Overview
The accurate interpretation of images of the postsurgical breast depends on the availability of high-quality pictures and pertinent medical and surgical breast history. Many findings can be mistaken for cancer. Skin thickening, architectural distortion, and other indicators of malignancy can be seen in both malignant and benign conditions. Prior breast surgery, trauma, and breast conservation treatment (BCT), or lumpectomy, can result in scarring and distortion as seen on imaging studies. These findings can be mistakenly interpreted as suspicious for malignancy. Thus, understanding the expected postsurgical imaging findings is important to ensuring an accurate interpretation and recommendation. See the image below.
Prebiopsy craniocaudal mammogram demonstrates a 1-cm mass in the medial aspect of the breast (see arrow). Subsequent stereotactic biopsy was performed. The pathophysiology of postsurgical changes, as observed on mammograms, is associated with the type of surgical intervention and the time elapsed since the procedure. The 4 most common breast interventional procedures are percutaneous biopsy; excisional breast biopsy; breast conservation treatment (BCT); and breast reduction, augmentation, or reconstruction. Postsurgical mammographic findings are also related to the time sequence from the procedure and can be classified into 2 general categories: acute changes and chronic changes. See the image below.
Postbiopsy craniocaudal mammogram of the breast obtained immediately after stereotactic biopsy of a lesion (same patient as in Image above). Interval development of a mass has occurred in the biopsy bed (see arrow); this finding is consistent with a hematoma. A marking clip has been placed. Acute mammographic changes refer to the immediate postoperative period extending for the first several weeks and months. Acute changes include hematoma, seroma, and edema. Chronic changes refer to findings identified after the acute period, usually several months to years after surgery. These include scar formation, retraction, development of dystrophic calcifications, tissue asymmetry (from tissue removal), fat necrosis, and architectural distortion. See the images below.
Mediolateral magnification view of the tumor bed after breast conservation treatment. A few coarse calcifications are noted consistent with fat necrosis. Mild architectural distortion is apparent in the lumpectomy site (see arrow). A scar marker was placed over the incision site. 
Craniocaudal view in a patient after a reduction mammoplasty. Scattered parenchymal densities, architectural distortion, and extensive calcifications (due to fat necrosis) are noted (see arrows). 
Craniocaudal mammogram demonstrating multiple oil cysts. Note the multiple radiolucent masses with smooth internal margins and typical eggshell-like calcifications (see arrows). Frequently, a history of previous trauma or surgery can be elicited from the patient. 
Mediolateral oblique mammogram in a patient 3 years after a mastectomy and reconstruction with a transverse rectus abdominis muscle (TRAM) flap. The patient noticed the development of palpable firm masses in the upper-outer portion of the reconstructed breast (see arrows). The mammogram demonstrates the typical appearance of a TRAM flap. In addition, extensive macrocalcifications have developed related to fat necrosis. These calcifications corresponded to the palpable mass. Architectural distortion is the disturbance of the normal-appearing curvilinear crescentic planes of the breast. The mammogram may demonstrate a pulling in of the Cooper ligaments to form a spiculated appearance. Architectural distortion may be the only mammographic indication of cancer. However, this finding is also seen after surgery, and it may be observed as a result of the superimposition of normal structures. Therefore, a thorough mammographic evaluation is needed to evaluate any areas of architectural distortion and to correlate the finding with the clinical history.
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Percutaneous Breast Biopsy
Percutaneous breast biopsies commonly are performed on masses and calcifications and include fine-needle aspiration, core-needle biopsy, and cyst aspiration.[1] These procedures involve the introduction of a needle into the suspicious lesion, usually under ultrasonographic or stereotactic guidance. A sample of tissue is removed and analyzed by the pathologist. See the image below.
Immediate mediolateral view after a stereotactic biopsy for calcifications in the inferior breast. Little mammographic evidence reveals that a biopsy has occurred, except for the placement of a clip (see arrow). Mammographic findings immediately after percutaneous biopsy are usually related to bleeding and the local anesthesia injected into the biopsy area. These findings include increased density in the area, formation of a mass (hematoma), and trabecular thickening from edema. A clip may be left intentionally in the biopsy area to document the sampled lesion. In most women, the biopsy area heals with little or no residual evidence on the mammogram other than reduced or absent calcifications or the presence of a marking clip.
