Abstract

In a rapidly evolving world, with a steep rise in breast cancer incidence, there has been many advances in imaging and therapeutic options of breast cancer care. In this review article, we are trying to cover imaging guideline for cancer detection and their therapeutic options. These help in the reduction of morbidity and mortality.

Introduction

According to latest GLOBOCAN statistics,[1] breast cancer (BC) is the leading cause of mortality amongst all cancers. Early detection of BC improves survival. There are various societies like JCC, NCCN, ASCO, ACR, RSNA, ESR, IRIA/ICRI, National Cancer Grid (NCG) which have their guidelines for the evaluation and treatment of BC. Here in this review, we are aiming to cover imaging guidelines for the evaluation of BC.

Epidemiology, Clinical presentation in India and Globally

Globally, BC is the leading cancer among women, contributing to 2,261,419 new cases and 684,996 deaths annually.[1] There is a wide variation in incidence rates, with some countries like Netherlands and Belgium having estimated age adjusted incidence (AAI) of over 100 and others like Bhutan with AAI of 5.[2] Globally, both incidence and mortality of BC have increased significantly in all age groups since 1990. Mortality increased by 0.23%-per year and incidence by 1.28%-per year in age group of 50 to 69 and by 1.55%-per year (under 50).[3] BC is the most common cancer among Indian women both in terms of incidence and mortality. There are estimated 178,361 (13.5%-cancers among women) cases and 90,408 (10.6%) deaths due to BC in India.[3]

The AAI is 25.8 in India overall, with the highest burden being observed in metropolitan cities. Around 57%-of BCs are diagnosed at the locally advanced stage.[4]

Risk Factors and Etiopathogenesis

Cancer, in general, is a multistep process and after decades of studies we are now aware that there are three types of risk factors: (1) exogenous modifiable risk factors like oncogenic viruses, tobacco usage, atmospheric radiation, chemical carcinogens, lack of exercise, obesity, low activity level, etc.; (2) endogenous partially modifiable risk factors like hereditary risk, hormones, inflammation, growth factors, and (3) intrinsic risk factors which are non-modifiable and created due to random errors in DNA replication.[5] The later may be responsible for over 60%-of tissue cancer burden.[5] If a cause is known, it is much easier to know whether it can (e.g., tobacco use) or cannot (e.g., ionizing radiation in the atmosphere) be avoided easily.[6] These factors then result in uncontrolled growth and the etiopathogenesis of cancer is summarized in [Fig. 1].

| Fig. 1 :Etiopathogenesis of cancer.

Various specific risk factors for BC are as follows.

Non-modifiable risk factors are the one which cannot be changed. These are increasing age, genetic mutations (BRCA1, BRCA 2, and p53), early menarche, late menopause, dense breast, family and personal history of BC, history of radiation to chest wall, and exposure to certain drugs like diethylstilbestrol used to prevent abortion till 1970s.

Modifiable risk factors are obesity, lack of exercise, hormones in the form of HRT and contraceptive pills, late pregnancy, avoiding breastfeeding and alcohol consumption.[7]

| Figure 2:A 50-year-old female with right breast lump since 1 month. No other complains. On mammogram (A and B) and USG: a well-defined high-density mass with partly obscured margins is seen in the upper outer quadrant of right breast, measuring approximately 1.9 × 2.2 × 2.3 cm. No suspicious microcalcifications are seen. No other associated features are seen. On USG (C) irregular mass with microlobulated margin is seen at 10 o'clock position in right breast. The lesion is predominantly hypoechoic with posterior acoustic enhancement. The lesion is parallel in orientation. No suspicious axillary lymph nodes are seen on imaging. Histopathology of lesion is TNBC. As this lesion is early stage breast cancer without nodal involvement (stage IIA), further metastatic work-up is not needed. (TNBC, triple-negative breast cancer; USG, ultrasonography).

