2012 EDUCATIONAL BOOK - American Society of Clinical Oncology

lumpectomy rather than mastectomy, then there is still no
reason to vary the protocol from that of a female patient.
The Reconstructed Breast
The reconstructed breast has not been the subject of
imaging surveillance until more recently. Some advise the
use of mammographic surveillance of transverse rectus
abdominus myocutaneous (TRAM) flap reconstructions,
sometimes called “tramograms,” which can be performed
just like any other surveillance mammogram. 28,29 The findings
of recurrent cancer are typical and have been reported
before they become palpable, advancing the stage of diagnosis.
Others advocate for only selecting women with a high
risk-of-recurrence score to have tramograms (Fig. 3).
The most sensitive test for the reconstructed breast is
MRI, although it is a relatively expensive test that is not
always covered by health insurance in this situation, even
Fig. 3. Tramogram image showing TRAM recurrence in the right
XCCL mammogram. Lesion was not initially not detected until the
mammogram finding showed the lesion.
Abbreviations: TRAM, transverse rectus abdominus myocutaneous;
XCCL, exaggerated craniocaudal view.
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FLOWERS, MOONEY, AND DRUKTEINIS
Fig. 4. Developing microcalcifications in scar on routine mammogram.
though it is the most effective test. According to Devon, 30
MRI is useful in the detection of locally recurrent tumors in
patients who have undergone breast reconstruction with a
TRAM flap. It detects cancer recurrences at an earlier stage
than noncompliant annual surveillance.
Improved access to dedicated breast MRI is making evaluation
of the reconstructed breast more affordable and
accessible. Early detection may potentially save health care
dollars by catching recurrence before loco-regional spread,
but there are no data to show that this improves survival.
False-Positive Examinations on Follow-up
There are frequently false-positive clinical findings after
reconstruction, mainly with palpable lumps. Palpable lesions
should be first evaluated with US. The palpable lumps
are generally multiple, appear in the upper outer quadrant
or 6 o’clock positions, and are caused by fat necrosis. This is
more common in women with implant reconstruction than