Excisional Breast Biopsy
Excisional breast biopsy is usually performed by the surgeon and involves a skin incision and removal of breast tissue. The amount of breast tissue removed and the degree of tissue interruption are variable and are dependent on the surgical technique and subsequent treatment, such as radiation (see the images below). Acute postsurgical changes are most prominent in the immediate postoperative period (as long as 1-2 wk) and are related to hematoma, edema, and tissue disruption. Mammographic images may show an ill-defined mass, area of increased density, skin thickening, and/or distortion.
Craniocaudal mammogram after breast conservation treatment, axillary dissection, and radiation therapy. Note the skin and trabecular thickening (see arrows). 
Craniocaudal mammogram demonstrating extensive keloid scarring in the medial aspect of the breast. Note the irregular, macrolobulated, circumscribed densities with wide margins, outlined by a thin surrounding halo of air (see arrows). The keloids are superimposed on the breast tissue on the mammogram and can mimic breast lesions. Careful documentation of skin lesions is important so that dermal lesions are not confused with breast pathology. Gradually, as healing occurs, the surgical site matures. Fibrosis may occur, leading to scarring. The mammogram may show a spiculated mass, area of architectural distortion, or development of dystrophic calcifications. Some patients may heal with little or no mammographic findings. Seldom, extensive scarring can occur, resulting in keloid formation (see the image below). Careful documentation on the history form and the placement of scar markers can help prevent misinterpretation of these lesions. In general, a baseline postsurgical mammogram is performed 6 months after biopsy. The findings on this mammogram are regarded as the new baseline.
Craniocaudal mammogram demonstrating extensive keloid scarring in the medial aspect of the breast. Note the irregular, macrolobulated, circumscribed densities with wide margins, outlined by a thin surrounding halo of air (see arrows). The keloids are superimposed on the breast tissue on the mammogram and can mimic breast lesions. Careful documentation of skin lesions is important so that dermal lesions are not confused with breast pathology. Breast Conservation Treatment
BCT involves the removal of the breast cancer with a surrounding rim of noncancerous tissue. Some patients undergo complete lymph node dissection, whereas other patients undergo only a sentinel lymph node biopsy. Most patients undergo adjuvant radiation therapy to the breast to eradicate any possible residual occult cancer.
Acute mammographic changes observed after BCT are usually related to the extent of surgery and the time elapsed since radiation therapy. Mammograms performed during the acute surgical period usually demonstrate findings related to the surgery such as skin and/or trabecular edema, seromas, architectural distortion, and surgical clips placed within the tumor bed. Patients may have early postoperative mammograms to document possible residual calcifications and nodules or masses.
Interpreting early mammogram findings may be confusing because masses and architectural distortion may be misinterpreted as residual cancer. Therefore, correlating mammographic findings with the surgical approach and the pathology report is important. Additional imaging such as compression and/or magnification views and ultrasonography may be useful. A sonogram of a solid mass within the tumor bed would be worrisome for residual cancer in place of the expected finding of a complex fluid collection indicating a seroma or hematoma (see the image below).[2] Differentiating a complex fluid collection from a solid mass is sometimes difficult sonographically.
Mediolateral oblique view obtained after breast conservation treatment and axillary dissection in a patient with a 2-cm invasive ductal cancer. Mild architectural distortion is noted in the tumor bed in the upper quadrant of the breast (see arrow). Clips are placed within the tumor bed to assist with radiation therapy planning. Chronic mammographic findings after BCT are related to the volume of tissue excised and to radiation therapy. Architectural distortion, a spiculated or ill-defined mass, and a change in an appearance of the breast are common findings identified after a lumpectomy. Follow-up mammographic evaluation may involve a 6-month series of mammographic examinations to assess the treated breast. However, some institutions may have different protocols.
