Sonography of Axillary Masses - pdfs.semanticscholar.org · fibrosis within the tumor. The enhancement is more gradual in fibroadenomas than in cancers, but this finding is not useful

Sonography of Axillary MassesWhat Should Be Considered Other Than theLymph Nodes?

Eun Young Kim, MD, Eun Young Ko, MD, Boo-KyungHan, MD, Jung Hee Shin, MD, Soo Yeon Hahn, MD,Seok Seon Kang, MD, Eun Yoon Cho, MD, Min JungKim, MD, Sun Young Chun, MD

Objective. The purpose of this study was to review the sonographic findings of various axillary mass-es other than lymph nodes in correlation with other imaging and pathologic findings. Methods. Froma sonographic database, we collected interesting cases of axillary masses with pathologic or otherimaging corroboration from the last 10 years. Results. Images of various soft tissue masses werereviewed. They included masses associated with accessory breasts (fibroadenomas, hamartomas, fatnecrosis, and cancer arising from axillary breasts), other soft tissue masses (lipomas, schwannomas,hemangiomas, fibromatosis, epidermoid cysts, and malignant fibrous histiocytomas), and complica-tions presenting as masses after axillary lymph node dissection (seromas, hematomas, suture granulo-mas, pseudoaneurysms, and lymphangiectasia). Conclusions. Awareness of the characteristicsonographic findings of various disease entities that cause axillary masses will help in the correct diag-nosis of axillary masses. Key words: axilla; non-nodal mass; sonography.

Received November 4, 2008, from the Departmentsof Radiology (E.Y.Ki., E.Y.Ko, B.-K.H., J.H.S., S.Y.H.,S.S.K.) and Pathology (E.Y.C.), SungkyunkwanUniversity School of Medicine, Samsung MedicalCenter, Seoul, Korea; and Departments of Radiology(M.J.K.) and Pathology (S.Y.C.), Hallym UniversityHospital, Seoul, Korea. Revision requested November19, 2008. Revised manuscript accepted for publica-tion February 12, 2009.

Address correspondence to Eun Young Ko, MD,Department of Radiology and Center for ImagingScience, Samsung Medical Center, SungkyunkwanUniversity School of Medicine, 50 Irwon-dong,Gangnam-gu, Seoul 135-710, Korea.

E-mail: [email protected]

AbbreviationsCT, computed tomographic; MFH, malignant fibroushistiocytoma; MRI, magnetic resonance imaging

he axilla is a triangular area located between theupper arm and thorax. The clavicle, scapula, andfirst rib form its borders. The most common palpa-ble axillary masses are lymph node metastases

from breast cancer. However, the axilla also contains vari-ous mesenchymal tissues such as fat, vessels, and nerveswhere various disorders can develop. The use of sonogra-phy can detect most of these anatomic elements.Particularly, sonography is useful to establish whether amass is solid or cystic. As a method with low cost, blood flowevaluation capability with Doppler imaging, and real-timeguidance capability for interventional approaches, sonog-raphy is the first choice for evaluation of an axillary mass.

The aim of this study was to review the sonographicfindings and correlative mammographic, computedtomographic (CT), and magnetic resonance imaging(MRI) findings of various soft tissue masses that arose inthe axilla other than in the lymph nodes that were con-firmed by pathologic examinations or pathognomonicfindings on images. Awareness of the sonographic find-ings of various diseases that cause axillary masses willhelp in their differential diagnosis.

© 2009 by the American Institute of Ultrasound in Medicine • J Ultrasound Med 2009; 28:923–939 • 0278-4297/09/$3.50

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Sonography of Axillary Masses

Accessory Breast-Related Masses

The overall prevalence of accessory breastsranges from 0.6% to 6%.1 The occurrence ofaccessory breasts varies by ethnicity, with thehighest prevalence in Japanese populations andthe lowest in white populations compared withother groups, and they are found much more fre-quently in women than men.1,2 Development ofmammary tissue in the human embryo begins at5 weeks’ gestation with the appearance of thebilateral ectodermal milk line extending from theaxilla to the inguinal line. As the mammary ridgedevelops in the thoracic area at 7 weeks’ gesta-tion, the remaining mammary streaks generallyregress. However, incomplete involution ofexcessive dispersion of the mammary streaks canresult in the development of an accessory breastalong the primitive mammary streaks or in otherparts of the body.3 An accessory breast is mostcommonly located in the axilla and may enlargeduring pregnancy or lactation. Sometimes, anaccessory breast is difficult to differentiate fromextension of normal breast parenchyma towardthe axilla, even though the superficial location ofthe accessory breast and the characteristic mam-mographic features are helpful.4 The use of mam-mography can depict an accessory breast as anirregular linear-shaped high-density lesion in theaxilla (Figure 1A). On sonography, an accessorybreast is typically seen as an echogenic area withthe same appearance as that of the normal glan-dular tissue (Figure 1B). Various lesions, bothbenign and malignant, that can involve thebreast can also occur in ectopic breast tissue.Occasionally, the accessory breast itself may pre-sent as a palpable mass that may have monthlypremenstrual changes such as tenderness andswelling. The sonographic appearances of theselesions are usually the same as those of the usualbreast tissue.

