Cancer Recurrence in Autologous Reconstructed Breast

A 40-year-old female diagnostic mammogram for suspicious left breast calcifications.

Figure 1: Spot compression magnification CC and MLO views of the left breast demonstrate tightly clustered pleomorphic calcifications in the superior central region of the left breast.

Figure 2 – Screening CC and MLO views of the same patient two years later after left breast reconstruction demonstrate tightly clustered pleomorphic calcifications in the superior central region of the reconstructed left breast.

Diagnosis:

A 40-year-old African-American female was diagnosed with ductal carcinoma in situ (DCIS) in the left breast (Figure 1) and underwent surgical excision. She declined radiation therapy, had a recurrence, and subsequently underwent mastectomy with TRAM flap reconstruction.

Two years after TRAM flap reconstruction, a screening mammagram demonstrated a tight cluster of pleomorphic microcalcifications at the twelve o’clock position (Figure 2) of the left breast. These calcifications were biopsied and proven to be recurrent DCIS without evidence for invasive carcinoma.

Conclusion:

Mammographic imaging of breast reconstructions remains controversial. The lack of breast parenchyma and the large number of false positive cases related to fat necrosis within the reconstructed breast are reasons why imaging centers may not routinely image breast reconstructions. The expected site of recurrence is along the perimeter of the mastectomy site, approximately 50 percent on the chest wall and 50 percent in the skin; recurrence can occur within the autologous flap itself.

There are limited data regarding the incidence and nature of recurrence but recurrence rates are estimated to range from 2.1 percent to 13.8 percent for palpable and nonpalpable cancer. However, cases of nonpalpable locally recurrent disease continue to be mammographically detected (1.9 percent). The risk is increased in women younger than 35, Stage III disease, positive lymph nodes, unfavorable tumor characteristics and poor neoadjuvant chemotherapy.

Mammographic findings of recurrent disease may include irregular masses, pleomorphic calcifications, and masses associated with calcifications. Although rare, as cases of recurrent disease in breast reconstructions continue to be reported, the benefit of routine mammography in patients with breast reconstructions may eventually be proven.

Edward Harter, MD, and Erini Makariou, MD. Georgetown University Hospital. 

References:

Hogge JP, Zuurbier RA, de Paredes ES. Mammography of Autologous Myocutaneous Flaps. Radiographics. October 1999 19:S63-S72

Helvie MA, Wilson TE, Roubidoux MA, Wilkins EG, Chang AE. Mammographic appearance of recurrent breast carcinoma in six patients with TRAM flap breast reconstructions. Radiology. December 1998 209:711-715.

Yamada T, Mori N, Watanabe M, Kimijima I, Okumoto T, Seiji K, Takahashi S. Radiologic-Pathologic Correlation of Ductal Carcinoma in Situ. Radiographics. September 2010 30:1183-1198.

Rissanen TJ, Makarainen HP, Mattila SI, Lindholm EL, Heikkinen, Kiviniemi HO. Breast cancer recurrence after mastectomy: diagnosis with mammography and US. Radiology. August 1993 188:463-467.

Zakhireh J, Fowel B, and Esserman J. L. Application of Screening Principles to the Reconstructed Breast. Journal of Clinical Oncology. January 2010 10, 173-180.