Fat necrosis of the breast simulating recurrent carcinoma after primary radiotherapy in the management of early stage breast carcinoma

Necrose gordurosa multinodular mamária: Diagnóstico diferencial com o carcinoma da mama através da citologia por punção aspirativa

A necrose gordurosa da mama é um processo de desintegração de células adiposas, acompanhado de uma reação granulomatosa de intensidade variável. E decorrente do reconhecimento de lipídios extravasados do citoplasma de adipócitos como substâncias estranhas ao meio extracelular. O quadro clínico-radiológico pode ocasionar dificuldades no diagnóstico diferencial com neoplasias mamárias. Neste relato é descrito um caso de necrose gordurosa multinodular mamária sendo enfatizada a importância da citologia por punção aspirativa com agulha fina para a confirmação do diagnóstico.

A new indication and surgical procedure to reduce fat necrosis after breast-conserving surgery using an inframammary adipofascial flap

BACKGROUND

There is little information on the risk factors for fat necrosis after breast-conserving surgery using an inframammary adipofascial flap (IAF).

METHODS

We conducted a retrospective cohort study from a single institution evaluating the risk factors for fat necrosis after breast-conserving surgery using an IAF (n = 41) performed from 2005 to 2020 for newly diagnosed stage 0-2 breast cancer or phyllodes tumor.

RESULTS

Age (≥50 years of age vs. <50 years of age), mammographic density (fatty vs. other) and operation period (before vs. after revision of surgical procedure and patient indication) were significantly associated with fat necrosis (p = 0.006, p = 0.04 and p = 0.02, respectively).

CONCLUSION

Our study suggested that the use of an IAF with crescent dermis and selection of appropriate cases for IAF after breast-conserving surgery may be useful for the purpose of reducing fat necrosis. Further study is needed.

3D Printing Breast Tissue Models: A Review of Past Work and Directions for Future Work

Breast cancer often results in the removal of the breast, creating a need for replacement tissue. Tissue engineering offers the promise of generating such replacements by combining cells with biomaterial scaffolds and serves as an attractive potential alternative to current surgical repair methods. Such engineered tissues can also serve as important tools for drug screening and provide in vitro models for analysis. 3D bioprinting serves as an exciting technology with significant implications and applications in the field of tissue engineering. Here we review the work that has been undertaken in hopes of generating the recognized in-demand replacement breast tissue using different types of bioprinting. We then offer suggestions for future work needed to advance this field for both in vitro and in vivo applications.

Fat necrosis after breast-conserving oncoplastic surgery

BACKGROUND

Fat necrosis is a subjective early as well as delayed complication, which sometimes mimics local recurrence and ruins the quality of life by pain and poor cosmetic result. While, the frequency and severity of fat necrosis are important issues that breast surgeons should explain to the patient, these data are not revealed well.

METHODS

A total of 1476 patients who underwent breast surgery from January 2000 to December 2012 were enrolled in the present study. We assessed fat necrosis by mammographic and physical findings and created grading criteria: Grade (G) 0, no fat necrosis; G1, no symptomatic fat necrosis (mammographic dystrophic calcification); G2, mild symptomatic necrosis (mammographic dystrophic necrosis with tumor); G3, severe symptomatic necrosis (mammographic dystrophic necrosis with pain or skin change); and G4, symptomatic necrosis requiring surgical intervention.

RESULTS

Of the 1476 patients enrolled, 393 (27%) underwent mastectomy, and 1083 (73%) underwent breast-conserving surgery. We achieved a high rate of breast-conserving surgery at a total rate of 73% over the study period and maximum rate of 88% in 2010, using oncoplastic procedures. We mainly adopted a pedicled fat flap (417/1083; 39%) and a free dermal fat flap (40/1083; 3.7%). Among the 626 patients who underwent partial resection with no replacement for the defect, G1-G2 fat necrosis was seen in 29/626 (4.6%). While, the incidence of fat necrosis with pedicled fat flap and free dermal fat graft was 68/417 (16%) and 40/40 (100%), respectively, showing a significant difference (p < 0.01). Furthermore, the incidence of G3-G4 fat necrosis was significantly higher with free dermal fat grafts (25%; 10/40) than with pedicled flap (2.9%; 12/417) (p < 0.01). Among pedicled flaps, the incidence of fat necrosis with inframammary adipofascial flaps was 56% (14/25) which was higher than that with lateral epidermal fat flaps (12%; 33/276) (p < 0.01), and rotation of surrounding breast tissues (8%; 21/116) (p < 0.01). The incidence of G3 fat necrosis was also high at 20% (5/25) in inframammary adipofascial flaps.

CONCLUSIONS

Breast-conserving oncoplastic surgery carries a risk of fat necrosis as a delayed complication. The incidence rate and severity of fat necrosis with each procedure should be assessed. We should select fat grafts with a good blood supply to replace defects of breast-conserving therapy.

A Review of Inflammatory Processes of the Breast with a Focus on Diagnosis in Core Biopsy Samples

Inflammatory and reactive lesions of the breast are relatively uncommon among benign breast lesions and can be the source of an abnormality on imaging. Such lesions can simulate a malignant process, based on both clinical and radiographic findings, and core biopsy is often performed to rule out malignancy. Furthermore, some inflammatory processes can mimic carcinoma or other malignancy microscopically, and vice versa. Diagnostic difficulty may arise due to the small and fragmented sample of a core biopsy. This review will focus on the pertinent clinical, radiographic, and histopathologic features of the more commonly encountered inflammatory lesions of the breast that can be characterized in a core biopsy sample. These include fat necrosis, mammary duct ectasia, granulomatous lobular mastitis, diabetic mastopathy, and abscess. The microscopic differential diagnoses for these lesions when seen in a core biopsy sample will be discussed.

Laser lipolysis without suction: reality or myth?

