REVIEW ARTICLE
Focal breast edema associated with malignancy on T2-weightedimages of breast MRI: peritumoral edema, prepectoral edema,and subcutaneous edema
Takayoshi Uematsu
Received: 17 June 2014 / Accepted: 7 October 2014 / Published online: 22 October 2014
� The Japanese Breast Cancer Society 2014
Abstract Edema, defined as high signal intensity on T2-
weighted images, is a useful breast MRI finding, which
compensates for the moderate specificity of breast MRI.
Although diffuse breast edema can be caused by benign
and malignant etiologies, focal edema is commonly asso-
ciated with malignancy except for previous procedures
including biopsy and surgery. For more accurate compre-
hension of the appropriate usage of breast edema, focal
breast edema should be divided into three different types:
peritumoral edema, prepectoral edema, and subcutaneous
edema. It is useful to review and clarify these types of focal
breast edema based on pathological findings as this may
help predict the likelihood of malignancy in breast MRI
lesions.
Keywords Breast � MRI � Edema � T2-weighted image �High signal intensity
Introduction
The sensitivity of breast MRI is high; however, the wide
range of specificities creates the need for further
improvement in breast MRI characterization [1–4]. A T2-
weighted image (T2WI) is a key to increase the specificity
of breast MRI [5–15]. Edema, defined as high signal
intensity (SI) on T2WI, is a useful breast MRI finding,
which can compensate for the moderate specificity of
breast MRI [5, 7, 8, 11–15]. Diffuse breast edema can be
caused by benign and malignant etiologies. The benign
etiologies include mastitis, post-radiation changes, post-
operative state, nephrotic syndrome, lymphoma, venous
congestion, and congestion heart failure [16]. However,
focal breast edema on T2WI is associated with malignancy
in the majority of cases [7, 8, 11–15], and is a very
important breast MRI finding, especially for inflammatory
breast cancer (IBC) and occult IBC [13–15]. For improved
understanding of the appropriate use of breast edema on
T2WI, focal edema can be divided into three different
types: peritumoral edema, prepectoral edema, and subcu-
taneous edema. Each focal breast edema has its own eti-
ology and location. This review article clarifies the findings
on the three different types of focal breast edema on T2WI
based on clinicopathological findings.
Peritumoral edema
The mechanisms of induction of peritumoral edema are
only partially understood. Increased vascular permeability
in newly formed tumor vessels and the release of peritu-
moral cytokines lead to peritumoral edema (Fig. 1) [7].
Increased vascular permeability may occur because of the
tumor volume that can cause increased peritumoral pres-
sure. The presence of central fibrosis is a cause of a pe-
ritumoral edema [10]. Furthermore, it is significantly more
common in malignant tumors of [2 cm in size [7]. In aprevious report, there were no cases of peritumoral edema
in masses of \10 mm in size [10]; therefore, tumor sizecan be a significant diagnostic factor. Moreover, peritu-
moral edema is specific to invasive breast cancer but less
frequently diagnosed in invasive lobular carcinoma (ILC)
when comparing ILC and invasive ductal carcinoma [17].
The primary reason may be the growth pattern of ILC and
the resulting low tumor density of the lesions. Comparing
T. Uematsu (&)Breast Imaging and Breast Intervention Section, Shizuoka
Cancer Center Hospital, Naga-Izumi, Shizuoka 411-8777, Japan
e-mail: [email protected]
123
Breast Cancer (2015) 22:66–70
DOI 10.1007/s12282-014-0572-9
the MRI findings of the three major different breast cancer
subtypes [triple-negative (TN), luminal, and HER2-over-
expressing], peritumoral edema was more common in TN
breast cancer [18]. The MRI findings of TN breast cancer,
including mass formation and rim enhancement, can help
diagnose the peritumoral edema [9, 18]. Additionally, pe-
ritumoral edema is significantly correlated with rim
enhancement [10].
Prepectoral edema
The primary lymphatic drainage from the whole breast is
to the axillary lymph nodes [19, 20]. The likelihood of
lymphatic drainage from the whole breast to the axillary,
internal mammary, infraclavicular, supraclavicular, and
interpectoral node areas are approximately, 98, 35, 2, 3,
and 1 %, respectively [20]. Breast cancer induces an
Fig. 1 A 72-year-old woman with a 27-mm intermediate-gradeinvasive ductal carcinoma of not otherwise specified. a An axial fat-suppressed T1-weighted dynamic breast MR image obtained at 120 s
after gadolinium administration shows a heterogeneous enhanced
mass with an irregular margin. b An axial fat-suppressed T2-weightedMR image shows a mass with an irregular border and peritumoral
edema (arrows). c The cut surface of a gross specimen reveals a masswith an irregular margin
Fig. 2 A 60-year-old woman with an 18-mm intermediate-gradeinvasive micropapillary carcinoma with marked lymphovascular
invasion. a An axial fat-suppressed T2-weighted MR image showsclear prepectoral edema (arrows) without a mass. b An axial fat-suppressed T1-weighted dynamic breast MR image obtained at 120 s
after gadolinium administration shows a non-mass enhancement
lesion. c, d The cut surface of gross specimens and a photomicrographof the histological specimen reveal extensive marked lymphovascular
invasion (arrows). The photomicrograph corresponds to the number
21 in c
Breast Cancer (2015) 22:66–70 67
123
increase in the number and diameter of tumor-draining
lymphatic vessels, consequently, lymph flow away from
the tumor is increased, which significantly increases
tumor cell metastasis toward drainage lymph nodes and
may contribute to systemic spread [21]. When primary
lymphatic drainage to the axilla is blocked by cancer
cells, drainage to the internal mammary and interpectoral
node areas can be the main collateral lymphatic drainage
routes [13–15, 19, 20]. Prepectoral edema is closely
related to a dilated lymphovascular system filled with
cancer cells in the retromammary area, including the
internal mammary and interpectoral node areas [14, 22,
23]. Consequently, prepectoral edema is suggested to be
caused by typical obstruction and dilation of lymphatic
drainage to the retromammary area by tumor emboli.
