Breast hemangioma: The luminous innocuity

INTRODUCTION

Breast hemangiomas are rare radiological entities that require careful observation of their characteristic features to raise the possibility of this diagnosis. The same has been described in prior literature across various imaging modalities, with distinctive features identified on mammography, ultrasound, and even magnetic resonance imaging (MRI); however, imaging features in contrast-enhanced mammography (CEM) are not widely described. In this case report, we aim to highlight the features of the rare breast hemangioma, with emphasis on its imaging appearance on CEM.

CASE REPORT

A 41-year-old female presented to us with a palpable lump in the right breast for 1 month. A solid lesion, with the added history of recent palpability, warranted diagnostic mammography with contrast.

Mammogram and CEM revealed a high-density oval mass with circumscribed margins in the middle third of the inner central quadrant of the right breast measuring 1.8 × 1.4 cm [Figure 1]. Homogeneous, intense enhancement with high conspicuity and washout on delayed-phase images was also noted [Figure 2].

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Figure 1:

Diagnostic contrast-enhanced mammogram of a 41-year-old female presenting with a right breast lump. Bilateral low-energy (a) craniocaudal (CC) and (b) mediolateral oblique (MLO) views demonstrate a high-density oval mass with circumscribed margins in the middle third of the inner central quadrant of the right breast (solid yellow arrows). Bilateral recombined (c) CC and (d) MLO views demonstrate corresponding homogeneous intense enhancement of high conspicuity (solid pink arrows).

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Figure 2:

Contrast-enhanced mammogram of a 41-year-old female presenting with a right breast lump. Recombined (a) craniocaudal (CC) (solid yellow arrow), (b) mediolateral oblique (MLO), and (c) delayed-CC views demonstrate the washout kinetics (solid yellow arrow).

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Correlative targeted ultrasound revealed an oval hypoechoic parallel mass with circumscribed margins measuring 1.6 × 1.5 × 0.9 cm at the 2 o’clock position of the right breast, 2 cm from the nipple, with posterior acoustic enhancement, demonstrating significant internal vascularity and appearing soft on elastography [Figure 3].

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Figure 3:

Targeted ultrasound images of a 41-year-old female presenting with a right breast lump. (a) An oval hypoechoic parallel mass with circumscribed margins (solid yellow arrow) with posterior acoustic enhancement (solid red arrow) (b) demonstrating significant internal vascularity (solid pink arrow) and (c) appearing soft on elastography (circles).

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Ultrasound-guided biopsy of the same was performed, and histopathological analysis confirmed it to be consistent with a capillary hemangioma [Figure 4].

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Figure 4:

(a) 20x and (b) 40x Hematoxylin & eosin histopathology from the lumpectomy specimen shows capillary-sized vascular channels lined by endothelial cells (solid yellow arrow) with surrounding stroma demonstrating hyalinization and mild edema (solid pink arrow). No features of atypia, increased mitosis, or necrosis were noted, confirming a benign capillary hemangioma.

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DISCUSSION

Hemangiomas are rare vascular tumors in the breast with an incidence between 1.2% and 11% and occur at almost any age.^[1] They are typically superficial in location and therefore usually palpable.^[2,3] Hemangiomas are broadly classified into two types – Capillary or cavernous – based on the size of the vessels constituting the hemangioma, the larger caliber being the cavernous type and the smaller being the capillary type.^[4]

The mammogram commonly presents as an oval or irregular, equal-density mass with circumscribed margins. Occasionally, they may show characteristic phleboliths, which appear as hyperdense lesions on mammography and echogenic foci on ultrasound.^[4,5] On ultrasound, an oval hypoechoic solid mass with circumscribed margins, parallel orientation, and complex echotexture is the typical presentation. Color Doppler US often shows hypovascularity or, at times, even avascularity.^[6] Contrast-enhanced imaging studies, such as CEM or MRI, however, are known to demonstrate early diffuse enhancement, raising high suspicion for malignancy. They are generally T2 hyperintense and T1 hypointense with variable diffusion restriction.^[7] However, in the circumstance in which a biopsy is performed and the pathology results are benign, without atypia, and concordant with the imaging and clinical findings, surgical excision is not indicated, as in our case.^[5,8]

A very close differential that requires special attention during imaging and significantly impacts further management is angiosarcoma. Angiosarcoma is a malignant condition known for its aggressive clinical progression and demands immediate action. As clinical radiologists, our role is to identify features that favor a typically benign entity over a malignant one, such as angiosarcoma (e.g., size >2 cm, hypervascularity on color Doppler, irregular shape, and invasive growth pattern).^[5]

To the best of our knowledge, there are no reports in the published literature emphasizing the imaging features of CEM. Through this case report, we aim to shed light on this commonly imaged lesion in an uncommon location, with a distinct imaging appearance.

DIFFERENTIAL DIAGNOSIS OF BREAST HEMANGIOMA

As some of the imaging features may overlap with other familiar entities, a few possible differentials include

CONCLUSION

Breast hemangioma, though rare, is a benign condition that can closely mimic malignancies on imaging, often creating concern for both patients and clinicians. This case highlights the importance of correlating imaging findings with biopsy results to avoid unnecessary surgery and being aware of the presence of such entities. Recognizing its typical features and distinguishing it from aggressive conditions like angiosarcoma ensures appropriate, conservative management while reducing patient anxiety and overtreatment.

TWO TEACHING POINTS FROM THE CASE REPORT

1. Presence of an intensely enhancing mass with suspicious kinetics should warrant a biopsy with an acceptable benign differential of a possible hemangioma in mind.

2. Knowledge of the characteristic features, along with the ability to differentiate it from worrisome malignant counterparts such as angiosarcoma, is vital.