Vascular abnormalities of the breast: A multimodality imaging approach to diagnosis

Transcription

1 Vascular abnormalities of the breast: A multimodality imaging approach to diagnosis Poster No.: C-0186 Congress: ECR 2014 Type: Educational Exhibit Authors: M. D. P. SANCHEZ-CAMACHO, A. Almenar, C. C. Romero, P M. Aguilar Angulo, O. Martin Ruiz, V. Segur Nieto ; TOLEDO/ 2 ES, BARCELONA/ES Keywords: Breast, Mammography, Ultrasound, MR, Biopsy, Diagnostic procedure, Aneurysms, Cancer, Hemangioma DOI: /ecr2014/C-0186 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 24

2 Learning objectives The purpose of our educational exhibit is to: 1. Describe the normal vascular anatomy of the breast and the normal imaging findings. 2. To identify key imaging features of arterial and venous disorders, benign and malignant vascular masses and mimic lesions. Background Vascular disorders of the breast represent a broad spectrum of conditions that may be encountered in breast imaging, including arterial and venous disorders and benign and malignant vascular masses. Understanding and assessing normal breast vasculature allows more accurate diagnosis of vascular disorders and masses. Normal anatomy and imaging appearance of breast The arterial supply to the breast is derived from branches of the internal thoracic artery, intercostal arteries, and the lateral thoracic artery. Superficially, arterial branches of the internal and lateral thoracic arteries arborize across the breast and send perforating branches deep into the breast parenchyma. The internal thoracic artery is the dominant artery supplying the breast (figure 1). The venous anatomy of the breast parallels the arterial anatomy in the deep breast tissues, with paired arterial and venous branches seen with posterior intercostal, axillary, and internal thoracic vascular pathways. Superficially, the venous anatomy is variable and does not accompany the arterial supply. Breast veins typically lack valves, and intramammary venous anastomoses are common. In general, veins are larger than arteries, but this may be a consequence of breast compression or gravitational effects during imaging. Veins that are not thrombosed are typically compressible. Arterial atherosclerotic calcification is usually pathognomonic for arteries, as venous calcifications in the breast are rare. Page 2 of 24

3 At ultrasonography, breast vessels are identified and differentiated on the basis of pulsatility, compressibility, and Doppler waveform analysis. Breast vessels are detectable in most female breasts, and arterial spectral Doppler analysis usually demonstrates a lowresistance waveform (figure 2). On contrast agent-enhanced MR images of the breast, vessels are recurrently encountered in predictable locations (figure 3). Multimodal imaging (mammography, B-mode and Doppler ultrasonography and magnetic resonance) plays an important role in the diagnosis and is often necessary to accurately diagnose several of these uncommon conditions. Classification ARTERIAL DISORDERS: Atherosclerosis Aneurysms Pseudoaneurysms VENOUS DISORDERS: Congestive heart failure Collateral venous flow Superficial thrombophlebitis BENIGN VASCULAR TUMORS: Hemangioma Lymphangioma Angiolipoma MALIGNANT VASCULAR TUMORS: Angiosarcoma Hemangiopericytoma Images for this section: Page 3 of 24

4 Fig. 1: Bilateral craniocaudal views show the internal (arrows) and lateral (arrowheads) thoracic vessels in medial and lateral margins of the breast. Veins are generally larger than arteries. Page 4 of 24

5 Fig. 2: Power Doppler sonogram (a) and spectral Doppler analysis (b) show an artery (arrow) with a low-resistence waveform and a continuous diastolic flow. Veins not thrombosed are typically compressible. Page 5 of 24

6 Fig. 3: Coronal (a) and axial (b) postcontrast MIP MR images show internal thoracic vessels (arrows) and lateral thoracic vessels (arrowheads). Differentiating arterial and venous branches is difficult. Page 6 of 24

