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Ho IW, Chichura A, Pederson HJ, Xavier BA, Ritner J, Schwarz GS. Current State of Evidence-Based Long-Term Monitoring Protocols for Breast Plastic Surgery Patients. Ann Surg Oncol 2024:10.1245/s10434-024-16003-3. [PMID: 39103688 DOI: 10.1245/s10434-024-16003-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 07/23/2024] [Indexed: 08/07/2024]
Abstract
BACKGROUND Recommendations for breast surveillance following breast plastic surgery are frequently changing. Establishing guidelines for long-term monitoring protocols may help identify treatable conditions and prevent untoward sequelae. We sought to evaluate the current state of evidence-based long-term monitoring protocols for patients following breast augmentation, reduction, and breast reconstruction. METHODS Official guidelines from various American societies and international societies were analyzed for alignment in evidence-based recommendations regarding breast surveillance. RESULTS The most recent US FDA update recommends magnetic resonance imaging or ultrasound starting 5-6 years after surgery and every 2-3 years thereafter. Discrepancies exist among professional societies: the American Society of Plastic Surgeons (ASPS) aligns with the FDA, while the American Society of Breast Surgeons and American College of Radiology (ACR) find no role for imaging for asymptomatic cases. Ultrasound is first-line for any implant concerns, with MRI if necessary. European societies oppose routine breast implant imaging. Breast reduction patients lack unique screening protocols; monitoring aligns with age and cancer risk factors. Following mastectomy and breast reconstruction, most organizations advocate for annual clinical examinations, with more frequent examinations initially. Evidence suggests that physical examination is sufficient to detect local cancer recurrence, with imaging only indicated if there is concern for recurrence. No surveillance imaging is recommended by the American Society of Clinical Oncology, National Comprehensive Cancer Network, or ASPS; however, ACR recommends mammography for autologous reconstruction only. CONCLUSION Multispecialty and regulatory body alignment may promote provider and patient adherence. Ongoing studies of long-term outcomes are needed to strengthen the level of evidence for monitoring guidelines.
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Affiliation(s)
- Isabel W Ho
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Anna Chichura
- Department of Breast Surgery, Cleveland Clinic, Cleveland, OH, USA
- Department of Subspecialty Gynecology, Cleveland Clinic, Cleveland, OH, USA
| | - Holly J Pederson
- Department of Breast Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Brian A Xavier
- Department of Radiology, Cleveland Clinic, Cleveland, OH, USA
| | - Julie Ritner
- Department of Radiology, Cleveland Clinic, Cleveland, OH, USA
| | - Graham S Schwarz
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH, USA.
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Thai JN, Sodagari F, Colwell AS, Winograd JM, Revzin MV, Mahmoud H, Mozayan S, Chou SHS, Destounis SV, Butler RS. Multimodality Imaging of Postmastectomy Breast Reconstruction Techniques, Complications, and Tumor Recurrence. Radiographics 2024; 44:e230070. [PMID: 38573814 DOI: 10.1148/rg.230070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
For women undergoing mastectomy, breast reconstruction can be performed by using implants or autologous tissue flaps. Mastectomy options include skin- and nipple-sparing techniques. Implant-based reconstruction can be performed with saline or silicone implants. Various autologous pedicled or free tissue flap reconstruction methods based on different tissue donor sites are available. The aesthetic outcomes of implant- and flap-based reconstructions can be improved with oncoplastic surgery, including autologous fat graft placement and nipple-areolar complex reconstruction. The authors provide an update on recent advances in implant reconstruction techniques and contemporary expanded options for autologous tissue flap reconstruction as it relates to imaging modalities. As breast cancer screening is not routinely performed in this clinical setting, tumor recurrence after mastectomy and reconstruction is often detected by palpation at physical examination. Most local recurrences occur within the skin and subcutaneous tissue. Diagnostic breast imaging continues to have a critical role in confirmation of disease recurrence. Knowledge of the spectrum of benign and abnormal imaging appearances in the reconstructed breast is important for postoperative evaluation of patients, including recognition of early and late postsurgical complications and breast cancer recurrence. The authors provide an overview of multimodality imaging of the postmastectomy reconstructed breast, as well as an update on screening guidelines and recommendations for this unique patient population. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.
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Affiliation(s)
- Janice N Thai
- From the Department of Radiology, Division of Breast Imaging (J.N.T., F.S., S.H.S.C.); and Department of Surgery, Division of Plastic and Reconstructive Surgery (A.S.C., J.M.W.), Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114; Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT (M.V.R., R.S.B.); Yale New Haven Health, Bridgeport Hospital, Bridgeport, CT (H.M., S.M.); and Elizabeth Wende Breast Care, Rochester, NY (S.V.D.)
| | - Faezeh Sodagari
- From the Department of Radiology, Division of Breast Imaging (J.N.T., F.S., S.H.S.C.); and Department of Surgery, Division of Plastic and Reconstructive Surgery (A.S.C., J.M.W.), Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114; Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT (M.V.R., R.S.B.); Yale New Haven Health, Bridgeport Hospital, Bridgeport, CT (H.M., S.M.); and Elizabeth Wende Breast Care, Rochester, NY (S.V.D.)
| | - Amy S Colwell
- From the Department of Radiology, Division of Breast Imaging (J.N.T., F.S., S.H.S.C.); and Department of Surgery, Division of Plastic and Reconstructive Surgery (A.S.C., J.M.W.), Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114; Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT (M.V.R., R.S.B.); Yale New Haven Health, Bridgeport Hospital, Bridgeport, CT (H.M., S.M.); and Elizabeth Wende Breast Care, Rochester, NY (S.V.D.)
| | - Jonathan M Winograd
- From the Department of Radiology, Division of Breast Imaging (J.N.T., F.S., S.H.S.C.); and Department of Surgery, Division of Plastic and Reconstructive Surgery (A.S.C., J.M.W.), Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114; Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT (M.V.R., R.S.B.); Yale New Haven Health, Bridgeport Hospital, Bridgeport, CT (H.M., S.M.); and Elizabeth Wende Breast Care, Rochester, NY (S.V.D.)
| | - Margarita V Revzin
- From the Department of Radiology, Division of Breast Imaging (J.N.T., F.S., S.H.S.C.); and Department of Surgery, Division of Plastic and Reconstructive Surgery (A.S.C., J.M.W.), Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114; Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT (M.V.R., R.S.B.); Yale New Haven Health, Bridgeport Hospital, Bridgeport, CT (H.M., S.M.); and Elizabeth Wende Breast Care, Rochester, NY (S.V.D.)
| | - Hagar Mahmoud
- From the Department of Radiology, Division of Breast Imaging (J.N.T., F.S., S.H.S.C.); and Department of Surgery, Division of Plastic and Reconstructive Surgery (A.S.C., J.M.W.), Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114; Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT (M.V.R., R.S.B.); Yale New Haven Health, Bridgeport Hospital, Bridgeport, CT (H.M., S.M.); and Elizabeth Wende Breast Care, Rochester, NY (S.V.D.)
| | - Sara Mozayan
- From the Department of Radiology, Division of Breast Imaging (J.N.T., F.S., S.H.S.C.); and Department of Surgery, Division of Plastic and Reconstructive Surgery (A.S.C., J.M.W.), Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114; Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT (M.V.R., R.S.B.); Yale New Haven Health, Bridgeport Hospital, Bridgeport, CT (H.M., S.M.); and Elizabeth Wende Breast Care, Rochester, NY (S.V.D.)
| | - Shinn-Huey S Chou
- From the Department of Radiology, Division of Breast Imaging (J.N.T., F.S., S.H.S.C.); and Department of Surgery, Division of Plastic and Reconstructive Surgery (A.S.C., J.M.W.), Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114; Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT (M.V.R., R.S.B.); Yale New Haven Health, Bridgeport Hospital, Bridgeport, CT (H.M., S.M.); and Elizabeth Wende Breast Care, Rochester, NY (S.V.D.)
| | - Stamatia V Destounis
- From the Department of Radiology, Division of Breast Imaging (J.N.T., F.S., S.H.S.C.); and Department of Surgery, Division of Plastic and Reconstructive Surgery (A.S.C., J.M.W.), Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114; Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT (M.V.R., R.S.B.); Yale New Haven Health, Bridgeport Hospital, Bridgeport, CT (H.M., S.M.); and Elizabeth Wende Breast Care, Rochester, NY (S.V.D.)
| | - Reni S Butler
- From the Department of Radiology, Division of Breast Imaging (J.N.T., F.S., S.H.S.C.); and Department of Surgery, Division of Plastic and Reconstructive Surgery (A.S.C., J.M.W.), Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114; Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT (M.V.R., R.S.B.); Yale New Haven Health, Bridgeport Hospital, Bridgeport, CT (H.M., S.M.); and Elizabeth Wende Breast Care, Rochester, NY (S.V.D.)
