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  Table of Contents  
LETTER TO THE EDITOR
Year : 2015  |  Volume : 52  |  Issue : 3  |  Page : 357-358
 

Granulomatous mastitis and angiosarcoma of the breast masquerading as non-mass enhancement


1 Department of Radiodiagnosis, Tata Memorial Centre, Mumbai, Maharashtra, India
2 Department of Radiodiagnosis, Tata Memorial Centre, Mumbai, Maharashtra, India; Department of Imaging Sciences and Biomedical Engineering, Kings College, London, UK
3 Department of Pathology, Tata Memorial Centre, Mumbai, Maharashtra, India

Date of Web Publication18-Feb-2016

Correspondence Address:
M Abhishek
Department of Radiodiagnosis, Tata Memorial Centre, Mumbai, Maharashtra, India; Department of Imaging Sciences and Biomedical Engineering, Kings College, London, UK

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.176723

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How to cite this article:
Subhash R, Abhishek M, Tanuja S, Meenakshi H T. Granulomatous mastitis and angiosarcoma of the breast masquerading as non-mass enhancement. Indian J Cancer 2015;52:357-8

How to cite this URL:
Subhash R, Abhishek M, Tanuja S, Meenakshi H T. Granulomatous mastitis and angiosarcoma of the breast masquerading as non-mass enhancement. Indian J Cancer [serial online] 2015 [cited 2019 Jun 26];52:357-8. Available from: http://www.indianjcancer.com/text.asp?2015/52/3/357/176723


Sir,

Non-mass enhancement (NME) is rare reported finding in granulomatous mastitis and angiosarcoma making these entities a diagnostic dilemma.[1] We herein present two pathology proven unusual cases of NME due to granulomatous mastitis and angiosarcoma, respectively.

A 29-year-old patient treated case of meningioma, presented with left breast lump since 1 month. Clinical breast examination revealed confluent lumps at 7–9'o clock in left Breast. Digital mammography revealed a focal asymmetry in the left lower inner quadrant [Figure 1]a. Volumetric breast density was increased in left breast (20% vs. 16% in right breast). Targeted ultrasonography was performed, which showed dilated tubular structures with moving internal echoes within. Ultrasound elastography revealed soft mass with maintained elasticity [Figure 1]a. Magnetic resonance imaging (MRI) breast revealed an area of NME in left breast extending from 4 to 9' O clock region, which showed a Type-3 kinetic curve. Compared to contralateral normal breast parenchyma, the NME region showed restricted diffusion with decreased signal intensity on apparent diffusion coefficient map. H 1-magnetic resonance spectroscopy showed a prominent lipid lactate peak with no e/o choline peak [Figure 1]b. Second look ultrasonography reconfirmed the findings. A biopsy was performed, and the histopathology revealed dense chronic inflammation and granulomas obscuring normal breast parenchyma. On high power microscopy, granuloma with central liquefaction and polymorphs and collar of epithelioid histiocytes were seen. Immunohistochemistry for cytokeratin revealed remnant of epithelium in the center of these granulomas indicating their terminal duct lobular unit distribution [Figure 1]c. The final diagnosis was granulomatous mastitis. The patient was treated with antibiotics for 4 weeks.
Figure 1: A 29-year-old patient treated case of meningioma, presented with left breast lump since 1 month, (a) digital mammography showing focal asymmetry in the left lower inner quadrant (star). Ultrasound with elastography showing dilated tubular structures with moving internal echoes and soft mass with maintained elasticity, (b) magnetic resonance imaging breast revealed an area of nonmass enhancement in left breast (plus) which showed a Type-3 kinetic curve with restricted diffusion with decreased signal intensity on apparent diffusion coefficient map, (c) higher power of the granuloma with central liquefaction and polymorphs and collar of epithelioid histiocytes (H and E, ×200). Immunohistochemistry for cytokeratin revealed remnant of epithelium in center of these granulomas indicating their terminal ductolobular unit (ABC, ×100)

