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Applied Aspects ofBreast Imaging

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inOncoplasty andReconstruction

KrithikaRangarajan, SanjayThulkar, andS.V.S.Deo

2.1 Basics ofBreast Cancer Imaging: Work-Up ofPatient withSuspected Breast Cancer

The workhorse of imaging for breast pathologies is mammography. Mammography is the only modality that has been shown to reduce the mortality from breast cancer owing to early detection [1]. Typically, patients being considered for breast conservation surgery would already have a mammogram, which may have been performed for screening or for evaluation of breast related complaints. Since mammography represents a 3-dimensional structure (the breast) in a 2- dimensional format, signicant tissue overlap may occur. In order to minimise the tissue overlap, compression of breast tissue is usually performed. Mammography is usually performed in 2 views: mediolateral oblique (MLO) and craniocaudal views (CC) where the breast is compressed from side to side (for MLO) or from top to bottom (for CC) (Fig.2.1). Overlap of normal broglandular tissue poses a signicant problem in interpretation of mammograms, often overlapping normal broglandular tissue may falsely give an impression of

K. Rangarajan · S. Thulkar (*) Department of Radiology, BRA-IRCH, AIIMS, New Delhi, India

S. V. S. Deo Department of Surgical Oncology, BRA-IRCH, AIIMS, New Delhi, India

a space occupying lesion within the breast. Digital breast tomosynthesis (DBT) involves a quasi 3D representation of the breast, where we can scroll mammography images from the lateral to medial side (on MLO view) and cranio-caudally (on CC view). Since it helps to reduce tissue overlap, it has been shown to be of particular value at characterisation of masses in dense breasts [2], as well as detecting additional lesions [3].

Mammographic breast density is an important factor which determines the sensitivity of mammography. Breast density is determined by the amount and distribution of broglandular tissue in comparison to fat in the breast. While fat is radiolucent (and therefore black, in simple words), broglandular tissue is radio-opaque. Thus the higher the amount of broglandular tissue in relation to fat, the more mammographically “dense” the breast is. Dense broglandular tissue tends to obscure the presence of cancers (which are also radio-opaque on mammograms). In addition, it has also been shown that mammographic density is also an independent risk factor for the development of cancer in the breast [4]. Due to the importance of breast density, every radiology report contains a density grading of the breast, as mandated by the American College of Radiology (ACR). This density grading ranges from ACR A (almost completely fatty) to ACR D (containing 75–100% broglandular tissue). This attains particular signicance in the context of oncoplastic surgery, as detailed below.

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Fig. 2.1 (a) MLO image of left breast of a patient with a breast lump, (b) a tomosynthesis section of the same breast shows not 1, but 2 spiculated masses (arrows), s/o

Ultrasonography (USG) of the breast is often complementary to mammography and is particularly of value in dense breasts. While masses get obscured due to dense broglandular tissue on mammography, the margins and shape of the mass can be well characterised on ultrasonography. USG however is highly operator dependent, and if used as the sole modality has been shown to have poor sensitivity and specicity for cancer detection [5]. However it offers several advantages such as ability to image real time (which makes it invaluable for guiding breast biopsies) and lack of radiation exposure. Since there is no ionising radiation involved in USG, it is an invaluable tool for young patients. Young patients (typically under the age of 35) in whom the breast tissue is more radiosensitive as well as tends to be more mammographically dense, USG may be the primary modality for evaluation.

Once a lesion has been detected on mammogram or USG, certain features help the radiologist characterise the lesion. These typically involve factors such as density, shape, margins

multifocal cancers, (c) CC image of mammogram of another patient shows high density lesions scattered throughout the breast, multicentric cancer

of a mass, and number, size and distribution for microcalcication. Based on their assessment, a standard radiology report would give a BIRADS classication along with a management recommendation, as dened by the American College of Radiology. The ACRBIRADS lexicon is presented in Table 2.1 for easy reference [6].

Once a BIRADS category has been assigned, in general BIRADS 4 and above lesions require a biopsy. If the lesion detected on mammogram is visible on USG, USG guided biopsy is preferred as the biopsy gun and lesion can be seen real time, therefore tends to be a faster and more comfortable process. Lesions not seen on USG may be targeted with mammography, this is called a stereotactic biopsy. In general biopsy is performed with a 14 G biopsy gun. It is generally ensured that atleast 3–4 cores are taken from within the lesion, in order to ensure adequate sampling. In case of a signicant discord between the radiological opinion and pathology report, a biopsy may need to be repeated.

