Identification of tumor recurrence after breast cancer surgery with multimodality imaging

Identification of tumor recurrence after breast cancer surgery with multimodality imaging Poster No.: C-0727 Congress: ECR 2014 Type: Educational Exhibit Authors: J. Y. Cheung, J. H. Moon ; Gyeonggi-do/KR, Anyang, Gyeonggi-do/KR Keywords: Metastases, Education, Ultrasound, PET-CT, Mammography, Breast DOI: 10.1594/ecr2014/C-0727 1 2 1 2 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. www.myesr.org Page 1 of 15

Learning objectives The purpose of this exibit is to review radiologic features of tumor recurrence after breast cancer surgery with different imaging modalities and to demostrate key points for differentiation of recurred cancer from normal postoperative changes. Background Patients with a history of breast cancer are at risk for developing local-regional recurrence. Recurrence occurs in approximately 5 % of patients at 5 years with a local failure rate of approximately 1%-2.5% per year. After 5 years, the risk of recurrence then diminishes, but patients remain at risk even 10 years after treatment. Early detection of recurrence of breast cancer can improve long-term survival. Variable imaging modalities are used to detect recurred tumor after breast cancer surgery for follow up study. So we performed retrospective review of breast cancer patients in our hospital who underwent breast surgery. We provide multimodality comparison of postoperative images representing tumor recurrence with mammography, ultrasound, chest CT and PET-CT. The list of imaging findings of tumor recurrence is followed. 1) in breast recurrence, ipsilateral or contralateral 2) regional lymph node 3) chest wall (skin) Findings and procedure details Imaging modalities 1) mammography (MG): Selenia Full Field Digial Mammography System (Lorad/Hologic, Danbury, Conn) 2) breast ultrasound (US): 5-12 MHz linear transducers and ultrasound units (ATL 5000 or IU-22, Philips Healthcare) Page 2 of 15

3) chest CT: Brillinace 63 (Philips) for diagnosis, Brilliance TM CT BIG BORE (Philips) for radiation therapy plan 4) PET-CT with the radiolabeled glucose analogue 2-[fluorine 18]fluoro-2-deoxy-dglucose (FDG): Gemini TF 64 (Philips) MG and US images were interpreted by 5 radiologists, Chest CT by 2 radiologists and PET-CT by 2 radiologist. 1. Recurred tumor in the breast (Fig. 1-9) With adequate treatment, it rarely occurs earlier than in the first 2 years. During that period, radiologic alterations are more likely to suggest benign process. It may or may not appear in a similar fashion as the primary malignancy. Also, recurred tumors can develop at the contralateral breast (Fig. 6-7, 8-9). So, bilateral breasts should be evaluated. 1) MG It is less sensitive for the detection of recurrence in postconservative breast because of operation and radiation related alteration. However, it is more useful to detect suspicious calcifications than US or other imaging modalities. increasing asymmetry, enlarging mass within the operative bed increasing edema, overall trabecular pattern, indicating lymphatic spread pleomorphic, coarse heterogenous or linear calcifications ; frequently same morphology as those found in the primary cancer 2) US It is more sensitive and specific for the detection of recurrence than mammography. However, it may be difficult to diffentiation between diffuse acoustic shadowing caused by scar and tumor, and its sensitivity is limited for evaluation of small or noninvasive lesion. circumscribed or ill-defined, spiculated, irregular, hypoechoic mass calcifications can be seen as echogenic foci. Page 3 of 15

3) CT Its sensitivity and specificity are lower than other modalities, but sometimes incidental findings can be detected on CT scan at first. Also, it provides the anatomic information. circumscribed or ill-defined, spiculated, irregular, enhancing mass 4) PET-CT It can detect unexpected uptake foci with higher sensitivity, especially patients with heterogenous breast parenchymal background. However, small tumors can not be detected. faint or intense hypermetabolic lesion 2. Regional lymph node recurrence (Fig. 4A-B, 5C-D, 10, 11) Regional lymph node recurrence occurs in about 1%- 16% of breast cancer patients, with associated with poor prognosis. The axillary, supraclavicular and internal mammary lymph nodes are the most common sites of regional lymph node recurrence. Sizes of benign and malignant nodes are similar. Cortical morphologic feature appears to be of greater importance than size. PET-CT is useful for detection of metastatic lymph nodes. 1) MG The limitation of mammography is that the field of view of mammography does not include this entire area. round shape, more hyperdense than normal lymph node 2) US round or irregular shape, thick and eccentric hypoechoic cortex (> 3mm in thickness), loss of echogenic hilum, less than 1.5 of long to short ratio, with or without calcifications Page 4 of 15

internal mammary lymph node metastasis: : normal lymphatic structures are not discernible with US, but metastases appear as spherical or ovoid hypoechoic masses of uniform echogenecity, confined to the intercostal space, distiguishable from the internal mammary vessels on longitudinal scans. 3) PET-CT It can show more accurate extent of node metastasis, so more sensitive than other modalities faint or intense uptake 3. Recurrence of chest wall (skin) (Fig. 4B, 5B, 12) It may occur by direct local extension of tumor through the pectoral fascia and into the pectoral muscles or by indirect extension via interpectoral nodes. It is best seen by US. Prior to US scanning, patients usually have palpable mass at the operative site or chest wall. 1) MG It is often difficult to be detected because of small size and superficial location. 2) US circumscribed or ill-defined, round, ovoid or irregular, taller than wide, hypoechoic mass 3) PET-CT faint or intense uptake Images for this section: Page 5 of 15

