As correctly stated, intramammary nodes are part of the axillary lymph nodes according to the TNM classification.
According to the study by Giuliano et al (JAMA 2017;318(10):918-926.doi: 10.1001/jama.2017.11470), if only 1 or 2 lymph nodes are positive, axillary dissection does not improve survival. The decision for the single case should be taken together with surgeons, oncologists, pathologists and radiation therapists at the local multidisciplinary meeting, also considering patient’s characteristics and ECOG status.

answered by E. Giannotti, P. Clauser & S. Schiaffino

Recent European guidelines (Rubio et al., 2023) suggest employing ultrasound guided Vacuum-Assisted Biopsy (VAB) as the primary approach when dealing with pathological nipple discharge and/or lesions exhibiting papillary features on imaging, such as solid-cystic masses or small masses within dilated ducts. Ultrasound-guided Vacuum-Assisted Excision (VAE) may be considered for B3 lesions identified on ultrasound or for those previously biopsied using stereotactic, tomosynthesis, or MRI guidance, with an ultrasound-visible clip.

Stereotactic-guided VAB is preferred over ultrasound-guided VAB for cases involving microcalcifications, as calcifications without accompanying mass or architectural distortion can be challenging to detect via ultrasound, particularly post-local anesthetic injection.

Although ultrasound-guided VAB can serve as an alternative for sonographically visible calcifications in patients unable to undergo stereotactic biopsy, such instances are rare. Additionally, in cases of very small breast volume, ultrasound-guided VAB may pose challenges or be impractical.

Literature suggests that for microcalcifications, diagnostic accuracy improves with a larger volume of biopsy samples, thereby reducing underestimation rates. Consequently, VAB should be prioritized as the initial approach for assessing microcalcifications without associated masses on ultrasound, whenever feasible, to minimize underestimation rates. The use of 14G Core Needle Biopsy (CNB) may sometimes yield inadequate calcifications in tissue samples, especially in patients with dense breast tissue.

Rubio IT, Wyld L, Marotti L, Athanasiou A, Regitnig P, Catanuto G, Schoones JW, Zambon M, Camps J, Santini D, Dietz J, Sardanelli F, Varga Z, Smidt M, Sharma N, Shaaban AM, Gilbert F. European guidelines for the diagnosis, treatment and follow-up of breast lesions with uncertain malignant potential (B3 lesions) developed jointly by EUSOMA, EUSOBI, ESP (BWG) and ESSO. Eur J Surg Oncol. 2024 Jan;50(1):107292. doi: 10.1016/j.ejso.2023.107292. Epub 2023 Nov 27. Erratum in: Eur J Surg Oncol. 2024 Jan 20;:107943. PMID: 38061151.

answered by E. Giannotti & M. Keupers

Currently, delayed CEM is still a topic of research. At the moment authors suggest at least 6-8 minutes after administration of the iodinated contrast media. The clinical implications for delayed phase CEM are however still a topic of debate.

The time is considered from the start of the injection of the contrast and they need to be completed within 10 minutes.

answered by T. van Nijnatten & E. Giannotti

Contrast-enhanced mammography (CEM) can be used as a guidance for stereotactic biopsy for non-mass enhancing lesions (see 10.1007/s00330-022-09021-w and 10.1007/s00330-022-09196-2). About MRI-only lesions, you first need to check their CEM visibility. At the moment, CEM-guided biopsy using a tomosynthesis approach is not already available in the market.

answered by S. Schiaffino

The response rate for luminal B tumours has been extensively investigated and enclosed a very interesting trial-level-analysis from Cortazar et al. regarding the response rates of neoadjuvant chemo-immunotherpy per breast cancer subtype (still before the era of pertuzumab). The chance of achieving breast pCR for luminal B is in general approximately 30% (without pertuzumab, with pertuzumab this will be some higher). The response of axillary lymph nodes to neoadjuvant chemo-immunotherapy is still challenging, as current imaging modalities are not able to accurately predict axillary pCR despite some response is observed on interim and post-neoadjuvant treatment exams.

Reference:
Cortazar P, Zhang L, Untch M, et al. Pathological complete response and long-term clinical benefit in breast cancer: the CTNeoBC pooled analysis. Lancet. 2014 Jul 12;384(9938):164-72.

answered by T. van Nijnatten

Prof. Chantal van Ongeval and Dr. Simone Schiaffino suggest the Tyrer-Cuzick Risk Calculator.

Prof. Chantal van Ongeval: We work with the Tyrer-Cuzick risk calculator (version 8, which includes the breast density) in our department for more than 5 years. Furthermore the radiological follow up scheme is based on the results of this score.

Prof. Francesco Sardanelli is referring to the EUSOBI recommendation paper on Breast MRI published in 2015. In Table 1, MRI for nipple discharge has been acknowledged as a “recently” proposed (in 2015) indication to breast MRI.

Please find here the link to the EUSOBI recommendation paper: https://link.springer.com/article/10.1007/s00330-015-3807-z

1) In a woman with a history of breast cancer (treated with breast conservation or mastectomy) is mammography performed annually or biannually?
The Netherlands: Annually, up to 5 years after surgery. After that a patient can return to the national screening programme, as is recommended by the guidelines. In practice, sometimes patients keep requesting to continue their annual screening (instead of biannual).
United Kingdom: Usually follow up mammography is for 5/10 years annually, according with the type of disease and age of the patient. This is usually done under a surveillance screening. After that time patient will return to National Screening Programme (Standard or High risk screening if the patient qualified for High risk screening) or if out of the age of the screening programme being discharge.

