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Post Breast-Conserving Surgery
Vilert Loving, MD; Wendie A. Berg, MD, PhD, FACR, FSBI
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KEY FACTS

  • Terminology

    • Imaging

      • Top Differential Diagnoses

        TERMINOLOGY

        • Definitions

          • Imaging findings following breast-conserving surgery (BCS), a.k.a. lumpectomy, segmental mastectomy
          • Breast conservation therapy (BCT) = BCS followed by radiation therapy (XRT)
          • Whole-breast irradiation (WBI): Hypofractionated WBI = higher radiation dose, 5 days per week, over 3 weeks, then 4-day boost
            • Skin tattoos to outline region undergoing treatment
            • Preferred over conventional WBI = lower radiation dose, 5 days per week, over 5 weeks, then boost; equally effective
            • Boost: Extra radiation treatment to high-risk area, typically lumpectomy site, supplementing WBI
          • Accelerated partial-breast irradiation (APBI): Localized treatment to lumpectomy cavity and surrounding 1-2 cm, often 2 treatments per day for 5 days
            • Primarily used for lower risk breast cancers (women aged ≥ 50, low-risk DCIS, margins negative by ≥ 2 mm)
          • Mastectomy: Removal of entire breast
            • Modified radical mastectomy, total mastectomy, skin-sparing mastectomy: Excision of entire breast and nipple-areolar complex
            • Simple mastectomy: Nipple-areolar complex retained
          • Tamoxifen (TAM): Drug to block ER
            • Most commonly prescribed drug for treatment of breast cancer (estrogen antagonist and agonist)
            • ↓ recurrence risk ER(+) breast cancer
              • Node-negative ER(+) breast cancer treated with BCT: 10-year recurrence 3-4% with TAM vs.12-14% without TAM
          • Aromatase inhibitors (AI): Block estrogen production in postmenopausal women

