Breast nonmalignant
Benign tumors / changes
Hemangioma and angiomatosis of breast

Author: Monika Roychowdhury, M.D. (see Authors page)

Revised: 7 December 2017, last major update November 2017

Copyright: (c) 2003-2017, PathologyOutlines.com, Inc.

PubMed Search: Hemangioma [title] breast
Cite this page: Roychowdhury, M. Hemangioma and angiomatosis of breast. PathologyOutlines.com website. http://www.pathologyoutlines.com/topic/breasthemangioma.html. Accessed December 12th, 2017.
Definition / general
    Hemangioma
  • Benign tumor or malformation of blood vessels (vascular malformation), well circumscribed, lined by flattened endothelial cells with no cytologic atypia
  • Origin from large nonneoplastic "feeding" vessels may be seen at the periphery of the lesion
  • May be divided in following categories:
    • Capillary (composed of capillary sized vessels)
    • Cavernous (large dilated vessels)
    • Venous (1 - 5 cm, proliferation of venous channels)
    • Perilobular (2 cm or less, perilobular location, may have nuclear pleomorphism and hyperchromasia but no complex anastomoses, no endothelial tufting, no mitotic figures) (Am J Surg Pathol 1985;9:491)

    Atypical Hemangioma
  • Nuclear pleomorphism; may have focal anastomosing vascular channels, microthrombi or rare mitotic figures but no significant solid areas, no necrosis, no hemorrhage, no endothelial growth patterns of angiosarcoma; has benign behavior, which should be indicated in report in comment section (Am J Surg Pathol 1992;16:553)

    Angiomatosis
  • Very rare (consultation recommended before making this diagnosis); associated with smoking, may recur after excision
  • Hemangioma and lymphangioma-like channels growing diffusely in breast tissue but sparing lobules and without nuclear atypia
  • May respond to isotretinoin (see Case reports below)
Essential features
  • All age groups, mass-like lesion on imaging
  • Well circumscribed nodule composed of vascular channels lined by flattened endothelial cells
  • Size of the vascular channels may vary, however, no complex anastomotic channels, solid areas, mitotic activity, necrosis or hemorrhage (excluding biopsy related change) should be seen
  • Involves breast stroma but does not invade lobules or ducts
  • Atypical hemangioma can have mild to moderate cytologic atypia and rare mitosis but no necrosis, hemorrhage or solid areas
  • Angiomatosis shows diffuse growth (but not infiltrative) but otherwise benign cytologic features
  • Diferential diagnosis: lymphangioma (for hemangioma) and angiosarcoma (for atypical hemangioma)
  • Excision is the treatment of choice
Epidemiology
Diagrams / tables

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Normal arterial and venous anatomy of the breast

Clinical features
  • Painless mass in breast or incidental mass lesion on imaging
Diagnosis
  • Biopsy or excision
Radiology description
  • Hemangioma: lobulated mass with well circumscribed or microlobulated borders, variable internal echotexture and variable calcifications
  • Difficult to differentiate from fibroadenoma or complex cysts
Radiology images

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Fig 2: Vessels converging in medial and lateral margins

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Fig 14a and 14b: Hemangiomas appear as superficially located oval with circumscribed or microlobulated borders

Prognostic factors
  • Can recur; no metastasis reported
Case reports
Treatment
  • Complete excision
Clinical images

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Image contributed by Dr. Mark R. Wick

Capillary hemangioma, breast skin



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Diffuse dermal angiomatosis

Gross images

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Angiomatosis composed
of vessels and breast
parenchyma


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Soft tissue mass with smooth external surface

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Cut surface shows congestion and slit like areas

Microscopic (histologic) description
    Hemangioma
  • Well circumscribed lesion with dilated vascular channels containing red blood cells and lined by flat endothelial cells
  • Does not invade or destroy the lobules
  • Cytologic atypia, hemorrhage and necrosis are absent

    Angiomatosis
  • Diffuse growth of large irregular vascular spaces lined by flattened endothelial cells without a muscular wall, with or without luminal red blood cells
  • Surrounds breast ducts and lobules without invading them
  • No cytologic atypia seen
  • Can have lymphatic channels

    Atypical hemangioma
  • Vascular proliferation with endothelial hyperplasia, nuclear pleomorphism, anastomotic channels, microthrombi and rare mitotic figures
  • Absence of destructive invasion, solid areas, hemorrhage and necrosis are important in differentiating from angiosarcoma
Microscopic (histologic) images

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Images hosted on PathOut server:

Angiomatosis:

Dilated vascular channels in breast tissue

Anastomosing
vascular channels,
flat endothelial cells,
no smooth muscle



Atypical hemangioma:

Cavernous vessels infiltrating into fat

Branching
vascular channels
lined by bland
endothelium

Cavernous
hemangioma above
and branching vascular
channels below



Capillary hemangioma:

Thin walled vessels of various sizes with
bland endothelium and complex branching
vessels are suggestive of granuloma
pyogenicum but without inflammation



Cavernous hemangioma:

Well circumscribed with dilated vascular channels, lobular-like pattern of dilated vessels but no anastomosing channel, vascular spaces are lined by inconspicuous endothelium; organizing clot with recanalization, no / rare Ki67 staining



Perilobular hemangioma:

Lesion in stroma is not lobules or ducts

Thin walled vessels
are congested
and extend into
adjacent fat



Atypical perilobular hemangioma:

Inconspicuous slit-like vascular spaces lacking red blood cells

Hyperchromatic endothelial nuclei

Extension into fat
and no distinct
congested
capillary channels

Compact vascular
proliferation
associated with
terminal duct



Contributed by Dr. Mark R. Wick:

Epithelioid

Lobular capillary

Tufted

Venous



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Angiomatosis:
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Hemangioma (black arrows), breast ducts and lobules

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Abnormal vascular spaces in the hemangioma

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Fig 14c: hemangioma

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Dilated vascular and lymphatic spaces

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Breast acini not involved by the vascular growth

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Vascular and lymphatic spaces lined by endothelial cells


Angiomatosis: diffuse dermal angiomatosis (H&E and CD31)

Atypical hemangioma: various images



Capillary hemangioma:

Thin walled vessels of various sizes with bland endothelium and complex branching vessels are suggestive of granuloma pyogenicum but without inflammation

Positive stains
Negative stains
Videos


Histopathology breast, soft tissue - hemangioma
Differential diagnosis
  • Angiosarcoma (for highly pleomorphic atypical hemangioma) has solid areas, mitotic activity, infiltrative pattern of growth and complex anastomosing vascular channels
Board review question #1
    A 54 year old woman had a breast lump. A stereotactic biopsy showed vascular channels lined by mildly pleomorphic endothelial cells and rare mitotic activity, however, no solid areas or necrosis was seen. What is the best treatment recommendation for this patient?

  1. Excision
  2. Lumpectomy with hormone receptor analysis for further treatment
  3. Lumpectomy with radiation
  4. No further treatment needed
Board review answer #1
A. This is an atypical hemangioma. Excision is adequate treatment.