Factors Influencing Recurrence in Medial Breast Cancer Tumors After Skin Sparing Mastectomy and Immediate Breast Reconstruction

BACKGROUND

Skin sparing mastectomy (SSM) with immediate breast reconstruction (IBR) has been established as a safe option for curative-intent surgical resection. Prior studies have shown that medial location of the primary tumor is associated with increased risk of local recurrence. The purpose of this study is to determine the factors associated with recurrence and survival in individuals with breast cancers located in the inner quadrants (medial) who underwent SSM with IBR.

METHODS

A retrospective chart review was done on individuals with medial breast cancer who received SSM with IBR in British Columbia between 1980 and 2012.

RESULTS

Of 136 individuals with medial breast cancer undergoing SSM with IBR, 27.9% experienced local recurrence and 42.6% overall recurrence. Factors associated with recurrence were T-stage (44.8 vs. 22.4% with T2 disease, P = .02), transverse rectus abdominis muscle (TRAM) flap reconstruction (48.3 vs. 29.5%, P = .00395), prior breast surgery (87.9 vs. 63%, P = .002), and prior radiation therapy (74.1 vs. 38.5%, P < .0001). LR was associated with higher mortality (OR 2.78, 95% CI: 1.26-6.09).

CONCLUSION

For patients with medial tumors undergoing SSM with IBR, potential risk factors for recurrence are T-stage, TRAM flap reconstruction, prior breast surgery, and prior radiation therapy. Local recurrence is associated with poor survival.

Spectrum of ultrasound findings in patients with history of breast conservative treatment

Breast conservative treatment (BCT) is currently accepted as the standard treatment option for breast cancer. Targeted ultrasound helps detect recurrent lesions, postoperative changes, and scarring tissue. In this pictorial essay, we review the ultrasound features of benign (seroma, hematoma, fat necrosis, traumatic neuroma, fibrosis/scarring) and malignant (recurrence, new primary cancer) causes of palpable lumps after BCT and provide images from our patients to illustrate some typical findings of common pathologies. Ultrasound, especially as an adjunct to mammography, can make a specific diagnosis in most cases.

Challenges in Interpretation of US Breast Findings in the Emergency Setting

Emergencies in breast imaging are infrequent but not rare. Although infectious conditions such as mastitis and breast abscess are the most common breast diseases encountered in acute care settings, other entities that may require additional imaging or different treatment approaches are also seen and include traumatic injury and breast cancer. While mammography is widely available for breast evaluation in outpatient facilities, most emergency departments do not have mammography units. This makes evaluation of patients with breast disease incomplete in the acute care setting and emphasizes the role of appropriate US techniques for interpretation. It also highlights the importance of effective sonographer-to-radiologist communication to ensure patient safety and diagnostic accuracy, especially in an era of increasing adoption of teleradiology. The authors discuss the challenges in image acquisition and remote interpretation that are commonly faced by radiologists when they assess breast anomalies in the emergency setting. They present strategies to overcome these challenges by describing techniques for proper US evaluation, highlighting the importance of sonographer-radiologist communication, defining the goals of the evaluation, reviewing common differential diagnoses, and providing appropriate follow-up recommendations. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Incidental Breast Findings on Computed Tomography and MR Imaging

Computed tomography (CT) and magnetic resonance (MR) imaging may demonstrate a wide variety of incidental findings in the breast, including primary breast carcinoma, the second most common cancer in women. It important to recognize the spectrum of pathologic conditions in order to properly assess the need for further workup. Some findings may be diagnosed as benign on the basis of CT/ MR imaging and clinical history alone, whereas others will require evaluation with dedicated breast imaging and possibly biopsy. This article serves to guide radiologists' management of the wide spectrum of incidental breast findings encountered on cross-sectional imaging.

Palpable Masses after Mastectomy: Differentiating Benign Postoperative Findings from Recurrent Disease

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.

