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World J Radiol. 2017 August 28; 9(8): 321–329.
Published online 2017 August 28. doi:  10.4329/wjr.v9.i8.321
PMCID: PMC5583527

Imaging of the treated breast post breast conservation surgery/oncoplasty: Pictorial review

Abstract

Mammographic appearance of the normal breast is altered in the post-operative setting. It is essential to be aware of the normal findings as well as to identify features of recurrent disease with particular emphasis on radiological-pathological concordance. Digital breast tomosynthesis and volumetric breast density add incremental value in this clinical setting. We present a pictorial review of various cases to illustrate normal post-operative findings as well as mammographic features suspicious for recurrent disease.

Keywords: Mammography, Digital breast tomosynthesis, Breast conservation surgery, Post breast-conserving therapy imaging, Breast cancer

Core tip: Mammographic imaging in patients after breast conservation surgery is challenging because surgery alters the normal breast architecture. The distinction of normal post-operative changes from true findings of recurrence becomes demanding even for a breast imager making it essential to update our knowledge in the subject. In the recent times digital breast tomosynthesis and volumetric breast density are adding an incremental value in this clinical setting.

INTRODUCTION

Breast conservation surgery (BCS) is the most commonly employed management of breast cancer in current practice and aims at surgical excision of the tumor while conserving the patient’s breast appearance and form. Breast radiologists need to update their knowledge of typical and atypical appearances of the treated breast in order to detect abnormalities signifying recurrence as well as to not raise unnecessary concern over benign course of post-operative change.

The expected changes on mammography after breast conservative surgery include skin thickening or edema, parenchymal edema, post-operative fluid collection, scar, fat necrosis and dystrophic calcifications which are more marked up to six months after therapy. Recurrence on mammographic imaging may be observed as a mass or microcalcifications, increase in skin thickening, increase in breast density, scar enlargement, axillary nodal recurrence or Paget’s disease. We present various mammography images to illustrate findings which may be left alone and those which require further intervention.

LEAVE-ME-ALONE FEATURES

Skin thickening and parenchymal edema

Normal skin thickness of the breast as seen on mammogram is 2 mm[1,2]. Skin thickening (more than 2 mm) is the most common finding after breast-conserving therapy (BCT), reported in up to 90% of patients[3]. On imaging it manifests as skin and trabecular thickening or overall increased breast density due to parenchymal edema which decrease on follow up studies and return to normal by 2 to 3 years (Figure (Figure11)[2]. Post radiation edema occurs more commonly after external beam radiotherapy (EBRT) than intraoperative radiotherapy[4,5]. Less commonly the skin thickening and parenchymal edema may be a consequence of lymphedema (secondary to axillary node dissection) or mastitis[3].

Figure 1
Patient underwent lumpectomy followed by radiation therapy. A-C: (A) Diffuse increase in skin thickness is seen in first post therapy mammogram which decreased on subsequent mammograms at two (B) and five (C) years respectively.

Post-operative collection

Fluid with or without blood which collects in the post-operative cavity appears as an oval or round circumscribed mass on mammography. When viewed on ultrasound, a mixed echogenic collection with variable fluid (anechoic) and haemorrhagic (echogenic) contents is observed. Post-operative fluid collections are seen in about half the patients at 1 mo after surgery and may remain in up to a fourth of cases till 6 mo[2] though in a few patients these may persist for years[6]. On sequential mammograms, the lesion becomes smaller, irregular and denser as the seroma retracts and is replaced by fibrous tissue (Figure (Figure2).2). However an increase in size on follow-up merits further evaluation to exclude a recurrent mass.

Figure 2
Two different patients post breast conservation. A and B demonstrate retraction of scar in right breast on follow up while C and D reveal serial decrease in size of a post-operative collection (seroma) in left breast.

Post-surgical scar

A post-surgical scar appears as an area of architectural distortion contiguous with contour deformity of surgery. In comparison to a true recurrence which appears same on all mammographic views and has a dense centre; on different projections a scar has varied appearances (appearing less distorted on one) and demonstrates fat lucencies within[3]. These features may be better imaged on spot compression or magnification views. As with a seroma, the scar usually decreases in density and/or size on serial imaging (Figure (Figure3)3) or remains stable while an increase in size or density is suspicious for recurrence (Figure (Figure44).

