Mammographic Changes Research Articles

Autologous breast reconstruction with endoscopic latissimus dorsi musculosubcutaneous flaps in patients choosing breast-conserving therapy: mammographic appearance.

The objective of this study was to define and evaluate mammographic changes in patients treated with breast-conserving therapy and a new reconstructive technique that uses autologous tissue from a latissimus dorsi musculosubcutaneous flap. Of 20 patients who underwent either immediate or delayed endoscopic latissimus dorsi muscle flap reconstruction after lumpectomy, 13 also had postsurgery mammograms available for review. Radiographic findings assessed included skin thickening, density or radiolucency at the reconstruction site, density around the flap, fat necrosis, calcifications, and the presence of surgical clips. Mammograms for three patients (23%) revealed thickening that we believed was attributable to radiation therapy. No patient had increased density in the flap itself; all flaps were relatively radiolucent centrally (13/13; 100%). Mammograms revealed density around the rim of the flap in four patients (31%). This density was most likely secondary to latissimus dorsi muscle fibers and did not limit radiographic evaluation. One patient had calcifications, probably secondary to fat necrosis. No oil cysts were seen. In the majority of patients (11/13; 85%), surgical clips were visible. Endoscopic latissimus dorsi muscle flap reconstruction, previously used only for mastectomy patients, is now being used for improved esthetic outcome in selected patients who desire breast conservation. Our results indicate that the mammographic findings are predictable. The most common findings are relative radiolucency centrally, with or without density from muscle fibers around the edges of the area of tissue transfer. The transplanted musculosubcutaneous flap does not interfere with mammographic evaluation.

Mammographic features after conservation therapy for malignant breast disease: serial findings standardized by regression analysis.

The purpose of this study was to determine the incidence and natural history of mammographic changes in patients within 5 years of conservation therapy for malignant breast disease. We reviewed the records of 164 consecutive patients with a history of conservation therapy for malignant disease. We recorded mammographic changes related to treatment for each year after surgery. Linear regression analysis was applied to determine trends for progression, regression, or stability of findings. We evaluated 158 patients with 162 lesions for which initial mammographic evaluation had occurred within 5 years of surgery. Of these 158 patients, 121 (77%) underwent serial studies. A total of 152 patients (96%) showed changes on mammograms that represented scarring, usually in multiple locations. Findings at initial evaluation included architectural distortion (n = 110; 82%), increased regional density or scarring (n = 106; 79%), skin thickening (n = 73; 54%), masses (n = 16; 12%), and calcifications (n = 4; 3%). All findings except calcifications showed partial resolution over time, with architectural distortion showing the most significant resolution (p = .05). Mammographic features after conservation therapy for breast cancer are common at 1 year after treatment. With the exception of calcifications, we found that all changes showed decreased prominence during the next 5 years. Recognition of such trends during routine surveillance should facilitate the early identification of changes that represent recurrence or do novo malignancy.

The use of mammography in breast preservation in locally advanced breast cancer

Purpose : As the feasibility of breast preservation in locally advanced breast cancer is currently under evaluation, little information is available correlating mammographic changes to chemotherapy with local outcome. To evaluate the role of mammography in selecting candidates with locally advanced breast cancer for conservative local therapy, we analyzed mammographic changes in the breast to induction chemotherapy and correlated the radiologic appearance with pathologic outcome. Methods and Materials : From 1985 through 1993, 91 patients with Stage III breast cancer were enrolled on a multimodality clinical trial using chemohormonal therapy followed by local treatment and maintenance therapy. Induction therapy consisted of cyclophosphamide, doxorubicin, methotrexate, and 5-fluorouracil with hormonal synchronization using tamoxifen and conjugated estrogens. After nine cycles, surgical biopsies of the breast were performed. Through 1988, clinical examination alone directed the site for postinduction biopsy; for patients treated after 1988, mammography, in addition to physical examination, determined the biopsy location. Local treatment was determined by biopsy result. Patients with a pathologic complete response received radiation only to the breast and regional nodes, while those with pathologically proven residual disease underwent mastectomy and postoperative radiotherapy. Nine additional cycles of maintenance chemotherapy were administered. Results : Fifty-three of 91 patients (58%) obtained a clinical complete response (CR) to induction chemotherapy. Twenty-eight of the 53 women with a clinical CR had both pre- and postinduction mammograms. Of these 28 women, 9 obtained a pathologic CR and 19 obtained a pathologic partial response (PR). Fifty-five percent (5) of the pathologic complete responders had resolution of mammographic abnormalities on the postinduction mammogram. Sixty-eight percent (13) of the pathologic partial responders had abnormal mammographic findings. The positive predictive value for residual cancer using physical examination was 92%, while the negative predictive value was only 36%. Among patients with a clinical complete response, the positive and negative predictive values for residual cancer using postinduction mammography were 79% and 56%, respectively. Limitations of mammography included uncertain significance of residual microcalcifications and residual masses on postinduction chemotherapy mammograms. Conclusions : Although mammography improved the accuracy of noninvasive evaluation in patients with a clinical complete response, pathologic assessment was still required to determine appropriate local therapy. More sensitive imaging modalities or modifications of film-screen mammography may improve noninvasive detection of residual disease following induction chemotherapy.

