Daily Bulletin 2015

CT and 3-D Printing Could Vastly Improve Breast Reconstruction

Monday, Nov. 30, 2015

CT volumetric imaging and 3-D printing could vastly improve breast reconstruction surgery by minimizing poor outcomes and revision surgeries, according to researcher Tatiana Kelil, M.D.

Tatiana Kelil, M.D.

Tatiana Kelil, M.D.

In her Sunday afternoon poster discussion, Dr. Kelil described how physicians at Brigham and Women's Hospital are preparing to use 3-D CT and printing to improve accuracy in preoperative planning and operative flap harvest.

"Breast reconstruction is an integral part of breast cancer management and has been shown to positively impact the patient's psychosocial adjustment and quality of life," said Dr. Kelil, a radiology resident specializing in breast imaging. "Yet many women undergo repeated secondary procedures to correct asymmetry."

Reconstruction of the breast following mastectomy involves either implants or autologous tissue flaps, in which a flap of skin, tissue, fat and sometimes muscle is excised from the abdomen and reattached to the chest. The procedure presents challenges for breast surgeons, including obtaining volume measurements of the diseased breast and the replacement flap or implant.

Dr. Kelil said 2-D photography and physical examination are currently used to estimate tissue volume. "But the methods used to determine the volume, shape and contour of the breast and size of the flap that needs to be harvested are subjective," she said.

Once harvested, the flap is serially excised until it matches the weight of the removed breast and symmetry of the contralateral breast.

"Matching the breast volume with the volume of the flap or implant is currently performed during surgery," she said. "This prolonged intraoperative tissue plane alteration can induce fat necrosis and poor surgical outcomes."

Dr. Kelil said harvesting a flap that is more than the required volume can also lead to tissue waste; she cited a study that reported average breast reconstruction volume of 568 cm3 and an average flap volume of 725 cm3.

Finding the location and course of dominant vessels with 2-D imaging is also a challenge for surgeons during breast reconstruction.

"Identifying the dominant perforator vessels is difficult with 2-D CT and requires a lot of back and forth between the image screen and surgery table," she said.

3-D Printed Models Help Reshape Tissue

Dr. Kelil said volumetric CT imaging is useful for determining the volume of flap that needs to be harvested and for identifying the location and course of dominant vessels, which can reduce tissue waste, sedation times and the potential for vessel injury. To optimize symmetry, 3-D printed models of the contralateral breast can also be used intraoperatively to help reshape the soft tissue flap.

"One may assume that breast reconstruction surgeries are just cosmetic, but the fact that some women refuse mastectomy and would rather die than live without a breast signifies how a woman's breasts are intricately associated with her self-image and feminine identity," she said.

Dr. Kelil once considered the detection of breast cancer before it metastasized followed by a mastectomy a triumph for both medicine and the patient, but her views changed after reading a book that chronicled one woman's journey following a mastectomy.

"Although lifesaving, mastectomy can cause tremendous distortion of body image, leaving survivors feeling less feminine, desirable and incomplete," she said. "Any technological innovation such as 3-D printing that promises to enhance surgical outcomes and improve a woman's quality of life should be embraced and further investigated."

Dr. Kelil said additional applications for the technology include printing customized prostheses and shields for radiation therapy as well as breast phantoms that more closely resemble life-like tissue for education and training.

Question of the Day:

We just purchased a new CT scanner from a different vendor and it's like trying to learn a new language to understand their parameters. How do I learn the new nomenclature?

Tip of the day:

Even if it is your personal lead apron, if it is stored on-site at the clinic, it must be checked annually as part of a quality assurance program.

The RSNA 2015 Daily Bulletin is owned and published by the Radiological Society of North America, Inc., 820 Jorie Blvd., Oak Brook, IL 60523.