British Journal of Radiology (2006) 79, e114-e116
© 2006 British Institute of Radiology
doi: 10.1259/bjr/33156239
Hydatid cysts in breast: mammography and ultrasound findings
N Tutar, MD
B Cakir, MD
E Geyik, MD
N C Tarhan, MD
and
E A Niron, MD
Baskent University Faculty Of Medicine, Radiology Department, Fevzi Cakmak Cad, 10. sok, No:45, Bahcelievler, 06490, Ankara, Turkey
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Abstract
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A case of a 48-year-old woman with hydatid disease of the breast is presented. The ultrasound and mammogram findings are shown and an uncommon ultrasound appearance of hydatid cyst in the breast is discussed.
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Introduction
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Hydatid disease due to Echinococcus granulosus is endemic in sheep-raising countries, parts of Africa, Australia, New Zealand, and South America [1–4]. The definitive host of the parasite is dogs, whereas intermediate hosts are sheep and other ruminants [2, 3]. Echinococcus granulosus is the most common cause of hydatid disease in humans. The location is mostly in the liver (75%) and lungs (15%), with only 10% occurring in other parts of the body [1–6]. Although more frequent reports have appeared in recent years, hydatid disease of the breast still remains rare and accounts for only 0.2% of all occurrences [2, 3, 5–7]. The classical mammographic and ultrasound findings of breast hydatid disease have been discussed [2, 3, 5, 6, 8, 9]. Here we describe an uncommon presentation of hydatid cyst in breast.
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Case report
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A 48-year-old woman was referred to our hospital for diagnostic mammography. She complained of palpable masses in both breasts. There was no associated pain, no nipple discharge, no fever and no family history of breast cancer. On her mammograms, there were two masses in her left breast (Figure 1a,b
). The first mass was in the retroareolar region, with minimal lobulated contours and a heterogeneous pattern in which some membrane-like tubular structures were seen. It had peripheral calcification and measured 20 mm (Figure 1c). The second mass was located in the upper outer quadrant and its contour was partially obscured by the normal breast tissue. This second mass measured 25 mm (Figure 1a,b). Both masses were benign. On ultrasound examination (VFX9-4 MHz Multi-D probe; Siemens Sonoline Antares, Erlangen, Germany), both lesions were well circumscribed and had curvilinear hypoechogenic band-like structures that were collected together without cystic fluid. They were solid lesions. The smaller one had partial peripheral calcifications (Figure 2). Doppler ultrasound imaging showed no vascularity in either lesion. The ultrasound appearance of both lesions was felt to be compatible with a trapped germinal layer within the cyst.
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Figure 1. (a) 48-year-old woman with palpable left breast lumps. Diagnostic mammogram, left mediolateral oblique (MLO) view. Mass in retroareolar region with peripheral calcification and mass in superior aspect with obscured margins within normal breast tissue. (b) Diagnostic mammogram, left caudocranial (CC) view showing same masses. (c) Diagnostic mammogram, left MLO, magnified view showing the lesion with peripheral multiple calcifications.
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Figure 2. (a) Breast ultrasound performed with SieScape imaging shows well-circumscribed lesion in retroareolar region with posterior acoustic shadowing on both sides due to calcification. Germinal layer is trapped inside without cyst fluid representing the "congealed waterlily sign". (b) Breast ultrasound performed with SieScape imaging shows second lesion in the upper outer quadrant of the left breast.
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The patient was diagnosed as having hydatid disease and referred to the general surgery department. Physical examination revealed two painless masses with clearly defined margins in the left breast. The laboratory findings were consistent with hydatidosis. After a 6 week course of albendazole treatment, ultrasound imaging showed no obvious changes in the size and shape of the lesions. At this time, the masses were excised and pathologic examination confirmed the radiological diagnosis.
