What is the management approach for a patient presenting with a large, visible, tender mass after mastectomy?

Management of a Large Visible Tender Mass in the Right Upper Quadrant Post-Mastectomy

A large, visible, tender mass in the right upper quadrant post-mastectomy should be evaluated with ultrasound imaging followed by biopsy to rule out local recurrence, and if confirmed as recurrence, surgical excision with wide margins is recommended.

Initial Diagnostic Evaluation

Imaging Assessment

1. Ultrasound examination should be the first imaging modality

   • Ultrasound has high sensitivity (85.25%) and specificity (84.48%) for detecting chest wall recurrence after mastectomy 1
   • Key ultrasound features suggestive of recurrence include:
     • Vascularity (strongest predictor with odds ratio of 4.0)
     • Irregular shape (odds ratio of 2.6)
     • Location in deep tissue layers (odds ratio of 2.2)
     • For masses ≤10mm, anatomic layer location is most helpful
     • For masses >10mm, presence of vascularity is most helpful 1

2. Additional imaging if ultrasound is inconclusive:

   • CT scan or MRI may be necessary to evaluate extent of disease and potential involvement of deeper structures

Tissue Diagnosis

• Core needle biopsy is essential to confirm diagnosis
• Correlation of imaging and pathology findings is critical to ensure accurate diagnosis 2
• If biopsy confirms malignancy, immunohistochemical studies should be performed to determine tumor characteristics

Management Approach for Confirmed Recurrence

Surgical Management

1. Wide local excision with clear margins is the standard approach 3

   • For large masses, more extensive surgery may be required
   • The goal is to achieve negative histological margins to reduce risk of further recurrence

2. Considerations for reconstruction:

   • For large recurrent tumors, delayed rather than immediate reconstruction is recommended
   • The British Journal of Cancer guidelines advise against immediate reconstruction in cases of large high-grade tumors due to:
     • Potential need for postoperative chest wall radiotherapy
     • Significant risk of local recurrence within the first two years 3

Adjuvant Treatment

1. Radiotherapy:

   • Postoperative radiotherapy should be considered for:
     • Large tumors (>5 cm)
     • Close (<5 mm) or positive margins
     • Multifocal disease
     • Recurrent disease 3
   • Radiotherapy improves local control but has not been shown to improve overall survival

2. Systemic therapy:

   • Consider systemic therapy based on tumor characteristics and previous treatments
   • For aggressive disease, induction chemotherapy may be considered, especially when surgery would be excessively morbid 3

Management of Specific Complications

Seroma Management

• Common complication post-mastectomy
• If seroma is confirmed by ultrasound:
  • Small seromas may resolve spontaneously
  • Larger symptomatic seromas may require aspiration
  • Persistent seromas may require surgical intervention 4

Hematoma Management

• Requires prompt intervention to prevent infection and delayed healing
• Ultrasound-guided aspiration for small hematomas
• Surgical evacuation for large or infected hematomas 4

Follow-up Protocol

• Regular clinical examinations every 3-6 months for the first 2-3 years
• Ultrasound surveillance is recommended as it can detect chest wall recurrence at an early stage 1
• Annual mammography of the contralateral breast is recommended 3

Key Pitfalls to Avoid

1. Misdiagnosis of benign post-surgical changes as recurrence

   • Fat necrosis is the most common benign finding in the early postoperative period and can mimic recurrence 3
   • Correlation of clinical, radiological, and pathological findings is essential

2. Inadequate margins during excision

   • Positive margins significantly increase risk of further recurrence
   • Re-excision should be performed if margins are positive 3

3. Delayed diagnosis

   • Early detection of recurrence improves outcomes
   • Ultrasound surveillance can help detect recurrence at an early stage 1

4. Overlooking the need for multidisciplinary management

   • Close collaboration between breast cancer MDT and sarcoma MDT is necessary for optimal management 3

By following this structured approach to evaluation and management, patients with a large visible tender mass in the right upper quadrant post-mastectomy can receive appropriate and timely care to optimize outcomes.