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Lee KE, Woo OH, Kim CY, Cho KR, Seo BK. Unusual US Findings of Diffuse Large B-Cell Lymphoma of the Breast: A Case Report. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2024; 85:415-420. [PMID: 38617862 PMCID: PMC11009123 DOI: 10.3348/jksr.2022.0177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 07/10/2023] [Accepted: 09/03/2023] [Indexed: 04/16/2024]
Abstract
Lymphoma is an uncommon type of breast malignancy, with low prevalence. The ultrasonographic findings of breast lymphoma have been described as nonspecific. Breast lymphoma most commonly appears as a solitary hypoechoic mass on US, and usually shows hypervascularity on color Doppler US. Herein, we report an unusual case of breast lymphoma that presented as multiple bilateral hyperechoic nodules on US.
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2
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Parashar S, Arora J, Mittal A. Bright Is Not Always Better: A Pictorial Review of Hyperechoic Malignant Breast Masses. Indian J Radiol Imaging 2023; 33:532-540. [PMID: 37811173 PMCID: PMC10556334 DOI: 10.1055/s-0043-1768641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2023] Open
Abstract
Hyperechogenic breast lesions are a relatively rare finding at breast ultrasonography and are traditionally thought to be benign. However, hyperechogenicity on the ultrasound alone does not provide enough evidence to rule out malignancy completely. We herein reported a short series of nine cases of echogenic malignant breast lesions, which include invasive ductal carcinoma, ductal carcinoma in situ, invasive lobular carcinoma, angiosarcoma, lymphoma, and metastasis to the breast. Echogenic breast lesions should be carefully evaluated and properly categorized based on any other suspicious sonographic characteristics and must be correlated with mammographic findings and clinical history to lower the threshold for biopsy and avoid delay in diagnosis. Hyperechogenicity should not be considered as a characteristically benign feature and should not supersede the less specifically benign features of the same lesion on the other examination.
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Affiliation(s)
- Shivya Parashar
- Department of Radiodiagnosis, Medanta the Medicity, Gurugram, Haryana, India
| | - Jyoti Arora
- Department of Radiodiagnosis, Medanta the Medicity, Gurugram, Haryana, India
| | - Ayushi Mittal
- Department of Radiodiagnosis, Medanta the Medicity, Gurugram, Haryana, India
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3
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Wang X, Liu C, Shang G, Xiong J, Zhou H, Tang W, Qin X. Multimodal Ultrasonography Features of Breast Lymphomas: 3 Cases Report. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2023; 42:1353-1359. [PMID: 36502374 DOI: 10.1002/jum.16137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 10/29/2022] [Accepted: 11/15/2022] [Indexed: 05/18/2023]
Abstract
To investigate the multimodal ultrasonography (US) features of breast lymphomas (BLs). Multimodal ultrasonography was performed on three patients who had been diagnosed BLs by pathology in our hospital. Two cases of primary BLs appeared hyper hyperechoic and hypoechoic, and one case of second BL appeared isoechoic and hypoechoic. Elastography of two lesions was soft elasticity and the elasticity score was 2 points. Contrast-enhanced ultrasound (CEUS) revealed rapid uniform high enhancement with clearly defined after injection. There are some common features in ultrasound. Combined with those features can help to improve the sonographer's understanding and diagnosis of the BLs.
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Affiliation(s)
- Xiuhua Wang
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Cong Liu
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Gongqun Shang
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Jiajia Xiong
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Hui Zhou
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Wenjuan Tang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaojuan Qin
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
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4
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Shin J, Kapoor M, Patel M, Krishnamurthy S, Whitman GJ. Comparing Breast Hemangiomas to Breast Angiosarcomas: An Imaging Based Review. Curr Probl Diagn Radiol 2023; 52:212-219. [PMID: 36804401 DOI: 10.1067/j.cpradiol.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 11/20/2022] [Accepted: 01/18/2023] [Indexed: 01/22/2023]
Abstract
Vascular tumors of the breast are rare, and most can be classified as either hemangiomas or angiosarcomas. Breast hemangiomas are benign vascular tumors that are often found incidentally at pathologic examination. Breast hemangiomas may mimic low grade angiosarcomas, which are malignant vascular tumors. This article illustrates the imaging characteristics of breast hemangiomas and breast angiosarcomas across multiple imaging modalities.
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Affiliation(s)
- Jane Shin
- Department of Breast Imaging, The University of Texas MD Anderson Cancer Center, Houston TX
| | - Megha Kapoor
- Department of Breast Imaging, The University of Texas MD Anderson Cancer Center, Houston TX
| | - Miral Patel
- Department of Breast Imaging, The University of Texas MD Anderson Cancer Center, Houston TX
| | - Savitri Krishnamurthy
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston TX
| | - Gary J Whitman
- Department of Breast Imaging, The University of Texas MD Anderson Cancer Center, Houston TX
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5
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Fat necrosis in the breast: a multimodality imaging review of its natural course with different aetiologies. Clin Radiol 2023; 78:323-332. [PMID: 36849280 DOI: 10.1016/j.crad.2023.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 01/30/2023] [Accepted: 01/30/2023] [Indexed: 02/18/2023]
Abstract
Fat necrosis of the breast is a commonly encountered condition in daily practice. It is a benign pathology, but it can have variable manifestations and patterns that may sometimes mimic malignancy, depending on its stage of evolution and its underlying cause. This review demonstrates the wide spectrum of appearances of fat necrosis on mammography, digital breast tomosynthesis (DBT), ultrasound, magnetic resonance imaging (MRI), computed tomography (CT), and positron-emission tomography (PET). Sequential follow-up images are included in some cases to illustrate the temporal change of the findings. The typical location and distribution of fat necrosis from a comprehensive list of aetiologies are discussed. Improved knowledge of the multimodality imaging features of fat necrosis could enhance diagnostic accuracy and clinical management, thus avoiding unnecessary invasive investigations.