Fig. 4: US images of same patient above.(a) shows spiculated, irregular, hypoechoic mass in the right breast adjacent to the operative site. US-guided core needle biopsy was performed, and it was confirmed to invasive ductal carcinoma. Two irregular, hypoechoic nodules are also seen at the skin layer of medial portion of the right breast (B), which were comfirmed to metastatic carcinomas from the breast by punch biopsy. (C, D) show round and irregular lymph nodes at both axillae, with loss of central hilum, suggestive of metastasis. Page 6 of 15

Fig. 6: A 65 years-old female underwent left breast conserving surgery for invasive ductal carcinoma. After 10 months, the initial postoperative mammography (A) shows postoperative change at the left breast, without other evidence of recurrence. However, a microlobulated isodense nodule is newly seen at the right breast on the follow up study (B) after 3 years since operation. Page 7 of 15

Fig. 7: Another images of same patient above. A microlobulated, irregular hypoechoic mass is noted (A) in the right breast on US, corresponding to the nodule on the mammography. Also, chest CT (B)shows an enhancing nodule at the right breast. However, it is not shown intense uptake on PET-CT (C).US-guided core needle biopsy was performed for this lesion, and it was confirmed to invasive ductal carcinoma. So, it is tumor recurrence of contralateral breast. (D) shows the preoperative US image of initial malignant mass in the left breast. Page 8 of 15

Fig. 10: A 35 years-old patient underwent right modifed radical mastectomy for invasive ductal carcinoma. After 10 years, an enlarged lymph node is identified at the right supraclavicular area on follow up US, which shows irregular shape, marked hypoechogenecity with microcalcifiations and loss of central hilum. US-guided fine needle aspiration was performed for this lesion, and it was diagnosed metastatic lymph node from breast. She underwent modifed radical neck dissection. Fig. 8: A 43-years-old patients underwent right breast conserving surgery due to invasive ductal carcinoma. (A) shows initial malignant mass which was located at the upper inner quadrant of the right breast. After 15 months, irregular hypoechoic mass was newly developed at the upper outer quadrant of the right breast (B). US-guided core needle biopsy was performed for this lesion, and it was confirmed to recurred invasive ductal carcinoma. Page 9 of 15

Fig. 9: Another images of same patient above. On the PET-CT, the recurred malignant mass of the right breast shows faint uptake (A), whereas another intense uptake is identified in the left breast (B). So, second look US was performed and irregular hypoechoic mass was detected at the left breast (C), corresponding to the lesion on PET-CT. US-guided core needle biopsy was performed for the lesion, and it was also comfirmed to recurred invasive ductal carcinoma. She was underwent bilateral modified radical mastectomy. Page 10 of 15

Fig. 1: A 51 years-old female underwent left breast conserving surgery due to invasive ductal carcinoma. After 4 years, clustered microcalcifications (blue arrows) are newly developed at the upper outer quadrant of the left breast on the follow up mammography, which are located at the same quadrant of the operative site. Page 11 of 15

Fig. 12: A 78 years-old female underwent right modified radical mastectomy due to invasive ductal carcinoma at the outside hospital. After 29 months, she came to our hospital because of palpable mass at the right chest wall. On US (A, B), there were irregular, hypoechoic masses at the right mastectomy site along the operative scar. On PET-CT (C, D), intense uptake lesions were noted at the right mastectomy site corresponding to the lesions on US. US-guided core needle biopsy was performed and it was comfirmed to recurrent ductal carcinoma. Fig. 2: Another images of same patient above. On US (A), irregular hypoechoic mass associated with calcifications is noted at the upper outer portion of the left breast, corresponding to suspicious calcifications on the mammography. On PET-CT (B), it shows intense uptake. US-guided core needle biopsy was performed and it was comfirmed to recurred invasive ductal carcinoma. She underwent left modified radical mastectomy. Fig. 11: A 45 years-old patient underwent right breast conserving surgery due to invasive ductal carcinoma. After 4 years, an enlarged intramammary lymph node was identified at Page 12 of 15

the right second intercostal space on the follow up US. US-guided fine needle aspiration was performed and it was confirmed to metastatic lymph node. Also, recurred tumor was identified in the right breast (this figure is not shown). Page 13 of 15

Conclusion This illustration of multimodality images will help to understand imaging features of recurred breast cancer after surgery. Personal information References Thanissara Chansakul, Kenny C. Lai, Priscilla J. Slanetz. The postconservation breast: Part 2, imaging findings of tumor recurrence and other long-term sequelae. AJR 2012;198:331-343 D.David Dershaw. Mammography in patients with breast cancer treated by breast conservation (lumpectomy with or without radiation). AJR 1995;164:309-316 Renee W. Pinsky, Murray Rebner, Lori J. Pierce, et al, Recurrent cancer after breastconserving surgery with radiation therapy for ductal carcinoma in situ: mammographic features, method of detection, and stage of recurrence. AJR 2007;189:140-144 Sun Mi Kim, Jeong Mi Park, Normal and abnormal US findings at the mastectomy site. Radiographics 2004;24:357-365 Deepak G. Bedi, Rajesh Krishnamurthy, Savitri Krishnamurthy, et al, Cortical morphologic features of axillary lymph nodes as a predictor of metastasis in breast cancer: in vitro sonographic study. AJR 2008;191:646-652 Hee Jung Moon, Min Jung Kim, Eun-Kyung Kim, et al, US surveillance of regional lymph node recurrence after breast cancer surgery. Radiology 2009;252:673-681. Jogn C. Scatarige, Izzie Boxen, Ralph L. Smathers, Internal mammary lymphadenopathy: imaging of a vital lymphatic pathway in breast cancer. Radiographics 1990;10:857-870 Page 14 of 15

Peter B. Hathaway, David A. Mankoff, Kenneth R. Maravilla, et al. Value of combined FDG PET and MR imaging in the evaluation of suspected recurrent local-regional breast cancer: preliminary experience. Radiology 1999;210:807-814 Page 15 of 15