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Edit Comment Close Premium member Presentation Transcript Breast Conservation Therapy : Breast Conservation Therapy Chairperson: Prof.Dr.Shivananda Presenter:Dr.Deviprasad Anatomy : Anatomy The breasts are modified sweat glands lying within the superficial fascia, largely anterior to the upper thorax Shape: breasts may be hemispherical, conical, variably pendulous, piriform or thin and flattened. In the adult female the base of the breast extends vertically from the second or third to the sixth rib, and from the sternal edge medially, to the midaxillary line laterally in the transverse plane Slide 3: The superolateral quadrant is prolonged towards the axilla along the inferolateral edge of pectoralis major, extend through the deep fascia into the axilla (the axillary tail). The breast lies upon the deep pectoral fascia, which in turn overlies pectoralis major and serratus anterior, and inferiorly, external oblique and its aponeurosis as the latter forms the anterior wall of the sheath of rectus abdominis. Between the breast and the deep fascia is loose connective tissue in the 'submammary space'. Slide 4: Fibrous suspensory ligaments of cooper extend from skin of breast to underlying pectoral fascia These ligaments provide the structural integrity to the breast Blood Supply : Blood Supply The blood supply of the breast is derived primarily from the internal mammary artery and the lateral thoracic artery. These arteries enter the breast from the superomedial and superolateral aspects, respectively. The internal mammary artery gives rise to the posterior intercostal arteries, and branches of the intercostal arteries penetrate the deep surface of thebreast Lymphatic drainage : Axillary nodes receive more than 75% of the lymph from the breast. Lymph flows from the skin to the subareolar plexus (Sappey's plexus) and then into the interlobular lymphatics of the breast parenchyma. There are 20-40 nodes, grouped as pectoral (anterior), subscapular (posterior), central and apical. Those lying below pectoralis minor are level 1, those behind the muscle are level 2, while the nodes between the upper border of pectoralis minor and the lower border of the clavicle are the level 3. Lymphatic drainage Slide 7: There may be one or two other nodes between pectoralis minor and major. (rotters) Efferent vessels directly from the breast pass round the anterior axillary border through the axillary fascia to the pectoral lymph nodes. Some may pass directly to the subscapular nodes. A few vessels pass from the superior part of the breast to the apical axillary nodes, sometimes interrupted by the infraclavicular nodes or by small, inconstant, interpectoral nodes. History : History The modern surgical treatment of breast cancer has its origins in the mid nineteenth century. During this period, the German pathologist Rudolf Virchow studied the morbid anatomy of breast cancer He undertook careful postmortem dissections, and postulated that breast cancer arose from epithelial cells and then spread along fascial planes and lymphatic channels. Slide 10: Virchow’s theory had a profound influence on the American surgeon William Halsted. He described the radical mastectomy for the treatment of breast cancer at John Hopkins hospital in 1882. The tumor-containing breast, underlying pectoral muscles, and ipsilateral axillary contents were removed en bloc. The radical mastectomy was very effective in achieving local control of the disease. Slide 11: In 1948, Patey and Dyson of the Middlesex Hospital in London published a brief report describing a “modified radical mastectomy,” The pectoralis major muscle was preserved, the operation was less disfiguring. The authors reported that its results were as good as those of the standard radical procedure. Soon it became the standard procedure for CA Breast and still being widely used. Slide 12: Mc Whirter in Edinburgh advocated simple mastectomy and high-voltage x-ray therapy in the treatment of primary breast cancer. In 1948, he published his paper “The value of simple mastectomy and radiotherapy in the treatment of cancer of the breast” in the British Journal of Radiology This became the foundation for the breast conserving surgery and radiotherapy Large number of randomized clinical trials were conducted comparing mastectomy and BCT, and they demonstrated equivalent survival. The long-term stability of this equivalence was confirmed