FibroadenomasFibroadenomas are relatively frequent and arethe most common benign neoplasms of the breast.They generally appear as well-circumscribedpainless masses in young women.5 Fibro -adenomas are rarely found in axillary accessorybreasts.6 Aughsteen et al6 reported a case of afibroadenoma in the axillary breast of a 28-year-

old woman for whom clinical and mammograph-ic test results were normal. However, a histopatho-logic examination showed the presence of afibroadenoma in the accessory breast.6 On mam-mography, a fibroadenoma can be seen as a non-specific mass (Figure 2A). On sonography, a clearly

Figure 1. Images from a 36-year-old female patient with anaccessory breast in the right axilla. A, Mammography showshigh density resembling normal breast parenchyma (arrow) inthe right axilla. B, On sonography, the axillary breast tissue isseen as a heterogeneous hyperechoic area just below the skin(arrows) with an appearance similar to that of the normal glan-dular tissue in the pectoral breast.

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circumscribed homogeneous solid mass is seen(Figure 2B). On gadolinium-enhanced MRI,enhancement of a fibroadenoma is highly vari-able and may be dependent on the degree offibrosis within the tumor. The enhancement ismore gradual in fibroadenomas than in cancers,but this finding is not useful in assessment ofindividual cases (Figure 2C).

HamartomasMammary hamartomas of the breast areuncommon benign tumors. The lesions arealso known as fibroadenolipomas, lipofi-broadenomas, and adenolipomas and arecomposed of varying amounts of glandular,

adipose and fibrous tissue. A hamartoma usu-ally arises intramammarily and could arise inan ectopic site. In the clinical literature, onlya few examples of mammary hamartomas thatarose in accessory breasts have been described.7

Clinically, a hamartoma presents as a discreteencapsulated painless mass. The patho -gnomonic mammographic appearance is a cir-cumscribed mass that consists of both softtissue and lipomatous elements surrounded bya thin radiolucent zone (Figure 3A).8,9 Thesonographic findings are variable, but a well-circumscribed oval mass with heterogeneousechogenicity from an accessory breast is usual-ly seen (Figure 3B).

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Figure 2. Images from a 36-year-old female patient with afibroadenoma that developed in an accessory breast in theright axilla. A, Axillary mammography shows a partially cir-cumscribed isodense mass (arrow) in the right axilla. The uppermargin of the mass is obscured by axillary breast parenchyma(asterisk). B, Sonography shows a well-circumscribed hypo -echoic mass (arrow) corresponding to the mammographicmass. C, Gadolinium-enhanced sagittal MRI shows a lobulatedwell- circumscribed mass with strong enhancement (arrow) inthe axilla on a delayed phase scan.

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Fat NecrosisFat necrosis of the breast is a benign nonsuppu-rative inflammatory process of adipose tissuethat most commonly occurs after trauma. A cascade of cellular events after the initialinjury causes varying imaging appearances.After the inflammatory process, fat cells undergoliquefaction necrosis. Subsequent accumula-tion of foreign body giant cells and fibrosis causereplacement of the fat necrosis with scar tissue oran oil cyst walled off by fibrous tissue.10 The stageof development of fat necrosis at the time of theexamination affects the imaging appearance.11

Typically, fat necrosis is clinically occult and isevident only on mammographic or sonographicimages.12 Occasionally, fat necrosis in the inflam-matory stage may mimic breast cancer when itappears as a poorly defined or spiculated densemass that is associated with skin retraction,ecchymosis, and erythema.13 An oil cyst witheggshell and dystrophic curvilinear calcificationsis the typical radiographic appearance of fatnecrosis (Figure 4A). On sonography, fat necrosischaracteristically is situated near the skin becausethose sites are the most vulnerable to trauma, andthe mass is most commonly solid, although it maybe complex or cystic. Borders may be discrete orpoorly defined, and the mass may containechogenic foci that accompany posterior shad-owing (Figure 4B). Computed tomography canshow lobulated low-density masses containingdense calcifications (Figure 4C). A pathologicexamination may reveal the presence of necroticadipocytes, foreign body giant cells, bands offibrosis, and calcifications (Figure 4D).