Figure 3
The scar usually decreases in density and/or size on serial imaging. A and B demonstrate a post-surgical scar in left breast which is contiguous with the skin contour deformity. Fat lucency (black dashed arrow) within the scar is seen on the MLO view ...
Figure 4
In a patient post breast-conserving therapy, scar (double headed arrow) is seen to increase in size at three (B) and four (C) years as compared to the initial mammogram shown in (A) which suggests recurrence.

Dystrophic calcifications and fat necrosis

Benign calcifications are seen on mammography in about a third of treated breasts beginning 2 to 3 years after completion of therapy due to a combination of surgical trauma and radiation. Morphologically these calcifications are large (> 5 mm) and irregular in outline with central lucencies, with no associated mass/density and always occur at the site of surgery[7].

Fat necrosis is tissue necrosis resulting from damage to the intima of arteries from surgery and radiation. It more commonly manifests as an oval or round lucency with curvilinear or arc-like peripheral calcifications which are characteristic for the same (Figure (Figure5).5). It is a common complication of myocutaneous flaps usually seen after 6-12 mo of treatment[3] and may clinically present as a palpable mass that is firm or hard[8]. When it presents as a palpable lesion with atypical appearance on mammography, sonography followed by biopsy may become requisite to confirm the diagnosis (Figure (Figure66)[9].

Figure 5
Calcifications associated with fat necrosis demonstrate a typical curvilinear or arc-like (arrows) morphology (A and B).
Figure 6
(A) Post breast-conserving therapy scar is seen in the right breast which appears to have increased in size on follow up mammogram after one year seen in (B). However fat lucencies are still seen within the lesion (which was better appreciated on tomography ...

WORRISOME MAMMOGRAPHY FINDINGS, I.E., "RED FLAGS"

Recurrences may present at clinical examination or, may be detected only on mammography (Figure (Figure7)7) as suspicious microcalcifications or masses. The rate of local recurrence after breast cancer surgery is 1%-2% per year[10]. Stability is defined as no interval change on two successive mammographic studies[7] and is generally observed at around 2-3 years after the completion of radiation therapy. Any retrograde change in imaging findings such as a new mass, microcalcifications, architectural distortion or an area of increased density at the scar site post stability should raise suspicion for tumor recurrence. Figure Figure88 lists the sites of recurrences to be looked for in conservatively treated breast on follow up.

Figure 7
How are recurrences detected on follow up.
Figure 8
Sites for recurrent lesions.

Masses

Palpable recurrences usually manifest as masses and even when seen as microcalcifications on a mammogram, they have associated densities. The temporal changes from prior mammogram determine the approach to patients[11]. Recurrences may be perceived as an increasing asymmetry or an enlarging mass within the operative bed or a new mass (neodensity) away from operative site[10] (Figure (Figure9).9). Any neodensity at mammography should be evaluated on ultrasound to determine whether it is solid or cystic (Figure (Figure10),10), and solid lesions should be biopsied (Figure (Figure1111).

Figure 9
Two patients post breast-conserving therapy with recurrent masses. A-C show a recurrent mass (dashed arrow in C) appearing at the scar site (solid arrow in A and B) two years after surgery; D-F demonstrate a post-surgical scar in the lower aspect (arrow ...
Figure 10
Approach to a neodensity.
Figure 11
Patient with a left breast mass (arrow), who underwent breast-conserving therapy (A), (B) follow up mammogram at 2 years revealed a neodensity (dashed arrow) which on ultrasound (C) was found to be a cyst.

Up to 65% of early recurrences occur at or within a few centimetres of the site of original tumor, usually within 6-7 years of treatment[1]. At follow up imaging, it is essential to ensure that scar site is visible in two views (CC and MLO or additional views), at least in the first decade after surgery[6]. A new lesion or a neodensity which is suspicious may remain stable due to ongoing hormonal treatment, and stability does not indicate benign finding. Morphology is the most important criteria, and it is necessary to achieve a radiological-pathological concordance (Figure (Figure12).12). Recurrence in the form of a developing asymmetry (Figure (Figure13)13) has a 27% likelihood of cancer post BCT[12]. Post-oncoplastic or breast reconstruction, locoregional tumor recurrence is seen in 2.3%. The most common site of tumor recurrence is the contact line, at the junction of the flap with the native tissue[13] (Figure (Figure1414).