Mediolateral oblique, craniocaudal, and mediolateral mammographic images are frequently supplemented by magnification and compression views. In general, radiation and postsurgical changes are noted to be most pronounced immediately after surgery and radiation, with maximum radiation changes at 6-12 months. On subsequent imaging, the areas of distortion and tissue edema should regress or remain stable. Therefore, any developing density or mass or calcifications need to be regarded as suspicious for recurrent cancer and thoroughly evaluated. Tissue sampling of any suspicious or indeterminate finding should be performed. See the images below.
Craniocaudal mammogram obtained 2 years after lumpectomy, axillary dissection, and chemotherapy. Note the periareolar skin thickening and retraction and scarring extending from the nipple to the chest wall as a result of the surgery (see triangles). Coarse macrolobulated calcifications have developed in the surgical site (see arrow). 
Craniocaudal mammogram obtained in the patient in Image 11 who presented with a palpable mass directly behind the nipple within the prior tumor site, 6 years later. An interval increase has occurred in the amount of dystrophic calcifications and scarring (see triangles) in the tumor bed. The palpable mass corresponded to the large calcification (see arrow). Fine-needle aspiration demonstrated fat necrosis. The development of calcifications after BCT is problematic because one third to one half of irradiated breasts develop calcifications. Most of the calcifications can be attributed to fat necrosis resulting from the surgery and/or radiation. Suture calcifications may also be seen, especially if catgut sutures were used; however, these types of sutures are no longer used. However, biopsy may be indicated when the calcifications appear suspicious or indeterminate.
Breast Reduction, Augmentation, or Reconstruction
Mammographic appearances of postsurgical changes after breast reduction, breast reconstruction, and breast augmentation commonly are encountered. A variety of surgical techniques are used in breast reduction surgery. One of the most common is the keyhole incision technique. In this procedure, an incision is made around the areola and extended vertically in the 6-o'clock position to the inferior mammary fold. Typical mammographic findings may include alteration of the parenchymal architecture, cranial displacement of the nipple, patchy densities due to tissue removal and scarring, and the development of fat necrosis. Approximately 6 months after surgery, a new baseline mammogram should be obtained. Any new findings from the baseline examination, such as a developing density, mass, or calcifications, require a thorough evaluation, including possible tissue sampling.
Breast reconstruction may be performed after a mastectomy by means of reconstruction with autogenous tissue transfer and/or implants. The most common autogenous tissue transfer site is from the panniculus or from a free myocutaneous flap. The most frequent location of the donor tissue is from a flap harvested from the latissimus dorsi muscle or the transverse rectus abdominis muscle (TRAM) flap.
Mammographic imaging of the reconstructed breast may be requested for the evaluation of a clinically suspicious finding, such as a palpable mass. Standard mammographic views are performed with additional views (compression, magnification, tangential) and ultrasonography if needed. In general, most of the mammographic and clinical findings are related to the development of dystrophic changes within the donor tissue, such as oil cysts and fat necrosis. Typically, dystrophic changes can be recognized easily on the mammogram as benign. However, fat necrosis, dystrophic microcalcifications, and scarring also can mimic cancer, thus prompting biopsy. See the images below.
Mediolateral oblique mammogram of the breast shows a subpectoral (behind the muscle) silicone implant. Free silicone is noted outside the implant, within the soft tissue of the upper breast, consistent with implant rupture (see arrows). 
Mediolateral oblique image of a transverse rectus abdominis muscle (TRAM) flap used to augment the breast volume instead of an implant. The native breast tissue is noted anterior to the TRAM flap and produces this unusual architecture. The postsurgical mammographic observations identified after breast augmentation are related to the technical placement of the implant and the type of the implant. Standard and implant-displaced views are recommended. Assessment of the implants includes the location (subglandular or subpectoral), type (silicone, saline, mixed), contour (evaluation for possible rupture or weakening), and evaluation for possible complications (rupture, capsular formation). The evaluation of the native breast tissue may be obscured by the implant, thus hampering breast cancer detection. Rarely, breast tissue may be augmented by using native tissue harvested from the muscle or pedunculus. This produces an unusual mammographic appearance.
