Case Report
Sonographic Diagnosis of Abscess Following Breast-Conserving Surgery with Insertion of Nonabsorbable Mesh Sung Eun Song, MD, PhD,1 Bo Kyoung Seo, MD, PhD,1 Gil-Soo Son, MD, PhD,2 Young-Sik Kim, MD, PhD3 1
Department of Radiology, Korea University Ansan Hospital, Korea University College of Medicine, Ansan-city, Kyunggi-do, Korea 2 Department of General Surgery, Korea University Ansan Hospital, Korea University College of Medicine, Ansan-city, Kyunggi-do, Korea 3 Department of Pathology, Korea University Ansan Hospital, Korea University College of Medicine, Ansan-city, Kyunggi-do, Korea Received 9 May 2013; accepted 18 February 2014
ABSTRACT: Immediate mesh insertion has been recently used for breast reconstruction after breastconserving surgery. We report a case of abscess formation following immediate nonabsorbable mesh insertion with breast-conserving surgery. In this article, we demonstrate multimodal breast imaging features and pathologic correlations of the case. In addition, we illustrate characteristic sonographic findings of nonabsorbable mesh fibers to differentiate them from a gossypiboma caused by a retained surgical sponge or C 2014 Wiley Periodicals, Inc. J Clin tumor recurrence. V Ultrasound 42:439–443, 2014; Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/jcu.22148 Keywords: breast; mesh; abscess; ultrasonography; CT; MR
B
reast conserving surgery (BCS) is now a standard surgical treatment for early breast cancer.1 BCS achieves an equivalent long-term survival rate and a better cosmetic outcome, when compared with mastectomy.2,3 However, poor patient satisfaction due to breast deformity is still a continuing problem, especially in patients with small breasts, large tumors, or tumors in the inner quadrant.4 Breast reconstruction using various tissue flaps or artificial prostheses has been performed to maintain the appearance of the breast. Correspondence to: B. K. Seo C 2014 Wiley Periodicals, Inc. V
VOL. 42, NO. 7, SEPTEMBER 2014
Mesh, of which there are two types (ie, absorbable and nonabsorbable), is an ideal alternative for volume replacement after BCS. Absorbable mesh has been widely used for breast reconstruction. However, complication rates after absorbable mesh insertion have varied from 2.9% to 14.3%.5–8 According to Koo et al.,6 follow-up results showed noticeable side effects. Therefore, mesh insertion should be considered only in select cases. There have been reports of satisfactory long-term results of nonabsorbable mesh insertion in the breasts.9–11 Nonabsorbable mesh was used in mastopexy to repair breast ptosis in those reports. In our hospital, nonabsorbable mesh has been used instead of absorbable mesh for breast reconstruction after BCS to reduce complications. In this article, we report a case of abscess formation following nonabsorbable mesh insertion with BCS. We demonstrate multimodal breast imaging features and pathologic correlations of the case. In addition, we illustrate characteristic ultrasound findings of nonabsorbable mesh fiber structures to differentiate them from absorbable mesh or gossypiboma.
CASE REPORT
A 49-year-old woman presented with a 1.7-cm invasive ductal carcinoma in the lower inner quadrant of the left breast. She underwent BCS with immediate mesh insertion. The tumor was 439
SONG ET AL
FIGURE 1. Postcontrast CT scan shows a circumscribed, oval-shaped cystic mass (arrows) without enhancement at the operation site of the left breast, suggesting seroma.
FIGURE 3. Transverse (A) and longitudinal (B) sonograms demonstrate a cystic mass (arrows) with internal hyperechoic whirling band-like meshwork (arrowheads) at the operation site of the left breast. The band-like structures have even thickness and regular pores, which suggest embedded mesh. FIGURE 2. At the operation site, a hard palpable mass (arrows) with erythematous skin changes and discharge are seen, suggesting infection.