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Guirguis MS, Arribas EM, Kapoor MM, Patel MM, Perez F, Nia ES, Ding Q, Moseley TW, Adrada BE. Multimodality Imaging of Benign and Malignant Diseases of the Nipple-Areolar Complex. Radiographics 2024; 44:e230113. [PMID: 38483829 DOI: 10.1148/rg.230113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
The nipple-areolar complex (NAC), a unique anatomic structure of the breast, encompasses the terminal intramammary ducts and skin appendages. Several benign and malignant diseases can arise within the NAC. As several conditions have overlapping symptoms and imaging findings, understanding the distinctive nipple anatomy, as well as the clinical and imaging features of each NAC disease process, is essential. A multimodality imaging approach is optimal in the presence or absence of clinical symptoms. The authors review the ductal anatomy and anomalies, including congenital abnormalities and nipple retraction. They then discuss the causes of nipple discharge and highlight best practices for the imaging workup of pathologic nipple discharge, a common condition that can pose a diagnostic challenge and may be the presenting symptom of breast cancer. The imaging modalities used to evaluate and differentiate benign conditions (eg, dermatologic conditions, epidermal inclusion cyst, mammary ductal ectasia, periductal mastitis, and nonpuerperal abscess), benign tumors (eg, papilloma, nipple adenoma, and syringomatous tumor of the nipple), and malignant conditions (eg, breast cancer and Paget disease of the breast) are reviewed. Breast MRI is the current preferred imaging modality used to evaluate for NAC involvement by breast cancer and select suitable candidates for nipple-sparing mastectomy. Different biopsy techniques (US -guided biopsy and stereotactic biopsy) for sampling NAC masses and calcifications are described. This multimodality imaging approach ensures an accurate diagnosis, enabling optimal clinical management and patient outcomes. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.
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Affiliation(s)
- Mary S Guirguis
- From the Departments of Breast Imaging (M.S.G., E.M.A., M.M.K., M.M.P., F.P., E.S.N., T.W.M., B.E.A.), Pathology-Anatomical (Q.D.), and Breast Surgical Oncology (T.W.M.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1350, Houston, TX 77030
| | - Elsa M Arribas
- From the Departments of Breast Imaging (M.S.G., E.M.A., M.M.K., M.M.P., F.P., E.S.N., T.W.M., B.E.A.), Pathology-Anatomical (Q.D.), and Breast Surgical Oncology (T.W.M.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1350, Houston, TX 77030
| | - Megha M Kapoor
- From the Departments of Breast Imaging (M.S.G., E.M.A., M.M.K., M.M.P., F.P., E.S.N., T.W.M., B.E.A.), Pathology-Anatomical (Q.D.), and Breast Surgical Oncology (T.W.M.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1350, Houston, TX 77030
| | - Miral M Patel
- From the Departments of Breast Imaging (M.S.G., E.M.A., M.M.K., M.M.P., F.P., E.S.N., T.W.M., B.E.A.), Pathology-Anatomical (Q.D.), and Breast Surgical Oncology (T.W.M.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1350, Houston, TX 77030
| | - Frances Perez
- From the Departments of Breast Imaging (M.S.G., E.M.A., M.M.K., M.M.P., F.P., E.S.N., T.W.M., B.E.A.), Pathology-Anatomical (Q.D.), and Breast Surgical Oncology (T.W.M.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1350, Houston, TX 77030
| | - Emily S Nia
- From the Departments of Breast Imaging (M.S.G., E.M.A., M.M.K., M.M.P., F.P., E.S.N., T.W.M., B.E.A.), Pathology-Anatomical (Q.D.), and Breast Surgical Oncology (T.W.M.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1350, Houston, TX 77030
| | - Qingqing Ding
- From the Departments of Breast Imaging (M.S.G., E.M.A., M.M.K., M.M.P., F.P., E.S.N., T.W.M., B.E.A.), Pathology-Anatomical (Q.D.), and Breast Surgical Oncology (T.W.M.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1350, Houston, TX 77030
| | - Tanya W Moseley
- From the Departments of Breast Imaging (M.S.G., E.M.A., M.M.K., M.M.P., F.P., E.S.N., T.W.M., B.E.A.), Pathology-Anatomical (Q.D.), and Breast Surgical Oncology (T.W.M.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1350, Houston, TX 77030
| | - Beatriz E Adrada
- From the Departments of Breast Imaging (M.S.G., E.M.A., M.M.K., M.M.P., F.P., E.S.N., T.W.M., B.E.A.), Pathology-Anatomical (Q.D.), and Breast Surgical Oncology (T.W.M.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1350, Houston, TX 77030
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Rijkx MEP, Heuts EM, Houwers JB, Hommes JE, Piatkowski AA, van Nijnatten TJA. Imaging findings after a total reconstructed breast with autologous fat transfer: what the radiologist needs to know. BJR Open 2024; 6:tzae010. [PMID: 38798692 PMCID: PMC11128096 DOI: 10.1093/bjro/tzae010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 03/09/2024] [Accepted: 04/13/2024] [Indexed: 05/29/2024] Open
Abstract
Autologous fat transfer (AFT) is an upcoming technique for total breast reconstruction. Consequently, radiological imaging of women with an AFT reconstructed breast will increase in the coming years, yet radiological experience and evidence after AFT is limited. The surgical procedure of AFT and follow-up with imaging modalities including mammography (MG), ultrasound (US), and MRI in patients with a total breast reconstruction with AFT are summarized to illustrate the radiological normal and suspicious findings for malignancy. Imaging after a total breast reconstruction with AFT appears to be based mostly on benign imaging findings with an overall low biopsy rate. As higher volumes are injected in this technique, the risk for the onset of fat necrosis increases. Imaging findings most often are related to fat necrosis after AFT. On MG, fat necrosis can mostly be seen as oil cysts. The occurrence of a breast seroma after total breast reconstruction with AFT is an unfavourable outcome and may require special treatment. Fat deposition in the pectoral muscle is a previously unknown, but benign entity. Although fat necrosis is a benign entity, it can mimic breast cancer (recurrence). In symptomatic women after total breast reconstruction with AFT, MG and US can be considered as first diagnostic modalities. Breast MRI can be used as a problem-solving tool during later stage. Future studies should investigate the most optimal follow-up strategy, including different imaging modalities, in patients treated with AFT for total breast reconstruction.
