Giant mixed hemangioma of the breast: A case report with imaging findings

Abstract

Hemangioma of the breast is an uncommon tumor type that is usually small, superficially located, and impalpable. The majority of cases are cavernous hemangiomas. We describe a rare case of a large, palpable mixed hemangioma of the breast which was located in the parenchymal layer, studied with magnetic resonance imaging, mammography, and sonography. Magnetic resonance imaging findings of slow and persistent enhancement from the center to periphery are useful in characterizing benign breast hemangiomas, where even the lesion presents with a suspicious shape and margin on sonography.

Introduction

Hemangiomas of the breast are uncommon benign vascular lesions accounting for only 0.4% of all breast tumors [1]. Breast hemangiomas are generally superficial in location, and mostly small and impalpable [2]. The 2 common types, capillary and cavernous, are based on the size of the vessels involved [3]. Cases of mixed type hemangiomas have rarely been reported. The mammographic and sonographic appearances of breast hemangiomas have been described in many case reports, but reports regarding magnetic resonance imaging (MRI) findings are relatively uncommon.

Here, we report the case of a 25-year-old woman who had a mixed hemangioma that was large enough to be palpable and was located in the parenchymal layer of the breast, along with its mammography, ultrasonography, and MRI findings. The present case is unique in terms of its clinical presentation, radiological findings, and pathological subtype.

Case report

A 25-year-old woman with an unremarkable family history of breast cancer presented with a 2-week history of a palpable mass in her left breast. Physical examination revealed a 1.0 × 2.0-cm smooth, mobile mass in the upper medial quadrant of the left breast.

Digital mammography (Lorad Selenia, Hologic, Danbury, CT) was performed in the standard craniocaudal and mediolateral oblique positions. Mammography revealed a heterogeneously dense breast with a lobular low-density mass with partially obscured but mostly circumscribed margin in the upper inner quadrant of the left breast over the palpable area (Figs. 1A and B). No associated calcifications or areas of architectural distortion were observed.

Fig. 1.

Standard mammographic view. (A) The left craniocaudal and (B) mediolateral oblique mammogram shows a lobular isodense mass with obscured margin (arrows) over the palpable area.

On sonography, performed with an 18-4 MHz transducer using a real-time linear array unit (EPIQ 5, Philips Medical System, Bothell, WA), an irregular mass in the parenchymal layer at the 11-o'clock position of the left breast was found. The mass was heterogeneous in echotexture, with a long axis parallel to the skin and a margin that was partially indistinct and partially circumscribed (Fig. 2A). The lesion measured approximately 4 cm in the longest diameter. The mass did not show shadowing. Color Doppler sonography revealed minimal vascularity within the mass (Fig. 2B). Enlarged axillary lymph nodes were not detected.

Fig. 2.

Sonographic images. (A) Sonography reveals an irregular shaped, heterogeneous echoic mass with partially indistinct margin (arrows) and partially circumscribed margin (arrowheads). (B) Minimal internal vascularity is observed on color Doppler ultrasound.

Based on its margin and shape, the patient's breast mass was assessed as breast imaging reporting and data system category 4. An ultrasonography-guided 14-gauge core biopsy was performed, which revealed a capillary hemangioma. The core biopsy result was benign, but the patient was scheduled to undergo complete surgical excision due to the lesion size and patient discomfort.

Preoperatively, dynamic contrast-enhanced (DCE) breast MRI (Discovery, GE Healthcare, Chicago, IL) was performed to assess the extent of the hemangioma. MRI demonstrated a circumscribed oval mass with high signal intensity on a T2-weighted image, measuring 4.3 × 3.2 × 3.8 cm. (Fig. 3A). It exhibited intermediate signal intensity on T1-weighted image. Gadolinium-enhanced dynamic study revealed a slow initial and delayed persistent enhancement pattern with heterogeneous internal enhancement from the center to the periphery (Figs. 3B and C). Restricted diffusion was observed as a high signal on diffusion-weighted imaging with corresponding reduced apparent diffusion coefficient values.

Fig. 3.

Dynamic contrast-enhanced MR images. (A) T2-weighted image shows a circumscribed oval mass with high signal intensity. (B, C) T1-weighted imaging with fat suppression (subtraction) at 120 seconds (B) and 360 seconds (C) after contrast injection shows slow persistent and heterogeneous enhancement in the early and delayed phase, respectively.

