Spectrum of Imaging findings in Post- operative breast: Challenges involved.

Transcription

1 Spectrum of Imaging findings in Post- operative breast: Challenges involved. Poster No.: C-1079 Congress: ECR 2015 Type: Educational Exhibit Authors: A. Sraj, S. Sripathi ; Westcliff-on-Sea/UK, Manipal/IN Keywords: Multidisciplinary cancer care, Vacuum assised biopsy, Screening, Biopsy, Ultrasound, MR, Mammography, Oncology, Breast DOI: /ecr2015/C Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 56

2 Learning objectives To demonstrate the spectrum of imaging findings in patients with breast conservative surgery/therapy. Background The diagnostic evaluation of the postoperative breast is challenging because of great variability due to surgery and irradiation. Breast conservation surgery involves tumor removal with a margin of normal breast tissue whereas additional irradiation - Breast conservative Therapy (BCT) makes interpretation difficult because of focal thickening, decreased compressibility and increased density. Distinguishing these treatment related findings from breast cancer recurrence in lumpectomy site is extremely challenging. Findings and procedure details Breast conservation surgery (lumpectomy, quadrantectomy,partial mastectomy) followed by breast radiotherapy produces changes on both physical examination and on imaging. Mammograms were done on digital mammographic unit (Siemens MAMMOMAT Inspiration) and on a conventional mammographic unit (GE Senograph DMR plus) with standard medio-lateral oblique (MLO) and cranio-caudal (CC) views. Special views were done where indicated. Ultrasound was performed on state of the art ultrasound machine (Toshiba Aplio 500 and Toshiba Aplio XG) using high frequency linear transducers. MRI of breast was done on PHILIPS Achieva 1.5 Tesla scanner using a dedicated 8 channel breast coil. The sequences used were as follows: T1W axial without fat suppression T2W axial, sagittal and coronal planes with fat suppression Page 2 of 56

3 STIR axial and sagittal Axial Diffusion Weighted Imaging using b = 0, 600. Pre contrast axial 3D T1 with fat suppression, both breasts (mask images for subtraction) Post contrast axial dynamic multiphase 3D T1 sequence with fat-suppression (60 sec to 90 sec acquisitions, 1 pre - 5 post-contrast acquisitions) followed by subtraction. A five year mammographic follow-up in surgical and oncological clinic is done for these patients. Imaging findings: A "baseline" diagnostic mammogram of the treated breast after completion of the lumpectomy and breast radiotherapy is done approximately 6-8 months after completion of surgery and radiotherapy to allow the breast to heal and to resolve immediate post-radiation inflammatory changes. The breast surgeon usually leaves metallic clips in the cavity edges to mark the outline of the surgical resection. These are visible on postoperative mammograms and computed tomography (CT) scanning, while less visible on ultrasound and MRI. The mammogram findings after breast conservative surgery include skin thickening, increased breast density, architectural distortion, seroma formation in the initial few months, however subsequent mammograms show scarring and dystrophic calcification and rarely recurrent mass at the operative site. (Fig. 1 on page 30) Page 3 of 56

4 Fig. 1: Line diagram (A-E) showing evolution of imaging findings on mammogram in post operative breast in patients with breast conservation therapy. References: Breast Unit, Southend University Hospital, United Kingdom. It is important to assess the evolution of changes in serial mammograms and compare the findings with previous mammograms. In a patient who has undergone lumpectomy, skin thickening is seen in the nipple areolar region which subsequently reduces on annual follow-up mammogram. (Fig. 2 on page 30) Page 4 of 56

5 Fig. 2: A 45 year old female underwent lumpectomy in right breast for infiltrative ductal carcinoma. Mammogram of right breast -CC view(a) shows skin thickening ( arrow) which reduced in thickness in mammogram done after one year(b). References: Dept of Radiodiagnosis, Kasturba Medical College, Manipal, Karnataka, India. Breast edema is noted more commonly in a breast treated with radiotherapy and its specific mammographic features include skin and stromal thickening, trabecular thickening in the subcutaneous fat, and diffuse increased breast density which become less over a period of time. ( Fig. 3 on page 31 ) Page 5 of 56