Figure 12
Morphology is the most important criteria, and it is necessary to achieve a radiological-pathological concordance. A-C: Patient underwent breast-conserving therapy for left breast carcinoma and on follow up imaging was found to have a developing asymmetry ...
Figure 13
Patient with a right breast mass (arrow in A) who underwent breast-conserving therapy shows a normal post therapy mammogram at two years (B) with a post-surgical scar (dashed arrow), follow up imaging demonstrates a developing asymmetry in the retro-areolar ...
Figure 14
The most common site of tumor recurrence is the contact line, at the junction of the flap with the native tissue. A-C: Patient post right lumpectomy (A) underwent subcutaneous mastectomy with LD flap (dashed arrows in B and C); D-F: At three year follow ...

Microcalcifications

Microcalcifications that are casting, fine linear or linear branching and not typical of fat necrosis are suspicious. They are frequently similar in morphology to the primary cancer[7] (Figure (Figure15).15). In an area of fat necrosis, fat like lucency is noted around or within the calcific densities, while in calcifications associated with recurrence, an associated mass density is seen in the region (Figure (Figure1616).

Figure 15
Microcalcifications. A, B: Patient presented with a right breast mass with microcalcifications (arrow in B) and underwent right breast-conserving therapy with latissimus dorsi flap; C, D: At two years post treatment casting microcalcifications developed ...
Figure 16
In dystrophic or benign calcifications, fat lucency (circle) is present within as seen in (A) while in calcifications associated with recurrence (arrows), the centre appears dense (circle) as shown in (B), (C) subtracted post contrast MRI image of the ...

Skin thickening

Progression of breast edema or skin thickening after the first post-surgical, post radiation therapy mammogram is abnormal and should be investigated[14]. Increasing skin thickening is better appreciated on digital mammography as compared to screen film mammography.

Radiation induced sarcoma is a rare complication which manifests as thickening of the skin or prominent trabecular pattern[15]. Angiosarcoma presents as a painless mass that may be associated with overlying blue or purplish discoloration of the skin (Figure (Figure1717).

Figure 17
(A) In a post breast-conserving therapy patient, the skin thickness increases at one-year (B) and two-year (C) follow up mammograms; (D) dynamic MR perfusion reveals increased perfusion along the skin of the right breast and an enhancing focus, on ultrasound ...

Paget’s disease: Incidence of Paget’s disease in ipsilateral breast tumor recurrences ranges from 3.1% to 10.6%. Paget’s disease following BCT or subcutaneous mastectomy and reconstruction in patients presenting with nipple changes is not uncommon and should prompt early biopsy of what could be considered post-RT nipple changes[16]. Microcalcifications in the nipple-areola region may be seen on the mammogram (Figure (Figure1818).

Figure 18
Microcalcifications in the nipple-areola region may be seen on the mammogram. A: Three year post breast-conserving therapy mammogram - normal. Patient presented with unilateral yellowish nipple discharge and no clinically palpable abnormality at five ...

Axillary recurrence

Axillary nodal recurrence is relatively rare after adequate nodal dissection (of level I and II) has been done, occurring in 1%-3% of women[17]. Patients who present with axillary recurrence have metastatic disease at other sites in about fifty percent. On mammogram enlarged nodes may be seen (Figure (Figure1919).

Figure 19
Patient underwent right skin sparing mastectomy with Deep Inferior Epigastric Perforator Flap (dashed arrows in A) and axillary and apical clearance, one year later she presented with right axillary nodes (arrow) on mammogram (A) which were FDG-avid on ...

ROLE OF DIGITAL BREAST TOMOSYNTHESIS AND VOLUMETRIC BREAST DENSITY

Digital breast tomosynthesis (DBT) as a technique entails imaging of the breast tissue in multiple sections (at varied angles) instead of a two-dimensional image as with conventional mammography. The overlap of parenchymal tissues is resolved thus reducing the false positives as well as adequately identifying true lesions thus increasing the sensitivity of a mammogram. DBT not only helps in triangulation of a lesion but also reduces the requirement for additional views and lowers the patient call-back rate. Studies related to digital breast tomosynthesis to date have primarily focussed on screening with fewer reports on its utility in diagnostic mammography. Most studies have concluded a definite advantage of DBT in dense breasts (i.e., patients who have types 3 and 4 breast parenchymal density) in terms of lesion characterisation[18].

