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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 15  |  Issue : 3  |  Page : 474-476

Ultrasonography, doppler, and elastograhic imaging of sebaceous cyst of breast


Department of Radio Diagnosis, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University) ,Wardha, Maharashtra, India

Date of Submission18-Sep-2020
Date of Decision24-Sep-2020
Date of Acceptance29-Sep-2020
Date of Web Publication1-Feb-2021

Correspondence Address:
Dr. Suresh Phatak
Department of Radio-Diagnosis, Jawaharlal Nehru Medical College, Sawangi (Meghe) Wardha - 442 001, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_136_19

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  Abstract 


Sebaceous cysts are very common, but their location in breast is unusual. The most common site of occurrence is the face, trunk, and neck. Breast ultrasound and elastography provides readily available, noninvasive, and cost-effective modality for evaluating various breast masses and discriminating between benign and malignant pathologies. We present an interesting case of a 66-year-old woman who presented with a history of a nontender lump in the left breast with the presence of a punctum. Gray-scale ultrasound, color Doppler, and sono-elastography findings are discussed.

Keywords: Breast lump, color Doppler, sebaceous cyst, sono-elastography, ultrasound


How to cite this article:
Patwa P, Phatak S, Lohchab B, Gulve S. Ultrasonography, doppler, and elastograhic imaging of sebaceous cyst of breast. J Datta Meghe Inst Med Sci Univ 2020;15:474-6

How to cite this URL:
Patwa P, Phatak S, Lohchab B, Gulve S. Ultrasonography, doppler, and elastograhic imaging of sebaceous cyst of breast. J Datta Meghe Inst Med Sci Univ [serial online] 2020 [cited 2021 Feb 25];15:474-6. Available from: http://www.journaldmims.com/text.asp?2020/15/3/474/308543




  Introduction Top


Sebaceous glands are holocrine glands, which develop from an epithelial bud and derive from the outer root sheath of the embryonic hair follicles. They are present in all parts of the human body, apart from the palmar and plantar regions, but are abundant on the face and scalp. As their origin suggests, they are usually observed in association with hair follicles.[1] Sebaceous cyst is a retention cyst caused by the occlusion of one or more ducts of sebaceous glands with the accumulation of the secretion.[2] Sebaceous cysts, therefore, are benign, capsulated, subepidermal nodules, lled with very dense keratin and often, calci?cations and cholesterol. They may slowly increase in size or remain volumetrically constant for years.[1]


  Case Report Top


A 66-year-old female presented with a palpable mass in the inner lower quadrant of the left breast which was present for 12 years. It was small initially (size of a pea) and gradually grew to the current size (size of a lemon). On clinical examination, a firm, nontender mass was palpated, which was mobile and showed the presence of a punctum [Figure 1]. No palpable mass was felt in the right breast. The patient was referred to the radiology department for further evaluation. Gray-scale ultrasound revealed a well-circumscribed, oval, heterogeneously hypoechoic mass in the left breast measuring approximately 42 mm × 26 mm [Figure 2]. The lesion was wider than taller and showed some tiny calcifications within. Minimal vascularity was noted on color and power Doppler [Figure 3]. There were multiple reactive lymph nodes noted in the bilateral axilla with a normal right breast. Elastographic imaging showed Score 2 (combination of green and blue on elastography color scale) with a strain ratio of 3.80, indicating a benign lesion [Figure 4]. An ultrasound-guided fine-needle aspiration cytology was performed, and the mass was further investigated by the pathologist, which showed clumps of squamous cells without nucleus and few foamy cytoplasmic flakes with the morphology suggestive of squamous inclusion cyst/sebaceous cyst.
Figure 1: Lump in the inner lower quadrant of the left breast with punctum (black arrowhead)

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Figure 2: Gray-scale ultrasound showing a well-circumscribed, oval, heterogeneously hypoechoic mass in the left breast measuring approximately 42 mm × 26 mm

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Figure 3: Color Doppler taking up minimal vascularity over the breast lesion

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Figure 4: El, indicating benign lesion