Preferred Examination
The workup of postsurgical breast changes includes a thorough mammographic evaluation and correlation with the clinical history and pathologic findings. Scar markers are helpful to document the surgical approach. Additional mammographic projections (tangential, compression, and/or magnification views), comparison with prior mammograms, clinical breast examination, and ultrasonography are helpful in the workup. Tissue sampling is recommended for any suspicious or indeterminate findings. Breast MRI may also be helpful in the evaluation of postsurgical changes.[3, 4]
The development of pleomorphic microcalcifications, especially in a branching pattern, is regarded as highly suggestive of new or recurrent cancer. Biopsy should be performed promptly. The development of oil cysts or fat necrosis is common and routine follow-up can be performed. Architectural distortion is a common mammographic finding after breast conservation surgery and should be closely monitored after an appropriate workup is performed (with magnification and/or compression views). Any developing or changing area of architectural distortion should be viewed as worrisome. Skin and trabecular thickening frequently are observed after radiation therapy.
Mammographic and ultrasonographic findings of malignant and benign lesions overlap. A thorough workup is needed for any new or changing mass, developing calcifications, developing areas of architectural distortion or density. Biopsy should be considered for any indeterminate or suspicious findings.
Radiography
The imaging appearance of postsurgical changes can be confusing because masses, calcifications, and architectural distortion can mimic cancer. In addition, cancers can develop in areas of prior surgery. Therefore, a thorough clinical history, including information regarding the type of surgical intervention, and pathologic correlation are needed for adequate assessment. In general, indeterminate or suspicious findings may require tissue sampling to exclude malignancy.
Acute mammographic changes refer to the immediate postoperative period extending for the first several weeks and months. Acute changes include hematoma, seroma, and edema. Chronic changes refer to findings identified after the acute period, usually several months to years after surgery. These include scar formation, retraction, development of dystrophic calcifications, tissue asymmetry (from tissue removal), fat necrosis, and architectural distortion.
The pathophysiology of postsurgical changes, as observed on mammograms, is associated with the type of surgical intervention and the time elapsed since the procedure. The 4 most common breast interventional procedures are percutaneous biopsy; excisional breast biopsy; breast conservation treatment (BCT); and breast reduction, augmentation, or reconstruction. Postsurgical mammographic findings are also related to the time sequence from the procedure and can be classified into 2 general categories: acute changes and chronic changes.
See the mammographic images below.
Prebiopsy craniocaudal mammogram demonstrates a 1-cm mass in the medial aspect of the breast (see arrow). Subsequent stereotactic biopsy was performed. Postbiopsy craniocaudal mammogram of the breast obtained immediately after stereotactic biopsy of a lesion (same patient as in Image above). Interval development of a mass has occurred in the biopsy bed (see arrow); this finding is consistent with a hematoma. A marking clip has been placed. Mediolateral magnification view of the tumor bed after breast conservation treatment. A few coarse calcifications are noted consistent with fat necrosis. Mild architectural distortion is apparent in the lumpectomy site (see arrow). A scar marker was placed over the incision site. Craniocaudal view in a patient after a reduction mammoplasty. Scattered parenchymal densities, architectural distortion, and extensive calcifications (due to fat necrosis) are noted (see arrows). Craniocaudal mammogram demonstrating multiple oil cysts. Note the multiple radiolucent masses with smooth internal margins and typical eggshell-like calcifications (see arrows). Frequently, a history of previous trauma or surgery can be elicited from the patient. Mediolateral oblique mammogram in a patient 3 years after a mastectomy and reconstruction with a transverse rectus abdominis muscle (TRAM) flap. The patient noticed the development of palpable firm masses in the upper-outer portion of the reconstructed breast (see arrows). The mammogram demonstrates the typical appearance of a TRAM flap. In addition, extensive macrocalcifications have developed related to fat necrosis. These