BACKGROUND AND OBJECTIVE

Liposuction is one of the most frequently performed aesthetic surgical procedures. Laser- and ultrasound-based systems have become especially popular in recent years, including laser lipolysis, which has a number of advantages over classic liposuction. Some researchers contend that the aspiration step is not necessary. Herein, we report a case that highlights the negative consequences when the basic surgical rule of not leaving any necrotic tissue is not followed.

MATERIALS AND METHODS

We report the case of a 50-year-old man who presented with a 15 cm mass in the right lower quadrant, located immediately subcutaneously, passing the midline infraumbilically, tender to touch, and with beginnings of abscess formation, who underwent laser lipolysis. The subcutaneous necrotic fat was removed with a skin island en bloc. No postoperative complications occurred and the patient was problem free 6 months post-surgery.

RESULTS

In the surgical literature, most studies on fat necrosis have focused on fat necrosis in the breast. Fat necrosis is usually a gradual process that is noticed by the patient or physician as a mass. Radiologically, it can imitate cancer, especially in breast tissue. Complications from fat necrosis are primarily linked to the amount of necrosis. Any amount of necrosis above the body's resorption capacity will lead the body into attempting self-limitation, with consequences to both the physical and psychological health of the patient.

CONCLUSIONS

We believe that claiming that no aspiration is required after laser lipolysis, without the necessary studies, has no scientific basis.

Fat necrosis of the breast in the accelerated partial breast irradiation era: the need for a universal grading system

Fat necrosis of the breast is increasingly reported and used as a trial endpoint in the treatment of breast cancer with accelerated partial breast irradiation (APBI). Yet, there is no universal toxicity scoring system within the latest version of the Common Terminology Criteria for Adverse Events (CTCAE v4.0). This requires investigators to adopt their own scoring system or improperly use those that exist, and limits accurate reporting of this entity. Fat necrosis of the breast also creates diagnostic uncertainty among clinicians and concern of recurrence among patients. In this review, we address the question of increasing incidence of fat necrosis through the comparison of recent APBI trials and literature. The pathogenesis, symptoms, clinical and radiologic diagnosis, clinical predictors of developing fat necrosis, management and follow-up are also discussed.Lastly, we propose a simplified and universal scoring system for the reporting of fat necrosis.

Sonography of fat necrosis of the breast: correlation with mammography and MR imaging

Fat necrosis (FN) of the breast is a benign nonsuppurative inflammatory process of the adipose tissue. The radiologic appearance ranges from benign to suspicious for malignancy; therefore, it is very important to know the distinguishing radiologic features of FN on different modalities. Mammography is more helpful in identifying FN than ultrasonography in most of the cases, and MRI may also be used to rule out malignancy as an adjunct to mammography and sonography. Even when modern diagnostic modalities are used, biopsy may still be unavoidable for some cases. In conclusion, an accurate history and familiarity with the radiologic findings are crucial to recognizing FN and avoiding unnecessary interventions.

Important Inflammatory and Reactive Lesions of the Breast

Some inflammatory and reactive lesions of the breast present problems clinically but are treated without resort to biopsy. In others, biopsy is required to make the correct diagnosis and to distinguish the process from malignancy. Still others represent incidental microscopic findings that may create diagnostic problems. This article reviews a number of inflammatory and reactive conditions that are likely to be encountered in routine surgical pathology practice, as well as those that have been recently described.

Sonography of axillary masses: what should be considered other than the lymph nodes?

OBJECTIVE

The purpose of this study was to review the sonographic findings of various axillary masses other than lymph nodes in correlation with other imaging and pathologic findings.

METHODS

From a sonographic database, we collected interesting cases of axillary masses with pathologic or other imaging corroboration from the last 10 years.

RESULTS

Images of various soft tissue masses were reviewed. They included masses associated with accessory breasts (fibroadenomas, hamartomas, fat necrosis, and cancer arising from axillary breasts), other soft tissue masses (lipomas, schwannomas, hemangiomas, fibromatosis, epidermoid cysts, and malignant fibrous histiocytomas), and complications presenting as masses after axillary lymph node dissection (seromas, hematomas, suture granulomas, pseudoaneurysms, and lymphangiectasia).

CONCLUSIONS

Awareness of the characteristic sonographic findings of various disease entities that cause axillary masses will help in the correct diagnosis of axillary masses.

Axillary lump: an unusual presentation of fat necrosis in the breast

The clinical presentation of an axillary lump, in majority of cases, raises suspicion of an enlarged lymph node due to malignant causes. In this case report, we established a diagnosis of an axillary lump caused by fat necrosis. We present this case report with review of the literature to familiarize clinicians with this condition.

Fat necrosis after partial-breast irradiation with brachytherapy or electron irradiation versus standard whole-breast radiotherapy--4-year results of a randomized trial

PURPOSE

To examine the incidence and clinical relevance of fat necrosis after accelerated partial-breast irradiation (PBI) using interstitial high-dose-rate brachytherapy (HDR-BT) in comparison with partial-breast electron irradiation (ELE) and whole-breast irradiation (WBI).

METHODS AND MATERIALS

Between 1998 and 2004, 258 early-stage breast cancer patients were randomized to receive 50 Gy WBI (n = 130) or PBI (n = 128). The latter consisted of either 7 x 5.2 Gy HDR-BT (n = 88) or 50 Gy ELE (n = 40). The incidence of fat necrosis, its impact on cosmetic outcome, accompanying radiologic features, and clinical symptoms were evaluated.

RESULTS

The 4-year actuarial rate of fat necrosis was 31.1% for all patients, and 31.9%, 36.5%, and 17.7% after WBI, HDR-BT and ELE, respectively (p(WBI/HDR-BT) = 0.26; p(WBI/ELE) = 0.11; p(ELE/HDR-BT) = 0.025). The respective rate of asymptomatic fat necrosis was 20.2%, 25.3%, and 10% of patients. The incidence of symptomatic fat necrosis was not significantly different after WBI (8.5%), HDR-BT (11.4%), and ELE (7.5%). Symptomatic fat necrosis was significantly associated with a worse cosmetic outcome, whereas asymptomatic fat necrosis was not. Fat necrosis was detectable with mammography and/or ultrasound in each case. Additional imaging examinations were required in 21% of cases and aspiration cytology in 42%.

