JBR–BTR, 2007, 90: 167-169.
Magnetic resonance imaging of the breast, also known as magnetic resonance mammography (MRM),is a valuable tool in the diagnostic work-up of breast lesions. The stan-dard MRM examination is usually performed using T1- and T2-weight-ed quences, as well as dynamic contrast-enhanced studies to gener-ate time-intensity plots. T he purpo of this report is to demonstrate the value of diffusion-weighted imaging in the detection and differential diagnosis of breast lesions.Ca report
We prent a 22-year-old woman who consulted becau of a freely mobile nodule in the right breast just behind th风像什么
e nipple. She 硬件设施
first noticed the lesion one year ago after a holiday in The Philippines.According to the patient the lump had not grown in size, but recently she developed intermittent pain and tenderness. There was no personal or familial history of breast cancer,no trauma to the breast and no pre-vious biopsies. The patient was tak-ing oral contraceptives for 5years (Diane 35).Clinical examination showed a 1cm freely movable retro-areolar nodule in the right breast.Mammography revealed a well-circumscribed nodule without any calcifications, just behind the right nipple (Fig.1). Sonography con-firmed a round heterogeneous nod-ule with alternating hypoechoic and hyperechoic concentric rings; there were some small anechoic nodules in the internal layers of the rings (Fig.2). The nodule had an internal fluid level and through-transmis-
sion. There was no color Doppler flow signal in the lesion. A differen-tial diagnosis of epidermal inclusion cyst, complex cyst, well demarcated carcinoma and echinococcus cyst was propod. Further Echino-coccus screening (Rx thorax,abdominal ultrasound and rum anti-echinococcus antibody titre)was negative.
MRI of the breasts was performed on a 1.5 T superconducting system,with a bilateral breast coil. T2-weighted images showed a well cir-cumscribed, rounded mass with high signal intensity contents, a low intensity border and internal cone-shaped centre (Fig.3).
On T1-weighted fat saturated images the mass also showed a high signal intensity (Fig.4).
Axial echo-planar diffusion-weighted MRI (DW-MRI) was per-formed with b values of 0, 500, and 1000mm 2/s (trace images and ADC maps) (Fig.5). The DW-MRI scans
REGULAR ARTICLES
DIFFUSION RESTRICTION IN A SUPERFICIAL BREAST LESION
M. Spinhoven 1, I. Verslegers 1, M. Van Goethem 1, K. Van de vijver 2, I. Biltjes 1, P .M. Parizel 1
Objective:T o report the imaging findings of a 22-year-old Asian woman with a freely movable retro-areolar nodule in the right breast,first noticed after a holiday in The Philippines.
Material and methods:We preformed clinical examination,mammography and ultrasound with color Doppler imag-ing.A differential diagnosis of epidermal inclusion cyst,complex cyst,well demarcated carcinoma and echinococcus cyst was propod.For further differential diagnosis,a MRI of the breasts was performed on a 1.5 superconducting system,with a bilateral breast coil.T2- and T1 weighted images,followed by axial echo-planar diffusion-weighted MRI (DW-MRI) were performed with b values of 0,500,and 1000mm 2/s (trace images and ADC maps).
Results:The high signal intensity on T2 weighted images confirmed the cystic character of the lesion.The high sig-nal intensity on T1 FS weighted images can be en in complex cysts and inclusion cysts,but is less likely in an echinococcus cyst.On DW-MRI there is a marked diffusion restrictio懂的英文
n in the nodule,which can be en in complex cysts and inclusion cysts.A well demarcated carcinoma is less likely,unless a tumour with a very high cellularity.Becau neither carcinoma nor echinococcus cyst could be ruled out,a surgical excision was performed.Pathological exa mina tion r
evea led norma l squa mous epithelium with stra tifica tion a nd la mella ted kera tin,consistent with a n epidermal inclusion cyst.
Conclusion:We argue that in lected cas DW-MRI can be uful to narrow the differential diagnosis and notable differentiate epidermal inclusion cysts from echinococcus cysts.
Key-word:Breast,
cyst.
Fig.1.—Magnification mammogra-phy of the small and den right breast showing a sharply demarcated nodule without any calcifications (asterisk).
