Fat Necrosis: A Grand Imposter

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1 Fat Necrosis: A Grand Imposter Poster No.: C-0751 Congress: ECR 2015 Type: Educational Exhibit Authors: L. C. Flores Salinas, Y. A. Ramirez Galvan, A. Garza Báez, C. M. Ferrara Chapa; Monterrey/MX Keywords: Breast, MR, Ultrasound, Mammography, Biopsy, Education and training DOI: /ecr2015/C-0751 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 46

2 Learning objectives To describe and differentiate the imaging findings of fat necrosis on mammography, sonography, and MRI and correlates the imaging findings with the pathologic findings. Page 2 of 46

3 Background Introduction Fat necrosis is a common benign condition resulting from breast trauma. It may result from blunt trauma to the breast but more often occurs after surgery or radiation therapy. It is a benign process that is important to understand because it can clinically and radiologically mimic breast cancer. Lee and Adair described this condition as a distinct clinical entity in The various stages of fat necrosis result in a spectrum of findings that ranges from benign to suggestive of malignancy. Page 3 of 46

4 Findings and procedure details Epidemiology Represents about 2.75% of all benign lesions. The average age of patients is 50 years. The incidence of the disease is estimated to be 0.6% in the breast. Breast radiologists need to be familiar with its radiological appearance to avoid unnecessary biopsies. Etiological factors include: External trauma Surgical trauma (biopsy, lumpectomy, mammoplasty, breast reconstruction) Anticoagulation treatment Radiation therapy Pathogenesis Fat cells disruption The initial event of fat necrosis is disruption of fat cells accompanied by hemorrhage and influx of histiocytes. Immune response This is followed by progressive infiltration by multinucleated histiocytes, hemosiderin deposition, and calcification. Fibrosis Page 4 of 46

5 Fibrosis develops peripherally, enclosing an area of necrotic fat and cellular debris that may become cystic. In the later stages, reactive inflammatory components are replaced by fibrosis, which contracts into a scar. Loculated degenerated fat or oil can persist for months or years within a cyst surrounded by the scar. The imaging features of fat necrosis are variable, depending on its stage and degree of fibrosis. Clinical Features Most cases are clinically occult but sometimes fat necrosis may mimic carcinoma by presenting as a palpable painless mass or associated findings such as pain, skin dimpling, and nipple retraction. Some patients may not recall trauma to the breast and may be asymptomatic. Fat necrosis is most commonly seen in superficial breast tissue and in obese women with large pendulous breast. A history of trauma can be obtained in only 40-65% patients. The mean time for patients to present with a breast lump from the time of trauma is 68.5 weeks (range 3-208). Imaging Evaluation Mammography The most classic appearance is an oil cyst without or with rim calcification. The mammography appearance of fat necrosis can include: Discrete round or oval radiolucent oil cyst with thin capsule (27%) Thickening and deformity of skin and subcutaneous tissue (16%) Page 5 of 46

6 Focal mass (13%) Normal appearance (9%) Ill-defined spiculated mass (4%) Multiple clustered pleomorphic microcalcifications suspicious of malignancy (4%). The variable mammography changes are attributable to the different stages of the disease. At early stages, less extensive fibrosis is associated with a lipid cyst with fibrous capsule. Older lesions appear as radiolucent oil cysts with ring-like dystrophic calcifications in the wall. Fat necrosis may also appear as lipophagic granulomas that are associated with greater degree of fibrosis. Teaching Point: Occasionally fat necrosis may manifest as ill-defined, spiculated dense or focal masses associated with distortion, skin thickening and retraction as commonly seen in breast cancer. Fat necrosis may also be associated with pleomorphic, clustered or branching- type microcalcifications, which are indistinguishable from those associated with cancer. Ultrasound The ultrasound appearance of fat necrosis can include: Increased echogenicity of subcutaneous tissue (27%). Anechoic cyst with posterior acoustic enhancement (17%). Hypoechoic mass with posterior acoustic shadowing (17%). Page 6 of 46

