British Journal of Radiology (2006) 79, e177-e180
© 2006 British Institute of Radiology
doi: 10.1259/bjr/11217388
Cavernous haemangioma of the breast
S M Kim, MD
1
H H Kim, MD
1
H J Shin, MD
1
G Gong, MD
2 and
S-H Ahn, MD
3
Departments of 1Radiology 2Pathology 3General Surgery, , Asan Medial Center, University of Ulsan College of Medicine, 388-1 Pungnap-dong, Songpa-gu, Seoul 138-736, Korea
Correspondence: Hak Hee Kim, Department of Radiology, Asan Medial Center, University of Ulsan College of Medicine, 388-1 Pungnap-dong, Songpa-gu, Seoul 138-736, Korea; E-mail: hhkim{at}amc.seoul.kr.
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Abstract
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Vascular tumours of the breast are rare and most can be classified as either angiosarcomas or haemangiomas. Cavernous haemangiomas are the most common form of mammary haemangioma. We describe a case with unilateral whole breast involvement without associated calcifications, studied with mammography, ultrasound and MRI.
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Introduction
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Vascular tumours of the breast are rare and most can be classified as either angiosarcomas or haemangiomas [1–3]. Cavernous haemangiomas are the most common form of mammary haemangioma, but there are only a few published reports regarding this tumour. Most reported cases pertained to the localized form of mammary haemangioma [1, 4–6] and associated calcifications [1, 4–7]. In this study, we describe a case with unilateral whole breast involvement without associated calcifications, studied with mammography, ultrasound and MRI.
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Case report
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An 18-year-old woman came to our breast clinic outpatient department (OPD) complaining of an increase in the size of her left breast. She was nulliparous and had no prior history of breast disease. The breast enlargement was painless and was not associated with skin changes, nipple discharge, or fever. There was no history of breast trauma. A physical examination revealed a poorly defined, non-tender, moderately firm mass in the whole left breast. The left breast was approximately twice the size of the right breast. Bilateral mammography showed a huge, well-circumscribed and multi-lobulated isodensity mass in the left breast (Figure 1a
). On ultrasound, a poorly defined, multiseptated cystic mass replaced her left breast (Figure 1b). Ultrasound-guided needle aspiration of the mass yielded 15 ml of sanguinous fluid which was cytologically negative. After 3 months, the patient revisited our OPD complaining of greater increase in the size of her left breast associated with pain, reddish skin discolouration and a sensation of increased temperature. Ultrasound showed a slight increase in the size of the multiseptated cystic mass as well as associated diffuse skin thickening. The patient underwent a MRI scan to define the extent of the breast lesion as part of the surgical planning. The MRI scan showed an approximately 12 cm x 12 cm, multiseptated cystic mass with various signal intensities that occupied the bulk of the left breast (Figure 1c). The mass was surrounded by intact fat and did not involve the chest wall. The signal intensities of the cysts were various, i.e. isointense to high intensity on T1 weighted images with fat suppression (Figure 1d) and low to high on T2 weighted images (Figure 1c). Some cysts had a fluid-to-fluid level. After contrast enhancement with Gd-DTPA, the mass was slowly continuously enhanced in its peripheral portion (Figure 1e,f). Subcutaneous mastectomy and implant insertion was performed due to the size of the mass. The mastectomy specimen weighed 660 g and measured 14 cm x 13 cm x 6 cm. The majority of the breast was occupied by an ill-defined firm mass measuring 13.5 cm x 12 cm x 6 cm and consisting of numerous and variable-sized small cysts (Figure 1g). The cysts were between 0.1 cm and 4 cm in their greatest dimension and had a spongy appearance. The cystic spaces were filled with haemorrhagic fluid. Histopathological examination of the mass showed dilated vessels congested with red blood cells and lined with endothelial cells but without any atypical cells, thus suggesting cavernous haemangioma (Figure 1h).
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Figure 1. (a) Both mediolateral oblique mammograms show a well-circumscribed, multi-lobulated isodensity mass replacing the whole left breast (arrows). No calcification is seen. (b) Ultrasound shows a poorly defined, multiseptated cystic mass replacing her left breast. (c) T2 weighted and (d) pre-contrast T1 high resolution isotropic volume examination (3D T1 weighted gradient echo sequence with fat suppression) MR images at the same level reveal a 12 cm x 12 cm mass with various signal intense multiseptated cysts (arrows) occupying the bulk of the left breast. Some cysts had a fluid-to-fluid level (arrowhead). (e) Three-dimensional T1 weighted gradient echo sequence with fat suppression (subtraction) at 120 s after contrast injection shows heterogeneous enhancement in the peripheral portion of the mass (arrows) in the early phase. (f) Three-dimensional T1 weighted gradient echo sequence with fat suppression (subtraction) at 360 s after contrast injection shows heterogeneous enhancement in the peripheral portion of the mass (arrows) in the delayed phase. (g) Photomicrograph of a mastectomy specimen shows an ill-defined firm mass measuring 13.5 cm x 12 cm x 6 cm consisting of numerous and variable-sized small cysts (arrows). The cysts were 0.1 cm to 4 cm in their greatest dimension and had a spongy appearance. The cystic spaces were filled with haemorrhagic fluid. (h) Photomicrograph of a mastectomy specimen shows dilated vessels (arrows) congested with red blood cells and lined with endothelial cells but without any atypical cells, thus suggesting cavernous haemangioma (haematoxylin and eosin x40).