by the 20-year follow-up reports of the two largest studies, the Milan I and NSABP B-06 (National Surgical Adjuvant Breast Project) trials. PATIENT SELECTION : PATIENT SELECTION Patients should be carefully selected according to the established guidelines. The four critical elements in patient selection for BCT are History and physical examination, Mammographic evaluation, Histologic assessment of the resected breast specimen Assessment of the patient's needs and expectations History : History Family history – Relatives with breast cancer (age at diagnosis), ovarian carcinoma. History of prior therapeutic irradiation involving breast region. History of collagen vascular disease – type, documentation of diagnosis. Presence of breast implants – submammary or subpectoral. Date of last menstrual period/possibility of pregnancy. Symptoms suggestive of metastasis Physical examination : Physical examination Tumor size and location Fixation to skin Ratio of breast size to tumor size Evidence of multiple primary tumors Axillary node status – size, mobility Supraclavicular nodes Evidence of locally advanced cancer skin ulceration peau d’orange inflammatory carcinoma fixed axillary nodes lymphedema of the ipsilateral arm Mammography : Mammography Recent preoperative mammographic evaluation (usually within 3 months) is necessary to determine a patient’s eligibility for breast conservation treatment. It defines the extent of a patient’s disease, presence or absence of multi-centricity Bilateral mammo-graphy is required for palpable lesions as well as nonpalpable lesions Slide 19: The breast tumor should be measured in at least two dimensions on the mammographic views. The skin of the breast in the area of a mass should be evaluated for thickening that might signify tumor involvement. Assessment of the extent of the calcifications within and outside of the mass should be made, including the dimensions of the area in which calcifications are located Magnification mammo-graphy is important for characterizing microcalcifications and defining the margins of masses. Slide 20: Some studies have suggested that magnetic resonance imaging (MRI) is a useful adjunct to mammography Its benefit has not been established and results in greater, but unwarranted use of mastectomy It frequently identifies additional areas of involvement in the breast, but majority of this disease is controlled with RT Pathologic Evaluation : Pathologic Evaluation The excised tissue should be submitted for pathology examination with appropriate clinical history and anatomic site specifications including laterality and quadrant. Surgeon should orient the specimen (e.g., superior, medial, and lateral) for the pathologist with sutures or other markers. Frozen section preparation of tissue obtained from wire localization excisional biopsies of nonpalpable lesions or tumors less than 1 cm is strongly discouraged Slide 22: Small foci of invasive carcinoma or microinvasive disease may be lost by freezing artifact. In general, frozen sections should be prepared only when there is sufficient tissue Compression of specimen for radiography may be necessary to visualize a nonpalpable lesion in the specimen. May result in falsely close margins, due to the compressibility of fat relative to the tumor Pathology report should contain : Pathology report should contain How the specimen was received (e.g., number of pieces, fixative, orientation). The laterality and quadrant of the excised tissue and the type of procedure as specified by the surgeon. The measured size of the tumor (in three dimensions if possible), with verification by microscopic examination, Histologic type and grade. Slide 24: The presence or absence of coexistent DCIS or an EIC. The presence or absence of peritumoral vascular or lymphatic invasion. The presence or absence of gross or microscopic carcinoma (either invasive carcinoma or DCIS) at the margins of excision. If tumor is not at the margin, the distance of the tumor or biopsy site from the margin should be stated. Close margin is taken as 2mm. Needs re excision. Slide 25: The presence and location of microcalcifications. Lymph node status. This should be recorded as the number of lymph nodes found in the specimen the number of involved nodes, the size of the largest involved node, and the presence or absence of extension beyond the lymph node capsule. Estrogen and progesterone receptors (ER and PR) and HER2/neu status