AJR 2004; 183:1810-1812
© American Roentgen Ray Society
Mammographic Appearance of Lymphedema in a TRAM-Reconstructed Breast
Arcel P. Deguzman1,
Kimmie L. Bui1,
Joanne J. Lenert2,
Jocelyn A. Rapelyea1 and
Rachel F. Brem1
1 Breast Imaging and Intervention Center, Department of Radiology, The George
Washington University Medical Center, 2150 Pennsylvania Ave., NW, Washington,
DC 20037.
2 Division of Plastic Surgery, Department of Surgery, The George Washington
University Medical Center, Washington, DC 20037.
Received November 24, 2003;
accepted after revision February 2, 2004.
Address correspondence to R. F. Brem.
Introduction
This report describes a novel mammographic appearance of a transverse
rectus abdominal muscle (TRAM) flap reconstruction, which mimics a diffuse
infiltrative process. Although the patient profiled in this case report had
bilateral TRAM reconstructions after mastectomies, the side with the axillary
lymph node dissection showed the edematous appearance, although the
contralateral reconstruction did not. Pathology showed dilated lymphatics on
the side with the edematous appearance. It is thought that the mammographic
and clinical findings are a result of dilated lymphatics due to the axillary
lymph node dissection. With the increase in mammography of autologous breast
reconstructions, it is important to recognize the mammographic manifestations
of the reconstructed breast.
Immediate breast reconstruction after mastectomy for breast cancer
treatment is known to be safe and psychologically beneficial for patients
[1,
2]. Breast reconstruction
therefore has become an important component of breast cancer management.
Autologous breast reconstruction has evolved rapidly as patients and surgeons
strive to avoid implant complications and to achieve long-lasting
reconstructions with natural appearance and feel. Many approaches to breast
reconstruction with autologous tissue have been described. The most widely
used is the transverse rectus abdominal muscle (TRAM) flap
[1]. Although imaging of the
reconstructed breast initially was not advocated, several recent reports have
described mammographic detection of recurrent breast cancer in TRAM flaps
[3,
4]. Therefore, the practice of
imaging breasts reconstructed with autologous tissue is gaining wider
acceptance, and there is a need to understand the mammographic appearance of
benign and malignant findings in these breasts
[4].
The spectrum of mammographic and sonographic findings after TRAM flap
reconstruction has not been described extensively. This case report describes
diffuse lymphatic dilatation and edema in a TRAM flap, which mimicked a
diffuse infiltrative breast cancer recurrence.
Case Report
A 43-year-old woman presented with a complaint of vague pain in the lateral
aspect of the left reconstructed breast 6 years after bilateral mastectomy and
free TRAM flap reconstruction. At initial presentation, the patient had a TNM
classification T1N0M0 1.1-cm infiltrating ductal carcinoma in the upper outer
quadrant of the left breast. The carcinoma was found incidentally during
sonography for an unrelated, clinically insignificant palpable thickening in
the lateral left breast. The patient underwent left modified radical
mastectomy with axillary lymph node dissection and prophylactic simple right
mastectomy. Immediate reconstruction with bilateral free TRAM flaps was
performed. The deep inferior epigastric artery and vein were anastomosed
end-to-end to the lateral thoracic thoracodorsalis artery and vein. The
postoperative course was unremarkable. Lymphovascular invasion was present on
final pathology, and the patient underwent chemotherapy without
complications.
The patient did well until 6 years after surgery when she developed
intermittent pain in the lateral portion of the reconstructed left breast.
Physical examination demonstrated normal skin bilaterally with no evidence of
focal mass. There was minimal evidence of edema in the inferior portion of the
left TRAM flap. The breast mound was soft without evidence of fat necrosis.
Sonography and mammography of the reconstructed right breast showed a normal
appearance of the right TRAM flap (Fig.
1A,
1B). Sonogram of the
reconstructed left breast also had a normal appearance. Mammography of the
reconstructed left breast showed diffuse increased density with the greatest
skin thickening in the anterior portion of the flap (Fig.