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6
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Chesebro AL, Joseph S, Kuba MG, Lester S, Giess CS. Mixed and Purely Hyperechoic Breast Masses: A Radiologic-Pathologic Review. JOURNAL OF BREAST IMAGING 2023; 5:85-92. [PMID: 38416961 DOI: 10.1093/jbi/wbac079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Indexed: 03/01/2024]
Abstract
Breast US is a mainstay of modern-day breast imaging, especially in the diagnostic and interventional realm. The BI-RADS atlas described six echo patterns relative to the subcutaneous mammary fat: anechoic, hypoechoic, complex cystic and solid, isoechoic, heterogeneous, and hyperechoic. Hyperechoic breast masses demonstrate increased echogenicity relative to subcutaneous mammary fat or equal to fibroglandular tissue. Pathologically, the hyperechoic pattern at breast US results from the intermingling of different components: adipose tissue, fibrous tissue or stroma, secretions, blood or vascularity, and calcifications. Most hyperechoic masses are benign, especially homogeneously hyperechoic masses. However, hyperechogenicity does not exclude malignancy. Two echo patterns have been identified in hyperechoic malignant lesions, including those with a hypoechoic center and hyperechoic rim known as the rim pattern and a mass with hyperechoic areas distributed through the mass known as a dispersed pattern. This article aims to illustrate the echogenic patterns of breast lesions and various benign and malignant hyperechoic breast lesions with radiologic-pathologic correlation and to increase awareness of heterogeneously hyperechoic breast lesions as a manifestation of malignancy.
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Affiliation(s)
- Allyson L Chesebro
- Brigham and Women's Hospital, Department of Radiology, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Sumita Joseph
- Brigham and Women's Hospital, Department of Radiology, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - M Gabriela Kuba
- Memorial Sloan Kettering Cancer Center, Department of Pathology, New York, NY, USA
| | - Susan Lester
- Harvard Medical School, Boston, MA, USA
- Brigham and Women's Hospital, Department of Pathology, Boston, MA, USA
| | - Catherine S Giess
- Brigham and Women's Hospital, Department of Radiology, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Majithia J, Haria P, Popat P, Katdare A, Chouhan S, Gala KB, Kulkarni S, Thakur M. Fat necrosis: A consultant's conundrum. Front Oncol 2022; 12:926396. [PMID: 36873302 PMCID: PMC9978799 DOI: 10.3389/fonc.2022.926396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 11/21/2022] [Indexed: 02/18/2023] Open
Abstract
Fat necrosis of the breast is a benign non-suppurative inflammation of the adipose tissue and often mimics breast cancers, posing a diagnostic challenge for the clinician and radiologist. It has a myriad of appearances on different imaging techniques, ranging from the pathognomic oil cyst and benign dystrophic calcifications to indeterminate focal asymmetries, architectural distortions, and masses. A combination of different modalities can assist a radiologist in reaching a logical conclusion to avoid unnecessary interventions. The aim of this review article was to provide a comprehensive literature on the various imaging appearances of fat necrosis in the breast. Although a purely benign entity, the imaging appearances on mammography, contrast-enhanced mammography, ultrasound, and magnetic resonance imaging can be quite misleading, especially in post-therapy breasts. The purpose is to provide a comprehensive and all-inclusive review on fat necrosis with a proposed algorithm allowing a systematic approach to diagnosis.