triple negative and estrogen, progesterone, and human epidermal growth factor receptor-2 were all negative. We used soft-knitted polyester mesh (Parietex Composite; Covidien, Dublin, Ireland) for reconstruction. After surgery, a CT scan was performed to obtain cross-section images of the operation site for planning of radiation therapy. Postcontrast-enhanced CT scan showed a circumscribed, oval-shaped, cystic mass without enhancement at the operation site of the left breast, suggesting seroma (Figure 1). The patient received radiation therapy consisting of 60 Gy in 30 fractions. Four months after initiation of radiation therapy, she complained of a hard palpable mass with erythematous skin changes and discharge at the operation site (Figure 2). Breast ultrasound examination was performed with a 6–15-MHz 440
linear transducer (LOGIQ 9 unit; GE Medical Systems, Milwaukee, WI). On ultrasound, there was a well-encapsulated cystic mass with internal hyperechoic whirling bands characteristic of meshwork at the operation site (Figure 3). The band-like structures on ultrasound had even thickness and regular pores, which suggested embedded mesh. For assessment of infection or tumor recurrence, CT and MRI were performed with a 64-channel multidetector CT scan and a 3 T MRI unit. On postcontrast CT scan, the previously noted seroma had changed: the mass had thin-rimmed enhancement with surrounding tissue infiltration and overlying skin thickening (Figure 4). The T2-weighted MRI revealed an internal wavy band-like meshwork within the cystic mass (Figure 5). After we reviewed the multimodal breast imaging, we thought the cystic mass might be an abscess formation, so we recommended surgical intervention. Furthermore, we speculated that the internal, wavy, band-like structures were preserved JOURNAL OF CLINICAL ULTRASOUND
BREAST IMAGING OF MESH INSERTION
FIGURE 4. On follow-up CT scan, the previously noted seroma had become a cystic mass (arrows) with thin smooth rim enhancement. Surrounding tissue infiltration and overlying skin thickening are also seen.
FIGURE 5. On T2-weighted MRI, the cystic mass (arrows) shows internal, wavy, hypointense bands (black arrowheads).
nonabsorbable mesh rather than retained surgical sponge because the band-like structures had a regular thickness and internal pores on T2-weighted MRI and breast ultrasound. Most compellingly, breast ultrasound revealed internal morphology of the meshwork in detail. Surgical excision was performed, and mesh and inflammatory tissues were removed. The removed gross specimen showed that the embedded mesh was well preserved with characteristic regular pores within the breast (Figure 6). On pathologic examination, nonabsorbable mesh fibers and multinucleated giant cells ingesting the mass are noted (Figure 7). These findings are compatible with abscess formation with fibrosis and foreign body reaction.
DISCUSSION
Oncoplastic surgery, defined as the combination of tumor excision and immediate reconstruction VOL. 42, NO. 7, SEPTEMBER 2014
FIGURE 6. Photograph of the gross surgical specimen shows that the embedded mesh is well preserved with its characteristic pores.
FIGURE 7. Nonabsorbable mesh fibers (arrows) and multinucleated giant cells (arrowheads) ingesting the fibers are noted on pathologic examination (hematoxylin and eosin stain, 3200). These findings are compatible with abscess with fibrosis and a foreign body reaction.
of the breast, has been widely used for its achievement of oncological safety margins and satisfactory cosmetic results. For large-volume defects, flap reconstruction is suitable, but operation time is relatively long, and flap loss or contraction is possible.12 Immediate mesh insertion has been used since 2003 for patients with largevolume defect, for defects located in the inner portions of the breast, and for small breast.4,5,7,13 Various kinds of materials have been used to manufacture both absorbable and nonabsorbable mesh. In absorbable mesh, polyglactin or polyglycolic acid is commonly used in breast reconstruction.5,12,13 The absorbable mesh may enable the breast to maintain its shape after excision by forming reactive fluid with 441
SONG ET AL
FIGURE 8. A 48-year-old woman with an uncomplicated case of nonabsorbable mesh insertion after BCS. Transverse sonogram demonstrates an indistinct oval hypoechoic mass (arrows) without fluid collection.