2A,
2B). The skin thickening
suggested a diffuse lymphatic breast cancer recurrence.
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Fig. 1A. —43-year-old woman with bilateral TRAM. Mammograms show normal
mammographic appearance in TRAM flap. Right mediolateral oblique (A)
and right craniocaudal (B) views show predominately fatty tissue with
anterior soft-tissue density.
|
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Fig. 1B. —43-year-old woman with bilateral TRAM. Mammograms show normal
mammographic appearance in TRAM flap. Right mediolateral oblique (A)
and right craniocaudal (B) views show predominately fatty tissue with
anterior soft-tissue density.
|
|
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Fig. 2A. —43-year-old woman with bilateral TRAM. Mammograms show
diffuse lymphedema in TRAM flap. Left mediolateral oblique (A) and left
craniocaudal (B) mammograms show skin thickening and diffuse increased
density throughout flap.
|
|
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[as a PowerPoint slide]
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Fig. 2B. —43-year-old woman with bilateral TRAM. Mammograms show
diffuse lymphedema in TRAM flap. Left mediolateral oblique (A) and left
craniocaudal (B) mammograms show skin thickening and diffuse increased
density throughout flap.
|
|
Incisional biopsy of the TRAM flap was taken from the lower inner quadrant
of the reconstructed left breast. Pathology findings showed markedly enlarged
lymphatic spaces and no evidence of breast cancer (Fig.
3A,
3B).
Discussion
The postoperative imaging of breasts reconstructed with TRAM flaps and
other autologous tissue constructs is becoming more common. Knowledge of the
varying appearance of the flap on imaging is vital to the identification of
both malignant and benign findings.
This case shows the mammography finding of diffuse edema suggestive of an
infiltrative cancer recurrence in a reconstructed breast. Pathology findings
in this case showed that the edema was a consequence of diffuse dilatation of
lymphatic spaces in the reconstructed breast. Of note is that the edema was
present on the left side, the side of the axillary lymph node dissection.
Imaging of the reconstructed breast on the contralateral side, where axillary
lymph node dissection was not done, appeared normal. Although arterial and
venous anastomoses are performed in a free TRAM flap reconstruction,
lymphatics are not connected. Reestablishment of lymphatic connections may
have been discouraged by interruption of lymphatic drainage following axillary
node dissection. Because there were no clinical findings to suggest edema and
because no prior postreconstruction imaging had been done, it is not known how
long the edema was present or whether the onset of pain was related to the
development of edema. It is not known whether the lymphatic dilatation was the
cause of the patient's pain, although it is unlikely because of the 7-year
interval between surgery and the initial presentation of the patient's pain.
To our knowledge, lymphedema in a TRAM flap reconstruction has not been
previously reported.
In summary, we report the unusual mammographic appearance of a TRAM flap
breast reconstruction in which the diffuse increased density was suggestive of
recurrent cancer due to benign dilatation of lymphatic spaces. This process
may be a consequence of axillary dissection at the time of mastectomy and
reconstruction. Awareness of the clinical and radiography findings associated
with this benign condition is valuable given the increasing use of
postreconstruction imaging.
References
- Malata CM, McIntosh SA, Purushotham AD. Immediate breast
reconstruction after mastectomy for cancer. Br J Surg2000; 87:1455
–1472[Medline]
- Wilkins EG, Cederna PS, Lowery JC, et al. Prospective analysis of
psychosocial outcomes in breast reconstruction: one-year postoperative results
from the Michigan Breast Reconstruction Outcome Study. Plast
Reconstr Surg 2000;106:1014
–1025[Medline]
- Helvie MA, Bailey JE, Roubidoux MA, et al. Mammographic screening
of TRAM flap breast reconstructions for detection of nonpalpable recurrent
cancer. Radiology2002; 224:211
–216[Abstract/Free Full Text]
- Hogge JP, Zuurbier RA, de Paredes ES. Mammography of autologous
myocutaneous flaps. RadioGraphics1999; 19:S63
–S72
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Introduction
Case Report