CONCLUSIONS

Asymptomatic fat necrosis is a common adverse event of breast-conserving therapy, having no significant clinical relevance in the majority of the cases. The incidence of both symptomatic and asymptomatic fat necrosis is similar after conventional WBI and accelerated partial-breast HDR-BT.

Fat necrosis simulating recurrent neoplasia following external beam radiotherapy in a dog

A 4.5-year-old neutered male dog was diagnosed with incompletely excised well-differentiated lymphangiosarcoma in the right inguinal subcutaneous region. The mass had metastasized to the right hypogastric and medial iliac lymph nodes. Surgery followed by definitive radiation therapy was administered to the primary site and the sites of metastasis. The dog had a complete response to radiotherapy, and minimal acute side effects. Doxorubicin was administered after radiotherapy. Approximately 4 months following radiation therapy, the dog developed a mass, presumed recurrent tumor, in the original site. In a biopsy only steatitis and fibrosis were found. The mass continued to grow and conservative surgical excision was elected. Histopathologically the diagnosis was fat necrosis and steatitis, with a microscopic focus of lymphangiosarcoma. Fat necrosis is an uncommon sequelum to breast irradiation in people and also appears to be rare in animals. Fat necrosis should be considered as a differential diagnosis when recurrent tumor is suspected in a previously irradiated subcutaneous site in a dog.

Fat necrosis of the breast—A review

Fat necrosis of the breast is a benign condition that most frequently affects peri-menopausal women. It can mimic breast cancer clinically or radiologically. In other cases it can obscure malignant lesions. The core of this review is derived from a MEDLINE database literature search from 1966-2004. Further references were from lateral search. In this paper, we review the pathogenesis and pathology clinical and radiological features of fat necrosis of the breast. The implication of fat necrosis in the management of patients with breast lump is also discussed. Fat necrosis of breast is a complex process. Therefore, a systematic review of this condition will enable surgeons, radiologists and oncologists working in the field of breast disease to understand it better and improve its management.

Image-guided breast brachytherapy: an alternative to whole-breast radiotherapy

Lumpectomy and whole-breast radiotherapy (ie, breast-conservation treatment) are accepted as viable alternatives to mastectomy in locoregional management of breast cancer. These techniques are used to keep morbidity to a minimum, optimise cosmesis, and maintain treatment outcomes. Pathological and clinical data suggest that most recurrences of cancer in the ipsilateral breast are in the vicinity of the index lesion, and that remote recurrences are uncommon, whether or not whole-breast radiotherapy is delivered. These data lend support to the idea of partial-breast radiotherapy. Such a restricted treatment volume allows safe delivery of an accelerated hypofractionated regimen over a shortened course of 1 week. This technique differs from that of standard whole-breast tangential external-beam radiotherapy and necessitates investigation of accelerated partial-breast irradiation (APBI). Several techniques of APBI are being investigated; however, most experience, and the most favourable early outcomes, has been obtained with image-guided breast brachytherapy. This review highlights the rationale and outcomes of brachytherapy techniques.

The pathology of ionizing radiation as defined by morphologic patterns

This article presents a brief description of the effects of ionizing radiation in human tissues, as seen by the Pathologist. The lesions that occur in multiple organ/tissues will be discussed, dividing them into those that affect (a) the parenchyma or epithelia, (b) the stromal elements, and (c) the blood vessels. Since not all lesions fit into these patterns, the exceptions will be described as characteristic organ lesions. Unless specified otherwise the alterations presented are those that result from electromagnetic radiation (x-rays and gamma rays) as used for clinical radiation therapy. Most of the material presented will be delayed injury (i.e. months-to-years after exposure). The epithelial/parenchymal lesions include atrophy, necrosis, metaplasia, cellular atypia, dysplasia, and neoplasia. The common stromal lesions--the best recognized by pathologists--include fibrosis, fibrinous exudates, necrosis (with a paucity of cellular inflammatory exudates), and atypical fibroblasts. The vascular lesions are quite consistent: most often they affect the microvessels (capillaries, sinusoids) producing lethal and sublethal damage to the endothelial cells, with capillary rupture or thrombosis. Medium-size vessels show neointimal proliferation, fibrinoid necrosis, thrombosis, or acute arteritis. Damage in large vessels is less common; it occurs more in arteries than in veins and includes neointimal proliferation, atheromatosis, thrombosis and rupture (a dramatic complication). Some of the characteristic organ lesions are veno-occlusive liver disease, acute radiation pneumonitis, permanent bone marrow hypoplasia or aplasia, and colitis cystica profunda. Neoplasms are a well-recognized delayed complication of radiation and will not be described in detail. It is important to remember that there are no pathognomonic features of injuries produced by ionizing radiation. Nonetheless, although not specific individually, the combined features are characteristic enough to be recognized.

Membranous Fat Necrosis of the Breast: Diagnosis by Minimally Invasive Technique

Clinical and mammographic features of membranous fat necrosis (MFN) may simulate breast malignancy and tissue sampling is essential for accurate diagnosis. The aim of our study was to evaluate the clinical and imaging findings in these patients. Retrospective review of the records of breast biopsies (n = 1200) during the 5-year period 1998 to 2002 revealed eight (0.67%) cases of histologically proven MFN. Seven of the eight patients had a history of breast trauma or surgery. Seven patients underwent mammography: normal in two, a mass with curvilinear calcifications in one, and heterogeneous calcifications in four. Four patients underwent surgical excision of a palpable mass, one patient had complete excision of calcifications with large core biopsy technique, and three patients had stereotactic vacuum-assisted mammotome biopsy (VAMB). MFN should be included in the differential diagnosis of lesions in a breast with previous trauma or surgery. A minimally invasive diagnostic procedure should be considered in order to avoid excessive excisional surgery.

