Contrast-enhanced ultrasound features of breast capillary hemangioma: a case report and review of literature

Abstract

Breast capillary hemangioma is a rare benign vascular tumor. A 59‐year‐old asymptomatic woman underwent screening mammography and breast ultrasound. B-mode ultrasound revealed a lobulated, hypoechoic mass. Color Doppler ultrasound showed no intratumoral blood flow. Contrast-enhanced ultrasound (CEUS) revealed internal fast homogeneous contrast enhancement of the mass and persistent enhancement after 4 min. A 14‐gauge core needle biopsy was then performed. The radiologic and pathologic appearances were concordant with breast capillary hemangioma. The ultrasonic manifestations of breast hemangioma may vary, and differentiation from other inflammatory diseases and malignancies is challenging. CEUS may help in observing the vascular characteristics of breast capillary hemangioma.

Introduction

Breast vascular tumors are rarely found on breast imaging modalities, and most cases are either angiosarcomas or hemangiomas. Ultrasound (US), mammography, and MRI have been the mainstay for the investigation of these breast hemangiomas, although diagnosis with these modalities may be difficult [1]. Differentiation of breast hemangiomas from other fibrocystic diseases and malignancies is challenging on B-mode and color Doppler US. Contrast-enhanced ultrasound (CEUS) has shown efficacy superior to that of conventional US for the differential diagnosis of focal breast lesions without severe adverse reactions to intravenous contrast agents [2]. Little is known about the imaging features of breast capillary hemangioma on CEUS. This case report describes the CEUS findings of a breast capillary hemangioma.

Case report

A 54‐year‐old asymptomatic woman with a family history of breast cancer visited our institution for breast cancer screening. She had no specific medical history of breast disease. Screening digital breast tomosynthesis (DBT) and breast US were performed on the same day for this woman. DBT showed heterogeneously dense parenchyma and bilateral diffuse punctate microcalcifications. There was no definite mass visible on DBT. B-mode US and CEUS were performed with a US system (LOGIQ E9, GE Healthcare, Milwaukee, WI, USA) equipped with a linear transducer (6–15 MHz). The B-mode US revealed a 0.6‐cm hypoechoic lobulated mass in the right breast at the 1 o'clock position (Fig. 1a). Color Doppler US showed no intratumoral vascularity (Fig. 1b). There was no enlarged lymphadenopathy in either axillary area on US.

Fig. 1.

A 54‐year‐old asymptomatic woman with breast capillary hemangioma. a B-mode ultrasound presents a 0.6‐cm lobulated hypoechoic mass (arrow) in the right breast. b Color Doppler imaging shows a lack of intratumoral vascularity (arrow). c Contrast-enhanced ultrasound (CEUS) shows quick and homogeneous contrast enhancement within the mass (arrow). d Microscopic examination shows a picture of benign capillary proliferation composed of anastomosing capillary-sized blood vessels. Endothelial cells lining the vascular channels are highlighted by CD34 (immunoperoxidase, 200 ×)

She was considered to be an appropriate candidate for advanced examination using CEUS because of a positive family history. The woman received a single intravenous dose of sonazoid (Sonazoid; GE Healthcare, Oslo, Norway) at a dose of 0.12 μL of microbubbles/kg of body weight. Sonazoid injection was followed by a flush of 5 mL of 0.9% normal saline via the antecubital vein. CEUS showed homogeneous quick contrast enhancement and persistent enhancement after 4 min (Fig. 1c). US‐guided 14G core needle biopsy of the right breast mass was then performed. Pathology reported breast capillary hemangioma.

Histological sections showed capillary proliferation composed of anastomosing capillary-sized blood vessels with occasionally entrapped bland ductal epithelium and focal increased bland-looking stromal spindle cells. The prominent capillary-size vascular proliferation was decorated with positive CD31 and CD34 immunostaining (Fig. 1d), without endothelial cell nuclear atypia. The patient did not require surgical excision. She underwent clinical follow-up at our institution, and no interval change of breast US was found after 12 months.