7 Solid mass (14%). Cyst with internal echoes (11%). Normal appearance (11%). Cystic mural nodule (4%). The ultrasound appearance of fat necrosis range from solid nodules with posterior shadowing to complex intra-cystic masses that evolves over time. Fat necrosis may appear as an ill-defined echogenic area. These features depict the histological evolution of fat necrosis. Sonographically, fat necrosis may appear as cystic or solid masses. Cystic lesions appear complex with mural nodules or with internal echogenic bands. Solid masses have well-circumscribed or ill-defined margins, and are often associated with distortion of the breast parenchyma. Ultrasound can reliably diagnose oil cysts. Magnetic Resonance Imaging Its appearance varies widely with the amount of fat and the extent of inflammation and fibrosis. Fat necrosis often appears as a rim-enhancing mass with irregular margins and central non- enhancing fat. Is a common feature a thin rim of enhancement, the rim may also be thick, irregular, or spiculated. Fibrosis causes mass effect and architectural distortion, and the degree of inflammation dictates the degree of enhancement. The degree and pattern of enhancement vary widely from slow to rapid initially, with persistent, plateau, or even washout delayed kinetics. A fat-fluid level or thin enhancing internal septations may be present within the central fat collection. Fat necrosis may also Page 7 of 46

8 appear as an enhancing focus, or clumped non-mass-like enhancement when it contains a minimal amount of fat. The presence of non-enhancing loculated liquid fat is the key to diagnosing fat necrosis. The best sequence to detect the fat content is the precontrast T1-weighted sequence without fat suppression. On these images, fat shows high signal intensity similar to fat elsewhere in the breast or slightly lower signal intensity because of hemorrhagic or inflammatory contents. On fat-suppressed T1-weighted images, the loculated fat will show suppression of signals similar to the adjacent fat as well as a lack of contrast enhancement. The specificity of MRI for fat necrosis can be further improved by correlation with mammography to detect oil cyst or coarse microcalcifications and by its typical location. Fat necrosis due to blunt trauma is usually superficial in location. It is commonly seen in the lower central breast after reduction mammoplasty or in the periphery of the reconstruction flap where the blood supply is more tenuous. Page 8 of 46

Images for this section: Fig. 1: Right MLO and lateral mammogram in 46-year-old woman with history of right breast cancer who underwent breast conserving surgery and radiotherapy 5 years ago.

9 Images for this section: Fig. 1: Right MLO and lateral mammogram in 46-year-old woman with history of right breast cancer who underwent breast conserving surgery and radiotherapy 5 years ago. Currently asymptomatic. In the region of the surgical scar that corresponds to the posterior third of the upper outer quadrant of the right breast, a well-circumscribed radiolucency with central coarse calcifications and thin rim calcification was observed. Page 9 of 46

10 Fig. 2: Right CC and MLO views in 53-year-old woman with history of bilateral mastopexy 5 years ago. In the posterior third of the lower inner quadrant of the right breast, a radiolucent well-circumscribed round nodule of 17mm with thin rim calcification was observed. Page 10 of 46

11 Fig. 6: MLO view of both breasts in 51-year-old patient with history of liposuction and fat injected into breasts 4 years ago. Well-circumscribed radiolucencies with thin rim calcifications are identified in both breasts in the posterior third of the upper quadrants. Page 11 of 46

12 Fig. 7: MLO view of both breasts in 75-year-old woman with history of mastopexy 5 years ago. Dystrophic calcifications are identified in both breasts, in the right side localized in the lower central quadrant measuring 37 x 27mm, and in the left side on upper outer quadrant measuring 35 x 20mm, findings consistent with fat necrosis. Page 12 of 46

Fig. 8: Left CC and MLO views in 66-year-old woman with history of invasive micropapillary cancer of the breast with perineural infiltration in upper outer quadrant of the left breast, estrogen and

13 Fig. 8: Left CC and MLO views in 66-year-old woman with history of invasive micropapillary cancer of the breast with perineural infiltration in upper outer quadrant of the left breast, estrogen and progesterone receptor positive and HER2 negative, that underwent breast conserving surgery in August In the middle third of the upper outer quadrant of the left breast below the metallic marker, an architectural distortion that partially modifies in additional views was observed. Page 13 of 46

Fig. 9: Spot of compression in 66-year-old woman with history of invasive micropapillary cancer of the breast with perineural infiltration in upper outer quadrant of the left breast, estrogen and

14 Fig. 9: Spot of compression in 66-year-old woman with history of invasive micropapillary cancer of the breast with perineural infiltration in upper outer quadrant of the left breast, estrogen and progesterone receptor positive and HER2 negative, that underwent breast conserving surgery in August In the middle third of the upper outer quadrant of the left breast below the metallic marker, an architectural distortion that partially modifies in additional views was observed. Page 14 of 46

15 Fig. 10: 48-year-old woman with breast implants for about 9 months. Gray-scale sonogram reveals well-circumscribed anechoic oval images without posterior acoustic enhancement and no evidence of vascularity in the color flow imaging, findings consistent with fat necrosis. Page 15 of 46

16 Fig. 11: Gray-scale sonogram reveals well-circumscribed anechoic oval image that contains echogenic material, with no evidence of vascularity in the color flow imaging, findings consistent with fat necrosis. Page 16 of 46

