Radiologists role in every step of the BC patients will be disscused.
Diagnosis
Radiologists are the ones identifying and characterizing breast lesions. Mx is the cornerstone of BC screening, particularly in women over 40 years of age, being effective for detecting calcifications and asymmetries. US is the first imaging tool for the patients under 30 years old and the first that comes after a positive Mx. Breast US in women older than 40 can be negative for abnormalities.
After asseing the lesions, radiologists rely on the Breast Imaging Reporting and Data System (BI-RADS) for standardized reporting and communication, ensuring clarity in diagnostic interpretations. The next step of diagnosis is the biopsy. US-guided biopsies are widely used, being effective for superficial or easily accessible abnormalities. Stereotactic vacuum-assisted biopsies (VAB) are invaluable for targeting non-palpable lesions, especially microcalcifications identified on mammograms.
Informing the Patient
Delivering bad news is an emotional and ethical challenge faced by radiologists. They are often the first to inform patients about suspicious findings or biopsy results. Effective communication requires empathy, clarity and adherence to structured protocols like SPIKES, which provide a framework for discussing distressing news. Radiologists can help patients cope with their diagnoses and engage actively in their treatment journey.
Staging Breast Cancer
Radiologists are crucial in BC staging by integrating imaging findings with the American Joint Committee on Cancer (AJCC) TNM classification system, which considers tumor size (T), nodal involvement (N), and metastasis (M). The TNM classification of the BC is illustrated in Table 1.
Tumor size is assessed by integrating the Mx, US and MRI information, MRI measurements of the tumor being the most accurate.
Lymph node staging impacts prognosis and treatment planning, with US being the key examination of this step. When imaging findings suggest suspicious nodes (cortical thickening > 3 mm, lost fatty hilum, rounded morphology, extracapsular extension), a US-guided biopsy is performed to differentiate between benign and metastatic nodes.
For distant metastasis, a CT of the thorax, abdomen and pelvis is preferred and additionally a PET-CT and a bone scan. In cases of neurologic symptoms, a brain MRI can be considered.
Monitoring Therapy Response
Monitoring response to neoadjuvant therapy (NAT) is another critical step for radiologists. Mx plays an important role, particularly in identifying changes in calcifications, size, density.
Guiding Surgical Procedures
Radiologists support surgical planning by providing information that guide preoperative localization and intraoperative decisions. In cases of multicentric disease, radiologists identify multiple tumor foci, which influence the decision to proceed with mastectomy rather than breast-conserving surgery (BCS). Imaging findings that reveal chest wall invasion or nipple involvement impact surgical planning, as these require more extensive resections.
Techniques such as wire localization and skin marking are essential for identifying non-palpable lesions: wire localization, performed under US or stereotactic guidance, is useful for deep or complex lesions and skin marking offers an alternative for superficial lesions, but may lack the precision needed for deeper abnormalities.
Intraoperative imaging, including specimen radiography, allows surgeons to confirm complete excision of the lesion and assess margin status. Radiologists provide real-time evaluation for immediate feedback to the surgical team, which is critical in reducing reoperation rates and enhancing surgical outcomes.
Follow-Up
Immediate post-surgical imaging involves US for complications such as seromas and hematomas.
Radiologists face limitations across all these steps.
Diagnosis
Mx has reduced sensitivity in dense breast tissue, which may result in missed lesions. While US and MRI can help, they also have limitations. US is operator-dependent and can not visualise changes such as microcalcifications and lobular carcinoma in situ. US-guided biopsies are operator-dependent, leading to variability in outcomes, when identifying small or deep lesions. Despite being highly sensitive, MRI does not replace the Mx examination or the biopsy; it may produce false positive results, necessitating additional biopsies that can increase anxiety. Radiologists face significant challenges in interpreting atypical findings that overlap with benign conditions and mimic malignancy, like fat necrosis or fibrosis.
Informing the Patient
Radiologists often lack formal training in breaking bad news, making this aspect of their role particularly emotionally challenging. Providing patients with clear and compassionate explanations of imaging findings is critical to fostering trust and helping patients cope with their diagnosis.
Staging
Staging is limited by the sensitivity of current imaging modalities, making the detection of micrometastasis challenging. PET/CT, while highly sensitive for identifying active disease, may yield false positives due to inflammatory or benign conditions, emphasizing the importance of correlating imaging results with histopathological data. Some metastasis are not visible on CT examination and some concerning lesions visible on CT are non-FDG positive. Lymph nodes US also lacks 100% sensitivity in assessing metastasis. Post-treatment changes, including fibrosis or inflammation, can mimic disease progression. Another challenging situation comes when differentiating metastatis from synchronous primary tumors.
Monitoring Therapy
Radiologists face challenges in differentiating viable tumor tissue from post-treatment changes like fibrosis or necrosis. Emerging therapies such as immunotherapy introduce additional complexities, including pseudoprogression, where inflammation or immune cell infiltration may mimic tumor growth, which will require radiologists to integrate imaging findings with clinical and pathological data for accurate assessments.
Guiding Surgery
Wire localization can result in displacement or migration, potentially affecting surgical outcomes. Metallic clips placement is not always feasible when the tumor is in an area difficult to access/evaluate. Accessibility to small or deep lesions remains technically challenging, particularly when using stereotactic guidance. These factors necessitate close coordination between radiologists and surgeons to optimize outcomes.
Follow-Up
Follow-up imaging is challenging as the scar tissue and recurrent disease can appear similar on imaging.