Assessment of the patient's needs and expectations : Assessment of the patient's needs and expectations The following factors should be discussed: The absence of a long-term survival difference between treatments. The possibility and consequences of local recurrence with both approaches. Psychological adjustment, cosmetic outcome, sexual adaptation, and functional competence. Psychological research has found, women whose breasts are preserved have more positive attitudes about their body image and experience fewer changes in their sexual desirability. Patients treated with BCT have better physical functioning compared to patients treated with mastectomy. Who is suitable for BCT ? : Who is suitable for BCT ? T1 N2 M0 T2 N2 M0 Contraindications to Breast-Conserving Therapy : Contraindications to Breast-Conserving Therapy Absolute Pregnancy is an absolute contraindication to the use of breast irradiation. Women with two or more primary tumors in separate quadrants of the breast or with diffuse malignant-appearing microcalcifications are not considered candidates for breast conservation treatment A history of prior therapeutic irradiation to the breast region that would require retreatment to an excessively high total radiation dose Persistent positive margins after reasonable surgical attempts Relative : Relative Collagen vascular diseases like scleroderma, active SLE. Presence of a large tumor in a small breast. Neoadjuvant chemotherapy can be tried in such cases. Large pendulous breasts. Requires technical capability for 6 MV or greater photon beam irradiation. Non mitigating factors : Non mitigating factors Features that are NOT contra indications BCT Presence of clinically suspicious, mobile axillary lymph nodes or microscopic tumor involvement in axillary nodes. Tumor location superficial subareolar location may occasionally require the resection of the nipple/areolar complex High risk of systemic relapse is not a contraindication, but a determinant of the need for adjuvant therapy Slide 31: Family history of breast cancer is not a contraindication to breast conservation. Thre is no increased risk of ipsilateral breast tumor recurrence following BCT in patients with mutation in BRCA 1 or 2 Role of Preoperative systemic therapy : Role of Preoperative systemic therapy Indicated in women who desire BCT but have a large tumor relative to the size of the breast. Not appropriate for patients with multicentric carcinoma that precludes a cosmetic resection, or those who prefer treatment by mastectomy. Patients with unicentric, high-grade, ER-negative cancers are most likely to be benefited. Clinical response : Clinical response 49% with fluorouracil, epirubicin and cyclophosphamide (FEC) 79% with doxorubicin and cyclophosphamide (AC) 91% with doxorubicin cyclophosphamide and docetaxel (ACT) Addition of trastuzumab weekly for 24 weeks has increased response rates in HER-2 positive tumours Draw backs : Draw backs Difficulty of assessing the extent of residual viable tumor after preoperative chemotherapy. Patchy nature of cancer cell death in response to chemotherapy. Viable tumor remains scattered throughout the same volume of breast tissue, precluding BCT Due to these factors only only 25% to 30% of patients can undergo BCT after neoadjuvant chemotherapy. Slide 35: Local recurrence rate is higher in patients who underwent BCT after down staging chemo (14.5%) compared to 6.9% in those who were eligible for BCT at presentation. Percutaneous placement of tumor marker clips within the primary tumor is recommended to provide a landmark for localization and excision if a clinical and radiographic complete response to chemotherapy occurs. Endocrine therapy : Endocrine therapy Neoadjuvant endocrine therapy has also been used to increase rates of BCT. Aromatase inhibitors are used in postmenopausal women with hormone-receptor positive tumors. Letrozole 2.5 mg daily or anastrozole 1 mg daily for 3 to 4 months 44% of patients could undergo BCT after endocrine therapy. But long term results are lacking. TECHNICAL ASPECTS OF SURGERY : TECHNICAL ASPECTS OF SURGERY Excision of the primary tumor with preservation of the breast has been referred to by many names, lumpectomy partial mastectomy segmentectomy quadrantectomy Wide local excision is the most descriptive term, which removes the malignancy with a surrounding rim of grossly normal breast parenchyma(1cm). Slide 38: Quadrantectomy : removes 2 to 3 cm of adjacent