mammogramBy Marianne Matthews

One in every eight women will develop invasive breast cancer over the course of her lifetime.1 In fact, this year alone, more than 231,000 American women will be diagnosed with breast cancer. We all know them. They are wives, sisters, mothers, aunts, friends, and neighbors.

When a woman gets the news that she has breast cancer, she is faced not only with her own mortality, but also with a plethora of decisions.

Interestingly, recent research indicates that today, more than one in three patients who are eligible for breast-conservation therapy elect to undergo mastectomy instead, and recent data has shown that this number may be increasing.2-5 There are many reasons why women are opting for mastectomies, and chief among them is the fact that there are several cosmetically favorable breast-reconstruction techniques available to them today.

In recognition of breast cancer awareness month, two prominent breast imagers shared insights on best practices for plastic surgeons when it comes to medical imaging of the breast cancer patient who opts for reconstructive surgery. Some of their insights and advice follows.

“In my experience, plastic surgeons are very in tune to the needs of their patients,” says Debra Monticciolo, MD, FACR, chair of the American College of Radiology Commission on Breast Imaging and professor of radiology at Texas A&M University in College Station.

“The biggest issue is knowing which imaging method to use for any particular situation. I like to consult with our plastic surgeons on the imaging needed in their reconstructed patients. That way, we can tailor the exam and eliminate unnecessary imaging,” she continues.

When asked about imaging surveillance of breast cancer patients after they’ve had reconstruction, Monticciolo says that whether the woman has had a tissue flap or an implant, she will no longer need screening mammography.

“The only exception is a woman who has had a nipple-sparing procedure. In that case, screening mammography can be continued,” Monticciolo says. “Patients should understand that mastectomy can’t remove 100% of all breast cells—a tiny amount is understood to be left behind.”

MRI Does Double Duty

Monticciolo points out that the use of breast MRI can be a potential source of confusion for plastic surgeons. “Breast MRI is the best way to evaluate implants and also the most sensitive way to detect breast cancer, but the MRI technique is completely different depending on which of these is your goal.”

The MRI implant technique is silicone selective and does not involve contrast media. According to Monticciolo, the best MRI implant techniques suppress the signal from the surrounding tissues, making it a very poor way to assess cancer.

“For breast cancer detection, we give contrast and image with different pulse sequences, so we don’t evaluate the implant very well. Breast MRI is an outstanding method, but we need to select the correct type of MRI to meet the goal,” she explains.

Rachel Brem, MD, professor and vice chair of radiology at George Washington University and director of breast imaging and intervention, concurs. “Breast implants don’t last forever. They have about a 20-year lifetime. So the recommendation is to use a non-contrast MRI to look at implant integrity every 2 years,” Brem says.

Whether or not the implant is intact is a continual concern, Brem adds, and “MRI is the way to go for assessing implant integrity.”

However, for the woman with a history of cancer who has had an implant(s) after mastectomy, it might make sense to also do the MRI with contrast to look for cancer, Brem says. “If you are already doing the MRI, you might consider adding the contrast; it’s really two different studies,” Brem says.

When Problems Arise

Clinicians should keep in mind that for women who have undergone mastectomy, cancer can recur in the tissue that lines the chest wall or in the skin.

Regardless of the reconstruction technique used—a prosthetic implant, autologous tissue flap, or both—breast cancer may recur at the mastectomy site, and recurrences may be identified at an earlier stage by radiologists who are familiar with the spectrum of imaging findings.

Indeed, close collaboration on the part of plastic surgeons and breast imagers can be a true life-saver for the breast cancer patient. “We work closely with our plastic surgeons on assessing implant integrity and overall evaluation of patients with a history of cancer,” Brem says.

While plastic surgeons know that various problems can arise after reconstructive surgery, knowing which imaging exam makes sense in a given situation is not always obvious. Consider, for example, breasts reconstructed with autologous tissue flaps, where benign complications such as fat necrosis may occur.

“Unfortunately, fat is subject to fat necrosis, which can calcify and form irregular masses, which mimic cancer. This is a common problem seen on imaging. Fat necrosis can also cause palpable lumps—the most common reason we see transverse rectus abdominis muscle (TRAM) patients for imaging,” Monticciolo says.

Each woman’s propensity to develop fat necrosis is different. “Think of it as the healing process,” Brem adds. “Fat necrosis can present as a lump or a bump—it is the great mimicker—and it could require an additional biopsy, which will result in a benign biopsy.”