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Affiliation(s)
| | - Purvi Haria
- Radiology Department, Tata Memorial Hospital, Mumbai, India
| | - Palak Popat
- Radiology Department, Tata Memorial Hospital, Mumbai, India
| | - Aparna Katdare
- Radiology Department, Tata Memorial Hospital, Mumbai, India
| | - Sonal Chouhan
- Radiology Department, Tata Memorial Hospital, Mumbai, India
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Vijayaraghavan GR, Kona M, Maheswaran A, Kandil DH, Toke MK, Vedantham S. Ultrasound Imaging Morphology is Associated with Biological Behavior in Invasive Ductal Carcinoma of the Breast. J Clin Imaging Sci 2021; 11:48. [PMID: 34513212 PMCID: PMC8422408 DOI: 10.25259/jcis_60_2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 08/11/2021] [Indexed: 11/13/2022] Open
Abstract
Objectives: Ultrasound (US) is commonly used for diagnostic evaluation of breast lesions. The objective of this study was to investigate the association between US imaging morphology from routine radiologists’ interpretation and biological behavior such as receptor status and tumor grade determined from histopathology in invasive ductal carcinoma (IDC). Material and Methods: This retrospective study included 453 patients with pathology-verified diagnosis of IDC who had undergone US imaging and had surgery over a 5-year period. US and surgical pathology reports were reviewed and compiled. Correlation analyses and age-adjusted multivariable models were used to determine the association between US imaging morphology and receptor status, tumor grade, and germ line mutation of the breast cancer genes (BRCA1 and BRCA2). The odds ratio (OR), area under receiver operating characteristic curve (AUC), and 95% confidence intervals (CI) were obtained. Results: The likelihood for high-grade cancer increased with size (OR: 1.066; CI: 1.042–1.091) and hypo-echogenicity (OR: 2.044; CI: 1.337–3.126), and decreased with angular or spiculated margins (OR: 0.605; CI: 0.393–0.931) and posterior acoustic shadowing (OR: 0.352; CI: 0.238–0.523). These features achieved an AUC of 0.799 (CI: 0.752–0.845) for predicting high-grade tumors. The likelihood for Estrogen Receptor-positive tumors increased with posterior acoustic shadowing (OR: 3.818; CI: 2.206–6.607), angulated or spiculated margins (OR: 2.596; CI: 1.159–5.815) and decreased with US measured tumor size (OR: 0.959; CI: 0.933–0.986) and hypoechoic features (OR: 0.399; CI: 0.198– 0.801), and achieved an AUC of 0.787 (CI: 0.733–0.841). The likelihood for Progesterone Receptor-positive tumors increased with posterior acoustic shadowing (OR: 2.732; CI: 1.744–4.28) and angulated or spiculated margins (OR: 2.618; CI: 1.412–4.852), and decreased with US measured tumor size (OR: 0.961; CI: 0.937–0.985) and hypoechoic features (OR: 0.571; CI: 0.335–0.975), and achieved an AUC of 0.739 (CI: 0.689–0.790). The likelihood for Human epidermal growth factor receptor 2-positive tumors increased with heterogeneous echo texture (OR: 2.141; CI: 1.17– 3.919) and decreased with angulated or spiculated margins (OR: 0.408; CI: 0.177–0.944), and was marginally associated with hypoechoic features (OR: 2.101; CI: 0.98–4.505) and circumscribed margins (OR: 4.225; CI: 0.919–19.4). The model with the aforementioned four US morphological features and achieved an AUC of 0.686 (CI: 0.614–0.758). The likelihood for triple-negative breast cancers increased with hypo-echogenicity (OR: 2.671; CI: 1.249–5.712) and decreased with posterior acoustic shadowing (OR: 0.287; CI: 0.161–0.513), and achieved an AUC of 0.739 (CI: 0.671– 0.806). No statistical association was observed between US imaging morphology and BRCA mutation. Conclusion: In this study of over 450 IDCs, significant statistical associations between tumor grade and receptor status with US imaging morphology were observed and could serve as a surrogate imaging marker for the biological behavior of the tumor.
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Affiliation(s)
- Gopal R Vijayaraghavan
- Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts, United States
| | - Matthew Kona
- Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts, United States
| | - Abiramy Maheswaran
- Department of Medical Oncology, University of Massachusetts Medical School, Worcester, Massachusetts, United States
| | - Dina H Kandil
- Department of Pathology, University of Massachusetts Medical School, Worcester, Massachusetts, United States
| | - Madhavi K Toke
- Department of Medical Oncology, University of Massachusetts Medical School, Worcester, Massachusetts, United States
| | - Srinivasan Vedantham
- Department of Medical Imaging, University of Arizona, Tucson, Arizona, United States
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9
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Ramani SK, Rastogi A, Nair N, Shet TM, Thakur MH. Hyperechoic Lesions on Breast Ultrasound: All Things Bright and Beautiful? Indian J Radiol Imaging 2021; 31:18-23. [PMID: 34316107 PMCID: PMC8299501 DOI: 10.1055/s-0041-1729124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Ultrasound (US) lexicon of the Breast Imaging Reporting and Data System (BI-RADS) defines an echogenic breast mass as a lesion that is hyperechoic in comparison with subcutaneous adipose tissue. However, at sonography, only 0.6 to 5.6% of breast masses are echogenic and the majority of these lesions are benign. approximately, 0.5% of malignant breast lesions appear hyperechoic. The various benign pathologic entities that appear echogenic on US are lipoma, hematoma, seroma, fat necrosis, abscess, pseudoangiomatous stromal hyperplasia, galactocele, etc. The malignant diagnoses that may present as hyperechoic lesions on breast US are invasive ductal carcinoma, invasive lobular carcinoma, metastasis, lymphoma, and angiosarcoma. Echogenic breast masses need to be correlated with mammographic findings and clinical history. Lesions with worrisome features such as a spiculated margin, interval enlargement, interval vascularity, or association with suspicious microcalcifications on mammography require biopsy. In this article, we would like to present a pictorial review of patients who presented to our department with echogenic breast masses and were subsequently found to have various malignant as well as benign etiologies on histopathology.
