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If present, tumor deposits may be found within the primary lymphatic drainage area of the tumor. They are different from direct extension from the primary tumor and may be the result of lymphovascular invasion with extravascular extension, a totally replaced lymph node, or discontinuous spread. Nodules of tumor outside the primary lymphatic drainage area of the tumor are distant metastasis. Coding Instructions and Codes Note 1: Physician statement of Tumor Deposits can be used code this data item when no other information is available. Note 2: Tumor deposits are defined as one or more satellite peritumoral nodules in the pericolorectal adipose tissue of a primary carcinoma without histologic evidence of residual lymph node in the nodule. Note 4: Code X9 if surgical resection of the primary site is performed, the pathology report is available, and tumor deposits are not mentioned. Code Description 00 No tumor deposits 01 01-99 Tumor deposits 99 (Exact number of Tumor Deposits) X1 100 or more Tumor Deposits X2 Tumor Deposits identified, number unknown X8 Not applicable: Information not collected for this case (If this information is required by your standard setter, use of code X8 may result in an edit error. Alpha fetoprotein levels are usually undetectable in the blood of healthy adult men or women (who are not pregnant). An elevated level of alpha-fetoprotein suggests the presence of either a primary liver cancer or germ cell tumor. Note 3: A lab value expressed in micrograms per liter (ug/L) is equivalent the same value expressed in ng/ml. Code Description 0 Negative/normal; within normal limits 1 Positive/elevated 2 Borderline; undetermined if positive or negative 7 Test ordered, results not in chart 8 Not applicable: Information not collected for this case (If this item is required by your standard setter, use of code 8 will result in an edit error. If the liver is damaged, there will be too much bilirubin in the blood, and this can produce jaundice. Elevated bilirubin levels can indicate liver or blood disorders or blockage of bile ducts. Do not code individual conjugate, direct, unconjugated, indirect, or delta values or bilirubin in urine. Creatinine can be measured in blood serum or urine, but these data items apply blood levels only. An elevated level indicates the blood is too thin and does not clot properly, increasing the risk of bleeding. Note 2: Record the lab value of the highest Bilirubin Total test results documented in the medical record prior treatment. Note 3: Assay of Bilirubin Pretreatment Total Lab Value includes conjugated (direct) and unconjugated (indirect) bilirubin and total bilirubin values. Note 4: Record the nearest tenth of mg/dL or umol/L the highest total bilirubin value prior treatment. Bilirubin is commonly measured in units of Milligrams/deciliter (mg/dL) in the United States and Micromoles/liter (umol/L) in Canada and Europe. Code Description 1 Milligrams per deciliter (mg/dL) 2 Micromoles/liter (umol/L) 7 Test ordered, results not in chart 8 Not applicable: Information not collected for this case (If this item is required by your standard setter, use of code 8 will result in an edit error. Note 2: Record the lab value of the highest Creatinine test result documented in the medical record prior treatment.

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A dilated fundus examination may reveal preretinal, intraretinal (including white centered hemorrhages), or vitreous hemorrhages. Photographic documentation of retinal findings should be obtained immediately, as these findings may be fleeting. A variety 7 of retinal vascular changes can be seen in hypertensive patients; these depend in part on the severity and duration of the hypertension. Long-standing hypertension can produce arteriolar sclerotic vascular changes, such as copper or silver wiring of the arterioles, as shown by the two arrows on the right, or arteriorvenous nicking. Another sign of chronic hypertension is lipid exudates resulting from abnormal vascular permeability, as shown by the arrow at left. More ominous in this photograph is swelling of the optic disc, seen here by the blurring of the temporal disc margins. In the elderly, the most common source of emboli is fibrin and cholesterol from ulcerated plaques in the wall of the carotid artery. Ophthalmoscopic examination will reveal narrowed retinal arterioles and a pale retina. Edema with loss of retinal transparency in all areas except the fovea gives rise the appearance known as the cherry-red spot (left). Emergency treatment is directed decreasing intraocular pressure and vasodilation in an attempt allow the obstructing embolus pass into less critical, smaller-caliber vessels. The visual loss in amaurosis fugax typically consists of monocular dimming of vision or a sense of a curtain coming down over the eye, depending on what part of the retinal arterial tree is involved. Homonymous field defects involving both eyes may also occur due embolization of the cerebral circulation. Attacks usually lasts for 2?3 minutes, and then vision returns normal as the embolus travels through the affected artery or the focal vasospasm resolves. The examination should include auscultation and imaging (Doppler and echocardiogram) of the carotid arteries and the heart as well as measurement of blood pressure in both arms. Evaluation by an ophthalmologist may be indicated look for emboli and evidence of retinal and optic nerve ischemia. Patients with retinal embolization have a greater risk than the general population of developing a cerebral infarction over the next few months, particularly if the amaurosis fugax is accompanied by symptoms of transient cerebral ischemia. Talc emboli do not typically cause occlusion or ischemia although rarely they may be associated with retinal neovascularization. Blood workup rule out coagulopathies (including Factor V deficiency), hyperlipidemia, collagen vascular diseases, and paraneoplastic syndromes may be considered. These symptoms, which are presumably due focal cortical or ocular ischemia, may last from 15 45 minutes. Complicated migraine occurs when frequent severe migraine headache results in a persistent visual or other neurologic deficit. However, the visual phenomena may occur without headaches, which is called ocular or acephalgic migraine or migraine equivalent.

