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242
11 Ultrasound Examination After Breast Surgery
fl uid, which spreads as an anechoic layer surrounding the implant on an extent, increases the
risk of pericapsular fi brosis and capsular contracture and demands surgical care. US often
reveals cysts, local lymphatic edema with skin
thickening, and the increase in echodensity of
tissues.
The character of tissues, which form a postoperative scar (collagen fi bers, quaggy connective
tissue, fi brosis); the expression of edema; and
aseptic in fl ammation in fl uence the diversity of
US picture of postoperative area.
US sometimes detects no signs of a scar.
However, in many cases, it reveals the following
signs: areas of structural deformation; fi elds of
decreased and/or increased echodensity of irregular echostructure; linear (sometimes irregular)
shape, sometimes with acoustic shadows, avascular in CDI, PDI, and 3DPD; and mixed color
pattern with US elastography.
Recurrent Breast Cancer
1 2
Early detection of the recurrences of malignant
tumors is a principal problem of modern oncology. The incidence of breast carcinoma recurrence after radical resection or radical mastectomy
ranges from 2.8 % to 71 %. Even in the cases
without metastases in regional lymph nodes, its
incidence reaches 25–30 %.
Despite the advances in treatment of patients
with breast carcinoma, 40–50 % of women
exhibit cancer dissemination in fi ve years’ term
after radical treatment. The fl ow of the disease
does not necessarily depend on the stage of the
tumor. Different types of preoperative therapy
can in fl uence both the duration of healthy period
and the location of metastases (Goldhirsch et al.
1994 ; Goldhirsch et al. 2001 ) . The ef fi cacy of
treatment of cancer recurrence and metastases
depends on the one hand on their site and the
degree of local extension and, on the other, on
the methods of treatment of the primary tumor.
The basic prognostic criteria that characterize biological properties of a tumor are the type,
histological structure, and clinical stage of the
malignant process. Diffuse type of carcinoma
has 10–16 times worse prognosis than the nodular type. Scirrhous structure exhibits 2–3 times
worse prognosis than the glandular. When the
process is generalized, these prognostic features
appear insigni fi cant. Localization, the duration of
disease, and the rate of tumor growth are relative
prognostic tests in breast carcinoma.
Results of numerous studies underline high
risk of recurrence of breast carcinoma in young
women, especially with breast- conserving
operations. According to Fowble ( 1997 ) , local
recurrence appeared in 40 % of patients younger
than 35 years and only in 13 % of patients
above 50 years during 4.5 years of follow-up.
Local recurrence results in the dissemination of
tumoral process in 20–40 % of cases.
The risk of cancer recurrence is higher in the
fi rst 5 years. Nevertheless, it exists within 15–20
years after surgery.
Some clinical features in fl uence the rate of
recurrences of breast carcinoma. The incidence
of local recurrences corresponds with the size of
primary tumor and its local extension. Lobular
breast carcinoma is quite often associated with
local recurrence. It may be the consequence of
high incidence of multicentric growth, frequent
bilateral location, clinically latent affection of
lymph nodes, and positive edge of resection in
greater number of cases. Meanwhile, some retrospective studies did not reveal any signi fi cant
difference in long-term results after different
types of surgeries in patients with invasive lobular carcinoma.
Multicentric growth of breast tumor is associated with increased incidence of recurrence.
Many studies demonstrated that the rate of local
recurrence increases in patients with metastases
in lymph nodes correlates with their number.
Routine US is an affordable method of early
detection of the recurrence of breast carcinoma
and its regional and remote metastases ( Solbiati
and Rissato 1995 ; Zabolotskaya and Zabolotsky
1997 ; Sinyukova and Sholokhov 2010 ; Sencha
et al. 2011 ) . Complex use of standard and new
A.N. Sencha et al., Breast Ultrasound,
DOI 10.1007/978-3-642-36502-7_12, © Springer-Verlag Berlin Heidelberg 2013
243
244
12 Recurrent Breast Cancer
US technologies permits to supervise the ef fi cacy
of treatment (Sinyukova and Sholokhov 2010 ;
Evseeva et al. 2011 ) .
However, interpretation of US images is
dif fi cult. It especially concerns the examination
of the patients operated for breast cancer or after
radiation therapy. The dif fi culties arise due to frequent fi brosis within the breast and anterior thoracic wall. It signi fi cantly complicates early
detection and differential diagnosis of carcinoma
recurrence in the region of primary surgery.