Carcinomas Although ectopic breasts occur in up to 5% to 6%of women, the presence of a malignancy in theseaccessory breasts is quite rare.14 An accessorybreast carcinoma is seen as an irregularly shapedspiculated mass with an accessory breast in theaxilla, which is seen as a hypoechoic lesion onsonography (Figure 5A). Ectopic breast cancerseems to have a poorer prognosis than cancer inthe normal breast parenchyma. Ectopic breastcancer has a tendency to metastasize earlier andmore frequently than a carcinoma of the pectoralbreast.15 Most often, a pathologic examinationreveals the presence of an infiltrating ductal car-

cinoma with a ductal structure involving theaccessory breast (Figure 5B).

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Figure 3. Images from a 38-year-old female patient with ahamartoma that developed in an accessory breast. A, Medio -lateral oblique mammography shows an encapsulated circum-scribed mass (arrows) containing fat density located within theaxillary breast. B, Sonography shows an elongated well- circumscribed mixed echoic mass (arrows) originating fromaccessory breast tissue.

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Primary Soft Tissue Masses in the Axilla

Lipomas Lipomas are benign fatty tumors, although theymay occur in any location, including the axilla.The lesions are usually well-defined, sharplymarginated, homogeneous fatty masses andmay contain occasional septations. On sonogra-phy, lipomas are usually located in a subcuta-neous fatty layer but can locate anywhere,including the intramuscular areas of the axilla(Figure 6A). In addition, the echogenicity is some-what variable. Computed tomographic attenua-tion values are highly accurate for diagnosis offatty tumors.16 Lipomas have a well-defined mar-

gin and characteristic CT attenuation of –90 to–120 Hounsfield units, values that are usually lessthan or equal to the attenuation of the normalsubcutaneous fat (Figure 6B). Lipomas are usual-ly avascular and usually do not show any con-trast enhancement on CT. Liposarcomas aretypically heterogeneous and infiltrative with

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Figure 4. Images from a 32-year-old female patient with mass-forming fat necrosis in the right axilla. A, Chest radiographyshows multiple small round calcifications (arrows) in the rightaxilla. B, Sonography shows poorly defined hypoechoic lesionsin the right axilla (arrows). There are curvilinear echogenic fociwith posterior shadowing (arrowheads) within the mass. C,Contrast-enhanced axial CT shows a lobulated low-density mass(arrows) in the right axilla. Within the mass, dense round calcifi-cations are scattered. D, Photomicrograph shows a round fibro-calcific nodule (arrows) in the background of fat necrosis (hema-toxylin-eosin, original magnification ×40).

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poorly defined margins. The CT attenuation isusually higher than that of the normal fat, andthe lesions show contrast enhancement onpostenhancement CT.17

HemangiomasHemanigiomas are the most common benignvascular tumors. Most often, a hemangioma issuperficially located either subdermally or with-

in subcutaneous tissue. Mammographically, ahemangioma appears as a well-circumscribedmacrolobulated lesion that may contain calcifications (Figure 7A).18 Sonographically,hemangiomas appear as lobulated superficialwell-circumscribed solid masses that are pre-dominantly hypoechoic and may contain areasof calcifications (Figures 7B and 8A). ColorDoppler sonography can depict high vascularityin the masses (Figure 8B). Magnetic resonancesignal intensities are variable, and dynamicgadolinium-enhanced MRI shows delayedenhancement, indicating slow flow within thecapillary hemangioma (Figure 8, C–E).

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Figure 5. Images from a 33-year-old female patient with aninvasive ductal carcinoma that developed from an accessorybreast. A, Sonography of the right axilla shows an irregularlyshaped hypoechoic mass with a poorly defined margin (arrow)originating from surrounding accessory breast tissue. B, Photomicrograph from core needle biopsy shows an infiltra-tive carcinoma (arrows) with a ductal structure representing theaccessory breast without a definite nodal structure (hema-toxylin-eosin, original magnification ×40).

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Figure 6. Images from a 69-year-old male patient with an intra-muscular lipoma of the right axilla. A, Sonography shows asmall well-circumscribed hyperechoic mass (arrow) in the rightaxilla. The mass is surrounded by the hypoechoic pectoralismajor muscle (arrowhead). B, Noncontrast CT shows a homo-geneous low-density mass (arrow) within the pectoralis majormuscle (arrowhead). The CT attenuation was measured as –60Hounsfield units, suggesting fat.

