Imaging the Post Surgical Breast With Mammo, US an MRI

Post-Treatment Changes in the Surgically Altered Breast

We'll talk a little bit about the surgically altered breast.
We're going from the beginnings, really now to the end,
the follow up, of these patients whom we've diagnosed.
In the next half hour, we'll talk about
post-treatment changes, establishing a time course
for changes after lumpectomy and radiation therapy,
and really just how slowly things change.
It's a slow motion operation,
after radiation therapy, is given.

Breast Cancer Incidence and Mortality

Breast cancer is the most common cancer in women.
With about 230,000 new cases expected
to be diagnosed annually, the incidence has increased.
You'll see here that there were 184,000 cases,
diagnosed in 2008
and about 220,000 in 2004.
It went up and down.
What has been seen is an annual
decrease in breast cancer deaths,
although the numbers remain about 40,000,
and those numbers have been stable through time.

Post-Surgical and Post-Radiation Changes

What are some of the changes that we can observe
after surgery?
And we'll talk about what happens
after radiation, soon thereafter.
Soft tissue densities, asymmetries,
we have in the new birads,
and some of you may already have seen it.
It hit the shelves in its printed version
about a week ago.
Very few copies and there'll be more following suit.
Also the electronic version will probably be ready,
in a couple of months.
And I would imagine that most of us,
will find that that's more practical,
in its applications.
The printed version is very heavy.
I meant to bring it so you could all see it,
but I couldn't carry it.
So it's this thick,
and the paper is very shiny and heavy.
So soft tissue densities, asymmetries the scar itself
and absence of tissue, which is difficult,
to discern as.
It's one of the hardest things I think, in radiology, is
to notice when something is missing.
Masses
and pseudo masses, those are the fluid collections
and hematomas s romas that we're used to seeing.
And then fat necrosis, which will creep around
and mimic cancer, in many different, guises,
architectural distortion, calcifications, skin thickening
and edema, and tissue disor distortion.
All of these can be primary signs as well as signs,
or effects of biopsy and excision.

Benign Surgical Biopsy Examples

So let's look at a case or two for a benign surgical biopsy.
This is an older case
because we don't excise these sorts
of things anymore, I would hope.
A patient who has several masses,
they're all circumscribed.
You can see by the scar marker here
that she's been previously, excised as well.
And it was a benign finding.
So she insisted that these two areas,
and one in the outer, one in the inner be reviewed, removed.
And here you see in the outer breast,
a sort of spiculated asymmetry.
The scar marker marks the incision site,
and then a larger one in the medial breast that,
correlates with the smaller of the masses.
You'll see a little bit
of fact trapped within each of these.
This is about three months
after the biopsy, had been done.
These excisions, no localizations had been performed,
and the patient thought she, again, felt these areas.
So we imaged her.
And this is three months, you start
to see spicules at the scar sites.
And we told her things looked just fine,
and she should just come back in about six months,
and we would continue to watch the resolution of it,
which you can see here on the left.
And here, the scar is elongating,
similarly in the medial.
And then six months later, so it was a little
after a year had passed that there's almost no sign,
of previous intervention in that breast.
Complete healing. That is not the case,
with radiation.

Another patient, with benign findings.
But those that needed to be checked out,
she had had a mastectomy,
and the, incision had crossed over the midline,
to the opposite side.
Here, she developed a palpable mass.
About three years after the mastectomy.
You can see calcification in it. Here's the sonogram.
You do see that crescentic calcification
unshadowed emanating from it.
And this was a foreign body granuloma,
a suture granuloma.

Breast Conservation Therapy

Eligibility Criteria

So let's look at breast conservation,
and see what happens there.
These are the old
and classic eligibility criteria
that were followed in the United States,
for decades.
And these were published by Bernie Fisher, who was
a surgeon head of the N-S-A-B-P,
which with the NCI, did many studies,
multicenter, trials that established that conservation,
was equivalent in terms of survival,
to modified radical mastectomy stage for stage,
if these eligibility criteria,
were adhered to.
So T one, the tumor size up to two cm
or T two up to five centimeters,
the tumor should be confined to the breast, not metastatic,
and ipsilateral lymph nodes.
And if the lymph nodes were palpable,
it was not a contraindication.
Very important was a good cosmetic result.
If the cosmetic result were poor, it would not be,
an effective, treatment option.
Radiation therapy should not be contraindicated.
And these were mostly invasive cancers,
and the tumor not multicentric in more than one quadrant
or separated by five or six centimeters.
So those were in 1985, what he published.
And now we see a certain liberalization,
and I don't know if you all have seen this as well,
in your practices.
The excisions are larger.
We have done some extremely large bracketed localizations
of, DCIS, some with micro invasion.
And again, you ask
and ask, at your multidisciplinary conferences,
what you'll hear is, well,
if we can get a good cosmetic result
and can get margins, we're satisfied.
So the eligibility extension is something that,
we have observed very gradually over decades.

