DOI:10.2214/AJR.07.4051
AJR 2008; 191:1374-1380
© American Roentgen Ray Society
Variable Appearances of Fat Necrosis on Breast MRI
Caroline P. Daly1,2,
Barbara Jaeger1 and
David S. Sill1
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.
Received March 31, 2008;
accepted after revision May 20, 2008.
Address correspondence to C. P. Daly
(cpdaly{at}med.umich.edu).
CME
This article is available for CME credit.
See
www.arrs.org
for more information.
Abstract
OBJECTIVE. The purpose of this article is to illustrate the varying
appearances of fat necrosis on MRI.
CONCLUSION. Fat necrosis may mimic malignancy with varying
appearances on MRI. Suspicious morphologic and kinetic features may be
present, necessitating biopsy to exclude new or recurrent breast cancer.
Keywords: breast imaging • breast MRI • fat necrosis
Introduction
The use of contrast-enhanced breast MRI is rapidly increasing for both
diagnostic and screening indications. American Cancer Society guidelines are
now available for MRI screening of high-risk patients
[1]. One of the most rapidly
expanding indications for diagnostic breast MRI is staging of newly diagnosed
cancers and providing supplemental screening of the contralateral breast
[2]. MRI is already accepted as
the method of choice for evaluating occult cancer in patients with positive
axillary lymph nodes. The rapid expansion of MRI is promising because of its
high sensitivity and negative predictive value. Its specificity has been
reported to be more variable, although this may improve with standardized
protocols and increasing experience. Unfortunately, many benign lesions on MRI
may be indistinguishable from cancer, including fat necrosis.
Risk Factors
Fat necrosis is a relatively common benign entity in the breast, resulting
from a vascular insult to fat cells. The inciting event is often related to
blunt trauma—for example, a motor vehicle crash and seat-belt injury.
However, it is not unusual for patients presenting for breast MRI to have
undergone previous needle or surgical biopsy, lumpectomy, or reduction
mammoplasty. Reconstructed breasts, both with pedicled flaps and free flaps,
are also at risk for fat necrosis
[3,
4]. Radiation and subsequent
arteritis may also result in fat necrosis. A case report also implicates
heparin-induced thrombocytopenia
[5] as a cause. Concomitant
infection may further aggravate the development of fat necrosis. The degree
and appearance of enhancement on MRI appear to correlate with the stage of
development and the maturation of fat necrosis
[6].
Histopathology
A cascade of cellular events begins with the initial injury and results in
varying imaging appearances. Initially, fat cells and hemorrhage are
infiltrated by inflammatory cells, including histiocytes. Subsequently, fat
cells undergo liquefaction necrosis, and there is increased vascularization
and infiltration of fibroblasts, lymphocytes, and histiocytes that wall off
the focus of necrotic cellular debris. Proliferation of foreign body giant
cells with fibrosis eventually occurs. Ultimately, the focus of fat necrosis
may be replaced with a scar or persist as an oil cyst walled off by fibrous
tissue [7]. The stage of
development and the form of fat necrosis at the time of MRI affect the
appearance on imaging. The most avid enhancement usually occurs in the early
phase after the initial injury; as inflammatory changes resolve, the degree of
enhancement may decrease [8].
Variable appearances on MRI may include an oil cyst with or without
fat–fluid levels, focal scar, architectural distortion, and a spiculated
mass.
MRI Appearances of Fat Necrosis
Multiple reports regarding the MRI appearance of fat necrosis are now
available in the literature. Most descriptions are based on case reports
[9–13].
An excellent series of cases typical of fat necrosis in the postsurgical
breast are included in the atlas by Morris and Liberman
[6]. A few studies are also
available that address fat necrosis, most commonly regarding evaluation for
cancer recurrence in patients who have undergone breast conservation or flap
reconstruction [14,
15].
The most common MRI appearance is that of a lipid cyst. A round or oval
mass with hypointense T1-weighted signal on fat-saturated images is typical
(Fig. 1A,
1B,
1C). A fat–fluid level
may or may not be present. The rim of the mass commonly enhances, although to
varying degrees. The extent and avidity of enhancement may vary with the
proportion of acute and chronic inflammatory changes and granulation tissue. A
thin rim of enhancement is common. However, the rim may also be thick,
irregular, or spiculated, features that may be seen with recurrent or residual
cancer. Thin enhancing internal septations are also possible
[6]. The key to diagnosis is
assessing internal signal characteristics and enhancement of the mass: Fat
necrosis is usually nearly isointense to fat elsewhere in the breast.
