DOI:10.2214/AJR.07.3153
AJR 2008; 191:W17-W22
© American Roentgen Ray Society
Sonographic and Mammographic Appearances of Breast Hemangioma
Benoît Mesurolle1,
Vitaly Sygal1,
Lucie Lalonde2,
André Lisbona3,
Michel-Pierre Dufresne4,
Jean H. Gagnon1 and
Ellen Kao1
1 Department of Radiology, Cedar Breast Clinic, McGill University Health Center,
Royal Victoria Hospital, 687 Pine Ave. W, Montréal, PQ H3G 1A4,
Canada.
2 Département de Radiologie, Centre d'Imagerie du Sein, Centre
Hospitalier de l'Université de Montréal (CHUM), Montréal,
PQ, Canada.
3 Department of Radiology, Sir Mortimer B. Davis-Jewish General Hospital,
Montréal, PQ, Canada.
4 Département de Radiologie, Hôpital Maisonneuve-Rosemont,
Montréal, PQ, Canada.
Received September 14, 2007;
accepted after revision January 29, 2008.
Address correspondence to B. Mesurolle
(bmesurolle{at}yahoo.fr).
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Abstract
OBJECTIVE. The purpose of our study was to retrospectively evaluate
the clinical, imaging, and pathologic findings of breast hemangiomas in 16
patients.
CONCLUSION. A mass displaying an oval or lobular shape with
well-circumscribed or microlobulated margins on mammography and sonography,
and in a superficial location, should alert the radiologist to the possible
diagnosis of hemangioma. Imaging-guided biopsy appears sufficiently reliable
to rule out any malignant or premalignant component and to avoid a surgical
excision if doing so is clinically appropriate.
Keywords: breast tumor • hemangioma • mammography • sonography
Introduction
Hemangiomas have been described in many anatomic locations, but there are
few recorded examples of hemangiomas arising primarily in the breast
[1,
2]. The mammographic and
sonographic appearances of breast hemangiomas have been described in a few
case reports
[3–7]
but, to our knowledge, no case series including long-term follow-up imaging
have been published.
A search of the surgical pathology records at four institutions of breast
biopsies performed from 2000 to 2005 identified 16 patients with
pathologically proven breast hemangiomas. Clinical, mammographic, and sono
graphic features were reviewed, with particular emphasis on sonographic
findings.
Materials and Methods
Study Population
The combined data were obtained from four large institutions affiliated
with two academic medical centers (McGill University and University of
Montréal). A total of 23 pathologically proven hemangiomas diagnosed by
either sonographically guided, stereotactically guided, or surgical excision
biopsy performed between January 2000 and December 2005 were identified. Seven
patients for whom no imaging was available were excluded. Sixteen women (age
range, 43–75 years; mean age, 59.7 years) who met these criteria are the
subject of this article.
Two radiologists, specialists in breast imaging, retrospectively reviewed
in consensus the mammographic and sonographic features of the hemangiomas.
Approval by the institutional review board was not required for this
retrospective analysis.
Mammographic Findings
Mammography was performed in two standard imaging planes, mediolateral
oblique and craniocaudal, using dedicated film-screen mammo graphic equipment.
Mammographic characteris tics were assessed according to the American College
of Radiology Breast Imaging Reporting and Data System (BI-RADS)
[8]. Mammographic findings are
shown in Figures 1A,
1B,
1C,
2A,
2B,
2C,
3A,
3B,
3C,
4A,
4B.
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Fig. 1C —Asymptomatic 75-year-old woman. Breast sonogram shows 0.8-cm
oval solid mass (arrows) with circumscribed margins, parallel
orientation, abrupt interface, neutral sound transmission, and complex
echotexture. Surgical excision revealed hemangioma, cavernous type.
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Fig. 2A —Asymptomatic 62-year-old woman. Left craniocaudal screening
mammogram shows 1.2-cm lobular mass (arrow) with microlobulated
margins in upper inner aspect of breast. Mass (arrow) shows interval
increase in size compared with previous mammogram 8 years earlier
(B).