Local recurrence of breast carcinoma in the
region of radical resection or mastectomy usually
exhibits the following US features (Sencha et al.
2011 ) (Fig.
12.1 ):
Solid lesion •
Size of 1–2 cm •
Decreased echodensity •
Homogeneous structure •
Irregular or roundish shape •
Rough borders •
Indistinct contours •
Fig. 12.1 Status after
radical breast resection.
Recurrent breast carcinoma.
Sonograms. Grayscale US,
PDI, multislice view,
and US elastography
24512 Recurrent Breast Cancer
Fig. 12.1 (continued)
246
12 Recurrent Breast Cancer
Fig. 12.1 (continued)
24712 Recurrent Breast Cancer
Fig. 12.1 (continued)
248
Fig. 12.2 Status after
mammoplasty. Recurrent
breast carcinoma.
Grayscale US
12 Recurrent Breast Cancer
Intranodular blood fl ow pattern in CDI, PDI, •
and3DPD
Intensive hard (blue) staining with US •
elastography
The recurrences of breast carcinoma after
radical mastectomy arise more often in postoperative scar. Alternatively, recurrence after breastconserving surgery is usually not connected to
the scar ( Vtorushin 2012 ). Recurrence appears
often out of postoperative scar in the cases of
expressed in fl ammatory in fi ltration of the stroma
of primary neoplasm. According to Sinyukova
and Sholokhov ( 2010 ) , the recurrence in patients
after radical mastectomy located in 78 % of cases
in subcutaneous fat and in 18 % in the muscular
layer of anterior thoracic wall in the region of primary surgery. Only 57 % of patients had recurrent tumor in the depth of postoperative scar. The
recurrences, which arose in the region of radical
resection, located within the postoperative scar in
66 % of cases and in the breast tissue in 32 %
(Sinyukova and Sholokhov 2010 ) .
US differentiation of recurrent breast tumors
and other lesions in the presence of implants or gel
fragments requires special attention. Shumakova
et al. ( 2011 ) reported the incidence of breast carcinoma in 1.1 % and fi broadenoma in 3.5 % of
patients with silicone implants (Fig. 12.2 ).
24912 Recurrent Breast Cancer
Any surgical intervention may be accompanied
by oleogranuloma or adipose necrosis in late
postoperative term (3–6 months and later after
surgery). They arise as a reaction to the injury
during the operation. According to Sinyukova
and Sholokhov ( 2010 ) , lipogranulomas constitute
21 % of all lesions in the region of surgery.
Lipogranuloma can be detected along the
postoperative scars as a lesion of various echodensity (an-, hypo-, or hyperechoic) and size (more
often smaller than 10 mm) of roundish shape with
clear margins, homogeneous (or impure) echostructure, and avascular with CDI, PDI, and
3DPD (Fig.
12.3 ).
It is often accompanied with acoustic shadows, especially in cases of calci fi cations, which
are characteristic for lipogranulomas. Surrounding
tissues are usually intact or exhibit the signs of
lymphostasis. Adipose necrosis and lipogranuloma are dif fi cult to differentiae from recurrent
Fig. 12.3 Status after
radical breast resection.
Lipogranuloma. Sonograms.
Gray scale, PDI, 3D,
and US elastography
250
12 Recurrent Breast Cancer
Fig. 12.3 (continued)
Fig. 12.4 Status after radical
breast resection. Granuloma
( arrows ). Sonograms. Gray
scale and CDI
25112 Recurrent Breast Cancer
breast carcinoma. Recurrent tumors of small
sizes can have the same echodensity, echostructure, shape, contours, and vascularity.
Local fi brosis is characterized with decreased
echodensity (100 %) and layered structure
(93 %) and lipogranuloma with average or mixed
echodensity (29 and 45 % accordingly), heterogeneous structure (97 %), small calci fi ed incorporations (68 %), “egg shell” calci fi cation (32 %), and
fl uid component (29 %) (Figs. 12.4 and 12.5 ).
Acoustic shadows can be observed signi fi cantly
more often in patients with lipogranulomas
(87 %) than in recurrent tumors (2 %). Posterior
enhancement of US does not depend on the type
of the mentioned lesions. Lipogranulomas, local
fi brosis, and cystic lesions are usually avascular,
while recurrent breast carcinoma is vascularized
in CDI, PDI, and 3DPD in 83 % of cases.