| Figure 3:A 38-year-old female with increasing right breast lump since 15 months. Mammogram (A, B): An irregular high-density mass with indistinct margins is seen in predominantly upper inner quadrant also extending in the outer quadrant measuring approximately 4.4 × 4.4 × 5.5 cm. Pleomorphic microcalcifications (C) are seen within the mass, better seen on magnification view. Diffuse trabecular thickening with nipple areolar complex thickening and retraction is seen. Few suspicious right axillary nodes are seen, largest measuring 1.2 × 0.7 cm with 4.5-mm cortical thickness (D). In view of dense breast parenchyma, further evaluation with CEM was performed to rule out any other lesion in breast, CEM (E, F) is suggestive of large unifocal lesion. This is the case of locally advanced breast cancer (stage IIIA), further metastatic work-up was performed. On CT scan, (G, H) heterogeneously enhancing mass is seen involving right breast with involvement of overlying skin. Enlarged right axillary, right internal mammary, and right supraclavicular lymph nodes are seen. (CEM, contrast-enhanced mammogram.)

Positron emission tomography-computed tomography (PET-CT) is not routinely advised for early stage BC, however, according to NCCN guidelines, it may be advised for higher stage disease if available due to its higher detection of metastatic sites and its whole body coverage.[32] It may be beneficial in inflammatory BC or in oligometastatic disease to confirm absence of metastasis elsewhere in the body if radical treatment is considered for a single involved site.[17] [31] [33] [34]

The clinical and pathological prognostic stage groups may be different from the patient's anatomical stage group. For example, T1N0M0 tumor of anatomical stage group 1A would be pathological prognostic stage group IA if it is grade I tumor which is ER, PR, and HER2 receptor positive. However, if it is grade II ER, PR, and HER2 receptor negative it would change to pathological prognostic stage group IB.[31]

Clinical nodal (cN) category as per AJCC is based on clinical and imaging investigation of nodal basin. Axillary lymph node level depends on the location of lymph node with respect to pectoralis minor muscle. Level I lymph nodes are located lateral to the lateral margin of pectoralis minor muscle; level II lymph nodes are located between lateral and medial margins of the pectoralis minor muscle. Level II also includes interpectoral lymph nodes (Rotter's node). Level III includes lymph nodes that are located medial to medial margin of pectoralis minor muscle.[35] [36]

Suspicious imaging features for axillary lymph nodes on ultrasound are focal eccentric cortical thickness, irregular margin, loss of fatty hilum, and extra nodal extension. Uniformly thin cortex with cortical thickness of less than 3 mm is considered to be normal appearance of axillary lymph node.[37] [38] Metastatic disease is most commonly seen in bones, lungs, brain, and liver.[35] Additional brain imaging is performed for clinical symptoms like headache, mental status alteration, nausea, or vomiting. In such situation brain MRI is preferred over CT scan.[39]

Response Assessment Post NACT

Baseline and end of treatment mammography and ultrasound are the minimum imaging required for the assessment of response to neoadjuvant treatment. However, baseline and end of treatment CEMRI is the ideal modality to assess response.[17] [34] Recent studies have also shown comparable results with the use of CEM for response assessment.[40] Marker clip insertion is advised to mark the tumor bed for reliable identification if there is a radiologic complete response. This is especially important if the breast conservation surgery is planned. It can be placed at the time of initial biopsy or during the first few cycles of treatment if a substantial response is noted.[41] A tissue marker may also be inserted into the biopsied axillary lymph node if local policy includes image-guided localization of the biopsied lymph node and targeted lymph node dissection.[17] Depending on the molecular subtype, response rates of different types BC vary, for e.g., pCR (pathological complete response) is seen in approximately 30%-of the patients with triple negative BC, whereas some newer targeted therapies in Her2 positive cancer are able to achieve pCR rate of up to 60%.-Hormone receptor positive cancers have lowest pCR rate in range of approximately 20%. As per NCCN guidelines, response assessment should be performed on the modality on which prechemotherapy assessment is performed.[42]

In advanced cases with metastatic or oligometastatic disease, response is to be assessed objectively using acceptable criteria of RECIST guidelines. Preferably imaging on which metastatic disease is detected, should be the modality to assess response, like abnormality seen on CT thorax, should be monitored with CT thorax[32]. Multiple studies have shown promising result with the use of serial PET CT in response assessment in metastatic setting.[43] [44]

