DOI: 10.1148/radiol.2273011418
(Radiology 2003;227:773-775.)
© RSNA, 2003
Case 59: Angiolipoma of the Breast1
Susan P. Weinstein, MD,
Emily F. Conant, MD and
Geza Acs, MD
1 From the Department of Radiology, University of Pennsylvania Medical Center, 1 Silverstein Bldg, 3400 Spruce St, Philadelphia, PA 19104. Received August 24, 2001; revision requested October 1; revision received December 7; accepted January 7, 2002. Address correspondence to S.P.W.
Index terms: Angiolipoma, 00.314 • Breast neoplasms, US, 00.1298 • Diagnosis Please
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HISTORY
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A 70-year-old woman, with a medical history of breast cancer treated with mastectomy 11 years before presentation, had a new firm mass in the contralateral breast. The patient did not have nipple discharge or skin changes. Physical examination revealed a firm, nontender, mobile mass in the right lower outer quadrant at the 7-o’clock position. No axillary adenopathy was present. There was no skin thickening, skin or nipple retraction, or erythema. The patient did not have a history of trauma.
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IMAGING FINDINGS
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The craniocaudal and mediolateral oblique views (Fig 1a, 1b) of the right breast did not reveal a focal abnormality in the region of the palpable breast mass. The location of the breast mass was marked with a metallic marker. The spot compression view also did not reveal an underlying mass (Fig 1c). Ultrasonographic (US) examination revealed a homogeneously echogenic mass (Fig 2) without posterior acoustic enhancement or shadowing that was 9 mm in diameter, and the skin overlying the mass appeared to be normal.
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Figure 1a. (a) Craniocaudal and (b) mediolateral views of the right breast do not reveal a focal abnormality at the site of the palpable breast mass that is marked with a metallic marker (arrows). (c) Spot compression view of the right breast in the craniocaudal position also does not reveal a focal underlying breast mass (white dot).
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Figure 1b. (a) Craniocaudal and (b) mediolateral views of the right breast do not reveal a focal abnormality at the site of the palpable breast mass that is marked with a metallic marker (arrows). (c) Spot compression view of the right breast in the craniocaudal position also does not reveal a focal underlying breast mass (white dot).
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Figure 1c. (a) Craniocaudal and (b) mediolateral views of the right breast do not reveal a focal abnormality at the site of the palpable breast mass that is marked with a metallic marker (arrows). (c) Spot compression view of the right breast in the craniocaudal position also does not reveal a focal underlying breast mass (white dot).
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DISCUSSION
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Breast masses that are echogenic at US are unusual. However, the differential diagnosis for masses with increased echotexture includes focal acute hemorrhage or acute hematoma, focal fibrosis, hemangioma, angiolipoma, spindle cell lipoma, and malignancy (1–5).
In this case, the key to the diagnosis is suggested by the homogeneously echogenic US appearance. An angiolipoma, described in the literature as homogeneously echogenic (1,6,7), is one possible diagnosis. A history of prior removal of skin lesions from the trunk or extremities would aid in the diagnosis of angiolipoma (1,8), but the patient did not have such a history. Although angiolipomas may manifest as painful masses, those occurring in the breast are typically painless (1,6,9,10). A second possible diagnosis is a spindle cell lipoma, which has also been reported to have a homogeneously echogenic US appearance (5). Although hemangiomas may have an echogenic US appearance, they may exhibit posterior acoustic shadowing or even appear hypoechoic at US (11). Hemangiomas may also contain calcifications at mammographic evaluation (11). Acute hemorrhage or a breast hematoma would appear more heterogeneous with echogenic components. A hematoma would also be associated with a history of trauma and skin findings such as ecchymoses and change or resolve over time. Focal fibrous change has been described as manifesting as an echogenic breast mass (3); however, researchers in more recent articles have described focal fibrosis as being hypoechoic or isoechoic or as having a mixed echotexture rather than as being uniformly echogenic (12–14). Mammary malignancies may manifest with a thick echogenic halo, but again, these masses tend to have a heterogeneous echotexture with a hypoechoic center and irregular margins (3). Rarely, a colloid carcinoma has been reported to manifest as an echogenic mass (2).