Patient Assessment Before Treatment

So how do we assess patients
before they select treatment options?
Mammography is one.
There, if we are looking at microcalcifications
and you see, a category four C or five
after you've done the mag views,
you may wanna get a lateral view,
with a nipple in profile
and spot compression magnification views
of the calcifications
and look starting at the nipple
for a segmental distribution.
Sometimes it's very difficult to predict how the segment
or the affected area, will go through the breast.
There's a great deal of anatomic variability, asymmetries,
lateral view, and spots tomosynthesis if you have it,
or ultrasound, for verification
of underlying mass or abnormality.
Ultrasound, if no, MRI.
Now here we have a lot of options,
and these will probably come up,
in the next couple of days as we have panel discussions.
How do you do it? Just target it.
Only one focus in dense breast tissue, one quadrant,
one area, do the axilla or not.
Survey scanning, if MRI isn't done,
for extensive disease, is certainly a good possibility,
and you should include the ACI there.
A new problem now,
or not so new anymore, is the,
the surgical study, with Akron
of Z 11 was published a couple
of years ago about non palpable nodes.
And there, even if the node is abnormal by ultrasound criteria,
if that surgeon is following Z 11, they would be doing,
he or she would be doing a sentinel node procedure,
which is becoming
and is standard of care now, in those instances.
So there, there'd be no benefit to stand to doing a biopsy
of a sonographic abnormal node.
That is not palpable.
MRI, all new cancer patients invasive v lobular cancer
as a percutaneous diagnosis.
There, I think there is consensus,
young patient dense breasts with one known focus.
And Dr. Bram covered a lot
of these in her discussion about personalized screening,
which I think is a way we will be going Axillary metastasis
with unknown primary, is a distinct,
indication, if partial breast irradiation is being considered.
Certainly I think it would be important,
to know whether or not the focus that you have in that breast
is isolated, or if there are other areas,
in which case you might would want
to do whole breast radiation.
So there, it's an important indication, I think.
And then response monitoring.
When neoadjuvant chemotherapy is given,
or primary chemotherapy is given, as it would be
for inflammatory carcinoma, percutaneous image guided biopsy
with clipping for all suspected multicentric foci,
or at least those that are farthest apart,
if the surgical management is to be changed.

Chemotherapy Response Monitoring Examples

These are just a couple of examples.
This is MLO and cc, of a very large tumor.
You can see that there is skin retraction
and thickening here in the perial region.
The sonogram in two views, showing you the fingers of
that tumor extending out into the surrounding, tissue.
And then here,
after cycles of chemotherapy had been given, there is,
still disease,
but the central portion of it has been debolt.
You see that frequently,
the skin thickening hasn't gone away.
Neither has the retraction.
The size of a tumor is much smaller and it's flatter
and more plainer in appearance.
Another case where there's limited response, this is pre,
and this is after cycles of chemotherapy four had been given
here with MR on these mips, you can see
a large tumor being amply fed by lots of vessels here,
tangling themselves around the tumor.
And then four cycles later,
that breast has become quite quiet.
There are some foci remaining,
and the huge nodes that you have seen in the axilla,
but prior to chemo, are much smaller, now.
So there has been great consideration.
Now, what happens to this patient?
She must go to excision at this time.
And if you haven't placed a clip, can you find the area?
We can go back to mammography and,
do a lateral and a cranial craniocaudal view and measure distances,
and try to, isolate those areas
by using the vascular structures nearby.
It certainly is easier to clip,
but one recommendation, just from my own experience,
with this and outside cases that hadn't been clipped, is
that, if you go to ultrasound, you can find the area
of architectural distortion where that cancer,
had been, and the area of response,
and then do an ultrasound guided localization.