17 Fig. 12: 46-year-old woman with history of right breast cancer that underwent breast conserving surgery and radiotherapy 5 years ago. Gray-scale sonogram reveals at the level of the surgical scar in the right breast, an oval nodule with microlobulated margins, heterogeneous echogenicity, rim calcifications, and no evidence of vascularity in the color flow imaging. Page 17 of 46

18 Fig. 13: 53-year-old woman with history of bilatery mastopexy 5 years ago. Gray-scale sonogram reveals well-circumscribed anechoic round image without posterior acoustic enhancement and no evidence of vascularity in the color flow imaging, findings consistent with late stage of fat necrosis. Page 18 of 46

19 Fig. 14: 53-year-old woman with history of bilatery mastopexy 5 years ago. Gray-scale sonogram reveals well-circumscribed anechoic round image without posterior acoustic enhancement and no evidence of vascularity in the color flow imaging, findings consistent with late stage of fat necrosis. Page 19 of 46

20 Fig. 15: Gray-scale sonogram reveals oval nodule with rim calcification with posterior acoustic shadowing. Page 20 of 46

Fig. 16: 41-year-old woman with history of left breast cancer that underwent breast conserving surgery, chemotherapy, and radiotherapy in October 2012.

21 Fig. 16: 41-year-old woman with history of left breast cancer that underwent breast conserving surgery, chemotherapy, and radiotherapy in October Gray-scale sonogram reveals (arrow) an oval anechoic well-circumscribed imagen, measuring 5 x 5 x 3mm, without posterior acoustic enhancement, corresponding to fat necrosis. Additionally, architectural distortion and skin thickening was observed. Page 21 of 46

22 Fig. 17: Gray-scale sonogram reveals anechoic oval image, without posterior acoustic enhancement. Page 22 of 46

23 Fig. 18: Doppler color ultrasound reveals anechoic oval image, without posterior acoustic enhancement and no evidence of vascularity. Page 23 of 46

24 Fig. 19: Gray-scale sonogram reveals anechoic round image, without posterior acoustic enhancement. Page 24 of 46

25 Fig. 20: 48-year-old woman with breast implants for about 9 months. Gray-scale sonogram reveals well-circumscribed anechoic oval images without posterior acoustic enhancement and no evidence of vascularity in the color flow imaging, findings consistent with fat necrosis. Page 25 of 46

Fig. 21: T1 weighted sequence. Female 41 y/o with history of left breast cancer treated with conservative surgery in October 2012, chemotherapy and radiotherapy.

26 Fig. 21: T1 weighted sequence. Female 41 y/o with history of left breast cancer treated with conservative surgery in October 2012, chemotherapy and radiotherapy. Currently with skin thickening in left breast and skin biopsy 2 weeks ago. In the images obtained after administration of endovascular gadolinium, two ovoid lesions are viewed in the posterior third of the left superolateral quadrant. These lesions are hyperintense on T1 and T2 weighted sequences and show thin ring enhancement, with a type 1 curve (upward), measuring 16 x 10mm and 10 x 6mm, suggestive of fat necrosis. Page 26 of 46

Fig. 22: T2 weighted sequence. Female 41 y/o with history of left breast cancer treated with conservative surgery in October 2012, chemotherapy and radiotherapy.

27 Fig. 22: T2 weighted sequence. Female 41 y/o with history of left breast cancer treated with conservative surgery in October 2012, chemotherapy and radiotherapy. Currently with skin thickening in left breast and skin biopsy 2 weeks ago. In the images obtained after administration of endovascular gadolinium, two ovoid lesions are viewed in the posterior third of the left superolateral quadrant. These lesions are hyperintense on T1 and T2 weighted sequences and show thin ring enhancement, with a type 1 curve (upward), measuring 16 x 10mm and 10 x 6mm, suggestive of fat necrosis. Page 27 of 46

28 Fig. 23: Image obtained after administration of endovascular gadolinium. Female 41 y/o with history of left breast cancer treated with conservative surgery in October 2012, chemotherapy and radiotherapy. Currently with skin thickening in left breast and skin biopsy 2 weeks ago. In the images obtained after administration of endovascular gadolinium, two ovoid lesions are viewed in the posterior third of the left superolateral quadrant. These lesions are hyperintense on T1 and T2 weighted sequences and show thin ring enhancement, with a type 1 curve (upward), measuring 16 x 10mm and 10 x 6mm, suggestive of fat necrosis. Page 28 of 46

Fig. 24: Image obtained after endovascular contrast. Female 41 y/o with history of left breast cancer treated with conservative surgery in October 2012, chemotherapy and radiotherapy.

