DOI:10.2214/AJR.08.1041
AJR 2008; 191:1371-1373
© American Roentgen Ray Society
Malignant-Appearing Microcalcifications at the Lumpectomy Site with the Use of FloSeal Hemostatic Sealant
Amy Henkel1,
Richard A. Cooper1,
Kathleen A. Ward1,
Davide Bova1 and
Katharine Yao2
1 Department of Radiology, Loyola University, 2160 S First Ave., Maywood, IL
60153.
2 Department of Surgery, Loyola University, Maywood, IL.
Received April 9, 2008;
accepted after revision May 23, 2008.
Address correspondence to A. Henkel
(aehenkel{at}lumc.edu).
Abstract
OBJECTIVE. The aim of this article is to describe the benign
mammographic calcifications that occur at the lumpectomy site after the use of
a topical hemostatic sealant (FloSeal Matrix Hemostatic Sealant). These
calcifications can have an appearance similar to that of recurrent
carcinoma.
CONCLUSION. Application of FloSeal hemostatic sealant in the
lumpectomy cavity results in benign mammographic microcalcifications that
could be misinterpreted as malignant.
Keywords: breast cancer • breast imaging • hemostatic sealant • mammography • microcalcifications
Introduction
Mammographic surveillance after breast-conserving surgery is performed to
detect local recurrence, residual disease in the setting of positive
pathologic margins, and second primary breast cancers. In its current
guidelines, the American Society of Clinical Oncology
[1] recommends annual
mammography but no earlier than 6 months after definitive surgery and
radiation therapy. Microcalcifications in the lumpectomy site on a
postoperative mammogram can indicate residual or recurrent cancer. Here, we
present seven cases from our institution in which a topical hemostatic agent
(FloSeal Matrix Hemostatic Sealant, Baxter International) used during
lumpectomy mimicked the appearance of malignant microcalcifications on
mammography.
Achieving hemostasis is a concern of all surgeons, particularly in
breast-conserving surgery or lumpectomy in which a large hematoma can distort
the appearance of the breast and make follow-up more difficult. FloSeal is one
of a variety of topical hemostatic agents used as a surgical adjunct to
conventional methods of achieving hemostasis. It falls under a subcategory of
hemostatic agents that use a collagen-based matrix
[2]. FloSeal consists of two
products—a proprietary gelatin matrix and a dehydrated topical
thrombin—that are combined immediately before use. The collagen expands
to conform to irregular surgical cavities and the thrombin and gelatin
granules promote clot formation. The U.S. Food and Drug Administration has
approved FloSeal for achieving hemostasis in a variety of surgical settings.
Myriad uses and potential uses for FloSeal have been described, including in
the fields of urology, for nephrectomy and partial nephrectomy, and in
cardiovascular and peripheral vascular surgery
[2–6].
Materials and Methods
Recently at our institution, FloSeal was used for hemostasis during seven
lumpectomies performed for treatment of breast cancer. These cases are not the
first reported use of a hemostatic agent in breast surgery; a meta-analysis
investigating the use of fibrin sealants to prevent seroma after lumpectomy
was reported in 2006 [7]. The
products used in those studies
[7] differ from FloSeal in that
they are fibrin based instead of thrombin based and do not contain a gelatin
matrix. There was no mention of mammographic abnormalities after the use of
those fibrin agents.
Results
In our experience, follow-up mammograms for all seven patients in whom
FloSeal was used showed innumerable punctuate radiopaque densities throughout
the lumpectomy site that mimicked the appearance of malignant
microcalcifications. These microcalcifications were observed on the 6-month
follow-up mammogram in six patients. In the seventh patient, the
microcalcifications were observed on a mammogram obtained 1 month after
lumpectomy before radiation therapy to evaluate for residual malignant
calcifications (Figs. 1A,
1B and
2A,
2B). This finding contributed
to the decision to perform reexcision lumpectomy in this seventh patient, and
pathology results revealed numerous benign microcalcifications. In another
case, the calcifications were slightly fewer in number on the mammogram 1 year
after lumpectomy than on the initial 6-month postoperative study, suggesting
that they may eventually be reabsorbed. However, the risk for recurrent
disease after treatment of breast cancer is highest in the first 5 years after
surgery [8].
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Fig. 1A —56-year-old woman 1 month after lumpectomy and application of
FloSeal Matrix Hemostatic Sealant (Baxter International). Magnification
craniocaudal (A) and mediolateral (B) views of lumpectomy site
show pseudomalignant calcifications at lumpectomy site.
|
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Fig. 1B —56-year-old woman 1 month after lumpectomy and application of
FloSeal Matrix Hemostatic Sealant (Baxter International). Magnification
craniocaudal (A) and mediolateral (B) views of lumpectomy site
show pseudomalignant calcifications at lumpectomy site.
|
|
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Fig. 2A —61-year-old woman 5 months after lumpectomy and application
of FloSeal Matrix Hemostatic Sealant (Baxter International). Magnification
craniocaudal (A) and mediolateral (B) views show pseudomalignant
calcifications at lumpectomy site.
|
|
View larger version (134K):
[in this window]
[in a new window]
[as a PowerPoint slide]
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Fig. 2B —61-year-old woman 5 months after lumpectomy and application
of FloSeal Matrix Hemostatic Sealant (Baxter International). Magnification
craniocaudal (A) and mediolateral (B) views show pseudomalignant
calcifications at lumpectomy site.
|
|
Discussion
We applied FloSeal to an excised breast specimen but saw no microcalcific
densities when the specimen underwent both analog and digital examination.
Therefore, we conclude that the development of calcifications is a response to
FloSeal that requires a living host.
In conclusion, the gelatin matrix and thrombin-based hemostatic agent
FloSeal applied at a lumpectomy site mimics the appearance of malignant
microcalcifications on mammography, thus limiting evaluation for residual or
recurrent disease and is not recommended for use on breast tissue.
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Abstract
Introduction