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Affiliation(s)
- Maud E P Rijkx
- Department of Plastic, Reconstructive, and Hand Surgery, Maastricht University Medical Center+, 6202 AZ, Maastricht, The Netherlands
- NUTRIM School for Nutrition, and Translational Research in Metabolism, Maastricht University, 6229 ER, Maastricht, The Netherlands
| | - Esther M Heuts
- Department of Surgery, Maastricht University Medical Center+, 6202 AZ, Maastricht, The Netherlands
- GROW Research Institute for Oncology and Reproduction, Maastricht University, 6229 ER, Maastricht, The Netherlands
| | - Janneke B Houwers
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, 6202 AZ, Maastricht, The Netherlands
| | - Juliette E Hommes
- Department of Plastic, Reconstructive, and Hand Surgery, Maastricht University Medical Center+, 6202 AZ, Maastricht, The Netherlands
- NUTRIM School for Nutrition, and Translational Research in Metabolism, Maastricht University, 6229 ER, Maastricht, The Netherlands
| | - Andrzej A Piatkowski
- Department of Plastic, Reconstructive, and Hand Surgery, Maastricht University Medical Center+, 6202 AZ, Maastricht, The Netherlands
- NUTRIM School for Nutrition, and Translational Research in Metabolism, Maastricht University, 6229 ER, Maastricht, The Netherlands
| | - Thiemo J A van Nijnatten
- GROW Research Institute for Oncology and Reproduction, Maastricht University, 6229 ER, Maastricht, The Netherlands
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, 6202 AZ, Maastricht, The Netherlands
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5
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Stowell JT, Grage RA, Cortopassi IO, Little BP, Maimone S. Breast Findings at Chest CT. Radiographics 2023; 43:e220095. [PMID: 37440451 DOI: 10.1148/rg.220095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/15/2023]
Affiliation(s)
- Justin T Stowell
- From the Department of Radiology, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224
| | - Rolf A Grage
- From the Department of Radiology, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224
| | - Isabel O Cortopassi
- From the Department of Radiology, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224
| | - Brent P Little
- From the Department of Radiology, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224
| | - Santo Maimone
- From the Department of Radiology, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224
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6
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Jones LI, Klimczak K, Geach R. Breast MRI: an illustration of benign findings. Br J Radiol 2023; 96:20220280. [PMID: 36488196 PMCID: PMC9975519 DOI: 10.1259/bjr.20220280] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 08/24/2022] [Accepted: 09/29/2022] [Indexed: 12/13/2022] Open
Abstract
Despite its unparalleled sensitivity for aggressive breast cancer, breast MRI continually excites criticism for a specificity that lags behind that of modern mammographic techniques. Radiologists reporting breast MRI need to recognise the range of benign appearances on breast MRI to avoid unnecessary biopsy. This review summarises the reported diagnostic accuracy of breast MRI with particular attention to the technique's specificity, provides a referenced reporting strategy and discusses factors that compromise diagnostic confidence. We then present a pictorial review of benign findings on breast MRI. Enhancing radiological skills to discriminate malignant from benign findings will minimise false positive biopsies, enabling optimal use of multiparametric breast MRI for the benefit of screening clients and breast cancer patients.
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Affiliation(s)
- Lyn Isobel Jones
- Bristol Breast Care Centre, North Bristol NHS Trust, Bristol, United Kingdom
| | - Katherine Klimczak
- Bristol Breast Care Centre, North Bristol NHS Trust, Bristol, United Kingdom
| | - Rebecca Geach
- Bristol Breast Care Centre, North Bristol NHS Trust, Bristol, United Kingdom
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Portnow LH, Majid S, Maduram A, Chesebro AL, Karimova EJ, Chung SH, Gombos EC. Breast Malignancies After Mastectomy With Autologous or Implant Reconstruction. JOURNAL OF BREAST IMAGING 2022; 4:649-660. [PMID: 38417000 DOI: 10.1093/jbi/wbac068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Indexed: 03/01/2024]
Abstract
There are multiple indications for mastectomy for breast cancer, including extent of tumor, inability to achieve negative margins after re-excision, patient preference, or prevention in women with a high lifetime risk of breast cancer. Multiple types of autologous or implant reconstruction options are available for cosmesis. Although rare, breast cancers after mastectomy can occur, and it is important for both surgeons and radiologists to be aware of the associated risk factors, common locations, and classic imaging features of these malignancies. This article reviews the types of mastectomies, reconstruction options, and information about the location, presentation, and prognosis of cancers in the reconstructed breast.
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Affiliation(s)
- Leah H Portnow
- Brigham and Women's Hospital, Department of Radiology, Breast Imaging, Boston, MA, USA
| | - Sana Majid
- Brigham and Women's Hospital, Department of Radiology, Breast Imaging, Boston, MA, USA
| | - Amy Maduram
- Brigham and Women's Hospital, Department of Radiology, Breast Imaging, Boston, MA, USA
| | - Allyson L Chesebro
- Brigham and Women's Hospital, Department of Radiology, Breast Imaging, Boston, MA, USA
| | - E Jane Karimova
- Brigham and Women's Hospital, Department of Radiology, Breast Imaging, Boston, MA, USA
| | - Stephanie H Chung
- Brigham and Women's Hospital, Department of Radiology, Breast Imaging, Boston, MA, USA
| | - Eva C Gombos
- Brigham and Women's Hospital, Department of Radiology, Breast Imaging, Boston, MA, USA
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8
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Soh CL, Asher CM, Forouhi P, Moyle P, Healy NA, Malata CM. Diagnosis and management of breast implant capsule recurrence following mastectomy and subpectoral implant - innovative use of ADM for reconstruction. J Surg Case Rep 2022; 2022:rjac432. [PMID: 36226136 PMCID: PMC9550353 DOI: 10.1093/jscr/rjac432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 08/29/2022] [Indexed: 11/14/2022] Open
Abstract
It is well reported that patients who have undergone breast augmentation and subsequently develop breast cancer can successfully undergo breast-conserving therapy with preservation of their implants. However, there is a paucity of literature on the radiological investigations and surgical techniques in postmastectomy implant-reconstructed patients who develop recurrences to enable preservation of their implant-based reconstruction whilst effectively treating the local recurrence. The wide adoption of acellular dermal matrix use in prosthetic breast reconstruction in recent years has made radiological evaluation of such patients challenging. Herein presented is a case of a 37-year-old woman where wide local excision of a local recurrence abutting a peri-implant capsule following previous mastectomy and implant-acellular dermal matrix (ADM) reconstruction was performed with successful preservation of reconstruction volume (and shape) using an ADM patch to repair the capsular defect whilst retaining the implant in situ. Radiological investigation facilitated and guided the surgical planning and oncological clearance.
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Affiliation(s)
- Chien Lin Soh
- University of Cambridge School of Clinical Medicine, Addenbrooke’s Hospital, Cambridge, UK
| | - Christian M Asher
- Department of Plastic and Reconstructive Surgery, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Parto Forouhi
- Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Penelope Moyle
- Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Nuala Ann Healy
- Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Charles M Malata
- Correspondence address. Department of Plastic and Reconstructive Surgery, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK. E-mail:
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Abstract
Transgender and gender diverse (TGD) individuals may undergo a wide range of care during gender transition including mental health counseling, gender-affirming hormonal therapy, and various surgeries. Hormone therapy effectively converts the hormonal milieu into that of the affirmed gender and produces measurable alterations in serum markers for coronary artery disease and other hematologic conditions (eg, erythrocytosis, venous thrombosis). Although illegal in the United States, some transgender women may receive silicone injections for breast and soft tissue augmentation, which can lead to devastating local complications, as well as silicone migration, pulmonary embolism, systemic reactions, and death. Smoking rates are higher among transgender and sexual minority populations, placing them at elevated risk of smoking-related diseases, including lung cancer. Some opportunistic infections may be more common in the TGD populations, attributable to higher rates of coexisting infection with human immunodeficiency virus. Radiologists should be aware that these patients may develop cancer of their natal organs (eg, breast, prostate), especially as some of these tissues are not completely removed during gender-affirming surgery, which may manifest with thoracic involvement by secondary neoplasia. As more TGD patients seek medical care, thoracic radiologists can reasonably expect to interpret imaging performed in this population and should be aware of possible disease processes and potential complications of hormonal and surgical therapies.
