Internal mammary node involvement in patients with axilla-negative early breast cancer: a narrative review

Early breast cancer staging involves radiological and pathological evaluation of the tumour and regional lymph nodes. The internal mammary nodes (IMN) are an important site of possible metastasis and influence disease stage and prognosis. However, the recommendation for routine IMN assessment remains unclear. Internal mammary sentinel lymph node biopsy (SLNB) is associated with increased morbidity and an unknown survival benefit. Furthermore, the IMN are traditionally thought to be involved only synchronous with, or following, axillary node (AXN) metastasis. The aim of this review is to determine the prevalence of IMN metastasis in patients with axilla-negative early breast cancer. A narrative review of studies assessing IMN metastasis was performed. The literature search was completed using the database Medline (Ovid). Twenty-two retrospective studies were identified. The studies included data from SLNB, US, MRI, PET/CT and opportunistic biopsy during free-flap reconstruction (FFR). The prevalence of isolated IMN metastasis ranged from 1.2% to 17.9%.

Breast Imaging After Dark

Patients may present to the emergency department with breast complaints due to traumatic or nontraumatic changes in the breast. Benign and malignant breast pathologies may mimic each other both in clinical presentation and imaging appearance. A complex cystic and solid mass seen on ultrasound in a patient with a palpable mass can represent breast cancer, abscess, or hematoma. A unilateral swollen breast may result from inflammatory breast cancer, mastitis, or other benign etiologies; correlation with clinical history, physical exam, and close follow-up are required to ensure complete resolution of symptoms. Uncommon breast entities such as granulomatous mastitis and breast implant-associated anaplastic large-cell lymphoma may cause changes in the appearance of the breast that prompt a patient to seek initial evaluation in the emergency department. Imaging evaluation of the breast in the emergency department is limited, and it is important that patients with a breast complaint be referred to a dedicated breast center for complete evaluation at an appropriate time interval after their discharge from the emergency department.

Breast Cancer Staging: Updates in the AJCC Cancer Staging Manual, 8th Edition, and Current Challenges for Radiologists, From the AJR Special Series on Cancer Staging

The standardization of the AJCC TNM staging system for breast cancer allows physicians to evaluate patients with breast cancer using standard language and criteria, assess treatment response, and compare patient outcomes. Previous editions of the AJCC Cancer Staging Manual relied on the anatomic TNM method of staging that incorporates imaging and uses population-level survival data to predict patient outcomes. Recent advances in therapy based on biomarker status and multigene panels have improved treatment strategies. In the newest edition of the AJCC Cancer Staging Manual (8th edition, adopted on January 1, 2018), breast cancer staging integrates anatomic staging with tumor grade, biomarker data regarding hormone receptor status, oncogene expression, and gene expression profiling to assign a prognostic stage. This article reviews the 8th edition of the AJCC breast cancer staging system with a focus on anatomic staging and the challenges that anatomic staging poses for radiologists. We highlight key imaging findings that impact patient treatment and discuss the role of imaging in evaluating response to neoadjuvant therapy. Finally, we discuss biomarkers and multigene panels and how these impact prognostic stage. The review will help radiologists identify critical findings that affect breast cancer staging and understand ongoing limitations of imaging in staging.

Ultrasound Evaluation of the Axilla in the Breast Imaging Setting

ABSTRACT

Ultrasound evaluation of the axilla plays a critical role in the setting of newly diagnosed breast cancer as surgical management evolves toward more targeted axillary nodal resection. Regional nodal involvement by metastatic carcinoma is one of most important prognostic factors in breast cancer and guides local, regional, and systemic treatment. Ultrasound also evaluates response to neoadjuvant chemotherapy. This article will review ultrasound techniques and the anatomy and the morphology of axillary lymph nodes. Lymph node staging in breast cancer will also be discussed. Ultrasound-guided interventions and localizations and emerging technologies of elastography and contrast-enhanced ultrasound will be discussed. In addition, this article will discuss the role of ultrasound as it applies to management of the axilla since the American College of Surgeons Oncology Group Z011 and Z1071 trials. Finally, other causes of benign and malignant axillary lymphadenopathy, not related to breast cancer, are discussed.

Finding Inspiration for the Next Generation of Breast Radiologists

Challenges currently facing breast radiologists, including controversial screening mammography guidelines, radiologist burnout, and the perceived threat posed by artificial intelligence could deter potential candidates from pursuing a career in radiology. However, breast radiologists play a fulfilling role by decreasing the effect of breast cancer through both early detection and direct interaction with patients and interdisciplinary clinical colleagues. While perception is that artificial intelligence will threaten the need for radiologists, it is more likely that it will improve image interpretation and efficiency in workflow, thereby further improving patient care. Trainees can be engaged in breast imaging through interactive teaching methods and by role modeling clinical and image interpretation skills.

Incremental Cancer Detection of Locoregional Restaging with Diagnostic Mammography Combined with Whole-Breast and Regional Nodal Ultrasound in Women with Newly Diagnosed Breast Cancer

RATIONALE AND OBJECTIVES

This study aims to determine if locoregional restaging with diagnostic mammography and ultrasound (US) of the whole breast and regional nodes performed for quality assurance in women with newly diagnosed breast cancer who were referred to a tertiary care center yields incremental cancer detection.

MATERIALS AND METHODS

An institutional review board-approved retrospective, single-institution database review was performed on the first 1000 women referred to our center in 2010 with a provisional breast cancer diagnosis. Locoregional restaging consisted of diagnostic full-field digital mammography combined with US of the whole breast and regional nodal basins. Bilateral whole-breast US was performed in women with contralateral mammographic abnormality or had heterogeneously or extremely dense parenchyma. Demographic, clinical, and pathologic factors were analyzed.

RESULTS

Final analyses included 401 women. Of the 401 women, 138 (34%) did not have their outside images available for review upon referral. The median age was 54 years (range 21-92); the median tumor size was 2.9 cm (range 0.6-18.0) for women whose disease was upstaged and 2.2 cm (range 0.4-15.0) for women whose disease was not upstaged. Incremental cancer detection rates were 15.5% (62 of 401) in the ipsilateral breast and 3.9% (6 of 154) in the contralateral breast (P < 0.0001). The total upstage rate was 25% (100 of 401). Surgical management changed from segmentectomy to mastectomy in 12% (50 of 401). The re-excision rate after segmentectomy was 19% (35 of 189).

CONCLUSIONS

Locoregional restaging with diagnostic mammography combined with whole-breast and regional nodal US that is performed for standardization of the imaging workup for newly diagnosed breast cancer patients can reduce underestimation of disease burden and impact therapeutic planning.

Multidisciplinary Tumor Boards: An Opportunity for Radiologists to Demonstrate Value

In response to healthcare reform, a necessary evolution of radiology has shifted from generating volume to demonstrating value. Multidisciplinary tumor boards provide a critical opportunity for radiologists to demonstrate their value to their clinical colleagues, their patients, administrations, and society.