7 Findings and procedure details Atherosclerosis Atherosclerotic calcifications in breast arteries are commonly encountered at mammography, usually with increased frequency in women past menopause. In mammogram, these calcifications typically appear as high-attenuation parallel lines in arterial vessel walls (figure 4). Atherosclerosis may be associated with an increased risk of coronary artery disease. Care must be taken to differentiate atherosclerosis from the casting-type ductal calcifications encountered in ductal carcinoma in situ (latter not associate vascular structure). Usually no treatment is suggested unless coronary artery disease is identified. Aneurysms True aneurysms in the breast are rare but should be included in the differential diagnosis of any breast mass. They are thought to be due to prior trauma and are composed of intima, media and adventitia layers. The diagnosis may be suspected with a slowly enlarging pulsatile mass (figure 5) and Doppler ultrasound is ideal for confirming the diagnosis (anechoic ovoid nodule with posterior acoustic enhancement and turbulent internal flow) (figure 6). They should be included in the differential diagnosis of any mass. Their treatment may include external compression, thrombin injection, coiling, and surgical repair. Pseudoaneurysms Page 7 of 24

8 They may be secondary to penetrating trauma, invasive procedures (figures 7, 8 and 9), spontaneous hemorrhage due to coagulopathies or uncontrolled hypertension, or vascular invasion by breast malignancy. Pseudoaneurysms are characterized by a defect in the intima and media layers. Doppler ultrasound is ideal for confirming the diagnosis: Anechoic ovoid nodule with posterior acoustic enhancement and turbulent internal flow Typical ''ying-yang'' sign (figure 7) Diameter increases with time by blood pressure Computed tomography in the setting of acute trauma Their treatment may include external compression (figures 10a and 10b), thrombin injection, coiling, and surgical repair (figure 10c). VENOUS DISORDERS: Superficial thrombophlebitis Mondor's disease is a benign, acute, self-limited breast condition. It is characterized by thrombophlebitis of the superficial veins of the chest wall (lateral thoracic, thoracoepigastric and superior epigastric veins). Incidence rates of 0.5% and 0.8% have been reported, but these studies included symptomatic patients and, therefore, do not reflect the true incidence of the disease in an asymptomatic population. The etiology or the pathogenesis of this condition is still not clear. Some postulated theories are direct trauma, biopsy or surgery breast, inflammatory process, systemic coagulopathies and breast cancer, leading to stasis of blood. Mondor's disease may present clinically as a focally painful and palpable cordlike structure, which may be associated with overlying skin retraction, dimpling or discoloration. Page 8 of 24

9 At mammography, the finding of a superficial tubular or beaded structure in the upper outer aspect of the breast may potentially be mistaken for a dilated duct, a finding that may lead to biopsy. At sonography, the thrombosed vessel appears as a superficially located, long, tubular, non-compressible, hypo- or anechoic structure with a beaded appearance, with or without flow on color Doppler, depending on degree of recanalization (figure 11). Sonography enables us to identify the entire course of the thrombosed vessel, which may not be visible in a mammographically dense breast. Patients are conservatively treated for pain with anti-inflammatory and analgesic drugs, warm compresses to the skin over the affected site and systemic intravenous rehydration. The main complication is a cosmetic deformity due to phlebosclerosis and hyalinization. BENIGN VASCULAR TUMORS: Hemangioma Breast hemangioma is a benign vascular tumor with a frequency of as much as 11% in postmortem specimens. The subtypes (capillary and cavernous) are based on the size of the vessels involved. It is more commonly found in women (about 3 times more) than men. Breast hemangiomas typically appear as a palpable mass, a screening detected mass, or an increase in size of a previously screening-detected mass. The most common mammographic features are oval or lobulated superficial masses, with circumscribed or microlobulated margins, size of cm and density similar to that of fibroglandular breast tissue (figures 12a, 12b and 12c). Calcifications are uncommon and the amount is variable. The sonographic appearance is characterized by an oval, solid, superficial with an abrupt interface mass, with circumscribed margins, parallel orientation, neutral sound transmission and without a perceptible capsule. Internal echotexture is variable and not a reliable distinguishing feature, usually hypoechoic, isoechoic, or complex (figure 12d). 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. Hypovascularity with a single vascular pole has been reported in benign Page 9 of 24

