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35
Differentiation of Benign and Malignant Local Tumor Recurrence After Lumpectomy
D. David Dershaw1 Beryl McCormick2 Louise Cox3 Michael P. Osborne3
period, 28 women who had been treated conservatively for breast 29 reexcisions of the lumpectomy site because of suspicion of a recurrent malignant tumor. Biopsy results were benign in 19 cases and malignant in 10 cases. Sixteen of the 19 benign tumors had developed within 2 years after therapy. In 16 benign cases, a palpable lump developed at the scar and was found on biopsy to be fat necrosis During
a 5-year
carcinoma
had
or fibrosis.
Seven
of these
cases
had
normal
mammographic
findings.
Three
women
with abnormal mammographic findings but a normal breast examination had punctate microcalcifications develop at the scar; these were due to fibrosis in two and sclerosing adenosis in the other. Of the 10 malignant recurrent tumors, seven were palpable, four of which
also
were
identifiable
by mammography.
Of seven
mammographically
identifi-
able recurrent tumors at the surgical site, four were palpable. Mammographic findings were a single mass in two cases, multiple masses in one, microcalcifications in three, and a mass with microcalcifications in one. Malignant microcalcifications were all linear, irregular,
and
in one
case
branching.
Mean
time
to recurrence
in these
10 women
was
3 years. This
experience
suggests
that
benign
disease
usually
years after the original therapy and when palpable raphy. AJR
When
microcalcifications
155:35-38,
July
After conservative
represent
be malignant, a dysplastic
In this October 31 , 1989; accepted vision February 26, 1990. Received
I
Department
Sloan-Kettering
of
Imaging,
scar
within
2
on mammog-
punctate.
careful clinical and mammo-
is indicated to detect new or recurrent tumor. If develop at the lumpectomy site, they may not
but may be a sequela
of surgery
in the breast. Fibrosis, adenosis can mimic new tumor. study, we sought to establish new or recurrent
tumor
and irradiation
fat necrosis, criteria
benign
or
lymph
for differentiating
in the conservatively
treated
breast.
after reMemorial
Methods
and Materials
Cancer Center and Comell Univer-
sity Medical
College,
NY 10021. Dershaw.
Address
2
Medical
from
usually
process
retrospective
disease
are
for breast carcinoma,
of both breasts or calcifications
nodes, and sclerosing benign
they
at the
1990
treatment
graphic monitoring a suspicious mass
necessarily
do occur,
occurs
may not show changes
1 275 York Ave., reprint requests
of Radiation
Oncology,
New York, to D. D.
Memorial
Sloan-Kettering Cancer Center and Cornell University Medical College, 1275 York Ave., New York, NY 10021. 3Breast Service, morial Sloan-Kettering
University Medical York, NY 10021.
Department of Surgery, MeCancer Center and Comell College, 1275 York Ave., New
0361 -803X/90/1 551-0035 © American Roentgen Ray Society
Records of the Breast Service, Department of Surgery, from February 1 984 to February 1989 were reviewed retrospectively to identify 37 women who had undergone 39 biopsies of a previously
irradiated
breast.
Nineteen
women
were
found
to have benign
recurrent
tumor.
Eighteen women in whom the benign recurrent tumor was at the lumpectomy site were included in the study group. Eighteen women were found to have malignant recurrent tumor. Ten women in whom the malignant tumor recurred at the site of the lumpectomy scar were included
in the study
group.
All women had mammograms performed on dedicated mammography equipment and physical examination of the breast by a physician experienced in treating breast disease. These studies were done as routine posttherapy follow-up after conservative treatment of breast cancer. All women underwent wide, local excision of the initial primary carcinoma, and in all but one patient
this was followed
with definitive
breast
irradiation.
