Contrast-Enhanced Breast Ultrasonography Reveals an Unusual Breast Tumor in a Male Patient With Gynecomastia

Abstract

Pseudoangiomatous stromal hyperplasia (PASH), first described in 1986, is a benign breast lesion consisting of complex, anastomosing, slitlike pseudovascular spaces, which are either acellular or lined by slender, spindle-shaped cells. 1,2 The exact etiology of PASH is unknown. It usually presents as a breast mass, affecting women in their reproductive years. Pseudoangiomatous stromal hyperplasia has been reported in at least 25% of cases of gynecomastia. 2 Although PASH is a benign lesion, it has a propensity for growth over time and local recurrence after excision.3 Several small-scale studies already described the mammographic and gray scale ultrasonographic findings of PASH. 3,4,5 To our knowledge, the appearance of PASH on contrast-enhanced ultrasonography (CEUS) of the breast has never been described before. In past years, CEUS has been used increasingly in clinical practice to characterize indeterminate breast lesions. 6-14 In CEUS, a contrast agent consisting of a suspension of microbubbles is used to increase the blood echogenicity and to improve detection of slow and low-volume blood flow in microvessels (<5 μm). Because malignant breast tumors display neoangiogenesis that can be depicted by the contrast agent, it is believed that CEUS can be used to characterize breast masses and distinguish benign from malignant lesions. In this report, we describe the case of an elderly male patient with gynecomastia in whom conventional mammography and gray scale ultrasonography revealed a solid tumor in the left breast that was suggestive of malignancy. Additional workup of the lesion included CEUS of the breast with SonoVue (Bracco SpA, Milan, Italy) microbubbles to analyze tumor vascularization. On the basis of the CEUS findings, the lesion was down-staged to a benign breast lesion, probably a PASH. 6-13 After ultrasonographically guided biopsy of the lesion, histologic examination of the tissue confirmed the diagnosis. We describe the imaging characteristics of PASH on CEUS and provide an in-depth review of the literature.