Similar to screening mammography, DBT also helps resolve post conservation changes such as a scar or other asymmetric densities due to parenchymal edema from a true recurrence[19]. A recent study by Sia et al[20] also reported that DBT decreases the rate of indeterminate findings in surveillance imaging of conservatively treated breasts. The fat density within the scar and that associated with benign calcification is better appreciated on DBT (Figure (Figure20)20) whereas a true recurrence would demonstrate a mass. Increase in the volumetric breast density (Vbd) allows for a quantitative assessment for recurrences particularly where the presentation is without a definite mass (Figure (Figure2121).

Figure 20
(A) and (B) represent conventional or 2D mammographic (A) and digital breast tomosynthesis (B) views of the scar site recurrence wherein mass density within the lesion is better appreciated on digital breast tomosynthesis (arrow); (C) and (D) show appearance ...
Figure 21
Patient underwent left breast-conserving therapy. On follow-up mammograms at five (A) and six (B) years a subtle increase in density is noted. On volumetric assessment (C and D), the left breast density increased from 6 to 17; E and F: Ultrasound and ...

CONCLUSION

To conclude, mammographic appearance of the breast is altered in the post-operative setting and breast radiologists should be cognisant of features suggestive of recurrent disease to identify it early. It is just as essential to be aware of the normal evolution of post therapy changes to avoid unnecessary further workup and stress to the patient. DBT and Vbd add incremental value in characterising normal and abnormal findings in this clinical setting. Not many studies have assessed the value of DBT over digital mammography with scope for research in this area in future.

Footnotes

Conflict-of-interest statement: This manuscript is not published anywhere else; all authors conform that there is no conflict of interests (including none for related to commercial, personal, political, intellectual, or religious interests).

Manuscript source: Invited manuscript

Specialty type: Radiology, nuclear medicine and medical imaging

Country of origin: India

Peer-review report classification

Grade A (Excellent): 0

Grade B (Very good): B, B

Grade C (Good): 0

Grade D (Fair): 0

Grade E (Poor): E

Peer-review started: January 20, 2017

First decision: March 27, 2017

Article in press: May 15, 2017

P- Reviewer: Langdon S, Medina-Franco H, Olsha O S- Editor: Song XX L- Editor: A E- Editor: Lu YJ

Contributor Information

Subhash K Ramani, Department of Radiodiagnosis, JJ Hospital, Mumbai 400008, India. Department of Radiodiagnosis and Imaging, Tata Memorial Centre, Mumbai 400012, India.

Ashita Rastogi, Department of Radiodiagnosis and Imaging, Tata Memorial Centre, Mumbai 400012, India.

Abhishek Mahajan, Department of Radiodiagnosis and Imaging, Tata Memorial Centre, Mumbai 400012, India.

Nita Nair, Department of Surgical Oncology, Tata Memorial Centre, Mumbai 400012, India.

Tanuja Shet, Department of Pathology, Tata Memorial Centre, Mumbai 400012, India.

Meenakshi H Thakur, Department of Radiodiagnosis and Imaging, Tata Memorial Centre, Mumbai 400012, India.