10 lesions, whereas hypervascularity with multiple peripheral poles or internal vessels has been reported in malignant lesions. The MR imaging features vary depending on the possibility of internal thrombosis, but they usually include an ovoid mass with circumscribed borders that is isointense to surrounding fibroglandular tissue on T1-weighted images and hyperintense on T2weighted images, presumably owing to slow flowing blood. Peripheral arterial enhancement may be seen with delayed central enhancement (fill-in) on contrast materialenhanced images. Imaging-guided core biopsy may be used to confirm the diagnosis, and excessive bleeding during core biopsy may be a clue. It appears sufficiently reliable to rule out any malignant or premalignant component and avoids surgical excision in the absence of radiologic-pathologic discordance. Complete excision as opposed to imaging follow-up is controversial. Masses with classic imaging and pathologic features are often followed up with imaging. Excision should be considered when the imaging or pathologic features are not classic, to exclude the possibility of angiosarcoma and to avoid progression to angiosarcoma. Angiolipoma A breast angiolipoma is an uncommon fat-containing tumor in which mature fat cells are intermixed with vascular proliferations. They account for 5%-17% of benign fatty tumors. However, angiolipomas uncommonly arise in the breast. They typically occur in the upper extremities, abdomen and back. The patients may have either palpable breast masses or nonpalpable mammographically depicted masses. There are usually no overlying skin changes. May manifest as painful masses, those occurring in the breast are typically painless. There is no typical mammographic appearance of angiolipomas. Nothing may be seen, or a density or a nodule may be noted at mammography. Ultrasonographic examination revealed an oval, solid, superficial, well defined, homogeneously hyperechoic mass, with parallel orientation, abrupt interface and neutral sound transmission, and without a perceptible capsule (figure 13). It can mimic a lipoma or fibroadenolipoma (hamartoma). Page 10 of 24

11 As these masses have no malignant potential, they can be followed up with imaging or surgical excision. MALIGNANT VASCULAR TUMORS: Angiosarcoma Angiosarcomas are malignant vascular tumors that result from neoplastic transformation of endothelial cells that line blood vessels. Although these tumors are rare, the breast is one of the more common locations in which they occur. They are classified as primary (most cases, originating sporadically) or secondary (developing after breast radiation therapy). Angiosarcoma of the breast is rare, accounting for 0.04% of malignant breast neoplasms and 8% of breast sarcomas. The annual incidence of mammary angiosarcoma is 5.8 per 10 million women. Although this is rare, the breast is one of the most common anatomic sites, affecting younger adults in the 3er and 4th decades of life. Breast angiosarcomas may be asymptomatic (10-15%) or present clinically as enlarging palpable mass (70%) that may show blue discoloration of the overlying skin (20-25%). The mammographic appearance is nonspecific. The more common findings are a large, oval or lobulated, noncalcified mass (50%), focal asymmetry or architectural distortion (30%), or not visible (20%). The sonographic appearance is characterized by a solid, well-circumscribed, oval or lobulated mass (60%), or abnormal mixed echotexture without a definable mass (40%). Usually, it is hypervascularity in color Doppler (figures 14 and 15). MR imaging usually shows a heterogeneous mass with low signal intensity on T1weighted, intermediate-to-high signal intensity on T2-weighted images and rapid initial heterogeneous enhancement with washout kinetic features at dynamic imaging (figures 14 and 16). Treatment usually starts with Mastectomy and chemotherapy. For small, grade 1 primary lesions, breast conservation therapy may be indicated. Page 11 of 24

12 The prognosis depends on the tumor grade and. Metastases occur most frequently to bones, lungs, liver and contralateral breast. Images for this section: Fig. 4: Bilateral mediolateral oblique mammograms show atherosclerotic calcifications (arrows) in a patient on chronic hemodialysis. Page 12 of 24