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Affiliation(s)
- S K Ramani
- Department of Radiodiagnosis, Dr. D. Y. Patil Medical College, Navi Mumbai, Maharashtra, India
| | - Ashita Rastogi
- Department of Radiodiagnosis, Delhi State Cancer Institute, New Delhi, India
| | - Nita Nair
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Tanuja M Shet
- Department of Pathology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Meenakshi H Thakur
- Department of Radiodiagnosis, Tata Memorial Hospital, Mumbai, Maharashtra, India
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10
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AlSharif S, Alshamrani KM, Scaranelo A, Khoumais N, Subahi A, Mesurolle B. Unusual Male Breast Lesions. J Clin Imaging Sci 2021; 11:21. [PMID: 33948337 PMCID: PMC8088480 DOI: 10.25259/jcis_43_2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 03/18/2021] [Indexed: 12/18/2022] Open
Abstract
Most of male breast masses are benign with gynecomastia being the most common entity encountered. Primary male breast cancer accounts for less than 1% of the total number of breast cancer. Male breast can be affected by a variety of conditions affecting the female breast with less frequency due to the lack of hormonal influence and consequent glandular sub-development. Imaging features of male breast masses are quite similar to the female breast. Therefore, using the knowledge of the female breast and applying it may help in the diagnosis and management of male breast abnormalities. In this article, we aim to review a variety of unusual male breast masses. We discuss the demographics of male breast tumors, describe the diagnostic algorithm for evaluating male breast masses, and review the imaging features of rare breast masses and mimickers of male breast cancer.
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Affiliation(s)
- Shaza AlSharif
- Department of Medical Imaging, Ministry of the National Guard - Health Affairs, Saudi Arabia.,Department of Radiological Sciences, College of Applied Medical Sciences, King Saud bin Abdulaziz University for Health Sciences, Saudi Arabia.,King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Khalid Misfer Alshamrani
- Department of Radiological Sciences, College of Applied Medical Sciences, King Saud bin Abdulaziz University for Health Sciences, Saudi Arabia.,King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Anabel Scaranelo
- Department of Medical Imaging, University of Toronto, Toronto, Canada
| | - Nuha Khoumais
- Department of Radiology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Ahmad Subahi
- Department of Radiological Sciences, College of Applied Medical Sciences, King Saud bin Abdulaziz University for Health Sciences, Saudi Arabia.,Department of Basic Sciences, College of Science and Health Professions, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Benoit Mesurolle
- Department of Radiology, Pôle Santé République, Clermont-Ferrand, France
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11
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Mohamed A. Breast hamartoma: Unusual radiological presentation. Radiol Case Rep 2020; 15:2714-2717. [PMID: 33133326 PMCID: PMC7585869 DOI: 10.1016/j.radcr.2020.10.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 10/06/2020] [Accepted: 10/06/2020] [Indexed: 12/03/2022] Open
Abstract
Breast hamartomas are uncommon slowly growing lesions. Imaging findings are specific and usually relay on common mammographic picture of breast within breast appearance. I present a case of 48 years female patient, with recent history of palpable right breast mass, the imaging findings are atypical for breast hamartoma. The unusual presentation of breast hamartomas necessitates biopsy to exclude tumor. Incidence of malignancy is low, however has been reported before. Characteristic radiological imaging can help to minimize unnecessary surgery and morbidity.
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Affiliation(s)
- Abeer Mohamed
- Medical imaging Department, King Hamad University Hospital, Kingdom of Bahrain
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12
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Pryce C, Owen W. Palpable Masses after Mastectomy: Differentiating Benign Postoperative Findings from Recurrent Disease. JOURNAL OF BREAST IMAGING 2020; 2:501-510. [PMID: 38424907 DOI: 10.1093/jbi/wbaa048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Indexed: 03/02/2024]
Abstract
Due to postoperative changes, imaging evaluation of patients with palpable masses after mastectomy can be challenging. There is considerable overlap between the imaging characteristics of recurrent disease and benign postoperative findings in patients with or without breast reconstruction. US is the initial modality of choice for evaluating palpable masses in most patients after mastectomy. In cases where US findings are not classic, however, other modalities are useful in problem solving, including both mammography and MRI. It is imperative that radiologists are educated about benign and malignant imaging characteristics, further workup considerations, and appropriate management. In cases where findings are not characteristic across multiple imaging modalities, biopsy may be warranted.