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SchwannomasSchwannomas are benign neoplasms ofSchwann cell origin and most frequently occurin the extremities, trunk, and head and rarelypresent in the axilla. Sonography shows a well-defined oval homogeneous hypoechoic masswith or without posterior enhancement.19,20

Collagen deposit areas appear as a coarse echotexture or as focally increased echogenic areas.An echogenic ring within the mass is rare but apathognomonic feature of nerve sheath tumors(Figure 9A).21 An echogenic capsule is usuallyseen, and cystic spaces represent the presence ofdegenerated portions of the mass. Sonographycan provide confirmation of a neurovascularbundle adjacent to the mass (Figure 9B).22 OnMRI, the tumor appears as a well-defined massof intermediate signal intensity on T1-weighted

images and as a mass of high intensity on T2-weighted images, with an inhomogeneouscentral low-signal area and strong enhancementafter contrast agent administration (Figure 9,C–E). On T2-weighted images, the peripheralhyperintense signal is due to the presence ofmyxoid tissue, and the central low signal intensi-ty is due to the presence of fibrocollagenous tis-sue (Figure 9E).23,24

Fibromatosis (Extra-Abdominal DesmoidTumor)Fibromatosis represents a mass of benign inva-sive fibrous tissue that proliferates in variousanatomic areas. The axilla is a common locationfor these tumors. In one series, 3 of 13 lesionsoccurred in the chest wall or axilla.25 When adesmoid tumor occurs in the axilla, there may benerve involvement due to diffuse infiltration bythe mass. Fibromatosis tends to invade nearbystructures, making total surgical excision diffi-cult. It is usually necessary for patients to receivepostoperative radiation therapy, particularly ifthe tumor is not totally excised. On sonography,fibromatosis appears as an irregular hypoechoicmass with posterior acoustic shadowing andsimulates a malignancy (Figure 10A). The massshows isointensity to surrounding muscle on T1-weighted images (Figure 10B). On fat- suppressed T2-weighted images, the mass showsareas that are lower or higher in intensity thanthe normal surrounding muscle (Figure 10C). Oncontrast-enhanced fat-suppressed T1-weightedimages, the mass has a poorly defined marginand heterogeneous enhancement (Figure 10D).

Epidermal Inclusion CystsEpidermal inclusion cysts are often referred to assebaceous cysts. This term is a misnomerbecause no evidence exists that the lesionsdevelop from the sebaceous glands. The masspresents as a smooth mobile cutaneous or sub-cutaneous lump. Epidermal inclusion cysts arewell-defined lesions that can be seen as contigu-ous with the skin on mammography when theyoccur in the axilla (Figure 11). Sonographically, acystic mass may be seen as solid, circumscribed,and complex.26 An onion ring appearance withalternating concentric hyperechoic and hypoe-choic rings was described as a finding of epider-

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Figure 7. Images from a 43-year-old female patient with ahemangioma of the left axilla. A, Axillary mammography showsa lobulated soft tissue mass (arrows) in the left axilla. Within themass, there are macrocalcifications. B, Sonography shows anelongated hypoechoic mass. Posterior shadowing (arrow) isshown due to the calcification within the mass.

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Figure 8. Images from a 40-year-old female patient with ahemangioma in the right axilla. A, Sonography shows a trian-gular mixed isoechoic and hypoechoic lesion (arrow) in the rightaxilla. B, Color Doppler imaging shows markedly increased vas-cularity within the mass. C, Axial T1-weighted MRI shows a lob-ulated mass (arrow) in the subcutaneous fatty layer of the rightaxilla. The signal intensity is homogeneously isointense com-pared with muscles. D, Sagittal T2-weighted MRI shows alobulated hyperintense mass (arrow) in the right axilla. E, Gadolinium-enhanced sagittal T1-weighted MRI shows a rel-atively good enhancement of the mass (arrow).

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A


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Figure 9. Images from a 28-year-old female patient with aschwannoma in the right axilla. A, Sonography shows a well- circumscribed hypoechoic mass (arrow). The coarse echo textureis thought to represent areas of collagen deposition. B, ColorDoppler imaging shows hypervascularity in the mass. The masshas a connection with the axillary nerve sheath (arrow), giving adumbbell-like appearance. C, Axial T1-weighted MRI shows asmall isointense mass (arrow) in the right axilla. D, Gadolinium-enhanced axial T1-weighted MRI shows strong enhancement ofthe mass (arrow) after contrast agent administration. E, CoronalT2-weighted MRI shows a peripherally hyperintense mass(arrow) connected to the adjacent axillary nerve (arrowhead).The central portion of the mass shows slightly lower signal inten-sity compared with the periphery of the mass.

C D

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moid cysts of the breast.27 Diverse complicationscan occur with epidermal inclusion cysts, such asspontaneous rupture and development of squa-mous cell cancer.28 In cases of spontaneous rup-ture, these cysts release nonabsorbable keratin,which acts as an irritant, leading to secondaryforeign body reactions, granulomatous reac-tions, or abscess formation (Figure 12).

