Gen: Obese 65-year-old Caucasian woman who appears her stated age, in NAD VS: BP 135/76, P 78, RR 18, T 38.1 °C (100.6°F); ht 5'4", wt 100 kg (220 lbs).

Breast: Right: Hard 2.4? 3 cm mass in upper outer quadrant without associated erythema, dimpling or skin changes, not fixed to skin, no ulceration. No palpable lymph nodes in axilla. Left: Without masses or lymphadenopathy

Labs: All within normal limits

CXR: Lungs are clear

What information is suggestive of breast cancer?

What other tests do you need to make a diagnosis and develop a treatment plan?

In most instances, external-beam radiation therapy used in conjunction with breast-conserving procedures involves 4 to 6 weeks of radiation therapy directed to the breast tissue to eradicate residual disease. Complications associated with radiation therapy to the breast are minor and include reddening and erythema of the breast tissue and subsequent shrinkage of total breast mass beyond that predicted on the basis of breast tissue removal. Some clinical situations also require postmastectomy radiation therapy as well (see section on locally advanced breast cancer).

There are several contraindications to breast conservation that must be considered when selecting patients:

• Multiple sites of cancer within the breast

• Pregnancy (patient cannot receive radiation)

• Inability to attain negative pathologic margins on the excised breast specimen

• Pre-existing collagen-vascular diseases (e.g., scleroderma and systemic lupus erythematosus)

• Diffuse malignant-appearing microcalcifications on mammogram

• Prior radiation treatment to the breast or chest wall

• Large tumor volume in a woman with small breasts (better cosmetic results often can be obtained with mastectomy and reconstruction).

The importance of stage I/II axillary dissection is being challenged. Although highly accurate, its morbidity is significant, with an acute complication rate as high as

4"33 34

20% to 30% and rates of chronic lymphedema also on the order of 20% to 30% '

A new procedure involving lymphatic mapping and sentinel lymph node biopsy is be-

coming more acceptable at many academic centers across the United States. The sentinel lymph node is the first lymph node that drains a cancer. Injection of a dye around the primary breast tumor results in identification of the sentinel lymph node in the majority of patients, and the status of this lymph node may predict the status of the remaining nodes in the nodal basin. A sentinel lymph node can be identified in 90% of patients and can accurately predict the status of the remaining axillary nodes in 95% of patients.36

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