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Vascular Tumors of the Breast: Mammographic, Sonographic, and MRI Appearances

¹ Department of Radiology, Mayo Clinic, 200 First St. SW, Rochester, MN 55905.
² Division of Anatomic Pathology, Mayo Clinic, Rochester, MN 55905.

Received September 11, 2003; accepted after revision June 14, 2004.

 
Address correspondence to K. N. Glazebrook.

Introduction

Top Introduction Benign Vascular Tumors Malignant Vascular Tumors Conclusion References

 
Vascular tumors of the breast are rare. Anatomically, breast tissue is located between the anterior and posterior layers of the superficial pectoral fascia [1]. Lesions located superficial to the anterior pectoral fascia in the subcutaneous fat are extraparenchymal in origin with or without dermal involvement. Subcutaneous vascular masses are generally benign [2, 3], whereas most intraparenchymal lesions prove to be malignant angiosarcomas [2].

We sought to describe the imaging appearances of benign and malignant vascular tumors of the breast. A search of the surgical pathology records of approximately 10,000 breast biopsies performed at our institution from 1994 to 2004 yielded 18 cases of benign vascular tumors (15 hemangiomas and three angiolipomas) and two malignant angiosarcomas. Mammograms were available for 13 patients and sonograms for 14 patients. We used the records and images of these patients in our pictorial essay.

Benign Vascular Tumors

Top Introduction Benign Vascular Tumors Malignant Vascular Tumors Conclusion References

 
Hemangioma
Mammographic appearance.—Mammographically, a hemangioma appears as a well-circumscribed macrolobulated lesion that may contain calcification [1, 4] (Figs. 1A, 1B, 2A, 2B, 2C, 2D, 3A, 3B, 4A, 4B, 5A, 5B, 5C, 6A, and 6B). Most often, a hemangioma is superficial, located either subdermally or within the subcutaneous tissues. If the mass can be profiled on the tangential view on mammography, the superficial nature of the mass can be clearly seen. Rarely, a hemangioma may be intraparenchymal. In the series by Jozefczyk and Rosen [2], the size of benign intraparenchymal hemangiomas ranged from 0.2 to 2.5 cm, with few being larger than 1 cm, and most were well-circumscribed on mammography (Figs. 6A and 6B). Imaging findings are not specific for the diagnosis of a vascular tumor, and the differential diagnosis includes causes of a circumscribed mass, most often a fibroadenoma or cyst. Hemangiomas are rare in men, in whom they tend to present as a clinically palpable mass suspected to be malignant (Figs. 4A and 4B).

View larger version (84K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A. —56-year-old woman with palpable mass in inferior aspect of left breast. Magnified mediolateral oblique mammogram shows well-circumscribed superficial nodule.

View larger version (120K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B. —56-year-old woman with palpable mass in inferior aspect of left breast. Sonogram obtained in area of palpable mass shows 1-cm lesion that is poorly defined and mildly echogenic compared with adjacent adipose tissue. Mass (arrow) lies superficial to anterior layer of superficial pectoral fascia. Excisional biopsy confirmed mass to be hemangioma.

View larger version (80K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A. —53-year-old woman with superficial mass in left breast that had been present for 30 years but had recently been enlarging. Mediolateral oblique mammogram shows well-circumscribed lobulated superficial mass in upper part of breast.

View larger version (109K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B. —53-year-old woman with superficial mass in left breast that had been present for 30 years but had recently been enlarging. Sonogram shows heterogeneous, ill-defined, superficial, lobulated mass.

View larger version (80K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2C. —53-year-old woman with superficial mass in left breast that had been present for 30 years but had recently been enlarging. On color Doppler sonogram, hypoechoic cystic-appearing spaces do not show any blood flow, although large draining vein at periphery was identified on color Doppler and Doppler interrogations.

View larger version (121K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2D. —53-year-old woman with superficial mass in left breast that had been present for 30 years but had recently been enlarging. Photograph of cross-section of pathologic specimen shows circumscribed, lobulated, hemorrhagic mass measuring 7.0 x 3.0 x 2.5 cm. Lesion closely approximates overlying skin.

View larger version (88K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A. —89-year-old woman with palpable mass in medial aspect of right breast that had been present for many years. Blue discoloration of skin is consistent with vascular lesion. At fine-needle aspiration biopsy, mass was found to be benign. Magnified mediolateral mammogram shows well-circumscribed macrolobulated nodule.

View larger version (135K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B. —89-year-old woman with palpable mass in medial aspect of right breast that had been present for many years. Blue discoloration of skin is consistent with vascular lesion. At fine-needle aspiration biopsy, mass was found to be benign. Power Doppler sonogram obtained in area of palpable mass shows poorly defined region of mildly increased echogenicity compared with that of adjacent fat. Single feeding vessel (arrow) is visible at periphery of mass, but no blood flow is seen within mass.

View larger version (101K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4A. —83-year-old man with palpable mass in right breast. Mediolateral oblique mammogram shows well-defined lobulated mass. Retractable wire was placed to confirm that sonographic findings corresponded to nodule on mammography.