In non-metastatic setting, clinical examination and imaging studies should be routinely performed during preoperative therapy.[32]

Imaging Guidance for Surgery of Impalpable Malignant Lesions

Ultrasound is the modality of choice for preoperative-guided hook wire localization of nonpalpable masses.[24] Hook wire localization is performed prior to the surgery on the day of surgery. If lesions are not visualized on ultrasound, mammography and MR-guided localizations can be performed for lesions seen on mammography and MR-only lesions, respectively.[25] Radiograph or ultrasound of the excised surgical specimen is advised to confirm total excision of the abnormality. Confirmation of enhancement seen on MRI at the time of localization and follow-up MRI is performed for MRI-only abnormality. Radioactive seeds, magnetic seeds, and electromagnetic-radiofrequency tags can be used as alternatives for hook wire localizations.[45] [46]

Imaging Follow-Up

Annual mammography is recommended after the completion of treatment.[22] It is known that women with mammography detected cancers have better survival rates than clinically detected cancers.[17] Comparison with previous mammograms and biopsy of any new lesion not typically benign are advised.[34] MRI is emerging as a valuable tool in surveillance of patients with BC and has shown clear benefit in differentiating scar tissue from tumor recurrence.[47] [48]

Post-treatment changes in the form of fat necrosis and calcification are commonly seen on mammogram. These changes are commonly seen at the site of surgical suture and need to be carefully evaluated, if suspicious biopsy can be performed. Calcification due to fat necrosis in early stage may mimic suspicious morphology.[49]

If clinically asymptomatic, annual mammography screening should be initiated 6 to 12 months after the completion of radiotherapy.[32]

Supplementary ultrasound may be used. However, breast ultrasound alone is not recommended for routine surveillance.[17] In case of breast reconstruction, routine imaging follow-up for metastasis is not indicated.[32]

In cases of reconstruction with implant, unless there is a clinical concern, routine surveillance systemic imaging to detect metastases is not recommended.[34] There is no significant difference in imaging appearance of locoregional or distant recurrence disease. For follow-up of known visceral metastatic disease from a primary BC, CECT of thorax, abdomen, and pelvis is usually sufficient.[17] Other investigations may be helpful depending on specific clinical needs. Image-guided core biopsy and assessment of hormone receptor status of new distant metastasis are advised as receptor conversion in distant metastasis is known to occur.[50]

Patients on endocrine therapy, like those on tamoxifen – routine age appropriate gynecological screening is recommended. Routine annual pelvic ultrasound is not recommended. While those on aromatase inhibitors, should have periodic bone health monitoring with bone mineral density at baseline and regularly thereafter.[32]

There are no clear surveillance guidelines for patients with bilateral mastectomy and breast reconstruction with implants, however, small studies have shown, no additional benefit with MRI.[51]

Imaging in Pregnant and Lactating Women

Ultrasound is the modality of choice for initial assessment. Physiological changes may make interpretation difficult and hence a lower threshold for follow-up and/or biopsy is advised.[17] Mammography may be safely performed in pregnant women with a negligible risk to the fetus. Wearing a lead apron reduces the radiation dose to the fetus by at least half.[52] [53]

As stochastic risks from radiation have no threshold value, mammography should be carefully used. However, this should not deter us from performing necessary mammographic studies for women suspected to have BC. Breast feeding or pumping milk prior to the examination during lactation reduces breast density.[17] Gadolinium should be limited to situations where benefits clearly outweigh the risks to fetus and hence CEMRI is generally avoided in pregnancy.[54] Breast feeding does not need to be interrupted after gadolinium administration as the water soluble nature of gadolinium-based contrast agents results in a low concentration of gadolinium in the mother's milk.[54]

It is best to perform CEMRI after optimum counseling.