capsulation. In this case, inserted mesh is gradually absorbed.14 According to Kwag,15 breast size decreased approximately 47% by 12 months after surgery. Furthermore, Lee et al7 demonstrated that absorbable mesh insertion has a higher complication rate and no cosmetic gain when compared with a BCS-only without mesh insertion. Decrease in volume and changes in breast shape are common problems of absorbable mesh, which have an influence on the patients’ satisfaction.7,14,16 Infection or recurrent mastitis often occurs after absorbable mesh insertion due to reactions with foreign materials. In addition, cancer surveillance with breast imaging or physical examination to detect tumor recurrence may be difficult after absorbable mesh insertion.5 To overcome disadvantages of absorbable mesh, nonabsorbable mesh has been used in breast surgery.9–11 Polyester and polypropylene have been used as nonabsorbable mesh materials. In this report, we used polyester mesh. After insertion of the polyester mesh, the mesh embedded in adipose tissue and was surrounded by a thin layer of reactive histologically collagenous tissue.10 Polyester mesh has advantages for complete tissue integration and improving clinical outcomes. First, hydrophilic polyester encourages cells to adhere and spread, establishing fast and complete tissue in-growth. Second, the knitting technology creates various pores for true connective tissue differentiation. Last, polyester mesh has high compliance with multidirectional elasticity. Figure 8 demonstrates ultrasound imaging in an uncomplicated case of polyester mesh insertion after BCS in our hospital. There is no fluid collection and the internal meshwork structure is not clearly visualized. 442
In our case, postoperative seroma arose from the mesh insertion site before radiation therapy, and there was no serious shrinkage of breast volume. However, postoperative seroma changed into an abscess with inflammatory skin change after radiation therapy. Receiving radiation therapy may have led to either dermatitis or mastitis, resulting in inflammation of seroma. Known risk factors after absorbable mesh infection include a high body mass index, early initiation of radiation therapy after surgery, tumors located in the inner lower sides of the breasts, and previous history of autoimmune or allergic diseases.8,13 This patient had three risk factors for infection: tumors located in the inner lower side of the breast, previous history of rheumatoid arthritis, and radiation therapy. Although there is no comparative study regarding clinical complications of absorbable versus nonabsorbable mesh use in the breast, these infection risk factors may be related to each other. Abscess formation after mesh insertion and BCS should be differentiated from a gossypiboma caused by a retained surgical sponge or tumor recurrence. Multimodal breast imaging including ultrasound, CT, or MRI is helpful in solving this problem. A well-defined round or oval mass with strong rim enhancement on contrast-enhanced CT or MRI suggests an abscess or gossypiboma.17 On MRI, both abscess and gossypiboma may have internal, wavy, low signal intensity stripes on T2weighted imaging, which represent the gauze or mesh fibers. Based on our case, ultrasound is very effective to demonstrate the detailed internal structure of a cystic mass and to discriminate between abscess formation after mesh insertion and gossypiboma. Ultrasound shows internal wavy band-like structures with a regular thickness and internal pores, which represent inserted nonabsorbable mesh. Posterior acoustic shadowing, calcifications, or air bubbles suggest gossypiboma.17–19 In absorbable mesh, detail of mesh fibers cannot be evaluated on breast imaging because mesh is gradually absorbed and consequently smaller on follow-up series.15 We report a case with abscess formation following nonabsorbable mesh insertion after BCS. Although nonabsorbable mesh insertion is safe and effective in breast reconstruction, it should be performed carefully in patients at high risk of infection. Multimodal breast imaging is very useful to differentiate abscess formation from gossypiboma or tumor recurrence after mesh insertion and BCS. In particular, ultrasound illustrates the embedded nonabsorbable mesh structure in detail. JOURNAL OF CLINICAL ULTRASOUND
BREAST IMAGING OF MESH INSERTION REFERENCES 1. Veronesi U, Cascinelli N, Mariani L, et al. Twentyyear follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer. N Engl J Med 2002;347:1227. 2. Vallejo da Silva A, Destro C, Torres W. Oncoplastic surgery of the breast: rationale and experience of 30 cases. Breast 2007;16:411. 3. Fisher B, Bauer M, Margolese R, et al. Five-year results of a randomized clinical trial comparing total mastectomy and segmental mastectomy with or without radiation in the treatment of breast cancer. N Engl J Med 1985;312:665. 4. Fujishiro S, Mitsumori M, Kokubo M, et al. Cosmetic results and complications after breast conserving therapy for early breast cancer. Breast Cancer 2000;7:57. 5. Kim KS, Park MY, Kim WJ, et al. Nationwide survey of the use of absorbable mesh in breast surgery in Korea. J Breast Cancer 2009;12:210. 6. Koo MY, Lee SK, Hur SM, et al. Results from over one year of follow-up for absorbable mesh insertion in partial mastectomy. Yonsei Med J 2011;52:803. 7. Lee A, Won Hwang H, Chang J, et al. Outcomes of breast conserving surgery with immediate vicrylmesh insertion: is it safe and effective? Breast J 2012;18:334. 8. Cho JS, Shin SH, Park JY, et al. Analysis of infections occurring in breast cancer patients after breast conserving surgery using mesh. J Breast Cancer 2011;14:328. 9. de Bruijn HP, Johannes S. Mastopexy with 3D preshaped mesh for long-term results: development of the internal bra system. Aesthetic Plast Surg 2008;32:757. 10. de Bruijn HP, ten Thije RH, Johannes S. Mastopexy with mesh reinforcement: the mechanical
VOL. 42, NO. 7, SEPTEMBER 2014
11.