168JBR–BTR, 2007, 90 (3)
revealed markedly restricted diffu-sion within the mass (Fig.5A). The lesion was hypointen on the cor-responding ADC maps (Fig.5B).Given the uncertain diagnosis,we did not perform a fine needle biopsy, for this procedure in an echinococcus cyst is not without risk, becau leakage from the cyst can lead to condary cyst forma-tion or can cau vere anaphylac-tic reactions (1, 2). Surgical excision of the mass was performed.Pathological examination revealed normal squamous epithelium with stratification and lamellated keratin,consistent with an epidermal inclu-sion cyst (Fig.6).
Discussion
Epidermal inclusion cysts are rare in the breast. They are more com-monly found on the face, neck and trunk. The cysts are formed by inclusion of keratinising squamous epithelium within the dermis result-ing in a cyst filled with lamellated keratin (3). Neoplastic transforma-tion of epidermal inclusion cysts is known but very rare (3, 4).
Multiple sonographic appear-ances of breast epidermal inclusion cysts have been described: solid,cystic and complex. In our patient,the cyst had an onion-ring appear-ance on ultrasound as described by Crystal et al.(3).No extension into
the dermis was en. Becau the
Fig.2.—Breast sonography showing a smooth, rounded nodule with heterogeneous content, an internal fluid level and through-transmission. The nodule is made up of multiple alter-nating hypo-echoic and hyper-echoic concentric rings with the impression of small anechoic nodules in the internal layers of the rings. Power-Doppler showing no vascularisation in the
lesion.
Fig.3.—T2-weighted MR of the breasts showing a well cir-cumscribed, rounded mass with high signal intensity on the T2weighted images with a low intensity border and internal cone-
shaped centre.
Fig.4.—T1 FS weighted images showing high signal inten-sity in the rounded mass.
Fig.5.—Diffusion-weighted MR of the breasts (TRACE images and ADC maps, b =1000) showing a defined diffusion restriction in the mass.
A
B
DIFFUSION RESTRICTION IN A SUPERFICIAL BREAST LESION — SPINHOVEN et al 169
lesion appeared after a swimming trip to The Philippines, and the pres-ence of potentially ‘daughter-cysts’into the intern layers of the onion-ring, an echinococcus cyst was included in the differential diagnosis.An MRI was performed for further differentiation of the lesion. T he high signal intensity on T2 weighted images confirmed the cystic charac-ter of the lesion. The high signal intensity on T1 FS weighted images can be en in complex cysts and inclusion cysts, but is less likely in an echinococcus cyst. On DW-MRI there is marked diffusion restriction in the nodule, so a well demarcated carcinoma is less likely , unless a tumour with a very high cellulari-ty (5, 6). A diffusion restriction can be en in complex cysts and inclu-sion cysts.
Still we couldn’t rule out a carci-noma nor echinococcus cyst, so sur-gical excision was performed.
We didn’t perform a puncture of the lesion, becau there is still some controversy in the literature about the safety of this procedure
(1, 2, 9). More recent articles suggest biopsy as a safe preoperative tool,but sometimes inconclusive (9).Therefore we cho surgical excision over a biopsy.Conclusion
Epidermal inclusion cysts are rarely found in the breast. The lesions are difficult to detect on mammography. On ultrasound they often prent an onion-ring appear-ance, but this aspect is not p
athog-nomonic (3). The differential diagno-sis should include echinococcus cyst especially in certain clinical t-tings (such as travel to endemic areas) and when imaging studies reveal the impression of ‘daughter cysts’. The MRI appearance of the lesion on T1-and T2-weighted quences is not specific. One of the most interesting features of the lesion we report is the prence of diffusion restriction, which is pre-sumably due to the prence of lamellated keratin, similar to what
has been reported in epidermoid
Fig.6.—Pathology of the mass with a wall compod of t复课证明
rue epidermis with squamous, granula and horn cells. The cyst is filled with horny materialword怎么求和
arranged in laminated layers.
cysts in the brain (7). DW-MRI is not routinely performed in breast imag-ing. We argue that in lected cas,such as in our patient, DW-MRI can be uful to narrow the differential diagnosis, and notable differentiate epidermal inclusion cysts from echinococcus cysts, which do not exhibit diffusion restriction (8).Unfortunately, diffusion restriction can also be found in highly cell-den tumours, and the method does not formally rule out a malig-nancy.References
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