Surgical considerations in the treatment of early stage breast cancer with accelerated partial breast irradiation (APBI) in breast conserving therapy via intersitial brachytherapy

OBJECTIVE

To examine early and late toxicities, evaluate cosmetic results, and determine the need for reoperation or additional diagnostic procedures in patients treated with accelerated partial breast irradiation (APBI) delivered by way of an interstitial implant in breast-conserving therapy.

METHODS

A total of 199 patients with stage I or II breast cancer were managed with lumpectomy followed by radiation restricted to the tumor bed using an interstitial implant (APBI). Retrospective analyses were performed for early and late toxicities (infection, fat necrosis, breast pain, edema, erythema, fibrosis, pigmentation changes, and telangiectasias), need for reoperation or additional diagnostic procedures, cosmetic results, and local control. Patient selection criteria by the surgeon for referral to RT for APBI included age, tumor size, histology, nodal status, margin status, and absence of extensive intraductal component. Treatment was delivered with either a low-dose or high-dose rate implant. Median follow-up was 5.7 years, and 54% of the patients were followed-up for >7 years.

RESULTS

Infections developed in 22 of 199 (11%) patients: 7% early (</=1 month after implant removal) and 4% late (>1 month after implant removal). Five of the 22 patients (2% of all patients) required operative intervention for the infection, either incision and drainage or debridement. There was a statistically significant difference between infection rates with open (8.5%) versus closed (2.5%) cavity placement of the interstitial needles (P = 0.005). There was no statistically significant difference between low-dose rate (inpatient) and high-dose rate (outpatient) treatment (P = 0.207). Forty-five patients (23%) had an additional diagnostic procedure to evaluate a suspicious or uncertain finding on physical examination or mammogram. Fibrosis and fat necrosis were found in 26 of the 45 patients. The incidence of fat necrosis increased with time. More patients were found to have fat necrosis after 5 years. One patient had fat necrosis diagnosed at <6 months; 8 patients (4% of total) at >/=6 months to <2 years; 10 patients (5% of total) at >/=2 years to <5 years; and 22 patients (11% of total) at >/=5 years. The majority of fat necrosis was detected on mammogram (80%) and was asymptomatic (78%). Cosmesis and toxicities were assessed at 3 defined time points: </=6 months, 2 years, and >/=5 years of follow-up. Using Harvard criteria, good to excellent cosmetic results were observed in >90% of patients. Breast pain, edema, and erythema diminished with time. Of the 199 cases, there were only 5 ipsilateral breast failures, yielding a 5-year actuarial local recurrence rate of 1.2%. Of these 5 failures, 2 were true recurrences/marginal misses, yielding a 5-year actuarial true recurrence/marginal miss rate of 0.5%. The 5-year actuarial cause-specific survival rate was 99% for APBI patients.

CONCLUSIONS

In selected patients with early-stage breast cancer, APBI with targeted interstitial brachytherapy offers 5-year results comparable with conventional breast-conserving therapy employing whole-breast radiation therapy. Minimal long-term toxicities were noted, most of which demonstrated continued resolution over time. Acceptable acute (7%) and delayed (4%) infection rates were observed. Fat necrosis was identified with increasing frequency with time, but the majority was asymptomatic. Cosmetic results are good to excellent (>90%). Continued follow-up by the surgeon will be required to determine the long-term efficacy of this alternative treatment approach.

3D CT–based high-dose-rate breast brachytherapy implants: treatment planning and quality assurance

PURPOSE

Although accelerated partial breast irradiation (APBI) as the sole radiation modality after lumpectomy has shown promising results for select breast cancer patients, published experiences thus far have provided limited information on treatment planning methodology and quality assurance measures. A novel three-dimensional computed tomography (CT)-based treatment planning method for accurate delineation and geometric coverage of the target volume is presented. A correlation between treatment volume and irradiation time has also been studied for quality assurance purposes.

METHODS AND MATERIALS

Between May 2002 and January 2003, 50 consecutive patients underwent an image-guided interstitial implant followed by CT-based treatment planning and were subsequently treated with APBI with a high-dose-rate (HDR) brachytherapy remote afterloader. Target volume was defined as the lumpectomy cavity +2 cm margin modified to >/=5 mm to the skin surface. Catheter reconstruction, geometric optimization, and manual adjustment of irradiation time were done to optimally cover the target volume while minimizing hot spots. Dose homogeneity index (DHI) and percent of target volume receiving 100% of the prescription dose (32 Gy in 8 fractions or 34 Gy in 10 fractions) was determined. Additionally, the correlation between the treatment volume and irradiation time, source strength, and dose was then analyzed for manual verification of the HDR computer calculation.

RESULTS

In all cases, the lumpectomy cavity was covered 100%. Target volume coverage was excellent with a median of 96%, and DHI had a median value of 0.7. For each plan, source strength times the treatment time for every unit of prescribed dose had an excellent agreement of +/-7% to the Manchester volume implant table corrected for modern units.

CONCLUSIONS

CT-based treatment planning allowed excellent visualization of the lumpectomy cavity and normal structures, thereby improving target volume delineation and optimal coverage, relative to conventional orthogonal film dosimetry. Using the Manchester volume implant table calculated irradiation time can be used as quality assurance for the HDR computed time. Thus dosimetric quality assurance and adequate target volume coverage can be concurrently confirmed, allowing prospective evaluation and optimization of implants.

A case of fat necrosis after breast quadrantectomy in which preoperative diagnosis was enabled by MRI with fat suppression technique

A 63-year-old woman was found to have a left breast mass after quadrantectomy and radiation for bilateral breast cancer on postoperative cyclic examination. Intramammary recurrence could not be excluded by physical examination, mammography, or ultrasound examination. MR imaging with fat suppression technique revealed an oil-containing lesion, indicating fat necrosis. It was confirmed histologically that the mass-forming lesion included no cancer tissue. MR imaging with fat suppression technique appears to be a promising method for identification of postoperative mass lesions of the breast.