MRI for Re-Excision Guidance

One application, of breast MRI,
which doesn't come up very often in our practice, is
where you can guide a surgeon,
who is planning re-excision when one margin
has been positive.
Here, you can see shortly
after the excision that there is concentric
enhancement, around the, around the fluid collection.
And this clump of enhancement there, we localized in
that area, or at least, directed the surgeon to
that area, for excision.

Surgical Techniques

So what is breast conservation?
It's retention of the breast.
And the standard in the us, up
until fairly recently, has been lumpectomy
and radiation therapy in Europe,
when they were doing excisions,
with radiation, actually before,
long before they were done being done in the us,
it was wide excision and radiation.
Segmentectomy and quadrant ectomies were the types
of procedures done, outside of the US in Europe.
There, they would take skin.
They would close in a more deep fashion,
beneath the skin than we do,
in the classic lumpectomy
and radiation therapy procedure here and now.
In the last 10 years
or so, oncoplastic techniques, which are similar,
to those that were used in Europe, again, with taking
of skin, and it's almost a pseudo plastics type
of procedure for cancer control, as well as cosmesis.
It's perhaps an intra itra surgery turf battle.
If there are surgeons here who wanna weigh in on that,
we'd be glad to hear from you later on.
Classical surgical technique was a val linear incision
with removal of the tumor, axillary sampling
or dissection from a separate incision.
And at closure, no attempt to approximate the deeper tissue,
of the surgical bed and no drain place.
So here is a sort of diagrammatic,
depiction of that procedure with removal of a tumor,
closure right at the skin.
And you would find almost always,
a fluid collection which did not become, inflammatory.
No abscess formation was seen,
in these, and the slow resorption of that fluid was thought
to promote cosmesis, the radiation technique.
And now it's, that too was changing.

Radiation Therapy Developments

So all of this, the detection approaches,
the treatment approaches, both surgical
and radiation are also treating, are changing.
So here, radiation was given to the entire breast as soon
as it was, healed sufficiently,
to, for the patient to tolerate it, usually five, four
to six weeks additional radiation, often given
to supraclavicular and internal memory nodes.
And in some cases, a boost to the surgical site was
provided more often than not,
with the total dose as you see here.
And then that completed,
in five to six weeks with the patient coming daily except
for weekends, partial bra,
breast irradiation has developed.
And here one method, just show you
what it looks like, was placement of a balloon catheter,
fairly soon after the surgery, certainly is,
when there was still fluid present.
There are several ways of giving it in addition
to the balloon catheter.
More commonly now we see,
conformal external beam at Northwestern.
We've been doing intraoperative radiation therapy,
which is quick, and for a solitary tumor,
that is nearly circumscribed
and has been sci with clear margins.
The PA patient, acceptance has been great.
And we have had, few, if any, recurrences.
This is the ultrasound insertion
of a balloon catheter.
The you need to screen with ultrasound first.
We did about 60 of these until the surgeons decided
that they wanted to do, external beam,
and intraoperative, more than these,
they saw a fair amount of fat necrosis,
being associated with these placements.
But you need enough, thickness, distance
between the skin and the top
of the fluid collection, which you see here.
So this one was eligible,
otherwise, the inflated balloon,
with the radiation seeds that circulated
through twice a day, the radiation therapy given five days,
for five days.
And then the catheter pulled, here, not enough room.
You can see this is an uninfected seroma.
The seroma was certainly big enough to accommodate it,
but not enough tissue at the skin.
And here's what the inflated balloon looks like.
You place it very rapidly,
from a skin incision,
if you're doing it percutaneously with imaging guidance,
which we were doing, to make sure
that the margins were free.
Some surgeons placed this,
at the time of excision.
And just to show you that there are very few,
effects, from this type of radiation therapy.
This is a lateral and, and a craniocaudal spot.
Very little effect.
You can see, a little bit of fluid, but not much.

