AUTHOR AND EDITOR INFORMATION

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• Radiograph
• Mri
• Ultrasound
• Nuclear Medicine
• Intervention
• Multimedia
• References

INTRODUCTION

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Background

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.

This article primarily discusses postsurgical mammographic findings because mammography is the primary imaging modality. Breast ultrasonography and MRI are discussed briefly.

For excellent patient education resources, visit eMedicine's Women's Health Center and Cancer and Tumors Center. Also, see eMedicine's patient education articles Breast Lumps and Pain, Breast Self-Exam, Breast Cancer, and Mastectomy.

Pathophysiology

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; BCT; CT scanning; 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.

Acute mammographic changes refer to the immediate postoperative period extending for the first several weeks and months. Acute changes include hematoma, seroma, and edema (see Images 1-2). 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 Images 3-6).

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.

Percutaneous breast biopsy

Percutaneous breast biopsies commonly are performed on masses and calcifications and include fine-needle aspiration, core-needle biopsy, and cyst aspiration. 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.

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 (see Image 2, Image 7). 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 Image 8). 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.

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 Image 9). 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.

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 Image 6, Image 8, Image 10). Differentiating a complex fluid collection from a solid mass is sometimes difficult sonographically.

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.

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 (see Images 11-12). 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 (see Image 4). 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 (see Image 6). However, fat necrosis, dystrophic microcalcifications, and scarring also can mimic cancer, thus prompting biopsy.

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) (see Image 13). 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 (see Image 14).

Frequency

United States

The incidence of newly diagnosed breast cancer is 211,000 cases per year in the United States. According to the World Health Organization, more than 1.2 million people will be diagnosed with breast cancer this year worldwide. Breast cancer is the second leading cause of cancer deaths in women today and the most common cancer among women, excluding skin cancers. In the United States, more than 750,000 breast biopsies are performed each year and approximately 40,000 women die each year from breast cancer.

Sex

More than 99% of breast cancers occur in women. Approximately 1700 cases were diagnosed in men in 2005.

Age

Approximately 1 in 7 women have breast cancer by age 85 years. The probability of a patient's undergoing breast biopsy increases with age, as does the likelihood that the biopsy specimen will be found to be malignant.

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.

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.

Limitations of Techniques

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.

DIFFERENTIALS

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Other Problems to be Considered

The development of microcalcifications on mammogram images warrants meticulous analysis.

Calcifications are usually classified into 3 categories: malignant, indeterminate, or benign. Malignant calcifications may appear as casting (linear and branching) or pleomorphic (granular). Benign calcifications include dermal calcifications (tangential views can be useful), vascular calcifications (parallel tracks), coarse popcorn-like calcifications (fibroadenoma), large rod-like calcifications (secretory), round calcifications, lucent-centered or eggshell calcifications (oil cysts, fat necrosis), milk-of-calcium calcifications (layering or teacup), suture calcifications, and dystrophic calcifications. Indeterminate microcalcifications do not fit into the benign or malignant categories.

Tissue biopsy is recommended for calcifications that are classified as either malignant or indeterminate. A complete discussion of microcalcifications is beyond the scope of this article; therefore, the reader is directed to other
sources.

The development of masses, architectural distortion, and skin thickening can be noted following surgery (see Pathophysiology). A complete workup is recommended to determine if biopsy is indicated.

RADIOGRAPH

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Findings

Please refer to the complete discussion regarding the pathophysiology of postsurgical changes (see Pathophysiology).

Degree of Confidence

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.

False Positives/Negatives

In general, indeterminate or suspicious findings may require tissue sampling to exclude malignancy.

MRI

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Findings

• Acute changes seen on MRIs include the following:
  • 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:
  • Between 9-18 months, enhancement may or may not be present at a lumpectomy site. 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.

Degree of Confidence

Overlap exists between benign and malignant disease. Suspicious findings may warrant tissue biopsy.

False Positives/Negatives

Overlap exists between benign and malignant disease. Suspicious findings may warrant tissue sampling. A false-positive diagnosis may be made if enhancement is seen (see Findings above).

ULTRASOUND

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Findings

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.

• Simple cysts have 4 criteria. (1) They are usually well defined and round or ovoid, (2) they have thin smooth walls, (3) they contain no internal echoes, and (4) they have posterior acoustic enhancement (see Image 15). 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.
• A complex cyst is a lesion that lacks one or more of the 4 criteria for a simple cyst (see Image 16). 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 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.
• 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.
• 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 Images 15-16).
• 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 (see Image 17).
• 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 (see Image 17). 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.

Degree of Confidence

Ultrasonographic findings are nonspecific, and overlap exists between benign-appearing and malignant-appearing lesions. Suspicious and indeterminate lesions may warrant tissue sampling.

False Positives/Negatives

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 MEDICINE

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Findings

Scintimammography is performed by using technetium Tc 99m sestamibi (see Image 18). Research demonstrates that sestamibi is a lipophilic complex that can penetrate the cell membrane, preferentially in tumor cells. 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.

Degree of Confidence

Sestamibi studies are not currently recommended as the definitive tests for breast pathology.

INTERVENTION

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Indeterminate and suspicious findings may warrant surgical or percutaneous tissue sampling (see Pathophysiology).