Howard and Helwig (10) established angiolipomas as an entity in 1960. A variant of lipomas, they account for 5%–17% of benign fatty tumors (1). However, angiolipomas uncommonly arise in the breast (1,8,9). They typically occur in the upper extremities, the abdomen, and the back (15). Breast angiolipomas may manifest as solitary masses or multiple synchronous or metachronous breast masses (1,6–8,16). At presentation, the patients may have either palpable breast masses or nonpalpable mammographically depicted masses. There are usually no overlying skin changes (8), as was the case for our patient. If palpable, these masses may be of concern for malignancy at physical examination (2,16). The reported age at diagnosis ranges from 1 to 82 years (1,6–9,16).
Spindle cell lipoma was described by Enzinger and Harvey in 1975 (17). A variant of lipoma, it accounts for about 1.5% of all fatty tumors (15). Ninety percent of spindle cell lipomas occur in men, with a reported age range of 20 to 81 years (15). The majority of these tumors arise in the subcutaneous tissues of the back, the neck, and the shoulder, and they rarely occur in the breast (15). Similar to angiolipomas, spindle cell lipomas may manifest as palpable breast masses or as nonpalpable mammographic findings (5). Although patients typically have solitary spindle cell lipomas at presentation, synchronous lesions have been reported at presentation (5).
There is no typical mammographic appearance of angiolipomas. Nothing may be seen, or a density or a nodule may be noted at mammography (1,2,4). There is one reported case of an angiolipoma manifesting as a nodule with calcifications (7). Similarly, the mammographic appearance of spindle cell lipomas may vary from a well-circumscribed mass to one with ill-defined margins (5,18). At US, both angiolipomas and spindle cell lipomas are homogeneously hyperechoic and well defined (1,5–7). It is important to keep in mind that although fat-containing lesions in the body usually have an echogenic appearance at US, this is not true for breast masses. The fat and fatty lesions, such as lipomas, in the breast are hypoechoic relative to the fibroglandular elements. The US appearance is consistent with the finding of Stavros et al (3) that a homogeneously echogenic appearance with well-defined margins is a benign characteristic in breast masses (100% negative predictive value for malignancy for masses that fit these criteria). Others also agree that a homogeneously echogenic US appearance, an uncommon feature in breast masses, when present is associated with benign lesions (19). There is little information in the literature about the appearance of angiolipomas and spindle cell lipomas at Doppler interrogation.
From the history and imaging findings for the patient we describe, angiolipoma and spindle cell lipoma are likely diagnoses. However, in our patient, given that the mass was newly palpable and the patient had a history of breast carcinoma, the patient underwent an excisional biopsy of the breast mass. Findings at histologic examination indicated a relatively well-circumscribed and thinly encapsulated lesion composed of a mixture of mature adipose tissue and a network of capillaries (Fig 3) in keeping with an angiolipoma.
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Figure 3. Medium-power microscopic view of the angiolipoma shows a mixture of mature adipose tissue and capillaries enmeshed in a fibrous stroma. Capillaries form a network of anastomosing channels. (Hematoxylin-eosin stain; original magnification, x200.)
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Pathologically, mammary angiolipomas are encapsulated yellowish nodules that rarely exceed 2 cm in diameter (9). Microscopically, mature lipocytes are present with angiomatous proliferation (9). The hallmark of an angiolipoma is scattered microthrombi in small blood vessels (9). There are two varieties of angiolipoma, the infiltrative and the noninfiltrative types. Mammary angiolipomas have been reported to be of the noninfiltrative variety (9). Both types are benign with no malignant potential.
The treatment of mammary angiolipomas is simple excision because these are of the noninfiltrative variety. For the infiltrative variety that may occur elsewhere in the body, wide excision may be needed to prevent recurrence (8).
The cause of angiolipoma is unknown. Although some investigators (10) have suggested an association with repeated minor trauma, others (9) doubt this association.
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FOOTNOTES
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Part 1 of this case appeared 4 months previously and may contain larger images.