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Fig. 2B —Asymptomatic 62-year-old woman. Left craniocaudal screening
mammogram shows 1.2-cm lobular mass (arrow) with microlobulated
margins in upper inner aspect of breast. Mass (arrow) shows interval
increase in size compared with previous mammogram 8 years earlier
(B).
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Fig. 2C —Asymptomatic 62-year-old woman. Breast sonogram using tissue
harmonic imaging shows 1.1-cm subtle mass superficially situated against fatty
background. Lesion is ovoid with microlobulated margins, hypoechoic
echotexture, parallel orientation, and mild posterior acoustic shadowing
(arrows). Sonographically guided core biopsy using 14-gauge needle
yielded cavernous hemangioma. Follow-up imaging after 2 years (not shown)
confirmed stability of lesion.
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Fig. 3A —46-year-old woman with palpable mass in lateral aspect of
left breast. Left craniocaudal close-up image (A) and left mediolateral
oblique image (B) show mass (arrow) displaying irregular shape
and microlobulated margin and having no microcalcifications.
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Fig. 3B —46-year-old woman with palpable mass in lateral aspect of
left breast. Left craniocaudal close-up image (A) and left mediolateral
oblique image (B) show mass (arrow) displaying irregular shape
and microlobulated margin and having no microcalcifications.
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Fig. 3C —46-year-old woman with palpable mass in lateral aspect of
left breast. Breast sonogram shows 1.5-cm solid mass with irregular shape and
indistinct margins (arrows), parallel orientation, neutral sound
transmission, and hyperechoic echotexture. Sonographically guided biopsy using
14-gauge needle yielded capillary hemangioma. Surgical excision confirmed
hemangioma, capillary type.
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Fig. 4A —Asymptomatic 58-year-old woman with screening-detected mass.
Mammogram of right breast showed 1-cm mass. Radiograph obtained during
stereotactic biopsy with 14-gauge needle in place shows round mass with
circumscribed margins and punctuate microcalcifications. Breast sonogram did
not identify any mass. Stereotactically guided biopsy using 14-gauge needle
yielded cavernous hemangioma.
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Fig. 4B —Asymptomatic 58-year-old woman with screening-detected mass.
Mammogram of right breast showed 1-cm mass. Follow-up right craniocaudal
close-up mammogram obtained 2 years later shows 0.7-cm mass
(arrow).
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Sonographic Findings
Breast sonography was performed to evaluate specific abnormalities
discovered either at clinical examination or on mammography. All 16 patients
under went a breast sonographic examination (Figs.
1A,
1B,
1C,
2A,
2B,
2C,
3A,
3B,
3C,
4A,
4B), but a mass was
sonographically de tected in only nine patients (Figs.
1A,
1B,
1C,
2A,
2B,
2C,
3A,
3B,
3C). The sono graphic
characteristics of the nine masses were assessed according to the American
College of Radiology BI-RADS criteria
[8]. Studies were reviewed on
hard-copy films (five patients) or on PACS images (four patients).
Core Needle Biopsy
Fifteen patients underwent an imaging-guided core needle biopsy. One
patient underwent surgical excision without preoperative biopsy. Biopsy of
masses was performed with either sonographic or stereotactic guidance. If the
mass was clearly identified sonographically, the biopsy was performed under
sonographic guidance. If not, the biopsy was performed under stereotactic guid
ance. Stereotactic biopsies were performed with dedicated prone stereotactic
biopsy tables (n = 7). Sonographically guided biopsy was performed
with patients in the supine position and with high-resolution sonographic
equipment (15L8W broad band transducer, Sequoia, Siemens Medical Systems;
high-frequency Matrix trans ducer PLT1204AX, Aplio, Toshiba; model 700, GE
Healthcare; and HDL, ATL) (n = 8). Generally, 10- to 15-MHz
transducers were used. Fourteen-gauge automated core biopsy needles were used
for stereotactically and sonographically guided biopsies.
Surgical Excision
Of the 15 patients who underwent core needle biopsy, three underwent
subsequent surgical excision. One patient underwent surgical excision without
preoperative biopsy.
