting factors such as direct trauma from tight clothing, surgery, or underlying system diseases such as breast cancer or hypercoagulable states have been described as causes for the resulting sclerosing thrombophlebitis of affected superficial veins. This process evokes an inflammatory response including, pain, swelling, and redness at the site with a resultant fibrosed cord-like superficial vein that is visible and palpable. The process of re-cannulization can take between four and eight weeks with most patients having a complete resolution of symptoms [1]

History and Physical

A thorough history and physical is paramount to an accurate diagnosis. The account will vary slightly depending on the affected venous drainage basin: axillary, penile or anterior chest wall. The history will, however, involve aspects consistent with Virchow's triad of stasis, hypercoagulability and vessel wall damage. Patients will complain of a sudden onset of mild discomfort with a palpable cord in the affected area. Penile lesions may involve a history of excessive sexual activity, trauma, or abstinence [8]. Anterior chest lesions may include a history of recent mammoplasty, tight brassier, or another injury such as weight lifting or biopsy [3]. Axillary injuries may involve a history of recent oncologic surgery with either sentinel lymph node biopsy, axillary dissection or core needle biopsy. When combined with physical findings of a palpable cord with scant overlying inflammation and no distal edema Mondor Disease should be strongly considered.

Evaluation

The diagnosis of Mondor Disease is a clinical one confirmed by history and physical alone. With so few cases represented in the medical literature, there is no accepted consensus on evaluation or management. While some authors have suggested a link between underlying breast cancer and Mondor Disease, others have denied this link and attribute the coexistence of disease to the direct or indirect trauma associated with the diagnosis and treatment of the underlying malignancy [9]. In patients with a classic story and no other systemic complaints and otherwise regular physical exam, it is reasonable to proceed without a laboratory, radiographic or another invasive testing for diagnosis. In those patients with signs or symptoms suggestive of underlying pathology further evaluation with either mammography of the breast or ultrasound of the breast or penis is warranted [8].  

In cases where the clinical picture is not definitive, ultrasound is considered the first line in the imaging evaluation of Mondor’s disease. Ultrasound in the location of the patient’s area of palpable concern will show a non-compressible, hypoechoic tubular structure which is the superficial vein. An area of intraluminal thrombus may or may not be visible[10]. Color Doppler should be used to confirm the diagnosis by demonstrating the absence of flow within the vein[11]. Mammography may be inconclusive, or it may reveal a linear density in the breast in patients with superficial thrombophlebitis. MRI and other advanced imaging techniques are generally not indicated in the evaluation of Mondor’s disease[12].

Treatment / Management

Supportive care and expectant management are sufficient in most cases of Mondor Disease. Warm compresses, nonsteroidal anti-inflammatory medications, and abstinence from irritating clothing or activities are first-line therapy. Most lesions will resolve with cessation of discomfort and dissolution of the palpable cord [13]. Treatment with low molecular weight heparin or aspirin has been reported in some case series; this is not recommended in patients without an underlying hypercoagulable state inciting superficial thrombophlebitis and associated Mondor's Cord. intralesional triamcinolone injections for a Mondor's cord after breat augmentation has been successful in shortening the disease[14]. J Clin Aesthet Dermatol. 2014 Apr; 7(4): 50–5

Differential Diagnosis

The differential diagnosis of Mondor Disease varies depending upon the location of symptoms. In general, such conditions as thrombophlebitis migrans, infectious mastitis, Buerger disease, Behçet disease, and polyarteritis nodosa should be entertained and ruled out. Other breast pathology including mastitis and breast abscesses will be accompanied by a patient complaining of significant pain with palpable fluctuance in the case of an abscess. Inflammatory breast cancer is known for its quickly progressive skin changes and ability to mimic worsening mastitis, as such, it must be considered in the evaluation of patients presenting with any breast complaint. Patients with inflammatory breast cancer will have progressive, worsening symptoms with skin changes including erythema, breast enlargement, and pain [15].

Prognosis

Mondor Disease is usually a self-limited condition resolving in six to eight weeks. In cases where the situation is secondary to a hypercoagulable state, the prognosis is directly linked to the inciting condition. 

Complications

 It is a self-limiting condition typically resolving in four to eight weeks. As with any thromboembolic disease there is a small chance of the development of a deep venous thrombosis.

Deterrence and Patient Education

Patients should be counseled that Mondor Disease is a self-limiting condition that leaves no permanent sequela. Patients should be educated on the need to follow up to ensure improvement and resolution of symptoms.  

