Breast imaging is a highly clinical sub-specialist role that involves direct patient contact and performing clinical examinations, ultrasound scans, and image guided biopsies, together with communicating results, and this work takes radiologists away from the ‘invisible role’ they often assume due to the digitisation of radiology, Prof. Michael Fuchsjäger, professor of radiology at Graz Medical University, Austria, and ESR President, told ECR Today.

Breast radiologists have to be aware that the job involves close personal contact, and good communication is vital to the whole process. Radiologists might well be the first to deliver bad news about breast cancer, for instance, and that it is an important part of their role.

The subspecialty of breast imaging is super important and rewarding because you can really make a difference to a patient’s life if you detect cancer, said ESR President, Prof. Michael Fuchsjäger from Graz, Austria, who was originally going to chair this session.

“There is a great need for training in communication skills, especially when delivering bad news,” he said, adding that currently there is no formal training curricula in this area. “Like everything in life, it does not get any easier to break bad news to patients.”

Breast radiologists must have a high clinical interest in their patients’ history and pay great attention to detail when they are reading diagnostic mammograms because if they miss something, it may well be a cancer. Fuchsjäger commented that some young radiologists are not choosing to become breast radiologists as a subspecialty for this reason, because there may be professional consequences if they miss a cancer.

“Even for highly distinguished experts, there may be cases that you miss, and this could lead to litigation,” he said. “But this subspecialty is super important and rewarding because you can really make a difference to a patient’s life if you detect cancer.”

Future research will need to address the acceptability, as well as the ethical, social, and legal implications, of using artificial intelligence (AI) in breast cancer screening services. Computers cannot be held accountable, but radiologists applying AI algorithms for reporting will be, he asserted. It is important to be certain that the right examination is performed at the right time for the right patient, and radiologists have good reason to be excited about AI as another asset that will enhance their ability to provide the best possible care for patients, he added.

Fuchsjäger said that today’s session comprises “an all-star cast, a who’s who of breast radiology in Europe, where ECR delegates can hear about the pearls of radiology, what to look for, how to image, and what’s new in technology, and get tips on what to do in everyday practice. If you attend the session, you will be able to enhance your everyday knowledge of breast radiology.”

At the session, Prof. Dr. Ayşenur Oktay, head of breast imaging in the Department of Radiology, Ege University, Izmir, Turkey, will present her top tips on imaging the axilla. Delegates will learn why imaging the axilla is crucial in the staging and prognosis of breast cancer and why it guides therapy decisions.

Ultrasound has emerged as the preferred technique for preoperative nodal assessment and for image-guided lymph node interventions for suspicious axillary lymph nodes. Staging ultrasonography of the axilla should include careful evaluation of levels I and II, as well as the axillary tail of the breast, she explained. In the identification of nodal metastasis, morphologic criteria are more important than size criteria.

Prof. Dr. Ayşenur Oktay, head of breast imaging in the Department of Radiology, Ege University, Izmir, Turkey, will present her top tips on imaging the axilla.

There are several well-established morphologic characteristics for abnormal lymph nodes. Suspicious features include cortical thickening greater than 2.5–3mm, focal eccentric cortical thickening (bulge in cortical contour) and narrowing or loss of a central fatty hilum. Malignant nodes tend to be rounder, with a long-to-short axis ratio of less than two. Nodes with indistinct or spiculated margins suggest extranodal tumour extension.

Nonhilar blood flow on colour Doppler imaging may also enhance the diagnostic sensitivity of ultrasonography, Oktay continued. When these morphologic characteristics are used, ultrasound has a sensitivity ranging from 26% to 76%, depending on the experience of both the operator and the pathologist, and a specificity of 88%–98% for depicting metastatic lymph nodes. Ultrasound-guided sampling by fine needle aspiration or core needle biopsy should be performed for confirming the presence of metastasis in a suspicious node.