2) Is mammography performed as part of the national screening programme?
The Netherlands: Yes, in women from age 50-70.
United Kingdom: There is no age cut off at within surveillance mammography ceases.

3) Is there an age cut off at which mammography ceases?
The Netherlands: See 2. However in elderly patients (age>70) after treatment of breast cancer, these patients will also receive mammography as part of follow-up up to 5 years after treatment. According to the guideline, they don’t require any further follow-up after 5 years.
United Kingdom: National Screening Programme usually finish at the age of 69 in the general population.

In case of developing National Guidelines it is suggested to find evidence in the literature that can support your choice.

The following paper gives a nice overview: Bucchi L, Belli P, Benelli E, Bernardi D, Brancato B, Calabrese M, Carbonaro LA, Caumo F, Cavallo-Marincola B, Clauser P, Fedato C, Frigerio A, Galli V, Giordano L, Golinelli P, Mariscotti G, Martincich L, Montemezzi S, Morrone D, Naldoni C, Paduos A, Panizza P, Pediconi F, Querci F, Rizzo A, Saguatti G, Tagliafico A, Trimboli RM, Zuiani C, Sardanelli Recommendations for breast imaging follow-up of women with a previous history of breast cancer: position paper from the Italian Group for Mammography Screening (GISMa) and the Italian College of Breast Radiologists (ICBR) by SIRM. Radiol Med. 2016 Dec;121(12):891-896. doi: 10.1007/s11547-016-0676-8.

answered by P. Clauser, E. Giannotti & T. van Nijnatten

We evaluate response to treatment according with RECIST 1.1. criteria, although we know that they role can be limited in evaluating response to NAC. We know that MRI is the best examination we have, but it is not perfect in evaluation Pcr with lack of specificity, as can over or underestimate the response to therapy. For that we talk about radiological response.

Regarding your question partial radiological response is when maximum diameter of the lesion has reduced of 30%. We consider a mixed response when there is a lesion that decreases in size and other lesion that grows.

Slow delayed enhancement could be sign of residual disease/residual DCIS or fibrosis post NAC, and thus it is correct to describe the maximum diameter of the area in the report, giving also the two possible differential diagnosis.

Regarding the second questions depend on different things, what kind of cancer is, size of the breast, presence of microcalcifications, kind of surgery that is offered from the service and size at diagnosis, so again answer is variable and need to be discuss in multidisciplinary meeting.

answered by E. Giannotti & P. Clauser

Please find here the link to the EUSOBI Position Paper: https://pubmed.ncbi.nlm.nih.gov/27807699/

Additionally, this could be also helpful: https://www.sciencedirect.com/science/article/pii/S0960977620300606?via%3Dihub

answered by P. Clauser

There are specific tools to assess the risk of developing breast cancer, which do not only consider the family history of breast cancer or other risk factors. It is important to follow as much as possible well established guidelines and recommendations when defining a woman’s risk level.

Information on how to classify a patient as FH patient can be found here, according with NICE guidelines: https://cks.nice.org.uk/topics/breast-cancer-managing-fh/management/breast-cancer-managing-fh/

Starting age is influenced by different factors. Information from the High Risk screening programme in UK can be found here:
https://www.gov.uk/government/publications/breast-screening-higher-risk-women-surveillance-protocols

answered by E. Giannotti & P. Clauser

YES:
If surgical candidate with either dense breast/ suspicion of multifocality/-centricity on conventional imaging (with equivocal findings on conventional imaging).
If neoadjuvant chemotherapy planned
If not surgical candidate and neoendocrine treatment planned if MRI is tolerated (otherwise US)

NO:
Bilateral mastectomy planned
Non-dense breast with unifocal cancer/ no suspicion of multifocality/-centricity on conventional imaging
Obviously, in case of contraindications to MRI or contrast agent administration

answered by R. Mann, K. Pinker-Domenig and P. Clauser

In case of a focus (enhancing lesion < 5 mm), it is important to make sure that there is no correlate in the pre-contrast and in the T2-weighted images that might help with further characterization towards a small suspicious mass or benign lesion. In the absence of a correlate on T1 and T2 weighted sequence, the symmetry should be evaluated: diffuse, symmetric foci  are in general expression of diffuse benign changes in the breast.

In case of a single focus or focal non mass enhancement, there is only a little number of findings specific for a benign diagnosis. Small intralesional cysts, high ADC values and homogeneous and persistent enhancement curves suggest a benign finding. In the clinical context of cancer staging, it is very important whether the additional finding may be oncologically relevant (thus, discuss the impact on the therapy with the team). In many cases, such findings represent B3 lesions which e.g. in case of adjuvant radiation therapy and antihormonal therapy may be oncologically well treated without dedicated surgery. It is a difficult and case-by-case decision to biopsy such lesions or not (thus, all imaging and clinical information should be considered).

answered by P. Baltzer and P. Clauser

Linear enhancement is most frequently intraductal in origin, and consequently follows the ductal structure of the breast.

The term stippled however does no longer exist, as stippled enhancement has been grouped with background parenchymal enhancement.

In the area of non-mass enhancement you might encounter a focal area of enhancement or regional enhancement that does not conform to a ductal tree structure. These may still be worrysome as they may be caused by diffusely growing infiltrative tumors (e.g. lobulars). In most of the cases you will find more features pointing in the direction of cancer (i.e. exceptionally rapid enhancement and wash-out, edema, low adc values, etc.)

answered by R.M. Mann