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Table 2.1 BIRADS categories to assess possibility of malignancy

Category Assessment 0 Assessment is incomplete 1 Normal 2 Benign nding(s), no follow-up required 3 Probably benign nding, 6 monthly

follow-up advised for 2years

4 Suspicious abnormality—biopsy

Should be considered Optional subdivisions: 4A: Finding needing intervention with a low suspicion for malignancy 4B: Lesions with an intermediate suspicion of malignancy 4C: Findings of moderate concern, but

not classic for malignancy 5 Highly suggestive of malignancy 6 Known biopsy-proven malignancy

2.2 Applied Aspects ofBreast Imaging Issues Pertaining toBCS

In this section, we discuss important imaging factors required to achieve optimal oncological outcome. BCS entails complete excision of the tumour with an adequate tumour free margin. Thus the aim of imaging the patient should be to dene exactly the site and size of a malignancy, excluding multifocality and multicentricity, as well as excluding possible presence of axillary, internal mammary nodes and distant metastasis. In addition, for non-palpable lesions, imaging may help localising these lesions for removal.

(a) Multicentricity and multifocality

Breast cancer is called “multifocal” when more than 1 distinct focus of cancer exists within the same quadrant, and “multicentric” when multiple cancers exist in different quadrants of the breast [7]. Pre-operative imaging should recognise multifocality and multicentricity in order to adequately assess feasibility of BCS and need for oncoplasty.

In this context, we discuss the role of preoperative MRI prior to BCS.MRI has a controversial role to play in breast imaging. While it is clearly demonstrated that MRI

does help in pick-up of additional lesions, it is not clear if this additional pick up affords any survival benet to the patient [8, 9]. This is largely because it is believed that many of these smaller lesions could potentially have been taken care of by chemoradiotherapy, thus MRI may contribute to converting BCS to MRM unnecessarily in many patients [10]. In addition, given the extremely high sensitivity of MRI, and relatively low specicity, many of the detected lesions may not even harbour malignancy. There is little or no evidence in large randomised control trials (RCT) to suggest that MRI reduces the resurgery rates of such patients.

MRI however has particular value in demonstrating pectoral muscle involvement. Abnormal enhancement in the pectoralis major muscle is shown to have 100% sensitivity as well as specicity in determining pectoral muscle involvement. It is also particularly helpful in demonstrating residual tumour in patients who have undergone neoadjuvant chemotherapy [11]. In fact, a recent study has shown that patients who have complete remission on MRI may not eventually require completion surgery (ref).

Thus MRI is not suggested routinely for all patients undergoing BCS, but may be useful in those who undergo NACT, and those with suspected chest wall involvement. This is particularly important in a country like India, where MRI is not readily accessible and is expensive. It is suggested that MRI be performed only in centres who have capability of MRI guided biopsy, as often lesions detected by MRI may not be found on targeted USG [12].

(b) Localisation of non-palpable lesions

Radiological localisation may be invaluable in very small, nonpalpable lesions [13]. Some methods of such localisation are briey discussed below.

Breast clips are generally inserted prior to neoadjuvant chemotherapy, where it is anticipated that the lesion may reduce signicantly in size or even disappear completely after neo-adjuvant chemotherapy. It

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Fig. 2.2 (a) MLO view of mammogram shows a clip placed into a lesion in the upper quadrant of the breast. (b) MLO view of the same patient after 3 cycles of chemotherapy shows the breast clip, though the mass is barely perceptible on mammography. (c) CC view of a patient

can also be inserted in lesions which are so small, that they may disappear post-biopsy. This is particularly of vacuum assisted biopsies, a clip is generally deployed in the same

with a non-palpable breast mass. A wire has been placed into the mass on the morning of surgery. (d) Specimen mammogram of the same patient as (c) after removal of the mass with the guidance of the wire

2.3 Oncoplasty, Reconstruction: Pre-operative, Postoperative, andFollow-Up Issues

sitting after the biopsy procedure. Breast clip insertion may be guided by mammography or ultrasonography.