6 Fig. 3: Serial annual Mammograms-CC view (A,B,C) in a patient who underwent breast conservation therapy shows increased breast density and skin thickening in the initial mammogram (A) which shows reduction with time. References: Dept of Radiodiagnosis, Kasturba Medical College, Manipal, Karnataka, India. On the initial mammogram following surgery, a fluid-filled round or oval cavity called seroma is seen at the postsurgical scar site, sometimes containing air along with breast edema and focal skin thickening. The surgical cavity, seen initially as a well defined density due to fluid-filled mass, may be partially obscured by the surrounding breast edema. With resolution of the surrounding breast edema, the cavity or seroma may become more apparent. (Fig. 4 on page 32) Page 6 of 56

7 Fig. 4: A 49 year old female who underwent breast conservation therapy of right breast underwent mammogram after one year. Mammogram -CC and MLO view shows a well defined opacity in right breast( arrow) suggestive of seroma. References: Radiology, The Breast Unit (Nightingale Centre), Southend University Hospital NHS Foundation Trust - Westcliff-on-Sea/UK The reporting radiologist should be aware of the appearance of seroma on various imaging modalities.the postoperative seroma or hematoma can have variable appearances on ultrasound, but is usually seen as a hypoechoic or complex (containing both solid and cystic components) mass which usually decreases in size over time. In some cases, the fluid collection may remain unchanged for years as a long-standing seroma or may be seen as a well defined cystic lesion with peripheral nodular margins. ( Fig. 5 on page 33) Page 7 of 56

8 Fig. 5: A well defined opacity is (arrow) seen on MLO view of right breast in a patient of postoperative breast. Ultrasound in the region of interest shows a well defined anechoic lesion at the lumpectomy site with thickened nodular echogenic wall which is suggestive of Seroma. References: Department of Radio-diagnosis, Kasturba Medical College, Manipal, India. In cases of treated breast where the breast density is increased due to edema and stromal thickening on mammogram and there is also seroma formation it is difficult to comment on the breast parenchyma. This is where the role of ultrasound comes in as it plays an important role in evaluation of underlying breast parenchyma to rule out any underlying mass. (Fig. 6 on page 34), ( Fig. 7 on page 35), (Fig. 8 on page 36) Page 8 of 56

9 Fig. 6: A 52 year old female underwent breast conservation surgery 2 years back and was on regular follow up. Mammogram of left breast CC and MLO view show a well defined opacity (arrow) and a possibility of seroma was considered. References: Department of Radio-diagnosis, Kasturba Medical College, Manipal, India. Page 9 of 56

10 Fig. 7: Ultrasound of left breast in the same patient as in Fig 6 in the region of interest shows a well defined heterogenous lesion with anechoic rim which was seroma. References: Department of Radio-diagnosis, Kasturba Medical College, Manipal, India. Page 10 of 56

11 Fig. 8: Ultrasound of left breast in the same patient shows another small ill-defined hypoechoic lesion near the seroma. Biopsy from this lesion was done which was suggestive of Infiltrative ductal carcinoma -recurrent mass. References: Department of Radio-diagnosis, Kasturba Medical College, Manipal, India. Over long periods of time, the cavity gradually decreases in volume until it either forms a chronic seroma or, in most cases, it evolves into a scar composed of dense connective tissue. Postsurgical scarring usually appears as a poorly marginated soft-tissue mass with interspersed radiolucent areas centrally. This should not be confused with a recurrent mass where there is increased density in the central portion of scar. A true scar should not grow in size with time.on Ultrasound the scar is seen as an ill-defined hypoechoic lesion with entrapped fat within which should not be confused with a recurrent mass. (Fig. 9 on page 37),( Fig. 10 on page 38) Page 11 of 56