Digital Mammographic Features of Breast Cancer Recurrences and Benign Lesions Mimicking Malignancy Following Breast-Conserving Surgery and Radiation Therapy

Mammography after breast-conserving surgery and radiation therapy is an important tool for followup. Early diagnosis of local recurrence enables prompt treatment decisions, which may affect patient prognosis. For complicated post-treatment changes, radiologists sometimes have difficulties in interpreting follow-up mammography. Fat necrosis, dystrophic calcifications, suture calcification features, breast edema, seroma and distorted breast are benign changes related to treatment. These findings may mimic or hide tumor recurrence making it difficult to diagnose recurrences or prevent inappropriate biopsies. Recurrent tumors in follow-up mammography show several typical findings such as increasing asymmetric density, enlarging mass, reappearance of breast edema, and micro-calcifications. The purpose of this pictorial review is to demonstrate and discuss mammographic findings of recurrent tumors and important post-treatment changes that may mimic benign or malignant lesions, also using breast ultrasound images or breast magnetic resonance images. Recognizing post-treatment changes may help radiologists to more effectively identify candidates for suspected local recurrences.

How should we manage women with fat necrosis following autologous breast reconstruction: An algorithmic approach

Fat necrosis is a common complication of autologous breast reconstruction; however, diagnostic criteria are yet to be standardized, making comparison of autologous breast reconstructive techniques challenging. A systematic review found six of 556 articles met inclusion criteria. These results were used to generate an algorithm for managing fat necrosis after autologous breast reconstruction.

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

Fat necrosis of the breast is a well-described benign entity that can result in unnecessary biopsy of breast lesions. The pathogenesis of fat necrosis is a non-suppurative inflammatory process of adipose tissue, which may be seen after trauma, surgery, biopsy, post-breast reconstruction, post-fat grafting, post-radiotherapy, infection, and duct ectasia, among other conditions. Clinically, these patients may be asymptomatic or may present with a palpable lump, skin tethering, induration, and occasionally axillary lymphadenopathy. Depending on the time at which diagnostic imaging is performed, fat necrosis can have highly variable appearances on different modalities as it evolves. This is directly related to whether inflammation or fibrosis is predominating within the lesion, and correlation with clinical history is paramount in evaluating these patients. This review aims to analyze benign and suspicious imaging features of fat necrosis confirmed by tissue sampling. Knowledge of both benign and malignant-appearing features of fat necrosis on conventional modalities such as mammography and ultrasound, as well as newer applications including digital breast tomosynthesis, PET/CT, and MRI, should help the radiologist minimize the number of unnecessary biopsies.

Ultrasound for postoperative surveillance after mastectomy in patients with breast cancer: A retrospective study

This study aimed to evaluate the clinical usefulness of postoperative surveillance by ultrasound (PSU) in patients after breast cancer surgery.In this retrospective study, 324 patients with breast cancer after mastectomy were included between January 2006 and December 2008. The final-positive lesions (FPL) were diagnosed according to the results of cytopathology, clinical and imaging examinations. The outcome evaluations included the sensitivity (SS), specificity (SC), ultrasound accuracy for FPL (UAFPL), and positive predictive value (PPV) after the mastectomy.A total of 5117 ultrasound examinations were conducted for all those patients to the December 2016. After mastectomy, the SS, SC, UAFPL, and PPV were as follows: mastectomy bed (SS, 100.0%; SC, 99.7%; UAFPL, 99.7%; and PPV, 36.0%), contralateral breast (SS, 100.0%; SC, 99.0%; UAFPL, 99.0%; and PPV, 25.4%), ipsilateral axillary or supraclavicular (SS, 91.7%; SC, 99.4%; UAFPL, 99.4%; and PPV, 25.6%), and contralateral axilla or supraclavicular lymph nodes (SS, 100.0%; SC, 99.9%; UAFPL, 99.9%; and PPV, 33.3%).In summary, we demonstrated that applied PSU can detect the malignant lesions in the breast regional area with high sensitivity, specificity and accuracy.

Intramammary Findings on CT of the Chest - a Review of Normal Anatomy and Possible Findings

Computed tomography (CT) is a frequently performed examination in women of all ages. In all thoracic CT examinations of the chest at least parts of the breasts are included. Therefore incidental breast pathology may be observed. It has been suggested that one out of 250 women undergoing chest CT will show a malignant incidental breast lesion. Given the high number of performed chest CT examinations, this contributes to a significant number of malignancies. In this review, after a brief discussion of the value of computed tomography in breast imaging, normal and pathologic findings are discussed to create awareness of this potential “black box” on chest CT.