Wire localisation of breast lesions is per-

In this section we discuss pre-, intra-, and postoperative issues pertaining to the cosmesis aspect of the surgery.

formed for localising non-palpable lesions prior to surgery. The wire traverses from the skin and may pass through or adjacent to a lesion that a radiologist wants to ag. It may be inserted antero-posteriorly or parallel to the chest wall and may also be guided by ultrasonography or mammography. However, a wire stands a chance of displacement and therefore is generally performed only on the morning of the surgery (Fig.2.2).

Intra-operative ultrasound guidance can also help inlocalising the lesion and ensuring that excessive amount of breast tissue is not unnecessarily removed, over and above that required to achieve negative margins.

(a) Pre-op Issues

1. Assessment of volume of breast tissue and tumour

Assessment of breast volume is important in planning oncoplastic reconstruction. However no universally accepted technique exists for volumetry. Usually volumetric assessment is performed clinically. However studies estimate volume with the aid of mammography[14], CT scan [15], and MRI [16]. Measurement of tumour volume may also be performed by 3D ultrasound as well as MRI [17], both modalities have been found to be comparable to water displacement method. However, in routine practice imaging volum-

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etry is not performed prior to surgery, the assessment continues to be clinical.

2. Breast Density Assessment Mammographic breast density is an

important factor for anthropometry [18]. Fatty breasts (ACR A and B) are more prone to ap necrosis than breasts with more broglandular tissue.

3. Imaging for ap Flaps used for whole breast reconstruc-

tion may be pedicled TRAM aps (which use superior epigastric artery), or may be free aps, which involve microvascular surgery to anastomose the donor tissue to recipient vasculature. These aps are names after the supplying vessel and include the DIEP (deep inferior epigastric perforator) ap, supercial inferior epigastric perforator (SIEP or SIEA) ap, superior gluteal artery perforator (SGAP) ap, and inferior gluteal artery perforator (IGAP) ap. The DIEP and SIEP aps include only the abdominal skin and subcutaneous fat, do not include muscle [22]. Microvascular procedures are more difcult to perform and ensuring adequate blood supply can help minimise chances of post-operative necrosis in the ap. For breast oncoplasty with less morbidity, thoracodorsal artery (TDAP), lateral thoracic artery (LTAP), and intercostal artery perforator aps (LICAP, MICAP, and AICAP) are performed.

Pre-operative mapping of aps and their

blood supply has the potential to identify small perforator vessels and map out aberrant anatomy, thereby helping reduce blood loss during surgery and reduce operative time [19]. CT angiography [20] provides a global view of the vessels, while Doppler can trace the vessels and help mark on the surface. Computed tomographic (CT) angiography has become the method of choice for vascular mapping [21]. Due to excellent spatial resolution and multiplanar capability, CT has very high sensitivity (99.6%) and positive predictive value (99.6%) for the identication of clinically relevant perforating branches [22]. For evaluation of microvascu-

lar aps, CT gives high quality information on perforating vessel size, location within the ap, and intramuscular course. A central location of a vessel within a ap is associated with lower risk of necrosis. It also helps in assessing vessel hemodynamics using maximal enhancement as a marker [19]. For optimal selection of vessel with pre-operative CT angiography it has been suggested that supercial inferior epigastric vein and artery in an SIEA ap should exceed 1.5mm and 1 mm, respectively[23]. If not, in order to ensure adequate ap vascularization, the use of a deep inferior epigastric (DIEP) ap should be considered. Present day MR angiography has high spatial and temporal resolution and can provide a non-irradiating alternative to CT angiography [23]. The thoracoacromial trunk, lateral thoracic, internal thoracic and its branches and perforator branches of lateral mammary can be imaged and traced prior to reconstructive surgery for the TDAP, LTAP, and intercostal perforator arteries respectively.

(b) Intra-operative issues:

• Specimen imaging: Mammography of the tumour mass ensures adequate margin of resection. This is particularly useful for masses/calcications for which image guided localisation was performed. Markers in the form of sutures are usually placed to indicate the anatomical orientation of the specimen. In our institution, a long end of suture is placed to indicate lateral side of specimen, short suture to indicate superior side of specimen. The anterior side is indicated by presence of skin. Thus by taking these markings into account, we can place the specimen in a craniocaudal/mediolateral orientation to perform specimen mammography. This can then be compared with the corresponding pre-operative image to ensure complete resection (Fig.2.3).