Partial breast irradiation with interstitial 60CO brachytherapy results in frequent grade 3 or 4 toxicity. evidence based on a 12-year follow-up of 70 patients

PURPOSE

To investigate the radiation-induced toxicity and cosmesis of brachytherapy (BT) alone in early stage breast cancer.

METHODS AND MATERIALS

A total of 70 women diagnosed with Stage I or II breast carcinoma participated in a BT study at the Municipal Oncoradiological Center, Uzsoki Hospital, Budapest, Hungary, between November 1987 and June 1992. They had undergone breast-conserving surgery with an unknown surgical margin. The postoperative tumor bed irradiation was performed with interstitial (60)Co sources with an active length of 4 cm, with 10-mm center-to-center spacing arranged in a single plane. The median number of inserted sources was 5 (range, 2-8), with a linear activity of 133-137 MBq/cm at the beginning of the study. The 50 Gy delivered dose at 5 mm from the surface of the (60)Co sources was administered during 10-22 h to the virtual postoperative lumpectomy cavity (i.e., plane). For radiobiologic considerations, the clinical target volume (CTV) was calculated retrospectively with a 10-mm safety margin, resulting in a 72-cm(3) median CTV (range, 36-108 cm(3)) irradiated with a reference dose of 28 Gy. In the assessment of the skin and subcutaneous toxicity, the RTOG late radiation morbidity scoring system was applied. The radiosensitivity of the cultured fibroblasts was determined by clonogenic assay to check whether individual radiosensitivity played a role in the development and course of radiation-induced side-effects.

RESULTS

The median follow-up was 12 years (range, 10-15 years). The population of the final study (34 cases) comprised all survivors with tumor-free breasts (27 cases) and patients with breasts erroneously ablated/excised for misinterpreted radiation-induced sequelae (7 patients). A total of 97% of the cohort (33/34) had grade > or =2, and 59% (20/34) had grade > or =3 radiation-induced toxicity. By the end of the follow-up, 85% of the patients experienced Grade > or =2 telangiectasis and 41% had Grade 3 telangiectasis. Eighty-eight percent had fibrosis of some form, and 35% had grade > or =3 fibrosis. Forty-one percent of the cohort displayed fat necrosis, which was always accompanied by Grade > or =3 fibrosis or telangiectasis. The cosmetic results were poor in 50% (17/34) of the patients. The radiosensitivity of the fibroblasts was increased in only 2/24 patients (8% of the investigated cases, in agreement with data published for the general population). Comparisons of our fibrosis prevalence data with those of others allowed an estimate of 0.47 h(-1) for the rate of recovery of DNA damage in the fibroblasts.

CONCLUSIONS

Interstitial (60)Co BT of the breast tumor bed alone with a limited CTV (median, 72 cm(3)) and a total dose of 28 Gy is associated with a high rate (59%) of grade > or =3 radiation-induced toxicity and a high rate (50%) of poor cosmetic outcome at the end of a median follow-up of 12 years. A relatively high BT dose rate (1.3-2.8 Gy/h) applied during a short overall treatment time (10-22 h) and a possible geographic miss (close to skin implantation) might have contributed to the development of these sequelae.

Radiation-induced Histopathologic Changes of the Breast

The increasingly frequent use of radiation therapy (RT) and systemic chemotherapy (CT) in the treatment of breast carcinoma requires surgical pathologists and cytologists to be familiar with the variable histologic changes initiated by these agents. Both treatment modalities can cause severe epithelial abnormalities, which are difficult to distinguish from carcinoma. The progression or regression of these histologic abnormalities in nonneoplastic breast tissue have not been extensively evaluated. Our study used 120 post-RT biopsy or mastectomy specimens from 117 patients (3 had bilateral carcinoma treated with RT) yielding 120 specimens. The interval from post-RT to biopsy or mastectomy ranged from 1 to 229 months with 25 of the specimens obtained 1 to 12 months after cessation of RT and 95 more than a year post-RT. Twenty-seven specimens were from >6 years after RT. The histologic features of pretreatment and posttreatment specimens were graded (0-3) blindly for each histologic feature to include stromal vascular and fibroblastic changes and epithelial cell changes of the terminal duct lobular unit and extralobular ducts as well as terminal duct lobular unit fibrosis/atrophy. The changes between the pre- and post-RT grades were all statistically significant (P < 0.05) using multiple nonparametric statistical methods and the parametric Student t test. The specimens obtained within the first year post-RT were compared with those from >1 year post-RT, >3 years post-RT, and >6 years post-RT. None of the histologic features evaluated showed significant changes over the various time intervals regardless of the statistical method used. The absence of regression of the radiation-induced histologic changes over time mandates the surgical pathologist be alert to the possibility of RT or CT even without that therapeutic history.

Dynamic MRI of breast hardness following radiation treatment

PURPOSE

To evaluate functional microvascular characteristics of breast induration several years after radiation treatment using dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) techniques.

MATERIALS AND METHODS

Fifteen women with moderate or marked breast induration after surgery and radiotherapy for breast cancer (2-15 years) were examined. Images of the irradiated breast (boost and nonboost sites) on short tau inversion recovery (STIR) and DCE-MRI sequences were subjectively evaluated for edema and the presence of enhancement and compared to the contralateral normal breast. Quantitative enhancement parameters-percent enhancing pixels, transfer constant (K(trans)), rate constant (k(ep)), leakage space (v(e)), and maximum contrast medium accumulation (MCMA)-were also compared.

RESULTS

No tumor recurrence was seen. Fat necrosis was seen in 2/15 cases. Increased parenchymal edema at the electron boost site was seen in 12/14 patients. Greater enhancement in the irradiated breast was seen in 11/14 evaluable patients. Kinetic parameter estimates including K(trans) were similar except for percent enhancing pixels, which was greater in the irradiated breast at both boost and nonboost sites (P = 0.03 and 0.04, respectively). v(e) and MCMA estimates were greater in breasts with marked induration compared to moderate grades (P = 0.002 and 0.01, respectively).