View larger version (147K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4B. —83-year-old man with palpable mass in right breast. Sonogram obtained in area of palpable mass shows poorly defined, mixed echogenic and isoechoic lesion (arrows). Sixteen-gauge core biopsy was performed under sonographic guidance. Histologic finding was capillary hemangioma.

View larger version (131K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5A. —48-year-old woman with palpable mass in lateral aspect of left breast. As a child, she had received radiation therapy in this area and in axilla for biopsy-proven capillary hemangioma. Bilateral mediolateral oblique mammograms show substantial reduction in size of left breast and increased interstitial markings due to previous radiation therapy. Lobulated mass containing phleboliths is in left axilla.

View larger version (108K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5B. —48-year-old woman with palpable mass in lateral aspect of left breast. As a child, she had received radiation therapy in this area and in axilla for biopsy-proven capillary hemangioma. Sonogram obtained in area of palpable mass shows poorly defined, hypoechoic lesion containing cystic-appearing spaces. No color flow was seen on color Doppler sonography (not shown).

View larger version (80K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5C. —48-year-old woman with palpable mass in lateral aspect of left breast. As a child, she had received radiation therapy in this area and in axilla for biopsy-proven capillary hemangioma. Two-dimensional axial gadolinium-enhanced fast spoiled gradient-echo MR image clearly shows extent of hemangioma (arrow), which extends into axilla.

View larger version (79K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6A. —63-year-old woman in whom mass was detected in left breast on screening mammography. Mediolateral oblique mammogram shows irregular mass with localization wire adjacent to mass.

View larger version (93K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6B. —63-year-old woman in whom mass was detected in left breast on screening mammography. Sonogram shows that mass was difficult to visualize because it was isoechoic compared with adjacent fat. Cursors define mass measuring 1.3 x 1.1 cm. Histologic finding was hemangioma with adjacent breast tissue, indicating hemangioma that was intraparenchymal.

Sonographic appearance.—Sonographically, hemangiomas appear as lobulated, superficial, well-circumscribed, solid masses that are predominantly hypoechoic and may contain areas of calcification [1, 4]. Hyperechoic nodules also have been described [4]. Sonography is the most accurate imaging tool with which to differentiate subcutaneous from intraparenchymal masses because the anterior pectoral fascia often can be well depicted using high-frequency transducers ( 7 MHz) [1]. At our institution, hemangiomas were much less conspicuous sonographically than they were clinically or mammographically. Most were ill defined and either isoechoic or mildly hyperechoic relative to the surrounding fat (Figs. 1A, 1B, 2A, 2B, 2C, 2D, 4A, 4B, 6A, and 6B). In a few cases, no mass could be identified sonographically, despite the lesion being discretely palpable and readily visible as a well-defined mammographic nodule surrounded by fatty tissue. One case of cavernous hemangioma was hypoechoic with multiple septations and increased acoustic transmission that was suggestive of a complex cyst (Figs. 7A and 7B).

View larger version (102K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7A. —73-year-old man with palpable mass in right breast. Sonogram shows complex cystic circumscribed mass with thick internal septations. No color flow was seen on color Doppler sonography (not shown).

View larger version (148K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7B. —73-year-old man with palpable mass in right breast. Photomicrograph shows histopathologic specimen obtained at excisional biopsy. Histologic finding was cavernous hemangioma with markedly dilated vessels congested with RBCs. Vessel walls were lined by inconspicuous flat endothelial cells. (H and E, x200)

Appearance on color Doppler sonography.—Color Doppler sonography of vascular skin lesions has high specificity and sensitivity for distinguishing benign from malignant lesions on the basis of the different patterns of vascularity [5]. Hypovascularity with a single vascular pole has been reported in benign lesions, whereas hypervascularity with multiple peripheral poles or internal vessels has been reported in malignant lesions. However, benign hemangiomas in the breast also have been described as displaying high vascularity [4] (Figs. 2A, 2B, 2C, 2D, 3A, 3B, 7A, and 7B).

MRI appearance.—MRI was performed in one patient with a benign hemangioma. Dynamic gadolinium-enhanced MR images showed a slow, delayed enhancement, indicating slow flow within the capillary hemangioma (Figs. 5A, 5B, and 5C).

Findings at percutaneous biopsy.—Because of interval growth of the breast lesion, two patients with hemangiomas underwent stereotactic biopsy performed with an automated 14-gauge core biopsy device. Lack of sonographic visualization precluded sonographically guided biopsy. One of these patients had a moderate amount of bleeding during the procedure, but this was well controlled with compression of the breast. Two additional patients underwent sonographically guided biopsy with automated 18- and 16-gauge needles because they each presented with an indeterminate palpable mass. No complications were noted.

Angiolipoma
An angiolipoma is a benign variant of lipoma and is a rare lesion in the breast. Noninfiltrating angiolipomas are more common in men, occurring in the subcutaneous tissue of the upper extremities and trunk, whereas the infiltrating type occurs in both children and adults of both sexes, usually involving muscle groups in the lower extremity, neck, or shoulder.