Assessment and Management of Challenging BI-RADS Category 3 Mammographic Lesions

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.

A Propensity-Matched Analysis of the Influence of Breast Reconstruction on Subsequent Development of Lymphedema

BACKGROUND

Recent literature demonstrates a lower incidence of lymphedema with breast reconstruction. This study compared the incidence of lymphedema after axillary dissection in a propensity-matched cohort of patients with and without immediate breast reconstruction.

METHODS

A review of patients undergoing axillary lymphadenectomy with or without immediate breast reconstruction from January 1, 2000, to July 1, 2013, was conducted. Comorbidities, cancer treatment, operative characteristics, and pathologic findings were reviewed. The primary outcome was postoperative lymphedema. Univariate analysis identified baseline differences between the patient groups. Cohorts were propensity-matched by age, body mass index greater than 30 kg/m, adjuvant radiation therapy, cardiovascular disease, and hypertension. Subsequent multivariate regression was performed to identify independent predictors of lymphedema among matched patients.

RESULTS

A total of 4647 patients underwent breast cancer resection, with 1955 having axillary lymphadenectomy (no reconstruction, n = 1200; autologous, n = 563; implant-based, n = 192). Matching yielded a cohort of 239 reconstruction and 239 no-reconstruction patients demonstrating no differences in age, body mass index, hypertension, adjuvant radiation therapy, or axillary dissection extent. With 55.9 months' follow-up, postoperative lymphedema was diagnosed in 94 patients (19.7 percent). Reconstruction patients developed lymphedema in 19.2 percent of cases versus 20.1 percent for no- reconstruction patients (p = 0.82). Regression identified two independent predictors of lymphedema: postoperative radiation therapy (OR, 2.90; p < 0.001) and obesity (OR, 2.36; p < 0.001).

CONCLUSIONS

This study demonstrates a 19.7 percent incidence of lymphedema following axillary lymphadenectomy. Reconstruction does not appear to alter lymphedema risk, whereas postoperative radiation therapy, obesity, and extensive axillary dissection greatly increase risk.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Mammographic and Ultrasonographic Findings of Oxidized Regenerated Cellulose in Breast Cancer Surgery: A 5-Year Experience

BACKGROUND

The purpose of this study was to describe the ultrasonographic (US) and mammographic (MX) findings in patients who underwent breast-conserving surgery followed by oxidized regenerated cellulose (ORC) implantation in the surgical cavity and their size variations in follow-up.

MATERIALS AND METHODS

We retrospectively reviewed 417 MX and 743 US images performed between January 2009 and January 2014 for 262 women who underwent breast-conserving surgery. All patients underwent US, only 203 women underwent MX examination.

RESULTS

In 170 of 262 patients, US examinations showed abnormal findings. Three main US patterns were identified: (1) complex masses: well-encapsulated ipoisoechoic lesions with circumscribed margins with internal hyperechoic nodules (56%); (2) hypoanechoic lesions without internal hyperechoic nodules (24%); and (3) completely anechoic collections (20%). Moreover, Doppler ultrasound examination was performed on all of the patients. In 95 of 203 patients, MX examinations showed abnormalities. Four main MX patterns were identified: (1) round or oval opacity with circumscribed margins (58%); (2) round or oval opacity with indistinct or ill-defined margins (17%); (3) irregular opacity with indistinct or spiculated margins (9%); and (4) architectural distortion or focal asymmetry (15%). Most of the lesions showed a decrease in size at US and MX follow-up examination and the decrease was statistically significant (P < .01).

CONCLUSION

When applied to the surgical residual cavity, ORC aids to control local hemorrhage and reduce the risk of postoperative infections, but can lead to alterations in surgical scar. Thus, knowledge of the radiological findings might allow avoidance of misdiagnosis of tumor recurrence or unnecessary diagnostic examinations.