Multidisciplinary Management of BC

Surgical Oncology

Management of BC needs a personalized multimodality approach. In the current era of de-escalation of therapy, we cannot lose sight of the spectrum theory. BC management has seen a paradigm shift from the Halstedian approach of radical local surgery to more conservative approaches based on Fishers' theory that BC is a systemic disease at inception. The current approach is personalized and straddles the spectrum of aggressive biology and genomics to more indolent cases.[55]

Surgery for BC has seen a trend toward conservation of both primary and axillary lymph nodes and increased focus on cosmetic outcome and quality of life (QOL). Oncoplastic techniques have allowed for conservative surgery even in larger tumors and better cosmetic outcomes.[56]

Sequencing of therapy and inclusion of various modalities of therapy (surgery, chemotherapy, targeted therapy, hormone therapy, and radiotherapy) are dependent on patients-related factors like ECOG, co-morbidities, age and tumor-related factors like tumor size, grade, lymph node positivity, hormone and HER2 neu receptor and Ki67 status. Even the 8th AJCC staging system has included grade, receptor status, and ability to take therapy into account when staging BC.[31]

Management Schema for various stages of BC adapted from NCG guidelines 2019[33] is discussed in more details in Annexure 2

Medical Oncology

BC encompasses several subtypes and systemic therapy is indicated depending upon the biology and staging of the disease.

Perioperative Therapy

A multitude of regimens are used with the aim of micrometastases control with comparable outcomes in either NACT or adjuvant chemotherapy (ACT) fashion ([Fig. 4]). Sequential and dose-dense regimens are preferred (Table 1 in Annexure 3). pCR is a robust prognosticator in HER2-positives and triple-negative breast cancer (TNBC) groups.[57] ACT is used to reduce the risk of recurrence (RR). RR risk may be predicted using various clinicopathological factors and genomic signatures (Table 2 in Annexure 3).

|  Figure 4:Neo-adjuvant and adjuvant therapy.

HER2-Positive Tumors

HER2-rich patients should receive perioperative anti-Her2 therapy; 1-year trastuzumab is the current standard with/without pertuzumab (Annexure 4).

Hormone Positive (HR + ) Tumors

Neoadjuvant endocrine therapy alone is sufficient in low RR, HR+ tumors. The duration of ET varies from 5 to 10 years depending upon RR.[58] In premenopausal women, additional ovarian function suppression may be considered if RR is high.

Triple-Negative Tumors

In the NA setting, the addition of immune checkpoint inhibitors (ICIs) has shown benefit.[59] [60] Adjuvant capecitabine and PARP are options in non-pCR groups.[61]

Metastatic Disease

The mainstay of treatment is prolonging life and QOL. The treatment determinants are disease biology, prior therapies, ECOG – performance status, potential toxicities, and patient wishes (Annexures 5, 6, and 7). Interestingly, outcomes of the short course ICI were found comparable to the standard course in a large real-world data.[62]

Specific Populations

Young patients with BC (<40 href="https://www.thieme-connect.com/products/ejournals/html/10.1055/s-0042-1760326#JR22810739-63" xss=removed>63] Pregnancy-associated BC is challenging; however, stage- and biology-matched outcomes are largely comparable if appropriately managed.[64]

Toxicity

Chemotherapy has various side effects including hematological and non-hematological factors (gastrointestinal, cardiac, renal, liver, body image issue, etc.). Chemo-induced alopecia is of major psychological concern; however, a scalp cooling strategy may help in mitigating this issue successfully.[65]

Refer to Table 2 in Annexure 3 for genomic signature, which could help in decide ACT and also regimens for adjuvant setting.

Radiation Oncology

BC patients experience an improvement in locoregional control and overall survival with the addition of adjuvant RT.[66] Nearly 70%-of all BC patients would require RT in their lifetime either in adjuvant or palliative setting and is well tolerated by most. In the adjuvant setting, addition of RT minimizes the microscopic tumor burden in the tumor bed (residual breast or the chest wall) and adjacent regions where the tumor cells are likely to migrate (clinically uninvolved supraclavicular region after a complete axillary clearance). Studies with long-term follow-up show that mastectomy can be avoided if adjuvant whole breast RT is delivered to the conserved breast.[67] In women <50 href="https://www.thieme-connect.com/products/ejournals/html/10.1055/s-0042-1760326#JR22810739-68" xss=removed>68] Whole breast RT can produce acute and late toxicities like radiation dermatitis, induration, breast pain, shrinkage, and leads to poor cosmetic outcomes. Partial breast RT with external beam or brachytherapy delivered over shorter duration helps minimize these toxicities in early, node-negative BC patients after breast conserving surgery.[69] [70]

Palliative RT is recommended to alleviate symptoms such as pain, bleeding, prevent neurological death in brain metastasis and functional loss, and is effective in 60 to 70%-of the patients with minimal side effects.

