Radiologists have a major responsibility and role in the care of patients with breast cancer, which makes it essential for them to understand their precise role within a multidisciplinary team. That’s the overwhelming view of experts from Croatia who are participating at this special session.

“You’re a gatekeeper of patients coming into the workup process and, depending on what you decide, you can change the outcome of their whole treatment – so there’s quite a bit of pressure,” explained Dr. Eugen Divjak, a radiology resident at the University Hospital ‘Dubrava’, Zagreb, Croatia.

Multidisciplinary breast team in University Hospital ‘Dubrava’. From left to right: pathologist Danko Müller, plastic surgeon Krešimir Martić, pathologist Čedna Tomasović-Lončarić, radiologist Gordana Ivanac, cytologist Tajana Štoos-Veić, plastic surgeon Rado Žic, oncologist Natalija Dedić Plavetić, radiologist Boris Brkljačić, radiologist Jovanka Vojnović, radiology resident Eugen Divjak, and nurse Kristina Šafran.

Listening to other members of a multidisciplinary team and working closely with colleagues from other specialties is crucial, along with passing on knowledge that is specific to radiologists, he added.

As an example, Divjak noted that radiologists tend to be visually orientated professionals who instinctively understand proportions. Other clinicians, by contrast, can assume that a breast tumour is ‘small’ or ‘large’ – without understanding the size of the tumour relative to the size of the patient’s breast.

“When you have the multidisciplinary meetings, you need to discuss every aspect of the patient,” he said.

Treatment options will be different for a young patient with a three-centimetre tumour in a relatively small breast, compared with an older patient with the same size of tumour in a larger breast composed mainly of fat tissue. One patient, for example, may be a candidate for immediate surgery, while another may be offered chemotherapy – and which treatment they are offered may depend on the expertise of the radiologist.

Fig 1A: Ultrasound scan of a 46-year-old woman shows malignant tumour lying closely to the pectoral muscle. Biopsy verified a triple-negative breast carcinoma, and at the multidisciplinary team meeting, neoadjuvant chemotherapy was recommended before surgical treatment.

In Croatia, the smallest multidisciplinary team consists of a radiologist, an oncologist, a pathologist with specialist training in cytology, and a plastic surgeon. A larger team might include a nurse and physiotherapist, plus a psychologist if the patient is having problems accepting the reality of their disease, according to Prof. Dr. Rado Žic, PhD, chief of the unit for hand and reconstructive surgery in the Department for Plastic, Reconstructive and Aesthetic Surgery, also from the University Hospital ‘Dubrava’ in Zagreb.

At today’s session, he plans to talk about the work of the breast cancer clinic at his hospital and some of the differences between breast surgery in Croatia and other countries. He is convinced about the benefits of having all breast surgery performed by a plastic and reconstructive surgeon.

“The main advantage of having all surgery done by one surgeon is that you don’t lose time with organisational issues and you don’t need to be conservative with treatment,” Žic stated. Reconstruction can be done at the same time as the main breast surgery, unlike in Germany and other countries, where the tumour removal and reconstructive surgeries need to be scheduled for different times, or at the same time by different surgeons, which can be an organisational challenge.

Fig 1B: Follow-up MRI in the same patient shows poor response to neoadjuvant chemotherapy. Surgical treatment was performed.

Plastic surgeons train for a minimum of five years and are taught both reconstructive and oncological techniques. In contrast, a breast surgeon in another country might only have taken a short course on reconstructing the breast. By understanding all options for removing and reconstructing breast tissue, a patient can be presented with a wide range of different possibilities for reconstruction.

“The patient has to be involved in decision making,” he said. “Some patients don’t want reconstruction – they want a mastectomy. And that’s their choice.”

He noted that patients won’t have the full range of options if the acting surgeon has only been trained in a limited number of reconstruction techniques. In his talk, he will describe how to perform skin- and nipple-sparing mastectomies, as well as the options to reconstruct the breast using either tissues from the patient’s own body or off-the-shelf materials.

Either way, teamwork is essential, Žic continued. Treatment of breast tumours is complex, and the patient’s situation can change on a daily basis. Treating the patient as an individual is crucial, and – by working in a team – the approach can be specific to the patient. The time needed to start or complete treatment is reduced too, and surgery can be scheduled when the patient has physically recovered.

Fig 1C: Postoperative follow-up MRI in the same patient one year after breast-conserving surgery. An irregular mass with postcontrast rim enhancement and wash-out kinetic curve is present in the postoperative scar. Findings are highly suspicious of carcinoma recurrence. This presents another challenge for the multidisciplinary team. (Provided by Dr. Eugen Divjak)

Surgery is often not the first option for treating breast cancer, and patients respond differently to immune or chemotherapy therapy. Some are ready for surgery straight away, while others need their operation to be postponed for a while, he explained.

In the future, he hopes that breast surgery will be even less important, as clinicians will be able to tell if a tumour has responded favourably to therapy and predict the possibility of tumour reoccurrence from a small tissue sample – rather than having to surgically remove tissue from the breast. In this situation, surgery would only be performed on patients who have not fully responded to neoadjuvant therapies.

LIVE
Multidisciplinary Session, Tuesday, November 24, 17:00–18:00
MS 7a Multidisciplinary team for breast cancer

  • Chairperson’s introduction
    Gordana Ivanac; Zagreb/HR
  • Radiologist’s perspective
    Eugen Divjak; Zagreb/HR
  • Pathologist’s perspective
    Čedna Tomasović-Lončarić; Zagreb/HR
  • Surgeon’s perspective
    Rado Žic; Zagreb/HR
  • Oncologist’s perspective
    Natalija Dedić Plavetić; Zagreb/HR
  • Live Q&A

FURTHER READING

Graña-López L, Herranz M, Domínguez-Prado I, Argibay S, Villares Á, Vázquez-Caruncho M (2019) Can dedicated breast PET help to reduce overdiagnosis and overtreatment by differentiating between indolent and potentially aggressive ductal carcinoma in situ? Eur Radiol. doi: 10.1007/s00330-019-06356-9: european-radiology.org/6356

Vogl WD, Pinker K, Helbich TH (2019) Automatic segmentation and classification of breast lesions through identification of informative multiparametric PET/MRI features. Eur Radiol Exp. 3(1):18: er-x.org/96

Sardanelli F, Aase HS, Álvarez M et al (2017) Position paper on screening for breast cancer by the European Society of Breast Imaging (EUSOBI) and 30 national breast radiology bodies from Austria, Belgium, Bosnia and Herzegovina, Bulgaria, Croatia, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Italy, Israel, Lithuania, Moldova, The Netherlands, Norway, Poland, Portugal, Romania, Serbia, Slovakia, Spain, Sweden, Switzerland and Turkey. Eur Radiol. 27(7):2737-2743: european-radiology.org/4612

Dratwa C, Jalaguier-Coudray A, Thomassin-Piana J et al (2016) Breast MR biopsy: Pathological and radiological correlation. Eur Radiol. 26(8):2510-9: european-radiology.org/4071

Joukainen S, Masarwah A, Könönen M et al (2019) Feasibility of mapping breast cancer with supine breast MRI in patients scheduled for oncoplastic surgery. Eur Radiol. 29(3):1435-1443: european-radiology.org/5681