Malignant Fibrous Histiocytomas Although rare, primary neoplasms of fibrous tis-sue, muscle, or fat can occur in the axilla. Thetumors classically do not respect soft tissue andmuscle planes. They may extend high in the axil-la, producing an initial clinical condition relatedto brachial plexus involvement, or they mayspread along the chest wall.29

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Figure 10. Images from a 15-year-old female patient with fibro-matosis in the left axilla. A, Sonography shows an irregularhypo echoic mass with posterior acoustic shadowing. These fea-tures mimic breast cancer. B, Axial T1-weighted MRI shows a tri-angular isointense mass (arrow) in the left axilla. C, Axial fat- saturated T2-weighted MRI shows hyperintensity of the mass(arrow). D, Postenhancement sagittal fat-saturated T1-weightedMRI shows strong enhancement of the mass (arrow). The sur-face of the mass has a shaggy appearance, indicating the pos-sibility of fibromatosis.

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A malignant fibrous histiocytoma (MFH) is themost common malignant soft tissue tumor, rep-resenting 24% of all cases of malignant soft tissuetumors.30 Malignant fibrous histiocytomas occurin adults, appear more frequently in men thanwomen, and show a greater predilection forwhite people than black or Asian people. Thelower extremity is the most common site ofinvolvement, followed by the upper extremityand retroperitoneum; an MFH that occurs in theaxilla is extremely rare. When a lesion consists ofmore than 50% myxoid tissue, it is classified as amyxoid MFH.31 A sonographic examination of anMFH, especially for myxoid lesions, often showsthe presence of an inhomogeneous mass withhypoechoic intratumoral areas of necrosis and ahyperechoic cellular area (Figure 13A).32 On aDoppler study, the solid portion of the myxoidtissue mass may show increased blood flow. OnMRI, an MFH shows nonspecific findings of asoft tissue mass, and there is no correlationbetween the histologic type and MRI appearance(Figure 13, B–D), except that a myxoid MFHappears less heterogeneous on T2-weightedimages.33 For a myxoid MFH, central myxoid areasshow low signal intensity on T1-weighted imagesand high signal intensity on T2-weighted

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Figure 11. Image from a 37-year-old female patient with anepidermal inclusion cyst in the left axilla. Sonography shows asmoothly marginated mass located in the subcutaneous fat layerjust beneath the skin. Internal echogenic material and multiplelayers represent layers of sloughed keratin within the cyst(arrow). The claw sign of hyperechoic skin around the edge ofthe mass, suggesting a skin origin, is not definite in this casebecause of the large size of the mass.

Figure 12. Images from a 47-year-old female patient with aruptured epidermal inclusion cyst in the left axilla. A, Dopplersonography shows a heterogeneous hypoechoic mass with anindistinct margin (arrow). The mass has peripherally increasedvascular flow. B, Postenhancement coronal CT shows anenhancing mass (arrow) with infiltrative margins in the left axil-la. C, Photomicrograph shows multinucleated giant cells con-taining keratin material (arrows), which is pathognomonic foran epidermal inclusion cyst (hematoxylin-eosin, original magni-fication ×200).

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images.33 Although the radiologic appearance ofmost soft tissue masses remains nonspecific, itmight be possible to obtain more detailed infor-mation if MRI is performed before surgerybecause the mass contains multiple foci of hem-orrhage and myxoid components.

Surgery-Related Masses

Seromas and Old HematomasSeromas are the most frequent postoperativecomplications after removal of the axillarylymph nodes and have been reported to be pre-sent in 15% to 85% of patients after axillary lym-

phadenectomy.34 Seromas are accumulations ofserous fluid that develop in the axillary deadspace, and they are usually absorbed within a fewweeks.

On sonography, a seroma is seen as just a fluidcollection with or without septations or can beseen as a round or oval soft tissue mass (Figure14). Reabsorption of seroma fluid can be slow, andthese masses can persist for many months andoccasionally for 2 or more years.35 Sometimes,when a lesion appears as a complex mass, thefindings do not differentiate the lesion from a car-cinoma. However, the use of serial sonographycan depict whether the lesions decrease or do

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Figure 13. Images from an 88-year-old male patient with an MFH in the left axilla. A, Sonography shows a partially poorly definedheterogeneous hypoechoic mass (arrow) in the left axilla. B, T1-weighted turbo field echo MRI of the mass (arrow) shows isointensi-ty compared with the adjacent muscle. C, T2-weighted triple-inversion black blood turbo spin echo MRI of the mass (arrow) showsisointensity compared with the adjacent muscle. D, Gadolinium-enhanced T1-weighted turbo field echo MRI shows strong homoge-neous enhancement of the mass (arrow) after injection of the contrast agent.