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Hermansyah D, Firsty NN. The Role of Breast Imaging in Pre- and Post-Definitive Treatment of Breast Cancer. Breast Cancer 2022. [DOI: 10.36255/exon-publications-breast-cancer-breast-imaging] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Divjak E, Ivanac G, Radović N, Biondić Špoljar I, Sović S, Bahnik V, Brkljačić B. Second-Look Ultrasound Using Shear-Wave Elastography in MRI-Suspected Locoregional Recurrence of Breast Carcinoma. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2022; 43:274-279. [PMID: 32663880 DOI: 10.1055/a-1178-0523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
PURPOSE To investigate if second-look US using shear-wave elastography (SWE) can help to differentiate between benign and malignant changes in the postoperative breast after surgical treatment of breast carcinoma. MATERIALS AND METHODS SWE and related sonographic features were reviewed in 90 female patients with a history of surgical treatment of breast carcinoma and a suspicious lesion detected on a follow-up MRI scan. A single experienced radiologist performed all second-look US exams with SWE measurements placing a circular region of interest measuring 2 mm in diameter over the stiffest part of the lesion. Tissue samples for histopathological analysis were obtained during the same US examination via core-needle biopsy. RESULTS Out of 90 lesions, 39 were proven malignant on histopathological analysis. 50 % of malignant lesions had Elmax values ranging from 128 to 199 kPa, and 50 % of benign lesions had Elmax values ranging from 65 to 169 kPa. The cut-off value of 171.2 kPa for Elmax shows a sensitivity of 59 % and specificity of 78.4 % for carcinoma recurrence, area under the curve 0.706 (CI95 % 0.6-0.81), P = 0.001. In univariate logistic models, restricted diffusion and stiffness on SWE, Elmax > 171.2 kPa, were shown as significant recurrence predictors. In the multivariate model, restricted diffusion remains significant independent recurrence predictor. With a recurrence prevalence of 43 %, the test sensitivity is 95 % (CI95 % 81-99 %) and the specificity is 75 % (CI95 % 60-85 %). CONCLUSION Stiffer lesions should be considered suspicious on second-look US in the postoperative breast and SWE can be a helpful tool in identifying malignant lesions, especially if this is related to restricted diffusion on MRI exam. Lesion stiffness, however, should not be considered as an independent predictor of lesion malignancy in the postoperative breast, because of benign changes that can appear stiff on SWE, as well as carcinoma recurrences that may appear soft.
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Affiliation(s)
- Eugen Divjak
- Department of Diagnostic and Interventional Radiology, University Hospital Dubrava, Zagreb, Croatia
| | - Gordana Ivanac
- Department of Diagnostic and Interventional Radiology, University Hospital Dubrava, Zagreb, Croatia
- Chair of Radiology, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Niko Radović
- Department of Diagnostic and Interventional Radiology, University Hospital Dubrava, Zagreb, Croatia
| | - Iva Biondić Špoljar
- Department of Diagnostic and Interventional Radiology, University Hospital Dubrava, Zagreb, Croatia
| | - Slavica Sović
- Department of Medical Statistics, Epidemiology and Medical Informatics, University of Zagreb Andrija Stampar School of Public Health, Zagreb, Croatia
| | - Valentina Bahnik
- Family medicine office, 'Zagreb Centar' Health Center, Zagreb, Croatia
| | - Boris Brkljačić
- Department of Diagnostic and Interventional Radiology, University Hospital Dubrava, Zagreb, Croatia
- Chair of Radiology, University of Zagreb School of Medicine, Zagreb, Croatia
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12
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Winkler NS, Tran A, Kwok AC, Freer PE, Fajardo LL. Autologous Fat Grafting to the Breast: An Educational Review. JOURNAL OF BREAST IMAGING 2022; 4:209-221. [PMID: 38422423 DOI: 10.1093/jbi/wbab055] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Indexed: 03/02/2024]
Abstract
Autologous fat grafting (AFG) is a technique that is increasingly utilized in breast cosmetic and reconstructive surgery. In this procedure, fat is aspirated by liposuction from one area of the body and injected into the breast. The procedure and process of AFG has evolved over the last few decades, leading to more widespread use, though there is no standard method. Autologous fat grafting is generally considered a safe procedure but may result in higher utilization of diagnostic imaging due to development of palpable lumps related to fat necrosis. Imaging findings depend on surgical technique but typically include bilateral, symmetric, retromammary oil cysts and scattered dystrophic and/or coarse calcifications when AFG is used for primary breast augmentation. More focal findings occur when AFG is used to improve specific areas of cosmetic deformity, scarring, or pain following breast cancer surgery. As with any cause of fat necrosis, imaging features tend to appear more benign over time, with development of rim calcifications associated with oil cysts and a shift in echogenicity of oil cyst contents on ultrasound towards anechoic in some cases. This article reviews the AFG procedure, uses, complications, and imaging findings.
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Affiliation(s)
- Nicole S Winkler
- University of Utah and Huntsman Cancer Institute, Department of Radiology and Imaging Sciences, Salt Lake City, UT, USA
| | - Alexander Tran
- University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Alvin C Kwok
- University of Utah and Huntsman Cancer Institute, Department of Plastic Surgery, Salt Lake City, UT, USA
| | - Phoebe E Freer
- University of Utah and Huntsman Cancer Institute, Department of Radiology and Imaging Sciences, Salt Lake City, UT, USA
| | - Laurie L Fajardo
- University of Utah and Huntsman Cancer Institute, Department of Radiology and Imaging Sciences, Salt Lake City, UT, USA
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Overview of Oncoplastic Breast Surgery Techniques for the Treatment of Breast Cancer with Review of Normal and Abnormal Postsurgical Imaging Findings. CURRENT RADIOLOGY REPORTS 2022. [DOI: 10.1007/s40134-022-00394-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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14
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Lee SC, Mendez-Broomberg K, Eacobacci K, Vincoff NS, Gupta E, McElligott SE. Nipple-sparing Mastectomy: What the Radiologist Should Know. Radiographics 2022; 42:321-339. [PMID: 35179983 DOI: 10.1148/rg.210136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Nipple-sparing mastectomy (NSM) is increasingly offered to patients undergoing treatment of breast cancer and prophylaxis treatment for reduction of breast cancer risk. NSM is considered oncologically safe for appropriately selected patients and is associated with improved cosmetic outcomes and quality of life. Accepted indications for NSM have expanded in recent years, and currently only inflammatory breast cancer or malignancy involving the nipple is considered an absolute contraindication. Neoplasms close to and involving the nipple areolar complex are common, and cancer of the lactiferous ducts can spread to the nipple. Therefore, accurate determination of nipple involvement at imaging examinations is critical to identifying appropriate candidates for NSM and preventing local recurrence. Multiple imaging features have been described as predictors of nipple involvement, with tumor to nipple distance, enhancement between the index malignancy and the nipple, and nipple retraction demonstrating the highest predictive values. These features can be assessed at multimodality breast imaging, particularly at breast MRI, which demonstrates high specificity and negative predictive value for determining nipple involvement in malignancy. Online supplemental material is available for this article. ©RSNA, 2022.
