PMC4197888_01
Bilateral mammography: bilateral mediolateral oblique (a) and craniocaudal (b) mammographic views demonstrate scattered fibroglandular tissue with global asymmetry and focal skin thickening in the left breast which was classified as moderate suspicious BI-RADS 4c. There was also an isodense, round, circumscribed mass, measuring 12 x 8 mm in the outer upper quadrant, requiring complementary ultrasonography (encircled). Nipples are marked.
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Bilateral mediolateral oblique (MLO) and craniocaudal (CC) mammographic views demonstrated scattered fibroglandular tissue with global asymmetry and focal skin thickening in the left breast (arrow), categorized as moderately suspicious (BI-RADS 4c) (Figures 1(a) and 1(b)).
Breast ultrasonography: ultrasonography of the left breast confirmed a hypoechoic, irregular, indistinct mass, with internal vascularity, measuring 47 x 16 mm (a). Ultrasonography of the right breast depicted two irregular, hypoechoic, circumscribed, parallel to the skin masses measuring 29 x 9 mm and 17 x 8 mm in the lower outer quadrant, near the inframammary fold (b and c).
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Ultrasonography of the upper outer quadrant of the left breast confirmed a hypoechoic, irregular, indistinct mass with internal vascularity, measuring 47 x 16 mm (Figure 2(a)). Ultrasonography of the lower outer quadrant of the right breast, near the inframammary fold, depicted two irregular, hypoechoic, circumscribed masses parallel to the skin, measuring 29 x 9 and 17 x 8 mm (Figures 2(b) and 2(c)).
Small parts ultrasonography: cervical (a), popliteal (b), and abdominal wall (c) ultrasonography confirmed hypoechoic, well-defined masses in right submandibular gland topography, gastrocnemius muscle thickness, and the subcutaneous tissue, measuring 54 x 37 mm, 98 x 44 mm, and 73 x 47 mm, respectively.
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Details of these findings are shown in Figures 3(a), 3(b), and 3(c).
Abdominal ultrasonography and tomography: abdominal ultrasonography showed a hypoechoic, ill-defined, pancreatic mass measuring 49 x 36 mm (a). Although the mass affected the pancreatic head, the patient manifested no jaundice. This is justified by the absence of bile duct compression (b). Coronal abdominal CT imaging revealed a solid ill-defined mass in the pancreatic head (single arrow) (c) and another similar lesion in the subcutaneous tissue of the left lateral abdominal wall (double arrows) (c).
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Abdominal ultrasonography showed a 49 x 36 mm hypoechoic, ill-defined pancreatic mass (Figure 4(a)). This is justified by the absence of bile duct compression (Figure 4(b)). Abdominal CT confirmed an ultrasonographic mass in the pancreatic head (Figure 4(c)).
Chest X-ray and tomography: chest X-ray revealed ill-defined opacities in both lungs, especially in the middle and inferior field of the right lung (a). There was no mediastinal enlargement, a remarkable sarcoidosis radiographic sign. Axial high-resolution computer tomography (HRCT) scan revealed multiple ground-grass opacities in bilateral subpleural areas, associated with interlobular septal thickening (b).
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There was no mediastinal enlargement, which is a remarkable sarcoidosis radiographic sign (Figure 5(a)). A chest high-resolution computed tomography (HRCT) showed multiple ground-glass opacities in subpleural areas of both lungs, associated with interlobular septal thickening (Figure 5(b)).
Head and neck magnetic resonance imaging: axial T2 MRI revealed enlargement of the lateral rectus muscle of right orbit (arrows) (a). A coronal contrast-enhanced T1 MRI showed an infiltrating lesion centered in the right masticator space extending into the submandibular space involving the submandibular gland. Note the avid gadolinium enhancement pattern of the lesion and its ill-defined margins (b).
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Magnetic resonance imaging (MRI) of the brain was within normal limits, except for enlargement of the lateral rectus muscle of the right orbit, justifying clinical exophthalmos (Figure 6(a)). Head and neck MRI showed an infiltrative lesion centered in the right masticator space that extended into the submandibular space involving the submandibular gland with avid gadolinium enhancement pattern and ill-defined margins (Figure 6(b)).
Pathological diagnosis: routine hematoxylin-eosin stained section of the skin of abdominal wall (a and b) revealed lymphocytic and granulomatous infiltration, with epithelioid macrophages and sparse eosinophils (original magnification: [100x] and [400x], resp.). Immunohistochemical study (c) showed positivity for CD3, a T-cell marker (original magnification: [100x]).
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The skin specimen showed a monotonous lymphocytic infiltration, intermingled by irregular granulomas, and frequent eosinophils, occupying entirely the dermis (Figures 7(a) and 7(b)). Lymphocytes were diffusely positive for T-cell markers (CD2, CD3, CD5, and CD7) (Figure 7(c)).
Positron emission tomography (PET-CT): there were hypermetabolic lesions at previously known locations, such as the right masticator space (a), right breast (b), left abdominal wall (c), and left popliteal fossa (f), and also locations that were not previously diagnosed such as left axillary lymph node (d) and the left thigh muscle (e).
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The hematologist sent the patient to PET-CT for lymphoma staging (Figures 8(a), 8(b), 8(c), 8(d), and 8(e)). There were hypermetabolic lesions in previously known sites and also in cervical, axillary, and paravertebral lymph nodes.
Posttreatment mammography: left breast mediolateral oblique (a) and craniocaudal (b) mammographic views confirmed complete left breast lesion resolution after the 3rd chemotherapy cycle.
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Mammography confirmed breast lesion resolution (Figures 9(a) and 9(b)).