Pathologic Findings
The prospective pathology reports by the institutional pathologists at the
time of core needle biopsy (12 patients with no subsequent surgery) and at the
time of the surgical excision (four patients, including three with previous
core needle biopsy) were considered to indicate the definitive pathologic
results.
Results
Clinical Data
Patients were referred to our institutions because of a palpable mass
(n = 2), a screening-detected mass (n = 8), or an increase
in size of a previously screening-detected mass (n = 6).
Mammographic Findings
In the 16 patients studied, mammographic parenchymal density was BI-RADS
class 3 (heterogeneously dense) in three patients (18.75%), class 2 (scattered
fibroglandular densities) in five (31.25%), and class 1 (fatty) in eight
(50%). One mammogram was normal (class 2), the mass being palpable and
situated in the axillary region. Fifteen mammograms showed a mass (mean size,
1.2 cm; range, 0.6–2.5 cm) (Fig.
5). Mammographic findings are summarized in
Table 1. The most common
mammographic features were masses with a lobular shape (n = 8),
circumscribed (n = 8) or microlobulated (n = 7) margins, and
density equal to that of the breast parenchyma (n = 14) (Figs.
1A,
1B,
1C and
2A,
2B,
2C). One patient had punctate
microcalcifications in a mass (Fig.
4A,
4B).
Sonographic Findings
Sonographic findings are summarized in
Table 2. Nine masses were
identified at sonographic examination (Figs.
1A,
1B,
1C,
2A,
2B,
2C,
3A,
3B,
3C). The mean sono graphic size
was 1.3 cm (range, 0.6–3.2 cm) in the largest diameter
(Fig. 6). The most common
sonographic features of hemangiomas were oval shape (n = 8);
circumscribed margins (n = 5); superficial with an abrupt interface
(n = 9); and nonhyperechoic (i.e., hypoechoic, isoechoic, or complex)
echotextures (n = 6). The two lesions displaying indistinct margins
had a hyperechoic echotexture (Fig.
3A,
3B,
3C).
Pathologic Findings
Final pathologic examination identified 14 cavernous-type hemangiomas and
two capillary-type hemangiomas. Among the four patients who underwent
excisional biopsy, no malignancy was diagnosed. Surgical excision confirmed
the diagnosis of hemangioma in three patients and established the diagnosis in
one patient.
Surveillance
Four patients (25%) underwent surgical excisional biopsy (Figs.
1A,
1B,
1C and
3A,
3B,
3C). Eight patients (50%)
underwent mammographic surveillance and were followed up for a mean of 3.7
years (range, 2–6 years) (Figs.
2A,
2B,
2C and
4A,
4B). Among these eight
patients, six breast masses were mammographically stable and two showed a
decrease in size. Four of the 16 patients (25%) had no mammographic
surveillance.
Among a subgroup of patients referred for increase in size of a previously
screening-detected mass (n = 6), two had no mammographic
surveillance, three showed mammographically stable masses (3–6 years),
and one showed a decrease in size of the mass on mammography.
Discussion
Vascular tumors of the breast are rare lesions. Three main entities have
been reported: hemangiomas, angiolipomas, and angiosarcomas
[9]. Hemangiomas are benign
vascular tumors of two common types (capillary or cavernous) that are based on
the size of the vessels involved. Breast hemangiomas are found in 1.2% of
mastectomy specimens and 11% of postmortem specimens of the female breast
[9]. In our case series we
focused our observations exclusively on the benign form of vascular tumors of
the breast, the hemangiomas.
Most of the breast hemangiomas in our series appeared on mammography as
oval or lobular isodense masses with well-circumscribed margins, similar to
the classic appearance of a hemangioma noted in previous case reports
[3,
6]. These findings are not
sufficiently specific and might explain the low incidence of diagnosed and
recognized breast hemangiomas, a significant number probably being classified
as BI-RADS category 3 and not differentiated from fibroadenomas or cysts
[10–12].