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Affiliation(s)
- Cherah Pryce
- University of Kentucky, Department of Radiology, Lexington, KY
| | - Wendi Owen
- University of Kentucky, Department of Radiology, Lexington, KY
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13
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Chen Y, Zhou JH, Fan HX, Luo Y, Peng YL, Ma BY. Ultrasound Diagnosis of Breast Lymphoma and the Identification of Breast Infiltrating Ductal Carcinoma. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2020; 39:1203-1211. [PMID: 31891216 DOI: 10.1002/jum.15209] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 11/20/2019] [Accepted: 12/08/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES By analyzing the B-mode ultrasound and color Doppler flow imaging characteristics of breast lymphoma (BL) and breast infiltrating ductal carcinoma (BIDC), we expected to discriminate these diseases. METHODS Thirty-two patients with BL and 30 with BIDC confirmed pathologically were selected. The BL group was divided into nodular and diffuse groups. We analyzed and compared the general and imaging characteristics of the BL subgroups and the BIDC group. RESULTS The mean maximum diameter of BL was 54.93 ± 43.74 cm, and that of BIDC was 23.90 ± 6.79 cm (P < .05). The differences between the nodular BL and BIDC groups in a circumscribed margin (60.00% versus 20.00%), calcification (20.00% versus 53.33%), aggregation characteristics (0.00% versus 53.33%), and density (73.33% versus 10.00%) were statistically significant (P < .05). The differences between the diffuse BL and BIDC groups in calcification (6.67% versus 53.33%), aggregation characteristics (6.67% versus 53.33%) and density (40.00% versus 10.00%) were statistically significant (P < .05). The difference in a circumscribed margin (60% versus 13.33%) between the BL subgroups was statistically significant (P < .05). The blood flow signal in BL lesions was richer than that in BIDC lesions (P < .05). CONCLUSIONS Extrasuperior-quadrant single lesions in the BL group were larger than those in the BIDC group. The edges of the lesions in the nodular BL group were circumscribed and dense. Lesions in the diffuse BL group did not have a circumscribed margin, calcification, aggregation characteristics, or density. The blood flow signal in BL lesions was richer than that in BIDC lesions.
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Affiliation(s)
- Yang Chen
- Department of Ultrasound, West China Hospital, Sichuan University, Chengdu, China
- Key Laboratory for Neuroinformation of the Ministry of Education, University of Electronic Science and Technology of China, Chengdu, China
| | - Jie-Hong Zhou
- Department of Ultrasound, West China Hospital, Sichuan University, Chengdu, China
| | - Hong-Xia Fan
- Department of Ultrasound, West China Hospital, Sichuan University, Chengdu, China
| | - Yan Luo
- Department of Ultrasound, West China Hospital, Sichuan University, Chengdu, China
| | - Yu-Lan Peng
- Department of Ultrasound, West China Hospital, Sichuan University, Chengdu, China
| | - Bu-Yun Ma
- Department of Ultrasound, West China Hospital, Sichuan University, Chengdu, China
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14
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Kuba MG, Giess CS, Wieczorek TJ, Lester SC. Hyperechoic malignancies of the breast: Underlying pathologic features correlating with this unusual appearance on ultrasound. Breast J 2019; 26:643-652. [PMID: 31512794 DOI: 10.1111/tbj.13501] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 07/03/2019] [Accepted: 07/08/2019] [Indexed: 11/28/2022]
Abstract
Hyperechogenicity in the breast on ultrasound (US) is usually regarded as a benign feature with only rare hyperechoic malignancies reported to date. In this study, we evaluated the pathologic findings on core needle biopsy of hyperechoic lesions and investigated the histologic features in malignancies that give rise to an echogenic pattern. A total of 163 core needle biopsies (CNB) were performed for "hyperechoic" or "echogenic" lesions between 1/1/05 and 7/31/17. Lesions were classified based on the proportion of hyperechoic areas identified. We found that all lesions with a homogenous hyperechoic pattern (>90% hyperechoic) were benign (n = 17), regardless of the type of margins. Malignancies were found in 21% (7/34, six invasive carcinomas and one lymphoma) of heterogenous lesions with ≥50% hyperechoic areas (all with noncircumscribed margins) and in 31% of lesions with <50% hyperechoic areas (19/61, 14 invasive carcinomas, two lymphomas, and three metastases), including five with circumscribed margins (one invasive carcinoma, one lymphoma, and three metastases). Two major US patterns were identified in malignant lesions, those with a hypoechoic center and hyperechoic rim, corresponding to a central tumor area with dense stroma and tumor cells infiltrating adipose tissue at the periphery ("rim pattern"), and a second "dispersed pattern" with hyperechoic areas distributed throughout the lesion. Hyperechoic malignancies were found to be comprised of a complex intermixture of elements of differing echogenicity including tumor cells, adipose tissue, and fluid (in tubules, stromal clefts, or blood vessels). Our findings support the importance of radiologists specifying the echogenic pattern of hyperechoic lesions, as heterogenous lesions are associated with a higher risk of malignancy and pathologists should be alert to the associated pathologic findings.
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Affiliation(s)
- Maria G Kuba
- Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.,Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Catherine S Giess
- Division of Breast Imaging, Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Tad J Wieczorek
- Department of Pathology, Brigham and Women's Faulkner Hospital, Boston, Massachusetts
| | - Susan C Lester
- Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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15
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Vasei N, Shishegar A, Ghalkhani F, Darvishi M. Fat necrosis in the Breast: A systematic review of clinical. Lipids Health Dis 2019; 18:139. [PMID: 31185981 PMCID: PMC6560815 DOI: 10.1186/s12944-019-1078-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Accepted: 05/31/2019] [Indexed: 01/03/2023] Open
Abstract
Breast fat necrosis (FN) originates from aseptic fat saponification, which is a typical lipid cyst or a spiculated lesion called mammographic presentation which mimics malignancy. In order to avoid biopsy, it would be necessary to identify the spectrum of fat necrosis appearances. A systematic research was conducted in October 2018 by using PubMed, MEDLINE, Embase, Google Scholar databases and Google to search for science literature published after 2004. Therefore, the aim of this systematic review, it is that the FN can provide radiologists, surgeons, and oncologists with better insight and help them manage the condition efficiently.