29 Fig. 24: Image obtained after endovascular contrast. Female 41 y/o with history of left breast cancer treated with conservative surgery in October 2012, chemotherapy and radiotherapy. Currently with skin thickening in left breast and skin biopsy 2 weeks ago. In the images obtained after administration of endovascular gadolinium, two ovoid lesions are viewed in the posterior third of the left superolateral quadrant. These lesions are hyperintense on T1 and T2 weighted sequences and show thin ring enhancement, with a type 1 curve (upward), measuring 16 x 10mm and 10 x 6mm, suggestive of fat necrosis. Page 29 of 46

30 Fig. 25: Type 1 curve. Female 41 y/o with history of left breast cancer treated with conservative surgery in October 2012, chemotherapy and radiotherapy. Currently with skin thickening in left breast and skin biopsy 2 weeks ago. In the images obtained after administration of endovascular gadolinium, two ovoid lesions are viewed in the posterior third of the left superolateral quadrant. These lesions are hyperintense on T1 and T2 weighted sequences and show thin ring enhancement, with a type 1 curve (upward), measuring 16 x 10mm and 10 x 6mm, suggestive of fat necrosis. Page 30 of 46

31 Fig. 27: T1 weighted sequence. Female 48 y/o with history of breast cancer treated with conservative surgery one year ago. In the images obtained after administration of endovascular gadolinium, one rounded lesion is viewed in the right superolateral quadrant. This lesion shows hyperintense center on T1 and T2 weighted sequences and show thin ring enhancement, with a type 1 curve (upward), measuring 7 x 6mm, suggestive of fat necrosis. Page 31 of 46

Fig. 28: Image obtained after administration of endovascular contrast. Female 48 y/o with history of breast cancer treated with conservative surgery one year ago.

32 Fig. 28: Image obtained after administration of endovascular contrast. Female 48 y/o with history of breast cancer treated with conservative surgery one year ago. In the images obtained after administration of endovascular gadolinium, one rounded lesion is viewed in the right superolateral quadrant. This lesion shows hyperintense center on T1 and T2 weighted sequences and show thin ring enhancement, with a type 1 curve (upward), measuring 7 x 6mm, suggestive of fat necrosis. Page 32 of 46

Fig. 29: Image obtained after administration of endovascular contrast. Female 48 y/o with history of breast cancer treated with conservative surgery one year ago.

33 Fig. 29: Image obtained after administration of endovascular contrast. Female 48 y/o with history of breast cancer treated with conservative surgery one year ago. In the images obtained after administration of endovascular gadolinium, one rounded lesion is viewed in the right superolateral quadrant. This lesion shows hyperintense center on T1 and T2 weighted sequences and show thin ring enhancement, with a type 1 curve (upward), measuring 7 x 6mm, suggestive of fat necrosis. Page 33 of 46

34 Fig. 30: Type 1 curve. Female 48 y/o with history of breast cancer treated with conservative surgery one year ago. In the images obtained after administration of endovascular gadolinium, one rounded lesion is viewed in the right superolateral quadrant. This lesion shows hyperintense center on T1 and T2 weighted sequences and show thin ring enhancement, with a type 1 curve (upward), measuring 7 x 6mm, suggestive of fat necrosis. Page 34 of 46

35 Fig. 26: T2 weighted sequences. Female 48 y/o with history of breast cancer treated with conservative surgery one year ago. In the images obtained after administration of endovascular gadolinium, one rounded lesion is viewed in the right superolateral quadrant. This lesion shows hyperintense center on T1 and T2 weighted sequences and show thin ring enhancement, with a type 1 curve (upward), measuring 7 x 6mm, suggestive of fat necrosis. Page 35 of 46

36 Fig. 32: T2 weighted sequence. Female 66 y/o with history of invasive micropapillary cancer of the breast with perineural infiltration in superoexternal left quadrant, estrogen and progesterone receptor positive and HER2 negative, that underwent breast conserving surgery in August In the images obtained after administration of endovascular gadolinium, one ovoid lesion is viewed in the right superolateral quadrant. This lesion shows hyperintense center on T1 and T2 weighted sequences and show thin ring enhancement, with a type 1 curve (upward), measuring 28 x 23mm, suggestive of fat necrosis. Page 36 of 46

37 Fig. 33: Image obtained after administration of endovascular contrast. Female 66 y/o with history of invasive micropapillary cancer of the breast with perineural infiltration in superoexternal left quadrant, estrogen and progesterone receptor positive and HER2 negative, that underwent breast conserving surgery in August In the images obtained after administration of endovascular gadolinium, one ovoid lesion is viewed in the right superolateral quadrant. This lesion shows hyperintense center on T1 and T2 weighted sequences and show thin ring enhancement, with a type 1 curve (upward), measuring 28 x 23mm, suggestive of fat necrosis. Page 37 of 46