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Affiliation(s)
- Samantha C Lee
- From the Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra University/Northwell Health System, 300 Community Dr, Manhasset, NY 11030
| | - Karen Mendez-Broomberg
- From the Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra University/Northwell Health System, 300 Community Dr, Manhasset, NY 11030
| | - Katherine Eacobacci
- From the Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra University/Northwell Health System, 300 Community Dr, Manhasset, NY 11030
| | - Nina S Vincoff
- From the Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra University/Northwell Health System, 300 Community Dr, Manhasset, NY 11030
| | - Ekta Gupta
- From the Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra University/Northwell Health System, 300 Community Dr, Manhasset, NY 11030
| | - Suzanne E McElligott
- From the Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra University/Northwell Health System, 300 Community Dr, Manhasset, NY 11030
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Goudreau SH, Woughter MA, Seiler SJ. Multimodality Review of Imaging Features Following Breast Reduction Surgery. Eur J Breast Health 2021; 17:206-213. [PMID: 34263147 DOI: 10.4274/ejbh.galenos.2021.2021-1-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 03/16/2021] [Indexed: 12/01/2022]
Abstract
Reduction mammoplasty is a common surgical procedure that removes a significant portion of the breast, and the resulting changes to the breast parenchyma are frequently seen on breast imaging studies. Any radiologist who interprets breast imaging studies must be able to recognize these changes in order to avoid unnecessary recall from screening and/or breast biopsy. The surgical techniques used in reduction mammoplasty are discussed in order to provide relevant background information for understanding the resulting imaging features. These imaging characteristics are presented for the most common breast imaging modalities, including mammography, ultrasound, and magnetic resonance imaging. Additionally, tips for distinguishing malignancy from postsurgical change are provided, as are potential pitfalls in imaging interpretation. To avoid unnecessary patient morbidity, it is critical to differentiate between the classic, benign imaging appearance of the breast after reduction mammoplasty and findings that indicate a potential malignancy.
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Affiliation(s)
- Sally H Goudreau
- Department of Radiology, UT Southwestern Medical Center, Texas, USA
| | | | - Stephen J Seiler
- Department of Radiology, UT Southwestern Medical Center, Texas, USA
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16
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Management of Granulomatous Mastitis Following Aesthetic Breast Surgery. Aesthetic Plast Surg 2021; 45:875-881. [PMID: 33033878 DOI: 10.1007/s00266-020-01992-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 09/22/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Granulomatous mastitis (GM) is not among the well-known diseases in the field of aesthetic breast surgery (ABS). The clinical presentation of GM resembles infectious diseases or malignancies, but the management of these diseases is quite different. In this study, we aimed to present the management of GM in patients who underwent ABS. METHODS In this study, patients with GM (n = 65) and patients who underwent ABS (n = 531) were evaluated. A total of six GM patients with a history of ABS were included in the study between January 1, 2010, and January 1, 2019. The data were collected retrospectively. The quantitative variables are shown as medians (minimum-maximum), and categorical variables are shown as numbers and percentages (%). RESULTS Median duration of disease onset after the ABS was 16 (8-38) months. After the diagnosis of GM was obtained, all patients received steroid treatment. Median steroid treatment duration was 10 (8-20) weeks. Methotrexate was administered in two patients due to persistent breast mass and steroid side effect. Surgical excision was performed in three patients with wide excision. No patient needed further surgery such as mastectomy. Median follow-up period was 37.5 (18-70) months. CONCLUSION This is the first study to declare GM in patients who underwent ABS. Atypical clinical presentation such as breast abscess, mass or fistula after ABS should alert the surgeon about GM. Unlike other mastitis, the primary treatment of this rare disease is steroid and immunosuppressive treatment. Insufficient knowledge about GM can lead to unnecessary surgeries or breast loss. LEVEL OF EVIDENCE IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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17
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Al-Khalili R, Alzeer A, Nguyen GK, Crane EP, Song JH, Jeon JL, Nellamattathil M, Makariou EV, Mango VL. Palpable Lumps after Mastectomy: Radiologic-Pathologic Review of Benign and Malignant Masses. Radiographics 2021; 41:967-989. [PMID: 33989071 DOI: 10.1148/rg.2021200161] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Patients who have undergone mastectomy, with or without reconstruction, are not universally screened with mammography or US. Therefore, clinical breast examination by the physician and patient-detected palpable abnormalities are crucial for detecting breast cancer or recurrence. Diagnostic US is the first-line modality for evaluation of postmastectomy palpable masses, with occasional adjunct use of diagnostic mammography for confirming certain benign masses. In the setting of a negative initial imaging evaluation with continued clinical concern, diagnostic MRI may aid in improving sensitivity. Knowledge of the typical multimodality imaging appearances and locations of malignant palpable abnormalities-such as invasive carcinoma recurrence, cancer in residual breast tissue, radiation-induced sarcoma, and metastatic disease-is crucial in diagnosis and treatment of these entities. In addition, familiarity with the range of benign palpable postmastectomy processes-including fat necrosis, fat graft, seroma, granuloma, neuroma, fibrosis, and infection-may help avoid unnecessary biopsies and reassure patients. The authors review common and rare benign and malignant palpable masses in mastectomy patients, describe multimodality diagnostic imaging evaluation of each entity, review radiologic and pathologic correlation, and acquaint the radiologist with management when these findings are encountered. ©RSNA, 2021.
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Affiliation(s)
- Rend Al-Khalili
- From the Departments of Radiology (R.A.K., G.K.N., E.P.C., J.H.S., J.L.J., M.N., E.V.M.) and Pathology (A.A.), MedStar Georgetown University Hospital, 3800 Reservoir Rd NW, Washington, DC 20007; and Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY (V.L.M.)
| | - Ali Alzeer
- From the Departments of Radiology (R.A.K., G.K.N., E.P.C., J.H.S., J.L.J., M.N., E.V.M.) and Pathology (A.A.), MedStar Georgetown University Hospital, 3800 Reservoir Rd NW, Washington, DC 20007; and Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY (V.L.M.)
| | - Giang-Kimthi Nguyen
- From the Departments of Radiology (R.A.K., G.K.N., E.P.C., J.H.S., J.L.J., M.N., E.V.M.) and Pathology (A.A.), MedStar Georgetown University Hospital, 3800 Reservoir Rd NW, Washington, DC 20007; and Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY (V.L.M.)
| | - Erin P Crane
- From the Departments of Radiology (R.A.K., G.K.N., E.P.C., J.H.S., J.L.J., M.N., E.V.M.) and Pathology (A.A.), MedStar Georgetown University Hospital, 3800 Reservoir Rd NW, Washington, DC 20007; and Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY (V.L.M.)
| | - Judy H Song
- From the Departments of Radiology (R.A.K., G.K.N., E.P.C., J.H.S., J.L.J., M.N., E.V.M.) and Pathology (A.A.), MedStar Georgetown University Hospital, 3800 Reservoir Rd NW, Washington, DC 20007; and Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY (V.L.M.)
| | - Janice L Jeon
- From the Departments of Radiology (R.A.K., G.K.N., E.P.C., J.H.S., J.L.J., M.N., E.V.M.) and Pathology (A.A.), MedStar Georgetown University Hospital, 3800 Reservoir Rd NW, Washington, DC 20007; and Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY (V.L.M.)
| | - Michael Nellamattathil
- From the Departments of Radiology (R.A.K., G.K.N., E.P.C., J.H.S., J.L.J., M.N., E.V.M.) and Pathology (A.A.), MedStar Georgetown University Hospital, 3800 Reservoir Rd NW, Washington, DC 20007; and Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY (V.L.M.)
| | - Erini V Makariou
- From the Departments of Radiology (R.A.K., G.K.N., E.P.C., J.H.S., J.L.J., M.N., E.V.M.) and Pathology (A.A.), MedStar Georgetown University Hospital, 3800 Reservoir Rd NW, Washington, DC 20007; and Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY (V.L.M.)
| | - Victoria L Mango
- From the Departments of Radiology (R.A.K., G.K.N., E.P.C., J.H.S., J.L.J., M.N., E.V.M.) and Pathology (A.A.), MedStar Georgetown University Hospital, 3800 Reservoir Rd NW, Washington, DC 20007; and Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY (V.L.M.)