36
DERSHAW
In the
benign
recurrence
group,
the
women’s
ages
at the
time
of
32 to 82 years (mean, 55 years). The initial biopsy revealed the following: 14 cases of infiltrating duct carcinoma (IFDC), two of colloid carcinoma, one of mixed IFDC with infiltrating lobular carcinoma (IFLC), and one unspecified type of their
original
cancer
Downloaded from www.ajronline.org by 117.245.43.10 on 10/08/15 from IP address 117.245.43.10. Copyright ARRS. For personal use only; all rights reserved
adenocarcinoma. in in
therapy
Disease
ranged
from
was in the right breast
in 1 1 patients
and
the left breast in seven. The original malignant tumor was located the upper outer quadrant in 12 women, the upper inner quadrant
in five women,
and the lower
outer
quadrant
in one woman.
In the malignant recurrence group, the women’s ages at the time of their original therapy ranged from 35 to 74 years (mean, 50 years). In seven women, the histologic findings from the original malignant tumor and the recurrent tumor were identical. In these seven women, the tumor types were IFDC in four, IFDC with duct carcinoma in situ (DCIS) in one, lobular carcinoma in situ (LCIS) and IFLC in one, and DCIS in one. In three cases, the histologic findings for the original and the recurrent tumor were different. One case of IFDC recurred as IFDC with DCIS, one case of medullary carcinoma recurred as IFDC and DCIS, and one case of IFLC and LCIS recurred as DCIS. Disease was on the right side in six patients and on the left side in four. Tumor was located in the upper outer quadrant in eight and the lower outer quadrant in two women.
In the 1 8 women with new, benign disease at the lumpectomy site, development of a palpable mammographic abnormality occurred within 3 years of completion of therapy in all but one patient in whom an area of nodularity was found on both palpation and mammography 10 years after therapy. Ten women had biopsies done 1 year after therapy, six underwent biopsy 2 years later, and two 3 years later, including one woman who had benign disease diagnosed on two biopsies performed 2 and 3 years after her cancer treatment.
Of these same women, in 1 6 cases (1 5 patients) a palpable lump was present, and nine of these lumps showed a corre2). Seven
AJR:155,
July 1990
A mammographic abnormality without palpable findings prompted biopsy in three women with benign findings. In all three, microcalcifications were present at the lumpectomy site. Biopsy in these women showed fat necrosis with fibrosis and calcifications consistent with radiation effect in one, sclerosing
adenosis
and LCIS
in another,
and periductal
fibrosis
with microcalcifications and LCIS in the third (Fig. 3). Both women with LCIS had a component of lobular carcinoma in their original lumpectomy specimen. These women are included in the benign group because the mammographic findings prompting biopsy were due to a benign process, and because LCIS as a distinct entity has a controversial position as a malignant tumor. Microcalcifications developed within 2 years of the completion of cancer therapy in all three women. The only patient in whom microcalcifications not related to fibrosis developed did not have radiation therapy after her original surgery for carcinoma. In the 10 women with malignant tumor recurrence at the lumpectomy site, the mean time to recurrence was 3 years. Four of these malignant tumors recurred 2 years after the original treatment, two at 6 years, and one tumor each recurred at 1 3, 4, and 5 years after the original therapy. In seven women, malignant tumor recurred as a palpable mass; three women had normal findings on physical examination. In women with a palpable mass, mammography showed calcifications in one and a noncalcifled mass in three, including one woman with a single palpable mass whose ,
Results
sponding
ET AL.
noncalcified
women
mass
on the mammogram
with a palpable
mass
(Figs.
1 and
had no mammo-
graphic abnormality. The pathologic findings were fibrosis eight cases, fat necrosis in seven, and granuloma in one.
in
mammogram
showed
two masses,
both of which
were
found
to be malignant on biopsy (Fig. 4). Three women with palpable recurrent tumors had normal mammographic findings. Mammography
showed
abnormality
in seven
of the
10
women with malignant recurrent tumor: a single mass in two women, multiple masses in one, microcalcifications in three, and a mass with microcalcifications in one. All malignant calcifications were linear and irregular, and these were branching in one case (Fig. 5). No rounded, punctate calcifications, which
were
characteristic
were seen in women
of the
in whom
benign
recurrence
malignant
tumors
group,
recurred.
Fig. 1.-A and B, Coned mediolateral mammograms of surgical site in right breast of a 52year-old woman 2 (A) and 3 (B) years after surgery and irradiation. New fullness (arrows) was present on mammography and physical cxamination at 3 years. On biopsy, fat necrosis was found.