12.
13.
14.
15.
16.
characteristics of polyester mesh in the female breast. Plast Reconstr Surg 2009;124:364. van Deventer PV, Graewe FR, W€ uringer E. Improving the longevity and results of mastopexy and breast reduction procedures: reconstructing an internal breast support system with biocompatible mesh to replace the supporting function of the ligamentous suspension. Aesthetic Plast Surg 2012;36:578. Sanuki J, Fukuma E, Wadamori K, et al. Volume replacement with polyglycolic acid mesh for correcting breast deformity after endoscopic conservative surgery. Clin Breast Cancer 2005;6:175. Lee JH, Hong YI, Jeong JH, et al. Volume replacement with polyglactin 910 mesh for breast reconstruction after endoscopy-assisted breast conserving surgery for treating early breast cancer: the early results. J Breast Cancer 2009;12: 193. Klinge U, Schumpelick V, Klosterhalfen B. Functional assessment and tissue response of shortand long-term absorbable surgical meshes. Biomaterials 2001;22:1415. Kwag HJ. Imaging findings of implanted absorbable mesh in patients with breast partial resection. Yonsei Med J 2008;49:111. Dieterich M, Reimer T, Dieterich H, et al. A shortterm follow-up of implant based breast reconstruction using a titanium-coated polypropylene mesh (TiLoopV Bra). Eur J Surg Oncol 2012;38:1225. Kul S, G€ unes G. Gossypiboma of the breast: imaging findings. J Radiol Case Rep 2010;4:21. Manzella A, Filho PB, Albuquerque E, et al. Imaging of gossypibomas: pictorial review. AJR Am J Roentgenol 2009;193:S94. Fornage BD. Sonographic diagnosis of a retained surgical sponge in the breast. J Clin Ultrasound 1987;15:285. R
17. 18.
19.
443
Sonographic Diagnosis of Abscess Following Breast-Conserving Surgery with Insertion of Nonabsorbable Mesh Sung Eun Song, MD, PhD,1 Bo Kyoung Seo, MD, PhD,1 Gil-Soo Son, MD, PhD,2 Young-Sik Kim, MD, PhD3 1
Department of Radiology, Korea University Ansan Hospital, Korea University College of Medicine, Ansan-city, Kyunggi-do, Korea 2 Department of General Surgery, Korea University Ansan Hospital, Korea University College of Medicine, Ansan-city, Kyunggi-do, Korea 3 Department of Pathology, Korea University Ansan Hospital, Korea University College of Medicine, Ansan-city, Kyunggi-do, Korea Received 9 May 2013; accepted 18 February 2014
ABSTRACT: Immediate mesh insertion has been recently used for breast reconstruction after breastconserving surgery. We report a case of abscess formation following immediate nonabsorbable mesh insertion with breast-conserving surgery. In this article, we demonstrate multimodal breast imaging features and pathologic correlations of the case. In addition, we illustrate characteristic sonographic findings of nonabsorbable mesh fibers to differentiate them from a gossypiboma caused by a retained surgical sponge or C 2014 Wiley Periodicals, Inc. J Clin tumor recurrence. V Ultrasound 42:439–443, 2014; Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/jcu.22148 Keywords: breast; mesh; abscess; ultrasonography; CT; MR
B
reast conserving surgery (BCS) is now a standard surgical treatment for early breast cancer.1 BCS achieves an equivalent long-term survival rate and a better cosmetic outcome, when compared with mastectomy.2,3 However, poor patient satisfaction due to breast deformity is still a continuing problem, especially in patients with small breasts, large tumors, or tumors in the inner quadrant.4 Breast reconstruction using various tissue flaps or artificial prostheses has been performed to maintain the appearance of the breast. Correspondence to: B. K. Seo C 2014 Wiley Periodicals, Inc. V
VOL. 42, NO. 7, SEPTEMBER 2014
Mesh, of which there are two types (ie, absorbable and nonabsorbable), is an ideal alternative for volume replacement after BCS. Absorbable mesh has been widely used for breast reconstruction. However, complication rates after absorbable mesh insertion have varied from 2.9% to 14.3%.5–8 According to Koo et al.,6 follow-up results showed noticeable side effects. Therefore, mesh insertion should be considered only in select cases. There have been reports of satisfactory long-term results of nonabsorbable mesh insertion in the breasts.9–11 Nonabsorbable mesh was used in mastopexy to repair breast ptosis in those reports. In our hospital, nonabsorbable mesh has been used instead of absorbable mesh for breast reconstruction after BCS to reduce complications. In this article, we report a case of abscess formation following nonabsorbable mesh insertion with BCS. We demonstrate multimodal breast imaging features and pathologic correlations of the case. In addition, we illustrate characteristic ultrasound findings of nonabsorbable mesh fiber structures to differentiate them from absorbable mesh or gossypiboma.