        IMAGING

        • Mammographic Findings

          • Ultrasonographic Findings

            • MR Findings

              • Nuclear Medicine Findings

                • Imaging Recommendations

                  DIFFERENTIAL DIAGNOSIS

                    PATHOLOGY

                    • General Features

                      • Microscopic Features

                        CLINICAL ISSUES

                        • Natural History & Prognosis

                          DIAGNOSTIC CHECKLIST

                          • Consider

                            • Image Interpretation Pearls

                              Selected References

                              1. Lowry KP et al: Predictors of surveillance mammography outcomes in women with a personal history of breast cancer. Breast Cancer Res Treat. 171(1):209-15, 2018
                              2. Monticciolo DL et al: Breast cancer screening in women at higher-than-average risk: recommendations from the ACR. J Am Coll Radiol. 15(3 Pt A):408-14, 2018
                              3. Smith BD et al: Radiation therapy for the whole breast: Executive summary of an American Society for Radiation Oncology (ASTRO) evidence-based guideline. Pract Radiat Oncol. 8(3):145-52, 2018
                              4. Wiens N et al: Effect of BioZorb® surgical marker placement on post-operative radiation boost target volume. J Radiat Oncol. 7(2):175-79, 2018
                              5. Liu G et al: Efficacy and safety of accelerated partial breast irradiation: a meta-analysis of published randomized studies. Oncotarget. 8(35):59581-91, 2017
                              6. Patel BK et al: Variability of postsurgical imaging surveillance of breast cancer patients: a nationwide survey study. AJR Am J Roentgenol. 1-6, 2017
                              7. Landén NX et al: Transition from inflammation to proliferation: a critical step during wound healing. Cell Mol Life Sci. 73(20):3861-85, 2016
                              8. Lehman CD et al: Screening MRI in women with a personal history of breast cancer. J Natl Cancer Inst. 108(3), 2016
                              9. Michaels AY et al: Assessment and management of challenging bi-rads category 3 mammographic lesions. Radiographics. 36(5):1261-72, 2016
                              10. Marta GN et al: Accelerated partial irradiation for breast cancer: systematic review and meta-analysis of 8653 women in eight randomized trials. Radiother Oncol. 114(1):42-9, 2015
                              11. Khatcheressian JL et al: Breast cancer follow-up and management after primary treatment: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol. 31(7):961-5, 2013
                              12. Arasu VA et al: Benefit of semiannual ipsilateral mammographic surveillance following breast conservation therapy. Radiology. 264(2):371-7, 2012
                              13. Berg WA et al: Detection of breast cancer with addition of annual screening ultrasound or a single screening MRI to mammography in women with elevated breast cancer risk. JAMA. 307(13):1394-404, 2012
                              14. Chansakul T et al: The postconservation breast: part 1, expected imaging findings. AJR Am J Roentgenol. 198(2):321-30, 2012
                              15. Chansakul T et al: The postconservation breast: part 2, imaging findings of tumor recurrence and other long-term sequelae. AJR Am J Roentgenol. 198(2):331-43, 2012
                              16. Drukteinis JS et al: MR imaging assessment of the breast after breast conservation therapy: distinguishing benign from malignant lesions. Radiographics. 32(1):219-34, 2012
                              17. Gunia SR et al: Evaluation of appropriate short-term mammographic surveillance in patients who undergo breast-conserving Surgery (BCS). Ann Surg Oncol. 19(10):3139-43, 2012
                              18. Sheth GR et al: Radiation-induced sarcoma of the breast: a systematic review. Oncologist. 17(3):405-18, 2012
                              19. Wahner-Roedler DL et al: The use of molecular breast imaging to assess response in women undergoing neoadjuvant therapy for breast cancer: a pilot study. Clin Nucl Med. 37(4):344-50, 2012
                              20. Houssami N et al: Accuracy and outcomes of screening mammography in women with a personal history of early-stage breast cancer. JAMA. 305(8):790-9, 2011
                              21. Monticciolo DL et al: Breast conserving therapy with accelerated partial breast versus external beam whole breast irradiation: comparison of imaging sequela and complications in a matched population. Breast J. 17(2):187-90, 2011
                              22. Vanderwalde LH et al: Breast MRI after bilateral mastectomy: is it indicated? Am Surg. 77(2):180-4, 2011
                              23. Brennan S et al: Breast MRI screening of women with a personal history of breast cancer. AJR Am J Roentgenol. 195(2):510-6, 2010
                              24. Li J et al: Breast MRI after conservation therapy: usual findings in routine follow-up examinations. AJR Am J Roentgenol. 195(3):799-807, 2010
                              25. Anderson SJ et al: Prognosis after ipsilateral breast tumor recurrence and locoregional recurrences in patients treated by breast-conserving therapy in five National Surgical Adjuvant Breast and Bowel Project protocols of node-negative breast cancer. J Clin Oncol. 27(15):2466-73, 2009
                              26. Evans SB et al: Persistent seroma after intraoperative placement of MammoSite for accelerated partial breast irradiation: incidence, pathologic anatomy, and contributing factors. Int J Radiat Oncol Biol Phys. 65(2):333-9, 2006
                              27. Rosen EL et al: Accuracy of MRI in the detection of residual breast cancer after neoadjuvant chemotherapy. AJR Am J Roentgenol. 181(5):1275-82, 2003
                              28. Solomon B et al: Delayed development of enhancement in fat necrosis after breast conservation therapy: a potential pitfall of MR imaging of the breast. AJR Am J Roentgenol. 170(4):966-8, 1998
                              29. Zenn MR et al: TRAM flap reconstruction: the single pedicle, whole muscle technique. In Spear SL et al: Surgery of the Breast: Principles and Art. Philadelphia: Lippincott Williams & Wilkins. 511-9, 1998
                              30. Brenner RJ et al: Mammographic changes after excisional breast biopsy for benign disease. AJR Am J Roentgenol. 167(4):1047-52, 1996
                              31. Dershaw DD: Mammography in patients with breast cancer treated by breast conservation (lumpectomy with or without radiation). AJR Am J Roentgenol. 164(2):309-16, 1995
                              32. Heywang-Köbrunner SH et al: Contrast-enhanced MRI of the breast after limited surgery and radiation therapy. J Comput Assist Tomogr. 17(6):891-900, 1993
                              33. Mendelson EB: Evaluation of the postoperative breast. Radiol Clin North Am. 30(1):107-38, 1992
                              34. Sickles EA et al: Mammography of the postsurgical breast. AJR Am J Roentgenol. 136(3):585-8, 1981
                              Related Anatomy
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                              Related Differential Diagnoses
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                              References
                              Tables