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AJR:155,
LOCAL
July 1990
TUMOR
RECURRENCE
Fig. 2.-A, Mediolateral xeromammogram of a 58-year-old woman shows breast mass. Biopsy revealed infiltrating duct cancer, and patient was treated with lumpectomy and irradiation. B, Mediolateral mammogram of same woman 2 years later shows new palpable, subareolar mass at site of surgery. No interval films were available. On biopsy, only fibrosis was found.
AFTER
‘
.,
LUMPECTOMY
37
-. -
.,
-:
‘.;‘:.#{149}-
.d,
.,t
Fig. 3.-Magnified(x3) mogram of a 67-year-old calcifications (arrowheads)
photograph of a mamwoman shows microthat developed 2 years after an infiltrating duct carcinoma was excised from this site, followed by breast irradiation. Histologic examination of microcalcifications revealed periductal fibrosis and lobular carcinema in situ.
Physical malignant
examination recurrent
failed tumors
to detect detected
with
.
-
A
B
Fig. 4.-Craniocaudal mammogram of 44year-old woman 2 years after irradiation for infiltrating duct carcinoma shows two masses (ar. rowheads) due to recurrent infiltrating duct carcinoma.
Fig. 5.-Magnified (x3) photograph shows microcalcifications developing at original tumor
three
of the seven
mammography.
After treatment of primary breast carcinoma by local excision and breast irradiation, follow-up mammography shows an immediate pattern of ill-defined density representing postsurgical alteration at the operative site, as well as diffuse increase in breast density, coarsening of the breast stroma, and thickening of the skin of the breast reflecting acute irradiation change. These findings are most pronounced in the first 12 months and diminish or disappear in the next 2 years [1 -4]. A mammographically identifiable scar, seen as a localized mass at the site of surgery and often directly connected with localized changes in the overlying skin, has been reported in 25% of patients [3]. Mammographic and physical findings of decreasing density at the site of tumor excision
cinoma.
after
These
tions were noma.
due
treatment
irregular,
for Intraductal
linear
to recurrent
car-
microcalcifica-
intraductal
carci-
normally evolve during the subsequent 2 years. The presence of a new or enlarging mass or new fine calcifications suggests recurrent
Discussion
site 2 years
tumor
at the site of previous
resection.
Chaudary et al. [5] have reported 1 7 patients in whom a new lump developed in breasts treated conservatively for carcinoma.
Ten
of the
lumps
were
found
though it was not possible to differentiate nant disease on physical examination. masses that developed, seven were due two to foreign body granuloma formation; case, only scar tissue was found. On benign
masses
were
to be benign,
free of microcalcifications.
cases in that series with a new mass containing cations,
malignant
tumor
was
present
al-
benign from maligOf the 1 0 benign to fat necrosis and in the remaining mammography, all In the three
microcalcifi-
in all. Rostom
and El-
Sayed [6] have reported two additional cases of fat necrosis presenting as a new lump at the site of previous lumpectomy after breast irradiation. Both of these masses developed at the site of surgical scar.
DERSHAW
38
In our group,
in 1 5 of 1 7 patients
with
new lump without microcalcifications previous tumor excision on follow-up seven
women,
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Conversely,
mammography
benign
disease
a
was found at the site of physical examination; in
failed to show
only three of 1 0 women
any abnormality.
with a developing
malig-
nant tumor at the scar had normal mammographic findings, and as in previous reports, the single mass with microcalcifi-
cations was malignant.
alteration
in physical findings
at the site of previous tumor mandates mammographic findings may be a hopeful may be due to fibrosis or fat necrosis.
