A pictorial review: multimodality imaging of benign and suspicious features of fat necrosis in the breast

Monitoring for Breast Cancer Recurrence Following Goldilocks Breast Reconstruction

BACKGROUND

The Goldilocks breast reconstruction utilizes redundant mastectomy skin flaps to fashion a breast mound; however, there is concern that imbrication of these skin flaps may predispose to fat necrosis and make detection of local breast cancer recurrence more difficult. Goldilocks patients follow a traditional postmastectomy screening pathway that includes clinical examination for locoregional recurrence, but it is unclear if this is sufficient. We evaluate our Goldilocks reconstruction case series to determine rates of diagnostic imaging, biopsy, and locoregional and distant recurrence.

METHODS

Sixty-six patients (94 breasts) undergoing Goldilocks breast reconstruction were retrospectively reviewed. Any diagnostic postoperative imaging/biopsies performed and that confirmed local or distant breast cancer recurrence were noted.

RESULTS

Average time of follow-up was 45 months. Most patients in this cohort had stage 0 (27.3%) or stage I (40.9%) breast cancer. There were a total of 11 (11.7%) concerning breast masses identified. Seven (7.4%) masses were biopsied, of which 5 were benign and 2 were invasive cancer recurrence. Four masses (4.3%) underwent diagnostic imaging only, all with benign findings. Five patients in this series were found to have either distant disease or a second primary cancer in the nonoperative contralateral breast.

CONCLUSIONS

Rates of local recurrence following Goldilocks are not higher than expected after other types of postmastectomy reconstruction. Clinical monitoring successfully detected local recurrence in all affected patients in this series. More definite guidelines around the routine screening of Goldilocks mastectomy patients may aid in early detection of local breast cancer recurrence.

Imaging findings after a total reconstructed breast with autologous fat transfer: what the radiologist needs to know

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.

Fat necrosis in the breast: a multimodality imaging review of its natural course with different aetiologies

Fat necrosis of the breast is a commonly encountered condition in daily practice. It is a benign pathology, but it can have variable manifestations and patterns that may sometimes mimic malignancy, depending on its stage of evolution and its underlying cause. This review demonstrates the wide spectrum of appearances of fat necrosis on mammography, digital breast tomosynthesis (DBT), ultrasound, magnetic resonance imaging (MRI), computed tomography (CT), and positron-emission tomography (PET). Sequential follow-up images are included in some cases to illustrate the temporal change of the findings. The typical location and distribution of fat necrosis from a comprehensive list of aetiologies are discussed. Improved knowledge of the multimodality imaging features of fat necrosis could enhance diagnostic accuracy and clinical management, thus avoiding unnecessary invasive investigations.

Influence of vertical location and spacing of perforators on perfusion in deep inferior epigastric artery perforator flap breast reconstruction: quantitative analysis using indocyanine green angiography

Background

This study quantitatively assessed perfusion of the deep inferior epigastric artery perforator (DIEP) flap according to vertical location and vertical spacing of perforators during DIEP flap breast reconstruction.

Methods

In 67 patients who underwent unilateral DIEP flap breast reconstruction between November 2018 and August 2021, flap perfusion was intraoperatively assessed using indocyanine green angiography. Perforators located at or above the umbilicus were defined as vertical zone 1 perforators and those below the umbilicus as vertical zone 2 perforators. Perfusion assessment was conducted in two stages: at stage 1, perfusion solely by single dominant perforators was assessed. At stage 2, the perfusion increment effected by adding a single additional perforator was assessed. Perfused area proportions were compared between patients with dominant perforators in zone 1 versus zone 2. The effect of adding an additional perforator to another vertical zone ("vertical spacing") was also assessed.

Results

The perfused proportion was significantly higher among vertical zone 2 perforators compared with zone 1 perforators in the evaluation of single dominant perforators (70% vs. 56%; P<0.001). In the evaluation of incremented perfusion by single additional perforators, the perfused proportion was significantly higher in the vertical-spacing group compared to the no-vertical-spacing group (17% vs. 12%; P=0.004). Fat necrosis developed in 4.5 percent of the patients over at least 6 months of follow-up.

Conclusions

DIEP flap perfusion can be affected by the vertical location of perforators, and flap perfusion can be augmented effectively by vertical spacing of perforators.