breast and skin over the tumor. These more extensive margins and skin excision have not been shown to improve survival and are not used in current breast conservation. Skin Incision : Skin Incision The placement of the skin incision can be critical to the quality of cosmesis. Curvilinear skin incisions following Langer’s lines generally achieve the best cosmetic result. Slide 40: At 3 o’clock and 9 o’clock positions and in the lower breast, a radial incision provides a better result, particularly if skin removal is necessary. Radial incisions in the upper half of the breast may displace of the ipsilateral nipple-areola complex due to scar contracture. Similarly, curvilinear incisions in the lower half of the breast may displace the nipple-areolar complex downward. Slide 41: The incision should be over the tumor and of adequate size to allow the tumor to be removed in one piece. In the upper inner aspect of the breast, some retraction of the skin may be necessary to avoid an incision that may be visible with clothing. Breast Tissue : Breast Tissue The primary lesion should be excised with a rim of grossly normal tissue, avoiding excessive sacrifice of breast tissue. Very superficial tumors in the subareolar area may require excision of the nipple areolar complex to assure adequate tumor margins Lesions within the substance of the breast should be approached by incising the overlying breast tissue. The resulting defect after wide excision should not be approximated if small. Larger defects approximated after mobilizing the breast tissue from the skin. Slide 43: Meticulous hemostasis is very important. Hematoma formation produces changes that are difficult to interpret by physical examination. The evolving scar from a hematoma makes mammography interpretation difficult. These changes may be long-lasting and lead to unnecessary biopsy. Drains in the breast should be avoided. Slide 44: Specimen is oriented by the surgeon with the use of sutures, clips or multicolored indelible ink. Specimen should not be sectioned before it is submitted to the pathologist. The surgeon should examine the specimen for the determination of a grossly clear margin. If a clear margin is not evident, re-excision should be performed at that time. Routine frozen section evaluation of margins is optional and does not guarantee negative margins after a complete examination. Surgical Technique : Surgical Technique Skin incision is made over the lump. Skin flaps are elevated 1 to 2 cm beyond the edge of the cancer. Slide 46: The fingers of the nondominant hand are then placed over the palpable cancer and the breast tissue divided beyond the fingertips. The line of incision should be 1 cm beyond the limit of the palpable mass. The deep aspect of the tumor can be palpated and breast tissue under the cancer is divided. Slide 47: The tumor and surrounding breast tissue lifted and grasped between the fingers and the thumb of the nondominant hand and excision is completed at the other margins. Slide 48: Small defect (<5% breast volume) can be left open and produce a good final cosmetic result. Larger defect in the breast is closed by mobilizing the surrounding breast tissue from both the overlying skin and subcutaneous tissue and the underlying chest wall with interrupted absorbable sutures. Breast skin wounds should be closed in layers with absorbable sutures, finishing with a subcuticular suture. Image-Directed Surgery : Image-Directed Surgery If a patient has a nonpalpable carcinoma diagnosed by image-guided biopsy, then BCS should be conducted with presurgical localization with a guidewire. The methods of localization may be by needle-hookwire, blue dye injection, or a combination of both. Labeled craniocaudal and lateral films that show the hookwire should be available for surgeon’s orientation. Slide 50: The surgeon usually should assess the exact location based on the position, depth of penetration, and angle of the wire and place the incision closest to the tip of the wire. The breast tissue is dissected until the wire is identified within the parenchyma. Traction on the wire should be avoided at all times. Titanium clips may be left in the excision cavity to aid in placement of the irradiation boost. Specimen Radiograph : Specimen Radiograph A radiograph of the specimen should be obtained to confirm the complete removal of the lesion The specimen film should be correlated with a preoperative mammogram. The radiologist’s