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Discussion
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Echinococcus granulosus is a serious problem in sheep- and cattle-raising countries. Although hydatid disease of the breast is extremely rare, it can be the only primary site or part of disseminated hydatidosis [1, 2, 4–7]. Screening modalities for diagnosis of breast hydatid disease are ultrasound, mammography and MRI, but for classification of the cysts ultrasound is considered the method of choice [1–4]. Mammography shows a non-specific, homogeneous, smooth, circumscribed lesion [3, 5, 6, 8]. The characteristic ring-shaped structures inside the mass can be seen in overpenetrated views as previously described [8]. These structures are due to the differences in the densities of the walls or the contents of the daughter cysts within the main cyst [8]. If these structures are not seen, then the differential diagnosis includes cyst, fibroadenoma, phylloides tumour and, rarely, circumscribed carcinoma [3, 6, 8]. MRI may suggest a hydatid cyst of the breast unless the results of a physical examination are suggestive of a breast abscess, which demonstrates similar MRI findings [2, 3, 6, 8].
Gharbi and coworkers have described five types of ultrasound findings for the hydatid cyst including pure fluid collection (type 1), fluid collection with a split wall (type 2), fluid collection with septa (type 3), heterogeneous echo patterns (type 4) and reflecting thick walls (type 5) [9]. Durr-e-Sabih and colleagues have described another pattern called "congealed waterlily sign" where the hydatid fluid changes from watery to viscid gel, giving rise to the appearance of curvilinear structures to intact folds of the germinal layer, which are trapped within the viscid matrix. They also pointed out that this sign was reliable and strongly suggestive of hydatid cysts [5]. Our case demonstrated similar findings to those of Durr-e-Sabih in the liver and, to our knowledge, this is the first report describing these specific findings in the breast. It is important to include hydatid cyst in the differential diagnosis of painless and mammographically benign masses, especially in countries where the disease is endemic.
Although mammogram, ultrasound, MRI and serological tests such as Casoni's test can be carried out, fine needle aspiration cytology can provide a safe pre-operative diagnosis [4]. Complete excision of the cyst is the curative procedure for hydatid cyst of the breast [4, 7].
Depending on the literature, the mammographic signs of breast Echinococcus are non-specific and are similar to those of other benign lesions. Hydatid disease of the breast is extremely rare, but should be included in the differential diagnosis for breast masses. In our patient, screening mammography and ultrasound made the initial diagnosis.
Received for publication March 15, 2005.
Revision received May 24, 2005.
Accepted for publication June 7, 2005.
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References
|
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- el-Tahir MI, Omojola MF, Malatani T, al-Saigh AH, Ogunbiyi OA. Hydatid disease of the liver: evaluation of ultrasound and computed tomography. Br J Radiol 1992;65:390–2.[Abstract/Free Full Text]
- Engin G, Acunas B, Rozanes I, Acunas G. Hydatid disease with unusual localization. Eur Radiol 2000;10:1904–12.[CrossRef][Medline]
- Kiresi DA, Karabacakoglu A, Odev K, Karakose S. Uncommon locations of hydatid cysts. Acta Radiol 2003;44:622–36.[Medline]
- Das DK, Choudhury U. Hydatid disease: an unusual breast lump. J Indian Med Assoc 2002;100:327–8.[Medline]
- Durr-e-Sabih, Sabih Z, Khan AN. "Congealed waterlily" sign: a new sonographic sign of liver hydatid cyst. J Clin Ultrasound 1996;24:297–303.[CrossRef][Medline]
- Acar T, Gomcel Y, Guzel K, Yazgan A, Aydin R. Isolated hydatid cyst of the breast. Scott Med J 2003;48:52–3.[Medline]
- Erkan N, Haciyanli M, Yildirim M, Yilmaz C. A case report of the unusual presence of hydatid disease in the pancreas and breast. JOP 2004;10:368–72.
- Vega A, Ortega E, Cavada A, Garijo F. Hydatid cyst of the breast: mammographic findings. AJR Am J Roentgenol 1994;162:825–6.[Free Full Text]
- Gharbi HA, Hassine W, Brauner MW, Dupuch K. Ultrasound examination of the hydatic liver. Radiology 1981;139:459–63.[Abstract/Free Full Text]
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Abstract
Introduction