Imaging After Breast Conservation

So the imaging techniques
after conservation are these three.
We'll look at these in sequence, companion,
findings or edema and skin thickening with a new baseline,
not 30 days or a week, or three weeks, or three months
or six weeks after, but a new baseline in two years.
An older case of a patient,
with a fatty breast who was probably a little bit over radiated.
Here is her, excision site.
And six months later, you can see that it is
a little bit smaller and beginning to become linear.
There's some clearance
of this very profound edema going from
posterior to anterior.
And you can see in the anterior aspects of the breast
where it lingers.
So here's a six month interval.
And these changes very florid.
You can see, you tell if there's any residual cancer here.
No, you certainly can,
get magnification views if this has been for,
DCIS.
Ultrasound can show you the direction
that you're going here, corresponding
with the initial study, which was at six months
after treatment completion.
And then another six months later,
you can see some thinning,
of the skin as well, but not normal and,
not nearly the normal two millimeter thickness of skin
that you'd expect.

Skin Thickening Differential

Skin thickening does have a fairly long differential,
and we saw skin thickening
and edema related there to radiation therapy and surgery.
That ma, which is a form of mastitis,
systemic processes can cause it.
But in many instances,
the chief differentiating point that you need to make is
between mastitis and abscess, and inflammatory carcinoma.
So there, ultrasound has a very important role.

Inflammatory Carcinoma

This happens to be inflammatory carcinoma,
and, it's a clinical entity rather than
a histologic type.
The skin punch biopsy, which is a, doing it
with a little cookie cutter device of three
to five millimeters in diameter, may show you,
a dermal lymphocytic, infiltrate
with the tumor cells found in this infiltrate in many cases.
But if you find that all of the clinical
manifestations are there, whether
or not you have cytologic evidence, doesn't matter,
that patient will be treated.
As for inflammatory carcinoma, what does ultrasound look like here?
Very thick skin or reticular.
It's a network really of inter interlocking,
lymphatics that are, dilated.
The echogenicity here is not over gain,
but reflective of the water that you find in the tissues
and deeper down.
And you don't see the focal zone setting here.
It wasn't set for that.
It was set for, the more subcutaneous tissue,
are two masses.
Moving your transducer, you can find several more.
This is the same patient in another area,
where you have three, separate masses that you can see
and, direct your needle into for the
diagnosis histologically,
it's usually grade three invasive ductal.
So here in another patient. And Dr.
Bram showed you a couple of examples
of whole breast ultrasound.
This is from, one of the supine versions,
which we have here at this meeting at the skin.
You can see the pores.
So here's po orange, manifested,
on automated ultrasound,
with the three different planes that you can,
you can interpret in.
Here again, is coronal the acquisition,
which is a broad transverse, acquisition.
All of those same manifestations,
I wouldn't look at this sagittal view.
It has been shifted or can be shifted to horizontal,
which is, more likely,
to be used in, in ultrasound by radiologists.
In any case here, you can see additional masses.
So it's a very good way deeper down in the breast.
This is the same patient, additional masses
and the profound architectural distortion.
Another patient,
whose inflammatory carcinoma was seen on CT with all
of the mediastinal involvement and internal memory nodes.
And here, Mr.
In axial and coronal pre contrast with large,
lymph nodes and underlying masses
and skin thickening that you can see on any modality.

Fluid Collections and Scars

Fluid collections
and scars developed in six to 18 months as fluid resorbs,
and the scars elongate and become speculated.
As I said earlier, there was an interdiction
to aspirating fluid collections.
I think in some places, they did to think, thinking
that it was easier to image, mammographically
after these collections were aspirated,
but, the surgeons really did not like that.
And so this is without any aspiration.
There was here a year's interval.
This was six months,
and then this was 18 after the surgery.
And the linear appearance of the scar, you can see,
the, area of, incision
is marked by the scar marker.
So no intervention
and clearance of both the, some of the fluid
and skin thickening, as well as evolution of the scar.
Here, when you're looking with ultrasound, connect the area
of the surgical bed to the skin.
And you'll see thickening here.
It's always a v at the skin.
This is at the time,
of what was left in that 18 month,
mammogram.
And this is a fluid collection.
This, echogenic area is just probably a little fat
or some detritus, and it does not indicate involvement.