12 Fig. 9: Mammogram of right breast ( MLO and CC) view in a 35 year old female who underwent lumpectomy for infiltrative ductal carcinoma shows an ill-defined opacity with central area of lucency near the site of surgical staples (arrow). On ultrasound it was seen as an ill-defined hypoechoic area with entrapped fat within. There was no vascularity and no mass was seen. These features were suggestive of scar tissue. References: Radiology, The Breast Unit (Nightingale Centre), Southend University Hospital NHS Foundation Trust - Westcliff-on-Sea/UK Page 12 of 56

13 Fig. 10: Mammogram of left breast (A,B) in a patient with breast conservative surgery shows skin thickening and scar tissue. Ultrasound (C) of left breast in the same region shows a well defined hypoechoic area with irregular margins suggestive of scar. References: Radiology, The Breast Unit (Nightingale Centre), Southend University Hospital NHS Foundation Trust - Westcliff-on-Sea/UK For women who are treated with accelerated partial breast irradiation (APBI), there are more focal edematous changes, fat necrosis, dystrophic breast calcifications and/ or further scarring at the lumpectomy site. Fat necrosis is a benign, nonsuppurative inflammatory process that results from trauma to the breast and is an extremely common finding in the breast conservation setting. It commonly shows as coarse or dystrophic calcifications, calcified or noncalcified oil/lipid cysts, or even focal asymmetries or masses.these benign, fat necrosis-associated calcifications later appear as large (>5 mm), lucent centered, egg-shell or rim-like calcifications and form around a fatty center. On ultrasound it is seen as either a simple cyst or a well defined cystic lesion with nodular margins. Dystrophic calcifications are seen as multiple irregular foci of macrocalcifications.( Fig. 11 on page 39) (Fig. 12 on page 39) ( Fig. 13 on page 40 ), (Fig. 14 on page 42 ) Page 13 of 56

14 Fig. 11: Post-operative mammogram of left breast- MLO view (A) in a 72 year old female shows surgical staples and a well defined rounded lucency adjacent to it suggestive of fat necrosis. Ultrasound (B) of the same region shows a round well defined anechoic to hypoechoic lesion with peripheral hyperechoic nodular rim which was suggestive of fat necrosis. References: Breast Unit, Southend University Hospital,Westcliff -on-sea,united Kingdom. Page 14 of 56

15 Fig. 12: Mammogram of right breast- MLO view (A) in a 64 year old female who underwent breast conservation surgery shows surgical staples and a well defined rounded lucency with a radio-opaque rim suggestive of fat necrosis. Ultrasound (B) of the same region shows a round well defined anechoic lesion with peripheral nodularity which was suggestive of fat necrosis. References: Breast Unit, Southend University Hospital,Westcliff -on-sea,united Kingdom. Page 15 of 56

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17 Fig. 13: Post-operative mammogram of right breast -CC view, in a 64 year old woman shows a well defined lucent area with predominantly peripheral calcifications along with a few central calcific densities. Features represent fat necrosis. References: Breast Unit, Southend University Hospital,Westcliff -on-sea,united Kingdom. Page 17 of 56

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19 Fig. 14: Mammogram of left breast -CC view (A) of a woman who underwent breast conservation shows surgical staples and multiple ill-defined calcific foci suggestive of dystrophic calcification. References: Radiology, The Breast Unit (Nightingale Centre), Southend University Hospital NHS Foundation Trust - Westcliff-on-Sea/UK Fig. 15: Magnified view of the left breast of the same patient as in Fig 14 shows the dystrophic calcifications. References: Radiology, The Breast Unit (Nightingale Centre), Southend University Hospital NHS Foundation Trust - Westcliff-on-Sea/UK Page 19 of 56

20 Linear, branching, and pleomorphic calcifications are highly suspicious and warrant a stereotactic core needle biopsy.pleomorphic, segmental and granular microcalcifications are important markers for recurrent cancer and can usually be distinguished from the thick, calcified plaques and elongated dystrophic calcifications associated with scarring. (Fig. 16 on page 44) ( Fig. 17 on page 45) Page 20 of 56