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not change in size. Moreover, as the lesionsregress, fibrosis of the surgical cavity can developas a scar at the surgical site.

Suture Granulomas Suture granulomas are rare complications afteraxillary dissection and can occur anywhere in

the body after a variety of surgical procedures.Usually, a suture granuloma occurs after the useof nonabsorbable suture material deep withinthe skin, especially after abdominal surgery. Thereported characteristic sonographic finding of asuture granuloma is the presence of a hypo -echoic lesion with hyperechoic double lines(rail-like lines) or a single line (Figure 15).36

However, differentiation between recurrence anda suture granuloma is not easy on postoperativesonography, and the use of sonographically guid-ed fine-needle aspiration or excision is needed forconfirmation. Most often, a pathologic examina-tion reveals islands of amorphous eosinophilicmaterial with an associated foreign body giant cellreaction and foci of dystrophic calcification.

Pseudoaneurysms To our knowledge, pseudoaneurysms of the axil-la have not been reported in the literature, andjust a few cases of pseudoaneurysms of thebreast have been reported, in which most casesdeveloped after a core biopsy.37 A pseudo -aneurysm is not a true aneurysm because it lacksan arterial wall. It is the result of a puncture ortear of the 3 layers of an arterial wall withextravasation of blood and hematoma formationin the adjacent tissues (Figure 16A). Because apseudoaneurysm appears on sonography as acomplex lesion with an anechoic component, itcan be misdiagnosed as a simple hematoma orcystic lesion on gray scale sonography (Figure16B). However, diagnosis of a pseudoaneurysmis easily obtained with the use of color Dopplersonography because this technique can showthe presence of swirling flow in the mass or cavi-ty, which is connected by a track to an adjacentvessel (Figure 16C). Apart from surgical treat-ment, various interventional procedures such asmicrocoil insertion, thrombin injection, alcoholinjection, and sonographically guided compres-sion have been reported as successful in thetreatment of pseudoaneurysms.

Lymphangiectasia Most lymphangiomas are congenital forms dueto malformations of the lymphatic system, andmost of these malformations occur in the neck(75%) and axilla (20%).38 An acquired lymphan-gioma (lymphangiectasia) can occur after

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Figure 14. Image from a 67-year-old female patient with apathologically confirmed old hematoma in the right axilla fromfine-needle aspiration. Six months previously, the patient under-went ipsilateral partial mastectomy and axillary lymph node dis-section for invasive ductal carcinoma. Postoperative sonographyshows an oval hypoechoic mass in the right axilla (arrow).

Figure 15. Image from a 58-year-old female patient with apathologically confirmed suture granuloma in the left axilla fromexcisional biopsy. Two years previously, the patient underwentipsilateral partial mastectomy and axillary lymph node dissectionfor invasive ductal carcinoma. Sonography shows a hypoechoiclesion with internal hyperechoic foci at the deep layer of the leftaxilla.


surgery or radiotherapy because of damage tothe draining lymphatic channels. For example,acquired progressive lymphangiomas have beenrecognized as complications following axillarynode dissection and radiotherapy for breast carci-noma.39 Axillary lymphangiomas may be diag-nosed antenatally on the basis of the sonographicfinding of a cystic mass, which may be loculatedand septated in the area of the axilla (Figure17A).40 The lesions are best visualized on MRI.Usually, a lymphangioma may appear as ahomogeneous cystic mass without septa or asolid component. Axial T2-weighted MRI showsa mass with homogeneous high signal intensityand marginal enhancement after gadoliniuminjection (Figure 17, B–D).41

Conclusions

Many different pathologic conditions in additionto lymph node enlargement can present as axil-lary masses. Awareness of the variety of these dis-ease entities and characteristic sonographicfindings can aid in correct diagnosis of an axillarymass. The use of color Doppler sonography andcorrelation of sonographic findings with the fea-tures of other imaging modalities, includingmammography, CT, and MRI, can provide infor-mation about the relationship between the massand adjacent structures and sometimes providecharacteristic findings for specific tumors.

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Figure 16. Images from a 42-year-old female patient with a palpable nodule in the right axilla. The patient underwent mass excision,and a pathologic examination revealed dilated vessels with an organizing thrombus and fibrosis, compatible with a pseudoaneurysm.One year previously, the patient underwent partial mastectomy and sentinel lymph node biopsy for breast carcinoma. A, Mediolateraloblique mammography of the right breast shows a small area of nodular density (arrow) in the axilla, which is located close to theaxillary vessels. B, Gray scale sonography shows a small hypoechoic nodular lesion (arrow) in the subcutaneous fatty layer of the axil-la. C, On color Doppler imaging, the nodular lesion shows intense vascularity and a connection with the superficial axillary vessel.These findings are compatible with a postoperative pseudoaneurysm.