Positron emission tomography: 2-deoxy-2-Z 18F]-fluoro- d-glucose uptake in locally advanced breast cancers

Fifteen patients with locally advanced breast cancers were studied using the radiopharmaceutical 2-deoxy-2-[18F]-fluoro-D-glucose (FDG) with positron emission tomography (PET). Five patients were sequentially imaged before and after two pulses of chemotherapy. In 14 of 15 tumours increased uptake of FDG was observed which correlated with the clinical site of the tumour. The PET images were compared with the mammographic and ultrasonomammographic appearances of the tumours in selected patients. In two patients with normal mammograms PET imaging detected the tumour and in a further four patients, with suspicious but not conclusively malignant mammographic changes, a well-defined area of increased FDG uptake was demonstrated by PET. In all five sequentially imaged tumours, following chemotherapy, there was a decrease of the FDG tumour: normal breast uptake ratio. In four patients who completed a full chemotherapeutic course this change preceded a pathological response of their tumours. These findings suggest that this technique may be of benefit in imaging carcinomas in the breasts of pre-menopausal women which may appear dense on mammography and moreover, that sequential imaging may have a role in the prediction, at an early stage, of the response of locally advanced carcinomas to chemotherapy.

Mammographic changes in postmenopausal women undergoing hormonal replacement therapy.

Increasing numbers of postmenopausal women are undergoing hormonal replacement therapy. In this pictorial essay, we present the spectrum of mammographic changes seen in these women. These changes include symmetric and asymmetric increase in breast density, increase in size of fibroadenomas, and development or increase in size of cysts. Our examples illustrate that differentiation of hormonal therapy changes from neoplasm can occasionally be problematic when a focal density or mass is seen on mammograms. Furthermore, reexamination of published reports and our cases suggests that treatment with estrogen alone promotes enlargement of cysts and fibroadenomas, whereas treatment with a combination of estrogen and progesterone is more likely to be associated with diffuse increase in density.

The natural history of mammographic calcifications subjected to interval follow-up.

The purpose of this investigation was to determine the natural history and risk of malignancy associated with isolated indeterminate microcalcifications subjected to interval follow-up. During a 2-year study, 91 patients were identified with indeterminate microcalcifications alone. Specific roentgenographic features of the calcifications were evaluated on initial and follow-up mammograms. During a mean follow-up of 36 months, 19 (21%) of the women exhibited mammographic changes. Ten patients (11%) with suspicious changes underwent a needle-directed biopsy 6 to 30 months after the initial mammographic screening. Five women (5.5%) were diagnosed as having breast carcinoma; three had invasive ductal carcinoma and two had purely intraductal lesions. Four patients had axillary lymph node dissections and no metastatic disease was found. We found no significant differences in the roentgenographic features associated with malignant vs benign lesions apart from an increased overall estimation of the probability of malignancy rating in the five patients with breast carcinoma. We recommend that patients be followed up with mammography at regular intervals for at least 18 months following recognition of indeterminate microcalcifications.

The post therapy breast.

Both systemic and local therapy, for conditions of the breast and unrelated to it, may produce mammographic changes. Some of these are characteristic, such as the pattern of scarring seen in reduction mammoplasty. In many other instances, however, the changes produced overlap features commonly seen in malignancy. A knowledge of the timing, natural history and spectrum of these changes will aid mammographic interpretation.

Stereotaxic localization for fine-needle aspiration breast biopsy. Initial experience with 300 patients.

The efficacy of stereotaxic aspiration biopsy was evaluated in 300 consecutive patients with nonpalpable mammographic lesions. Sixty-eight patients (23%) had suspicious or malignant aspirates; all cases were proved malignant by subsequent examination of operative specimens. Two hundred sixteen patients (72%) had benign aspirates. Of these, 65 were confirmed by operation and 151 had subsequent mammography at 6- and 12-month intervals with no demonstrable mammographic change. In 10 instances (3%), the aspirates were atypical, and in six (2%), nondiagnostic. Biopsy specimens were obtained in all 16 instances, and eight were malignant. The sensitivity of stereotaxic breast aspiration for the diagnosis of cancer was 96%, and the specificity was 100%. Our experience confirms the efficacy of stereotaxic aspiration for the initial evaluation of mammographically detected, nonpalpable lesions.