Subsequently, complete surgical excision of the mass was performed. On gross examination, soft brown-to yellow lesions with irregular borders were identified. The lesion measured 4.5 × 2.5 × 1.5 cm. On microscopic examination with hematoxylin and eosin staining, the lesion was shown to consist of vascular channels, whose sizes varied from the large dilated cavernous type to the small capillary type (Figs. 4A and B). On immunohistochemical analysis, the tumor was positive for CD31, a sensitive and specific marker for hemangiomas (Fig. 4C). Thus, the patient was pathologically diagnosed with a mixed hemangioma.

Fig. 4.

Histopathological findings of a mixed hemangioma of the breast. (A) Low magnification view of the tumor demonstrats vascular channels of various sizes, ranging from the large dilated cavernous type to the small capillary type (hematoxylin and eosin, × 1.25). (B) Capillary and cavernous and spindle types are found on histological examination (× 100). (C) On immunohistochemical analysis, the lesion is positive for CD31 (× 40).

Discussion

Breast hemangiomas are usually subcutaneous vascular masses, and most intraparenchymal lesions are malignant angiosarcomas [4]. To date, a few cases of intraparenchymal hemangiomas of the breast have been reported [5], [6]–7]. Intraparenchymal hemangiomas measure 0.2-2.5 cm, with few lesions being larger than 1 cm [8]; thus, they are typically impalpable [2]. The majority of palpable and symptomatic vascular tumors of the breast are angiosarcomas [9]. Hemangiomas are divided into the capillary, cavernous, venous, and mixed types, depending on the size of their vascular channels [8]. There have been multiple case reports of cavernous breast hemangiomas [6,[10], [11], [12], [13], [14]–15], but only 2 reports of mixed hemangiomas [5,16]. One of which describes a mixed palpable hemangioma located in the parenchymal layer of the breast, similar to the current case [5].

The majority of the breast hemangiomas in previous articles appeared as oval or lobular masses with circumscribed or microlobulated margins on mammography and sonography [3]. Calcifications, known as phleboliths, may be seen within the mass, but are uncommon finding [3]. The mass in our case was similar to the classic appearance of a hemangioma on mammography, but showed an irregular shape and partially indistinct margin on sonography, which has rarely been reported previously [3,17]. According to the study by Mesurolle et al., indistinct margins have been associated with hyperechoic lesions [3]. Considering that study, the hyperechoic portion among heterogeneous echotexture of our mass might account for the indistinct margin. For this reason, the breast hemangioma in our case was less conspicuous on sonography than it was on mammography or MRI.

The MRI features of a hemangioma depend on its size. Large hemangiomas are often heterogeneous, presumably due to the different stages of internal thrombosis [7]. They appear as circumscribed masses, exhibiting a high signal intensity on T2-weighted imaging and intermediate signal intensity on T1-weighted imaging [15]. The MRI findings in the present case were consistent with these findings. The high signal intensity of hemangiomas on T2-weighted images is likely caused by the slow blood flow and thrombosis [7]. Various dynamic gadolinium-enhanced imaging patterns for breast hemangiomas have been described. Many previous articles have reported early intensive enhancement of breast hemangiomas followed by a plateau or wash-out kinetics, mimicking an invasive lesion [4], [5]–6,16,18]. Contrary to those prior articles, the mass in our case showed an early slow and delayed persistent enhancement. [7]. This is similar to a giant cavernous hemangioma of the breast, as reported by Kim et al., which was enhanced in the peripheral portion, but the present case showed gradual enhancement from center to periphery. There were no areas of intense enhancement simulating malignancy. To the best of our knowledge, no studies have shown this enhancement pattern of breast hemangiomas.

In this case, the differentiation between angiosarcomas and hemangiomas is more problematic due to the intraparenchymal location and large size of the mass. The indistinct margin and irregular shape of the mass on sonography can mimic an angiosarcoma, but minimal internal vascularity aids in distinguishing a hemangioma from an angiosarcoma, as hypervascularity is typically observed in angiosarcomas on color Doppler ultrasound [19,20]. On MRI, angiosarcomas present as a heterogeneous mass with variable kinetic enhancement, depending on the tumor grade [21]. Although lower grade angiosarcomas show persistent enhancement kinetics similar to our case, they are extremely vascular lesions compared to hemangiomas, showing more pronounce enhancement in the early arterial phase, and large draining veins, contrary to our case [21].

In conclusion, a palpable mass displaying an irregular shape, with indistinct margins on sonography, and showing an intraparenchymal location cannot be excluded as a breast hemangioma. In this case, MRI finding of the slow and persistent enhancement from center to periphery was useful in characterizing the benign breast hemangioma.

Patient consent

A written consent was obtained from the patient for publication of this case and any accompanying images.