Management of Locoregional or Distant Recurrence

Locoregional or distant metastatic recurrence is managed depending on the site, however, repeat core biopsy from the first recurrence site is obtained – to look for hormone receptor status evaluation.[32]

Image-Guided Interventions in Palliative Conditions

In symptomatic clinical cases having metastatic bone disease, high intensity focused ultrasound/cryoablation of symptomatic bone metastasis can be performed.[71] [72] Image-guided vertebroplasty is performed for vertebral body collapse.[73] RFA or microwave ablation of liver lesions can be performed by IR (interventional radiology). Chemoport insertion can be performed by IR or surgeons depending on institutional practice.

Summary

There is a rise in the incidence of BC all over the world in recent times. In this era of personalized cancer care, cross specialty knowledge of advances in cancer care is of utmost importance in the management of cancer patients. In this document we have described diagnostic work-up for BC with an emphasis on imaging.

• Diagnostic work-up.

• Staging of BC.

• Response assessment post NACT.

This work-up is followed by philosophies of various treatment approaches (surgery, chemotherapy, or radiotherapy) for different stages and biology of BC. All these has led to decrease in cancer-specific mortality.

Synoptic reporting formats for mammogram, USG, MRI breast, CT scan, and PET CT are discussed in Annexure 8.

ANNEXURE 1 AMERICAN CANCER SOCIETY RECOMMENDS SCREENING MAMMOGRAM (MG)

American Cancer Society recommends screening mammogram (MG) as follows:

( https://www.cancer.org/cancer/breast-cancer/screening-tests-and-early-detection/american-cancer-society-recommendations-for-the-early-detection-of-breast-cancer.html ; last revised January 14, 2022).

American College of Radiology [ACR] and Society of Breast Imaging [SBI] recommends

Annual MG from age 40

( https://www.acraccreditation.org/Mammography-Saves-Lives/Guidelines )

United States Preventive Service Task Force (USPSTF) recommends Biennial screening MG for women from 50 to 74 years (B recommendation)

( https://www.acraccreditation.org/Mammography-Saves-Lives/Guidelines )

European Commission Breast Cancer Guidelines (ECIBC's Guideline Development Group [GDG)]) recommend:

( https://healthcare-quality.jrc.ec.europa.eu/european-breast-cancer-guidelines/screening-ages-and-frequencies )

Canadian Task Force recommends:

Abbreviation: MG, mammogram.

( https://canadiantaskforce.ca/guidelines/published-guidelines/breast-cancer-update )

Breast screening program in Australia recommends:

( https://www.cancer.org.au/cancer-information/causes-and-prevention/early-detection-and-screening/breast-cancer-screening )

Invitation-based screening MG at biennial interval for 50 to 74 years age. Younger and older women may undergo mammography, without invitation.

Swedish BC guidelines

( https://www.swedish.org/services/womens-health/our-services/mammography/screening-guidelines )

Annual screening MG for age over 40 years

Breast Imaging Society of India (BISI) recommends:

(https://www.bisi.co.in/guidelines/mammography)

|  :

*Number of cycles should be based on tumor response/institutional practice.

#Tailoring treatment based on IHC, to be able to consider post NACT adjuvant therapy to non-responders can be discussed with patients ©.

***Contraindications to BCS include: diffuse microcalcification, persistent positive margins, poor patient compliance, previous chest or breast radiation, relative contraindication is multicentricity. Contraindications to radiotherapy, e.g., collagen vascular diseases.

3SNB can be performed either using Dual Dye-Radio Colloid and Blue Dye (preferred method) OR using Blue Dye alone. 1 to 2 mL peritumoral and/or subareolar injection/subdermal injection of patent Blue Dye or 2%-Methylene Blue 10 minutes prior to the surgical incision and 40 MBq in 0.5 mL of 99m-technetium-labeled sulfur/antimony colloid peritumoral and/or subareolar injection/subdermal injection 2 to 12 hours prior to surgery.