CONCLUSION

Parenchymal edema may be an important contributor to palpable induration several years after breast radiotherapy. Increased fluid content may be related to increased numbers of perfused microvessels and/or impaired lymphatic drainage.

Magnetic resonance imaging of induration in the irradiated breast

BACKGROUND

The causes of induration (hardness) in the breast many years after tumour excision and whole breast radiotherapy for early stage breast cancer are not well established. The purpose of this study is to describe morphological magnetic resonance imaging (MRI) appearances and MRI-derived microvascular functional characteristics of the indurated breast several years post-treatment.

PATIENTS AND METHODS

Fifteen women with moderate or marked induration at the electron boost site after breast preserving surgery and radiotherapy for early breast cancer (median 6 years; range, 2-15 years) underwent MRI, including 6/15 with very marked breast shrinkage and 8/15 with marked induration. Morphological T1- and T2-weighted and STIR images were obtained followed by a dynamic contrast medium enhanced sequence. The breast skin and underlying parenchyma of the irradiated breast were evaluated for thickening, oedema and the presence of enhancement compared to the contralateral breast. Particular note of boost site findings was made.

RESULTS

No evidence of tumour recurrence was seen. Fat necrosis was seen in 2/15 cases. Skin thickening and skin oedema not evident clinically were seen in 11/15 patients. Increased parenchymal oedema at the electron boost site was seen in 12/15 patients. The parenchymal oedema was not confined to the electron boost site, but was strongest in this location in 9/12 patients. Post-contrast images in 12/14 patients showed persistent parenchymal enhancement in nine (marked in three, who also had severe breast shrinkage and marked induration), a finding consistent with, but not diagnostic of tissue fibrosis.

CONCLUSIONS

Fat necrosis is not likely to contribute to breast induration several years after radiotherapy in more than a minority of patients. Increased fluid content in the breast parenchyma and skin oedema are likely to be more important contributors to palpable induration. Increased fluid content may be related to persistent capillary leakage even many years post-treatment, an expression of radiation-induced vascular injury. Fibrosis cannot be scored directly on MRI, but persistent parenchymal enhancement in a high proportion of post-contrast images is compatible with this pathology.

Fat necrosis of the female breast – Hadfield re-visited

Examination of pathology records from three hospitals over an 8-year period identified 42 cases of primary fat necrosis of the female breast. The mean age of the women was 56 (range 24-85) and the lump was most commonly in the upper, inner quadrant of the breast having been present for a mean of 11 weeks (range 1-56). Twenty-one percent of patients gave a history of trauma which had occurred a mean of 69 weeks (range 3-208) previously. The mammograms gave an appearance of malignancy in 12 of the 22 cases where they were performed. Cytology was suspicious in five cases. Thirty-seven patients subsequently underwent wide local excision to confirm the diagnosis. The histology was re-examined by a pathologist and a subgroup of patients were identified who had fat necrosis associated with periductal mastitis. Two patients who had a core biopsy diagnosis of fat necrosis were found to have malignancy on wide local excision. Here we review the changes in presentation since the original description of the condition, and highlight that although this series reflects difficult cases, fat necrosis remains a condition which can still be difficult to diagnose.

Improving the dosimetric coverage of interstitial high-dose-rate breast implants

PURPOSE/OBJECTIVE

We performed a retrospective computed tomography (CT)-based three-dimensional (3D) dose-volume analysis of high-dose-rate (HDR) interstitial breast implants to evaluate the adequacy of lumpectomy cavity coverage, and then designed a simple, reproducible algorithm for dwell-time adjustment to correct for underdosage of the lumpectomy cavity.

METHODS AND MATERIALS

Since March 1993, brachytherapy has been used as the sole radiation modality after lumpectomy in selected protocol patients with early-stage breast cancer treated with breast-conserving therapy. In this protocol, all patients received 32 Gy in 8 fractions of 4 Gy over 4 days. Eleven patients treated with HDR brachytherapy who underwent CT scanning after implant placement were included in this analysis. For each patient, the postimplant CT dataset was transferred to a 3D treatment planning system, and the relevant tissue volumes were outlined on each axial slice. The implant dataset, including the dwell positions and dwell times, were imported into the 3D planning system and then registered to the visible implant template in the CT dataset. The calculated dose distribution was analyzed with respect to defined volumes via dose-volume histograms. Due to the variability of lumpectomy cavity coverage discovered in this 3D quality assurance analysis, dwell times at selected positions were adjusted in an attempt to improve dosimetric coverage of the lumpectomy cavity. Using implant data from 5 cases, a dwell-time adjustment algorithm was designed and was then tested on 11 cases. In this algorithm, a point P was identified using axial CT images, which was representative of the underdosed region within the cavity. The distance (d) from point P to the nearest dwell position was measured. A number of dwell positions (N) nearest to point P were selected for dwell time adjustment. The algorithm was tested by increasing the dwell times of a variable number of positions (N = 1, 3, 5, 7, 10, and 20) by a weighting factor (alpha), where alpha = f(d) and alpha > 1, and subsequently performing 3D dose-volume analysis to evaluate the improvement in lumpectomy cavity coverage.

RESULTS

Before adjustment in the 11 implants, the median proportion of the lumpectomy cavity and target volume that received at least the prescription dose was 85% and 68%, respectively. After dwell-time adjustment, lumpectomy cavity coverage was significantly improved in all 11 cases. The median distance from point P to the nearest dwell position (d) was 1.4 cm (range 0.9-1.9). The median volume of the lumpectomy cavity receiving 32 Gy increased from 85.3% in the actual implant to 97.0% (range 74-100%) by increasing the dwell time of a single dwell position by a median factor (alpha) of 12.2 according to the above algorithm. With N = 3, the median proportion of the cavity volume receiving 32 Gy was improved to 97.5% (range 77-100%), with a median alpha of 5.7. Further improvement in lumpectomy cavity coverage was relatively small by increasing additional dwell times. In addition, with N = 20, the median absolute volume of breast tissue receiving 150% of the prescription dose was 70.3 cm3 compared to 26.3 cm3 in the actual implant; whereas with N = 1 or N = 3, this median volume was only 35.9 and 42.0 cm3, respectively.