report should indicate whether the mammographic abnormality is seen in the specimen and if it has been removed completely. Slide 52: The proximity of the abnormality to the edge of the resected tissue should be noted. The findings should be communicated to OT so that the surgeon can resect additional tissue. Subsequent tissue should also be radiographed Management of the Axilla : Management of the Axilla Level I and II axillary lymph node dissection is indicated in patients who present with unequivocally positive nodes or nodes that have been documented to contain metastases by FNA. It will provide accurate staging information and maintain local control in the axilla. In the patient undergoing breast conservation, the axillary incision should be separate. Slide 54: A transverse incision in the axilla from just posterior to the border of the pectoralis major to nearly the anterior border of the latissimus dorsi obtains an excellent cosmetic result and exposure. Slide 55: Alternatively a vertical incision posterior and parallel to the border of the pectoralis major can be used which also provides good exposure and cosmesis Slide 56: During dissection, the long thoracic nerve, the thoraco dorsal nerve, and the medial pectal nerve should be preserved. Preservation of the intercostal brachiocutaneous nerve is desirable. Stripping of the axillary vein is unnecessary and should be avoided because it increases the incidence of lymphedema. Closed suction drainage should be placed. Sentinel node biopsy : Sentinel node biopsy The sentinel lymph node is the first lymph node or group of nodes to harbour metastasis Identified by injecting blue dye (isosulfan blue) radio labeled colloid (technetium sulfur colloid) or both near the primary tumour. Slide 58: Dye and/or the radioactivity is traced in the axillary nodes draining the area bearing the tumour. This node or group of nodes are excised and sent for biopsy. Any palpably abnormal nodes intraoperatively should be excised since lymph nodes that contain a heavy tumor burden may not take up the mapping agent Slide 59: Sentinel node identification is possible with lymphatic mapping in 98% of clinically node negative patients. No significant difference is seen in the rate of sentinel node identification with the use of blue dye alone, radio-colloid alone, or the combination of the two. Increasing body mass index and increasing age are associated with a significant decrease in sentinel node identification rate. Slide 61: Contraindications to sentinel node biopsy include pregnancy and lactation, locally advanced breast cancer, prior axillary surgery. Sentinel node biopsy allows the pathologist to perform a more detailed examination of the sentinel node. This has resulted in the increasingly frequent detection of very small metastases. In general, patients with metastases in sentinel nodes should undergo complete Level I and II axillary dissection Radiotherapy : Radiotherapy Patient should receive adjuvant radiotherapy as soon as BCS incision heals. Usualluy within 2 to 4 weeks. Whole breast irradiation is done to a total dose of 4500 to 5000 cGy. Radiation is given 5 days a week with daily fraction of 180 to 200 cGy. Slide 63: Boost is the additional 1000 to 1600 cGy of radiation given to the tumour bed after whole breast radiation. Boost irradiation usually is delivered using electron beam or interstitial implantation. Use of boost has reduced the incidence of ipsilateral breast recurrence from 10.2% to 6.2% Supraclavicular area should be irradiated if 4 or more axillary nodes are positive. Adjuvant Systemic Therapy : Adjuvant Systemic Therapy The modalities are Endocrine treatments such as tamoxifen, aromatase inhibitors, or ovarian suppression, Anti-HER-2 therapy with the humanized monoclonal antibody, trastuzumab, and Chemotherapy. Slide 66: Patients with tumors that are hormone-receptor positive are candidates for adjuvant endocrine therapy. Patients with tumors that are HER-2 over-expressing are candidates for trastuzumab. Chemotherapy is utilized irrespective of tumor hormone-receptor status or HER-2 status, based largely on features such as tumor size and nodal status. Adjuvant Endocrine Therapy : Adjuvant Endocrine Therapy Tamoxifen 20mg daily for 5 years as adjuvant hormonal therapy for all women with hormone-receptor positive breast cancer irrespective of age, menopausal status, tumor size, or nodal status. It is not effective in preventing