MRI for Evaluation of Complications of Breast Augmentation

Breast augmentation is one of the most common aesthetic procedures performed in the United States. Several techniques of breast augmentation have been developed, including the implantation of breast prostheses and the injection of autologous fat and other materials. The most common method of breast augmentation is to implant a prosthesis. There are different types of breast implants that vary in shape, composition, and the number of lumina. The rupture of breast implants is the leading cause of implant removal. The rupture rate increases substantially with the increasing age of the implant. Most implant ruptures are asymptomatic. Implant complications can be grouped into two categories: local complications in the breast and adjacent soft tissue, and systemic complications associated with rheumatologic or neurologic symptoms. The onset of local complications may be early (infection and periprosthetic collections including seromas, hematomas, or abscesses) or late (capsular contraction, implant rupture, gel bleed, or breast implant-associated anaplastic large cell lymphoma). Although mammography is the imaging modality for breast cancer screening, noncontrast breast MRI is the imaging modality of choice for evaluation of the integrity of breast implants and the complications of breast augmentation, for equivocal findings at conventional imaging, and as a supplement to mammography in patients with free injectable materials. The fifth edition of the Breast Imaging Reporting and Data System (BI-RADS) provides a systematic outline for MRI evaluation of patients with breast implants. Silicone- and water-selective sequences provide useful supplemental information to confirm intracapsular and extracapsular rupture. Breast MRI for evaluation of implant integrity does not require intravenous contrast material. The use of MRI contrast material in patients with breast augmentation is indicated when infection or malignancy is suspected. Radiologists should have a thorough understanding of the different techniques for breast augmentation, normal imaging features, and complications specific to breast augmentation. An invited commentary by Ojeda-Fournier is available online. ^©RSNA, 2022.

Sonographic Features of Palpable Breast and Axillary Lesions in Adult Male Patients: A Pictorial Essay

The male breast is a non-functional and rudimentary organ, but similarly to the female breast, it can be affected by various diseases. In contrast to female breast cancer, male breast cancer has a low incidence, and there is no established breast cancer screening program for male patients. Therefore, the diagnostic evaluation is usually performed in male patients with symptoms such as palpability or pain in the breasts. Furthermore, most adult male patients who visit breast clinics sometimes present with not only breast symptoms but also axillary symptoms, and both the breast and axilla are usually examined during breast ultrasonography in daily clinical practice. The purpose of this pictorial essay was to present the sonographic features of various palpable breast and axillary lesions in adult male patients.

Autologous Fat Grafting to the Breast: An Educational Review

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.

Mimickers of breast malignancy: imaging findings, pathologic concordance and clinical management

Many benign breast entities have a clinical and imaging presentation that can mimic breast cancer. The purpose of this review is to illustrate the wide spectrum of imaging features that can be associated with benign breast diseases with an emphasis on the suspicious imaging findings associated with these benign conditions that can mimic cancer. As radiologic-pathologic correlation can be particularly challenging in these cases, the radiologist’s familiarity with these benign entities and their imaging features is essential to ensure that a benign pathology result is accepted as concordant when appropriate and that a suitable management plan is formulated.

Natural course of fat necrosis after breast reconstruction: a 10-year follow-up study

Background

Although fat necrosis is a minor postoperative complication after breast reconstruction, occasionally it mimics to tumor recurrence in patients with breast cancer. Therefore, the surgeon should distinguish between benign fat necrosis and true local recurrence. The authors evaluated the clinical characteristics of fat necrosis after breast reconstruction and investigated the natural course of fat necrosis.

Methods

Between 2007 and 2013, a total of 362 patients underwent breast reconstruction after partial or total mastectomy for breast cancer in Kyungpook National University Hospital. Clinicopathologic characteristics and the occurrence of fat necrosis were assessed during surveillance for 10 years of mean follow-up period.

Results

There were 42 cases (11.6%) of fat necrosis after breast reconstruction with partial or total mastectomy which were confirmed by needle or excision biopsy. The fat necrosis was resolved after a mean period of 45.9 months (SD, ± 42.1) and 26 cases (61.9%) of fat necrosis were almost completely resolved (less than 5 mm) during 10-year follow-up period.

Conclusion

Based on the natural course of fat necrosis, the fat necrosis after breast reconstruction can be only monitored, if pathologic confirmation was done. More than half of the cases will be resolved within 2–3 years.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-07881-x.

Breast fat necrosis secondary to warfarin-induced calciphylaxis, a rare mimicker of breast cancer: A case report and a review of literature

Breast fat necrosis (BFN) is usually a benign inflammatory response to breast trauma. However, an extremely rare cause of fat necrosis is calciphylaxis, a calcification of small- and medium-sized arteries causing thrombosis and ischemia. It is classified into (A) uremic (B) nonuremic-induced calciphylaxis. Calciphylaxis has been reported to be encountered in different parts of the body. However, to the best of our knowledge there is only one case in the English literature of BFN 2ry to warfarin-induced calciphylaxis. We report a 65-year-old female, known case of atrial fibrillation on warfarin, presented with a left breast mass of 4-month duration. The mass was painful and progressively enlarging. Examination of the left breast showed 7 × 4 cm mass, spanning from 10-2 o'clock, free from surrounding structures, with preserved overlying skin. However, the mass was not visualized on mammogram. Ultrasound showed a left breast lobulated hypoechoic mass containing a hyperechoic component. Biopsy showed fat necrosis. After 1 month, she presented with ulceration of the overlying skin. After wide local excision, histopathology demonstrated a calciphylaxis-induced fat necrosis. Considering the patient's background, the diagnosis was BFN secondary to warfarin-induced calciphylaxis. Hence, the warfarin was shifted to Rivaroxaban, 6 months follow-up showed no evidence of recurrence. In conclusion, the rarity of nonuremic calciphylaxis is reflected on the delay of diagnosis in some of the reported cases and the lack of grading system used to guide the management of such difficult wounds. However, keeping a high index of suspicion is important whenever such wounds are encountered with presence of risk factors other than end-stage kidney disease.