So how should a plastic surgeon proceed when a symptom presents? Make no assumptions, Brem says. “After a mastectomy and reconstruction, if a woman comes in with a symptom, do not assume it is necrosis. Get it worked up.”

And which imaging method is the tool of choice? “Imaging will be decided and directed by any symptoms that arise. The imaging may be mammography, ultrasound, or breast MRI,” Monticciolo adds. She notes that women who have had autologous tissue transfer with TRAM, deep inferior epigastric artery perforator (DIEP) flap, gluteal or latissimus flaps—with or without an implant—and later have a symptom such as a palpable lump, typically start with a mammogram.

Monitoring the High-Risk Patient

Recent research suggests that monitoring with breast MRI might be of specific value to women with a high risk for breast cancer recurrence due to factors such as a histologically aggressive primary tumor type or a genetic susceptibility.

In an article published in the March-April 2013 issue of Radiographics, Canadian clinicians from the departments of Radiology and Plastic Surgery at Hôtel-Dieu de Montréal, Centre Hospitalier de l’Université de Montréal looked at a range of normal and abnormal imaging appearances of reconstructed breasts, including features of benign complications as well as those of malignant change.

The authors write, “Images representing this spectrum of findings were selected from the clinical records of 119 women who underwent breast MRI at the authors’ institution between January 2009 and March 2011, after mastectomy and breast reconstruction. In 32 of 37 women with abnormal findings on MR images, only benign changes were found at further diagnostic workup; in the other five, recurrent breast cancer was found at biopsy. Four of the five had been treated initially for invasive carcinoma, and one, for multifocal ductal carcinoma; three of the five were carriers of a BRCA gene mutation. On the basis of these results, the authors suggest that systematic follow-up examinations with breast MRI may benefit women with a reconstructed breast and a high risk for breast cancer recurrence.”6

Brem makes another important point regarding cancer risk. “Recent data suggests that those who have a personal history of breast cancer have a substantially increased chance of developing another cancer,” she says.

With this in mind, Brem encourages plastic surgeons treating women who have had a unilateral mastectomy to communicate with patients and remind them to have their annual mammogram on their healthy breast. “Always remember the other breast. You never know; you may be the only doctor she is seeing,” she says.

Monticciolo, too, points out the importance of clear communication with patients with reconstructed breasts. “Patients should be made aware that implants placed along with native breast tissue will limit mammography to some degree,” she says.

“As a radiologist who specializes in imaging the breast, I look forward to working with my plastic surgery colleagues to address special imaging needs of their reconstructed patients,” Monticciolo adds. “The best advice I can give is to work together to address any issues that arise. Each situation is unique; we can work together to provide the best care possible.”

Matthews.Marianne_1467_color 2-1Marianne Matthews is a contributing writer for Plastic Surgery Practice magazine. She can be reached via PSPeditor@allied360.com.

References

  1. American Cancer Society http://www.cancer.org/cancer/breastcancer/detailedguide/breast-cancer-key-statistics. Accessed September 10, 2015.
  2. Dragun AE, Huang B, Tucker TC, Spanos WJ. Increasing mastectomy rates among all age groups for early stage breast cancer: a 10-year study of surgical choice. Breast J. 2012;18(4):318–325.
  3. Tokin C, Weiss A, Wang-Rodriguez J, Blair SL. Oncologic safety of skin-sparing and nipple-sparing mastectomy: a discussion and review of the literature. Int J Surg Oncol. 2012(2012):article 921821. doi: 10.1155/2012/921821. Published July 17, 2012. Accessed August 22, 2015.
  4. Habermann EB, Abbott A, Parsons HM, Virnig BA, Al-Refaie WB, Tuttle TM. Are mastectomy rates really increasing in the United States? J Clin Oncol. 2010;28(21):3437–3441.
  5. McGuire KP, Santillan AA, Kaur P, et al. Are mastectomies on the rise? A 13-year trend analysis of the selection of mastectomy versus breast conservation therapy in 5865 patients. Ann Surg Oncol. 2009;16 (10):2682–2690.
  6. Pinel-Giroux FM, El Khoury MM, Trop I, Bernier C, David J, Lalonde L. Breast reconstruction: review of surgical methods and spetrum of imaging findings. Radiographics. 2013 Mar-Apr;33(2):435-53. doi: 10.1148/rg.332125108. PMID: 23479706.