What is the role of mammography in postsurgical breast imaging?

Updated: Dec 19, 2018
  • Author: Susan Ackerman, MD; Chief Editor: Eugene C Lin, MD  more...
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Answer

Answer

The imaging appearance of postsurgical changes can be confusing because masses, calcifications, and architectural distortion can mimic cancer. In addition, cancers can develop in areas of prior surgery. Therefore, a thorough clinical history, including information regarding the type of surgical intervention, and pathologic correlation are needed for adequate assessment. In general, indeterminate or suspicious findings may require tissue sampling to exclude malignancy.

Acute mammographic changes refer to the immediate postoperative period extending for the first several weeks and months. Acute changes include hematoma, seroma, and edema. Chronic changes refer to findings identified after the acute period, usually several months to years after surgery. These include scar formation, retraction, development of dystrophic calcifications, tissue asymmetry (from tissue removal), fat necrosis, and architectural distortion.

The pathophysiology of postsurgical changes, as observed on mammograms, is associated with the type of surgical intervention and the time elapsed since the procedure. The 4 most common breast interventional procedures are percutaneous biopsy; excisional breast biopsy; breast conservation treatment (BCT); and breast reduction, augmentation, or reconstruction. Postsurgical mammographic findings are also related to the time sequence from the procedure and can be classified into 2 general categories: acute changes and chronic changes.

See the mammographic images below.

Prebiopsy craniocaudal mammogram demonstrates a 1- Prebiopsy craniocaudal mammogram demonstrates a 1-cm mass in the medial aspect of the breast (see arrow). Subsequent stereotactic biopsy was performed.
Postbiopsy craniocaudal mammogram of the breast ob Postbiopsy craniocaudal mammogram of the breast obtained immediately after stereotactic biopsy of a lesion (same patient as in Image above). Interval development of a mass has occurred in the biopsy bed (see arrow); this finding is consistent with a hematoma. A marking clip has been placed.
Mediolateral magnification view of the tumor bed a Mediolateral magnification view of the tumor bed after breast conservation treatment. A few coarse calcifications are noted consistent with fat necrosis. Mild architectural distortion is apparent in the lumpectomy site (see arrow). A scar marker was placed over the incision site.
Craniocaudal view in a patient after a reduction m Craniocaudal view in a patient after a reduction mammoplasty. Scattered parenchymal densities, architectural distortion, and extensive calcifications (due to fat necrosis) are noted (see arrows).
Craniocaudal mammogram demonstrating multiple oil Craniocaudal mammogram demonstrating multiple oil cysts. Note the multiple radiolucent masses with smooth internal margins and typical eggshell-like calcifications (see arrows). Frequently, a history of previous trauma or surgery can be elicited from the patient.
Mediolateral oblique mammogram in a patient 3 year Mediolateral oblique mammogram in a patient 3 years after a mastectomy and reconstruction with a transverse rectus abdominis muscle (TRAM) flap. The patient noticed the development of palpable firm masses in the upper-outer portion of the reconstructed breast (see arrows). The mammogram demonstrates the typical appearance of a TRAM flap. In addition, extensive macrocalcifications have developed related to fat necrosis. These calcifications corresponded to the palpable mass.

 

Immediate mediolateral view after a stereotactic b Immediate mediolateral view after a stereotactic biopsy for calcifications in the inferior breast. Little mammographic evidence reveals that a biopsy has occurred, except for the placement of a clip (see arrow).
Craniocaudal mammogram after breast conservation t Craniocaudal mammogram after breast conservation treatment, axillary dissection, and radiation therapy. Note the skin and trabecular thickening (see arrows).
Craniocaudal mammogram demonstrating extensive kel Craniocaudal mammogram demonstrating extensive keloid scarring in the medial aspect of the breast. Note the irregular, macrolobulated, circumscribed densities with wide margins, outlined by a thin surrounding halo of air (see arrows). The keloids are superimposed on the breast tissue on the mammogram and can mimic breast lesions. Careful documentation of skin lesions is important so that dermal lesions are not confused with breast pathology.
Mediolateral oblique view obtained after breast co Mediolateral oblique view obtained after breast conservation treatment and axillary dissection in a patient with a 2-cm invasive ductal cancer. Mild architectural distortion is noted in the tumor bed in the upper quadrant of the breast (see arrow). Clips are placed within the tumor bed to assist with radiation therapy planning.
Craniocaudal mammogram obtained 2 years after lump Craniocaudal mammogram obtained 2 years after lumpectomy, axillary dissection, and chemotherapy. Note the periareolar skin thickening and retraction and scarring extending from the nipple to the chest wall as a result of the surgery (see triangles). Coarse macrolobulated calcifications have developed in the surgical site (see arrow).
Mediolateral oblique mammogram of the breast shows Mediolateral oblique mammogram of the breast shows a subpectoral (behind the muscle) silicone implant. Free silicone is noted outside the implant, within the soft tissue of the upper breast, consistent with implant rupture (see arrows).
Mediolateral oblique image of a transverse rectus Mediolateral oblique image of a transverse rectus abdominis muscle (TRAM) flap used to augment the breast volume instead of an implant. The native breast tissue is noted anterior to the TRAM flap and produces this unusual architecture.

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