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Case Report |
1
Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical
School, 330 Brookline Ave., Boston, MA 02115.
2
Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical
School, Boston, MA 02115.
Received December 11, 2000;
accepted after revision July 19, 2001.
Address correspondence to B. Siewert.
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The differential diagnosis included hematoma in the subcutaneous soft tissues and an early sebaceous cyst not yet involving the dermis; close follow-up rather than biopsy of the lesion was suggested. At clinical followup 2 months later, the skin changes had completely resolved, but the lesion was still palpable. Sonographically, the lesion was unchanged, but the patient elected to have it surgically removed.
At surgery, the nodule was located by palpation in the lower inner quadrant of the right breast. Dissection was carried through a minimal amount of subcutaneous tissue with total excision of the nodule. Another piece of tissue deep relative to the lesion and its fascial plane was then removed and sent separately for pathologic examination. The excision specimen consisted of a fibrofatty fragment of tissue, which on gross examination revealed a circumscribed tan—gray nodule, measuring up to 5 mm in maximum dimension. Microscopically, the lesion was composed of small vascular spaces arranged in a lobular pattern. The vascular channels were lined by unremarkable endothelial cells without cytologic atypia (Figs. 1C and 1D). Scattered larger vascular spaces were also identified in the lesion. Endothelial cell atypia, papillary tufting, mitotic figures, necrosis, or other features suggestive of an atypical vascular lesion or angiosarcoma were not identified. The lesion was surrounded by adipose tissue without mammary ducts or lobules showing focal fat necrosis. These findings were diagnostic of a hemangioma, predominantly capillary in pattern, in the subcutaneous tissue of the breast.
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Lesions can be seen anterior to the anterior layer of the superficial pectoral fascia and in the subcutaneous fatty layer, with or without dermal layer involvement. Localizing a lesion and its relationship to adjacent tissues aids in accurately formulating a differential diagnosis; in the present case, the mass is clearly located anterior to the anterior layer of the superficial pectoralis fascia. Thus a primary breast mass, in particular, breast cancer, can be excluded from the differential diagnosis (Figs. 1A,1B,1C,1D and 2). A sebaceous cyst, a more common subcutaneous lesion, can be eliminated because this typically also involves the dermis (Fig. 3).
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In our experience, the superficial layer of the pectoral fascia can be identified in most cases using 10-MHz transducers that are widely used in clinical practice (for sonographic evaluation of the breast). However, to our knowledge, no large study has yet established the level of confidence with which the fascia can be shown, thus confirming the superficial location of a lesion and perhaps predicting histology. This may be a fruitful subject for further study.
The use of a high-frequency 20-MHz transducer with a maximum depth of penetration of 2 cm and a focal zone centered in the region of interest has proved helpful in the differentiation of the layers of the skin and subcutaneous tissues, facilitating the evaluation of lesions such as the one reported here [5]. However, the use of a high-frequency 20-MHz transducer is not the current standard of clinical care. Another potential problem is the size of the lesion. In the present case, the small size (5 mm) of the lesion made the identification of surrounding structures easy. With a larger lesion, it may be difficult to determine whether the mass is separate from the dermis, and its relation to the superficial pectoral fascia may be obscured.
Benign mesenchymal tumors in and adjacent to the breast tissues have been described [6], including several types of hemangioma. Although such lesions occur only rarely, hemangiomas may be detected more often with the increased use of breast self-examination, physician-performed breast examination, and more intensive imaging of the breast.
Although gray-scale sonography has been shown to be sensitive in the detection of subcutaneous lesions, the differentiation of malignant and benign lesions has been more problematic. Betti et al. [2] have described gray-scale sonography criteria that may be helpful in allowing further analysis of proliferative vascular lesions of the skin; high-resolution sonography reveals hemangiomas as small hypoechoic areas separated by thin, echogenic septae. In contrast, malignant vascular lesions, such as Kaposi's sarcoma, reveal a mixed sonographic pattern with illdefined margins. These criteria could not be applied in the present case because a lower frequency transducer (10- to 5-MHz compact linear array transducer) was used.
With color Doppler sonography, tumor neovascularity can be analyzed, and the presence of arteriovenous shunting and distortion of internal vessels, as well as increased tumor vascularity relative to the surrounding tissue, can be assessed. Although there is some overlap between benign and malignant lesions and no general consensus exists about the significance of the vascularity of breast masses, some distinguishing features have been described in breast lesions [7]. Giovagnorio et al. [3] were able to distinguish between benign and malignant lesions of the skin and subcutaneous soft tissues using different patterns of vascularity. Lesions were classified as avascular (type 1), hypovascular with a single vascular pole (type 2), hypervascular with multiple peripheral poles (type 3), and hypervascular with internal vessels (type 4). They reported a sensitivity of 100% and a specificity of 90% for hypovascularity in benign lesions and a sensitivity and specificity of 90% and 100%, respectively, for malignant lesions. Some malignant lesions had a type 1 pattern, but a type 2 pattern was seen only in benign lesions. Applying these authors' criteria for benignity, the lesion reported here would be classified as a type 2 pattern, considered benign, and surgery could have been averted.
In conclusion, sonography of the breast using commercially available high-frequency transducers can help to distinguish the types of breast masses and to determine whether a lesion shown on mammography or at clinical examination is actually in the breast tissues. Sonography with highfrequency transducers may also predict lesion histology, although this will require further study.
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