CONCLUSION

Lumpectomy cavity coverage sometimes appears suboptimal with interstitial HDR breast brachytherapy using our current technique. A simple dwell-time increase at only 1-3 dwell positions can compensate for some underdosage without creating significant regions of overdosage. Using simple methodology, a single reference point representing the underdosed region can be utilized for initial selection of the dwell positions to be increased.

Fat necrosis following breast reduction

Between 1984 and 1992, 300 patients underwent breast reduction in our unit. Three patients during the follow-up period were found to have a palpable mass in their breast. Excision biopsy revealed fat necrosis of the breast. The clinical, radiological and pathological features of fat necrosis of the breast are described.

Pseudosclerodermatous panniculitis after irradiation: an unusual complication of megavoltage treatment of breast carcinoma

An unusual edematous and indurated erythema developed in four patients with breast carcinoma 1 to 6 months after conservative surgical treatment and irradiation. The radiation therapy consisted of megavoltage x-ray photon with or without either electron beam or iridium-192 interstitial boost. Several tissue biopsy specimens revealed pronounced lymphocytic dermal and fat inflammation in conjunction with focal areas of plasma cells. The connective tissue bundles were enlarged and hyalinized. Macrophages and isolated giant cells were noted in the dermis. One biopsy specimen showed elastic tissue in giant cell cytoplasm. No mucin, fibrin, formation of cysts, or calcification was present. Lipophages and hyaline connective tissue replaced some fat lobules. The radiation-induced changes of dilated and hyalinized blood vessels, endothelial cell hyperplasia, fibrosis associated with involution of epidermal appendages, and fibroblasts were present. This combination of radiation-related and inflammatory pathologic changes is unusual and emphasizes the remarkable qualities of this rare reaction. The clinical differential diagnoses of recurrent carcinoma, cellulitis, and connective tissue disease can be excluded by reviewing the pathologic characteristics.

Radiation and other pathological changes in breast tissue after conservation treatment for carcinoma

Histological changes in breast tissue after radiotherapy were evaluated. Changes in tissue from 17 patients previously treated for breast cancer by surgery and radiotherapy were compared with those seen in a control group treated with surgery alone. Vascular and epithelial changes were seen only in tissue from patients who had received radiotherapy and, therefore, seemed to be relatively specific; stromal changes were seen in both groups and seemed, therefore, to be non-specific. Epithelial atypia is of particular importance as it may be severe and be confused with recurrent malignancy. The presence of other changes associated with radiotherapy, particularly those in vessels, should help to avoid such misdiagnosis.

The utilization of I-125 seeds as a substitute for Ir-192 seeds in temporary interstitial implants: an overview and a description of the William Beaumont Hospital technique

In August of 1986, the Department of Radiation Oncology at William Beaumont Hospital (WBH) initiated the routine use of high activity I-125 seeds as a substitute for Ir-192 seeds in temporary implants where the afterloading plastic tube technique was used. Through March 6, 1987, 42 temporary I-125 implants were performed as a boost for curative therapy (38 breasts, 2 sarcomas, 2 tongues). Thus far, we have observed no differences in acute toxicity. Sources ranging from 2 to 5 mCi were utilized. The advantages of I-125 are as follows: (a) Easy to shield; (b) Radiation safety; (c) Decreased exposure to sensitive organs in close proximity to the implanted site; (d) Dosimetric advantages both intrinsic and extrinsic; and (e) Any private room can be used for these patients allowing a central brachytherapy ward to be established. While the advantages were obvious, we anticipated potential disadvantages and shortcomings and these will be discussed in detail. Furthermore because of significant differences in tube and ribbon construction, the I-125 afterloading plastic tube technique has important differences from that technique used with Ir-192. These modifications must be fully understood to maintain the integrity of the I-125 seed-ribbon afterloading tube assembly. A detailed description of the technique will be emphasized.

Fat necrosis of the breast following lumpectomy and radiation therapy for early breast cancer

Between January 1980 and December 1985, 121 patients with early breast cancer were treated in the Department of Radiation Oncology at Westmead Hospital by external beam irradiation and an iridium wire boost following "lumpectomy". After a median follow-up of 26 months, 14 patients have developed recurrent masses in the treated breast. In four, recurrent carcinoma was strongly suspected and subsequently confirmed by fine needle aspiration biopsy, but in only two was a subsequent salvage mastectomy possible. The remaining 10 patients developed a nodule which was usually tender. With three exceptions, the nodule was at the primary tumour site and developed 4-43 months after treatment. In seven, tumour recurrence was suspected but not confirmed by biopsy and the other three were accepted as having post-treatment "radiation fibrosis". Excision biopsy was undertaken in eight of the 10 patients. Another patient underwent partial mastectomy for presumed local recurrence. The histological appearance in all cases was similar, with areas of fat necrosis and fibrosis with atypical stromal fibroblasts. Suture material was present microscopically in eight patients and was noted macroscopically (that is, by mammogram) in the one patient who did not undergo surgery. This complication is most likely caused by a combination of surgical and radiation factors. The difficulty in management is differentiation between tumour recurrence and a benign condition.