recurrence of hormone-receptor negative breast cancer. Use of adjuvant tamoxifen concurrent with RT or after RT following BCS has been found to reduce the ipsilateral recurrence from 14.7 to 4.3% Slide 68: Aromatase inhibitors may be used in postmenopausal women as an alternative to tamoxifen. Letrozole 2.5 mg daily or anastrozole 1 mg daily. Choice of treatment should depend on adverse effects and the relative tolerability. Tamoxifen is associated with risks of thromboembolism and uterine cancer. AI treatment is associated with accelerated osteoporosis and an arthralgia syndrome. Both are associated with menopausal symptoms like hot flushes, night sweats. Adjuvant Chemotherapy (CT) : Adjuvant Chemotherapy (CT) Adjuvant CT given concurrently or sequentially with RT after BCS reduces local recurrence and increases survival. Adjuvant chemotherapy is of minimal benefit to women with negative nodes and cancers < 0.5 cm in size and is not recommended. Women with negative nodes and cancers 0.6 to 1.0 cm are divided into those with a low and high risk of recurrence. High risk group benefit from adjuvant CT Slide 70: High risk group is identified by following features. Blood vessel or lymph vessel invasion High nuclear grade High histologic grade HER-2neu overexpression and Negative hormone receptor status. Slide 71: Women with hormone receptor–negative and node negative cancers that are >1 cm in size, adjuvant chemotherapy should be given. If receptor positive: tamoxifen + CT All node positive patients should receive adjuvant chemotherapy. Regimens : Regimens CMF Cyclophosphamide: 750mg/m2 Methotrexate : 50mg/m2 5-FU: 600mg/m2 Given once in every 3 weeks, for 6 cycles. Slide 73: CAF Cyclophosphamide: 100mg/m2/d, D1-14 Adriamycin: 30mg/m2, D1,8 5FU: 500mg/m2, D1,8 6 cycles are given, once in 4 weeks Slide 74: AC Adriamycin : 60mg/m2, D1 Cyclophosphamide: 600mg/m2, D1 4 cycles are given, once every 3 weeks Slide 75: FAC 5FU 500mg/m2 Adriamycin 50mg/m2 Cyclophosphamide 500mg/m2 On day one every 3 weeks for 6 weeks. Slide 76: FEC 5FU 500mg/m2 Epirubicin 50mg/m2 Cyclophosphamide 500mg/m2 On day one, every 3 weeks for 6 cycles Slide 77: TAC Docetaxel 75mg/m2 on D1 Adriamycin 50mg/m2 on D1 Cyclophosphamide 500mg/m2 on D1 6 cycles are given, every 3 weeks. Slide 78: AC T Adriamycin : 60mg/m2,D1 Cyclophosphamide: 600mg/m2, D1 For 4 cycles once every 3 weeks Followed by Taxol (paclitaxel) 175mg/m2. Every 3 weeks for 4 cycles Adjuvant Trastuzumab : Adjuvant Trastuzumab Is the humanised monoclonal antibody against HER-2 neu. (Herceptin) HER-2 expression has been considered an adverse prognostic factor associated with a higher risk of recurrence, an early risk of recurrence, and relative resistance to established therapies such as CMF-based chemotherapy. Addition of trastuzumab to adjuvant chemotherapy regimen has improved survival and recurrence in short term studies. Slide 80: Cardiomyopathy is a novel side effect of trastuzumab therapy. Cardiac dysfunction is more pronounced in patients receiving anthracycline-based adjuvant chemotherapy+ trastuzumab. Other risk factors for cardiac dysfunction with adjuvant trastuzumab include pre-existing cardiac disease ,hypertension and age greater than 65. All patients being considered for adjuvant trastuzumab require baseline determination of left ventricular ejection fraction and serial monitoring of cardiac function. Duration of therapy is 1yr. Slide 81: During and following paclitaxel, docetaxel, or docetaxel / carboplatin: Initial dose of 4mg/kg as an intravenous infusion over 90 minutes Then at 2 mg/kg as an intravenous infusion over 30 minutes weekly during chemotherapy for the first 12 weeks (paclitaxel or docetaxel) or 18 weeks (docetaxel/carboplatin). One week following the last weekly dose of Herceptin, administer Herceptin at 6 mg/kg as an intravenous infusion over 30-60 minutes every three weeks. Slide 82: As a single agent within three weeks following completion of multi-modality, anthracycline-based chemotherapy regimens. Initial dose at 8 mg/kg as an intravenous infusion over 90 minutes Subsequent doses at 6 mg/kg as an intravenous infusion over 30-minutes every three weeks. For a total period of 52 weeks. Complications After Breast-Conservation Therapy : Complications After Breast-Conservation Therapy Infection The majority of cases present with pain, erythema, axillary swelling, and warmth in the involved breast. Breast abscess or seroma may present as