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Affiliation(s)
- Narges Vasei
- Department of Surgery, Besat Hospital, AJA University of Medical Sciences, Tehran, Iran
| | - Azita Shishegar
- Department of Surgery, Besat Hospital, AJA University of Medical Sciences, Tehran, Iran
| | - Forouzan Ghalkhani
- Department of Surgery, Besat Hospital, AJA University of Medical Sciences, Tehran, Iran
| | - Mohammad Darvishi
- Infectious Diseases and Tropical Medicine Research Center (IDTMRC), Department of Aerospace and Subaquatic Medicine, AJA University of Medical Sciences, Tehran, Iran
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16
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17
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Tayyab SJ, Adrada BE, Rauch GM, Yang WT. A pictorial review: multimodality imaging of benign and suspicious features of fat necrosis in the breast. Br J Radiol 2018; 91:20180213. [PMID: 29987981 DOI: 10.1259/bjr.20180213] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Fat necrosis of the breast is a well-described benign entity that can result in unnecessary biopsy of breast lesions. The pathogenesis of fat necrosis is a non-suppurative inflammatory process of adipose tissue, which may be seen after trauma, surgery, biopsy, post-breast reconstruction, post-fat grafting, post-radiotherapy, infection, and duct ectasia, among other conditions. Clinically, these patients may be asymptomatic or may present with a palpable lump, skin tethering, induration, and occasionally axillary lymphadenopathy. Depending on the time at which diagnostic imaging is performed, fat necrosis can have highly variable appearances on different modalities as it evolves. This is directly related to whether inflammation or fibrosis is predominating within the lesion, and correlation with clinical history is paramount in evaluating these patients. This review aims to analyze benign and suspicious imaging features of fat necrosis confirmed by tissue sampling. Knowledge of both benign and malignant-appearing features of fat necrosis on conventional modalities such as mammography and ultrasound, as well as newer applications including digital breast tomosynthesis, PET/CT, and MRI, should help the radiologist minimize the number of unnecessary biopsies.
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Affiliation(s)
- Sidra J Tayyab
- 1 Diagnostic Radiology, University of Texas MD Anderson Cancer Center , Houston, TX , USA
| | - Beatriz E Adrada
- 1 Diagnostic Radiology, University of Texas MD Anderson Cancer Center , Houston, TX , USA
| | | | - Wei Tse Yang
- 1 Diagnostic Radiology, University of Texas MD Anderson Cancer Center , Houston, TX , USA
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18
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Journo G, Bataillon G, Benchimol R, Bekhouche A, Dratwa C, Sebbag-Sfez D, Tardivon A, Thibault F, Ala-Eddine C, Chérel P, Malhaire C. Hyperechoic breast images: all that glitters is not gold! Insights Imaging 2018; 9:199-209. [PMID: 29476429 PMCID: PMC5893486 DOI: 10.1007/s13244-017-0590-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 12/07/2017] [Accepted: 12/27/2017] [Indexed: 11/27/2022] Open
Abstract
Abstract Hyperechogenicity is a sign classically reported to be in favour of a benign lesion and can be observed in many types of benign breast lesions such as hamartoma, lipoma, angiolipoma, haemangioma, haematoma, fat necrosis, fibrosis and galactocele, among others. However, some rare malignant breast lesions can also present a hyperechoic appearance. Most of these hyperechoic malignant lesions present other characteristics that are more typically suggestive of malignancy such as posterior shadowing, a more vertical axis or irregular margins that help to guide the diagnosis. Post magnetic resonance imaging, second-look ultrasound may visualise hyperechoic malignant lesions that would not have been identified at first sight and radiologists must know how to recognise these lesions. Teaching Points • Some rare malignant breast lesions can present a hyperechoic appearance. • Malignant lesions present other characteristics that are suggestive of malignancy. • An echogenic mass with fat density on mammography does not require biopsy.
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Affiliation(s)
| | | | | | | | - Chloe Dratwa
- Institut Curie, 26 rue d'Ulm, 75005, Paris, France
| | | | | | | | | | - Pascal Chérel
- Centre René Huguenin, 35 rue Dailly, 92210, Saint-Cloud, France
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19
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Abstract
Breast lymphomas only account for approximately 0.15% of malignant breast carcinomas. Half of these are primary lymphomas, and the other half are metastatic to the breast. Ultrasound elastography has been proven to aid in the diagnosis of breast lesions as malignant or benign, with malignancy appearing stiffer compared with normal breast tissue. However, in this study, we review the findings of breast lymphoma on strain and shear wave ultrasonography. Lymphoma appears drastically different on sonoelastography than primary breast cancers, and it could easily be interpreted as benign. Therefore, the unique imaging findings in addition to the patient's clinical history are important in differentiating lymphoma of the breast from other possible diagnoses.
