Patterns of Locoregional Breast Cancer Recurrence: Role of Multimodality Imaging.

Transcription

1 Patterns of Locoregional Breast Cancer Recurrence: Role of Multimodality Imaging. Poster No.: C-0715 Congress: ECR 2015 Type: Educational Exhibit Authors: A. Bitencourt 1, L. Graziano 2, C. Guatelli 2, C. Boaventura 2, J. Souza 2, M. Poli 2, E. F. Marques 1 ; 1 Sao Paulo, Sao Paulo/BR, 2 Sao Paulo/BR Keywords: DOI: Cancer, Diagnostic procedure, Ultrasound, MR, Mammography, Breast /ecr2015/C-0715 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 10

2 Learning objectives To discuss the role of multimodality imaging in the evaluation of locoregional breast cancer recurrence. Background The follow up of breast cancer patients after curative primary therapy focuses on early detection of recurrent disease. Locoregional recurrence is an independent predictor of subsequent distant metastases. The risk of local recurrence after conservative surgery is around 2.5% per year in the period between 2-6 years after treatment, remaining stable approximately for 10 years. Current data shows that there is a survival benefit from early detection of asymptomatic loco-regional breast cancer recurrences. The current standard of surveillance practices requires a multi-disciplinary approach from radiologists, surgeons, and oncologists. Most guidelines suggest annual mammography following breast-conserving therapy. However, supplemental imaging may be considered in symptomatic patients and patients at high risk for recurrent disease. Dedicated breast MRI may be considered for post-therapy surveillance in women at high risk. Supplemental ultrasound is an option in women with intermediate risk and dense breasts, and for high risk women who are not candidates for breast MRI. Findings and procedure details Locoregional recurrence after breast cancer may occur in the surgical bed, skin, chest wall and lymph node basins (axilla, supraclavicular and internal mammary). The majority of breast recurrences are clinically detectable by physical examination. However, approximately one-third is detectable by mammography alone. Even when the recurrence is suspect on clinical examination, imaging methods are important to confirm the diagnosis and evaluate its extent. On mammography, tumor recurrences usually show developing asymmetry or enlarging mass within the operative bed or axilla; increasing edema or skin thickening; pleomorphic, indistinct, coarse heterogeneous, or linear calcifications that have developed within or near the operative bed. Page 2 of 10

3 At ultrasound, the appearance of new masses or the enlargement of an architectural distortion must be considered suspected for recurrence. When mammography and ultrasound are indeterminate, MRI can reliably distinguish post treatment scar tissue from recurrence when performed at least months after completion of breast conservation therapy. MRI findings suggestive of recurrence include: irregular or enlarging mass; segmental non-mass enhancement; washout kinetic curve; and any mass larger than 5 mm near the surgical bed. Other imaging modalities, such as CT and PET-CT may also be useful in the evaluation of locorregional breast cancer recurrence and screening for distant metastasis. Images for this section: Fig. 1: Example of breast cancer recurrence on the surgical scar. A) Mammography shows architectural distortion on the surgical bed. B) Ultrasound shows a hypoechoic irregular mass near the surgical scar. C) MRI shows an irregular mass with heterogeneous enhancement in the same topography. Page 3 of 10

4 Fig. 2: Examples of enhancing small masses near the surgical bed (arrows) on MRI in two different patients, suggestive of recurrence. Page 4 of 10

5 Fig. 3: Example of breast cancer recurrence after mastectomy with a peripheral small irregular mass on the reconstructed breast. A) Mammography. B) Ultrasound. C) MRI. Page 5 of 10

6 Fig. 4: Example of breast cancer recurrence on the pectoral muscle after mastectomy. A) Ultrasound. B) MRI. Page 6 of 10

7 Fig. 5: Example of breast cancer recurrence after mastectomy on the latissimus dorsi flap. A) Mammography (does not show the lesion). B) Ultrasound. C) CT. Page 7 of 10

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9 Fig. 6: Example of breast cancer recurrence after mastectomy with an enlarged left internal thoracic lymph node. A) MRI. B) Ultrasound. Fig. 7: Example of breast cancer recurrence on the skin after mastectomy. A) Mammography - MLO view. B) Mammography - spot tangential view. C) CT. Page 9 of 10

10 Conclusion The interpretation of imaging findings after breast cancer treatment requires an understanding of the expected postoperative changes and the imaging characteristics of tumor recurrence in a multimodality setting. Personal information References 1. Chansakul T, Lai KC, Slanetz PJ. The postconservation breast: part 1, Expected imaging findings. AJR Am J Roentgenol Feb;198(2): Chansakul T, Lai KC, Slanetz PJ. The postconservation breast: part 2, Imaging findings of tumor recurrence and other long-term sequelae. AJR Am J Roentgenol Feb;198(2): Clemons M, Danson S, Hamilton T, Goss P. Locoregionally recurrent breast cancer: incidence, risk factors and survival. Cancer Treat Rev Apr;27(2): Cuccurullo V, Cascini GL, Mansi L. Structural, pathophysiological and clinical aspects of diagnostic imaging in breast recurrence: the breast after treatment. Q J Nucl Med Mol Imaging Dec;57(4): Drukteinis JS, Gombos EC, Raza S, Chikarmane SA, Swami A, Birdwell RL. MR imaging assessment of the breast after breast conservation therapy: distinguishing benign from malignant lesions. Radiographics Jan- Feb;32(1): Khatcheressian JL, Hurley P, Bantug E, Esserman LJ, Grunfeld E, Halberg F, et al. Breast cancer follow-up and management after primary treatment: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol Mar 1;31(7): Margolis NE, Morley C, Lotfi P, Shaylor SD, Palestrant S, Moy L, et al. Update on imaging of the postsurgical breast. Radiographics May- Jun;34(3): Schneble EJ, Graham LJ, Shupe MP, Flynt FL, Banks KP, Kirkpatrick AD, et al. Current Approaches and Challenges in Early Detection of Breast Cancer Recurrence. J Cancer Mar 16;5(4): Whitehouse GH, Moore NR. MR imaging of the breast after surgery for breast cancer. Magn Reson Imaging Clin N Am Nov;2(4): Page 10 of 10