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Discussion
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Haemangiomas are benign vascular tumours that are usually identified incidentally during histological examination of specimens obtained during lumpectomy or mastectomy [8]. They can occur in patients ranging in age from 18 months to 82 years [2]. There is also no predilection for any particular location in the breast [2]. Grossly, haemangiomas tend to be well-circumscribed [2]. This lesion is typically described as a dark red or brown circumscribed mass that may grossly appear to be spongy [2]. Most haemangiomas have well-circumscribed borders grossly, but microscopically the vascular channels may blend with the surrounding breast parenchyma [2]. Microscopic examination reveals dilated vessels congested with red blood cells, separated by fibrous septa, and with extensive fibrosis and sometimes with phleboliths [2, 7].
The reported mammographic appearance of a cavernous haemangioma is of a well-defined, lobulated mass that may have fine or coarse calcifications [1, 4–7]. Coarse or egg-shell macrocalcifications indicate phleboliths. However, in our patient, the mass had no calcifications and appeared to be well-defined, large, and involving a unilateral whole breast.
On ultrasound, the cavernous haemangioma was a well-defined, solid, mainly hypoechoic lesion containing small, bright echoes consistent with areas of calcifications [4, 6] or cystic septated lesions with an echogenic area of calcification [7]. Our case had similar ultrasound features of the latter with mutiseptated cystic lesions, but without associated calcification.
Cavernous haemangiomas may present as masses, depending on their size and location, but most palpable and symptomatic vascular tumours are angiosarcomas [8]. In our case, haemangioma was large enough to be clinically palpable. Symptomatic vascular tumours of the breast are regarded as angiosacoma unless otherwise proven [3]. In the treatment of cavernous haemangioma, excision is recommended to exclude the possibility of an underlying malignant lesion [9]. Re-excision of the biopsy site may be indicated if it appears that a substantial portion of the lesion has not been extirpated [2]. Further surgery is not necessary if only a few peripheral capillaries extend to the margin of excision [2]. However, as in our case the lesion was very large and involved the unilateral whole breast, subcutaneous mastectomy was indicated. In order to reduce the possibility of recurrence of haemangiomas, it is important to determine their size and extent prior to treatment. Because MRI provides great soft-tissue contrast in haemangiomas, MRI was used to assess the extent of haemangioma in young women [10] and to assess the relationship of the haemangioma to the breast bud in infantile and immature breasts [11]. There is another report of multiple mammary haemangiomas demonstrated by MRI in the breast of a 41-year-old woman with Kasabach-Merritt syndrome [7]. On T2 weighted sequences, it was of high signal with well-defined borders, the high signal presumably being related to slow flowing blood [7, 10]. On unenhanced spoiled gradient-echo images isointense to the glandular tissue, some were hyperintense, presumably because of thrombosis [7]. In our case, the tumour had various signal intensities, mainly low on both T1 and T2 weighted sequences, presumably because of the different stages of thrombosis. On the post-contrast sequence, focal areas of intense enhancement simulating malignancy were seen which on histology undoubtedly represented areas of capillary haemangioma [10] or the haemangioma filling slowly, with some filling only partially 30 min after the gadopetetate dimeglumin administration [7]. Also in our case, the tumour filled slowly, especially in the peripheral area, and there was no area of intense enhancement simulating malignancy.
In most of the reported cases, mammography was helpful in diagnosing haemangiomas because of the phleboliths they contain, but our patient had no phleboliths. In this case, MRI was useful in characterizing of the mass and for evaluating its extent.
Received for publication September 26, 2005.
Revision received December 27, 2005.
Accepted for publication January 19, 2006.
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References
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- Dener C, Sengul N, Tez S, Caydere M. Haemangiomas of the breast. Eur J Surg 2000;166:977–9.[CrossRef][Medline]
- Rosen PP. Rosen's breast pathology, 2nd edn. Lippincott Williams & Wilkins, 2001:789–97
- Sebek BA. Cavernous hemangioma of the female breast. Cleve Clin Q 1984;51:471–4.[Medline]
- Webb LA, Young JR. Case report: haemangioma of the breast-appearances on mammography and ultrasound. Clin Radiol 1996;51:523–4.[CrossRef][Medline]
- Markopoulos C, Sampalis F, Gogas H, Despotidis P, Kyriakou V. Cavernous haemangioma of the breast. A case report. Eur J Gynaecol Oncol 1998;19:246–8.[Medline]
- Carreira C, Romero C, Rodriguez R, Martin de Francisco J, Urbasos M, Pinto J. A cavernous haemangioma of breast in male: radiological-pathological correlation. Eur Radiol 2001;11:292–4.[CrossRef][Medline]
- Courcoutsakis NA, Hill SC, Chow CK, Gralnick H. Breast hemangiomas in a patient with Kasabach-Merritt syndrome: imaging findings. AJR Am J Roentgenol 1997;169:1397–9.[Free Full Text]
- Mesurolle B, Wexler M, Halwani F, Aldis A, Veksler A, Kao E. Cavernous hemangioma of the breast: mammographic and sonographic findings and follow-up in a patient receiving hormone-replacement therapy. J Clin Ultrasound 2003;31:430–6.[CrossRef][Medline]
- Kinoshita S, Kyoda S, Tsuboi K, et al. Huge cavernous hemangioma arising in a male breast. Breast Cancer 2005;12:231–3.[CrossRef][Medline]
- Vuorela AL. MRI of breast hemangioma. J Comput Assist Tomogr 1998;22:1009–10.[CrossRef][Medline]
- Miaux Y, Lemarchand-Venencie F, Cyna-Gorse F, et al. MR imaging of breast hemangioma in female infants. Pediatr Radiol 1992;22:463–4.[CrossRef][Medline]
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Abstract
Introduction