Enhancing Healthcare Team Outcomes

Mondor Disease is a rare clinical entity affecting more women than men. Patients may develop lesions in sensitive areas such as the breast or penis. Some patients may be embarrassed or afraid to discuss their symptoms with a physician. Having a well-informed health care team with providers such as nurses, technicians, and physicians aware of rare clinical disease is vital to identifying patients at risk for more sinister diagnoses. Some patients may be more comfortable sharing their symptoms with a different member of the health-care team, whom in turn must relate the privileged information to the appropriate provider.


  • Image 8647 Not availableImage 8647 Not available
    Image courtesy S Bhimji MD
Attributed To: Image courtesy S Bhimji MD

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Mondor Disease - Questions

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What is the term for superficial thrombophlebitis over the lateral aspect of the breast area?



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In a patient with Mondor disease, you would expect to see which of the following?



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A 33-year old post-partum female presents with tenderness in her right breast. She mentions that her right breast suddenly developed discoloration and was painful to the touch. She denies any trauma or use of any medications. She has no history of breast cancer. Examination reveals prominent and engorged superficial veins over the lateral aspect of the breast area. Palpating the breast area over these veins is associated with pain. How will you manage this patient?



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Mondor Disease - References

References

Wong SN,Lai LK,Chan PF,Chao DV, Mondor's disease: sclerosing thrombophlebitis of subcutaneous veins in a patient with occult carcinoma of the breast. Hong Kong medical journal = Xianggang yi xue za zhi. 2017 Jun;     [PubMed]
Tröbinger C,Wiedermann CJ, Bodybuilding-induced Mondor's disease of the chest wall. Physical therapy in sport : official journal of the Association of Chartered Physiotherapists in Sports Medicine. 2017 Jan;     [PubMed]
Marsaudon E,Legal C,Gayoux D,Weber O, [Mondor's disease of penis: A case report]. La Revue de medecine interne. 2016 Sep;     [PubMed]
Amano M,Shimizu T, Mondor's Disease: A Review of the Literature. Internal medicine (Tokyo, Japan). 2018 Sep 15;     [PubMed]
Goldman A,Wollina U, Mondor's Disease after Aesthetic Breast Surgery: A Case Series and Literature Review. Journal of cutaneous and aesthetic surgery. 2018 Jul-Sep;     [PubMed]
Nazir SS,Khan M, Thrombosis of the dorsal vein of the penis (Mondor's Disease): A case report and review of the literature. Indian journal of urology : IJU : journal of the Urological Society of India. 2010 Jul;     [PubMed]
Koehler LA,Haddad TC,Hunter DW,Tuttle TM, Axillary web syndrome following breast cancer surgery: symptoms, complications, and management strategies. Breast cancer (Dove Medical Press). 2019;     [PubMed]
Quéhé P,Saliou AH,Guias B,Bressollette L, [Mondor's disease, report on three cases and literature review]. Journal des maladies vasculaires. 2009 Feb;     [PubMed]
Halkier E,Bødker A, Mondor's disease: a review of five cases. Acta chirurgica Scandinavica. 1983;     [PubMed]
Pasta V,D'Orazi V,Sottile D,Del Vecchio L,Panunzi A,Urciuoli P, Breast Mondor's disease: Diagnosis and management of six new cases of this underestimated pathology. Phlebology. 2015 Sep;     [PubMed]
Menta A,Fouad TM,Lucci A,Le-Petross H,Stauder MC,Woodward WA,Ueno NT,Lim B, Inflammatory Breast Cancer: What to Know About This Unique, Aggressive Breast Cancer. The Surgical clinics of North America. 2018 Aug;     [PubMed]
Shah NA,Gryskiewicz J,Crutchfield CE 3rd, Successful Treatment of a Recalcitrant Mondor's Cord Following Breast Augmentation. The Journal of clinical and aesthetic dermatology. 2014 Apr;     [PubMed]
Salemis NS,Merkouris S,Kimpouri K, Mondor's disease of the breast. A retrospective review. Breast disease. 2011     [PubMed]
Kim HS,Cha ES,Kim HH,Yoo JY, Spectrum of sonographic findings in superficial breast masses. Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine. 2005 May     [PubMed]
Adeniji-Sofoluwe A,Afolabi O, Mondor's disease: classical imaging findings in the breast. BMJ case reports. 2011 Aug 19     [PubMed]

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