5If the patient and tumor characteristics meet the ACOZOG Z-11 (T1, micro metastasis in node, low-grade tumor, ER/PR positive, BCS done, whole breast RT using tangential fields planned) and 1–2 SLN positive, no further axillary surgery may be considered. ©

****Breast reconstruction may be performed by surgeons in motivated and suitable patients following mastectomy. Implant or autologous flap reconstruction can be performed based on patient's suitability and choice of surgeon.

7If cN0 prior to NACT or an OBC with cN1 post chemotherapy cN0: can be considered for SLN/low axillary sampling.

&If FS not available: LAS and final HPR or ALND (level II if no gross enlarged nodes).

Margins in BCS: negative margin defined as no tumor on inked surface. In case of positive margins, should be revised. In case of persistent positive margins, MRM to be considered.

In patients with family history of cancer, younger than 40 years, male breast cancer or patients with synchronous and metachronous breast cancer, can be referred for genetic counselling and those who are willing may be considered for testing to rule out presence of germline pathogenic variant. ©

Screen detected low-grade DCIS undergoing lumpectomy may not require axillary assessment. ©

|  :

*Source: Adapted from NCG guidelines 2019 (Accessed March 19, 2022).

|  :

Abbreviations: HER2, human epidermal growth factor receptor; PCR, pathological complete response; TDM1, trastuzumab emtansine.

ANNEXURE 5 METASTATIC BREAST CANCER

|  :

Abbreviations: ADC, antibody drug conjugate; BRCA WT, breast cancer gene wild type; PDL1, programmed death ligand receptor L1.

ANNEXURE 6 HORMONE POSITIVE AND HER2-NEGATIVE METASTATIC TUMOR

|  :

ANNEXURE 7 METASTATIC HER2-POSITIVE TUMOR

|  :

ANNEXURE 8 SYNOPTIC REPORTING FORMATS FOR MAMMOGRAM, USG, MRI BREAST, CT SCAN AND PET CT

Digital mammograms: dated

Bilateral/unilateral

Indication: Screening/diagnostic

Right breast:

Breast composition:

a. The breasts are almost entirely fatty.

b. There are scattered areas of fibroglandular density.

c. The breasts are heterogeneously dense, which may obscure small masses.

d. The breasts are extremely dense, which lowers the sensitivity of mammography.

Normal/Abnormal

If abnormal

A. Mass: Absent/present

If present:

Size:

Location:

|  :

Density: iso/high/low/fat containing.

Shape: oval/round/irregular.

Margins: circumscribed/obscured/microlobulated/indistinct/spiculated.

B. Calcifications: absent/present.

If present:

Benign: Vascular/coarse/popcorn/rod-like/round/lucent centered/eggshell/milk of calcium/dystrophic/punctuate/sutural.

Suspicious morphology: Amorphous/coarse heterogeneous/fine pleomorphic/fine linear or fine-linear branching.

Distribution: diffuse/regional/grouped/linear/segmental.

C. Architectural distortion: Absent/present

D. Asymmetry: Absent/present

E. Associated findings:

Skin thickening/skin retraction/nipple retraction/trabecular thickening/abnormal axillary or intramammary nodes.

F. Additional information:

G. Comparison: No change/new lesion/regression/increase in existing lesion.

H. Assessment category:

BIRADS 0/1/2/3/4a/4b/4c/5/6

Left breast:

Breast composition:

a. The breasts are almost entirely fatty.

b. There are scattered areas of fibroglandular density.

c. The breasts are heterogeneously dense, which may obscure small masses.

d. The breasts are extremely dense, which lowers the sensitivity of mammography.

Normal/Abnormal

If abnormal

A. Mass: Absent/present

If present:

Size:

Location:

|  :

Density: Iso/high/low/fat containing

Shape: Oval/round/irregular

Margins: Circumscribed/obscured/microlobulated/indistinct/spiculated

B. Calcifications: absent/present If present:

If present:

Benign: Vascular/coarse/popcorn/rod-like/round/lucent centered/eggshell/milk of calcium/dystrophic/punctuate/sutural.