• Doppler for tracing vessels: Intra- operative Doppler can be performed to trace vessels. However this has been seen to increase operative time. Doppler also

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Fig. 2.3 Intra-operative specimen mammogram. (a) Surgical specimen placed on mammography detector (b) The presence of the skin, long thread and short thread

suffers from limitations in delineating subfascial and intramuscular branches. Surface tracing for TDAP, LTAP, and intercostal perforators is described below.

– Thoracodorsal artery: Thoracodorsal

artery arises from subscapular artery, which is a branch of the third part of axillary artery (lateral to pectoralis minor). The thoracodorsal arises after origin of the circumex scapular artery from subscapular, divides into 2 branches at 45 degrees angulation. Perforators may arise from the main trunk or from the lateral branch. The rst perforator can be traced about 6–8cm below the posterior axillary fold. Subsequent perforators up to 3 of them arise inferior to this. Each perforating artery is accompanied by two venae comitans.

– Lateral thoracic artery: We can trace

the lateral thoracic (which arises from the second part of axillary artery) by scanning between the latissimus dorsi and the breast tissue. Perforators arising from the lateral thoracic artery are used for LTAP ap.

– Intercostal artery perforators: These

aps are named according to the region of the inframammary fold involved. The region is divided into 3: the medial portion supplied by medial intercostal perforators (MICAP ap), the middle segment supplied by anterior intercos-

indicating the anterior, lateral, and superior ends of the specimen. (c) Specimen mammogram conrming adequate margins

tal perforators (AICAP ap), and lateral segment by lateral intercostal perforators (LICAP ap) (Fig.2.4).

1. Normal imaging appearances: A recon- structed breast looks signicantly different from a native breast on imaging, and in order to pick up pathologies, one must rst be familiar with the normal imaging appearance of post-reconstruction breast.

(a) Prosthetic implant: Mammographic

surveillance after implant is performed to look for complications such as rupture and calcication, as well as to look for development of malignancy. One must be familiar with the normal contour of the implant in order to identify possible rupture [24]. The appearance of implant on MRI depends on whether the implant has silicone, saline, or both.

(b) Autologous implant: After recon-

struction with autologous tissue, the appearance of the breast is largely fatty. Only a sliver of muscle tissue is seen posteriorly. Surgical clips may be seen on mammography (Fig.2.5).

2. Benign ap related complications: Seromas, hematomas, fat necrosis, and brosis [25] are commonly seen after reconstruction. Oedema, trabecular thickening, and skin thickening are often seen in the rst 6 months after radiation therapy

ab cd

2 Applied Aspects ofBreast Imaging inOncoplasty andReconstruction

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Fig. 2.4 Schematic diagram showing the position and branching of major vessels

Fig. 2.5 (a) and (b) MLO and CC images of a patient who has undergone right breast reconstruction. The right breast shows only fat density without presence of bro-

and may reduce in many patients in 2–3 years following surgery. Fat necrosis occurs due to inadequate vascularization. The lesser the amount of fascia and muscle harvested, the more likely fat necrosis is. Appropriate pre-operative selection as described above may minimise the occurrence of fat necrosis. Fat necrosis can usually be identied easily on mammography with a lucent centre and smooth margins.

In case of breast implants, ruptures may be seen on mammography and MRI when it is an extracapsular rupture as a wavy

glandular tissue, unlike the left breast. (c) and (d) Mammographic and ultrasound appearance of a breast implant

contour of the implant. However intracapsular rupture can be detected only by MRI and USG. Implants are normally entirely anechoic on ultrasound. Intracapsular rupture of the implant is described as a stepladder pattern (Fig.2.6).

3. Imaging tumour recurrence: Mammographic appearance of a tumour recurrence may be similar to the primary tumour. Sometimes, however, they may look similar to fat necrosis, presenting a diagnostic dilemma. Ultrasound can help differentiate the 2. In the post-operative

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Fig. 2.6 (a) and (b) T1 and STIR images of a patient who had undergone BCS for left breast. Arrows show presence of fat necrosis. The signal intensity of the lesion follows that of fat (white in a) and fat-suppressed in (b). (c) shows

setting, ultrasound is more sensitive than mammography and may be useful in nding these tumours particularly in the extreme edges of the breast hidden to mammography. MRI can also demonstrate recurrences as irregular masses with early enhancement and delayed washout [19].