Although
biopsy, unchanged sign that the mass
New microcalcifications
in a breast
(80%)
as opposed
of five that developed
treated
to four malignant
in a quadrant
other
for
tumors
than that of
the original tumor. In another series, six of 1 1 women
in whom
microcalcifications developed in the previously treated breast within 5 years of therapy were found to have benign disease, including fibrosis and atrophy [3]. These calcifications ob-
viously coarse,
are related to the previous classically benign calcifications
breast therapy. More frequently are seen in
irradiated breasts. These may be linear, rounded, or crossshaped calcifications and are readily differentiated from those fine, irregular calcifications that suggest new or recurrent tumor [9-1 1 ]. Just as formation of these coarse calcifications may be related to irradiation, fine dystrophic calcifications also may result from therapy [9]. When their pattern is compared with the pattern of calcifications seen in women who had
recurrent
tumor,
irregular
linear or branching
microcalcifica-
tions appear to herald recurrence whereas smoother calcifications are associated with change.
The time elapsed
between
completion
AJR:155,
veloping at the surgical site within 1 year of benign in 10 of 1 1 women in this study, and to biopsy for benign disease was shorter than nant disease (2 vs 3 years). This longer period
treatment was the mean time that for maligfor recurrence
of malignant
punctate, dystrophic
of therapy
for the
original tumor and appearance of changes on the mammogram or physical examination also may be helpful in differentiating benign from recurrent malignant tumors. Disease de-
tumor
corresponds
to a mean
recurrence
July 1990
time
at the site of the original tumor of 34 months reported by Stotter et al. [12]. In their series, relapse elsewhere in the breast had an even longer mean recurrence time of 69 months. The development of disease at the site of the original tumor within a year or two of completion of therapy suggests a benign
previously
carcinoma may be thought to represent recurrent or new breast carcinoma, but these calcifications are frequently benign. Stomper et al. [7] have reported that three of six women who had been treated conservatively for breast carcinoma with limited surgery and irradiation and in whom suspicious microcalcifications developed had benign disease. In a report of 19 patients with microcalcifications developing in the same clinical setting, Solin et al. [8] found eight patients (42%) had benign disease. However, when microcalcifications developed in the same quadrant as the original tumor, only seven (54%)
of 13 were malignant
ET AL.
process.
Although
we have found
some
differences
in those women with benign, as opposed to malignant, recurrent tumors, abnormal findings on physical examination and suspicious mammographic changes still mandate biopsy in this select group of patients.
REFERENCES 1 . Bloomer WD, Berenberg AL, Weissman BN. Mammography tively irradiated breast. Radiology 1976;1 18:425-428
2.
Libshitz HI, Montague ED, Paulus DD Jr. Skin tically irradiated breast. AiR 1978;130:345-347
thickness
of the definiin the therapeu-
3. Dershaw DD, Shank B, Reisinger S. Mammographic findings after breast cancer treatment with local excision and definitive irradiation. Radiology 1987;164:455-461 4. Berenberg AL, Levene
the postirradiated vative
MB, Tonnesen
GL. Mammographic
evaluation
of
breast. In: Hams JR, Hellman 5, Silen w, eds. Conser-
management
of breast
cancer:
new surgical
and radiotherapeutic
Philadelphia: Lippincott, 1983:265-272 5. Chaudary MM, Grilling A, Girling 5, Habib F, Millis RR, Hayward JL. New lumps in the breast following conservation treatment for early breast techniques.
cancer.
Breast
Cancer
1988;1 1 :51-58
6. Rostom AY, El-Sayed ME. Fat necrosis of the breast: an unusual complication of lumpectomy and radiotherapy in breast cancer. Clln Radiol 1987;38:31
7. Stomper PC, Recht A, Berenberg AL, Jochelson MS, Hams JR. Mammographic detection of recurrent cancer in the irradiated breast. AJR 1987;148:39-43
8. Solin U, Fowble BL, Troupin RH, Goodman RL. Biopsy results of new calcifications in the postirradiated breast. Cancer 1989;63: 1956-1961 9. Libshitz HI, Montague ED, Paulus DD. Calcifications and the therapeutically irradiated breast. AJR 1977;128: 1021-1 025 10. Buckley JH, Roebuck EJ. Mammographic changes following radiotherapy. Br J Radiol
1986;59:337-344
1 1 . Harris KM, Costa-Greco MA, Baratz AB, Britton CA, llkhanipour ZS, Ganott MA. The mammographic features of the postlumpectomy, postirradiation breast. RadioGraphics 1989;9:253-268 12. Stotter AT, McNeese MD, Ames FC, Oswald MJ, Ellerbrock NA. Predicting the rate and extent of locoregional failure after breast conservation therapy for early breast cancer. Cancer 1989;64 :2217-2225
35
Differentiation of Benign and Malignant Local Tumor Recurrence After Lumpectomy
D. David Dershaw1 Beryl McCormick2 Louise Cox3 Michael P. Osborne3
period, 28 women who had been treated conservatively for breast 29 reexcisions of the lumpectomy site because of suspicion of a recurrent malignant tumor. Biopsy results were benign in 19 cases and malignant in 10 cases. Sixteen of the 19 benign tumors had developed within 2 years after therapy. In 16 benign cases, a palpable lump developed at the scar and was found on biopsy to be fat necrosis During
a 5-year
carcinoma
had
or fibrosis.