21 Fig. 16: A 50 year old patient underwent breast conservative surgery for infiltrative ductal carcinoma of left breast. Follow-up mammogram - MLO and CC view (A,B) after one year showed segmental linear calcification ( arrow). References: Radiology, The Breast Unit (Nightingale Centre), Southend University Hospital NHS Foundation Trust - Westcliff-on-Sea/UK Page 21 of 56

22 Fig. 17: Magnification view of the left breast of the same patient as in Fig 16 showed suspicious calcifications. Biopsy from this area was done which showed infiltrative ductal carcinoma - suggestive of recurrence. References: Radiology, The Breast Unit (Nightingale Centre), Southend University Hospital NHS Foundation Trust - Westcliff-on-Sea/UK The normal mammographic changes associated with BCT changes usually decrease over years or may remain stable. Progression of breast edema after the first postsurgical, postradiation therapy mammogram is abnormal and should be investigated. Recurrences at the original tumor site may be due to failure to excise all of the original cancer or microscopic residual tumor deposits that are resistant to radiotherapy and/or systemic therapy.any focal increase in density at the surgical site or in the axilla can be due to a recurrent mass or lymphnodal mass.( Fig. 18 on page 46) ( Fig. 19 on page 47) ( Fig. 20 on page 48) Page 22 of 56

23 Fig. 18: Post-operative follow-up mammogram of right breast -MLO and CC view in a woman shows an ill-defined radio-opacity with irregular margins ( arrow). Biopsy from the same was suggestive of infiltrative ductal carcinoma. References: Radiology, The Breast Unit (Nightingale Centre), Southend University Hospital NHS Foundation Trust - Westcliff-on-Sea/UK Fig. 19: Mammogram of right breast MLO and CC view(a,b) in a 36 year old woman who underwent breast conservation surgery for infiltrative ductal carcinoma one year back shows an ill-defined radio-opacity in axillary tail region(a). References: Department of Radio-diagnosis, Kasturba Medical College, Manipal, India. Page 23 of 56

24 Fig. 20: Ultrasound of the right breast in the axillary tail region of same patient as in fig 19 shows a well defined hypoechoic lobulated mass lesion s/o lymphnodal mass. Ultrasound at the operative site shows an ill-defined hypoechoic area suggestive of scar. Biopsy from the axillary tail lesion was confirmed to be metastatic lymph nodes. References: Department of Radio-diagnosis, Kasturba Medical College, Manipal, India. MRI is used as a problem solving modality to distinguish between post operative changes and mass. It plays an important role in women with dense breast who have undergone breast conservation therapy to rule out recurrence especially in those cases where there is a positive tumour margin on surgical resection. On MRI, the surgical cavity is displayed as a non-enhancing fluid-filled structure, representing the seroma or hematoma, with an enhancing thin rim and should correspond with a mammographic mass. Any focal, nodular enhancement along the periphery or away from the surgery site is viewed with suspicion. If it is felt that the finding might be visible by ultrasound, the finding should warrant further evaluation with a "second look" ultrasound in an appropriate clinical setting. (Fig. 21 on page 49) (Fig. 22 on page 50 )( Fig. 23 on page 51) ( Fig. 24 on page 52 )( Fig. 25 on page 53) Page 24 of 56

25 Fig. 21: Mammogram of left breast-mlo and CC view(a,b) in a 35 year old female who underwent breast conservative surgery shows post operative changes. References: Department of Radio-diagnosis, Kasturba Medical College, Manipal, India. Page 25 of 56

26 Fig. 22: MRI of breast of the same patient as in Fig 21 was done to look for recurrence. Axial sections of MRI left breast near axillary tail region show a well defined area which was hypointense on T1W(A), hyperintense on T2W and STIR (B,C) and showed peripheral enhancement on post contrast dynamic sequence(d) suggestive of seroma. There was no enhancing mass seen. References: Department of Radio-diagnosis, Kasturba Medical College, Manipal, India. Page 26 of 56