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18
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Pryce C, Owen W. Palpable Masses after Mastectomy: Differentiating Benign Postoperative Findings from Recurrent Disease. JOURNAL OF BREAST IMAGING 2020; 2:501-510. [PMID: 38424907 DOI: 10.1093/jbi/wbaa048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Indexed: 03/02/2024]
Abstract
Due to postoperative changes, imaging evaluation of patients with palpable masses after mastectomy can be challenging. There is considerable overlap between the imaging characteristics of recurrent disease and benign postoperative findings in patients with or without breast reconstruction. US is the initial modality of choice for evaluating palpable masses in most patients after mastectomy. In cases where US findings are not classic, however, other modalities are useful in problem solving, including both mammography and MRI. It is imperative that radiologists are educated about benign and malignant imaging characteristics, further workup considerations, and appropriate management. In cases where findings are not characteristic across multiple imaging modalities, biopsy may be warranted.
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Affiliation(s)
- Cherah Pryce
- University of Kentucky, Department of Radiology, Lexington, KY
| | - Wendi Owen
- University of Kentucky, Department of Radiology, Lexington, KY
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19
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Russo D, Campanino MR, Cepurnaite R, Gencarelli A, De Rosa F, Corvino A, Menkulazi M, Tammaro V, Fuggi M, Insabato L. Primary High-Grade Angiosarcoma of the Breast in a Young Woman With Breast Implants: A Rare Case and a Review of Literature. Int J Surg Pathol 2020; 28:906-912. [PMID: 32423273 DOI: 10.1177/1066896920924087] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Primary angiosarcoma (AS) of the breast is an extremely unusual variant of breast malignancies, and its incidence is about 0.05% of all primary breast tumors. In this article, we present a rare case of a primary AS that developed in a young woman with breast implants. This case report emphasizes importance of early investigation for accurate diagnosis and proper management of the breast AS, along with a correlation of histopathologic, radiologic, and clinical findings.
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Affiliation(s)
- Daniela Russo
- 9307University of Naples "Federico II," Naples, Italy.,Contributed equally
| | | | | | | | | | | | | | | | - Mariano Fuggi
- 9307University of Naples "Federico II," Naples, Italy
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Ramli Hamid MT, Rahmat K, Hamid SA, Kirat Singh SK, Hooi TG. Spectrum of Multimodality Findings in Post-surgical Breast Cancer Imaging. Curr Med Imaging 2020; 15:866-872. [PMID: 32008533 DOI: 10.2174/1573405614666180627101520] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Revised: 05/25/2018] [Accepted: 06/12/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Breast cancer is the commonest cancer affecting Malaysian women, accounting for an estimated 30% of all new cancer diagnosed annually. Improvements in breast cancer management have increased the breast cancer survival rate in Malaysia. Clinical and radiological surveillance of the treated breast is vital, as early detection of recurrence improves patient's survival rate. DISCUSSION As surgery and radiotherapy alter the appearance of the breasts, distinguishing between recurrence and benign post-surgical changes can be challenging radiologically due to overlapping features. Despite this, differentiation between these two entities is usually possible by recognizing characteristic features of post-treatment sequelae and the evolution of the appearance of the conservatively treated breast by comparing interval findings on serial studies. CONCLUSION This pictorial review aims to describe the typical and unusual features of post-treated breasts in the multimodality imaging workup of an established breast care centre in a teaching hospital in Malaysia.
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Affiliation(s)
| | - Kartini Rahmat
- Department of Biomedical Imaging, University Malaya Research Imaging Centre, Kuala Lumpur, Malaysia
| | - Shamsiah Abdul Hamid
- Department of Biomedical Imaging, University Malaya Research Imaging Centre, Kuala Lumpur, Malaysia
| | - Shaleen Kaur Kirat Singh
- Department of Biomedical Imaging, University Malaya Research Imaging Centre, Kuala Lumpur, Malaysia
| | - Tan Gie Hooi
- Breast Care Unit, University Malaya Medical Centre, Kuala Lumpur, Malaysia
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21
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Van De Merckt C. Anomalie clinique et seins traités : comment répondre clairement aux cliniciens ? IMAGERIE DE LA FEMME 2019. [DOI: 10.1016/j.femme.2019.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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22
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Fan KL, Yang S, Park S, Park TH, Song SY, Lee N, Lew DH, Kim MJ, Lee DW. Postoperative Cancer Surveillance Following Oncoplastic Surgery with Latissimus Dorsi Flap: a Matched Case-Control Study. Ann Surg Oncol 2019; 26:4681-4691. [PMID: 31605343 DOI: 10.1245/s10434-019-07898-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND The latissimus dorsi (LD) myocutaneous flap is a widely used local option in oncoplastic surgery for avoiding breast deformities; however, concerns exist regarding its influence in monitoring recurrence. In this study, we evaluated the impact of this flap on postoperative cancer surveillance. METHODS Each patient receiving oncoplastic surgery with LD flap after partial mastectomy were matched in age, cancer stage, and body mass index with patients receiving partial mastectomy alone. Twenty-nine patients with the oncoplastic LD flap received 99 mammograms and 139 ultrasonograms, while 29 patients with partial mastectomy alone underwent 92 mammograms and 129 ultrasonograms. Mammographic and ultrasonographic findings were classified by Breast Imaging Reporting and Data System (BI-RADS) category and reviewed. Any recommendations for additional evaluation and recurrence were documented. RESULTS During an average follow-up period of 44 months, although the oncoplastic group demonstrated more newly developed benign calcifications (control 14% vs. oncoplastic 41%; p = 0.019) on mammography, the percentage of recall for additional imaging in category 0, and the short-interval follow-up in category 3, was not different between the control and oncoplastic group. Regarding ultrasonography, BI-RADS category was also not different between the two groups; however, the control group showed more fluid collections than the oncoplastic group (control 21% vs. oncoplastic 0%; p = 0.023). One case of local recurrence was observed in the control group. CONCLUSION Although there was an increase in benign calcifications in the oncoplastic group, there were no additional abnormal findings requiring further intervention. We concluded that the LD flap for oncoplastic surgery does not interfere with cancer surveillance, and even decreases the rate of fluid collection.
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Affiliation(s)
- Kenneth L Fan
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Simon Yang
- Department of Plastic and Reconstructive Surgery, and Institute for Human Tissue Restoration, Yonsei University College of Medicine, Seoul, Korea
| | - Seho Park
- Division of Breast Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Korea.,Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Tae Hwan Park
- Department of Plastic and Reconstructive Surgery, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Seung Yong Song
- Department of Plastic and Reconstructive Surgery, and Institute for Human Tissue Restoration, Yonsei University College of Medicine, Seoul, Korea
| | - Nara Lee
- Department of Plastic and Reconstructive Surgery, and Institute for Human Tissue Restoration, Yonsei University College of Medicine, Seoul, Korea
| | - Dae Hyun Lew
- Department of Plastic and Reconstructive Surgery, and Institute for Human Tissue Restoration, Yonsei University College of Medicine, Seoul, Korea
| | - Min Jung Kim
- Department of Radiology, Research Institute of Radiologic Science, Yonsei University College of Medicine, Seoul, Korea.
| | - Dong Won Lee
- Department of Plastic and Reconstructive Surgery, and Institute for Human Tissue Restoration, Yonsei University College of Medicine, Seoul, Korea.
