CASE 363 Published on 06.01.2002

The painful mass

Section

Breast imaging

Case Type

Clinical Cases

Authors

Ilie I.Craciun MD

Patient

50 years, female

Categories

No Area of Interest ; Imaging Technique Ultrasound

No Procedure ; No Special Focus ;

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Clinical History

Palpable, painful, right breast mass

Imaging Findings

First mammographic examination <> Married + 5 <> Last period: 11 days ago <> Painful, small, palpable, right breast mass <> Painful skin eruption over the right chest

Discussion

LYMPHATICS OF THE BREAST <> Although intramammary lymph nodes are found on dissection throughout the breast, by mammography they are mostly demonstrated in the lateral half and especially in the upper quadrant, along the margin of the breast parenchyma. They may be seen in about 5% of the mammographic examinations. Normal intramammary lymph nodes are up to 1 cm. in greatest diameter, well defined, sharply bordered and not calcified. They usually have a hilus and central fat. The differential diagnosis should include, fibroadenomas and hemangiomas but all these three entities are benign and no further action should be taken for any of them except for at most, follow-up. Ultrasound is usually not recommended for normal intramammary lymph node detection and the cause is that when not infiltrated, they have almost the same echogenicity as fatty tissue and the hilar structures are similar in appearance to the fibrous tissue of the breast. Sometimes a palpable mass may show the characteristics of a lymph node, an isoechoic or slightly hypoechoic mass with an echogenic hilum. <> Normal intramammary lymph nodes may appear or enlarge in the breast as a reaction to inflammatory conditions of the skin but also as a reaction to metastatic involvement. When they do so, a round, well defined, homogeneous, high-density mass, larger than 1 cm. in diameter may be seen. The central fat of the hilum disappears. By ultrasound, metastatic lymph nodes looks larger are easier to identify, hypoechoic, well defined and usually the hilum is obliterated.

Differential Diagnosis List

Reactive intramammary lymph node – Right chest herpes zoster

Final Diagnosis

Reactive intramammary lymph node – Right chest herpes zoster

References

[1] Hoefken W. Lanyi M. (1977)
The Normal Breast Anatomy (in)
Mammography: Technique, Diagnosis, Differential Diagnosis, Results
Georg Thieme Verlag Stuttgart, pp 62.

[2] Kopans DB (1998)
Anatomy, Histology, Physiology, and Pathology Lymphatics
In Kopans DB (ed) Breast Imaging
Lippincott - Raven, Philadelphia-New York, pp 11-12.

[3] Kopans DB (1998)
Anatomy, Histology, Physiology, and Pathology Intramammary Lymph Nodes
In Kopans DB (ed) Breast Imaging
Lippincott - Raven, Philadelphia-New York, pp 12-13.

[4] Homer MJ (1991)
Benign Lesions in the Breast Intramammary lymph node
In Homer MJ Mammographic Interpretation A practical approach
McGraw-Hill, Inc. pp 79-81.

[5] Tohno E (1994)
Diagnostic Features on Ultrasound Lymph node enlargement
In Tohno E, Cosgrove DO, Sloane JP Ultrasound Diagnosis of Breast Diseases
Churchill Livingstone Longman Group UK Limited, pp 68-70.

Case information

URL:	https://www.eurorad.org/case/363
DOI:	10.1594/EURORAD/CASE.363
ISSN:	1563-4086

Figure 1

Standard mammogram

Cranio-caudal views shows fatty breasts with some benign microcalcifications scattered bilaterally and a 10 mm. mass, well defined, homogeneous, located at the periphery of the fibroglandular tissue on the lateral part of the right breast.

Oblique views of the mammogram shows again fatty breasts with benign microcalcifications scattered bilaterally. The round, well defined, homogeneous, dominant mass may be seen in the upper part of the right breast. There are no calcifications attached to it.

Figure 2

Digital magnification of the suspicious finding

The mass is well defined, somewhat irregular in shape, with lobular margins, homogeneous. No fat or microcalcifications are seen accompanying it. The mass appeared suddenly within few days and was painful and palpable.

Figure 3

Ultrasound of the palpable mass

A hypoechoic , 12 mm. mass with an isoechoic ridge of tissue within it. Some posterior enhancement may be seen. The mass was interpreted as a cyst with solid content and stereotactic biopsy was indicated.