Suspicious morphology: Amorphous/coarse heterogeneous/fine pleomorphic/fine linear or fine-linear branching.

Distribution: Diffuse/regional/grouped/linear/segmental.

C. Architectural distortion: Absent/present.

D. Asymmetry: Absent/present.

E. Associated findings: Skin thickening/skin retraction/nipple retraction/trabecular thickening/abnormal axillary or intramammary nodes.

F. Additional information:

I. Comparison: No change/new lesion/regression/increase in existing lesion.

G. Assessment category:

BIRADS 0/1/2/3/4a/4b/4c/5/6

Breast ultrasound synoptic reporting

Indication

Family history of cancer: Yes/no

Parenchyma

a. Homogeneous background echotexture – fat.

b. Homogeneous background echotexture – fibroglandular.

c. Heterogeneous background echotexture.

Laterality

Right / left / both

Primary lesion evaluation

Single/multiple

Size

Quadrants involved with o'clock position

Shape

Oval/round/irregular

Margin

Circumscribed or

Non-circumscribed (indistinct/angular/microlobulated/spiculated).

Orientation

Parallel /nonparallel

Echopattern

Anechoic/hyperechoic/hypoechoic /isoechoic/complex solid cystic/heterogeneous

Posterior features

No posterior features/enhancement/shadowing/combined pattern

Vascularity

Absent/internal vascularity/vessels in rim

Elasticity assessment

Soft/intermediate/hard

Calcification: yes/no

If yes,

In Mass / Outside Mass / Intraductal

Distance from nipple

Duct

Ductal changes: Yes/No

Satellite lesions

Yes/no

Size

Quadrants

Numbers

Positions in o'clock

Distance from primary lesion and nipple

Axillary nodes

Yes/no

Size

Cortical thickening yes/no (measurement in mm)

Preserved hilum yes/no

Microcalcification in lymph node yes/no

Matted yes/no

Perinodal extension yes/no

Non-hilar blood flow yes/no

Intramammary lymph nodes

Yes/no

Size

Special cases:

Simple cyst

Clustered microcysts

Complicated cyst

Mass in or on skin

Foreign body including implants

Lymph nodes – intramammary

Lymph nodes – axillary

Vascular abnormalities AVMs (arteriovenous malformations/ pseudoaneurysms)

Mondor disease

Postsurgical fluid collection

Fat necrosis

Any other relevant finding

Assessment category

BIRADS 0/1/2/3/4a/4b/4c/5/6

Breast MRI:

Breast MRI performed in a 1.5 T/3T scanner using a dedicated breast coil. Multiplanar Plain T1, T2, STIR, DWI, post contrast dynamic T1 weighted sequence after administration of 0.1 mmol/kg body weight contrast.

Indication:

Any prior breast imaging available: Yes/no

Last menstrual period:

Amount of fibroglandular Parenchyma: Type a, b, c, d

Background parenchymal enhancement intensity:minimal, mild, moderate, severe

Symmetry: Symmetric/asymmetric

Right breast

Mass:

Location

Size

Shape: Round/oval/irregular

Margins: Circumscribed non-circumscribed: irregular/spiculated

T2 SI

DWI:

Enhancement morphology: Homogeneous/heterogeneous/rim/dark internal septations

Kinetic curve assessment:

Initial phase: Fast/medium/slow

Delayed phase: wash-out/persistent/plateau

Non-mass enhancement:

Distribution: Focal/linear/ segmental/regional/ multiple regions/diffuse

Morphology: Homogeneous/heterogeneous/ clumped/clustered ring

Focus: Number and symmetry

Other findings: Cysts/non enhancing mass/dilated ducts/etc.

Skin thickening

Nipple retraction:

Chest wall invasion:

Axillary nodes

Internal mammary nodes:

Left breast

Mass:

Location

Size

Shape: round oval irregular

Margins: Circumscribed non-circumscribed: irregular/spiculated

T2 SI

DWI:

Enhancement morphology: homogeneous/heterogeneous/rim/dark internal septations

Kinetic curve assessment:

Initial phase: fast/medium/slow

Delayed phase: Washout/persistent/plateau

Non-mass enhancement:

Distribution: Focal/linear/segmental/regional/multiple regions/diffuse

Morphology: Homogeneous/heterogeneous/clumped/clustered ring

Focus: Number and symmetry

Other findings: Cysts/non enhancing mass/dilated ducts/etc.