Periodic mammographic follow-up of probably benign lesions: results in 3,184 consecutive cases.

The author prospectively evaluated the value of periodic mammographic surveillance among 3,184 consecutive cases of nonpalpable, probably benign breast lesions detected with mammography. Follow-up consisted of four mammographic examinations during a 3- or 3.5-year period. Clinical outcome was ascertained in each case after the study period, whether or not patients complied with the protocol. Probably benign lesions were subsequently found to be malignant in 17 cases (positive predictive value for cancer, 0.5%). Fifteen of the 17 cancers were identified by means of interval mammographic change prior to development of a palpable mass; all 17 were stage 0 or stage 1 tumors. All 17 women who had cancer currently show no evidence of tumor recurrence (median duration of follow-up, 5 years). These results should help establish the validity of managing mammographically detected, probably benign lesions with periodic mammographic surveillance. By decreasing the number of biopsies of benign lesions and thereby substantially reducing costs, this approach may help overcome a major barrier to widespread use of mammographic screening.

Mammographic follow-up of low-suspicion lesions: compliance rate and diagnostic yield.

All recommendations for mammographic follow-up of low-suspicion lesions seen at mammography during a 6-month period were reviewed to establish compliance rate and eventual outcome. One hundred forty-four of 2,650 mammograms (5%) showed minimal abnormalities that warranted short-term and periodic mammographic follow-up. Rates of compliance at 4 months and at 1, 2, and 3 years were 88%, 71%, 60%, and 47%, respectively. Progressive mammographic change was found in 10 patients, only one of whom had a carcinoma. It was concluded that mammographic follow-up of low-suspicion lesions is a reasonable alternative to surgical biopsy, although patient compliance remains a significant problem.

Mammographic changes associated with postmenopausal hormone replacement therapy: a longitudinal study.

A retrospective study of radiologic findings from 50 postmenopausal women who underwent hormone replacement therapy was performed to determine the frequency and distribution of changes in the screen-film mammographic appearance of breast tissue between pretreatment and posttreatment mammography. Twelve (24%) of the women developed increased parenchymal density during a median follow-up of 18 months (range, 6-39 months). Mammographic changes included diffuse increase in density in seven (14%) of the women; increased multifocal, asymmetric densities in two (4%); and cyst formation in three (6%). A greater percentage of women who received estrogen-progesterone replacement (26%, 10 of 38) demonstrated changes than those who received estrogen alone (17%, two of 12), but the difference was not statistically significant. The authors conclude that benign increases in mammographic density associated with postmenopausal hormone replacement therapy are not uncommon, and they suggest that the serial changes observed in some women may diminish the sensitivity of mammography for the earlier detection of breast cancer.

Hormonal replacement therapy: mammographic manifestations.

Anecdotal observation of mammographic changes in patients receiving hormonal replacement therapy prompted a retrospective review of a screening population of 1,500 consecutive patients. Thirty patients were identified who underwent mammography both before or after therapy and during therapy. The duration of hormonal replacement therapy ranged from 1 to 72 months (mean, 22.2 months). An increase in fibroglandular tissue was seen on the mammograms of five of the 30 patients (17%) receiving therapy. The mammograms from the remaining 25 patients (83%) showed no change. A proportion of women receiving hormonal replacement therapy will show increased tissue density at mammography. Awareness of this response should temper concern and, in the absence of suggestive anatomic changes, allow for serial, vigilant monitoring of these patients.

The mammographic features of the postlumpectomy, postirradiation breast.

Lumpectomy with radiation therapy is becoming widely accepted as an alternative treatment for breast carcinoma in place of radical mastectomy. This article illustrates the spectrum of mammographic changes seen at various intervals after lumpectomy with irradiation to help the mammographer distinguish postoperative scar from a recurrent carcinoma.

Mammographic Changes Following Reduction Mammaplasty

Mammographic findings after reduction mammaplasty may be similar to those seen with carcinoma. A knowledge of the expected mammographic alterations would be helpful in differentiating postoperative changes from those seen with carcinoma of the breast. Accordingly, the clinical records and mammograms of patients who underwent reduction mammaplasty at the Dartmouth-Hitchcock Medical Center between March of 1977 and July of 1985 were analyzed. Forty-two patients had at least one mammographic examination following reduction mammaplasty. Periareolar soft-tissue changes and inferior pole alterations were present in almost all examinations of patients during the first 6 months after operation, but they decreased during the next few years. Asymmetrical densities were present in approximately half the patients throughout the follow-up period but decreased in degree. Parenchymal calcifications occurred later; few x-rays showed these calcifications during the first year, but 50 percent were apparent after 2 years. Evidence of fat necrosis occurred in approximately 10 percent. Four patients had biopsies for suspicious densities. Chronic inflammation and inclusion cyst were reported. We believe that changes after reduction mammaplasty are predictable and can usually be differentiated from those associated with cancer.