27 Fig. 23: Kinetic curve through the region of interest in the same patient as in Fig 22 showed a Type 1 curve suggestive of benign findings. References: Department of Radio-diagnosis, Kasturba Medical College, Manipal, India. Page 27 of 56

28 Fig. 24: A 29 year old female underwent breast conservation surgery for infiltrative ductal carcinoma of right breast. Since the surgical margins were positive for malignancy, MRI was done to look for residual lesion. MRI axial section DWI (A) showed restricted diffusion and Post contrast dynamic sequence(b) showed a small enhancing are near the scar site with subsequent wash out in delayed phase. References: Department of Radio-diagnosis, Kasturba Medical College, Manipal, India. Fig. 25: Kinetic curve through the region of interest of the same patient as in Fig 24 showed a Type 3 curve suggestive of malignant pathology. Patient underwent a completion mastectomy and was confirmed to be a residual lesion. References: Department of Radio-diagnosis, Kasturba Medical College, Manipal, India. Many breast cancer patients undergo Thoracic CT scan at some point during or after treatment which often show findings related to patient's surgical or adjuvant treatment. The postsurgical changes visible may include those related to lumpectomy, breast reconstruction, axillary surgery and postsurgical complications like fluid collections, Page 28 of 56

29 infection, fat necrosis and lymphedema. The proper interpretation of these findings is important to avoid unnecessary diagnostic imaging and minimize patient anxiety. ( Fig. 26 on page 53) Fig. 26: Coronal and Sagittal CECT sections (A,B) of a 64 year old female who underwent breast conservative surgery. A well defined fluid attenuation collection is noted in the postoperative site between left pectoralis major and minor muscles( arrow) which was extending posteriorly to abut the left subscapularis muscle. Features suggestive of seroma. References: Department of Radio-diagnosis, Kasturba Medical College, Manipal, India. Postsurgical changes in conservatively treated breast may overlap with radiographic features of malignancy and hence mammographic evaluation in these patients may be difficult. The reporting radiologists must be aware of the evolution of changes with time in follow-up mammograms. Ultrasound can be used as a complementary modality while MRI is used as a problem solving tool in these cases. Page 29 of 56

30 Images for this section: Fig. 1: Line diagram (A-E) showing evolution of imaging findings on mammogram in post operative breast in patients with breast conservation therapy. Page 30 of 56

31 Fig. 2: A 45 year old female underwent lumpectomy in right breast for infiltrative ductal carcinoma. Mammogram of right breast -CC view(a) shows skin thickening ( arrow) which reduced in thickness in mammogram done after one year(b). Page 31 of 56

32 Fig. 3: Serial annual Mammograms-CC view (A,B,C) in a patient who underwent breast conservation therapy shows increased breast density and skin thickening in the initial mammogram (A) which shows reduction with time. Page 32 of 56

33 Fig. 4: A 49 year old female who underwent breast conservation therapy of right breast underwent mammogram after one year. Mammogram -CC and MLO view shows a well defined opacity in right breast( arrow) suggestive of seroma. Page 33 of 56

34 Fig. 5: A well defined opacity is (arrow) seen on MLO view of right breast in a patient of postoperative breast. Ultrasound in the region of interest shows a well defined anechoic lesion at the lumpectomy site with thickened nodular echogenic wall which is suggestive of Seroma. Page 34 of 56

35 Fig. 6: A 52 year old female underwent breast conservation surgery 2 years back and was on regular follow up. Mammogram of left breast CC and MLO view show a well defined opacity (arrow) and a possibility of seroma was considered. Page 35 of 56

36 Fig. 7: Ultrasound of left breast in the same patient as in Fig 6 in the region of interest shows a well defined heterogenous lesion with anechoic rim which was seroma. Page 36 of 56