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Figure 17. Images from a 69-year-old female patient with anenlarging palpable mass in the left axilla. After mass excision,the final diagnosis was cystic lymphangiectasia with chronicinflammation. Several years previously, the patient underwentipsilateral modified radical mastectomy and axillary lymph nodedissection for Paget disease. A, Sonography shows conglomer-ated variably sized cystic masses (arrows) in the left axilla. Someof the lesions have echogenic debris. On color Doppler imaging,the periphery of the cystic lesions shows mild vascularity. B, AxialT1-weighted MRI shows an irregularly shaped isointense mass(arrows) in the left axilla. C, Coronal T2-weighted MRI shows amultiseptated hyperintense cystic mass (arrows) in the left axilla.D, Gadolinium-enhanced axial T1-weighted MRI shows periph-eral and septal enhancement of the multiseptated cystic mass(arrows) after contrast agent administration.

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References

1. Teke Z, Kabay B, Akbulut M, Erdem E. Primary infiltratingductal carcinoma arising in aberrant breast tissue of the axil-la: a rare entity. Report of a case. Tumori 2008; 94:577–583.

2. Marshall MB, Moynihan JJ, Frost A, Evans SR. Ectopic breastcancer: case report and literature review. Surg Oncol 1994;3:295–304.

3. De Cholnoky T. Accessory breast tissue in the axilla. NY StateJ Med 1951; 51:2245–2248.

4. Adler DD, Rebner M, Pennes DR. Accessory breast tissue inthe axilla: mammographic appearance. Radiology 1987;163:709–711.

5. Coras B, Landthaler M, Hofstaedter F, Meisel C,Hohenleutner U. Fibroadenoma of the axilla. Dermatol Surg2005; 31:1152–1154.

6. Aughsteen AA, Almasad JK, Al-Muhtaseb MH.Fibroadenoma of the supernumerary breast of the axilla.Saudi Med J 2000; 21:587–589.

7. Dworak O, Reck T, Greskötter KR, Kockerling F. Hamartomaof an ectopic breast arising in the inguinal region.Histopathology 1994; 24:169–171.

8. Gatti G, Mazzarol G, Simsek S, Viale G. Breast hamartoma:a case report. Breast Cancer Res Treat 2005; 89:145–147.

9. Herbert M, Sandbank J, Liokumovich P, et al. Breast hamar-tomas: clinicopathological and immunohistochemical studiesof 24 cases. Histopathology 2002; 41:30–34.

10. Rosen PP. Inflammatory and reactive tumors. In: Rosen P (ed).Rosen’s Breast Pathology. 3rd ed. Philadelphia, PA: LippincottWilliams & Wilkins; 2009:33–70.

11. Daly CP, Jaeger B, Sill DS. Variable appearances of fat necro-sis on breast MRI. AJR Am J Roentgenol 2008; 191:1374–1380.

12. Hogge JP, Robinson RE, Magnant CM, Zuurbier RA. Themammographic spectrum of fat necrosis of the breast.Radiographics 1995; 15:1347–1356.

13. Clarke D, Curtis JL, Martinez A, Fajardo L, Goffinet D. Fatnecrosis of the breast simulating recurrent carcinoma afterprimary radiotherapy in the management of early stagebreast carcinoma. Cancer 1983; 52:442–445.

14. Markopoulos C, Kouskos E, Kontzoglou K, Gogas G,Kyriakou V, Gogas J. Breast cancer in ectopic breast tissue.Eur J Gynaecol Oncol 2001; 22:157–159.

15. Roorda AK, Hansen JP, Rider JA, Huang S, Rider DL. Ectopicbreast cancer: special treatment considerations in the post-menopausal patient. Breast J 2002; 8:286–289.

16. Friedman AC, Hartman DS, Sherman J, Lautin EM, GoldmanM. Computed tomography of abdominal fatty masses.Radiology 1981; 139:415–429.

17. Hunter JC, Johnston WH, Genant HK. Computed tomogra-phy evaluation of fatty tumors of the somatic soft tissues:clinical utility and radiologic-pathologic correlation. SkeletalRadiol 1979; 4:79–91.

18. Siewert B, Jacobs T, Baum JK. Sonographic evaluation of sub-cutaneous hemangioma of the breast. AJR Am J Roentgenol2002; 178:1025–1027.