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Helal M, Mansour S, Ahmed H, Abdel Ghany A, Kamel O, Elkholy N. The role of contrast-enhanced spectral mammography in the evaluation of the postoperative breast cancer. Clin Radiol 2019; 74:771-781. [DOI: 10.1016/j.crad.2019.06.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 06/05/2019] [Indexed: 02/07/2023]
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24
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Oldrini G, Troufléau P, Boyer B, Chanson A, Lesanne G, Henrot P. Surveillance des seins traités et ses pièges. IMAGERIE DE LA FEMME 2018. [DOI: 10.1016/j.femme.2018.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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25
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Mastectomy Flap Thickness and Complications in Nipple-Sparing Mastectomy: Objective Evaluation using Magnetic Resonance Imaging. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2017; 5:e1439. [PMID: 28894660 PMCID: PMC5585433 DOI: 10.1097/gox.0000000000001439] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 06/14/2017] [Indexed: 12/11/2022]
Abstract
Background: Ischemic complications after nipple-sparing mastectomy (NSM) have been associated with numerous variables. However, the impact of NSM flap thickness has been incompletely evaluated. Methods: NSM flap thickness was determined for all NSMs from 2006 to 2016 with available pre- or postoperative breast magnetic resonance imaging (MRIs). Demographics and outcomes were stratified by those with and without ischemic complications. Results: Of 1,037 NSM reconstructions, 420 NSMs had MRI data available, which included 379 preoperative MRIs and 60 postoperative MRIs. Average total preoperative skin/subcutaneous tissue NSM flap thickness was 11.4 mm. Average total postoperative NSM flap thickness was 8.7 mm. NSMs with ischemic complications were found to have significantly thinner overall postoperative NSM flap thickness compared with those without ischemic complications (P = 0.0280). Average overall postoperative NSM flap thickness less than 8.0 mm was found to be an independent predictor of ischemic complications (odds ratio, 6.5263; P = 0.026). In NSMs with both pre- and postoperative MRIs, the overall average postoperative NSM flap thickness was 68.2% of preoperative measurements. Average overall postoperative NSM flap thickness was significantly less than average overall preoperative NSM flap thickness (P < 0.0001). NSMs with ischemic complications were found to have a significantly lower ratio of overall postoperative to preoperative flap thickness (52.0% versus 74.0%; P < 0.0001). Conclusions: Ischemic complications after NSM are significantly associated with thinner postoperative NSM flap thickness. Particularly, NSM flap thickness less than 8.0 mm is a positive independent predictor of ischemic complications. The ratio of postoperative to preoperative NSM flap thickness was significantly lower in reconstructions with ischemic complications.
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27
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Follow-Up of Patients with Breast Cancer. Breast Cancer 2017. [DOI: 10.1007/978-3-319-48848-6_65] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Michaels AY, Birdwell RL, Chung CS, Frost EP, Giess CS. Assessment and Management of Challenging BI-RADS Category 3 Mammographic Lesions. Radiographics 2016; 36:1261-72. [PMID: 27541437 DOI: 10.1148/rg.2016150231] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Breast Imaging Reporting and Data System (BI-RADS) category 3 lesions are probably benign by definition and are recommended for short-interval follow-up after a diagnostic workup has been completed. Although the original lexicon-derived BI-RADS category 3 definition applied to lesions without prior imaging studies (when stability could not be determined), in clinical practice, many lesions with prior images may be assigned to BI-RADS category 3. Although the BI-RADS fifth edition specifically delineates lesions that are appropriate for categorization as probably benign, it also specifies that the interpreting radiologist may use his or her discretion and experience to justify a "watchful waiting" approach for lesions that do not meet established criteria. Examples of such lesions include evolving masses or calcifications suggestive of prior trauma and instances when stability cannot be ascertained because of image quality. Although interval change is an important feature of malignancy, many benign lesions also change over time; thus, use of prior imaging studies and ongoing imaging surveillance to demonstrate the evolution of a probably benign lesion is justified. Some examples of common pitfalls associated with inappropriate BI-RADS category 3 assessment include failure to use proper BI-RADS descriptors, failure to perform a complete diagnostic workup, and overreliance on negative ultrasonographic findings. When appropriately used, short-interval follow-up saves many patients from undergoing biopsy of benign lesions, without decreasing the rate of cancer detection. (©)RSNA, 2016.
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Affiliation(s)
- Aya Y Michaels
- From the Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115
| | - Robyn L Birdwell
- From the Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115
| | - Chris SungWon Chung
- From the Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115
| | - Elisabeth P Frost
- From the Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115
| | - Catherine S Giess
- From the Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115
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Ortiz-Pomales YT, Priyanka Handa, Newell MS, Losken A. Reduction Mammaplasty and Breast Cancer Screening. Clin Plast Surg 2016; 43:333-9. [PMID: 27012791 DOI: 10.1016/j.cps.2015.12.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Breast reduction surgery is one of the most popular procedures performed by plastic surgeons; based on the current literature, it is safe and does not have a negative impact on identifying breast cancer in women. There are no evidence-based data to confirm the utility of unique screening protocols for women planning to undergo reduction surgery or for those who already had reduction. Women undergoing this surgery should not deviate from the current recommendations of screening mammography in women older than 40 years of average risk. Experienced radiologist can readily distinguish postsurgical imaging findings of rearranged breast parenchyma from malignancy.
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Affiliation(s)
- Yan T Ortiz-Pomales
- Division of Plastic and Reconstructive Surgery, Emory University, 550 Peachtree Street, Suite 84300, Atlanta, GA 30308, USA
| | - Priyanka Handa
- Division of Plastics and Reconstructive Surgery, Department of Radiology, Emory University, 550 Peachtree Street, Suite 84300, Atlanta, GA 30308, USA
| | - Mary S Newell
- Division of Plastics and Reconstructive Surgery, Department of Radiology, Emory University, 550 Peachtree Street, Suite 84300, Atlanta, GA 30308, USA
| | - Albert Losken
- Division of Plastic and Reconstructive Surgery, Emory University, 550 Peachtree Street, Suite 84300, Atlanta, GA 30308, USA.
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Abstract
Patients with pathologic processes of the breast commonly present in the Emergency Department (ED). Familiarity with the imaging and management of the most common entities is essential for the radiologist. Additionally, it is important to understand the limitations of ED imaging and management in the acute setting and to recognize when referrals to a specialty breast center are necessary. The goal of this article is to review the clinical presentations, pathophysiology, imaging, and management of emergency breast cases and common breast pathology seen in the ED.
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Dolan R, Patel M, Weiler-Mithoff E, Mansell J, Stallard S, Doughty JC, Romics L. Imaging Results Following Oncoplastic and Standard Breast Conserving Surgery. Breast Care (Basel) 2015; 10:325-9. [PMID: 26688680 DOI: 10.1159/000437105] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Oncoplastic breast-conserving surgery (OBCS) requires more complex surgical techniques than standard wide local excision (WLE) and the postoperative complication rate may be higher. Since these can have an impact on postoperative imaging, we compared imaging and biopsy results after OBCS and WLE. METHODS Findings for patients undergoing OBCS (n = 83) or standard WLE (n = 128) were compared. Numbers, indications and outcomes of mammograms, breast ultrasounds, magnetic resonance imaging scans and biopsies done within 2 years after surgery were analysed. RESULTS OBCS was applied for more advanced malignancy. Significantly more patients required breast ultrasound after OBCS than WLE (20/71 vs. 17/116; p = 0.024). Breast Imaging Reporting and Data System (BI-RADS) category 3 or 4 ultrasound results were found only in patients with OBCS (6/29 vs. 0/19; p = 0.034). Significantly more biopsies were required after OBCS (9/71 vs. 3/116; p = 0.006). New lumps or lumpiness were the commonest indications, and pathology confirmed fat necrosis in the majority (7/12). The rate of fat necrosis after OBCS was 18% on clinical examination (13/71), 15% with ultrasound (11/71) and 7% confirmed on pathology (5/71). CONCLUSION Patients treated with OBCS require significantly more ultrasound scans and consequent biopsies than patients who underwent WLE. This is mainly due to fat necrosis developing after OBCS in the majority of cases.