Skin thickening

Nipple retraction:

Chest wall invasion:

Axillary nodes

Internal mammary nodes:

Visualized Liver: If any abnormality seen

Visualized bones:

Impression:

BIRADS: 1/2/3/4a/4b/4c/5/6

Breast cancer CT scan

CT scan of chest, abdomen, and pelvis

Contrast enhanced CT scan performed.

Indication:

Base line evaluation/post-NACT evaluation. Comparison made with prior CT dated ()/other indication

Primary lesion evaluation

Laterality: Right/left

Tumor size

Skin thickening: present absent

Nipple retraction: present absent

Chest wall invasion: present absent

Axillary nodes: present absent

If present, number and size of largest

Internal mammary nodes: present absent

If present, number and size of largest

Supraclavicular nodes: present absent

If present, number and size of largest

Contralateral breast: unremarkable

Contralateral axilla: unremarkable

Metastatic disease evaluation:

Mediastinal nodes:

Lungs:

Pleura:

Heart and mediastinal great vessels:

Liver:

Adrenals:

Gall bladder:

Pancreas:

Spleen:

Kidneys:

Bowel:

Peritoneum:

Urinary bladder:

Uterus:

Ovaries:

Retroperitoneal and pelvic adenopathy

Free fluid:

Major vessels:

Visualized bones:

Any other finding:

Impression:

Synoptic reports for FDG PETCT:

References

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2. nbsp;Global Cancer Observatory. Accessed March 18, 2022, at: https://gco.iarc.fr/
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74. Address for correspondence
    

    Meenakshi Thakur, MD
    Department of Radiodiagnosis, Tata Memorial Centre
    Mumbai 400012
    India   
    Email: thakurmh@yahoo.co.in
    
    

    Publication History

    Article published online:
    04 May 2023
    

    © 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

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| Fig. 1 :Etiopathogenesis of cancer.

| Figure 2:A 50-year-old female with right breast lump since 1 month. No other complains. On mammogram (A and B) and USG: a well-defined high-density mass with partly obscured margins is seen in the upper outer quadrant of right breast, measuring approximately 1.9 × 2.2 × 2.3 cm. No suspicious microcalcifications are seen. No other associated features are seen. On USG (C) irregular mass with microlobulated margin is seen at 10 o'clock position in right breast. The lesion is predominantly hypoechoic with posterior acoustic enhancement. The lesion is parallel in orientation. No suspicious axillary lymph nodes are seen on imaging. Histopathology of lesion is TNBC. As this lesion is early stage breast cancer without nodal involvement (stage IIA), further metastatic work-up is not needed. (TNBC, triple-negative breast cancer; USG, ultrasonography).

| Figure 3:A 38-year-old female with increasing right breast lump since 15 months. Mammogram (A, B): An irregular high-density mass with indistinct margins is seen in predominantly upper inner quadrant also extending in the outer quadrant measuring approximately 4.4 × 4.4 × 5.5 cm. Pleomorphic microcalcifications (C) are seen within the mass, better seen on magnification view. Diffuse trabecular thickening with nipple areolar complex thickening and retraction is seen. Few suspicious right axillary nodes are seen, largest measuring 1.2 × 0.7 cm with 4.5-mm cortical thickness (D). In view of dense breast parenchyma, further evaluation with CEM was performed to rule out any other lesion in breast, CEM (E, F) is suggestive of large unifocal lesion. This is the case of locally advanced breast cancer (stage IIIA), further metastatic work-up was performed. On CT scan, (G, H) heterogeneously enhancing mass is seen involving right breast with involvement of overlying skin. Enlarged right axillary, right internal mammary, and right supraclavicular lymph nodes are seen. (CEM, contrast-enhanced mammogram.)

|  Figure 4:Neo-adjuvant and adjuvant therapy.

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