19. Sintzoff SA Jr, Gillard I, Van Gansbeke D, Gevenois PA,Salmon I, Struyven J. Ultrasound evaluation of soft tissuetumors. J Belge Radiol 1992; 75:276–280.

20. Beggs I. Sonographic appearances of nerve tumors. J ClinUltrasound 1999; 27:363–368.

21. Beggs I. The ring sign: a new ultrasound sign of peripheralnerve tumours. Clin Radiol 1998; 53:849–850.

22. Beggs I. Pictorial review: imaging of peripheral nervetumours. Clin Radiol 1997; 52:8–17.

23. Suh JS, Abenoza P, Galloway HR, Everson LI, Griffiths HJ.Peripheral (extracranial) nerve tumors: correlation of MRimaging and histologic findings. Radiology 1992; 183:341–346.

24. Verstraete KL, Achten E, De Schepper A, et al. Nerve sheathtumors: evaluation with CT and MR imaging. J Belge Radiol1992; 75:311–320.

25. Hudson TM, Vandergriend RA, Springfield DS, et al.Aggressive fibromatosis: evaluation by computed tomogra-phy and angiography. Radiology 1984; 150:495–501.

26. Kwak JY, Park HL, Kim JY, et al. Imaging findings in a case ofepidermal inclusion cyst arising within the breast parenchy-ma. J Clin Ultrasound 2004; 32:141–143.

27. Crystal P, Shaco-Levy R. Concentric rings within a breast masson sonography: lamellated keratin in an epidermal inclusioncyst. AJR Am J Roentgenol 2005; 184(suppl): S47–S48.

28. Stephenson TJ, Cotton DW. Paget’s disease in an epidermalcyst. Dermatologica 1987; 174:186–190.

29. Fishman EK, Zinreich ES, Jacobs CG, Rostock RA, SiegelmanSS. CT of the axilla: normal anatomy and pathology.Radiographics 1986; 6:475–502.

30. Kransdorf MJ. Malignant soft-tissue tumors in a large refer-ral population: distribution of diagnoses by age, sex, andlocation. AJR Am J Roentgenol 1995; 164:129–134.

31. Miller TT, Hermann G, Abdelwahab IF, Klein MJ, Kenan S,Lewis MM. MRI of malignant fibrous histiocytoma of soft tis-sue: analysis of 13 cases with pathologic correlation. SkeletalRadiol 1994; 23:271–275.

32. Ros PR, Viamonte M Jr, Rywlin AM. Malignant fibrous histi-ocytoma: mesenchymal tumor of ubiquitous origin. AJR AmJ Roentgenol 1984; 142:753–759.

33. Murphey MD, Gross TM, Rosenthal HG. From the archives ofthe AFIP. Musculoskeletal malignant fibrous histiocytoma:radiologic-pathologic correlation. Radiographics 1994;14:807–826.

34. Soon PS, Clark J, Magarey CJ. Seroma formation after axil-lary lymphadenectomy with and without the use of drains.Breast 2005; 14:103–107.

35. Brenner RJ, Pfaff JM. Mammographic features after conser-vation therapy for malignant breast disease: serial findingsstandardized by regression analysis. AJR Am J Roentgenol1996; 167:171–178.


36. Rettenbacher T, Macheiner P, Hollerweger A, Gritzmann N,Weismann C, Todoroff B. Suture granulomas: sonographyenables a correct preoperative diagnosis. Ultrasound MedBiol 2001; 27:343–350.

37. Al Hadidy AM, Al Najar MS, Farah GR, Tarawneh ES.Pseudoaneurysm of the breast after blunt trauma: success-ful treatment with ultrasound-guided compression. J ClinUltrasound 2008; 36:440–442.

38. Anderson NG, Kennedy JC. Prognosis in fetal cystic hygro-ma. Aust NZ J Obstet Gynaecol 1992; 32:36–39.

39. Celis AV, Gaughf CN, Sangueza OP, Gourdin FW. Acquiredlymphangiectasis. South Med J 1999; 92:69–72.

40. Hoffman-Tretin J, Koenigsberg M, Ziprkowski M. Antenataldemonstration of axillary cystic hygroma. J Ultrasound Med1988; 7:233–235.

41. An JK, Oh KK, Jung WH. Soft-tissue axillary masses (exclud-ing metastases from breast cancer): sonographic appear-ances and correlative imaging. J Clin Ultrasound 2005;33:288–297.

J Ultrasound Med 2009; 28:923–939 939

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Sonography of Axillary Masses - pdfs.semanticscholar.org · fibrosis within the tumor. The enhancement is more gradual in fibroadenomas than in cancers, but this finding is not useful