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Variable Appearances of Fat Necrosis on Breast MRI

¹ Department of Radiology, Mercy Medical Center, Baltimore, MD 21202.
² Present address: Department of Radiology, University of Michigan Health System, TC2910R, 1500 E Medical Center Dr., Ann Arbor, MI 48109.

View larger version (79K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A —60-year-old woman with a history of right mastectomy for recurrent extensive ductal carcinoma in situ followed by deep inferior epigastric perforator (DIEP) flap reconstruction. MRI was performed for 6-month follow-up of the contralateral left breast, which had probably benign enhancing foci on initial staging MRI. Axial T1-weighted 3D maximum-intensity-projection contrast-enhanced image with subtraction shows oval masslike enhancement in the reconstructed breast.

View larger version (77K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B —60-year-old woman with a history of right mastectomy for recurrent extensive ductal carcinoma in situ followed by deep inferior epigastric perforator (DIEP) flap reconstruction. MRI was performed for 6-month follow-up of the contralateral left breast, which had probably benign enhancing foci on initial staging MRI. From left: Axial T1-weighted fat-saturated unenhanced, axial T2-weighted fat-saturated, and axial T1-weighted fat-saturated contrast-enhanced images with subtraction show thick, irregular rim enhancement in the inferior right breast. Central signal is isointense to fat elsewhere in the breast.

View larger version (157K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1C —60-year-old woman with a history of right mastectomy for recurrent extensive ductal carcinoma in situ followed by deep inferior epigastric perforator (DIEP) flap reconstruction. MRI was performed for 6-month follow-up of the contralateral left breast, which had probably benign enhancing foci on initial staging MRI. Sagittal T1-weighted fat-saturated contrast-enhanced image shows enhancing fat necrosis (arrowhead) at the periphery of the DIEP flap. Clinical management: Fat necrosis was included in the differential diagnosis because of peripheral location in the flap and fat signal in the mass; however, biopsy was recommended because of thick, irregular rim enhancement and patient risk factors. Core needle biopsy showed fat necrosis with histiocytic infiltrate and focal foreign body giant cell reaction.

View larger version (83K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A —55-year-old woman with newly diagnosed recurrent ductal carcinoma in situ in the right breast. MRI was performed before surgery. Axial maximum-intensity-projection contrast-enhanced image with subtraction shows clumped enhancement (arrow) posterior to left nipple.

View larger version (99K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B —55-year-old woman with newly diagnosed recurrent ductal carcinoma in situ in the right breast. MRI was performed before surgery. Clockwise from top left: Axial T1-weighted unenhanced, axial T1-weighted fat-saturated, axial T1-weighted fat-saturated contrast-enhanced, and axial T1-weighted contrast-enhanced with subtraction images show clumped enhancement in the superficial subareolar region and a subtle focus of hypoenhancement (arrow) in the center that is best appreciated on subtraction.

View larger version (118K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2C —55-year-old woman with newly diagnosed recurrent ductal carcinoma in situ in the right breast. MRI was performed before surgery. Coned mediolateral oblique mammogram shows coarse calcifications (arrow) consistent with fat necrosis in the subareolar region corresponding to hypoenhancement on MRI. Clinical management: This lesion is being followed on a short-term basis due to correlative findings on mammography.

View larger version (83K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A —46-year-old woman with multifocal left breast cancer. MRI was performed for staging and evaluation of contralateral breast before surgery. Axial maximum-intensity-projection contrast-enhanced image with subtraction shows multifocal enhancement in the left breast consistent with known cancer. Tiny foci of enhancement are also present in the subareolar right breast (arrowhead).

View larger version (45K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B —46-year-old woman with multifocal left breast cancer. MRI was performed for staging and evaluation of contralateral breast before surgery. From left: Sagittal T1-weighted fat-saturated unenhanced, contrast-enhanced, and subtraction images show a 5-mm focus of enhancement (circle) in the superficial aspect of the breast just beneath the skin.

View larger version (26K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3C —46-year-old woman with multifocal left breast cancer. MRI was performed for staging and evaluation of contralateral breast before surgery. Kinetic analysis shows intermediate initial enhancement, late-phase bowing, and mild (58%) washout. Clinical management: This patient did not recall a history of trauma. Biopsy was recommended because of multifocal cancer in the contralateral breast, isolated enhancement in the right breast, and suspicious kinetics. Needle localization biopsy showed benign breast tissue with fat necrosis.

View larger version (81K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4A —64-year-old woman with the history of cancer in upper outer quadrant after lumpectomy for breast cancer and subsequent benign biopsy in the medial breast showing fat necrosis. Patient presents for evaluation of a new palpable left medial breast mass. Mammographic findings are benign. Axial maximum-intensity-projection contrast-enhanced image with subtraction shows an isolated focus of enhancement (arrowhead) in the medial breast in the area of palpable concern.

View larger version (48K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4B —64-year-old woman with the history of cancer in upper outer quadrant after lumpectomy for breast cancer and subsequent benign biopsy in the medial breast showing fat necrosis. Patient presents for evaluation of a new palpable left medial breast mass. Mammographic findings are benign. Focus of enhancement on T1-weighted fat-saturated subtracted image (arrow, right) is near the previous biopsy clip site, noted by dephasing artifact on unenhanced T1-weighted image (arrow, left).

