Edward Harter, MD

 A 53-year old female patient presents with palpable breast masses, right greater than left.

Figure 1 – Longitudinal and transverse grayscale ultrasound images of the right breast at the 1:00 position in the region of the palpable abnormality. Images demonstrate multiple subcentimeter hypoechoic nodules. Lesions are homogenous and very well defined with smooth margins. The largest nodule measuring approximately 1.5 cm contains a thin internal septation. Although not shown, color Doppler images demonstrated a lack of internal vascular flow within all lesions.

Figure 2 - Longitudinal and transverse grayscale ultrasound images of the left breast at the 12:00 position in the region of the palpable abnormality. Images demonstrate several very small hypoechoic nodules. Lesions are also homogenous and very well defined with smooth margins. Although not shown, color Doppler images demonstrated a lack of internal vascular flow within these lesions as well.

 A 53-year-old female patient with biopsy proven lobular carcinoma in situ in the right breast and biopsy proven invasive ductal carcinoma in the left breast underwent bilateral mastectomies with immediate reconstruction with silicone implants in November 2011. Due to postoperative assymetry, the patient underwent second-stage reconstruction and bilateral lipofilling of the breasts right greater than left six months later. In November 2012, she presented with new bilateral breast lumps right greater than left.

Ultrasound findings of multiple well defined, smoothly marginated, homogenously hypoechoic breast masses in a patient with a history of autologous fat transfer are virtually diagnostic for oil cysts.

 When detectable on mammography, areas of lipoinjection typically have a rounded radiolucent appearance. Occasionally fat necrosis can give rise to microcalcifications which are usually classified as dystrophic and therefore easily distinguishable from malignant calcifications. At ultrasound, oil cysts from fat injection typically appear as ovoid hypoechoic lesions which lack internal vascular flow. Areas of lipoinjection that have undergone fat necrosis usually demonstrate a hetereogenous echotexture with complex features and may appear mass-like.

Recent literature suggests that oil cysts are best characterized using ultrasound. For difficult cases where the differential includes both fat necrosis and cancer, MRI is probably the most sensitive method for differentiation.

The transfer of autologous fat to diminish breast asymmetries in patients who have undergone breast reconstruction is a practice that is becoming more common. Unfortunately the development of fat necrosis and/or oil cyst formation after this procedure occurs frequently. In patients with a history of breast cancer, the presence of a new breast nodule(s) can be a stressful experience. Surgeons performing this procedure must discuss the potential of liponecrotic pseudocyst formation with their patients.

Edward Harter, MD, and Erini Makariou, MD


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Articles

Liponecrotic Nodules After Autologous Fat Transfer For Breast Augmentation

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.

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.

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. 

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A 40-year-old female diagnostic mammogram for suspicious left breast calcifications. Two years after TRAM flap reconstruction, a screening mammagram demonstrated a tight cluster of pleomorphic microcalcifications in the left breast.

Edward Harter, MD

Articles

Liponecrotic Nodules After Autologous Fat Transfer For Breast Augmentation

Cancer Recurrence in Autologous Reconstructed Breast