suspicious mammographic changes or a clinically palpable breast mass. The median latency period for the development of delayed cellulitis is 3 to 5 months postradiotherapy, and it may even occur many years after the completion of therapy. Slide 84: Arm lymphedema is the most important risk factor for the development of delayed breast cellulitis. Lymphedema results in stasis within the lymphatic channels, serving as a medium for bacterial growth. Any trivial trauma and desquamation of skin will lead to cellulitis. Treated with empirical oral antibiotics for 14 days. IV antibiotics may be required when pt has severe systemic symptoms. Slide 85: Preventive techniques such as compression therapy to reduce lymphoedema and skin care. Patients with axillary or breast seromas should be counseled on the signs, symptoms, and treatment of cellulitis Slide 86: Fat Necrosis Fat necrosis commonly presents as an indurated mass in the region of the lumpectomy scar, with overlying skin fixation and retraction. The average time to onset of symptoms is approximately 12 months post therapy. In most patients, the presentation of fat necrosis clinically mimics that of recurrent tumor. Mammographic evaluation is helpful in identifying the lesion if characteristic changes such as radiolucent oil cysts are present. Slide 87: However, fat necrosis may also appear on mammography as round opacities, dystrophic calcifications, and clustered pleomorphic calcifications. Ultrasound-guided core biopsy should be performed in patients when imaging is inconclusive. Excision may be necessary if not responding to symptomatic treatment. Musculoskeletal Effects BCT : Musculoskeletal Effects BCT Standard irradiation of the breast with tangential fields covers the anterolateral chest wall and a portion of the sternum. The clavicle, portions of the scapula, and occasionally the medial third of the humeral head will be within the treatment field when upper axilla or supraclavicular regions are treated in patients with multiple positive lymph nodes. Slide 89: The effects are muscle and connective tissue fibrosis, osteitis and potentially even osteoradionecrosis. Pain, decreased range of motion, or fracture may result due to these changes. Extent of axillary surgery also contributes to arm pain and lymphoedema. Range of motion exercises along with analgesics is the treatment. FOLLOW-UP : FOLLOW-UP Regular follow-up examinations are needed Early detection of recurrent or new cancer, allowing timely intervention. Identification of any complications and appropriate interventions where indicated Examinations and Mammography are the standard follow up methods. Frequency of examination : Frequency of examination Every 3 to 6 months, for first 3 years Every 6 months, from 3 to 5 years Yearly after 5 years. Mammography : Mammography A goal of follow-up imaging of the treated breast is the early recognition of tumor recurrence. Postoperative and irradiation changes overlap with signs of malignancy on a mammogram. The changes include masses, edema, skin thickening, and calcifications. Slide 93: These changes are most marked in the first 6 months. Thereafter the radiographic changes will slowly diminish, and demonstrate stability within 2 years for most patients. Mammogram must be compared in sequence to preceding studies in order to correctly interpret the signs. Ultrasonography can characterize a postoperative mass, such as a seroma, as fluid-filled rather than solid. Schedule of imaging of the treated breast : Schedule of imaging of the treated breast Postoperative, preradiation therapy mammography is particularly important after malignant microcalcifications have been removed. Magnification mammography is useful in identifying residual malignant calcifications. A baseline mammogram for comparison should be performed 6 to 12 months after tumor excision and completion of radiation. Annually thereafter References : References Devita, Hellman & Rosenberg's Cancer: Principles & Practice of Oncology, 8th Edition Townsend: Sabiston Textbook of Surgery, 18th ed. Schwartz's Principles of Surgery 9th edition Practice guidelines for breast conservation therapy in management of invasive breast carcinoma; American College of Radiology, American College of Surgeons, College of American Pathologists, Society of Surgical Oncology Gray's Anatomy 39th edition Fischer, Josef E; Mastery of Surgery, 5th Edition. 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