View larger version (24K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4C —64-year-old woman with the history of cancer in upper outer quadrant after lumpectomy for breast cancer and subsequent benign biopsy in the medial breast showing fat necrosis. Patient presents for evaluation of a new palpable left medial breast mass. Mammographic findings are benign. Kinetic analysis shows slow initial enhancement and mild delayed washout. Clinical management: Biopsy was performed because of palpable findings, isolated enhancement, and patient risk factors. Based on our current understanding of MRI appearances of fat necrosis, this lesion could have been followed up because of the proximity to the previous biopsy site. Histology showed fibrosis, fat necrosis, and chronic inflammation.

View larger version (68K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5A —45-year-old woman with history of right breast cancer treated with lumpectomy and radiation therapy in 2002. Patient presents for follow-up 5 years later. Axial maximum-intensity-projection contrast-enhanced image with subtraction shows two sites of enhancement in the right breast. The lumpectomy bed (arrowhead) is centrally located with probably benign enhancement. Additional enhancement (arrow) is present in the axillary tail.

View larger version (86K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5B —45-year-old woman with history of right breast cancer treated with lumpectomy and radiation therapy in 2002. Patient presents for follow-up 5 years later. Enhancement in the axillary tail on T1-weighted subtracted image (right) corresponds to scar on axial T2-weighted fat-saturated image at the site of a previous surgical biopsy (arrow, left).

View larger version (84K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5C —45-year-old woman with history of right breast cancer treated with lumpectomy and radiation therapy in 2002. Patient presents for follow-up 5 years later. Sagittal T1-weighted fat-saturated contrast-enhanced image shows linear, clumped enhancement (arrow) in the axillary tail.

View larger version (20K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5D —45-year-old woman with history of right breast cancer treated with lumpectomy and radiation therapy in 2002. Patient presents for follow-up 5 years later. Kinetic analysis shows rapid initial enhancement (248%) with plateau delayed phase. Clinical management: Although fat necrosis may be considered in the differential diagnosis because of history of biopsy, no typical features of fat necrosis (e.g., oil cyst) were evident. This lesion was considered suspicious because of both kinetic and morphologic features. Core needle biopsy showed necrosis of fat associated with acute and chronic inflammation.

View larger version (73K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6A —48-year-old woman with history of metaplastic left breast cancer treated with lumpectomy, chemotherapy, and radiation therapy 2 years earlier. Coned mediolateral oblique mammogram shows expected posttherapeutic changes. Lumpectomy bed is stable compared with older studies.

View larger version (58K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6B —48-year-old woman with history of metaplastic left breast cancer treated with lumpectomy, chemotherapy, and radiation therapy 2 years earlier. Fluorine-18-FDG PET scans were obtained for follow-up of liver metastasis. From left: Pretreatment, postlumpectomy, and follow-up FDG PET scans show faint but increasing uptake (arrowhead) in the lumpectomy bed. MRI was subsequently requested for further evaluation.

View larger version (58K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6C —48-year-old woman with history of metaplastic left breast cancer treated with lumpectomy, chemotherapy, and radiation therapy 2 years earlier. From left: Sagittal T1-weighted fat-saturated unenhanced, contrast-enhanced, and subtraction images. Irregular rim enhancement (arrowheads) is present at the lumpectomy site, particularly along the superior margin corresponding to uptake on PET scan. Clinical management: Biopsy was recommended despite stable mammogram and intralesional fat signal due to thick irregular enhancement on MRI and corresponding uptake on FDG PET scan; findings were suspicious for cancer recurrence. Reexcision of the lumpectomy site was negative for cancer and showed posttreatment changes, including fibrosis, necrosis of fat, chronic inflammation, and foreign body giant cell reaction.

View larger version (145K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7A —53-year-old woman with history of right lumpectomy and radiation in the upper outer quadrant 7 months earlier. Magnification lateral mammogram shows suspicious calcifications (arrow) in the lumpectomy bed.

View larger version (79K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7B —53-year-old woman with history of right lumpectomy and radiation in the upper outer quadrant 7 months earlier. Axial maximum-intensity-projection contrast-enhanced image with subtraction shows small mass (arrowhead) in the upper outer quadrant adjacent to focal clumped enhancement (dotted line) anterior to the lumpectomy bed (solid line).

View larger version (53K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7C —53-year-old woman with history of right lumpectomy and radiation in the upper outer quadrant 7 months earlier. From left: Sagittal T1-weighted fat-saturated unenhanced, contrast-enhanced, and subtraction images show focal clumped enhancement (arrow) anterior to lumpectomy bed (solid line) corresponding to calcifications on mammography.

View larger version (21K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7D —53-year-old woman with history of right lumpectomy and radiation in the upper outer quadrant 7 months earlier. Kinetic analysis of the mass lateral to the lumpectomy bed shows slow initial enhancement and plateau delayed enhancement. Clinical management: These lesions were considered suspicious for recurrence on basis of masslike and clumped enhancement along the border of the lumpectomy bed, especially with new calcifications on mammography. No typical morphologic features of fat necrosis were present in either lesion. Biopsies of calcifications, the mass, and clumped enhancement showed fibrosis, fat necrosis, and giant cell reaction with focal calcifications.

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