Uematsu et al. [15] reported that a high degree of lym-
phovascular invasion is significantly associated with pre-
pectoral edema (Fig. 2). Prepectoral edema is also
significantly associated with IBC and occult IBC (Fig. 3)
[13, 14].
Subcutaneous edema
Subcutaneous edema is caused when lymphatic drainage in
the dermal and subdermal area is blocked by tumor emboli
because of extensive lymphovascular invasion of the breast
(Fig. 4) [13, 14, 23]. Subcutaneous edema is considered a
final stage of breast edema associated with malignancy
according to the relationship between IBC and occult IBC
(Figs. 3, 4) [13, 14]. Occult IBC is defined as an invasive
cancer without any clinical IBC signs, such as edema, but
with pathologically proven dermal lymphovascular inva-
sion [14]. Therefore, the presence of prepectoral edema
always precedes that of subcutaneous edema in the theory
of malignant breast edema.
Fig. 3 A 62-year-old woman with left occult inflammatory breastcancer (IBC). a Photograph shows normal looking left breast withoutskin changes or breast swelling. b An axial fat-suppressed T2-weighted MR image shows clear peritumoral (arrow) and prepectoral
edema (arrowhead) with a mass. c An axial fat-suppressed T1-weighted dynamic breast MR image obtained at 60 s after gadolinium
administration shows a thin rim-enhancing mass. The breast cancer
advanced despite chemotherapy. d Photograph shows that erythema(arrows) and swelling appeared 2 months after chemotherapy. These
are diagnostic criteria for IBC. e An axial fat-suppressed T2-weightedMR image shows increased prepectoral edema (arrowhead) with a
mass. Slight subcutaneous edema also appears (small arrows). f Anaxial fat-suppressed T1-weighted dynamic breast MR image obtained
at 60 s after gadolinium administration shows the mass became larger
68 Breast Cancer (2015) 22:66–70
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Benign inflammatory breast disease
A study reported that prepectoral edema was observed in
some cases of acute mastitis (AM); however, it was sig-
nificantly associated with IBC compared with AM [22].
Furthermore, the main localization of AM is the subareolar
area because of ascending bacterial infection from the
nipple [22]. Another study reported that prepectoral edema
was not observed in 38 benign inflammatory breast dis-
eases [23]. It has also been suggested that most cases of
AM have no prepectoral edema because AM edema results
from inflammation of infection, not from lymphatic inva-
sion of cancer cells [13]. Therefore, the existence of pre-
pectoral edema is the key to distinguish between
benignancy and malignancy in case of diffuse breast
edema. Further studies are needed to analyze the relation-
ship between breast edema and a benign inflammatory
breast disease such as AM.
Other benign breast edema
Breast and skin edemas have been described as typical
MRI findings after radiation therapy [16, 24]. Post-opera-
tive edema has been reported to be related to the axillary
procedure [16]. Other benign etiologies that cause diffuse
breast edema are nephrotic syndrome, lymphoma, venous
congestion, and congestion heart failure [16]. In such cases,
knowledge of patient clinical history is very important to
diagnose them.
Summary
Focal breast edema can be divided into three different types:
peritumoral edema, prepectoral edema, and subcutaneous
edema. It is useful to review and clarify the findings on the
three different focal breast edemas on T2WI based on patho-
logical findings, because this can help to predict the likelihood
of malignancy of breast MRI lesions. Especially, prepectoral
edema has a low prevalence but is specific for breast cancer,
such as IBC and occult IBC, and is correlated with the prog-
nostic factors. Therefore, prepectoral edema can be a new
breast MRI sign that will increase the specificity.
Conflict of interest The author declares that they have no conflictof interest.
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Focal breast edema associated with malignancy on T2-weighted images of breast MRI: peritumoral edema, prepectoral edema, and subcutaneous edemaAbstractIntroductionPeritumoral edemaPrepectoral edemaSubcutaneous edemaBenign inflammatory breast diseaseOther benign breast edemaSummaryConflict of interestReferences
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