Medical/Legal Pitfalls

• Failure to diagnose breast cancer in a timely fashion is the most common reason that a physician is sued.
• • The interpretation of images in a postsurgical breast can be extremely complex and difficult.
  • Postsurgical findings can mimic cancer and result in a confusing imaging picture.
  • A subtle developing cancer in an area of prior surgery may be overlooked initially.
  • Residual cancer within a breast treated with BCT can be difficult to detect.
• Reducing the medical/legal pitfalls in regards to the postsurgical breast includes ensuring high-quality breast imaging, accurate documentation of the clinical history and pathology findings, treatment (if any), clinical breast examination, and listening to the patient's concerns (developing retraction, pulling sensation, or swelling within the breast).
• Written documentation of the clinical history and findings, thorough documentation of communication to both the referring physician and patient, as well as taking a conservative approach (biopsy or early follow-up observation) can help reduce medical/legal exposure.
• A detailed discussion regarding the legal aspects of mammography is beyond the scope of this article; therefore, the reader is directed to other sources.

MULTIMEDIA

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Media file 1:  Prebiopsy craniocaudal mammogram demonstrates a 1-cm mass in the medial aspect of the breast (see arrow). Subsequent stereotactic biopsy was performed.
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Media file 2:  Postbiopsy craniocaudal mammogram of the breast obtained immediately after stereotactic biopsy of a lesion (same patient as in Image 1). 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.
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Media file 3:  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.
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Media file 4:  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).
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Media file 5:  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.
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Media file 6:  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.
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Media file 7:  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).
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Media file 8:  Craniocaudal mammogram after breast conservation treatment, axillary dissection, and radiation therapy. Note the skin and trabecular thickening (see arrows).
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Media file 9:  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.
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Media file 10:  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.
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Media file 11:  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).
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Media file 12:  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.
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Media file 13:  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).
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Media file 14:  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.
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Media file 15:  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.
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Media file 16:  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.
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Media file 17:  Ultrasonogram demonstrates acoustic shadowing and an irregular hypoechoic mass (see arrow). This appearance can be seen in cancers as well as in postsurgical scars.
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Media file 18:  Lateral scintimammogram obtained with technetium Tc 99m sestamibi shows a 2-cm palpable breast cancer in the center of the breast (see arrow).
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Media file 19:
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REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• Mri
• Ultrasound
• Nuclear Medicine
• Intervention
• Multimedia
• References

• American Cancer Society. American Cancer Society Breast Cancer Facts & Figures, 2005. Available at: http://www.cancer.org/downloads/STT/CAFF2005f4PWSecured.pdf. Atlanta, Ga. [Full Text].
• Brenner RJ, Bassett LW, Fajardo LL, et al. Stereotactic core-needle breast biopsy: a multi-institutional prospective trial. Radiology. Mar 2001;218(3):866-72. [Medline].
• Giess CS, Keating DM, Osborne MP, et al. Comparison of rate of development and rate of change for benign and malignant breast calcifications at the lumpectomy bed. AJR Am J Roentgenol. Sep 2000;175(3):789-93. [Medline].
• Jemal A, Murray T, Ward E, et al. Cancer statistics, 2005. CA Cancer J Clin. Jan-Feb 2005;55(1):10-30. [Medline].
• Khalkhali I, Cutrone JA, Mena IG, et al. Scintimammography: the complementary role of Tc-99m sestamibi prone breast imaging for the diagnosis of breast carcinoma. Radiology. Aug 1995;196(2):421-6. [Medline].
• Klaus AJ, Klingensmith WC 3rd, Parker SH, et al. Comparative value of 99mTc-sestamibi scintimammography and sonography in the diagnostic workup of breast masses. AJR Am J Roentgenol. Jun 2000;174(6):1779-83. [Medline].
• Leibman AJ, Styblo TM, Bostwick J 3rd. Mammography of the postreconstruction breast. Plast Reconstr Surg. Mar 1997;99(3):698-704. [Medline].
• Liberman L. Clinical management issues in percutaneous core breast biopsy. Radiol Clin North Am. Jul 2000;38(4):791-807. [Medline].
• Liberman L, Drotman M, Morris EA, et al. Imaging-histologic discordance at percutaneous breast biopsy. Cancer. Dec 15 2000;89(12):2538-46. [Medline].
• Mankoff DZ, Dunnwald LK. MIBI Scintimammography: Current Concepts and Controversies. Society of Breast Imaging Newsletter. Feb 2001;1-6. [Full Text].
• Miller JA, Festa S, Goldstein M. Benign fat necrosis simulating bilateral breast malignancy after reduction mammoplasty. South Med J. Aug 1998;91(8):765-7. [Medline].
• Olson JA Jr, Morris EA, Van Zee KJ, et al. Magnetic resonance imaging facilitates breast conservation for occult breast cancer. Ann Surg Oncol. Jul 2000;7(6):411-5. [Medline].
• Orel SG, Reynolds C, Schnall MD, et al. Breast carcinoma: MR imaging before re-excisional biopsy. Radiology. Nov 1997;205(2):429-36. [Medline].
• Physicians Insurers Association of America. PIAA Breast Cancer Study. Washington, DC: Physician Insurers Association of America;1995.

Article Last Updated: Feb 15, 2006