Breast imagingCase Type
Cristina Álvarez Sánchez, Nancy Sánchez Rubio, María José Ciudad Fernández, Beatriz Lannegrand Menéndez , Elena Cebada Chaparro, Myriam Montes FernándezPatient
74 years, female
A 74-year-old woman, active smoker and dyslipidemic with no other significant past medical history, presented right breast nodule she recently discovered on self-examination.
At physical examination, the nodule was approximately 1 cm in size and feels firm. It was not painful and there was not any palpable axillary lymphadenopathy.
A contrast-enhanced mammography was performed. It revealed an ovoid nodule in the upper outer quadrant with partial ill-defined borders (FIG. 1), fine mural enhancement and hyperenhancing nodular component in the lower pole of the lesion (FIG. 2). Correlate ultrasound showed a complex cystic lesion (FIG. 3). These findings could be suggestive of malignancy (BIRADS 4), so a core needle biopsy of the solid and nodular component was performed.
On MRI the lesion presented as a partial solid and cystic nodule with hyperintense T1 signal and heterogeneous T2 signal on fat-saturation. On contrast-enhanced images, the solid and nodular part shows a progressive enhancement (curve type I) and high signal intensity on the diffusion-weighted images (DWI) without significant signal drop on the ADC map (FIG. 4,5).
Histopathology demonstrated fibrosis with presence of hemosiderophages and multinucleated giant cells associated with a foreign body (cholesterol crystals) (FIG. 6) and fragments of a fibrous wall with apocrine changes and apocrine hyperplasia (anatomopathological category B3).
Cholesterol granuloma is a rare benign condition that tends to be more common in the middle ear and mastoid processes. It is infrequent to find it out of these locations and has been rarely reported in the breast [1,2].
The pathophysiology is unclear but it was traditionally thought to be due to duct ectasia accompanied by the rupture of the ecstatic ducts. A response of the organism to localize haemorrhage or extracellular lipid material cause the formation of cholesterol crystals with a surrounding foreign body inflammatory reaction [2,3,4]. However, Gahie Nam et al suggest in their retrospective review of 79 cases that the cause of breast cholesterolomas is more closely related to macrocysts rather than duct ectasia of the extralobular ducts .
Anatomopathological study is characterized by the presence of multinucleated giant cells phagocytizing cholesterol crystals [4,5].
Clinical presentation is variably. It can be an incidental finding in routine imaging examinations, but most of them present as a palpable nodules, mimicking malignant processes, so it is important to perform a complete radiological study and keep these pathologies in mind.
On mammography and ultrasound, cholesteroloma has non-specific imaging findings. It usually presents as a mass-forming lesion and less frequently as microcalcifications. Solid and mixed (solid and cystic) nodules are the most frequent presentation, and its appearance sometimes simulates malignancy (BIRADS 4) so a biopsy is needed for establish the final diagnosis. Diagnostic evaluations include mammography +/- contrast, ultrasound and biopsy. MRI is useful to establish differential diagnostic with malignancy , guide the biopsy and for follow up. It is typically presented with type 1 curves on the dynamic post-contrast study and without significant signal drop on the ADC map.
Cholesteroloma is a benign condition of the breast (BIRADS 2), so surgery is not necessary. If biopsy is not conclusive, an excisional biopsy is needed to rule out malignancy.
In our clinical case, the anatomopathological exam showed a cholesterol granuloma associated to a B3 category, so the recommendation was surgical excision.
Take-Home Message / Teaching Points:
Cholesterol granuloma is a rare benign condition of the breast, that could be confused with malignant process.
It could be present like a complex cystic lesion, as in our case, so the contrast mammogram and MRI are a very useful techniques for guide the biopsy to the solid and hyperenhancing part.
MRI is a useful technique to establish a differential diagnosis with malignant process, mainly T1-weighted dynamic contrast-enhanced and DWI sequences.
 Gahie Nam MD, Tisha M. Singer MD, Ana P. Lourenco MD, Yihong Wang MD (2019) Cholesteroloma of the breast: A 10 year retrospective review of 79 cases with radiology correlation. Breast J.00:1–5 (PMID: 31280486).
 Takuya Osada, Joji Kitayama, Hirokazu Nagawa (2002) Cholesterol Granuloma of the Breast Mimicking Carcinoma: Report of a Case.Surg Today 32:981–984 (PMID: 12444435)
 Hu CC, Chang TH, Hsu HH, Pen YJ, Yu JC (2018) Weighted Dynamic Contrast-Enhanced Magnetic Resonance Imaging (DCE-MRI) to Distinguish Between Concurrent Cholesterol Granuloma and Invasive Ductal Carcinoma of the Breast: A Case Report. Am J Case Rep 19: 593-598 (PMID: 29789520).
 Khan R1, Narula V, Jain A, Maheshwari V (2013) Cholesterol granuloma of the breast mimicking malignancy. BMJ Case Rep Published online (PMID: 23925685)
 Young-Seon Kim MD, Jung Min Chang MD (2017) Sonographic Appearance of a Cholesterol Granuloma Mimicking Breast Cancer. J Clin Ultrasound 45:608-611 (PMID: 28220943).
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