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20
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Arslan G, Celik L. Sonographically Unusual Breast Carcinomas, 2 Case Reports. Pol J Radiol 2016; 81:434-437. [PMID: 27822324 PMCID: PMC5085334 DOI: 10.12659/pjr.897780] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 02/15/2016] [Indexed: 01/18/2023] Open
Abstract
Background For infiltrative breast lesions; sonography might not always be as helpful as mammography and MRI (magnetic resonance imaging). For higher sensitivity and specificity, these 3 imaging methods should be carried out together. Radiologists should be aware of the patient’s history and complaints. Patients who have a specific history like a long-term drug treatment or a palpable tumour should be approached differently. Case Report We would like to present 2 cases with atypical sonographic findings. The first case is an infiltrative breast cancer with occult sonography findings in a patient with a history of a long-term immunosuppressive drug treatment due to kidney transplantation and the second case is a malignant breast tumour which is hyperechogenic on sonography. Conclusions Overall breast sonography should always be correlated with mammography in patients over 40 years old and the images should be interpreted along with the patient’s history and clinical status.
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Affiliation(s)
- Gozde Arslan
- Department of Radiology, Maltepe University, Istanbul, Turkey
| | - Levent Celik
- Radiologica Imaging Center, Maltepe University, Istanbul, Turkey
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21
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Nassar L, Issa G, Farah Z, El Zein Y, Berjawi G. Predictors of Malignancy in Hyperechoic Breast Lesions. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2016; 35:783-790. [PMID: 26969597 DOI: 10.7863/ultra.15.05020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Accepted: 07/28/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVES Hyperechogenicity has been strongly associated with benign breast lesions. Although it is correct in most cases, hyperechogenicity must not always be considered synonymous with benignancy, as hyperechoic breast cancers do occur. The purpose of this study was to review clinical and imaging characteristics of hyperechoic breast lesions, looking for features associated with malignancy. METHODS Institutional Review Board approval was granted for this research. A total of 19,417 sonographic examinations were performed between January 2009 and June 2013. Among these, hyperechoic lesions with histologic diagnoses, stability on long-term followup, or characteristic imaging appearances were included in the study. The patients' clinical charts, mammograms, and sonograms were reviewed. The clinical and imaging features were recorded, and the data was analyzed by the χ(2) test, Fisher exact test, and independent-samples t test, looking for statistically significant predictors of malignancy. RESULTS Among the 19,417 scans, 42 patients (0.2%) with 44 hyperechoic lesions were identified. Twenty-six lesions fulfilling the inclusion criteria were included in the study: 5 malignancies (3 invasive ductal carcinomas, 1 invasive lobular carcinoma, and 1 invasive mucinous cancer) and 21 benign lesions. An irregular shape, a nonparallel orientation, and noncircumscribed margins were significantly associated with the risk of malignancy (P = .002, .02, and .01, respectively). CONCLUSIONS A hyperechoic breast lesion must not always be assumed to be benign. Instead, a full sonographic assessment according to the American College of Radiology Breast Imaging Reporting and Data System descriptors is needed for correct characterization and avoidance of misdiagnosis.
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Affiliation(s)
- Lara Nassar
- Department of Diagnostic Radiology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ghada Issa
- Department of Diagnostic Radiology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Zeina Farah
- Epidemiological Surveillance Program, Ministry of Public Health, Beirut, Lebanon
| | - Youssef El Zein
- Department of Diagnostic Radiology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ghina Berjawi
- Department of Diagnostic Radiology, American University of Beirut Medical Center, Beirut, Lebanon
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22
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Medeiros MM, Graziano L, de Souza JA, Guatelli CS, Poli MRB, Yoshitake R. Hyperechoic breast lesions: anatomopathological correlation and differential sonographic diagnosis. Radiol Bras 2016; 49:43-8. [PMID: 26929460 PMCID: PMC4770396 DOI: 10.1590/0100-3984.2014.0032] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Hyperechoic lesions are not a frequent finding at breasts ultrasonography, and
most of times are associated with benign pathologies that do not require further
evaluation. However, some neoplasms such as invasive breast carcinomas and
metastases may present with hyperechogenicity. Thus, the knowledge about
differential diagnoses and identification of signs of lesion aggressiveness are
of great relevance to avoid unnecessary procedures or underdiagnosis, and to
support the correct clinical/surgical approach. On the basis of such concepts,
the present essay describes and illustrates the main features of hyperechoic
lesions at breast ultrasonography in different cases, with anatomopathological
correlation.
