4.3 Surgical, Nonsurgical, and Reconstruction Options

What ARRT Expects You to Know

Patient Care C, Breast Cancer Treatment Options, carries an ARRT footnote: the mammographer needs definitions and basic descriptions of these terms. You will not be asked to choose a chemotherapy regimen or draw a surgical flap. You will be asked what the operation removed, what the drug class is for, and how the treated breast behaves under a paddle.

Effective September 1, 2025, TRAM flap and latissimus dorsi flap were removed from this Patient Care list. Current reconstruction content is implant reconstruction. Older textbooks still devote pages to those flaps; do not treat them as live exam items. The 2025 update also removed cyst aspiration, fine-needle aspiration (FNA), and sentinel node mapping from Procedures. Do not study those as mammography procedures you perform. Sentinel axillary node biopsy remains as a treatment-history term: something that was done to the patient, not a mapping injection you perform in the mammography room.

Surgical Options

Lumpectomy / breast-conserving surgery (BCS) removes the tumor plus a margin of surrounding breast tissue and leaves the remainder of the breast. It is local therapy aimed at the primary site. The breast is still there to compress, with a scar and often clips at the lumpectomy bed. Radiation usually follows BCS; that pairing matters for skin and edema even though radiation is listed separately as a nonsurgical option.

Sentinel axillary node biopsy removes one or a few sentinel lymph nodes, the first axillary nodes that drain the breast, to see whether cancer has spread. It is staging surgery, not a mammographic mapping procedure. Expect a small axillary scar, soreness, and limited abduction that can shorten how much pectoralis muscle you include on the MLO.

Simple (total) mastectomy removes the entire breast, typically including the nipple-areola complex, without a full axillary lymph node dissection. Sentinel nodes may still have been sampled through a separate incision. There is no native breast mound to screen with routine craniocaudal and MLO tissue that no longer exists.

Modified radical mastectomy removes the entire breast plus axillary lymph node dissection (classically levels I and II) while preserving pectoralis major. The word modified makes sense only if you remember that historic radical mastectomy also took pectoralis major. Radical mastectomy is not on the current option list; modified radical is.

Prophylactic mastectomy is risk-reducing removal of a breast that does not have a known cancer, often in patients with high inherited risk. Imaging afterward follows the mastectomy or reconstruction anatomy, not a screening intact-breast pathway. The mammographer still documents laterality carefully: one side may be prophylactic while the other is a cancer operation.

Nonsurgical Options

Radiation therapy delivers ionizing radiation to the breast or chest wall, most often after lumpectomy to treat residual microscopic disease, and sometimes after mastectomy when tumor size or nodes warrant it. Skin may be erythematous during treatment and later thickened, edematous, or taut. Compression must be firm enough for image quality and gentle enough not to split fragile skin. Edema and trabecular thickening can persist and will look like pathology if you do not record the radiation history.

Chemotherapy is systemic cytotoxic drug treatment given before surgery (neoadjuvant), after surgery (adjuvant), or for metastatic disease. It does not leave surgical clips by itself, but the patient may have a port scar, treatment fatigue, and cytopenias that make bruising easier. Your concern is safe positioning and accurate history, not drug names or cycle counts.

Hormone therapy / antiestrogen therapy is used when the tumor is estrogen-receptor positive (ER+) and/or progesterone-receptor positive (PR+). These drugs block estrogen effect or estrogen production. ER-negative / PR-negative tumors are not candidates for this class. ARRT wants receptor-status literacy, not a pharmacy list. If the history says the patient is on antiestrogen therapy, you can infer the cancer was hormone-receptor positive; you still write the history rather than diagnosing receptor status yourself.

Anti-HER2/neu therapy targets tumors that overexpress human epidermal growth factor receptor 2 (HER2/neu). It is a separate decision from ER/PR. A cancer can be ER-positive and HER2-positive (both classes) or ER-negative and HER2-positive (anti-HER2 without antiestrogen). You record that the patient is on or has completed anti-HER2 therapy as treatment history. You do not interpret the pathology report's staining percentages.

Implant Reconstruction

After mastectomy, the mound may be rebuilt with a tissue expander followed by a saline or silicone implant, or with a direct-to-implant operation. Reconstruction may be immediate (same day as mastectomy) or delayed. The implant may sit in front of or behind pectoralis major. This is the reconstruction method that remains on the outline.

Do not pad this paragraph with autologous flap eponyms. If a patient reports flap reconstruction, document the history in their words and image the chest you have, but do not study flap anatomy as 2025 test content.

Implant reconstruction is not the same as cosmetic augmentation of an intact breast, which you already captured as previous surgery. After mastectomy plus implant, there may be little native parenchyma. The order may be for implant evaluation, a chest-wall concern, or screening of the contralateral intact breast. Follow the order. Do not automatically run a four-view augmented-breast screening protocol on a reconstructed mastectomy side.

Imaging Implications at Technologist Level

A lumpectomy scar plus clips on the MLO can look aggressive if unmarked. Radiation edema can mimic inflammatory disease if you do not record the treatment year. An axillary sentinel-node scar that you ignore will be called limited MLO, pec muscle not visualized, with no explanation. None of those points are interventional-procedure trivia. They are why treatment history sits in Patient Care.

Sequence of care is often lumpectomy or mastectomy, nodal staging, then radiation and/or systemic therapy. You do not need oncology timelines memorized by week. You need to ask what surgery, what radiation, what drugs, and what reconstruction, then mark, position, and protocol the breast that resulted.

Exam traps to leave behind

• Do not describe sentinel node mapping, cyst aspiration, or FNA as current mammography Procedures content. They were removed.
• Do not treat TRAM or latissimus dorsi flaps as testable 2025 reconstruction items. They were removed.
• Do not confuse sentinel axillary node biopsy (a surgery the patient already had) with a procedure you perform today.
• Do not call simple mastectomy and modified radical mastectomy the same operation; the difference is axillary dissection and, historically, the pectoralis muscle.
• Do not assume every implant is cosmetic augmentation. After cancer treatment it may be implant reconstruction with almost no native tissue to displace.