The number of involved regional lymph nodes is one of the important prognostic factors in early breast cancer, she said. Low/minimal axillary disease burden include microscopic spread and isolated tumour cells in the axillary lymph nodes, and also one or two macrometastatic positive sentinel lymph nodes with no extracapsular extension in stage T1 or T2 tumour. The presence of three or more abnormal nodes in the axilla on an initial ultrasound scan is indicative of high/advanced metastatic burden, and in these patients, axillary dissection remains the standard if neoadjuvant therapy is not indicated. Ultrasound usually identifies patients with higher disease burden.

In practice, for clinically negative patients, sentinel lymph node biopsy is recommended, and when the sentinel node becomes positive and conserving surgery is not advised, the next step will be axillary lymph node dissection.

A: Ultrasound scan shows axillary metastasis, with cortex more than 3mm.
B: Note round shape with loss of fatty hilum in axillary metastasis.
C: Nonhilar blood flow is visible on colour Doppler.
D: Ultrasound-guided needle biopsy from cortex of a suspicious lymph node (provided by Prof. Ayşenur Oktay).

Oktay is excited about the future, particularly advances in technology that may improve the sensitivity of imaging. She is keeping a close eye on novel studies involving elastography and B mode for axillary lymph node metastasis, including quantitative radiomics features from these techniques in patients with breast cancer.

“Radiomics and radiogenomics are rapidly evolving fields in breast imaging and MRI is the main focus for research. Computer-assisted diagnostic algorithms and artificial intelligence algorithms are promising applications that might provide better detection and characterisation of the nodes,” she concluded.

Please note that for pre-recorded sessions published during the ECR Highlight Weeks, there will be no chairpersons. However, we still wanted to keep Professor Fuchsjäger’s interview and statements for the article as he initially gave them, when he was supposed to chair this session.

Special Focus Session
SF 9c My top three tips for breast imaging

  • Screening with tomosynthesis
    Sophia Zackrisson; Malmö/SE
  • Automated breast ultrasound
    Athina Vourtsis; Athens/GR
  • Complex cystic and solid lesions
    Panagiotis Kapetas; Vienna/AT
  • Imaging the axilla
    Aysenur Oktay; Izmir/TR
  • Contrast-enhanced spectral mammography
    Corinne S. Balleyguier; Villejuif/FR
  • Stereotactic-guided biopsy
    Dragana Djilas-Ivanovic; Sremska Kamenica/RS
  • US-guided biopsy
    Gordana Ivanac; Zagreb/HR
  • MRI-guided biopsy
    Ritse M. Mann; Nijmegen/NL
  • Treatment response and therapy monitoring
    Eva M. Fallenberg; Munich/DE
  • Post-therapy evaluation
    Julia Camps Herrero; Valencia/ES

FURTHER READING

Rodriguez-Ruiz A, Gubern-Merida A, Imhof-Tas M et al (2018) One-view digital breast tomosynthesis as a stand-alone modality for breast cancer detection: do we need more? Eur Radiol. 28(5):1938-1948: european-radiology.org/5167

Vourtsis A, Kachulis A(2018) The performance of 3D ABUS versus HHUS in the visualisation and BI-RADS characterisation of breast lesions in a large cohort of 1,886 women. Eur Radiol. 28(2):592-601: european-radiology.org/5011

Zanardo M, Cozzi A, Trimboli RM et al (2019) Technique, protocols and adverse reactions for contrast-enhanced spectral mammography (CESM): a systematic review. Insights Imaging. 10(1):76: i3-journal.org/756

Jain A, Khalid M, Qureshi MM et al (2017) Stereotactic core needle breast biopsy marker migration: An analysis of factors contributing to immediate marker migration. Eur Radiol. 27(11):4797-4803: european-radiology.org/4851

Ciritsis A, Rossi C, Eberhard M, Marcon M, Becker AS, Boss A (2019) Automatic classification of ultrasound breast lesions using a deep convolutional neural network mimicking human decision-making. Eur Radiol. 29(10):5458-5468: european-radiology.org/6118