13 Fig. 5: Screening mammograms with a 2-year interval (a, b) show a fusiform aneurysm of the left lateral thoracic artery (arrows) with aneurysm growth in current mammogram (arrow in b). Close-up view of the aneurysm (c) with peripheral microcalcifications and its relationship with artery (arrowheads). Page 13 of 24

14 Fig. 6: Craniocaudal mammograms of the same patient show a new nodule (arrow in b) in inner quadrant of the right breast adjacent to an internal mammary vessel (arrowheads in b). Gray-scale and power Doppler sonograms (c, d) show an ovoid, anechoic mass with arterial internal flow, corresponding with a fusiform aneurysm of the internal mammary artery. Page 14 of 24

15 Fig. 7: (a) Bilateral mediolateral oblique views show a architectural distortion (arrow) in upper quadrants of the left breast, performing stereotactic biopsy (with bleeding in the procedure and histological features of radial scar). Four days later, the patient presented with a new onset palpable mass at the biopsy site. Gray-scale and color Doppler sonograms (b, c) show an oval, anechoic, 2 cm mass with posterior acoustic enhancement, turbulent internal flow and a typical ''ying-yang'' sign. Arterial pulse was demonstrated. Fig. 8: Magnetic resonance imaging study shows an oval mass with signal void (arrows) on coronal T1-weighted (a), T2-weighted (b) and TIRM (c) sequences. Coronal MIP image of a 3D subtracted dataset (d) shows a rounded, well-defined, enhancing lesion in upper quadrants of the left breast, corresponding to the indicated pseudoaneurysm (arrow). Page 15 of 24

16 Fig. 9: Postcontrast fat-suppressed T1-weighted (a) and subtracted (b) MR images from the dynamic series show the pseudoaneurysm. Time-signal intensity curve (c) of the lesion shows a type III time course. Fig. 10: Ultrasound-guided compression was determined. In successive controls, the pseudoaneurysm was partially thrombosed (arrows in a, b). Three months later, a metallic harpoon (arrowhead in c) was placed under ultrasonography guidance in the architectural distortion in upper quadrants of the left breast, adjacent to the residual Page 16 of 24

17 pseudoaneurysm (arrow in c). The excisional biopsy result was sclerosing radial scar with ductal hyperplasia and focal atypical hyperplasia. Fig. 11: Patient with a palpable and painful cord in lower external quadrant of the right breast. Ultrasound shows a non-compressible structure (thrombosed vein) (orange arrow) with lack of internal color Doppler flow (white arrow), compatible with superficial thrombophlebitis of the right thoracoepigastric vein. Page 17 of 24

18 Fig. 12: Patient with a palpable mass in the right breast. Mediolateral oblique, craniocaudal and true lateral mammograms show a lobulated, superficial, wellcircumscribed, 15 mm nodule (circles in a, b; metallic clip in c) with density similar to fibroglandular tissue in outer quadrants of the right breast. Ultrasound image (d) shows a circumscribed, oval, hypoechoic, hypovascular nodule without posterior acoustic phenomena. Ultrasound guided core needle biopsy results in low-grade vascular tumor, advising surgical removal, with the histologic diagnosis of thrombosed capillary angioma. Page 18 of 24

19 Fig. 13: Craniocaudal view in a screening mammography shows a oval, wellcircumscribed, 9 mm nodule with density similar to fibroglandular tissue in lower outer quadrant of the left breast (circles in a, b). Ultrasound image (c) shows a circumscribed, oval, superficial, hyperechoic with hypoechoic center nodule, with major axis parallel to the skin and without posterior acoustic phenomena, suggestive of lipoma versus Page 19 of 24

