Doaa Ibrahim, MD

 A 47-year-old female patient complaining from tender mass in upper outer left breast. Clinically cord-like structures were palpable in the upper outer quadrant of her left breast.

 Craniocaudal (Fig. A) and mediolateral oblique (B) mammograms show superficial tubular densities. Breast ultrasound scan (Fig. C) showed a long, superficial, beaded, tubular, hypoechoic structure in the left breast at 3 o’ clock position. Additionally noted low-level echoes were seen within it. It measured 5 mm in its widest diameter and showed no flow on color by spectral Doppler study.

Left breast upper outer subcutaneous thrombophlebitis (Mondor’s disease)

Mondor’s disease of the breast is a benign, self-limiting condition; characterized by thrombophlebitis of the superficial veins of the mammary region (1). Direct trauma and pressure on the superficial veins of the breast leading to stasis has been postulated in the etiopathogenesis of the disease. Breast biopsy and surgery, trauma, infection and breast cancer are risk factors (2).

It commonly affects middle-aged women. Mammogram showed a superficial tubular density in the affected side. The Breast Imaging Reporting and Data System assessment was category 3 for these cases. A short-interval follow-up in six months was recommended.

Mondor's disease presents as a palpable cord or mass in the breast sometimes with pain. Sonographic and mammographic evaluations are indicated in patients with suspected Mondor’s disease. Finding a dilated tubular density may potentially be mistaken for a dilated duct. Mondor’s disease is managed conservatively with treatment of pain using anti inflammatory and analgesic drugs. Biopsy, anticoagulants and antibiotics are unnecessary (3).


1. Pugh CM, DeWitty RL. Mondor’s disease. J Natl Med Assoc 1996;:359–63.
2. Bejanga BI. Mondor’s disease: analysis of 30 cases. J R Coll Surg Edinb 1992;:322–4.
3. Shetty MK, Watson AB. Mondor’s disease of the breast: sonographic and mammographic findings. AJR Am J Roentgenol 2001;:893–6.

Doaa Ibrahim, MD, in radio-diagnosis, Zagazig University Hospitals and TechnoScan Centers in Egypt

Articles

Clinical History: A 47-year-old female patient complaining from tender mass in upper outer left breast. Clinically cord-like structures were palpable in the upper outer quadrant of her left breast.

Mondor’s Disease

 A 48-year-old female presented with vaginal bleeding, urinary frequency and lower abdominal pain.

 A large intra-uterine irregular margin prolapsed pedunculated mass attached to the uterine fundus via broad pedicle , extends down reaching to the upper vagina and the myometrium invaded in the lower part with loss of the characteristic cervical low signal smooth muscle (Fig. A), the mass displacing the urinary bladder anteriorly as well as the rectum posteriorly but still preserved fat planes between them and the outer myometrial layer. The lesion displaying heterogeneous high signal intensity at T2WI (Fig. A) and T2FS (Fig. B), with a small rounded left para-central more high signal intensity area , while in the T1WI (Fig. C) the lesion displaying heterogeneous low signal intensity and high signal intensity within the same left para-central area denoting methemoglobin from subacute hemorrhage. Minimal heterogeneous enhancement noted at the sagittal post contrast T1 WI (Fig. D).

 Pedunculated leiomyoma with sarcomatous changes( leiomyosarcoma).

 Leiomyomas are the most common uterine neoplasm and are composed of smooth muscle with varying amounts of fibrous connective tissue. As leiomyomas enlarge, they may outgrow their blood supply, resulting in various types of degeneration: hyaline or myxoid degeneration, calcification, cystic degeneration, and red degeneration. Leiomyomas are classified as submucosal, intramural, or subserosal (1-3).

Leiomyosarcomas account for one third of uterine sarcomas. Leiomyosarcomas may arise either de novo from uterine musculature or the connective tissue of uterine blood vessels or in a preexisting leiomyoma. The incidence of sarcomatous change in benign uterine leiomyomas is reported to be 0.1-0.8% (4).

Leiomyosarcoma usually presents as a massive uterine enlargement with irregular central zones of low attenuation, suggesting extensive necrosis and hemorrhage. The pattern of tumor spread is to the myometrium, pelvic blood vessels and lymphatics, contiguous pelvic structures, abdomen, and then distantly, most often to the lungs. Although it has been suggested that an irregular margin of a uterine leiomyoma on MRI is suggestive of sarcomatous transformation, the specificity of this finding has not been established (5).

 1. Parker WH, Fu YS, Berek JS. Uterine sarcoma in patients operated on for presumed leiomyoma and rapidly growing leiomyoma. Obstet Gynecol 1994; 83:414-418.
2. Garcia CR, Tureck RW. Submucosal leiomyomas and infertility. Fertil Steril 1984; 42:16-19.
3. Corson SL. Hysteroscopic diagnosis and operative therapy of submucous myoma. Obstet Gynecol Clin North Am 1995; 22:739-755.
4. Janus CJ, White M, Dottino P, Brodman M, Goodman H. Uterine leiomyosarcoma: magnetic resonance imaging. Gynecol Oncol 1989; 32:79 –81.
5. Pattani SJ, Kier R, Deal R, Luchansky E. MRI of uterine leiomyosarcoma. Magn Reson Imaging 1995; 13:331 –333

Clinical History: A 48-year-old female presented with vaginal bleeding, urinary frequency and lower abdominal pain.

Pedunculated Leiomyoma with Sarcomatous Changes (Leiomyosarcoma)

A 28-year-old man presented with history of pulsing noise in the head and progressive right hemiparesis. 

