AJR 2001; 176:734-736
© American Roentgen Ray Society
Is a Pseudocystic Serpentine Mass a Sonographic Indicator of Breast Lymphoma? Radiologic-Histologic Correlation of an Unusual Finding
Eva C. Gal-Gombos1,
Lisa E. Esserman1,
Anna W. Poniecka2 and
Robert J. Poppiti, Jr.2
1
Comprehensive Breast Center, Mount Sinai Medical Center, 4306 Alton Rd., Miami
Beach, FL 33140.
2
Department of Pathology and Laboratory Medicine,Mount Sinai Medical Center,
4300 Alton Rd., Miami Beach, FL 33140.
Received July 7, 1999;
accepted after revision June 26, 2000.
Address correspondence to E. C. Gal-Gombos.
Introduction
A hypoechoic, homogeneous or heterogeneous well-defined mass is the most
common sonographic finding in patients with malignant lymphoma of the breast
[1,
2]. However, the literature
describes a wide range of imaging features that are not specific for malignant
lymphoma of the breast and may also be associated with fibroadenomata,
invasive carcinomas, metastases, or other mass lesions. These findings range
from hypoechoic to hyperechoic
[3], from poorly defined to
well delineated, and from focal involvement to diffuse involvement of the
breast [3,
4].
In addition to these sonographic findings, we have observed an elongated,
complex, superficial mass with small cystic-looking spaces associated with
breast lymphoma. To our knowledge this finding has not been previously
described in the literature. It can be mistaken for an atypical appearance of
ductal ectasia or an unusually elongated fibroadenoma or phyllodes tumor.
Case Report
The first patient in whom we observed this finding was a 67-year-old woman
whose primary breast lymphoma (diffuse, cleaved cell) on the right side had
been diagnosed 5 years earlier and who had been disease-free since that time.
She presented with a superficial, soft, palpable lump in the left breast,
superior and lateral to the nipple. A faint, obscured mass of approximately 1
cm was detected on her mammogram (Fig.
1A). Sonography revealed an elongated cystic structure that
measured 1.6 x 0.7 cm (Fig.
1B). This finding corresponded to the palpable mass and the
mammographic density. The sonographically guided 14-gauge core biopsy revealed
a mixed-cell type follicular lymphoma (Figs.
1C and
1D). No other site of disease
was found in a subsequent workup for lymphoma. The patient was treated with
chemotherapy alone. Follow-up mammography and sonography 2 months later and 1
year later revealed no abnormalities.
View larger version (102K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1A. —67-year-old woman with primary lymphoma of left breast. Left
mediolateral oblique mammogram shows a low-density mass (arrows)
corresponding to palpable abnormality. Scar markers (Beekley, Bristol, CT)
above and below nipple are from previous biopsy with benign results. White dot
near end of lower marker is calcification.
|
|
View larger version (92K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1C. —67-year-old woman with primary lymphoma of left breast.
Low-power view of core needle biopsy specimen shows follicular lymphoma
separated by thin strands of fibroadipose tissue (arrows). (H and E,
x40)
|
|
The second patient was 84 years old when she presented with a clinically
detectable thickening in the left breast. She had a history of malignant
lymphoma and mucinous adenocarcinoma of the pancreas that had been diagnosed
12 and 15 years earlier, respectively. There was no known residual disease at
presentation. The mammogram showed a newly developed, circumscribed, oval mass
corresponding to the palpable area (Fig.
2A). Targeted sonographic examination revealed an ellipsoid,
well-defined, 2.6 x 0.8 cm, complex lesion (Figs.
2B and
2C) that was similar to the
image seen in the first patient (pseudocystic serpentine mass). Because the
patient had been disease-free for 12 years, recurrent lymphoma was not
clinically suspected; however, we suggested the diagnosis of malignant
lymphoma on the basis of these findings. Open surgical biopsy and subsequent
histologic analysis revealed diffuse, mixed cell malignant lymphoma
(Fig. 2D). Lymphoma workup
revealed no other organ involvement.
