Ask the Expert
Do you have a question on breast cancer/imaging?
Ask an expert via the contact field on the EUSOBI Homepage or send an email to firstname.lastname@example.org (subject line: Ask the Expert)! Our panel of experts in all the fields of breast will answer all of your questions. Share your thoughts with us on either breast imaging techniques, imaging interpretation, diagnosis, treatment, follow up or on research issues.
We are collecting your questions and publish them right here:
Regarding contrast-enhanced mammography, how many minutes after the contrast administration should we wait ideally for acquiring a delayed image?
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
Can contrast mammography already be used for stereotactic biopsy for non mass lesions and MRI-only lesions? If so, is it also possible with the use of tomosynthesis?
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
Do the Luminal B tumors have poor response to the chemotherapy?
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.
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
Which calculator is recommended to estimate risk for breast cancer (and than assign to the group "intermediate-risk" or "high-risk")?
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.
Regarding unilateral, uniductal and persistant bloody nipple discharge, what is EUSOBI's recommendation on the approach of such a finding?
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
What are the protocols for mammography for women with a history of breast cancer in the various European countries?
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
If the index tumor has no suspicious enhancement detected on MRI after chemotherapy and there is only delayed and slow enhancement seen, do we consider this a good or a mixed response to treatment? Also are the surgeons required to only remove the residual areas that appear suspicious on MRI, or the volume of tissue that corresponds to the original tumor before treatment??
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
Can I find any information about EU standards for Breast Unit on the EUSOBI website?
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
At what age would you consider a women as a high risk candidate for developing breast cancer if you only take into account family history? By this, I am referring only to close relatives of the hypothetical candidate (ie. mother, sister, daughter). At what age is a woman thought of as high risk if she has one close family member with breast cancer? At what age is a woman thought of as high risk if she has 2 close family members with breast cancer?
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:
answered by E. Giannotti & P. Clauser
Is MRI indicated in patients >80 with bilateral breast cancer?
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)
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
A focus or focal area of NME on MRI breast that is separate to the known primary cancer in the context of a patient with known breast cancer, how does one manage it?
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
Does linear-ductal non mass stippled enhancement always have to enhance in the direction of the nipple to be considered worrisome...or is it possible that this type of worrisome non mass enhancement can configure in a direction away from the nipple?
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