Discussion

Breast hemangiomas have been reported as rare breast tumors that are only infrequently observed in women between 43 and 75 years of age, averaging around 59 years [3]. Hemangiomas are benign vascular tumors, which are classified into capillary or cavernous types based on the size of the involved vessels [3]. Capillary hemangioma is the most common type of hemangioma found in the breast; however, only a few cases of US images have been reported in the literature [3].

The most common mammographic feature of a breast hemangioma is a non-asymptomatic 0.6–2.5-cm oval mass during screening exam or progressive enlargement of previously screening-detected masses [3]. Calcifications in breast hemangiomas are uncommon and have variable imaging characteristics [3]. Mammographic findings are not specific for diagnosing breast hemangiomas, and the differential diagnoses on mammography include cysts, fibroadenomas, and benign-looking malignancies [4].

The most common type of lesion on B-mode US is a superficially located, hypoechoic, oval mass with a circumscribed margin [3]. The echogenicity of breast hemangiomas may make their diagnosis on a fatty background difficult [3]. The mass was found to be avascular on color Doppler US [3]. The mean longest diameter on B-mode US was 1.3 cm [3]. Breast hemangioma may be difficult to differentiate from fibroadenomas or complex cysts on US [5].

On MRI, breast hemangiomas typically present as circumscribed masses of intermediate signal intensity on T1 images and high signal intensity on T2 images [6]. On DCE-MRI, a capillary hemangioma could present as a small circumscribed mass with homogeneous fast enhancement and a washout or plateau type curve [6, 7]. Although morphological features on MRI suggest a benign lesion, its fast early enhancement is a concerning factor that cannot exclude breast malignancy [7].

There are several new technologies to assess the nature of focal breast lesions on ultrasound using computer-aided image analysis [8] or quantitative elastography [9]. US contrast agents consist of stable microbubbles, which enable the continuous real-time display of vascular imaging and tumor perfusion under low mechanical index settings [2]. Imaging features of CEUS can be used to differentiate between benign and malignant breast lesions [10]. Benign breast lesions are characterized by homogeneous enhancement, whereas breast cancers mainly show heterogeneous or peripheral rim-like hyperenhancement [10]. The prevalence of perfusion defects and peripheral radial or penetrating vessels is significantly higher in malignant than benign breast lesions [10]. A previous study revealed that the persistence of the contrast agent in the late phase (4–6 min) helps to differentiate between benign and malignant tumors [11]. Contrast enhancement in the late phase of CEUS was found in 88.9% of breast cancers, while in only 9.7% of benign lesions [11]. In our CEUS case, the breast capillary hemangioma presented with a homogeneously enhancing mass with rapid early enhancement and persistent enhancement after 4 min. The persistent enhancement may be related to the accumulation of microbubbles in the capillary channels. We found that the intratumoral vascularity detected between color Doppler and CEUS is quite different, which can be suggestive of a slow-flow vascular tumor, such as a capillary hemangioma.

Imaging-guided biopsy with adequate tissue appears to be sufficiently reliable in excluding malignancy [3]. The diagnosis of angiosarcoma cannot be excluded when imaging-pathologic discordance is noted [3]. Breast hemangioma usually shows a stable size or a decrease in size on mammography [3].

In conclusion, the manifestation of a breast capillary hemangioma on CEUS is a lobulated hypoechoic mass with rapid early enhancement and persistent late enhancement. Physicians should be aware of the imaging features of breast capillary hemangioma and consider it as one of their differential diagnoses.

Data availability statement

All data generated or analyzed during this study are included in this article.

Author contributions

CPC, JSH, JSW, and HPP contributed to the research and writing of this manuscript.

Funding

This work was supported by Grants from Kaohsiung Veterans Hospital Research Found (VGHKS109-146).

Compliance with ethical standards

Conflict of interest

Huay-Ben Pan and other co-authors have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed consent for publication

Written informed consent was obtained from the patient for the publication of this case report and accompanying images.