New lumps in the breast following conservation treatment for early breast cancer

A new lump in the breast following conservation treatment for early breast cancer may represent a recurrence of the disease or may be a benign lesion. Clinical evaluation of these lumps is often extremely difficult and, potentially, mammography would seem to be of great importance in the assessment. Between November 1981 and March 1986, 214 patients with operable breast cancers of 4 cm or less in diameter underwent conservative treatment. The conservation technique comprised synchronous excision of the primary tumour without a wide margin, axillary clearance, interstitial irradiation with iridium 192 (2000 cGy), and subsequent external beam radiotherapy to the breast (4600 cGy). After an average follow-up of 26 months, 17 patients developed a new lump in the treated breast necessitating further biopsy. Seven of these were malignant and 10 benign. In the latter category the most frequent finding was fat necrosis. Clinically, the lesions were indistinguishable from each other. The mammographic signs, which best predicted malignancy, were either of a mass or of a malignant type of microcalcification. This study illustrates the problems associated with deciding the nature of a new lump in the breast following conservation treatment. Mammography is complementary to physical examination, and a base-line mammogram six months after completion of therapy is helpful. Despite the use of mammography, biopsy is the only definitive way of excluding recurrence.

Dose-volume and complication in interstitial implants for breast carcinoma

A common radiotherapeutic technique for treating breast cancer is the combination of external beam radiation with an interstitial iridium-192 boost. When smaller tumors (T1 and T2) are treated using this technique, the soft tissue complication rate is small. However, with treatment of more advanced stages of disease, where large volumes of breast tissue must be treated to high radiation doses, the incidence of complication increases. This paper investigates the dose and volume relationships for breast tissue treated by interstitial technique and correlates this to the risk of soft tissue radiation injury. A method of analysis of interstitial radiation implants suitable for intra- or inter-institutional clinical evaluations is offered. The records of 111 patients treated at Georgetown University Hospital, were retrospectively analyzed and the five who had experienced radiation-related complications were compared to 51 randomly selected patients experiencing no complications. The volumes of tissue enclosed by selected isodose surfaces were calculated and used to determine a relationship between these dose-volumes and the probability of complication. The mean volume at specified dose levels between 10 Gy and 50 Gy was significantly higher (p less than .05) for the patients developing complications than those in whom no complications were seen. Using the 20 Gy isodose surface as defining our usual treated volume, a complication probability versus dose-volume curve was developed using a linear logistic model. The curve fitted the data closely (p less than .006) suggesting that, for our cases, the calculated treatment volume (within the 20 Gy isodose surface) can be used to effectively separate patients into groups that have different probabilities of developing complications. We propose this method as a basis for specification of dose and volume which can be used for clinical risk assessment, and for intra- and inter-institutional comparison.

Once weekly irradiation in breast cancer

Eighty-four elderly patients with carcinoma of the breast were treated with a once-weekly schedule using 650 cGy per fraction to a total of six fractions. According to the TNM classification there were 8 patients with Stage I, 29 patients with Stage II, 45 patients with Stage III, and 2 patients with Stage IV disease. Primary surgical treatment included biopsy, that is, truecut needle biopsy or open biopsy in 53 patients and excision biopsy in 13 patients; the remaining 18 patients had mastectomy. The average age of patients was 69.2 years with the oldest 91 years of age. Ten patients died of concomitant causes during the follow-up period at an average age of 84.5 years. Patients included in this report had at least a 36 month follow-up period with the longest being 94 months. Acute reactions were noticeably less than those with daily treatment. Only one of the 36 patients, where the breast was preserved, had severe delayed skin reaction. Of the 37 patients with Stage I and II, 24 were alive and disease-free at the time of reporting. Three died of concomitant causes, 2 are alive with disease, and the remaining 8 patients died of recurrent of progressive disease. There were 45 patients with Stage IIIA and IIIB and in this group 11 are alive and disease-free, 7 died of concomitant causes, 12 died of progressive breast cancer, and the remaining 4 patients are alive with disease. The two remaining Stage IV patients died of their disease. Once-weekly treatment was well tolerated by all patients and the early local control result is encouraging. We are continuing to assess this type of fractionation in selected elderly patients, especially in those who live away from our center.

Fat necrosis of the breast: an unusual complication of lumpectomy and radiotherapy in breast cancer

Fat necrosis is a well-recognised complication of trauma to the breast. It has also been described following breast surgery. In this report, we describe four patients who developed a small tender nodule following excision and radiotherapy for early breast cancer. These were in or near the excision scar. Histology of the resected nodules revealed fat necrosis with no evidence of recurrence. It is recommended that in all cases when a tender, inflamed nodule in or adjacent to the excision scar is found, a biopsy should be carried out to distinguish between this condition and recurrence.

Conservative treatment for breast cancer. Complications requiring reconstructive surgery

Women who select conservative treatment for carcinoma of the breast (tumor excision followed by supervoltage radiation therapy) place a premium on breast preservation and aesthetics. When local control fails and they require a mastectomy, or when the aesthetic appearance is unacceptable, they may request breast reconstruction. The goal of this study is to evaluate a series of 10 patients who required reconstructive breast surgery after complications of conservative treatment. Patient classification: I. Breast or chest wall necrosis (3). II. Breast fibrosis and gross asymmetry (3). III. Local recurrence of breast cancer (5). IV. Positive margins after the initial lumpectomy (1). The mean age was 34 years. Radiation dosage average was 5252 rads with two patients receiving iridium-192 implant boosts. The reconstructive management was complex and usually required a major musculocutaneous flap because of the radiation effects.

The postirradiated breast

High-energy irradiation is used increasingly as a part of breast conservation treatment of malignant disease. The response of the breast tissue encompassed by the treatment fields varies considerably, even in well-conducted therapeutic programs. Early and late changes in the tissues include redness, edema, pigmentation, fibrosis, and retraction. Fibrosis and retraction may cause suboptimal cosmetic results and occur most frequently in obese patients, large breasts, and breasts from which a large (greater than 4 cm) primary tumor has been excised. Combinations of treatment modalities, such as adjuvant chemotherapy, surgical excision, and irradiation, seem to produce fewer excellent cosmetic results than single-modality treatment. In patients who have undergone breast conservation treatment, careful follow-up is necessary for detection of possible local, regional, or distant recurrence of the malignant disease, as well as of other diseases related or unrelated to the earlier treatment.