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  Discussion Top


Sebaceous cyst, also known as epidermal inclusion cyst, is in fact a misnomer. It does not contain sebum and is formed by the inclusion of keratinizing squamous epithelium within the dermis, resulting in a cyst. It is a small, dome-shaped cyst that is very common and is either found incidentally or present as a firm, nontender lump which typically appears as a smooth, round nodule attached to the skin. Due to the rare location of appearance, it is not uncommon for breast sebaceous cysts to be clinically misdiagnosed initially.[2],[3]

Imaging plays a very important role in the accurate diagnosis, management, and follow-up of such patients. Ultrasound is a readily available and noninvasive modality which helps in delineating the size and extent of the mass, presence or absence of regional and distant lymphadenopathy, and vascular assessment of the tumor.

Sebaceous cyst of the breast appears as a well-circumscribed, usually noncalcified complex mass lesion on ultrasound, although older cysts can develop calcification. Alternating concentric hyperechoic and hypoechoic rings correspond to the layers of lamellated keratin.[4] In view of its uncommon occurrence, such palpable breast lump with the described sonographic appearance is more likely to be thought of as a fibroadenoma. In addition, in view of the increasing size of the lesion, tissue diagnosis needs to be carried out to exclude carcinoma with a well-defined border.[5]

Sono-elastography is an evolving ultrasound modality that aids in assessing the elasticity of tissues. Elasticity can be evaluated using the Tsukuba Elasticity Score, also known as the Itoh-Score or Elasto-Score, which is a 5-point scoring system where score 1 represents an even strain for entirely hypoechoic lesion (imparting an entire green color), score 2 represents strain in most of the hypoechoic areas while some areas with no strain (a mixed pattern of green and blue color is visualized), score 3 represents strain at the periphery of lesion sparing its center (where periphery is imparted green color and center appears blue), score 4 represents no strain in the entire hypoechoic lesion but sparing of its periphery (where center appears blue and periphery appears green), and a score of 5 represents no strain in the entire hypoechoic lesion (imparting an entire blue color). Lesions with scores 1 and 2 are considered benign, lesions with with score 3 are considered to be probably benign, and lesions with scores 4 and 5 are considered malignant.[6]

Strain ratio is another parameter used for interpreting the elasticity of tissues. It is a semi-quantitative measurement useful for differentiating benign from malignant lesions. It is obtained by comparing a strain within the lesion with that of the surrounding normal tissue of same depth. The higher the strain ratio, higher will be the probability of malignancy.[7]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Solivetti FM, Desiderio F, Elia F, Guerrisi A, Cota C, Morrone A. Sonographic appearance of sebaceous cysts. Our experience and a review of the literature. Int J Dermatol 2019;58:1353-9.  Back to cited text no. 1
    
2.
Mukherjee S, Datta P, Datta S. Atypical sebaceous cyst: Uncommon and unusual locations. Int Surg J 2016;2:431-3.  Back to cited text no. 2
    
3.
Crystal P, Levy RS. Concentric rings within a breast mass on sonography: Lamellated keratin in an epidermal inclusion cyst. AJR Am J Roentgenol 2005;184:S47-8.  Back to cited text no. 3
    
4.
Martin C, Bombard T, Coker M, Payne E, Yoxtheimer ML, Elsamalot H. Rare case of benign epidermal inclusion cyst mimicking malignancy. Appl Radiol 2016;45:34-6.  Back to cited text no. 4
    
5.
Lam SY, Kasthoori JJ, Mun KS, Rahmat K. Epidermal inclusion cyst of the breast: A rare benign entity. Singapore Med J 2010;51:e191-4.  Back to cited text no. 5
    
6.
Itoh A, Ueno E, Tohno E, Kamma H, Takahashi H, Shiina T, et al. Breast disease: Clinical application of US elastography for diagnosis. Radiology 2006;239:341-50.  Back to cited text no. 6
    
7.
Carlsen JF, Ewertsen C, Lönn L, Nielsen MB. Strain elastography ultrasound: An overview with emphasis on breast cancer diagnosis. Diagnostics (Basel) 2013;3:117-25.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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