References

1. Mendelson EB. Evaluation of the postoperative breast. Radiol Clin North Am. 1992;30:107–138. [PubMed]
2. Krishnamurthy R, Whitman GJ, Stelling CB, Kushwaha AC. Mammographic findings after breast conservation therapy. Radiographics. 1999;19 Spec No:S53–S62; quiz S262-S263. [PubMed]
3. Chansakul T, Lai KC, Slanetz PJ. The postconservation breast: part 1, Expected imaging findings. AJR Am J Roentgenol. 2012;198:321–330. [PubMed]
4. Rivera R, Smith-Bronstein V, Villegas-Mendez S, Rayhanabad J, Sheth P, Rashtian A, Holmes DR. Mammographic findings after intraoperative radiotherapy of the breast. Radiol Res Pract. 2012;2012:758371. [PMC free article] [PubMed]
5. Elsberger B, Romsauerova A, Vinnicombe S, Whelehan P, Brown DC, Dewar JA, Thompson AM, Evans A. Comparison of mammographic findings after intraoperative radiotherapy or external beam whole breast radiotherapy. Eur J Surg Oncol. 2014;40:163–167. [PubMed]
6. Dershaw DD. Breast imaging and the conservative treatment of breast cancer. Radiol Clin North Am. 2002;40:501–516. [PubMed]
7. Gutierrez R, Horst KC, Dirbas FM, Ikeda DM. Breast imaging following breast conservation therapy. In: Dirbas FM and Scott-Conner CEH., editor. Breast surgical techniques and interdisciplinary management. New York: Springer Science Business Media; 2011. pp. 975–995.
8. Hogge JP, Zuurbier RA, de Paredes ES. Mammography of autologous myocutaneous flaps. Radiographics. 1999;19 Spec No:S63–S72. [PubMed]
9. Hedegard W, Niell B, Specht M, Winograd J, Rafferty E. Breast reconstruction with a deep inferior epigastric perforator flap: imaging appearances of the normal flap and common complications. AJR Am J Roentgenol. 2013;200:W75–W84. [PubMed]
10. Chansakul T, Lai KC, Slanetz PJ. The postconservation breast: part 2, Imaging findings of tumor recurrence and other long-term sequelae. AJR Am J Roentgenol. 2012;198:331–343. [PubMed]
11. Hadjiiski L, Sahiner B, Chan HP, Petrick N, Helvie MA, Gurcan M. Analysis of temporal changes of mammographic features: computer-aided classification of malignant and benign breast masses. Med Phys. 2001;28:2309–2317. [PubMed]
12. Leung JW, Sickles EA. Developing asymmetry identified on mammography: correlation with imaging outcome and pathologic findings. AJR Am J Roentgenol. 2007;188:667–675. [PubMed]
13. Farras Roca JA, Dao TH, Lantieri L, Lepage C, Bosc R, Meyblum E, Pigneur F, Beaussart P, Assaf E, Totobenazara JL, et al. Ipsilateral breast cancer recurrence after Deep Inferior Epigastric Perforator (DIEP) flap reconstruction: Incidence and radiological presentation. Diagn Interv Imaging. 2016;97:203–209. [PubMed]
14. Gage I, Schnitt SJ, Recht A, Abner A, Come S, Shulman LN, Monson JM, Silver B, Harris JR, Connolly JL. Skin recurrences after breast-conserving therapy for early-stage breast cancer. J Clin Oncol. 1998;16:480–486. [PubMed]
15. Yi A, Kim HH, Shin HJ, Huh MO, Ahn SD, Seo BK. Radiation-induced complications after breast cancer radiation therapy: a pictorial review of multimodality imaging findings. Korean J Radiol. 2009;10:496–507. [PMC free article] [PubMed]
16. Plastaras JP, Harris EE, Solin LJ. Paget’s disease of the nipple as local recurrence after breast-conservation treatment for early-stage breast cancer. Clin Breast Cancer. 2005;6:349–353. [PubMed]
17. Clemons M, Danson S, Hamilton T, Goss P. Locoregionally recurrent breast cancer: incidence, risk factors and survival. Cancer Treat Rev. 2001;27:67–82. [PubMed]
18. Margolies L, Cohen A, Sonnenblick E, Mandeli J, Schmidt PH, Szabo J, Patel N, Hermann G, Weltz C, Port E. Digital breast tomosynthesis changes management in patients seen at a tertiary care breast center. ISRN Radiol. 2014;2014:658929. [PMC free article] [PubMed]
19. Curran J. How effective is mammography in detecting breast cancer recurrence in women after Breast Conservation Therapy (BCT) - A systematic literature review. Radiography 2016; 22: 252-256.
20. Sia J, Moodie K, Bressel M, Lau E, Gyorki D, Skandarajah A, Chua B. A prospective study comparing digital breast tomosynthesis with digital mammography in surveillance after breast cancer treatment. Eur J Cancer. 2016;61:122–127. [PubMed]

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