Occasionally, the T1-weighted signal may be lower than that of fat elsewhere
in the breast, perhaps because of hemosiderin deposition and inflammatory
changes [8]. Unenhanced
non-fat-saturated T1-weighted images may be particularly helpful in
distinguishing fat necrosis from necrotic tumor. We now routinely perform this
sequence with an eye toward improving specificity because we have encountered
multiple cases of fat necrosis. Correlation with mammography can be extremely
helpful to establish the presence of a corresponding oil cyst or coarse
calcifications (Fig. 2A,
2B,
2C), findings that may obviate
biopsy.
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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.
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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.
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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.
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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.
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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.
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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.
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The specificity of MRI for fat necrosis may be improved by considering
several variables. The degree of lipid cyst formation is a key factor; oil
cysts with a thin rim of enhancement may be confirmed on non-fat-saturated
images. Lesion location in the breast is another factor affecting specificity.
A superficial location may prompt fat necrosis to be included in the
differential diagnosis, particularly if there is a history of blunt trauma
[16] (Figs.
3A,
3B,
3C and
4A,
4B,
4C). Fat necrosis is commonly
seen in the inferior, central breast after reduction mammoplasty. When present
in the reconstructed breast, fat necrosis is typically seen at the periphery
of the flap, which may have a more tenuous blood supply
[3,
4] (Fig.
1A,
1B,
1C). When multiple signs
typical of fat necrosis are present, such as a signal isointense to fat, a
thin rim of peripheral enhancement, superficial or peripheral location,
concordant history of trauma or surgery, or typical mammographic features such
as oil cyst or coarse calcifications, biopsy may be deferred
[17]. Routine or short-term
follow-up may be selected on the basis of the degree of confidence in the
imaging diagnosis.
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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).
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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.
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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.
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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.
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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).
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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.
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Unfortunately, there will be instances in which fat necrosis is
indistinguishable from cancer on MRI. Lesions with no gross lipid and a
preponderance of fibrosis can appear spiculated and nearly solid, suggesting
cancer rather than fat necrosis
[12] (Figs.
5A,
5B,
5C,
5D and
6A,
6B,
6C). Kinetic analysis also may
be of little help. Fat necrosis exhibits the full spectrum of benign and
malignant enhancement patterns, including rapid and slow initial phase
enhancement and progressive, plateau, and washout delayed kinetics
[14]. An additional factor
confounding specificity is that fat necrosis may show 18F-FDG
avidity on PET (Fig. 6A,
6B,
6C). Interpretation of
corresponding findings on MRI may increase suspicion for cancer rather than an
inflammatory process. Fat necrosis may also have differing appearances in the
same patient [6] (Fig.
7A,
7B,
7C,
7D), leading the reader away
from the diagnosis of fat necrosis.
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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.
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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).
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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.
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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.
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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.
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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.
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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.
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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.
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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).
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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.
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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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Enhancement may persist for years after surgery, depending on the amount of
inflammatory infiltrate and granulation tissue
[12] (Fig.
5A,
5B,
5C,
5D). Should active
inflammation persist, this appearance may not change significantly over time.
Unfortunately, there is little or no information in the existing literature
regarding the MRI appearance of fat necrosis on follow-up studies
[8] or the frequency with which
it should be followed up. However, we may infer from the mammography
literature that some fat necrosis may continue to evolve over time and assume
a more benign appearance (e.g., less enhancement) should inflammation
resolve.
When fat necrosis cannot be confidently established as the diagnosis on the
basis of imaging, biopsy should be pursued to confirm histology. Patient
factors may also affect decision making; for example, patients at high risk
for recurrence or who present with palpable complaints may require biopsy.
Biopsy is especially critical for genetically high-risk and known cancer
patients who may be considering mastectomy.
Conclusion
Fat necrosis has long been known to be a great mimic of breast cancer on
mammography and sonography; MRI has proven to be no exception to this rule.
Certain benign features may suggest the diagnosis of fat necrosis and, in the
setting of a concordant clinical history, short-term follow-up may be
appropriate. As we become more familiar with the variable appearances of fat
necrosis, biopsy may be deferred in certain cases. However, considerable
morphologic and kinetic overlap is seen between fat necrosis and breast
cancer. Lesions with suspicious morphologic or kinetic features may
necessitate biopsy to exclude new or recurrent cancer, particularly in
patients who are considering mastectomy.
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Abstract
Introduction
