Applied Radiology

Prepared by Charles Master, MD , 4th-year Radiology Resident, and Ruwini de Silva, MD, Attending GI and Breast Radiologist, St. Vincent's Medical Center of Staten Island, NY.

CASE SUMMARY

The patient is a 47-year-old white woman who presented for a routine mammogram. There was no family history of breast cancer and no prior breast surgery. She was not receiving any hormone replacement therapy and had no palpable breast mass. On routine mammogram, an oval, mammographically benign density was seen in the left posterior lower breast in the mediolateral oblique (MLO) view (Figures 1 and 2). Sonographic evaluation of the left breast revealed a 1.9-cm hyperechoic area with posterior shadowing (Figure 3).

DIAGNOSIS

Cavernous breast hemangioma

IMAGING FINDINGS

On the spot compression mammographic views, a focal density, with sharp anterior margins measuring approximately 2 cm was identified on the MLO view (Figure 2). It was located very deeply and its posterior margin could not be adequately visualized mammographically. The patient subsequently had an ultrasound of the left breast. Sonographic evaluation of the left breast revealed a 1.9-cm hyperechoic area with posterior shadowing 10 cm from the nipple at the 6 o'clock axis (Figure 3). Because the lesion was hyperechoic, the lesion was thought to be benign. Due to the posterior shadowing of the lesion and its posterior location, which made adequate follow-up difficult, the patient was advised to have a core biopsy.

PATHOLOGIC FINDINGS

The patient subsequently underwent a core biopsy of the lesion. The specimens were deep red in color. The lesion was believed to be a hemorrhagic lesion. Pathology revealed a hemangioma. The patient had the lesion surgically removed. Pathology revealed a nodule measuring 1.1 * 0.8 * 0.7 cm and the surrounding tissue was slightly hemorrhagic (Figure 4). Microscopically, the lesion was found to be a cavernous hemangioma (Figure 5).

DISCUSSION

Hemangiomas are benign vascular tumors. They are usually thin-walled, blood-filled vascular spaces that are separated by fibrous septa with occasional phleboliths. ¹ Histologically, there are two major types: the capillary hemangioma and the cavernous hemangioma. Capillary hemangiomas are composed of blood vessels that resemble capillaries. Cavernous hemangiomas have large, cavernous vascular channels. ² Hemangiomas of the breast can be divided into intralobular and extralobular types, depending on whether they are found in the intra- or interlobular stroma. ³ Hemangiomas within the breast have an incidence of 1.2% to 11%. Mammographic findings of a breast hemangioma include a normal mammogram, or a well-circumscribed mass with punctate calcifications. ^4-6 Sonographic findings of breast hemangiomas include hypoechoic or hyperechoic lesions that can be ill-defined or well-defined, and can have internal bright echoes that likely represent calcifications within them. ⁵ Unlike most cases of breast hemangiomas seen in the literature, ^4-6 this case did not show any calcifications mammographically, on ultrasound, or on histology. On ultrasound, it was hyperechoic and well-defined and also had posterior acoustic shadowing.

There are a few published cases of sonographic findings of breast hemangiomas. One showed a well-defined, solid, mainly hypoechoic lesion with small bright echoes consistent with areas of calcification. ⁵ Another case showed a poorly defined hyperechoic mass with marked distal shadowing. ^5,7 A third case revealed a hyperechoic area with imprecise borders and a hypoechoic nodule in the center. ⁸ A fourth case only described the sonographic findings of well-defined, hypoechoic, homogenous, and multiple solid lesions within the breast parenchma. ⁹ Pathologically our case was a cavernous hemangioma with no calcifications seen within it.

ACKNOWLEDGMENT

The authors would like to thank Dr. Ko of the Department of Pathology of St. Vincent's Medical Center of Staten Island, NY for his photographs of the gross pathologic and microscopic findings of our case.