Although these lesions were superficial in location (subdermal or in the
subcutaneous tissues), this location made it difficult to visualize them on
regular craniocaudal and mediolateral oblique views; tangential views are
necessary to prove the superficial nature of the mass. Only one patient showed
a mass displaying benign round calcifications that were presumably related to
phleboliths. A few cases of hemangiomas displaying suspicious mammographic or
clinical features have been reported
[5,
13]. One article reports a
large palpable mass measuring 12 cm, occupying the lower quadrant of the left
breast, showing reddish discoloration of the overlying skin and nipple areolar
complex, and mimicking an inflammatory carcinoma
[5]. A second article reported
a spiculated mass on mammography, leading the radiologists to classify the
mass as BI-RADS category 5
[13]. In our series, no such
features were noted. Only one patient had calcifications in the mass. Fine,
punctuate, or phlebolith-type calcifications have been reported in breast
hemangiomas [3]. Although
calcifications are classic, their frequency has not been established. They can
be of the venous type because of phleboliths, or they may be coarse
[3].
As noted in several articles, the sonographic appearance of breast
hemangioma is variable. The shape and margins are usually consistent with
benign lesions and similar to the mammographic features. The lesions display
an ovoid shape with well-circumscribed margins (Fig.
1A,
1B,
1C). Microlobulations or
indistinct margins are less often seen; the latter have been associated with
hyperechoic lesions. The echotexture of hemangiomas is variable; one third
display a hyperechoic echotexture and two thirds display an isoechoic (to the
fat), hypoechoic, or complex echotexture. Interestingly, the echotexture is
complex in a significant number of cases (Fig.
1A,
1B,
1C). This relative echotextural
heterogeneity may be related to the presence of multiple small vascular
channels seen pathologically in hemangiomas (large blood-filled spaces or
sinuses being seen in cavernous hemangiomas)
[3,
7]. The isoechoic or slightly
hypoechoic appearances likely explain the difficulty in identifying such
lesions against a fatty background. For this reason, hemangiomas are less
conspicuous sonographically than they are clinically or mammographically
[7]. This characteristic might
account for the invisibility of the lesions on sonography in seven of our
patients, despite these lesions being readily visible on mammography as
well-defined masses surrounded by fatty tissue. In such cases, the knowledge
of the superficial location of the lesion alerts the radiologist to focus the
examination on the subcutaneous region (adequate focus positioning), which
allows better identification of the lesions. In addition, the use of specific
settings on sonography, such as tissue harmonic imaging, increases the
visibility of such lesions against a fatty background
[14] (Fig.
2A,
2B,
2C).
Superficial location is another characteristic of these lesions. The
subcutaneous location may theoretically help to select the correct diagnosis
from the differential diagnosis, which includes hematoma, hemangioma, and
sebaceous cyst [6]. To
ascertain the subcutaneous location, the mass must be located anterior to the
superficial pectoralis fascia
[15], which is often difficult
to visualize. In our study, the lesions appeared superficial and were presumed
to be in the subcutaneous tissue even though the superficial pectoralis fascia
was not visualized.
Complete excision is usually recommended when a hemangioma is diagnosed at
biopsy. The two main reasons for excision would be to exclude the possibility
of an underlying angiosarcoma and to avoid progression to angiosarcoma. On one
hand, imaging-guided biopsy appears sufficiently reliable to rule out any
malignant or premalignant component; therefore, if no
pathologic–radiologic discordance is noted, the diagnosis of
angiosarcoma can probably be excluded. On the other hand, progression of
hemangioma to angiosarcoma has been reported but is controversial
[16]. Because microscopic
hemangioma shows a relatively high incidence at autopsy (11%)
[17] and because the incidence
of angiosarcoma is extremely low, progression of hemangiomas to angiosarcoma
is extremely rare if it exists at all.
Hence, although needle biopsies may produce false-negative results, we
consider that a superficial breast mass displaying the classic mammographic
and sonographic appearances of a hemangioma and diagnosed as a hemangioma
(cavernous or capillary type, without atypia) by imaging-guided core biopsy,
can be followed up with periodic imaging surveillance without surgical
excision. Because of the established validity of mammographic surveillance,
follow-up with mammography alone at 12-month intervals for the first 2 years
should be sufficient to show stability.