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Affiliation(s)
- Ross Dolan
- Department of Surgery, Victoria Infirmary, Glasgow, UK
| | - Meera Patel
- Department of Surgery, Victoria Infirmary, Glasgow, UK
| | | | - James Mansell
- Department of Surgery, Victoria Infirmary, Glasgow, UK
| | | | | | - Laszlo Romics
- Department of Surgery, Victoria Infirmary, Glasgow, UK
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Sutton EJ, Watson EJ, Gibbons G, Goldman DA, Moskowitz CS, Jochelson MS, Dershaw DD, Morris EA. Incidence of Internal Mammary Lymph Nodes with Silicone Breast Implants at MR Imaging after Oncoplastic Surgery. Radiology 2015; 277:381-7. [PMID: 26098457 DOI: 10.1148/radiol.2015142717] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE To assess the incidence of benign and malignant internal mammary lymph nodes (IMLNs) at magnetic resonance (MR) imaging among women with a history of treated breast cancer and silicone implant reconstruction. MATERIALS AND METHODS The institutional review board approved this HIPAA-compliant retrospective study and waived informed consent. Women were identified who (a) had breast cancer, (b) underwent silicone implant oncoplastic surgery, and (c) underwent postoperative implant-protocol MR imaging with or without positron emission tomography (PET)/computed tomography (CT) between 2000 and 2013. The largest IMLNs were measured. A benign IMLN was pathologically proven or defined as showing 1 year of imaging stability and/or no clinical evidence of disease. Malignant IMLNs were pathologically proven. Incidence of IMLN and positive predictive value (PPV) were calculated on a per-patient level by using proportions and exact 95% confidence intervals (CIs). The Wilcoxon rank sum test was used to assess the difference in axis size. RESULTS In total, 923 women with breast cancer and silicone implants were included (median age, 46 years; range, 22-89 years). The median time between reconstructive surgery and first MR imaging examination was 49 months (range, 5-513 months). Of the 923 women, 347 (37.6%) had IMLNs at MR imaging. Median short- and long-axis measurements were 0.40 cm (range, 0.20-1.70 cm) and 0.70 cm (range, 0.30-1.90 cm), respectively. Two hundred seven of 923 patients (22.4%) had adequate follow-up; only one of the 207 IMLNs was malignant, with a PPV of 0.005 (95% CI: 0.000, 0.027). Fifty-eight of 923 patients (6.3%) had undergone PET/CT; of these, 39 (67.2%) had IMLN at MR imaging. Twelve of the 58 patients (20.7%) with adequate follow-up had fluorine 18 fluorodeoxyglucose-avid IMLN, with a median standardized uptake value of 2.30 (range, 1.20-6.10). Only one of the 12 of the fluorodeoxyglucose-avid IMLNs was malignant, with a PPV of 0.083 (95% CI: 0.002, 0.385). CONCLUSION IMLNs identified at implant-protocol breast MR imaging after oncoplastic surgery for breast cancer are overwhelmingly more likely to be benign than malignant. Imaging follow-up instead of immediate metastatic work-up may be warranted.
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Affiliation(s)
- Elizabeth J Sutton
- From the Department of Radiology (E.J.S., E.J.W., G.G., M.S.J., D.D.D., E.A.M.) and Department of Epidemiology & Biostatistics (D.A.G., C.S.M.), Memorial Sloan-Kettering Cancer Center, 300 E 66th St, Suite 715, New York, NY 10065
| | - Elizabeth J Watson
- From the Department of Radiology (E.J.S., E.J.W., G.G., M.S.J., D.D.D., E.A.M.) and Department of Epidemiology & Biostatistics (D.A.G., C.S.M.), Memorial Sloan-Kettering Cancer Center, 300 E 66th St, Suite 715, New York, NY 10065
| | - Girard Gibbons
- From the Department of Radiology (E.J.S., E.J.W., G.G., M.S.J., D.D.D., E.A.M.) and Department of Epidemiology & Biostatistics (D.A.G., C.S.M.), Memorial Sloan-Kettering Cancer Center, 300 E 66th St, Suite 715, New York, NY 10065
| | - Debra A Goldman
- From the Department of Radiology (E.J.S., E.J.W., G.G., M.S.J., D.D.D., E.A.M.) and Department of Epidemiology & Biostatistics (D.A.G., C.S.M.), Memorial Sloan-Kettering Cancer Center, 300 E 66th St, Suite 715, New York, NY 10065
| | - Chaya S Moskowitz
- From the Department of Radiology (E.J.S., E.J.W., G.G., M.S.J., D.D.D., E.A.M.) and Department of Epidemiology & Biostatistics (D.A.G., C.S.M.), Memorial Sloan-Kettering Cancer Center, 300 E 66th St, Suite 715, New York, NY 10065
| | - Maxine S Jochelson
- From the Department of Radiology (E.J.S., E.J.W., G.G., M.S.J., D.D.D., E.A.M.) and Department of Epidemiology & Biostatistics (D.A.G., C.S.M.), Memorial Sloan-Kettering Cancer Center, 300 E 66th St, Suite 715, New York, NY 10065
| | - D David Dershaw
- From the Department of Radiology (E.J.S., E.J.W., G.G., M.S.J., D.D.D., E.A.M.) and Department of Epidemiology & Biostatistics (D.A.G., C.S.M.), Memorial Sloan-Kettering Cancer Center, 300 E 66th St, Suite 715, New York, NY 10065
| | - Elizabeth A Morris
- From the Department of Radiology (E.J.S., E.J.W., G.G., M.S.J., D.D.D., E.A.M.) and Department of Epidemiology & Biostatistics (D.A.G., C.S.M.), Memorial Sloan-Kettering Cancer Center, 300 E 66th St, Suite 715, New York, NY 10065
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Ceugnart L, Pasquier D, Jarraya H, Rocourt N, Boulanger T, Bercez H, Bachelle F, Chaveron C, Taieb S. Sein traité. Symptômes et imagerie. IMAGERIE DE LA FEMME 2015. [DOI: 10.1016/j.femme.2015.03.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Arleo EK, Saleh M, Schwartz MH, Eisen CS. Cosmetic fat augmentation following breast reconstruction: sonographic appearance with cytopathologic correlation. Clin Imaging 2014; 38:872-6. [PMID: 25128090 DOI: 10.1016/j.clinimag.2014.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Revised: 07/02/2014] [Accepted: 07/10/2014] [Indexed: 12/11/2022]
Abstract
This series presents the history and imaging of patients who had cosmetic fat augmentation following mastectomy and reconstruction. The cases provide the useful reminder that a complete surgical history is essential when assessing the imaging of a post-operative breast patient and that speaking directly with patients can be a critical step in putting together a complete clinical picture and adding value to their care.
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Affiliation(s)
- Elizabeth Kagan Arleo
- New York-Presbyterian Hospital, Weill Cornell Medical Center, 425 East 61st Street, New York, NY 10065.
| | - Marwa Saleh
- New York-Presbyterian Hospital, Weill Cornell Medical Center, 425 East 61st Street, New York, NY 10065
| | - Mark H Schwartz
- New York-Presbyterian Hospital, Weill Cornell Medical Center, 425 East 61st Street, New York, NY 10065
| | - Carolyn Sharyn Eisen
- New York-Presbyterian Hospital, Weill Cornell Medical Center, 425 East 61st Street, New York, NY 10065
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35
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Heller SL. Invited commentary. Radiographics 2014; 34:660-2. [PMID: 24819787 DOI: 10.1148/rg.343135188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Samantha L Heller
- Department of Radiology, St. George's Hospital London, United Kingdom
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