References

1. Ltd BPG.Review: mammography reduces breast cancer mortality rates. BMJ Evid-Based Med. 2003 Mar 1;8(2):45–5.

2. Rangarajan K, Hari S, Thulkar S, Sharma S, Srivastava A, Parshad R. Characterization of lesions in dense breasts: Does tomosynthesis help? Indian J Radiol Imaging. 2016, June;26(2):210–5.

3. Batohi B, Vinci V, Peacock C, et al. Comparison of MRI and digital breast tomosynthesis in the preoperative evaluation of multifocal breast cancer. Breast Cancer Res. 2015;17:P11. https://doi.org/10.1186/

bcr3773.

4. Boyd NF.Mammographic density and risk of breast cancer. Am Soc Clin Oncol Educ Book. 2013;

5. Geisel J, Raghu M, Hooley R. The role of ultrasound in breast cancer screening: the case for and against ultrasound. Semin Ultrasound CT MR. 2018 Feb;39(1):25–34.

6. Breast Imaging Reporting & Data System. Available from: https://www.acr.org/Clinical-Resources/ Reporting-and-Data-Systems/Bi-Rads

7. Neri A, Marrelli D, Megha T, et al. Clinical signicance of multifocal and multicentric breast cancers and choice of surgical treatment: a retrospective study on a series of 1158 cases. BMC Surg. 2015;15:1.

https://doi.org/10.1186/1471- 2482- 15- 1.

the USG appearance of a seroma, (d) mammogram of a patient post-BCS shows dystrophic calcication at the scar site

8. Turnbull L, Brown S, Harvey I, Olivier C, Drew P, Napp V, et al. Comparative effectiveness of MRI in breast cancer (COMICE) trial: a randomised controlled trial. Lancet Lond Engl. 2010 Feb 13;375(9714):563–71.

9. Peters NHGM, van Esser S, van den Bosch MAAJ, Storm RK, Plaisier PW, van Dalen T, etal. Preoperative MRI and surgical management in patients with nonpalpable breast cancer: The MONET– Randomised controlled trial. Eur J Cancer. 2011 Apr 1;47(6):879–86.

10. Houssami N, Turner R, Morrow M. Preoperative magnetic resonance imaging in breast cancer: metaanalysis of surgical outcomes. Ann Surg. 2013 Feb;257(2):249–55.

11. Morris EA, Schwartz LH, Drotman MB, Kim SJ, Tan LK, Liberman L, etal. Evaluation of pectoralis major muscle in patients with posterior breast tumors on breast MR images: early experience. Radiology. 2000 Jan;214(1):67–72.

12. Ong E.Preoperative imaging for breast conservation surgery—do we need more than conventional imaging for local disease assessment? Gland Surg. 2018 Dec;7(6):554–9.

13. Corsi F, Sorrentino L, Bossi D, Sartani A, Foschi D.Preoperative Localization and Surgical Margins in Conservative Breast Surgery. Int J Surg Oncol. 2013 Aug;5(2013):e793819.

14. Kalbhen CL, McGill JJ, Fendley PM, Corrigan KW, Angelats J. Mammographic determination of breast volume: comparing different methods. Am J Roentgenol. 1999 Dec 1;173(6):1643–9.

15. Erić M, Anderla A, Stefanović D, Drapšin M.Breast volume estimation from systematic series of CT scans using the Cavalieri principle and 3D reconstruction. Int J Surg. 2014 Sep 1;12(9):912–7.

16. Yoo A, Minn KW, Sik U. Jin magnetic resonance imaging-based volumetric analysis and its relationship to actual breast weight. Arch Plast Surg. 2013 May;40(3):203–8.

17. Lagendijk M, Vos EL, Ramlakhan KP, Verhoef C, Koning AHJ, van Lankeren W, etal. Breast and tumour volume measurements in breast cancer patients using

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3-D automated breast volume scanner images. World J Surg. 2018;42(7):2087–93.

18. Mokkapati PR, Gowda M, Deo S, Dhamija E, Thulkar S. Breast anthropometry—results of a prospective study among Indian breast cancer patients. Indian J Surg Oncol. 2020 Mar;11(1):28–34.