                              Tables

                              KEY FACTS

                              • Terminology

                                • Imaging

                                  • Top Differential Diagnoses

                                    TERMINOLOGY

                                    • Definitions

                                      • Imaging findings following breast-conserving surgery (BCS), a.k.a. lumpectomy, segmental mastectomy
                                      • Breast conservation therapy (BCT) = BCS followed by radiation therapy (XRT)
                                      • Whole-breast irradiation (WBI): Hypofractionated WBI = higher radiation dose, 5 days per week, over 3 weeks, then 4-day boost
                                        • Skin tattoos to outline region undergoing treatment
                                        • Preferred over conventional WBI = lower radiation dose, 5 days per week, over 5 weeks, then boost; equally effective
                                        • Boost: Extra radiation treatment to high-risk area, typically lumpectomy site, supplementing WBI
                                      • Accelerated partial-breast irradiation (APBI): Localized treatment to lumpectomy cavity and surrounding 1-2 cm, often 2 treatments per day for 5 days
                                        • Primarily used for lower risk breast cancers (women aged ≥ 50, low-risk DCIS, margins negative by ≥ 2 mm)
                                      • Mastectomy: Removal of entire breast
                                        • Modified radical mastectomy, total mastectomy, skin-sparing mastectomy: Excision of entire breast and nipple-areolar complex
                                        • Simple mastectomy: Nipple-areolar complex retained
                                      • Tamoxifen (TAM): Drug to block ER
                                        • Most commonly prescribed drug for treatment of breast cancer (estrogen antagonist and agonist)
                                        • ↓ recurrence risk ER(+) breast cancer
                                          • Node-negative ER(+) breast cancer treated with BCT: 10-year recurrence 3-4% with TAM vs.12-14% without TAM
                                      • Aromatase inhibitors (AI): Block estrogen production in postmenopausal women