37 Fig. 8: Ultrasound of left breast in the same patient shows another small ill-defined hypoechoic lesion near the seroma. Biopsy from this lesion was done which was suggestive of Infiltrative ductal carcinoma -recurrent mass. Page 37 of 56

38 Fig. 9: Mammogram of right breast ( MLO and CC) view in a 35 year old female who underwent lumpectomy for infiltrative ductal carcinoma shows an ill-defined opacity with central area of lucency near the site of surgical staples (arrow). On ultrasound it was seen as an ill-defined hypoechoic area with entrapped fat within. There was no vascularity and no mass was seen. These features were suggestive of scar tissue. Page 38 of 56

39 Fig. 10: Mammogram of left breast (A,B) in a patient with breast conservative surgery shows skin thickening and scar tissue. Ultrasound (C) of left breast in the same region shows a well defined hypoechoic area with irregular margins suggestive of scar. Fig. 11: Post-operative mammogram of left breast- MLO view (A) in a 72 year old female shows surgical staples and a well defined rounded lucency adjacent to it suggestive of fat necrosis. Ultrasound (B) of the same region shows a round well defined anechoic to hypoechoic lesion with peripheral hyperechoic nodular rim which was suggestive of fat necrosis. Page 39 of 56

40 Fig. 12: Mammogram of right breast- MLO view (A) in a 64 year old female who underwent breast conservation surgery shows surgical staples and a well defined rounded lucency with a radio-opaque rim suggestive of fat necrosis. Ultrasound (B) of the same region shows a round well defined anechoic lesion with peripheral nodularity which was suggestive of fat necrosis. Page 40 of 56

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42 Fig. 13: Post-operative mammogram of right breast -CC view, in a 64 year old woman shows a well defined lucent area with predominantly peripheral calcifications along with a few central calcific densities. Features represent fat necrosis. Page 42 of 56

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44 Fig. 14: Mammogram of left breast -CC view (A) of a woman who underwent breast conservation shows surgical staples and multiple ill-defined calcific foci suggestive of dystrophic calcification. Fig. 15: Magnified view of the left breast of the same patient as in Fig 14 shows the dystrophic calcifications. Page 44 of 56

45 Fig. 16: A 50 year old patient underwent breast conservative surgery for infiltrative ductal carcinoma of left breast. Follow-up mammogram - MLO and CC view (A,B) after one year showed segmental linear calcification ( arrow). Page 45 of 56

46 Fig. 17: Magnification view of the left breast of the same patient as in Fig 16 showed suspicious calcifications. Biopsy from this area was done which showed infiltrative ductal carcinoma - suggestive of recurrence. Page 46 of 56

47 Fig. 18: Post-operative follow-up mammogram of right breast -MLO and CC view in a woman shows an ill-defined radio-opacity with irregular margins ( arrow). Biopsy from the same was suggestive of infiltrative ductal carcinoma. Page 47 of 56

48 Fig. 19: Mammogram of right breast MLO and CC view(a,b) in a 36 year old woman who underwent breast conservation surgery for infiltrative ductal carcinoma one year back shows an ill-defined radio-opacity in axillary tail region(a). Page 48 of 56

49 Fig. 20: Ultrasound of the right breast in the axillary tail region of same patient as in fig 19 shows a well defined hypoechoic lobulated mass lesion s/o lymphnodal mass. Ultrasound at the operative site shows an ill-defined hypoechoic area suggestive of scar. Biopsy from the axillary tail lesion was confirmed to be metastatic lymph nodes. Page 49 of 56

50 Fig. 21: Mammogram of left breast-mlo and CC view(a,b) in a 35 year old female who underwent breast conservative surgery shows post operative changes. Page 50 of 56

51 Fig. 22: MRI of breast of the same patient as in Fig 21 was done to look for recurrence. Axial sections of MRI left breast near axillary tail region show a well defined area which was hypointense on T1W(A), hyperintense on T2W and STIR (B,C) and showed peripheral enhancement on post contrast dynamic sequence(d) suggestive of seroma. There was no enhancing mass seen. Page 51 of 56