Seven
of these
cases
had
normal
mammographic
findings.
Three
women
with abnormal mammographic findings but a normal breast examination had punctate microcalcifications develop at the scar; these were due to fibrosis in two and sclerosing adenosis in the other. Of the 10 malignant recurrent tumors, seven were palpable, four of which
also
were
identifiable
by mammography.
Of seven
mammographically
identifi-
able recurrent tumors at the surgical site, four were palpable. Mammographic findings were a single mass in two cases, multiple masses in one, microcalcifications in three, and a mass with microcalcifications in one. Malignant microcalcifications were all linear, irregular,
and
in one
case
branching.
Mean
time
to recurrence
in these
10 women
was
3 years. This
experience
suggests
that
benign
disease
usually
years after the original therapy and when palpable raphy. AJR
When
microcalcifications
155:35-38,
July
After conservative
represent
be malignant, a dysplastic
In this October 31 , 1989; accepted vision February 26, 1990. Received
I
Department
Sloan-Kettering
of
Imaging,
scar
within
2
on mammog-
punctate.
careful clinical and mammo-
is indicated to detect new or recurrent tumor. If develop at the lumpectomy site, they may not
but may be a sequela
of surgery
in the breast. Fibrosis, adenosis can mimic new tumor. study, we sought to establish new or recurrent
tumor
and irradiation
fat necrosis, criteria
benign
or
lymph
for differentiating
in the conservatively
treated
breast.
after reMemorial
Methods
and Materials
Cancer Center and Comell Univer-
sity Medical
College,
NY 10021. Dershaw.
Address
2
Medical
from
usually
process
retrospective
disease
are
for breast carcinoma,
of both breasts or calcifications
nodes, and sclerosing benign
they
at the
1990
treatment
graphic monitoring a suspicious mass
necessarily
do occur,
occurs
may not show changes
1 275 York Ave., reprint requests
of Radiation
Oncology,
New York, to D. D.
Memorial
Sloan-Kettering Cancer Center and Cornell University Medical College, 1275 York Ave., New York, NY 10021. 3Breast Service, morial Sloan-Kettering
University Medical York, NY 10021.
Department of Surgery, MeCancer Center and Comell College, 1275 York Ave., New
0361 -803X/90/1 551-0035 © American Roentgen Ray Society
Records of the Breast Service, Department of Surgery, from February 1 984 to February 1989 were reviewed retrospectively to identify 37 women who had undergone 39 biopsies of a previously
irradiated
breast.
Nineteen
women
were
found
to have benign
recurrent
tumor.
Eighteen women in whom the benign recurrent tumor was at the lumpectomy site were included in the study group. Eighteen women were found to have malignant recurrent tumor. Ten women in whom the malignant tumor recurred at the site of the lumpectomy scar were included
in the study
group.
All women had mammograms performed on dedicated mammography equipment and physical examination of the breast by a physician experienced in treating breast disease. These studies were done as routine posttherapy follow-up after conservative treatment of breast cancer. All women underwent wide, local excision of the initial primary carcinoma, and in all but one patient
this was followed
with definitive
breast
irradiation.