Our study has some limitations. The small size of the population and the
retrospective nature of the study probably limit our results. Nevertheless,
although 25% of patients had no follow-up imaging, we emphasize the benefit of
imaging surveillance in the management of patients diagnosed with breast
hemangioma by imaging-guided biopsy if no discord exists among mammographic,
sonographic, and pathologic findings.
In conclusion, a mass displaying an oval or lobular shape, with
well-circumscribed or microlobulated margins on mammography and sonography,
and showing a superficial location should alert the radiologist to a possible
diagnosis of hemangioma. Imaging-guided biopsy appears to be sufficiently
reliable to rule out any malignant or premalignant component and to avoid
surgical excision in the absence of radiologic–pathologic
discordance.
References
- Jozefczyk MA, Rosen PP. Vascular tumors of the breast. II.
Perilobular hemangiomas and hemangiomas. Am J Surg
Pathol 1985; 9:491
–503[Medline]
- Rosen PP. Vascular tumors of the breast. V. Nonparenchymal
hemangiomas of mammary subcutaneous tissues. Am J Surg
Pathol 1985; 9:723
–729[Medline]
- Webb LA, Young JR. Case report: haemangioma of the
breast—appearances on mammography and ultrasound. Clin
Radiol 1996; 51:523
–524[CrossRef][Medline]
- Chung SY, Oh KK. Mammographic and sonographic findings of a breast
subcutaneous hemangioma. J Ultrasound Med2002; 21:585
–588[Free Full Text]
- Gopal SV, Nayak P, Dharanipragada K, Krishnamachari S. Breast
hemangioma simulating an inflammatory carcinoma. Breast
J 2005; 11:498
–499[CrossRef][Medline]
- Siewert B, Jacobs T, Baum JK. Sonographic evaluation of
subcutaneous hemangioma of the breast. AJR2002; 178:1025
–1027[Free Full Text]
- Glazebrook KN, Morton MJ, Reynolds C. Vascular tumors of the
breast: mammographic, sonographic, and MRI appearances.
AJR 2005; 184:331
–338[Free Full Text]
- American College of Radiology. Breast imaging reporting
and data system: breast imaging atlas, 4th ed. Reston, VA:
American College of Radiology, 2003
- Lesueur GC, Brown RW, Bhathal PS. Incidence of perilobular
hemangioma in the female breast. Arch Pathol Lab Med1983; 107:308
–310[Medline]
- Graf O, Helbich TH, Hopf G, Graf C, Sickles EA. Probably benign
breast masses at US: is follow-up an acceptable alternative to biopsy?
Radiology 2007;244
: 87–93[Abstract/Free Full Text]
- Sickles EA. Probably benign lesions: when should follow-up be
recommended and what is the optimal follow-up protocol?
Radiology 1999;213
: 11–14[Free Full Text]
- Graf O, Helbich TH, Fuchsjaeger MH, et al. Follow-up of palpable
circumscribed noncalcified solid breast masses at mammography and US: can
biopsy be averted? Radiology 2004;233
: 850–856[Abstract/Free Full Text]
- Mariscal A, Casas JD, Balliu E, Castella E. Breast hemangioma
mimicking carcinoma. Breast 2002;11
: 357–358[CrossRef][Medline]
- Mesurolle B, Helou T, El-Khoury M, Edwardes M, Sutton EJ, Kao E.
Tissue harmonic imaging, frequency compound imaging, and conventional imaging:
use and benefit in breast sonography. J Ultrasound Med2007; 26:1041
–1051[Abstract/Free Full Text]
- Fornage BD, McGavran MH, Duvic M, et al. Imaging of the skin with
20-MHz US. Radiology 1993;189
: 69–76[Abstract/Free Full Text]
- Rupec M, Batzenschlager I. Pseudoangiosarcoma (Masson): a
histological study [in German]. Z Hautkr1981; 56:1360
–1363[Medline]
- 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 Pathol1992; 16:553
–560[Medline]
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Abstract
Introduction