CASE REPORT
A 49-year-old woman presented with a 1.7-cm invasive ductal carcinoma in the lower inner quadrant of the left breast. She underwent BCS with immediate mesh insertion. The tumor was 439
SONG ET AL
FIGURE 1. Postcontrast CT scan shows a circumscribed, oval-shaped cystic mass (arrows) without enhancement at the operation site of the left breast, suggesting seroma.
FIGURE 3. Transverse (A) and longitudinal (B) sonograms demonstrate a cystic mass (arrows) with internal hyperechoic whirling band-like meshwork (arrowheads) at the operation site of the left breast. The band-like structures have even thickness and regular pores, which suggest embedded mesh. FIGURE 2. At the operation site, a hard palpable mass (arrows) with erythematous skin changes and discharge are seen, suggesting infection.
triple negative and estrogen, progesterone, and human epidermal growth factor receptor-2 were all negative. We used soft-knitted polyester mesh (Parietex Composite; Covidien, Dublin, Ireland) for reconstruction. After surgery, a CT scan was performed to obtain cross-section images of the operation site for planning of radiation therapy. Postcontrast-enhanced CT scan showed a circumscribed, oval-shaped, cystic mass without enhancement at the operation site of the left breast, suggesting seroma (Figure 1). The patient received radiation therapy consisting of 60 Gy in 30 fractions. Four months after initiation of radiation therapy, she complained of a hard palpable mass with erythematous skin changes and discharge at the operation site (Figure 2). Breast ultrasound examination was performed with a 6–15-MHz 440
linear transducer (LOGIQ 9 unit; GE Medical Systems, Milwaukee, WI). On ultrasound, there was a well-encapsulated cystic mass with internal hyperechoic whirling bands characteristic of meshwork at the operation site (Figure 3). The band-like structures on ultrasound had even thickness and regular pores, which suggested embedded mesh. For assessment of infection or tumor recurrence, CT and MRI were performed with a 64-channel multidetector CT scan and a 3 T MRI unit. On postcontrast CT scan, the previously noted seroma had changed: the mass had thin-rimmed enhancement with surrounding tissue infiltration and overlying skin thickening (Figure 4). The T2-weighted MRI revealed an internal wavy band-like meshwork within the cystic mass (Figure 5). After we reviewed the multimodal breast imaging, we thought the cystic mass might be an abscess formation, so we recommended surgical intervention. Furthermore, we speculated that the internal, wavy, band-like structures were preserved JOURNAL OF CLINICAL ULTRASOUND
BREAST IMAGING OF MESH INSERTION
FIGURE 4. On follow-up CT scan, the previously noted seroma had become a cystic mass (arrows) with thin smooth rim enhancement. Surrounding tissue infiltration and overlying skin thickening are also seen.
FIGURE 5. On T2-weighted MRI, the cystic mass (arrows) shows internal, wavy, hypointense bands (black arrowheads).
nonabsorbable mesh rather than retained surgical sponge because the band-like structures had a regular thickness and internal pores on T2-weighted MRI and breast ultrasound. Most compellingly, breast ultrasound revealed internal morphology of the meshwork in detail. Surgical excision was performed, and mesh and inflammatory tissues were removed. The removed gross specimen showed that the embedded mesh was well preserved with characteristic regular pores within the breast (Figure 6). On pathologic examination, nonabsorbable mesh fibers and multinucleated giant cells ingesting the mass are noted (Figure 7). These findings are compatible with abscess formation with fibrosis and foreign body reaction.