Mammographic changes after reduction mammoplasty.

Mammograms obtained in 24 patients after reduction mammoplasty were reviewed retrospectively to define the mammographic findings seen after this procedure. Nine characteristics were found. The most frequent findings were skin thickening and retraction of the lower portion of the breast, transposition of breast parenchyma from a high to a low position, and a high nipple. The image characteristics were then correlated with the surgical type of mammoplasty performed, that is, dermal transposition of the nipple vs full-thickness nipple-areolar graft. All patients who had dermal transposition had complete or partial preservation of continuity between the subareolar ducts and the nipple. Patients who had nipple-areolar grafts showed either disruption of the subareolar ducts or very fatty breasts without visible ductal tissue. Reduction mammoplasty produces characteristic and predictable mammographic changes.

Mammography after breast-preserving therapy of breast cancer

Follow-up after tumorectomy and intensive irradiation for carcinoma of the breast creates new diagnostic problems. In particular, more experience is necessary about the value of mammography. We have therefore analysed the mammograms of 104 patients intensively followed over one to eight years after primary treatment. Changes in the appearances of the breast due to irradiation are compared with mammographic changes caused by recurrence of tumor. It can be shown that definite structural patterns can be recognised regularly. Optimal diagnosis of recurrencies, however, is only possible by comparing all follow-up mammograms, and additionally the pre-operative films. Close cooperation between the surgeon, radiotherapist and diagnostic radiologist is essential.

The Changing Mammogram

• Screening mammography results in improved detection and survival for women with breast cancer. Interval mammographic changes may be one of the major indications for biopsy. Four hundred fifty-two needle localization biopsies carried out for microcalcifications, mass, asymmetric density, or a combination of calcifications with mass or asymmetric density detected 95 cancers (21%). Interval mammographic changes detected 35 cases (17.9%). Invasive cancers constituted 51% of the initial group but only 34% of the cancers detected because of interval change. Benign breast disease occurred in 160 of 195 women who had undergone biopsy because of interval changes. These changes continued into the postmenopausal period. Hyperplasia and/or atypia was found in 57 (35%) of 160 of the interval group. Interval mammographic abnormalities detect significant pathologic changes in the breast and should be considered a major indication for breast biopsy. ( Arch Surg 1986;121:1311-1314)

The changing mammogram. A primary indication for needle localization biopsy.

Screening mammography results in improved detection and survival for women with breast cancer. Interval mammographic changes may be one of the major indications for biopsy. Four hundred fifty-two needle localization biopsies carried out for microcalcifications, mass, asymmetric density, or a combination of calcifications with mass or asymmetric density detected 95 cancers (21%). Interval mammographic changes detected 35 cases (17.9%). Invasive cancers constituted 51% of the initial group but only 34% of the cancers detected because of interval change. Benign breast disease occurred in 160 of 195 women who had undergone biopsy because of interval changes. These changes continued into the postmenopausal period. Hyperplasia and/or atypia was found in 57 (35%) of 160 of the interval group. Interval mammographic abnormalities detect significant pathologic changes in the breast and should be considered a major indication for breast biopsy.

Mammographic changes following radiotherapy.

Fifty-seven patients with carcinoma of the breast were assessed with serial mammograms following local excision and radiotherapy. The mammographic appearances due to radiotherapy were categorised and the changes in these with the passage of time have been studied. Residual tumour was identified on the basis of remaining malignant-type microcalcification. Local recurrence was identified on mammography. The most useful signs were the development of a mass lesion and the increase or development of malignant-type microcalcification. Differentiation of radiotherapy changes from recurrence of carcinoma can be made when a reaction that is normally due to radiotherapy occurs to an inappropriate degree, or with inappropriate timing.

The role of mammography in evaluating radiation response of inoperable primary breast cancer.

The role of mammography in assessing the radiation response of inoperable primary breast cancer was evaluated. Forty-three patients with nodular and inflammatory breast tumors were studied. Mammographic changes were correlated with clinical findings and in some cases with biopsy or autopsy findings. Mammography proved to be a valuable adjunct to the clinical examination in evaluation of the irradiated breast. It was found to be more accurate than physical findings in recognition of residual disease, differentiation of radiation fibrosis from persistent disease, and detection of reactivation of disease which is not yet clinically obvious.