38 Fig. 34: Image obtained after administration of endovascular contrast. Female 66 y/o with history of invasive micropapillary cancer of the breast with perineural infiltration in superoexternal left quadrant, estrogen and progesterone receptor positive and HER2 negative, that underwent breast conserving surgery in August In the images obtained after administration of endovascular gadolinium, one ovoid lesion is viewed in the right superolateral quadrant. This lesion shows hyperintense center on T1 and T2 weighted sequences and show thin ring enhancement, with a type 1 curve (upward), measuring 28 x 23mm, suggestive of fat necrosis. Page 38 of 46

39 Fig. 35: Tyoe 1 curve. Female 66 y/o with history of invasive micropapillary cancer of the breast with perineural infiltration in superoexternal left quadrant, estrogen and progesterone receptor positive and HER2 negative, that underwent breast conserving surgery in August In the images obtained after administration of endovascular gadolinium, one ovoid lesion is viewed in the right superolateral quadrant. This lesion shows hyperintense center on T1 and T2 weighted sequences and show thin ring enhancement, with a type 1 curve (upward), measuring 28 x 23mm, suggestive of fat necrosis. Page 39 of 46

40 Fig. 31: T1 weighted sequences. Female 66 y/o with history of invasive micropapillary cancer of the breast with perineural infiltration in superoexternal left quadrant, estrogen and progesterone receptor positive and HER2 negative, that underwent breast conserving surgery in August In the images obtained after administration of endovascular gadolinium, one ovoid lesion is viewed in the right superolateral quadrant. This lesion shows hyperintense center on T1 and T2 weighted sequences and show thin ring enhancement, with a type 1 curve (upward), measuring 28 x 23mm, suggestive of fat necrosis. Page 40 of 46

41 Fig. 4: CC spot of compression in 45-year-old woman with history of right breast cancer that underwent breast conserving surgery 2 years ago. Architectural distortion is noted in the upper central quadrant of the right breast corresponding to postoperative changes, with oval well-circumscribed radiolucency with thin rim calcification. Page 41 of 46

Fig. 5: Lateral spot of compression in 45-year-old woman with history of right breast cancer that underwent breast conserving surgery 2 years ago.

42 Fig. 5: Lateral spot of compression in 45-year-old woman with history of right breast cancer that underwent breast conserving surgery 2 years ago. Architectural distortion is noted in the upper central quadrant of the right breast corresponding to postoperative changes, with oval well-circumscribed radiolucency with thin rim calcification. Page 42 of 46

Fig. 3: Right MLO view and spot compression in 45-year-old woman with history of right breast cancer that underwent breast conserving surgery 2 years ago.

43 Fig. 3: Right MLO view and spot compression in 45-year-old woman with history of right breast cancer that underwent breast conserving surgery 2 years ago. Architectural distortion is noted in the upper central quadrant of the right breast corresponding to postoperative changes, with oval well-circumscribed radiolucency with thin rim calcification. Page 43 of 46

44 Conclusion Managment A carefully history and physical examination of the breast is suggested to evaluated history of trauma, surgery, radiation or anticoagulation treatment. Not all of the patients with history of breast trauma and a breast mass have fat necrosis. Careful evaluation of imaging findings is needed. Often trauma may simply draw a patient s attention to an existing mass/malignancy. If clinical and imaging are suggestive of fat necrosis, a short-term imaging and clinical follow up is recommended. Mammographic densities and sonographic masses may decrease in size over time. Calcifications may become more dystrophic. If there is any diagnostic uncertainly a core needle biopsy is recommended. Page 44 of 46

45 Personal information Autor: Lydia Catalina Flores Salinas Coautor: Yazmín Aseret Ramírez Galván Carla Melissa Ferrara Chapa Azalea Garza Baez Page 45 of 46

46 References P.H. Tan. Fat Necrosis of the Breast- A review. Department of Surgery, Hillingdon Hospital NHS Trust, Pield Health Road, Uxbridge, Middlesex, UB8 3NN, UK. The Breast (2006) 15, Breast MRI. Molleran Virginia M. Mahoney Mary C Elsevier. Fat Necrosis: The Great Mimicker in breast imaging. A. Wadhwa, MD. Medical College of Wisconsin, Milwaukee, WI. RSNA Diagnostic Imaging. Breast. Berg, Birdwell. First Edition. Page 46 of 46

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