DISCUSSION
Oncoplastic surgery, defined as the combination of tumor excision and immediate reconstruction VOL. 42, NO. 7, SEPTEMBER 2014
FIGURE 6. Photograph of the gross surgical specimen shows that the embedded mesh is well preserved with its characteristic pores.
FIGURE 7. Nonabsorbable mesh fibers (arrows) and multinucleated giant cells (arrowheads) ingesting the fibers are noted on pathologic examination (hematoxylin and eosin stain, 3200). These findings are compatible with abscess with fibrosis and a foreign body reaction.
of the breast, has been widely used for its achievement of oncological safety margins and satisfactory cosmetic results. For large-volume defects, flap reconstruction is suitable, but operation time is relatively long, and flap loss or contraction is possible.12 Immediate mesh insertion has been used since 2003 for patients with largevolume defect, for defects located in the inner portions of the breast, and for small breast.4,5,7,13 Various kinds of materials have been used to manufacture both absorbable and nonabsorbable mesh. In absorbable mesh, polyglactin or polyglycolic acid is commonly used in breast reconstruction.5,12,13 The absorbable mesh may enable the breast to maintain its shape after excision by forming reactive fluid with 441
SONG ET AL
FIGURE 8. A 48-year-old woman with an uncomplicated case of nonabsorbable mesh insertion after BCS. Transverse sonogram demonstrates an indistinct oval hypoechoic mass (arrows) without fluid collection.
capsulation. In this case, inserted mesh is gradually absorbed.14 According to Kwag,15 breast size decreased approximately 47% by 12 months after surgery. Furthermore, Lee et al7 demonstrated that absorbable mesh insertion has a higher complication rate and no cosmetic gain when compared with a BCS-only without mesh insertion. Decrease in volume and changes in breast shape are common problems of absorbable mesh, which have an influence on the patients’ satisfaction.7,14,16 Infection or recurrent mastitis often occurs after absorbable mesh insertion due to reactions with foreign materials. In addition, cancer surveillance with breast imaging or physical examination to detect tumor recurrence may be difficult after absorbable mesh insertion.5 To overcome disadvantages of absorbable mesh, nonabsorbable mesh has been used in breast surgery.9–11 Polyester and polypropylene have been used as nonabsorbable mesh materials. In this report, we used polyester mesh. After insertion of the polyester mesh, the mesh embedded in adipose tissue and was surrounded by a thin layer of reactive histologically collagenous tissue.10 Polyester mesh has advantages for complete tissue integration and improving clinical outcomes. First, hydrophilic polyester encourages cells to adhere and spread, establishing fast and complete tissue in-growth. Second, the knitting technology creates various pores for true connective tissue differentiation. Last, polyester mesh has high compliance with multidirectional elasticity. Figure 8 demonstrates ultrasound imaging in an uncomplicated case of polyester mesh insertion after BCS in our hospital. There is no fluid collection and the internal meshwork structure is not clearly visualized. 442
In our case, postoperative seroma arose from the mesh insertion site before radiation therapy, and there was no serious shrinkage of breast volume. However, postoperative seroma changed into an abscess with inflammatory skin change after radiation therapy. Receiving radiation therapy may have led to either dermatitis or mastitis, resulting in inflammation of seroma. Known risk factors after absorbable mesh infection include a high body mass index, early initiation of radiation therapy after surgery, tumors located in the inner lower sides of the breasts, and previous history of autoimmune or allergic diseases.8,13 This patient had three risk factors for infection: tumors located in the inner lower side of the breast, previous history of rheumatoid arthritis, and radiation therapy. Although there is no comparative study regarding clinical complications of absorbable versus nonabsorbable mesh use in the breast, these infection risk factors may be related to each other. Abscess formation after mesh insertion and BCS should be differentiated from a gossypiboma caused by a retained surgical sponge or tumor recurrence. Multimodal breast imaging including ultrasound, CT, or MRI is helpful in solving this problem. A well-defined round or oval mass with strong rim enhancement on contrast-enhanced CT or MRI suggests an