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Affiliation(s)
- Marcelo Menezes Medeiros
- MD, Resident in Radiology, Department of Radiology and Imaging Diagnosis - A.C.Camargo Cancer Center, São Paulo, SP, Brazil
| | - Luciana Graziano
- Physicians, Department of Radiology and Imaging Diagnosis - A.C.Camargo Cancer Center, São Paulo, SP, Brazil
| | - Juliana Alves de Souza
- Physicians, Department of Radiology and Imaging Diagnosis - A.C.Camargo Cancer Center, São Paulo, SP, Brazil
| | - Camila Souza Guatelli
- Physicians, Department of Radiology and Imaging Diagnosis - A.C.Camargo Cancer Center, São Paulo, SP, Brazil
| | - Miriam Rosalina B Poli
- Physicians, Department of Radiology and Imaging Diagnosis - A.C.Camargo Cancer Center, São Paulo, SP, Brazil
| | - Rafael Yoshitake
- Physicians, Department of Radiology and Imaging Diagnosis - A.C.Camargo Cancer Center, São Paulo, SP, Brazil
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23
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Goh LW, Wong SLJ, Tan PH. Four cases of echogenic breast lesions: a case series and review. Singapore Med J 2016; 57:339-43. [PMID: 26891743 DOI: 10.11622/smedj.2016042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Echogenic breast lesions are generally thought to be benign. We herein report four cases of echogenic breast lesions that were seen at our centre over 38 months. One patient had a prior history of wide excision and radiotherapy for breast cancer and was imaged as part of routine cancer surveillance, while the other three were recalled for further assessment following an abnormal screening mammogram. All four patients were assessed on ultrasonography, which demonstrated an echogenic lesion in each patient. All four lesions underwent ultrasonography-guided core biopsy, followed by excision biopsy. The indications for biopsy were interval increase in the size of lesion or indeterminate features demonstrated in the lesion. Three lesions were benign, while the lesion from the patient who had received previous radiotherapy was angiosarcoma. Not all echogenic lesions are benign and lesions with suspicious features on ultrasonography should undergo biopsy.
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Affiliation(s)
- Lin Wah Goh
- Department of Diagnostic Radiology, Khoo Teck Puat Hospital, Singapore
| | - Su Lin Jill Wong
- Department of Oncologic Imaging, National Cancer Centre, Singapore
| | - Puay Hoon Tan
- Department of Pathology, Singapore General Hospital, Singapore
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24
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Lepori D. Inflammatory breast disease: The radiologist's role. Diagn Interv Imaging 2015; 96:1045-64. [PMID: 26372222 DOI: 10.1016/j.diii.2015.07.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 07/05/2015] [Indexed: 11/16/2022]
Affiliation(s)
- D Lepori
- Réseau lausannois du sein et imagerie du Flon, rue de la Vigie 5, 1000 Lausanne, Switzerland.
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25
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Fat Necrosis of the Breast: A Pictorial Review of the Mammographic, Ultrasound, CT, and MRI Findings with Histopathologic Correlation. Radiol Res Pract 2015; 2015:613139. [PMID: 25861475 PMCID: PMC4378709 DOI: 10.1155/2015/613139] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Accepted: 01/27/2015] [Indexed: 11/17/2022] Open
Abstract
Fat necrosis of the breast is a challenging diagnosis due to the various appearances on mammography, ultrasound, CT, PET-CT, and MRI. Although mammography is more specific, ultrasound is a very important tool in making the diagnosis of fat necrosis. MRI has a wide spectrum of findings for fat necrosis and the appearance is the result of the amount of the inflammatory reaction, the amount of liquefied fat, and the degree of fibrosis. While CT and PET-CT are not first line imaging examinations for the diagnosis of breast cancer or fat necrosis, they are frequently performed in the surveillance and staging of disease. Knowledge of how fat necrosis presents on these additional imaging techniques is important to prevent misinterpretation of the imaging findings. Gross and microscopic appearances of fat necrosis depend on the age of the lesion; the histologic examination of fat necrosis is usually straightforward. Knowledge of the variable appearances of fat necrosis on a vast array of imaging modalities will enhance a radiologist's accuracy in the analysis and interpretation of fat necrosis versus other diagnoses.
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26
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Shim E, Song SE, Seo BK, Kim YS, Son GS. Lymphoma affecting the breast: a pictorial review of multimodal imaging findings. J Breast Cancer 2013; 16:254-65. [PMID: 24155754 PMCID: PMC3800721 DOI: 10.4048/jbc.2013.16.3.254] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2013] [Accepted: 09/06/2013] [Indexed: 11/30/2022] Open
Abstract
Hematological malignancies rarely affect the breast, and the majority of those that do are lymphomas. In this review, we describe the clinical aspects and multimodal imaging findings of breast lymphoma. We also illustrate the key clinical and radiological findings that allow it to be distinguished from various other malignant and benign diseases of the breast. Breast lymphoma manifests as a breast mass, a change in the subcutaneous tissue or the skin, or enlargement of the associated lymph node on radiological examination. Radiological findings associated with other breast malignancies, such as calcifications, spiculations, or architectural distortions are extremely rare. Skin and subcutaneous changes frequently accompany T-cell lymphoma. Multimodal breast imaging characteristics may aid in the diagnosis of breast lymphoma.
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Affiliation(s)
- Euddeum Shim
- Department of Radiology, Korea University Ansan Hospital, Ansan, Korea
| | - Sung Eun Song
- Department of Radiology, Korea University Ansan Hospital, Ansan, Korea
| | - Bo Kyoung Seo
- Department of Radiology, Korea University Ansan Hospital, Ansan, Korea
| | - Young-Sik Kim
- Department of Pathology, Korea University Ansan Hospital, Ansan, Korea
| | - Gil Soo Son
- Department of General Surgery, Korea University Ansan Hospital, Ansan, Korea
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