Sonographic and Mammographic Appearances of Breast Hemangioma

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1 Women s Imaging Clinical Observations Mesurolle et al. Sonography and Mammography of reast Hemangioma Women s Imaging Clinical Observations WOMEN S IMGING enoît Mesurolle 1 Vitaly Sygal 1 Lucie Lalonde 2 ndré Lisbona 3 Michel-Pierre Dufresne 4 Jean H. Gagnon 1 Ellen Kao 1 Mesurolle, Sygal V, Lalonde L, et al. Keywords: breast tumor, hemangioma, mammography, sonography DOI: /JR Received September 14, 2007; accepted after revision January 29, Department of Radiology, Cedar reast Clinic, McGill University Health Center, Royal Victoria Hospital, 687 Pine ve. W, Montréal, PQ H3G 14, Canada. ddress correspondence to. Mesurolle (bmesurolle@yahoo.fr). 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. Davis-Jewish General Hospital, Montréal, PQ, Canada. 4 Département de Radiologie, Hôpital Maisonneuve- Rosemont, Montréal, PQ, Canada. CME This article is available for CME credit. See for more information. WE This is a Web exclusive article. JR 2008; 191:W17 W X/08/1911 W17 merican Roentgen Ray Society Sonographic and Mammographic ppearances of reast Hemangioma OJECTIVE. The purpose of our study was to retrospectively evaluate the clinical, imaging, and pathologic findings of breast hemangiomas in 16 patients. CONCLUSION. 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. H emangiomas 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. 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). 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, 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. pproval 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 merican College of Radiology reast Imaging Reporting and Data System (I-RDS) [8]. Mammographic findings are shown in Figures 1 4. Sonographic Findings reast sonography was performed to evaluate specific abnormalities discovered either at clinical examination or on mammography. ll 16 patients under went a breast sonographic examination (Figs. 1 4), but a mass was sonographically de tected in only nine patients (Figs. 1 3). The sono graphic characteristics of the nine masses were assessed according to the merican College of Radiology I-RDS criteria [8]. Studies were reviewed on hard-copy films (five patients) or on PCS images (four patients). Core Needle iopsy Fifteen patients underwent an imaging-guided core needle biopsy. One patient underwent surgical excision without preoperative biopsy. iopsy 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, JR:191, July 2008 W17

2 Mesurolle et al. C Fig. 1 symptomatic 75-year-old woman., Right mediolateral oblique mammogram shows 0.8-cm mass in superior aspect of breast. Mass (arrow) displays lobular shape and circumscribed margins., Close-up view of mass, also in right mediolateral oblique orientation. C, reast 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. C Fig. 2 symptomatic 62-year-old woman. and, 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 (). C, reast 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. W18 JR:191, July 2008

3 Sonography and Mammography of reast Hemangioma Fig year-old woman with palpable mass in lateral aspect of left breast. and, Left craniocaudal close-up image () and left mediolateral oblique image () show mass (arrow) displaying irregular shape and microlobulated margin and having no microcalcifications. C, reast 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. Fig. 4 symptomatic 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. reast sonogram did not identify any mass. Stereotactically guided biopsy using 14-gauge needle yielded cavernous hemangioma., Follow-up right craniocaudal close-up mammogram obtained 2 years later shows 0.7-cm mass (arrow). Siemens Medical Sys tems; high-frequency Matrix trans ducer PLT1204X, plio, Toshiba; model 700, GE Healthcare; and HDL, TL) (n = 8). Generally, 10- to 15-MHz transducers were used. Fourteengauge 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 screeningdetected 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 I-RDS 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, 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. 1 and 2). One patient had punctate microcalcifications in a mass (Fig. 4). Sonographic Findings Sonographic findings are summarized in Table 2. Nine masses were identified at sonographic examination (Figs. 1 3). The mean sono graphic size was 1.3 cm (range, 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. 3). Pathologic Findings Final pathologic examination identified 14 cavernous-type hemangiomas and two capillary-type hemangiomas. mong the four patients who underwent excisional biopsy, no malignancy was diagnosed. Surgical excision confirmed the diagnosis of hemangioma C JR:191, July 2008 W19

4 Mesurolle et al. Lesion Size (cm) No. of Lesions TLE 1: Mammographic Characteristics of 15 Hemangiomas ccording to I-RDS Lexicon [8] Mass Characteristic No. % Shape Round Oval Lobular Irregular Margins Circumscribed Microlobulated Obscured 0 0 Indistinct 0 0 Spiculated 0 0 Density High Equal Low 0 0 Fat 0 0 Calcifications in three patients and established the diagnosis in one patient Fig. 5 Scatterplot shows size of 15 masses that were visible on mammography. TLE 2: Sonographic Characteristics of Nine Hemangiomas ccording to I-RDS Lexicon [8] Mass Characteristic No. % Shape Irregular 1 11 Round 0 0 Oval 8 89 Margins Circumscribed 5 56 Microlobulated 2 22 ngular 0 0 Spiculated 0 0 Indistinct 2 22 Orientation Parallel Not parallel 0 0 Lesion boundary brupt interface Echogenic halo 0 0 Echo pattern Hypoechoic 2 22 Isoechoic 1 11 Hyperechoic 3 33 Complex 3 33 Surveillance Four patients (25%) underwent surgical excisional biopsy (Figs. 1 and 3). Eight patients (50%) underwent mammographic surveillance and were followed up for a mean of 3.7 years (range, 2 6 years) (Figs. 2 and 4). mong 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. mong a subgroup of patients referred for increase in size of a previously screeningdetected 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. reast 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 I-RDS category 3 and not differentiated from fibroadenomas or cysts [10 12]. lthough 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. 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]. second article reported a spiculated mass on mammography, leading the radiologists to classify the mass as I-RDS 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]. lthough 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]. s 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. 1). Microlobulations or indistinct margins are less often seen; the latter have W20 JR:191, July 2008

5 Sonography and Mammography of reast Hemangioma Lesion Size (cm) No. of Lesions 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. 1). 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. 2). 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 Fig. 6 Scatterplot shows size of nine masses that were visible on sonography. 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]. ecause 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. ecause 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 1. Jozefczyk M, Rosen PP. Vascular tumors of the breast. II. Perilobular hemangiomas and hemangiomas. m J Surg Pathol 1985; 9: Rosen PP. Vascular tumors of the breast. 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