2012 EDUCATIONAL BOOK - American Society of Clinical Oncology

SURVEILLANCE FOLLOWING BREAST CANCER DIAGNOSIS
cells in the ducts, with subsequent developing ductal microcalcifications.
Some centers advocate a postsurgical, preradiation
therapy mammogram of the treated side as a
baseline for just this purpose.
In general, calcifications developing in the first 2 years are
dystrophic and thereafter are more likely as a result of
recurrent disease.
For palpable findings, targeted breast US is the initial
imaging modality of choice. Findings are usually related to
scarring or to a lump caused by development of fat necrosis.
Imaging Appearances of Recurrent Disease
Table 1. Examples of Breast Conservation Surveillance Protocol by Institution
Institution Mammography Physical Examination
M. D. Anderson Cancer Center At 6 mo, then annual diagnostic for 5 yr; screening from year 6 Every 6 mo for 5 yr, then annual
University of California, San Francisco Every 6 mo for 5 yr, then annual screening Every 6 mo for 5 yr, then annual
University of California, Los Angelas Every 6 mo for 2 yr, then annual diagnostic Left to primary care
Moffitt Cancer Center Every 6 mo for 2 yr, then annual diagnostic until yr 10 Every 6 mo for 5 yr, then annual
Brigham and Women’s Hospital and
Dana-Farber Cancer Center
At 6 mo after completion of radiotherapy, then annual diagnostic Every 6 mo for 5 yr
Abbreviations: mo, months; yr, years.
In general, a recurrent cancer shows similar appearances
to the original malignancy, such that a patient with DCIS
will have developing microcalcifications in the treated breast,
and high-grade tumors with DCIS may present as a developing
focal asymmetry containing calcifications (Fig. 1).
Fig. 1. Example of recurrent DCIS with a sharp margin corresponding
to the edge of the radiotherapy boost site.
Abbreviation: DCIS, ductal carcinoma in situ.
We recommend that spot magnification views be part of
the initial post-lumpectomy mammogram for patients in
whom calcified DCIS is present, whether invasive or in situ.
This will act as the new baseline exam for comparison.
Developing microcalcifications usually ring alarm bells but
can be commonly seen in patients prone to developing fat
necrosis.
Special types of tumors, such as angiosarcomas, require
more specialized follow-up, which can be a combination of
Doppler US and MRI. The permeative vascular nature of the
recurrent tumor is best seen on MRI (Fig. 2).
Mastectomy without Reconstruction
A patient who has been treated by mastectomy has a
contralateral breast cancer risk of approximately 7%, and so
surveillance of the treated breast is almost entirely covered
by physical examination, with targeted US scan of any
palpable area. The contralateral breast will continue to be
monitored by a regular annual mammographic examination,
with additional imaging being reserved for patients who are
symptomatic or who have a palpable finding.
Male Survivors of Breast Cancer
These are the forgotten survivors of cancer. The surveillance
protocol for a male patient should be the same as that
for a woman who has had a mastectomy without reconstruction.
Most recurrences in men should be palpable, hence the
importance of a regular physical exam, and possibly “breast
awareness” on the part of the man. If the patient has had a
Fig. 2. MRI image showing enhancing nodule adjacent to seroma/
lumpectomy site. Patient is 5 years post-surgery and 2 months
post-completion of 5 years of tamoxifen.
Abbreviation: MRI, magnetic resonance imaging.
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