Postoperative Changes

and Christian Waldherr¹

(1)

Bern, Switzerland

7.1 Case 1

General Information/Clinical Issues

Patient was a 62-year-old female; breast-conserving therapy on left side medial in 2011, S-vacuum-assisted biopsy (S-VAB) in 2012.

Mammographic Analysis on 2D (Synthetic) and 3D

Breast density ACR I. 2D (synthetic) (Fig. 7.1a, b) and 3D (Fig. 7.2a, b and Fig. 7.3 [3D magnification, same figure as Fig. 7.2b]) in 2012 show an extensive oval irregularly shaped nonspecific density that may be due to postoperative scar; also persistent seroma with additional lucent round oil cyst or fat necrosis and associated dystrophic calcifications; BI-RADS 0. Follow-up 2D (synthetic) (Fig. 7.4a, b) and 3D (Figs. 7.5a, b and Fig. 7.6 [3D magnification, same figure as Fig. 7.5b]) in 2013 show a decrease in size and density after S-VAB; BI-RADS 2.

Fig. 7.1

(a, b) 2D synthetic (a) obl and (b) cc in 2012

Fig. 7.2

(a, b) 3D (a) obl and (b) cc in 2012

Fig. 7.3

3D Magnification in 2012

Fig. 7.4

(a, b) 2D synthetic (a) obl and (b) cc in 2013

Fig. 7.5

(a, b) 3D (a) obl and (b) cc in 2013

Fig. 7.6

3D Magnification in 2013

Differential Diagnosis on 2D (Synthetic)

In the situation of previously treated breast cancer, benign scarring, persistent seroma, oil cysts, fat necrosis, and dystrophic calcifications are common; risk of recurrence increases with positive margins (R1) and without radiation therapy (BI-RADS 0).

Conclusion/Diagnosis with 3D

3D may avoid unnecessary biopsies due to its more detailed morphology of scar and fat necrosis (BI-RADS 2).

Recommendation

Additional US, no S-VAB recommended in this case (S-VAB was the explicit request of the patient in 2012).

Benign scar with partial posterior shadowing and associated absorbed seroma on follow-up (Fig. 7.7)

Fig. 7.7

US in 2012 and 2013

Histology After S-VAB

Granulated calcified fat necrosis and extensive scarred areas; B2 (Fig. 7.8).

Fig. 7.8

S-VAB in 2012

Further Imaging/Further Diagnostic

In diagnostic uncertainty perform MRI and distinguish scar from recurrence.

7.2 Case 2

General Information/Clinical Issues

Patient was a 67-year-old female; breast-conserving therapy in 2006 on right side at 11–12 o’clock.

Mammographic Analysis on 2D and 3D

Breast density ACR III. Preoperative situation on conventional 2D (Fig. 7.9a, b) in 2006 BI-RADS 4. Postoperative situation on conventional 2D (Fig. 7.10a, b) in 2008 BI-RADS 2; follow-up situation with digital 2D (Fig. 7.11a, b) in 2009 BI-RADS 2. 3D Lcc slices (Fig. 7.12a, b and Fig. 7.20 [3D magnification, same figure as 7.12a]) show additional architectural distortion in the medial part of the breast at 1–2 o’clock; BI-RADS 0/4.

Fig. 7.9

(a, b) 2D (a) obl and (b) cc in 2006

Fig. 7.10

(a, b) 2D (a) obl and (b) cc in 2008

Fig. 7.11

(a, b) 2D (a) obl and (b) cc in 2009

Fig. 7.12

(a, b) 3D slices cc (a) and (b) in 2009

Fig. 7.13

3D Magnification Rcc

Fig. 7.14

MRI in 2009

Differential Diagnosis on 2D

Typical imaging findings after breast-conserving therapy include lucent round oil cyst or fat necrosis, distortion of adjacent normal breast tissue, post-surgical scar, typical trabecular thickening, skin thickening, retraction, and dystrophic calcifications (BI-RADS 2).

Conclusion/Diagnosis with 3D

Additional suspicious changes outside the former tumor area in the medial part of the breast, diagnostic work-up required (BI-RADS 0/4).

Recommendation

US guided biosy or MRI.

No internal US.

Histology After US Guided Biopsy

Fat necrosis and scarred areas; B2.

Further Imaging/Further Diagnostic

In diagnostic uncertainty perform MRI and distinguish scar from recurrence, even fat necrosis can mimic recurrence; MRI in 2009 without signs of a relapse, fat necrosis at 11 and 1 o’clock (Fig. 7.14).