calcifications corresponded to the palpable mass. Immediate mediolateral view after a stereotactic biopsy for calcifications in the inferior breast. Little mammographic evidence reveals that a biopsy has occurred, except for the placement of a clip (see arrow). Craniocaudal mammogram after breast conservation treatment, axillary dissection, and radiation therapy. Note the skin and trabecular thickening (see arrows). Craniocaudal mammogram demonstrating extensive keloid scarring in the medial aspect of the breast. Note the irregular, macrolobulated, circumscribed densities with wide margins, outlined by a thin surrounding halo of air (see arrows). The keloids are superimposed on the breast tissue on the mammogram and can mimic breast lesions. Careful documentation of skin lesions is important so that dermal lesions are not confused with breast pathology. Mediolateral oblique view obtained after breast conservation treatment and axillary dissection in a patient with a 2-cm invasive ductal cancer. Mild architectural distortion is noted in the tumor bed in the upper quadrant of the breast (see arrow). Clips are placed within the tumor bed to assist with radiation therapy planning. Craniocaudal mammogram obtained 2 years after lumpectomy, axillary dissection, and chemotherapy. Note the periareolar skin thickening and retraction and scarring extending from the nipple to the chest wall as a result of the surgery (see triangles). Coarse macrolobulated calcifications have developed in the surgical site (see arrow). Mediolateral oblique mammogram of the breast shows a subpectoral (behind the muscle) silicone implant. Free silicone is noted outside the implant, within the soft tissue of the upper breast, consistent with implant rupture (see arrows). Mediolateral oblique image of a transverse rectus abdominis muscle (TRAM) flap used to augment the breast volume instead of an implant. The native breast tissue is noted anterior to the TRAM flap and produces this unusual architecture. Magnetic Resonance Imaging
Acute changes seen on MRIs include the following[4, 5, 6] :
- Hemorrhage can have variable signal intensity on nonenhanced T1-weighted images.
- Early or intense enhancement, or both, may occur.
- Hematomas and seromas manifest as a cavity with variable signal intensity (low to high), depending on whether it is acute or chronic.
- Generally, hematomas and seromas have a thinner, smoother capsule, whereas residual or recurrent tumor is more nodular and irregular.
- Granulation tissue usually enhances moderately, and enhancement is delayed; however, fast enhancement may lead to false-positive diagnosis.
Chronic and later changes seen on MRIs include the following[4] :
- Between 9-18 months, enhancement may or may not be present at a lumpectomy site.[7] Therefore, residual or recurrent disease is excluded if no enhancement is seen.
- A false-positive diagnosis may be made if enhancement is seen.
- The morphology of the enhancement (ie, smooth and thin walled vs irregular and thick walled) may help to differentiate between the 2 conditions.
- Scar tissue should not be enhancing after 18 months. Therefore, tissue that enhances must be considered suspicious, and biopsy should be considered.
Overlap exists between benign and malignant disease. Suspicious findings may warrant tissue sampling. A false-positive diagnosis may be made if enhancement is seen.
Ultrasonography
Ultrasonography of the breast, in conjunction with mammography and clinical breast examination, can be extremely helpful in evaluating postsurgical changes in the breast. Ultrasonography is usually performed with a high-frequency linear-array transducer (10 MHz or greater). The examination is directed toward palpable or mammographic lesions. Information regarding the internal architecture, shape, and margins of a lesion are used to determine if a lesion is cystic or solid.
Sonographic findings subsequent to surgery may include skin thickening (scarring), architectural distortion of the parenchyma, and development of a mass and/or calcifications (scarring, fibrosis, fat necrosis). These findings can appear on the sonogram as hypoechoic or hyperechoic structures and/or masses with acoustic shadowing. These findings can mimic cancer, thus prompting a thorough workup to determine if tissue sampling is indicated to exclude malignancy. In the acute stage, hematomas may be ill defined or may present as a mass containing complex echoes with distal acoustic enhancement or shadowing. In time, the hematoma organizes and becomes more masslike, and the fluid becomes more hypoechoic and may even appear cystic.
See the ultrasound images of the postsurgical breast below.
