New Right Breast Nodule in 58F • Xray of the Week 2016 • Week #45
This 58 year old woman was hospitalized for DVT and suspected pulmonary emboli. The chest CT showed no pulmonary emboli, but there was a lesion in the upper part of the right breast. What rare type of breast mass could this be?
Figure 1. Bilateral mammogram 6 months ago was normal.
Figure 2. Left image: MLO Mammogram, shows a nodule with lobular shape and circumscribed margins in the right breast superiorly.
Right image: CC Mammogram, shows a nodule with lobular shape and circumscribed margins in the right breast posteriorly.
Figure 3: Ultrasound images show a hypoechoic right breast nodule with angular margin, peripheral flow, parallel orientation, abrupt interface, neutral sound transmission, and complex echotexture.
Figure 4: Axial MRI images show an enhancing mass in the right breast. The MRI features are suspicious for malignancy. MRI images courtesy of Nadja Lindhe, MD - Radiologist at Department of Mammography, Central Hospital Falun, Falun, Sweden
Figure 5: Ultrasound images show biopsy of the mass. Histology is hemangioma. Histology images are courtesy of Tibor Tot, MD PhD - Associate Professor, Department of Pathology and Clinical Cytology, Central Hospital Falun, Falun, Sweden
Due to the malignant appearance on MRI, ultrasound biopsy was performed [Fig.5] followed by excision of the nodule. Pathology was hemangioma of the breast.
Figure 6: Specimen radiograph of excisional biopsy with associated large section histology. There is no invasive component. Histology images are courtesy of Tibor Tot, MD PhD - Associate Professor, Department of Pathology and Clinical Cytology, Central Hospital Falun, Falun, Sweden
Figure 7: Histology demonstrated a partially fibrotic/hyalinized hemangioma containing dilated vessels with no evidence of malignancy. Note the dilated vascular channels of varying size (green arrow) and compact, dense aggregates of capillary structures (yellow arrow). Histology images are courtesy of Tibor Tot, MD PhD - Associate Professor, Department of Pathology and Clinical Cytology, Central Hospital Falun, Falun, Sweden
Hemangioma of the breast is a rare vascular tumor of the breast which is usually extraparenchymal and for that reason is superficial [1-4]. According to an analysis of 15 cases, the mammographic appearance has an oval shape in 33% of cases and a lobular shape in 53% of cases; while the margins are circumscribed 53% of the time and microlobulated 46% of the time. Rarely the mammogram may show characteristic phleboliths [1,3,4,5]. Tangential views may show the mass to be superficial in location . Sonography usually demonstrates a lobulated, superficial, well-circumscribed, solid mass. Due to the dilated blood vessels the nodules are often heterogeneous on ultrasound; however, hemangiomas may be difficult to visualize on ultrasound as about 11% are isoechoic [1,6]. MRI of the lesions is not well documented with one case showing slow, delayed enhancement within a capillary hemangioma . A second report demonstrated avid early homogenous contrast enhancement with plateau formation seen on dynamic enhancement curve following initial early washout of contrast . On occasions such as in this case when there are malignant features on imaging studies [Figs. 2-4], biopsy is indicated [8,9]. Jozefczyk and Rosen in their study of 62 angiosarcomas and 24 hemangiomas found that angiosarcomas were rarely smaller than 2 cm . Histology of hemangiomas demonstrates unencapsulated aggregates of closely packed, thin-walled capillaries, with endothelial lining. Their lumens may be thrombosed and organized [10-12]. This case has the histologic appearance of a complex hemangioma [Figs. 5-7] with dilated vascular channels of varying size and compact, dense aggregates of capillary structures . As in this case, when a hemangioma is diagnosed by core needle biopsy, complete excision is advised as low grade angiosarcoma may be indistinguishable and there is the remote possibility of malignant transformation to angiosarcoma [1, 10]. In conclusion, a superficial mass measuring less than 2 cm with oval or lobular shape and complex or isoechoic echotexture may give the radiologist a clue to this unusual diagnosis
Other breast imaging cases:
Invasive Ductal Carcinoma of the Breast in 27 Year Old
Medullary Breast Cancer
1. Mesurolle B, Sygal V, Lalonde L, et al. Sonographic and Mammographic Appearances of Breast Hemangioma. AJR 2008; 191:W17–W22 www.ajronline.org/doi/full/10.2214/AJR.07.3153
2. Chung SY, Oh KK. Mammographic and sonographic findings of a breast subcutaneous hemangioma. J Ultrasound Med 2002; 21:585 –588. http://www.jultrasoundmed.org/content/21/5/585.long
3. Webb LA, Young JR. Case report: haemangioma of the breast—appearances on mammography and ultrasound. Clin Radiol 1996; 51:523 –524. https://www.ncbi.nlm.nih.gov/pubmed/8689834?dopt=Abstract
