Presentation and Presenting Images

( ▶ Fig. 14.1, ▶ Fig. 14.2, ▶ Fig. 14.3, ▶ Fig. 14.4)

A 44-year-old female presents for asymptomatic screening mammography.

14.2 Key Images

( ▶ Fig. 14.5, ▶ Fig. 14.6, ▶ Fig. 14.7, ▶ Fig. 14.8)

14.2.1 Breast Tissue Density

The breasts are heterogeneously dense, which may obscure small masses.

14.2.2 Imaging Findings

Within the subareolar region of the right breast, there is a partially circumscribed and partially obscured mass with heterogeneous composition. There are elements of fat and fibroglandular tissue within the mass. The anterior, medial/lateral, and superior/inferior margins are well seen on the conventional digital mammograms ( ▶ Fig. 14.5 and ▶ Fig. 14.6). The posterior margin is obscured. The synthetic mammograms highlight this mass within the breast tissue and make it stand out more than on the conventional mammogram ( ▶ Fig. 14.3 and ▶ Fig. 14.4). The digital breast tomosynthesis (DBT) images better define all margins of this mass ( ▶ Fig. 14.7 and ▶ Fig. 14.8). The craniocaudal (CC) DBT is best for demonstrating the posterior margin ( ▶ Fig. 14.7). The left breast is normal.

14.3 BI-RADS Classification and Action

Category 2: Benign

14.4 Differential Diagnosis

1. 
   

   Hamartoma: This mass is encapsulated which is clearly seen on the DBT images. It also contains adipose and fibroglandular components.

   
   
2. 
   

   Fibroadenoma: These masses do not contain adipose components, They are isodense masses that typically present as circumscribed or partially circumscribed masses.

   
   
3. 
   

   Lipoma: Lipomas are encapsulated fatty masses; however, they do not contain fibroglandular components.

14.5 Essential Facts

• 
  

  Hamartomas account for 4.8% of benign breast tumors.

  
  
• 
  

  Most hamartomas are asymptomatic, but, if symptomatic, they present as a palpable lump.

  
  
• 
  

  Histologically hamartomas have all the constituents of normal breast tissue and thus are often reported as normal breast tissue on a biopsy report.

  
  
• 
  

  Hamartomas consist of varying degrees of normal breast tissue elements (benign parenchyma, epithelium, fibrous tissue, and adipose tissue).

  
  
• 
  

  Mammographically hamartomas appear as encapsulated or pseudoencapsulated tumors, but microscopically they are not encapsulated. Rather, the margin is composed of condensed fibrous tissue or collagen around the mass.

  
  
• 
  

  At DBT, a hamartoma has a round or oval shape with a thin, water-density capsule delineating its border.

14.6 Management and Digital Breast Tomosynthesis Principles

• 
  

  Most encapsulated masses that contain fat, such as hamartomas, lipomas, galactoceles, and lipid cysts, can be classified as benign.

  
  
• 
  

  Hamartomas (also called fibroadenolipomas) contain normal components of breast tissue. They are benign masses; however, due to their breast tissue components, they have the risk of developing breast cancer within them. Suspicious findings within a hamartoma should be evaluated.

14.7 Further Reading

[1] Freer PE, Wang JL, Rafferty EA. Digital breast tomosynthesis in the analysis of fat-containing lesions. Radiographics. 2014; 34(2): 343‐358 PubMed

[2] Wahner-Roedler DL, Sebo TJ, Gisvold JJ. Hamartomas of the breast: clinical, radiologic, and pathologic manifestations. Breast J. 2001; 7(2): 101‐105 PubMed

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