36
DERSHAW
In the
benign
recurrence
group,
the
women’s
ages
at the
time
of
32 to 82 years (mean, 55 years). The initial biopsy revealed the following: 14 cases of infiltrating duct carcinoma (IFDC), two of colloid carcinoma, one of mixed IFDC with infiltrating lobular carcinoma (IFLC), and one unspecified type of their
original
cancer
Downloaded from www.ajronline.org by 117.245.43.10 on 10/08/15 from IP address 117.245.43.10. Copyright ARRS. For personal use only; all rights reserved
adenocarcinoma. in in
therapy
Disease
ranged
from
was in the right breast
in 1 1 patients
and
the left breast in seven. The original malignant tumor was located the upper outer quadrant in 12 women, the upper inner quadrant
in five women,
and the lower
outer
quadrant
in one woman.
In the malignant recurrence group, the women’s ages at the time of their original therapy ranged from 35 to 74 years (mean, 50 years). In seven women, the histologic findings from the original malignant tumor and the recurrent tumor were identical. In these seven women, the tumor types were IFDC in four, IFDC with duct carcinoma in situ (DCIS) in one, lobular carcinoma in situ (LCIS) and IFLC in one, and DCIS in one. In three cases, the histologic findings for the original and the recurrent tumor were different. One case of IFDC recurred as IFDC with DCIS, one case of medullary carcinoma recurred as IFDC and DCIS, and one case of IFLC and LCIS recurred as DCIS. Disease was on the right side in six patients and on the left side in four. Tumor was located in the upper outer quadrant in eight and the lower outer quadrant in two women.
In the 1 8 women with new, benign disease at the lumpectomy site, development of a palpable mammographic abnormality occurred within 3 years of completion of therapy in all but one patient in whom an area of nodularity was found on both palpation and mammography 10 years after therapy. Ten women had biopsies done 1 year after therapy, six underwent biopsy 2 years later, and two 3 years later, including one woman who had benign disease diagnosed on two biopsies performed 2 and 3 years after her cancer treatment.
Of these same women, in 1 6 cases (1 5 patients) a palpable lump was present, and nine of these lumps showed a corre2). Seven
AJR:155,
July 1990
A mammographic abnormality without palpable findings prompted biopsy in three women with benign findings. In all three, microcalcifications were present at the lumpectomy site. Biopsy in these women showed fat necrosis with fibrosis and calcifications consistent with radiation effect in one, sclerosing
adenosis
and LCIS
in another,
and periductal
fibrosis
with microcalcifications and LCIS in the third (Fig. 3). Both women with LCIS had a component of lobular carcinoma in their original lumpectomy specimen. These women are included in the benign group because the mammographic findings prompting biopsy were due to a benign process, and because LCIS as a distinct entity has a controversial position as a malignant tumor. Microcalcifications developed within 2 years of the completion of cancer therapy in all three women. The only patient in whom microcalcifications not related to fibrosis developed did not have radiation therapy after her original surgery for carcinoma. In the 10 women with malignant tumor recurrence at the lumpectomy site, the mean time to recurrence was 3 years. Four of these malignant tumors recurred 2 years after the original treatment, two at 6 years, and one tumor each recurred at 1 3, 4, and 5 years after the original therapy. In seven women, malignant tumor recurred as a palpable mass; three women had normal findings on physical examination. In women with a palpable mass, mammography showed calcifications in one and a noncalcifled mass in three, including one woman with a single palpable mass whose ,
Results
sponding
ET AL.
noncalcified
women
mass
on the mammogram
with a palpable
mass
(Figs.
1 and
had no mammo-
graphic abnormality. The pathologic findings were fibrosis eight cases, fat necrosis in seven, and granuloma in one.
in
mammogram
showed
two masses,
both of which
were
found
to be malignant on biopsy (Fig. 4). Three women with palpable recurrent tumors had normal mammographic findings. Mammography
showed
abnormality
in seven
of the
10
women with malignant recurrent tumor: a single mass in two women, multiple masses in one, microcalcifications in three, and a mass with microcalcifications in one. All malignant calcifications were linear and irregular, and these were branching in one case (Fig. 5). No rounded, punctate calcifications, which
were
characteristic
were seen in women
of the
in whom
benign
recurrence
malignant
tumors
group,
recurred.