Cellular Spindled Histiocytic Pseudotumor: A Benign Mimic of Spindle Cell Neoplasia of the Breast

CONTEXT.—

Cellular spindled histiocytic pseudotumor (CSHPT) is an exuberant, dense histiocytic proliferation seen in the setting of mammary fat necrosis. CSHPT has a broad histologic differential diagnosis, including benign, malignant, and inflammatory etiologies.

OBJECTIVES.—

To highlight the most important histologic and immunohistochemical findings of CSHPT and provide comparisons to entities within the broad differential diagnosis.

DATA SOURCES.—

Recently published literature regarding CSHPT and other diagnostic considerations.

CONCLUSIONS.—

CSHPT is a benign histiocytic proliferation with a broad differential diagnosis, for which comprehensive ancillary studies may be required to exclude malignant and infectious entities.

[Cosmetic Breast Augmentation without Silicone Implants]

Cosmetic Breast Augmentation without Silicone Implants Abstract. Cosmetic breast augmentation procedures without silicone implants are becoming increasingly popular. Mastopexy can be adapted to the needs of the patient and usually result in an at least optical augmentation. Lipofilling is a safe procedure in reconstructive and aesthetic breast surgery and can help to restore natural appearance, compensate volume deficiencies, and correct asymmetries, that may be congenital or a consequence of prior surgeries. Cosmetic breast augmentation of very small breasts or when aiming at higher breast volumes using lipofilling only are usually combined with procedures for tissue expansion in order to increase the take rate of the injected fat. Hyaluronic acid injections is no valid alternative and are not recommended for cosmetic breast augmentation.

Does lipofilling after oncologic breast surgery increase the amount of suspicious imaging and required biopsies?-A systematic meta-analysis

OBJECTIVE

The aim of our systematic meta-analysis was to find out if lipofilling to the breast alters follow-up imaging procedures and leads to an increased number of biopsies because of suspicious findings.

METHODS

We conducted a systematic meta-analysis of the literature including all prospective and retrospective studies focusing on imaging outcomes in patients with a history of breast cancer who have received one or more lipofilling procedures after oncologic surgery to the breast.

RESULTS

Twelve studies met the inclusion criteria, comprising 1711 patients and at least 2261 lipofilling procedures. 564 patients (33%) were followed up only with ultrasound, 735 patients (43%) only received mammography, 273 (16%) had a combination of ultrasound, mammography and MRI, and 37 patients (2.1%) were followed up via ultrasound and mammography. A collective of 102 patients making up a matched-cohort study received ultrasound, mammography, MRI, and PET/CT, while only 51 of them made up the investigation group who had autologous fat grafting (3%). Biopsy rates were 1%-24% with a medium of 6.5% over all groups. Medium follow-up was 18.8 months (range 6-50 months). The rate of local oncologic events among the patients with lipofilling procedures detected during the study periods was 0.7%.

CONCLUSION

Lipofilling to the breast after oncologic operations appears to be a safe procedure with overall low biopsy and local recurrence rate. Suspicious imaging occurs in most cases out of physiologic remodeling and inflammation processes at the operation site and needs to be distinguished from malignant focusses. The amount of required biopsies stands in relation to the used imaging method and the time to follow-up.

Clinical Evaluation of Breast in Childhood

Childhood breast masses are mostly benign conditions starting from the newborn period continuing on to adolescence yet can cause high anxiety in the child and the family as well. As a complaint or physical finding, usually palpable mass, pain or discharge from the nipple is apparent in patients. All the clinicians interested in pediatric field should have full knowledge of immature and developing breasts so to proper diagnose and avoid overtreatment with unnecessary diagnostic or surgical procedures. Though malignancy or life-threatening disease has a very low probability during childhood, all child patients should be evaluated and followed up carefully. Especially training and then encouraging young people to periodically start self-assessment of the breasts after their 19th birthday while warning the ones who have had therapeutic chest radiation previously to begin self-assessment 8 years after the procedure or at 25 years of age whichever comes last, will be an appropriate intervention.