Mammographically, angiolipomas in the breast have been described as well-circumscribed nodular densities [6]. However, angiolipomas also may show irregular margins on mammography (Figs. 8A, 8B, 8C, 9A, and 9B). The sonographic appearance of an angiolipoma is a well-circumscribed, hyperechoic mass without posterior acoustic enhancement [6] (Figs. 8A, 8B, 8C, 9A, and 9B). Sonographically guided biopsy using an automated 14-gauge biopsy device has been performed without complication in patients with an angiolipoma.

View larger version (95K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8A. —63-year-old woman with palpable mass in inferior aspect of left breast. Mediolateral oblique mammogram of left breast shows irregular, ill-defined mass.

View larger version (109K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8B. —63-year-old woman with palpable mass in inferior aspect of left breast. On sonogram, cursors show well-defined echogenic mass measuring 10 x 6 mm.

View larger version (131K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8C. —63-year-old woman with palpable mass in inferior aspect of left breast. Photomicrograph of histopathologic specimen obtained at sonographically guided 14-gauge core biopsy shows mixture of mature adipose tissue and proliferation of narrow vascular channels consistent with angiolipoma. Mature fat cells are separated by branching network of small vessels that characteristically contain fibrinous thrombi. (H and E, x100)

View larger version (88K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9A. —52-year-old man with palpable masses in both breasts that had been present for many years. Biopsy results for several masses on patient's trunk showed angiolipomas and lipomas. Bilateral craniocaudal mammograms show ill-defined low-density nodules in both breasts, corresponding to palpable masses.

View larger version (104K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9B. —52-year-old man with palpable masses in both breasts that had been present for many years. Biopsy results for several masses on patient's trunk showed angiolipomas and lipomas. Sonogram of palpable mass in medial aspect of left breast shows well-defined echogenic mass (between cursors), measuring 2 x 1.2 cm.

Malignant Vascular Tumors

Top Introduction Benign Vascular Tumors Malignant Vascular Tumors Conclusion References

 
Most mammographically and clinically evident intraparenchymal vascular tumors prove to be malignant angiosarcomas [2] (Figs. 10A, 10B, 10C, and 10D). Liberman et al. [7] noted that in their study, the mammographic findings for 52% of the angiosarcomas were of a solitary ill-defined uncalcified mass ranging in size from 3 to 6 cm. Sonography of angiosarcomas showed solitary or multiple masses that were predominantly hypoechoic [7]. Angiosarcomas may be invisible mammographically and sonographically in a minority of cases. On MRI, angiosarcomas are extremely vascular lesions, showing blood lakes and large draining veins [8] (Figs. 10A, 10B, 10C, and 10D). In one patient at our institution, an angiosarcoma occurred in the chest wall after radiation therapy for primary breast cancer, a known, although rare, complication of this therapy.

View larger version (93K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10A. —41-year-old woman with fullness and engorgement of right upper breast. Bilateral mediolateral oblique mammograms show asymmetric density (arrow) in upper right breast.

View larger version (58K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10B. —41-year-old woman with fullness and engorgement of right upper breast. Sonogram of palpable mass shows increased vascularity on color Doppler evaluation. No discrete mass was detected, although there was diffuse increased echogenicity in region of palpable abnormality.

View larger version (87K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10C. —41-year-old woman with fullness and engorgement of right upper breast. Three-dimensional sagittal gadolinium-enhanced fast spoiled gradient-echo MR image of right breast shows multiple nodular areas of rapid and intense contrast enhancement within 7-cm mass. Draining vein (arrow) is noted. Areas of blood lakes (increased signal intensity on T1-weighted images, not shown) did not enhance.

View larger version (151K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10D. —41-year-old woman with fullness and engorgement of right upper breast. Photomicrograph of histopathologic specimen shows open anastomosed vascular channels surrounding and invading breast lobule, consistent with angiosarcoma. Vascular channels were lined by hyperchromatic focally pleomorphic nuclei. (H and E, x200)

Conclusion

Top Introduction Benign Vascular Tumors Malignant Vascular Tumors Conclusion References

 
Vascular tumors of the breast are rare. Hemangiomas of the breast are usually extraparenchymal and are therefore superficial. They present mammographically as well-defined masses and may contain calcification. Hemangiomas can be difficult to identify sonographically because they tend to be isoechoic relative to the surrounding adipose tissue. In our experience, angiolipomas present as irregular, nodular densities mammographically. Sonographically, angiolipomas are echogenic and well defined. Angiosarcomas are usually intraparenchymal and are typically larger than 3 cm at diagnosis.

References

Top Introduction Benign Vascular Tumors Malignant Vascular Tumors Conclusion References

 

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3. Rosen PP. Vascular tumors of the breast: V. Nonparenchymal hemangiomas of mammary subcutaneous tissues. Am J Surg Pathol 1985;9:723 -729[Medline]
4. Chung SY, Oh KK. Mammographic and sonographic findings of a breast subcutaneous hemangioma. J Ultrasound Med2002; 21:585 -588[Free Full Text]
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