Ultrasonogram demonstrates 2 ovoid, smooth, thin-walled, anechoic masses with acoustic enhancement. The larger is anechoic, compatible with a simple cyst (see arrow). The smaller contains some internal echoes, although it also was shown to represent a cyst. 
Ultrasonogram demonstrates a complex mass with internal echoes (see arrow). This appearance is consistent with a resolving hematoma after surgery. Solid masses (benign and malignant) can also demonstrate this sonographic appearance. 
Ultrasonogram demonstrates acoustic shadowing and an irregular hypoechoic mass (see arrow). This appearance can be seen in cancers as well as in postsurgical scars. Simple Cysts
Simple cysts have 4 criteria:
- They are usually well defined and round or ovoid.
- They have thin smooth walls.
- They contain no internal echoes.
- They have posterior acoustic enhancement (see the image below).
Diagnosing a simple cyst means that the lesion is benign and that no further testing is needed. However, if a lesion does not meet all 4 criteria for a simple cyst, it is classified as either a complex lesion or a solid lesion.
Complex Cyst
A complex cyst is a lesion that lacks one or more of the 4 criteria for a simple cyst. Complex cysts may contain internal echoes, limited posterior acoustic enhancement, wall irregularity, and/or an irregular shape. Further evaluation with cyst aspiration usually is recommended to exclude malignancy.
Solid Lesion
Solid lesions can display several characteristics on sonograms. Assessing if a lesion is a complex cyst or solid lesion may be difficult. Certain characteristics are helpful in assessing a solid lesion for malignant potential. Worrisome lesions may have irregular walls, contain internal echoes, be taller than they are wide, and/or exhibit broad acoustic shadowing. Further evaluation with tissue sampling is needed to exclude malignancy.
Acute Postoperative Period
In the acute postoperative period, sonographic findings include diffuse hemorrhage and/or edema, which is seen on sonograms as a region of increased or decreased echogenicity and/or an area of architectural distortion.
Scar Formation
Chronic or later (months to years) postsurgical ultrasonographic findings are usually related to scar formation, ie, retraction, dystrophic calcifications, and fat necrosis (lipophagic granuloma, oil cyst). Scar formation can be seen as a discrete area of architectural distortion with hypoechoic structures, acoustic shadowing, and interruption of the normal parenchyma. Frequently, these findings originate at the scar and extend into the breast parenchyma. This appearance can mimic that of cancer.
Fat Necrosis and Dystrophic Calcifications
Fat necrosis and dystrophic calcifications can be seen on the sonogram as a hypoechoic or hyperechoic irregular mass with acoustic shadowing. Correlation with mammographic images, surgical history, pathology findings, and clinical breast examination are important for accurate assessment. Serial ultrasounds and/or mammograms or biopsy (for suspicious lesions) may be needed.
Nonspecific Findings
Ultrasonographic findings can be nonspecific, unless the lesion has the characteristics of a simple cyst. For example, benign pathology such as fat necrosis and scarring can mimic cancer on sonograms. Both can be hypoechoic or hyperechoic, and they can appear as irregular, hypoechoic masses with acoustic shadowing. Thus, because of the overlap between benign and malignant disease, a thorough workup of the abnormalities is needed. Indeterminate or suspicious findings may warrant tissue sampling.
Nuclear Imaging
Scintimammography is performed by using technetium-99m sestamibi (see the image below).[8] Research demonstrates that sestamibi is a lipophilic complex that can penetrate the cell membrane, preferentially in tumor cells.[9, 10, 11]
Lateral scintimammogram obtained with technetium-99m sestamibi shows a 2-cm palpable breast cancer in the center of the breast (see arrow). Single-photon emission computed tomography improves resolution of planar-prone images. Initial data showed 83-97% sensitivity for palpable lesions and less than 50% sensitivity in lesions smaller than 1 cm. Sestamibi imaging is limited because tracer uptake is dependent on tumor size and tumor histology; other limitations are due to detector resolution. Therefore, at present, sestamibi is not a first-line imaging modality used in the workup of mammographic abnormalities.
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