52 Fig. 23: Kinetic curve through the region of interest in the same patient as in Fig 22 showed a Type 1 curve suggestive of benign findings. Fig. 24: A 29 year old female underwent breast conservation surgery for infiltrative ductal carcinoma of right breast. Since the surgical margins were positive for malignancy, MRI was done to look for residual lesion. MRI axial section DWI (A) showed restricted diffusion Page 52 of 56

53 and Post contrast dynamic sequence(b) showed a small enhancing are near the scar site with subsequent wash out in delayed phase. Fig. 25: Kinetic curve through the region of interest of the same patient as in Fig 24 showed a Type 3 curve suggestive of malignant pathology. Patient underwent a completion mastectomy and was confirmed to be a residual lesion. Page 53 of 56

54 Fig. 26: Coronal and Sagittal CECT sections (A,B) of a 64 year old female who underwent breast conservative surgery. A well defined fluid attenuation collection is noted in the postoperative site between left pectoralis major and minor muscles( arrow) which was extending posteriorly to abut the left subscapularis muscle. Features suggestive of seroma. Page 54 of 56

55 Conclusion Mammographic changes after breast conservation surgery and breast conservation therapy include skin and parenchymal edema, increased breast density,seroma, scar formation, fat necrosis and tumour recurrence making it difficult and challenging to detect a residual or recurrent mass. A comparison with previous mammograms is extremely helpful to evaluate the gradation of changes and establish a diagnosis. Ultrasound plays a complementary role and helps in confirming diagnosis. MRI is used as a problem solving tool and is done to distinguish between postoperative changes and residual/recurrent mass, especially in patients with dense breast. Personal information Dr. Aron Sraj, Consultant Radiologist, Breast Unit, Southend University Hospital, United Kingdom. Aron.Sraj@southend.nhs.uk Dr. Smiti Sripathi, Professor, Department of Radio-diagnosis, Kasturba Medical College, Manipal, India. smitis11@hotmail.com References 1. Brenner RJ, Pfaff JM. Mammographic features after conservation therapy for malignant disease: serial findings standardized by regression analysis. AJR Am J Roentgenol,1996 ;167: Soo MS, Kornguth PJ, Hertzberg BS. Fat necrosis in the breast: sonographic features. Radiology,1998;206(1): Rajesh Krishnamurthy, Gary J. Whitman, Carol B. Stelling, Anne C. Kushwaha Mammographic Findings after Breast Conservation Therapy, RadioGraphics, 1999, 19, S53-S62. Page 55 of 56

56 4. Giess CS, Keating DM, Osborne MP, Mester J, Rosenblatt R. Comparison of rate of development and rate of change for benign and malignant breast calcifications at the lumpectomy bed.ajr Am J Roentgenol. 2000;175(3): Olson JA Jr, Morris EA, Van Zee KJ, et al. Magnetic resonance imaging facilitates breast conservation for occult breast cancer. Ann Surg Oncol. Jul 2000;7(6): Chala LF, de Barros N, de Camargo Moraes P, Endo E, Kim SJ, Pincerato PM, et al. Fat necrosis of the breast: mammographic, sonographic, computed tomography, and magnetic resonanceimaging findings [review]. Curr Probl Diagn Radiol. 2004; 33(3): Preda L, Villa G, Rizzo S, Bazzi L, Origgi D, Cassano E, et al. Magnetic resonance mammography in the evaluation of recurrence at the prior lumpectomy site after conservative surgery and radiotherapy. Breast Cancer Res. 2006;8(5):R Litière S, Werutsky G, Fentiman IS, et al. Breast conserving therapy versus mastectomy for stage I-II breast cancer: 20 year follow-up of the EORTC phase 3 randomized trial. Lancet Oncol 2012; 13: Page 56 of 56