ACR Appropriateness Criteria® Imaging After Mastectomy and Breast Reconstruction

Abstract

Mastectomy may be performed to treat breast cancer or as a prophylactic approach in women with a high risk of developing breast cancer. In addition, mastectomies may be performed with or without reconstruction. Reconstruction approaches differ and may be autologous, involving a transfer of tissue (skin, subcutaneous fat, and muscle) from other parts of the body to the chest wall. Reconstruction may also involve implants. Implant reconstruction may occur as a single procedure or as multistep procedures with initial use of an adjustable tissue expander allowing the mastectomy tissues to be stretched without compromising blood supply. Ultimately, a full-volume implant will be placed. Reconstructions with a combination of autologous and implant reconstruction may also be performed. Other techniques such as autologous fat grafting may be used to refine both implant and flap-based reconstruction. This review of imaging in the setting of mastectomy with or without reconstruction summarizes the literature and makes recommendations based on available evidence. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Disclaimer: The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient's clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient's condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.

Imaging Surveillance of the Reconstructed Breast in a Subset of Patients May Aid in Early Detection of Breast Cancer Recurrence

“…According to the American College of Radiology appropriateness criteria, mammography might be beneficial in patients reconstructed with autologous reconstructions due to the transposed fatty flap that provides an excellent contrast to detect an early abnormality in the reconstructed breast. [ 20 ] This is especially true if the abnormality is deeply located and clinically occult. In a recent study, screening mammograms were performed in autologous reconstructed breasts.…”

“…In a recent study, screening mammograms were performed in autologous reconstructed breasts. [ 20 ] Of the 485 women, 390 (80.4%) underwent three rounds of screening mammography, and breast cancer recurred in 13 of the 485 patients. [ 21 ] Mammography detected five occult cancers, and the median size of the cancers in the screened group was 0.8 cm (range, 0.5–1.6 cm) versus 2.2 cm (range, 1.3–3.0 cm) (P = 0.001) in the non-screened group.…”

Canadian Association of Radiologists Breast Disease Imaging Referral Guideline

“…We reviewed relevant recommendations related to the 20 clinical/diagnostic scenarios previously published by radiology and specialty societies, including: the Canadian Association of Radiologists, 10 the American College of Obstetricians and Gynecologists, 11,12 the American College of Physicians, 13,14 the American College of Radiology and Society of Breast Imaging, 15 the American College of Radiology, [16][17][18][19][20][21][22][23][24][25][26][27] the American Society of Clinical Oncology, 28 the Brazilian guideline, 29 the multi-organizational Brazilian guideline (Brazilian College of Radiology and Diagnostic 18 1. In pregnant people at high risk of breast cancer who choose to continue screening, we suggest mammography/DBT h screening and supplemental screening with US i (↑).…”

Multidisciplinary approach to imaging for gender-affirming surgery: engaging surgeons, radiologists, and patients to ensure a positive imaging experience

“…Small mammographic paddles may help to image residual tissue, but may be quite uncomfortable. Targeted diagnostic ultrasound is recommended for palpable abnormalities (15).…”