Fig. 1.-A and B, Coned mediolateral mammograms of surgical site in right breast of a 52year-old woman 2 (A) and 3 (B) years after surgery and irradiation. New fullness (arrows) was present on mammography and physical cxamination at 3 years. On biopsy, fat necrosis was found.
Downloaded from www.ajronline.org by 117.245.43.10 on 10/08/15 from IP address 117.245.43.10. Copyright ARRS. For personal use only; all rights reserved
AJR:155,
LOCAL
July 1990
TUMOR
RECURRENCE
Fig. 2.-A, Mediolateral xeromammogram of a 58-year-old woman shows breast mass. Biopsy revealed infiltrating duct cancer, and patient was treated with lumpectomy and irradiation. B, Mediolateral mammogram of same woman 2 years later shows new palpable, subareolar mass at site of surgery. No interval films were available. On biopsy, only fibrosis was found.
AFTER
‘
.,
LUMPECTOMY
37
-. -
.,
-:
‘.;‘:.#{149}-
.d,
.,t
Fig. 3.-Magnified(x3) mogram of a 67-year-old calcifications (arrowheads)
photograph of a mamwoman shows microthat developed 2 years after an infiltrating duct carcinoma was excised from this site, followed by breast irradiation. Histologic examination of microcalcifications revealed periductal fibrosis and lobular carcinema in situ.
Physical malignant
examination recurrent
failed tumors
to detect detected
with
.
-
A
B
Fig. 4.-Craniocaudal mammogram of 44year-old woman 2 years after irradiation for infiltrating duct carcinoma shows two masses (ar. rowheads) due to recurrent infiltrating duct carcinoma.
Fig. 5.-Magnified (x3) photograph shows microcalcifications developing at original tumor
three
of the seven
mammography.
After treatment of primary breast carcinoma by local excision and breast irradiation, follow-up mammography shows an immediate pattern of ill-defined density representing postsurgical alteration at the operative site, as well as diffuse increase in breast density, coarsening of the breast stroma, and thickening of the skin of the breast reflecting acute irradiation change. These findings are most pronounced in the first 12 months and diminish or disappear in the next 2 years [1 -4]. A mammographically identifiable scar, seen as a localized mass at the site of surgery and often directly connected with localized changes in the overlying skin, has been reported in 25% of patients [3]. Mammographic and physical findings of decreasing density at the site of tumor excision
cinoma.
after
These
tions were noma.
due
treatment
irregular,
for Intraductal
linear
to recurrent
car-
microcalcifica-
intraductal
carci-
normally evolve during the subsequent 2 years. The presence of a new or enlarging mass or new fine calcifications suggests recurrent
Discussion
site 2 years
tumor
at the site of previous
resection.
Chaudary et al. [5] have reported 1 7 patients in whom a new lump developed in breasts treated conservatively for carcinoma.
Ten
of the
lumps
were
found
though it was not possible to differentiate nant disease on physical examination. masses that developed, seven were due two to foreign body granuloma formation; case, only scar tissue was found. On benign
masses
were
to be benign,
free of microcalcifications.
cases in that series with a new mass containing cations,
malignant
tumor
was
present
al-
benign from maligOf the 1 0 benign to fat necrosis and in the remaining mammography, all In the three
microcalcifi-
in all. Rostom
and El-
Sayed [6] have reported two additional cases of fat necrosis presenting as a new lump at the site of previous lumpectomy after breast irradiation. Both of these masses developed at the site of surgical scar.
DERSHAW
38
In our group,
in 1 5 of 1 7 patients
with
new lump without microcalcifications previous tumor excision on follow-up seven
women,
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Conversely,
mammography
benign
disease
a
was found at the site of physical examination; in
failed to show
only three of 1 0 women
any abnormality.
with a developing
malig-
nant tumor at the scar had normal mammographic findings, and as in previous reports, the single mass with microcalcifi-
cations was malignant.
alteration
in physical findings
at the site of previous tumor mandates mammographic findings may be a hopeful may be due to fibrosis or fat necrosis.