Configurational Changes and Tangential Views

So configurational changes in varying projections.
Radiolucent areas trapped in fibrotic tissue,
they usually fade with time.
Place a skin marker on the incision.
So here again, you can start to see spicules,
developing around the fluid collections.
And another, here, this is a tangential view,
which separates out the incision.
It's always a thickened area of skin,
where the, where the knife has passed,
a track down to the, the tumor bed.
And you can see clearly the strands of the scar.
Whereas if you're just directly imaging it with mammography,
you have all kinds, of summation densities,
and can't tell, as clearly
a mature scar on ultrasound.
Just see that, passage of the knife down
to this angular looking scar.
When recurrences are found, they're usually not in
the scar, in the tumor bed.
It's within about two centimeters or further away.
So that's not a problem.
So scar placement of the scar marker.
And then tangential views, as I've shown you here,
is another pair where not in tangent,
you really aren't certain whether there is
or isn't something new happening.
You really can be definitive when you separate things
out and get a tangential view.
We've retained this view for the last 30 years.
We started doing that in, Pittsburgh when I practiced there from 1985
to 2001, and have continued it, at Northwestern.

So another pair of mature scars.
Sometimes it takes a little longer to find these,
but go and scan.

Calcifications Post-Surgery

I'm going to finish in the next few minutes.
But wanted to talk briefly about calcifications.
Benign, coarse jagged around.
They're dystrophic most often, you don't see very often.
I'll show you, an example.
There was one article that appeared decades ago about,
about fat, about cat gut sutures.
Nobody uses cat gut sutures.
And I still hear this repeated.
And the case that I'll show you is not, was not done
with cat gut sutures, and
nor have most others that have been reported.
Radiolucent centers, fat necrosis
and then indeterminate malignant.
This is, su calcification.
You can see the knot sitting right in the middle
of this clipped suture.
Here's a wishbone with a knot in the middle of it.
Other dystrophic calcifications,
that are when they are linear, about the same thickness
as suru, another long suru calcification.
And here, you can see the knot right in the middle of it.
There was no recurrence here, recurrent tumor, two
and a half years, at
or within a few centimeters from the lumpectomy site.
Here was an early image.
And then, on the other view, you still see this calcification.
It's a big thick one. It's thought to be dystrophic.
The magnification views,
however, show you, some little ones behind.
I'll be, finished in a minute or two,
and that was recurrence.
So where there are calcifications that have been excised
as your primary
or involving your invasive ductal, and DCIS, make sure in your,
follow up images, mammographically,
and really, mammography is the most
important of the modalities.
Here you can find nearly all, of the changes
with mammography supplemented by ultrasound.
Here's a recurrence. Here was the original,
and the recurrence was about seven o'clock.
It was not a small one.
You don't see it going to the skin as you would,
for a scar.

Fat Necrosis

Fat necrosis variable.
Appearances here at the, at the scar, a
radiolucent area,
and three manifestations of
that same thing in three different planes, on ultrasound
with the echogenic fat that you see in the center
of the radiographic finding.
Present also within it, evolution
of fat necrosis at the scar.
Same patient, with two years difference.
And here, this large evolving area of fat necrosis.
This is the slow motion.
It's not happening the first year, the second year.
This is three years. It can be four years,
it can be five years later.
And then deposition of calcification
is this fat necrosis.
It was about two
or three centimeters, perhaps more away from the,
surgical bed.
The ultrasound image, wasn't characteristic.
You could consider that there was fat trap there.
Within that, this happened to be a recurrence.
So be very careful with this.
And just to show you the very gradual,
changing appearance, of the breast,
after conservation therapy, you can see here the companion curves.
Over a 48 month period, we followed a hundred patients,
and just saw this very gradual thing.
As I said, two years to the base.
The, new baseline scarring and fibrosis,
are evolving as fluid collections are absorbing, resorbing over time.
That's three years.
And then the most marked change early on.
So it helps you to see, as you go forward,
the changes resolve and you do derive confidence.
I think from that,

Follow-Up Mammography Schedule

there's no consensus for follow up.
Mammography schedules
after breast conservation, this is what we do.
Postoperative pre radiation mammography,
with mags for calcifications in two views, always
that tangential view.
Six months, a new baseline, 12 months, bilateral.
Now we are questioning, along with the surgeons
and also the discussion about whether you should see these
patients, as screening patients
after a certain period of time,
or whether you should follow them perpetually,
as diagnosis.
And that is an unresolved, discussion.
We are still seeing them, as diagnostic patients.
And then 24 months with return
to annual mammography when there's no change on two
successive studies in a resolving kind of finding.
And that is usually one to three years.
And I thank you very much.
And this is Chicago, when it isn't fogged in
and the hospital I practice in.
So thank you.