abscess or gossypiboma.17 On MRI, both abscess and gossypiboma may have internal, wavy, low signal intensity stripes on T2weighted imaging, which represent the gauze or mesh fibers. Based on our case, ultrasound is very effective to demonstrate the detailed internal structure of a cystic mass and to discriminate between abscess formation after mesh insertion and gossypiboma. Ultrasound shows internal wavy band-like structures with a regular thickness and internal pores, which represent inserted nonabsorbable mesh. Posterior acoustic shadowing, calcifications, or air bubbles suggest gossypiboma.17–19 In absorbable mesh, detail of mesh fibers cannot be evaluated on breast imaging because mesh is gradually absorbed and consequently smaller on follow-up series.15 We report a case with abscess formation following nonabsorbable mesh insertion after BCS. Although nonabsorbable mesh insertion is safe and effective in breast reconstruction, it should be performed carefully in patients at high risk of infection. Multimodal breast imaging is very useful to differentiate abscess formation from gossypiboma or tumor recurrence after mesh insertion and BCS. In particular, ultrasound illustrates the embedded nonabsorbable mesh structure in detail. JOURNAL OF CLINICAL ULTRASOUND
BREAST IMAGING OF MESH INSERTION REFERENCES 1. Veronesi U, Cascinelli N, Mariani L, et al. Twentyyear follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer. N Engl J Med 2002;347:1227. 2. Vallejo da Silva A, Destro C, Torres W. Oncoplastic surgery of the breast: rationale and experience of 30 cases. Breast 2007;16:411. 3. Fisher B, Bauer M, Margolese R, et al. Five-year results of a randomized clinical trial comparing total mastectomy and segmental mastectomy with or without radiation in the treatment of breast cancer. N Engl J Med 1985;312:665. 4. Fujishiro S, Mitsumori M, Kokubo M, et al. Cosmetic results and complications after breast conserving therapy for early breast cancer. Breast Cancer 2000;7:57. 5. Kim KS, Park MY, Kim WJ, et al. Nationwide survey of the use of absorbable mesh in breast surgery in Korea. J Breast Cancer 2009;12:210. 6. Koo MY, Lee SK, Hur SM, et al. Results from over one year of follow-up for absorbable mesh insertion in partial mastectomy. Yonsei Med J 2011;52:803. 7. Lee A, Won Hwang H, Chang J, et al. Outcomes of breast conserving surgery with immediate vicrylmesh insertion: is it safe and effective? Breast J 2012;18:334. 8. Cho JS, Shin SH, Park JY, et al. Analysis of infections occurring in breast cancer patients after breast conserving surgery using mesh. J Breast Cancer 2011;14:328. 9. de Bruijn HP, Johannes S. Mastopexy with 3D preshaped mesh for long-term results: development of the internal bra system. Aesthetic Plast Surg 2008;32:757. 10. de Bruijn HP, ten Thije RH, Johannes S. Mastopexy with mesh reinforcement: the mechanical
VOL. 42, NO. 7, SEPTEMBER 2014
11.
12.
13.
14.
15.
16.
characteristics of polyester mesh in the female breast. Plast Reconstr Surg 2009;124:364. van Deventer PV, Graewe FR, W€ uringer E. Improving the longevity and results of mastopexy and breast reduction procedures: reconstructing an internal breast support system with biocompatible mesh to replace the supporting function of the ligamentous suspension. Aesthetic Plast Surg 2012;36:578. Sanuki J, Fukuma E, Wadamori K, et al. Volume replacement with polyglycolic acid mesh for correcting breast deformity after endoscopic conservative surgery. Clin Breast Cancer 2005;6:175. Lee JH, Hong YI, Jeong JH, et al. Volume replacement with polyglactin 910 mesh for breast reconstruction after endoscopy-assisted breast conserving surgery for treating early breast cancer: the early results. J Breast Cancer 2009;12: 193. Klinge U, Schumpelick V, Klosterhalfen B. Functional assessment and tissue response of shortand long-term absorbable surgical meshes. Biomaterials 2001;22:1415. Kwag HJ. Imaging findings of implanted absorbable mesh in patients with breast partial resection. Yonsei Med J 2008;49:111. Dieterich M, Reimer T, Dieterich H, et al. A shortterm follow-up of implant based breast reconstruction using a titanium-coated polypropylene mesh (TiLoopV Bra). Eur J Surg Oncol 2012;38:1225. Kul S, G€ unes G. Gossypiboma of the breast: imaging findings. J Radiol Case Rep 2010;4:21. Manzella A, Filho PB, Albuquerque E, et al. Imaging of gossypibomas: pictorial review. AJR Am J Roentgenol 2009;193:S94. Fornage BD. Sonographic diagnosis of a retained surgical sponge in the breast. J Clin Ultrasound 1987;15:285. R
17. 18.
19.
443