Although
biopsy, unchanged sign that the mass
New microcalcifications
in a breast
(80%)
as opposed
of five that developed
treated
to four malignant
in a quadrant
other
for
tumors
than that of
the original tumor. In another series, six of 1 1 women
in whom
microcalcifications developed in the previously treated breast within 5 years of therapy were found to have benign disease, including fibrosis and atrophy [3]. These calcifications ob-
viously coarse,
are related to the previous classically benign calcifications
breast therapy. More frequently are seen in
irradiated breasts. These may be linear, rounded, or crossshaped calcifications and are readily differentiated from those fine, irregular calcifications that suggest new or recurrent tumor [9-1 1 ]. Just as formation of these coarse calcifications may be related to irradiation, fine dystrophic calcifications also may result from therapy [9]. When their pattern is compared with the pattern of calcifications seen in women who had
recurrent
tumor,
irregular
linear or branching
microcalcifica-
tions appear to herald recurrence whereas smoother calcifications are associated with change.
The time elapsed
between
completion
AJR:155,
veloping at the surgical site within 1 year of benign in 10 of 1 1 women in this study, and to biopsy for benign disease was shorter than nant disease (2 vs 3 years). This longer period
treatment was the mean time that for maligfor recurrence
of malignant
punctate, dystrophic
of therapy
for the
original tumor and appearance of changes on the mammogram or physical examination also may be helpful in differentiating benign from recurrent malignant tumors. Disease de-
tumor
corresponds
to a mean
recurrence
July 1990
time
at the site of the original tumor of 34 months reported by Stotter et al. [12]. In their series, relapse elsewhere in the breast had an even longer mean recurrence time of 69 months. The development of disease at the site of the original tumor within a year or two of completion of therapy suggests a benign
previously
carcinoma may be thought to represent recurrent or new breast carcinoma, but these calcifications are frequently benign. Stomper et al. [7] have reported that three of six women who had been treated conservatively for breast carcinoma with limited surgery and irradiation and in whom suspicious microcalcifications developed had benign disease. In a report of 19 patients with microcalcifications developing in the same clinical setting, Solin et al. [8] found eight patients (42%) had benign disease. However, when microcalcifications developed in the same quadrant as the original tumor, only seven (54%)
of 13 were malignant
ET AL.
process.
Although
we have found
some
differences
in those women with benign, as opposed to malignant, recurrent tumors, abnormal findings on physical examination and suspicious mammographic changes still mandate biopsy in this select group of patients.
REFERENCES 1 . Bloomer WD, Berenberg AL, Weissman BN. Mammography tively irradiated breast. Radiology 1976;1 18:425-428
2.
Libshitz HI, Montague ED, Paulus DD Jr. Skin tically irradiated breast. AiR 1978;130:345-347
thickness
of the definiin the therapeu-
3. Dershaw DD, Shank B, Reisinger S. Mammographic findings after breast cancer treatment with local excision and definitive irradiation. Radiology 1987;164:455-461 4. Berenberg AL, Levene
the postirradiated vative
MB, Tonnesen
GL. Mammographic
evaluation
of
breast. In: Hams JR, Hellman 5, Silen w, eds. Conser-
management
of breast
cancer:
new surgical
and radiotherapeutic
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8. Solin U, Fowble BL, Troupin RH, Goodman RL. Biopsy results of new calcifications in the postirradiated breast. Cancer 1989;63: 1956-1961 9. Libshitz HI, Montague ED, Paulus DD. Calcifications and the therapeutically irradiated breast. AJR 1977;128: 1021-1 025 10. Buckley JH, Roebuck EJ. Mammographic changes following radiotherapy. Br J Radiol
1986;59:337-344
1 1 . Harris KM, Costa-Greco MA, Baratz AB, Britton CA, llkhanipour ZS, Ganott MA. The mammographic features of the postlumpectomy, postirradiation breast. RadioGraphics 1989;9:253-268 12. Stotter AT, McNeese MD, Ames FC, Oswald MJ, Ellerbrock NA. Predicting the rate and extent of locoregional failure after breast conservation therapy for early breast cancer. Cancer 1989;64 :2217-2225