20 hemangioma. Ultrasound guided core needle biopsy results in adipose tissue which includes numerous vessels without atypia at the level of endothelium. Excisional biopsy (d) is recommended to rule out a low-grade angiosarcoma. The histologic diagnosis of the excisional biopsy is angiolipoma. Fig. 14: A 30-years-old patient with an area of increased consistency in upper inner quadrant of the left breast. Ultrasound shows normal glandular tissue (a), and skin thickening (arrowhead in b) and increased echogenicity of the underlying gland (arrow in b). Bilateral mediolateral oblique views (c) show asymmetric glandular tissue in left upper quadrants (arrow). Ultrasound guided core needle biopsy results in fibrosis and granulation tissue. The study is completed with magnetic resonance imaging. Postcontrast fat-suppressed T1-weighted (c) and subtracted (d) MR images from the Page 20 of 24

21 dynamic series show that the biopsy area corresponds to a 5 cm mass extending from retroareolar to left upper quadrants, that enhances intensely after contrast administration with suspicious curves. By the histopathologic and radiologic appearance, we recommend surgical biopsy of the lesion: poorly circumscribed tumor, compatible with angioma. Fig. 15: Patient presents new increase of consistency in upper quadrant of the left breast. Ultrasound (a, b) shows postsurgical changes and ill-defined, hypoechoic, vascularized area (arrow), surrounded by a lobulated echogenic halo (arrowheads), suggestive of recurrent angiomatous lesion. Bilateral mediolateral oblique views (c) show asymmetric glandular tissue in left upper quadrants (arrow). Page 21 of 24

22 Fig. 16: Magnetic resonance imaging study shows a heterogeneous multicenter mass (arrows) with intermediate-to-high signal intensity on coronal T2-weighted (a) and TIRM (b) sequences. Coronal MIP image of a 3D subtracted dataset (c) shows a rounded, welldefined, enhancing mass on the left breast (arrows). Postcontrast fat-suppressed T1weighted (d), positive enhancement integral map (e) and subtracted (f) MR images from the dynamic series show the corresponding area of tumour with intense enhancement after intravenous contrast medium. Time-signal intensity curve (g) of the lesion shows a type III time course. Left mastectomy result was well-differentiated (type I) angiosarcoma with infiltration of the skin. Page 22 of 24

23 Conclusion Vascular disorders of the breast may be seen with a variety of breast imaging modalities. Although most vascular breast pathologies are benign, timely differentiation from malignancy is critical. The imaging characteristics of benign vascular breast lesions facilitate differentiation from malignant entities. Knowledge of radiologic anatomy and imaging appearances of pathologic conditions affecting breast vasculature enables more accurate diagnosis and treatment planning and allow radiologists to have a more active role in breast care. Personal information References 1. Jesinger RA, Lattin GE Jr, Ballard EA, et al. Vascular abnormalities of the breast: arterial and venous disorders, vascular masses, and mimic lesions with radiologicpathologic correlation. Radiographics 2011; 31:E Glazebrook KN, Morton MJ, Reynolds C. Vascular tumors of the breast: mammographic, sonographic, and MRI appearances. AJR Am J Roentgenol. 2005; 184: Erdil I, Dursun M, Salmaslioglu A, et al. Pseudoaneurysm in the breast after core biopsy: doppler US and MRI findings. Breast J. 2010; 16: Shetty MK, Watson AB. Mondor's disease of the breast: sonographic and mammographic findings. AJR Am J Roentgenol. 2001; 177: Mesurolle B, Sygal V, Lalonde L, et al. Sonographic and mammographic appearances of breast hemangioma. AJR Am J Roentgenol. 2008; 191:W Kim SM, Kim HH, Shin HJ, et al. Cavernous haemangioma of the breast. Br J Radiol. 2006; 79:e Page 23 of 24

24 7. Weinstein SP, Conant EF, Acs G. Case 59: Angiolipoma of the breast. Radiology 2003; 227: Yang WT, Hennessy BT, Dryden MJ, et al. Mammary angiosarcomas: imaging findings in 24 patients. Radiology 2007; 242: Glazebrook KN, Magut MJ, Reynolds C. Angiosarcoma of the breast. AJR Am J Roentgenol. 2008; 190: Page 24 of 24