19. Pinel-Giroux FM, El Khoury MM, Trop I, Bernier C, David J, Lalonde L.Breast reconstruction: review of surgical methods and spectrum of imaging ndings. Radiogr Rev Publ Radiol Soc N Am Inc. 2013 Apr;33(2):435–53.

20. Lam DL, Mitsumori LM, Neligan PC, Warren BH, Shuman WP, Dubinsky TJ. Pre-operative CT angiography and three-dimensional image post processing for deep inferior epigastric perforator ap breast reconstructive surgery. Br J Radiol. 2012 Dec;85(1020):e1293–7.

21. Rozen WM, Phillips TJ, Ashton MW, Stella DL, Gibson RN, Taylor GI. Preoperative imaging for DIEA perforator flaps: a comparative study of computed tomographic angiography and

Doppler ultrasound. Plast Reconstr Surg. 2008 Jan;121(1):9–16.

22. Scott JR, Liu D, Said H, Neligan PC, Mathes DW. Computed tomographic angiography in planning abdomen-based microsurgical breast reconstruction: a comparison with color duplex ultrasound. Plast Reconstr Surg. 2010 Feb;125(2):446–53.

23. Margolis NE, Morley C, Lot P, Shaylor SD, Palestrant S, Moy L, Amy N. Melsaether Update on Imaging of the Postsurgical Breast. Radio Graphics. 2014;34(3):642–60.

24. Dershaw DD, Chaglassian TA. Mammography after prosthesis placement for augmentation or reconstructive mammoplasty. Radiology. 1989 Jan;170(1 Pt

1):69–74.

25. Devon RK, Rosen MA, Mies C, Orel SG. Breast reconstruction with a transverse rectus abdominis myocutaneous ap: spectrum of normal and abnormal MR imaging ndings. Radiogr Rev Publ Radiol Soc N Am Inc. 2004 Oct;24(5):1287–99.

Principles ofPlanning Incisions

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forBreast Oncoplasty andReconstruction

S.V.S.Deo, ManojGowda, BabulBansal, andP.Raghuram

3.1 General Principles ofIncision Planning forBreast Conservation Surgery andOncoplasty

Planning of incisions is a critical part of any surgical procedure, especially for breast surgery. With the introduction of several new surgical procedures, the importance of planning incisions has become extremely crucial in the eld of breast surgery [1]. The major objectives of planning a good incision include aesthetic placement of incision, provide adequate access for optimal cancer surgery, conform with the needs of reconstructive surgery, and leave behind minimal scar burden. Patients should be examined in sitting and supine positions and it is always recommended to keep the contralateral breast in the surgical eld as a reference point for cosmetic assessment during surgery.

Various factors can inuence incision planning in breast surgery eld. Patient related factors include built and body habitus, breast size, shape, degree of ptosis, and presence of previous surgical scars. Comorbidities such as obesity, smok-

S. V. S. Deo (*) · M. Gowda · B. Bansal Department of Surgical Oncology, AIIMS and NCI, New Delhi, India

P. Raghuram KIMS– USHALAKSHMI Centre for Breast Diseases, Secunderabad, India

ing, diabetes, and coronary artery disease should be accounted for as these patients have a higher risk of ap necrosis. Tumor related factors include number, size, location, distance from NAC, skin involvement, or proximity to skin.

The tumor versus breast ratio is a critical domain of assessment while planning breast conservation surgery and oncoplasty. Personality traits and expectations of the patient should also be considered while planning complex surgeries. Expectations of outcomes should be realistic to achieve optimal patient satisfaction.

Variety of oncoplastic techniques are described depending upon the quadrant in which the tumor is located and its proximity to NAC (Fig.3.1). A part of skin should be included in the incision in case the tumor is adherent or inltrating the skin (Fig.3.2). Prior surgical scars should be incorporated (Fig.3.3) in denitive surgery. In case the tumor is multicentric, incision should be carefully planned to facilitate optimal access for complete removal [2].

Incisions should be designed parallel to Langer’s line to minimize scar contracture (Fig.3.4) [3]. Circum-areolar or curvilinear incisions are preferred for tumors located in the upper half of the breast and radial incisions should be avoided. Radial incisions, reduction mammoplasty, and inverted “T” or triangular incisions are advisable for tumors in lower half. A better cosmesis may be achieved by making an incision in natural skin creases such as inframa-

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