                                    IMAGING

                                    • Mammographic Findings

                                      • Ultrasonographic Findings

                                        • MR Findings

                                          • Nuclear Medicine Findings

                                            • Imaging Recommendations

                                              DIFFERENTIAL DIAGNOSIS

                                                PATHOLOGY

                                                • General Features

                                                  • Microscopic Features

                                                    CLINICAL ISSUES

                                                    • Natural History & Prognosis

                                                      DIAGNOSTIC CHECKLIST

                                                      • Consider

                                                        • Image Interpretation Pearls

                                                          Selected References

                                                          1. Lowry KP et al: Predictors of surveillance mammography outcomes in women with a personal history of breast cancer. Breast Cancer Res Treat. 171(1):209-15, 2018
                                                          2. Monticciolo DL et al: Breast cancer screening in women at higher-than-average risk: recommendations from the ACR. J Am Coll Radiol. 15(3 Pt A):408-14, 2018
                                                          3. Smith BD et al: Radiation therapy for the whole breast: Executive summary of an American Society for Radiation Oncology (ASTRO) evidence-based guideline. Pract Radiat Oncol. 8(3):145-52, 2018
                                                          4. Wiens N et al: Effect of BioZorb® surgical marker placement on post-operative radiation boost target volume. J Radiat Oncol. 7(2):175-79, 2018
                                                          5. Liu G et al: Efficacy and safety of accelerated partial breast irradiation: a meta-analysis of published randomized studies. Oncotarget. 8(35):59581-91, 2017
                                                          6. Patel BK et al: Variability of postsurgical imaging surveillance of breast cancer patients: a nationwide survey study. AJR Am J Roentgenol. 1-6, 2017
                                                          7. Landén NX et al: Transition from inflammation to proliferation: a critical step during wound healing. Cell Mol Life Sci. 73(20):3861-85, 2016
                                                          8. Lehman CD et al: Screening MRI in women with a personal history of breast cancer. J Natl Cancer Inst. 108(3), 2016
                                                          9. Michaels AY et al: Assessment and management of challenging bi-rads category 3 mammographic lesions. Radiographics. 36(5):1261-72, 2016
                                                          10. Marta GN et al: Accelerated partial irradiation for breast cancer: systematic review and meta-analysis of 8653 women in eight randomized trials. Radiother Oncol. 114(1):42-9, 2015
                                                          11. Khatcheressian JL et al: Breast cancer follow-up and management after primary treatment: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol. 31(7):961-5, 2013
                                                          12. Arasu VA et al: Benefit of semiannual ipsilateral mammographic surveillance following breast conservation therapy. Radiology. 264(2):371-7, 2012
                                                          13. Berg WA et al: Detection of breast cancer with addition of annual screening ultrasound or a single screening MRI to mammography in women with elevated breast cancer risk. JAMA. 307(13):1394-404, 2012
                                                          14. Chansakul T et al: The postconservation breast: part 1, expected imaging findings. AJR Am J Roentgenol. 198(2):321-30, 2012
                                                          15. Chansakul T et al: The postconservation breast: part 2, imaging findings of tumor recurrence and other long-term sequelae. AJR Am J Roentgenol. 198(2):331-43, 2012
                                                          16. Drukteinis JS et al: MR imaging assessment of the breast after breast conservation therapy: distinguishing benign from malignant lesions. Radiographics. 32(1):219-34, 2012
                                                          17. Gunia SR et al: Evaluation of appropriate short-term mammographic surveillance in patients who undergo breast-conserving Surgery (BCS). Ann Surg Oncol. 19(10):3139-43, 2012
                                                          18. Sheth GR et al: Radiation-induced sarcoma of the breast: a systematic review. Oncologist. 17(3):405-18, 2012
                                                          19. Wahner-Roedler DL et al: The use of molecular breast imaging to assess response in women undergoing neoadjuvant therapy for breast cancer: a pilot study. Clin Nucl Med. 37(4):344-50, 2012
                                                          20. Houssami N et al: Accuracy and outcomes of screening mammography in women with a personal history of early-stage breast cancer. JAMA. 305(8):790-9, 2011
                                                          21. Monticciolo DL et al: Breast conserving therapy with accelerated partial breast versus external beam whole breast irradiation: comparison of imaging sequela and complications in a matched population. Breast J. 17(2):187-90, 2011
                                                          22. Vanderwalde LH et al: Breast MRI after bilateral mastectomy: is it indicated? Am Surg. 77(2):180-4, 2011
                                                          23. Brennan S et al: Breast MRI screening of women with a personal history of breast cancer. AJR Am J Roentgenol. 195(2):510-6, 2010
                                                          24. Li J et al: Breast MRI after conservation therapy: usual findings in routine follow-up examinations. AJR Am J Roentgenol. 195(3):799-807, 2010
                                                          25. Anderson SJ et al: Prognosis after ipsilateral breast tumor recurrence and locoregional recurrences in patients treated by breast-conserving therapy in five National Surgical Adjuvant Breast and Bowel Project protocols of node-negative breast cancer. J Clin Oncol. 27(15):2466-73, 2009
                                                          26. Evans SB et al: Persistent seroma after intraoperative placement of MammoSite for accelerated partial breast irradiation: incidence, pathologic anatomy, and contributing factors. Int J Radiat Oncol Biol Phys. 65(2):333-9, 2006
                                                          27. Rosen EL et al: Accuracy of MRI in the detection of residual breast cancer after neoadjuvant chemotherapy. AJR Am J Roentgenol. 181(5):1275-82, 2003
                                                          28. Solomon B et al: Delayed development of enhancement in fat necrosis after breast conservation therapy: a potential pitfall of MR imaging of the breast. AJR Am J Roentgenol. 170(4):966-8, 1998
                                                          29. Zenn MR et al: TRAM flap reconstruction: the single pedicle, whole muscle technique. In Spear SL et al: Surgery of the Breast: Principles and Art. Philadelphia: Lippincott Williams & Wilkins. 511-9, 1998
                                                          30. Brenner RJ et al: Mammographic changes after excisional breast biopsy for benign disease. AJR Am J Roentgenol. 167(4):1047-52, 1996
                                                          31. Dershaw DD: Mammography in patients with breast cancer treated by breast conservation (lumpectomy with or without radiation). AJR Am J Roentgenol. 164(2):309-16, 1995
                                                          32. Heywang-Köbrunner SH et al: Contrast-enhanced MRI of the breast after limited surgery and radiation therapy. J Comput Assist Tomogr. 17(6):891-900, 1993
                                                          33. Mendelson EB: Evaluation of the postoperative breast. Radiol Clin North Am. 30(1):107-38, 1992
                                                          34. Sickles EA et al: Mammography of the postsurgical breast. AJR Am J Roentgenol. 136(3):585-8, 1981