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: t.uematsu@scchr.jp

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

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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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