 Axial, coronal MR T2-WIs images and axial post-contrast MR T1-WI image show multiple flow voids and tubular structures lesion that involves the left tempro-parietal regions . The normal brain parenchyma is interspersed between the abnormal vessels no significant contrast enhancement detected. MRA shows enlarged arteries and draining veins, A-V shunting with early venous filling.

Classic left tempro-parietal arteriovenous malformations

 Vascular lesions of the brain are uncommon lesions that may pose a diagnostic challenge due to their similar clinical manifestations and imaging features. Different classification systems have been put forward. The most commonly used classification system separates vascular lesions into arteriovenous malformations (AVMs), which may be either pial or dural, depending on the location of the shunt; cavernous hemangiomas (or cavernomas); capillary telangiectasia; and developmental venous anomalies (DVAs, formerly known as venous angiomas) (1–3).

However, from a clinical, imaging, and prognostic standpoint, further subclassification of various diseases that were formerly subsumed under the heading “brain AVMs” seems necessary . MRA offers several advantages over conventional angiography. For example, because of its ability to image all vessels in a given volume, an AVM with multiple feeding arteries can be imaged noninvasively in a single study. In addition, 2-dimensional (2D) and 3-dimensional (3D) phase-contrast MRA can be used to examine the direction, rate, and quantity of blood flow. Another advantage of MRA is the ability to retrospectively examine images in any plane. (4–6).


1. Chaloupka JC, Huddle DC. Classification of vascular malformations of the central nervous system. Neuroimaging Clin N Am 1998;8(2):295–321.
2. Wagner BJ, Richardson KJ, Moran AM, Carrier DA. Intracranial vascular malformations. Semin Ultrasound CT MR 1995;16(3):253–268.
3. Zabramski JM, Henn JS, Coons S. Pathology of cerebral vascular malformations. Neurosurg Clin N Am 1999;10(3):395–410.
4. Lasjaunias PL, Landrieu P, Rodesch G, et al. Cerebral proliferative angiopathy: clinical and angiographic description of an entity different from cerebral AVMs. Stroke 2008;39(3):878–885.
5. Hoh BL, Putman CM, Budzik RF,Ogilvy CS. Surgical and endovascular flow disconnection of intracranial pial single-channel arteriovenous fistulae. Neurosurgery 2001;49(6):1351–1363; discussion 1363–1364.
6. Lasjaunias P, Manelfe C, Chiu M. Angiographic architecture of intracranial vascular malformations and fistulas: pretherapeutic aspects. Neurosurg Rev 1986;9(4):253–263.

Doaa Ibrahim, MD in radio-diagnosis, Zagazig University Hospitals and TechnoScan Centers in Egypt 

Case History: A 28-year-old man presented with history of pulsing noise in the head and progressive right hemiparesis.

Classic Left Tempro-parietal  Arteriovenous Malformations

 A 52-year-old female patient complaining from right hypochondrial pain and abdominal swelling for three months, nausea and vomiting.

 Large multilocular cyst involving most of the right hepatic lobe with enhanced through transmission. The content of the cysts having low-level echoes and mural nodules with papillary projections project into the cyst lumen.

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Triphasic CT axial images (arterial phase C-G), (portal phase H-K), (delayed phase L-M) showing large partially defined right hepatic cystic lesion, with heterogeneous enhanced soft tissue papillary projections and mural nodules in the arterial phase followed by wash out of contrast at both venous and delayed phases. Displaced surrounding abdominal structures by the large mass.

 A biliary cystadenocarcinoma is a rare cystic hepatic neoplasm. It can be thought of as a malignant counterpart of a biliary cystadenoma. The clinical symptoms are non-specific and are not distinctive from benign cystic liver lesions unless invasive growth of the tumor occurs or distant metastases are present.

The vast majority of these neoplasms are intrahepatic (97 percent) where a small proportion is extrahepatic (3 percent). Some biliary cystadenomas may rarely develop into a cystadenocarcinoma.

The appearance of the cyst fluid on CT is variable depending on its composition. It can range from that of water (HU = 0) to quite hyperattenuating if the cyst has been complicated by recent hemorrhage. Calcifications of septa or cyst wall may be seen. Additionally the septa may enhance following administration of contrast.

The MR signal intensity of biliary cystadenoma is variable on both T1- and T2-weighted images, depending on the content of the cyst fluid.


1. Levy AD, Murakata LA, Abbott RM et-al. From the archives of the AFIP. Benign tumors and tumorlike lesions of the gallbladder and extrahepatic bile ducts: radiologic-pathologic correlation. Armed Forces Institute of Pathology. Radiographics. 22 (2): 387-413.
2. Lewin M, Mourra N, Honigman I et-al. Assessment of MRI and MRCP in diagnosis of biliary cystadenoma and cystadenocarcinoma. Eur Radiol. 2006;16 (2): 407-13.
3. Horton KM, Bluemke DA, Hruban RH et-al. CT and MR imaging of benign hepatic and biliary tumors. Radiographics. 19 (2): 431-51.

Doaa Ibrahim, MD in radio-diagnosis, Zagazig University Hospitals and TechnoScan Centers in Egypt

Author | Doaa Ibrahim, MD

Articles

Mondor’s Disease

Pedunculated Leiomyoma with Sarcomatous Changes (Leiomyosarcoma)

Classic Left Tempro-parietal Arteriovenous Malformations

Biliary Cystadenocarcinoma