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A 50-year-old patient presented with skin discoloration and painless right breast lump. Clinical breast examination revealed a lump in the lower outer quadrant on the right side. Mammography revealed a subtle focal asymmetry in right lower outer quadrant [Figure 2]a. Targeted ultrasonography revealed heterogeneously hyperechoic mass showing minimal vascularity on color Doppler imaging [Figure 2]a. MRI breast showed NME in the lower outer quadrant on the right side corresponding to the lesion noted on mammography and sonography, which showed Type-1 kinetic curve on dynamic contrast MRI [Figure 2]b. Excision Biopsy of the lump was performed, and histologic section revealed irregular vascular channels infiltrating breast parenchyma and immunohistochemistry for CD31 was positive for the vascular channels infiltrating breast parenchyma findings suggestive of angiosarcoma Intermediate grade [Figure 2]c.
Figure 2: A 50-year-old patient presented with skin discoloration and painless right breast lump. (a) Mammography revealed subtle focal asymmetry in right lower outer quadrant (star). Targeted ultrasonography revealed heterogeneously hyperechoic mass (arrow) showing minimal vascularity on color Doppler imaging (b) magnetic resonance imaging Breast showed nonmass enhancement in the lower outer quadrant on the right side (arrow) which showed Type-1 kinetic curve on dynamic contrast magnetic resonance imaging, (c) histologic section reveals irregular vascular channels infiltrating breast parenchyma (H and E, ×100). Immunohistochemistry for CD31 highlights the vascular channels infiltrating breast parenchyma (ABC, ×200)

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Both the above described cases highlight the importance of multimodality imaging in doubtful cases of NME. A variable pattern of these lesions makes them an important differential for NME appearance on MRI.[2] We see that morphology on conventional MRI and histopathology is indispensable in making a diagnosis of granulomatous mastitis.[3] Idiopathic granulomatous mastitis is known to be variable in both plain and postcontrast enhancement MRI, with the most frequent finding being focal or diffuse asymmetrical signal intensity that appears hypointense on T1W and hyperintense on T2W images with no significant perilesional mass effect. On postcontrast images, it shows nodular lesions with a mass-like ring or nodular enhancement or just NME on MRI.[3] Furthermore, the time-intensity curves are found to differ from patient to patient and from the lesion to lesion. Second case highlights the importance of a rare but important cause of NME, which may mimic a malignant etiology; however analysis of delayed images and the kinetic curve may reveal prolonged and persistent enhancement in angiosarcoma lesions, which is a characteristic finding.[4] The prolonged enhancement correlates with the pathological findings that reflect blood-filled vascular spaces and channels.[4] Thus, MRI helps as an important modality to identify and characterize such breast lesions.

 
  References Top

1.
Chadashvili T, Ghosh E, Fein-Zachary V, Mehta TS, Venkataraman S, Dialani V, et al. Nonmass enhancement on breast MRI: Review of patterns with radiologic-pathologic correlation and discussion of management. AJR Am J Roentgenol 2015;204:219-27.  Back to cited text no. 1
    
2.
Giess CS, Raza S, Birdwell RL. Patterns of nonmasslike enhancement at screening breast MR imaging of high-risk premenopausal women. Radiographics 2013;33:1343-60.  Back to cited text no. 2
    
3.
Dursun M, Yilmaz S, Yahyayev A, Salmaslioglu A, Yavuz E, Igci A, et al. Multimodality imaging features of idiopathic granulomatous mastitis: Outcome of 12 years of experience. Radiol Med 2012;117:529-38.  Back to cited text no. 3
    
4.
O'Neill AC, D'Arcy C, McDermott E, O'Doherty A, Quinn C, McNally S. Magnetic resonance imaging appearances in primary and secondary angiosarcoma of the breast. J Med Imaging Radiat Oncol 2014;58:208-12.  Back to cited text no. 4
    


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