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REFERENCES
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- Mintz AD, Mengoni P. Angiolipoma of the breast: sonographic appearances of two cases. J Ultrasound Med 1998; 17:67-69.[Medline]
- Kopans DB. Ultrasound and breast evaluation In: Breast imaging. 2nd ed. Philadelphia, Pa: Lippincott-Raven, 1998; 409-444.
- Stavros AT, Thickman D, Rapp CL, Dennis MA, Parker SH, Sisney GA. Solid breast nodules: use of sonography to distinguish between benign and malignant lesions. Radiology 1995; 196:123-134.[Abstract/Free Full Text]
- Heywang-Kobrunner SH, Dershaw DD, Schreer I. Post-traumatic, post-surgical, and post-therapeutic changes In: Diagnostic breast imaging. 2nd ed. New York, NY: Thieme, 2001; 339-374.
- Smith DN, Denison CM, Lester SC. Spindle cell lipoma of the breast: a case report. Acta Radiol 1996; 37:893-895.[Medline]
- Sibala JL, Chang CH, Lin F, Thomas JH. CT of angiolipoma of the breast. AJR Am J Roentgenol 1980; 134:840-841.[Medline]
- Cheung YC, Wan YL, Ng SH, Ng KK, Lee KF, Chao TC. Angiolipoma of the breast with microcalcifications: mammographic, sonographic, and histologic appearances. Clin Imaging 1999; 23:353-355.[CrossRef][Medline]
- Fleishman JS, Schwartz RA. Angiolipoma presenting as a breast mass. Ariz Med 1980; 37:403-404.[Medline]
- Tavassoli FA. Mesenchymal Lesions In: Pathology of the breast. Norwalk, Conn: Appleton & Lange, 1992; 517-560.
- Howard WR, Helwig EB. Angiolipoma. Arch Dermatol 1960; 82:924-931.
- Webb LA, Young JR. Case report: haemangioma of the breast—appearance on mammography and ultrasound. Clin Radiol 1996; 51:523-524.[CrossRef][Medline]
- Revelon G, Sherman ME, Gatewood OM, Brem RF. Focal fibrosis of the breast: imaging characteristics and histopathologic correlation. Radiology 2000; 216:255-259.[Abstract/Free Full Text]
- Rosen EL, Soo MS, Bentley FC. Focal fibrosis: a common breast lesion diagnosed at imaging-guided core biopsy. AJR Am J Roentgenol 1999; 173:1657-1662.[Abstract]
- Venta LA, Wiley EL, Gabriel H, Adler YT. Imaging features of focal breast fibrosis: mammographic-pathologic correlation of noncalcified breast lesions. AJR Am J Roentgenol 1999; 173:309-312.[Abstract/Free Full Text]
- Kyriakos M. Tumors and tumorlike conditions of the soft tissue. In: Kissane JM, eds. Anderson’s pathology. 9th ed. St Louis, Mo: Mosby, 1990; 1838-1928.
- Brown RW, Bhathal PS, Scott PR. Multiple bilateral angiolipomas of the breast: a case report. Aust N Z J Surg 1982; 52:614-616.[Medline]
- Enzinger FM, Harvey A. Spindle cell lipoma. Cancer 1975; 36:1852-1859.[CrossRef][Medline]
- Lew WY. Spindle cell lipoma of the breast: a case report and literature review. Diagn Cytopathol 1993; 9:434-437.[Medline]
- Rahbar G, Sie AC, Hansen GC, et al. Benign versus malignant solid breast masses: US differentiation. Radiology 1999; 213:889-894.[Abstract/Free Full Text]
Congratulations to the three individuals who submitted the most likely diagnosis (in view of the history and imaging findings, credit was given for either angiolipoma or spindle cell lipoma) for Diagnosis Please, Case 59. The names and locations of the individuals, as submitted, are as follows:
- Eric L. Bressler, MD, Minnetonka, Minn
- Marc G. de Baets, MD, Lugano, Switzerland
- María Jesús Díaz Candamio, MD, La Coruña, Spain
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HISTORY
IMAGING FINDINGS