4. Tabar L, Dean PB. Teaching Atlas of Mammography. 2nd ed. New York, NY: Thieme; 1985:45.
5. Tabar L, Dean PB. Teaching Atlas of Mammography. 2nd ed. New York, NY: Thieme; 1985:209.
6. Glazebrook KN, Morton MJ, Reynolds C. Vascular tumors of the breast: mammographic, sonographic, and MRI appearances. AJR 2005; 184:331 –338 http://www.ajronline.org/doi/10.2214/ajr.184.1.01840331
7. Ameen R, Mandalia U, Marr A, et al. Breast Hemangioma: MR Appearance with Histopathological Correlation. J Clin Imaging Sci. 2012; 2: 53. Published online 2012 Aug 30. doi: 10.4103/2156-7514.100376
8. Mariscal A, Casas JD, Balliu E, Castella E. Breast hemangioma mimicking carcinoma. Breast 2002; 11:357–358. www.thebreastonline.com/article/S0960-9776(02)90453-4/abstract9
9. Hoda SA, Cranor ML, Rosen PP. Hemangiomas of the breast with atypical histological features: further analysis of histological subtypes confirming their benign character. Am J Surg Pathol 1992; 16:553 –560. www.ncbi.nlm.nih.gov/pubmed/1599035?dopt=Abstract
10. Jozefczyk MA, Rosen PP. Vascular tumors of the breast. II. Perilobular hemangiomas and hemangiomas. Am J Surg Pathol 1985; 9:491 –503 https://www.ncbi.nlm.nih.gov/pubmed/4091183?dopt=Abstract
11. Lesueur GC, Brown RW, Bhathal PS. Incidence of perilobular hemangioma in the female breast. Arch Pathol Lab Med 1983; 107:308 –310. https://www.ncbi.nlm.nih.gov/pubmed/6687795?dopt=Abstract
12. Hoda SA, Brogi E, Koerner F, Rosen PP. Rosen's Breast Pathology 4e. 2014. Lippincott, Williams, and Wilkins. (2014) ISBN-13: 978-1451176537 Buy it on Amazon
László Tabár, MD, FACR (Hon) the Professor Emeritus of Radiology Uppsala University, Faculty of Medicine, Sweden and the Medical Director Emeritus of the Department of Mammography, Falun Central Hospital, Sweden. Through his company, Mammography Education, Inc, he has also been the course director and principal lecturer at more than 300 mammography courses on 6 continents. His pioneering research has laid the foundation for early detection through modern mammographic screening. Dr. Tabár is the recipient of numerous awards including the Gold Medal from the Society of Breast Imaging, American Cancer Society's Distinguished Service Award, and the first Alexander Margulis Award for Scientific Excellence from the Radiological Society of North America (RSNA). Dr. Tabár will be sharing his vast knowledge of breast imaging at Imaging in Israel - 2017.
Kevin M. Rice, MD is the President of Global Radiology CME
Dr. Rice serves as the Chair of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is a radiologist with Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances and as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" award for the Most Effective Radiology Educator.
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