View larger version (124K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 2B. —84-year-old woman with secondary breast lymphoma. Right
longitudinal (B) and transverse grayscale (C) sonograms show
finding that has pseudocystic serpentine mass appearance. Sonographer should
be careful not to misinterpret findings as dilated ducts or breast cysts
containing septa.
|
|
View larger version (91K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 2C. —84-year-old woman with secondary breast lymphoma. Right
longitudinal (B) and transverse grayscale (C) sonograms show
finding that has pseudocystic serpentine mass appearance. Sonographer should
be careful not to misinterpret findings as dilated ducts or breast cysts
containing septa.
|
|
Discussion
The clinical histories of and imaging findings in the two patients were
consistent with non-Hodgkin's lymphoma of the breast
[5]: rapidly enlarging,
painless, palpable breast masses. Targeted breast sonography is currently the
main diagnostic procedure for imaging palpable lesions when the mammographic
findings are negative or nonspecific. Proper diagnosis of whether a breast
mass is cystic or solid is especially important in determining treatment. No
specific mammographic or sonographic appearance has been described in previous
reports on malignant lymphoma
[1,2,3,4,
6,7,8].
With its variety of presentations, lymphoma can be a radiologic mimic of other
diseases, and this characteristic applies to breast lymphoma as well. When the
pseudocystic serpentine mass appearance is seen, the examiner can include
breast lymphoma as a diagnostic consideration. We tried to find a morphologic
explanation for this appearance by comparing the sonographic findings with the
histopathologic findings.
In the first case of the woman diagnosed with malignant lymphoma
(follicular type), the pseudocystic serpentine mass appearance can be
attributed to the fibroadipose strands around the follicular structures (Fig.
1A,1B,1C,1D).
The "microcysts" found on sonography correspond to the
nodular-shaped lymphomatous folliculi on histologic examination. In the second
patient, who had a diffuse malignant lymphoma, this appearance can be
explained by fat and fibrous tissue surrounding the malignant lymphoid cells.
These relatively hyperechoic "septa" around the
"cysts" (lymphoid cell population) were probably produced by
numerous interfaces caused by fibrotic and fatty tissue, and the septa can be
seen on the magnification of the specimen (Figs.
2B,2C,2D).
On sonography, they can cause an overall multicystic appearance in diffuse
lymphoma, similar to the appearance of follicular lymphoma.
The superficial location of the neoplastic nodules provides an explanation
for their elongated appearance; the spread of the disease probably occurs
subcutaneously (in the direction of least resistance) dissecting the adipose
tissue planes between the breast tissue and dermis.
The pseudocystic serpentine mass appearance is a simple observation that
can lead to the suggestion of lymphoma as a diagnostic consideration. We were
able to identify this appearance in two patients. A larger investigation may
show this finding to be an unusual but characteristic sign of lymphomatous
involvement of the breast. The rare entity of breast lymphoma should be
considered if this pattern is detected.
References
-
Liberman L, Giess CS, Dershaw DD, Louie DC, Deutch BM. Non-Hodgkin
lymphoma of the breast: imaging characteristics and correlation with
histopathologic findings. Radiology
1994;192:157
-160[Abstract/Free Full Text]
-
Pope TL Jr, Brenbridge AN, Sloop FB Jr, Morris JR III, Carpenter J.
Primary histiocytic lymphoma of the breast: mammographic, sonographic and
pathologic correlation. J Clin Ultrasound
1985;13:667
-670[Medline]
-
Jackson FI, Zulfikarali H, Lalani ZH. Breast lymphoma: radiologic
imaging and clinical appearances. Can Assoc Radiol J
1991;42:48
-54[Medline]
-
Meyer JE, Kopans DB, Long JC. Mammographic appearances of malignant
lymphoma of the breast. Radiology
1980;135:623
-626[Abstract/Free Full Text]
-
Brustein S, Filippa DA, Kimmel M, Lieberman PH, Rosen PP. Malignant
lymphoma of the breast: a study of 53 patients. Ann
Surg 1987;205:144
-150[Medline]
-
D'Orsi CJ, Feldhaus L, Sonnenfeld M. Unusual lesions of the breast.
Radiol Clin North Am
1983;21:67
-80[Medline]
-
Yang WT, Metreweli C. Sonography of nonmammary malignancies of the
breast. AJR
1999;172:343
-348[Free Full Text]
-
Kopans DB, Swann CA, White G, et al. Asymmetric breast tissue.
Radiology
1989;171:639
-643[Abstract/Free Full Text]
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
This article has been cited by other articles:
|
|
|
|
 
A. A. Shi, D. Georgian-Smith, L. D. Cornell, E. A. Rafferty, M. Staffa, K. Hughes, and D. B. Kopans
Radiological Reasoning: Male Breast Mass with Calcifications
Am. J. Roentgenol.,
December 1, 2005;
185(6_Supplement):
S205 - S210.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Introduction
Case Report
