Treatment options for breast cancer have evolved from radical mastectomy to breast conservation procedures with radio-therapy and autologous reconstruction procedures.
Post-surgical appearances in breast surgery are due to wound complications related to breast cancer surgery are relatively minor,
self-limited,
and managed on an outpatient basis.Commonest is seroma.
Additional postsurgical complications include wound infection,
hematoma,
and chronic incisional pain.
Post surgical imaging appearances are due to :
Skin thickening
Edema
Scar/fibrosis - at native & flap junction -
Dystrophic calcifications
Surgical clips
Fluid collections-Seroma,Haematoma
Fat necrosis
These have definite time-line and stabilse in 3 years after completion of Radio-therapy.
(Fig.1)
Time-line in Post-op breast :
Skin thickening & edema decrease in 3 years.
Fibrosis & Calcification increase upto 3 years & then stabilise.
Fluid collection decease & almost disappear by 3 years.
TYPES OF SURGERY :
Mastectomy:
Modified Radical Mastectomy:
It is the treatment of choice for locally advanced invasive and inflammatory breast cancer.Indications for mastectomy are larger tumor size in relation to volume of breast,
multifocal and multicentric disease,
skin infiltration and patient's poor compliance for chemoradiation and becomes a treatment of choice in our population.
The breast tissue,
skin,
nipple areolar complex and level I,
II axillary lymph nodes are completely removed.
There are no post-mastectomy imaging guidelines since they are followed clinically with serial physical examinations.
When imaging is done seroma,
fat necrosis,
radiation-induced fibrosis,
lymphadenopathy,
and cancer recurrence can be identified with ultrasound (Fig.2).
Breast conservation therapy (BCT):
It is the standard of care in clinical stage I and stage II breast cancer along with whole-breast radiation therapy.
Surgical clips are placed to mark the site of tumor.Baseline mammogram is usually done at 6 months after Radio-therapy to be able to differentiate post-op changes from early recurrance .
On ultrasound and mammogram the architectural distortion,
increased density at the surgical site and post treatment edema can impair detection of recurrence and advanced imaging techniques like elastography,
tomosynthesis and MRI can help resolve an indeterminate lesion to a benign or malignant pathology.
Local recurrence in BCT occurs 3–7 years later.
Breast Reconstruction :
Breast reconstruction after mastectomy includes :
Autologous reconstruction
Synthetic implants
Autologous tissue transfer (flaps),
Autologous tissue transfer has the advantages of durability and perceived naturalness.
Pedicled flap : commonly include
TRAM (transverse rectus abdominis myocutaneous )
LDM (latissimus dorsi myocutaneous ).(Fig3)
The procedure involves the placing of muscle and an elliptical skin island into the mastectomy site.The free flaps are more complicated than pedicled flap and involves complete separation of the donor tissue from its original blood supply and microsurgery to anastomose with recipient vasculature.
Autologous fat grafting,
also known as autologous lipoaspirate grafting is a method of breast reconstruction.
Synthetic Implants
These are used for primary augmentation & in BCT.
silicone gel–filled implants are commonly used because increased density of silicone implants maintains shape in the upright position.
Disadvantage is the silent rupture.
Post-op breast is difficult to image by Conventional imaging- mammogram & ultrasound,
because of difficulties in positioning,
non-compressiblity due to scar formation ,pain,
edema,
& radiation changes which delays healing & the resolution of post-surgical changes.
Scars can mimic malignancy and the underlying breast is difficult to evaluate clinically & by Imaging Fig(4).
Post-op lesions due to wound healing on sequential mammograms & ultrasound lesion becomes smaller ,
irregular and denser as the seroma retracts and is replaced by fibrous tissue.These are Birads II & III "Left alone"
However an increase in size on follow-up merits further evaluation to exclude a recurrent mass are "Red Flags" BIRADS IV & V due to Secondary complications like
Lymphedema
Infection
Recurrance -occurs 2 to 3 years after RT and is progressive .
Early diagnosis of local recurrence increases survival and is by means of close clinical and imaging follow-up and is an important strategy in Breast Conservation.
The Imaging techniques used in evaluating the post-op breast include basic imaging mammography & ultrasound.Mammogram or clinical examination detect 35 to 40 % of recurrances.
Mammographically recurrance is suspected when there is a :
Developing density,
Mass,
Micro-Calcification,
Architectural distortion
May need MRI or other advanced imaging for confirmation.
Advanced techniques to study morphology like 3D Tomosynthesis ,
Elastography & functional imaging like MR mammography & PET CT are becoming essential if we have to look for early recurrance and we need to familiarise ourselves with the various techniques and their appearances especially with respect to advanced imaging options.