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When used in the neoadjuvant setting, the package insert recommends cardiac monitoring every 6 weeks. Radiation Older radiotherapy techniques for breast cancer involved signifcant doses of radi ation the heart. The spectrum of radiation-related cardiac disease includes myocardial damage and coronary artery disease when mediastinal radiation is used (31). This improvement could be related improved techniques or possibly decreased targeting of the internal mammary lymph nodes. It is unclear if one potentiates the efects of the other or if each has an independent mechanism (23). Cardiac safety analysis of doxorubicin and cyclophosphamide followed by paclitaxel with or without trastu zumab in the North Central Cancer Treatment Group N9831 adjuvant breast cancer trial. Cognitive Impairment and Fatigue Seventy-fve percent of breast cancer patients report decline of cognitive function during their treatment and 35% report continuing impairment afer treatment ends (34?36). The presence of treatable and contributing factors of cognitive impairment such as depression, insomnia, substance abuse, medication efects, and causes of fatigue should be evaluated (3,4). However, ofen no distinct cause can be identifed and the patient is assumed have cognitive impairment related treatment. Tese subtle yet signifcant efects on cognitive functioning can have a large impact on quality of life (37,38). Breast cancer patients appear be particularly susceptible cognitive defcits for numerous reasons including efects of cancer itself, emotional stress of the diagnosis, and the sequelae of chemotherapy and hormone therapy. Multiple stud ies have confrmed objective evidence of cognitive decline afer chemotherapy (37?39). Analyses using a battery of neuropsychological tests have shown defcits in various cognitive domains including visuospatial ability, executive function, information processing speed, and verbal and visual memory (40,41). Studies with brain imaging in breast cancer patients who have received chemotherapy show structural changes refective of treatment efects (42,43). In addition cytotoxic agents, breast cancer patients with hormone-receptor positive breast cancer receive adjuvant hormonal therapy. As health care providers for breast cancer survivors, understanding the pos sibility of cognitive dysfunction and its efect on quality of life and function in society is essential. Fatigue is very common in cancer patients treated with radiation and chemo therapy, and some patients experience longer lasting symptoms causing disrup tions in quality of life and increased distress. Estrogen has been shown have anti depressive efects, and treatment for breast cancer can lead an estrogen-deprived state (48).

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During the following decades,1 Egan is credited with disseminating his article allows only a brief glimpse into the early attempts at in vivo imaging of the direct x-ray technique for mammographic rich history of breast imaging. Innova breast did not sustain interest, mainly positioning and imaging, facilitating more tion, leadership, and commitment on due poor visualisation of breast tis widespread adoption of mammogra the part of many over the past decades sues (Figure 1). Charles Marie have contributed making breast radiologists who continued work on Gros, in Strasbourg, France, developed imaging the exciting feld it is today. With the development in mammographic imag mograms were printed on paper with and non-uniform toner (similar those Another major technological advance, addition of uniform thickness breast ing11. Screen out more evenly, allowing further reduc breast thereby improving the visuali and provides complementary informa process, and were well-suited imag tion, xeromammography was ultimately flm techniques allowed faster imaging tion of radiation dose and better visual sation of overlapping tissues. Just as mography led continued improve gram and may soon become the stan mammography has seen technological ments in breast image quality during dard for mammographic screening. However, because the images are read from electronic signals by a computer rather than developed on x-ray flm by B a technologist, images are available the radiologist in a much shorter time. Digital mammography has the added beneft of lower radiation dose compared with analogue (flm-based) mammog A raphy. As radiologists traded in their light boxes for computers and work stations, the digital transition allowed workfow improvements such as inte gration of imaging with the electronic medical record and reporting systems. For cosmetic results for the patient with malignancy or in cases where more Karolinska Hospital in Sweden32. Percutaneous biopsy via as a minimally invasive procedure but thus reducing the number of benign for breast cancer evaluation until gad was removed ensure the lesion was expanded include tissue diagno fne-needle aspiration technique under sufered from a high rate of insufcient biopsies, for example, in the case of the olinium contrast became available. Pioneers such sis with involvement of the breast stereotactic guidance for non-palpa sampling under general use and also simple cyst shown in Figure 4b15,16. The hook-wire held in place within Currently, core biopsy is successfully adenopathy, extent of disease eval the breast better than a straight needle. The stif ered the frst line approach obtain a detecting breast cancer (Figure 5) but is more accurate placement of the wire, for parallel the chest wall, targeting portion of the wire is centred diagnosis rather than surgical excision. Breast imaging radiologists today have showing cancer (arrow) in right reserved for supplemental screening for patients compared with the freehand more tools at their disposal and are posterior breast. The increased imally invasive needle biopsies of the strong family history of breast cancer. Breast localisation and minimally invasive biopsy procedures developed along Percutaneous Biopsy side mammography and other breast Development of image-guided percu imaging technologies. This ofers the most common cancer in the side faster and ensure that inno tious goal of improving methods for the graphy and 3D modalities. Since 2008, the European Institute procedures the individual patient structures across diferent types of the project team apply for further for Biomedical Imaging Research by integrating various types of med medical imaging. These specialists include pathologists examine tissue samples also have their own specifc language made up of leading organisations in Researchers created a unique database and unsuccessful treatment. For instance, radiol this information separately from the these specialists essentially speak countries and two partner organ like patient age, patient lifestyle and expertise from a number of medical ogists read images from scans and various specialist disciplines, which the same language.

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