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Background: Surgical axillary staging of the axilla is a topic of debate regarding the potential of de-escalation in clinically node negative (cN0) early breast cancer patients treated with breast-conserving therapy. Axillary ultrasound is important to determine clinical nodal status. The aim of the current narrative review is to provide an overview of prospective trials on de-escalating axillary surgical staging in cN0 early breast cancer patients, with an emphasis on axillary ultrasound protocols., Methods: This narrative review provides an overview of the prospective de-escalating axillary surgical staging trials, in terms of comparing sentinel lymph node biopsy (SLNB) versus complete omission of SLNB, in cT1/2N0 patients treated with breast-conserving therapy. Information from each trial was collected, including reported axillary ultrasound protocols (including cortical thickness cut-off value) and axillary ultrasound-guided biopsy technique (fine-needle aspiration or core-needle biopsy)., Results: There is one recently published prospective trial and three ongoing prospective trials within the topic of this narrative review. Number of included patients in these trials ranges from 1405 to 5505 patients. The included trials differed whether or not to include patients with suspicious axillary ultrasound findings and a negative ultrasound-guided biopsy. Cortical thickness cut-off value ranged from 2.3 mm to 3.0 mm. Different ultrasound-guided biopsy techniques were performed among the included trials., Conclusion: Prospective de-escalating axillary surgical staging trials in clinically node negative early breast cancer patients treated with breast-conserving therapy do report differences in terms of axillary ultrasound protocols and ultrasound-guided biopsy techniques. Axillary ultrasound protocols do require uniformity in order to improve extrapolation of these trial results., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Background: Breast cancer in pediatric patients is rare, but ultrasound (US) is widely utilized for symptomatic cases., Purpose: To determine biopsy and cancer detection rates of pediatric patients and to assess if breast US can be omitted., Material and Methods: A retrospective review of a 5-year period was conducted of single-center breast US performed in patients aged <19 years. Data regarding presentation, clinical opinion (P1-5 score), and US (U1-5 score) were collected. If biopsy or surgery was performed, pathology was reviewed (B1-5 score)., Results: In total, 579 patients were included (19 boys, 560 girls; mean age=16.2±1.9 years; age range=0-18 years). Clinical examination was normal or benign (P1/P2) in all boys (100%) and 557/560 (99.5%) girls, and P3 in 3 (0.5%) girls. Of US, 52% demonstrated normal findings (U1) for both sexes (300/579); in the remaining cases, the most frequent findings were gynecomastia in 12/19 boys and well-defined breast masses in 208/560 girls. Of the 560 girls, 6 (1%) underwent US-guided biopsy, with final histology of fibroadenoma (B2) in all cases, while 27 (5%) had a surgical excision, with final histology of fibroadenoma (22/27, 81.5%), hamartoma (2/27, 7.4%), benign phyllodes tumor (2/27, 7.4%), and angiomyxoma skin lesion (1/27, 3.7%). No malignant lesions were diagnosed at the time of clinical referral or during the 18-month follow-up in patients with a well-defined mass on US., Conclusion: Breast malignancy is extremely rare in pediatric population. US can be safely omitted if clinical examination is normal; this approach would have avoided breast US in 52% of patients in this study., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objectives: High-grade DCIS (HG DCIS) is associated with upgrade to invasive disease but few studies evaluate the role of MRI in this subset of DCIS. This study compared surgical outcomes of females with HG DCIS on biopsy who had pre-operative MRI with those that proceeded directly to surgery., Methods: This single-centre retrospective, observational study identified patients with pure HG DCIS on pre-operative biopsy from the pathology database. Surgical outcomes, clinicopathological and radiological features were obtained for all patients., Results: From August 2015 to February 2020, 217 patients had HG DCIS on biopsy. Pre-operative MRI was performed in 40 (MRI group) and not in 88 (No MRI group) patients. Initial mastectomy was performed in 25/40 (63%) women in the MRI group and 20/88 (23%) women in the no MRI group ( p < 0.0001). No difference was observed in re-operation rate between the two groups, 15% in MRI group vs 22% in No MRI group ( p = 0.4749). Mean tumour size on histology was larger in mastectomy cases in the MRI group (73.4 mm, range 6-140 mm), than the total MRI group, (58.3 mm, range 0-140 mm) or no MRI group (30.7 mm, range 0-130 mm) ( p < 0.0001)., Conclusions: Pre-operative MRI in HG DCIS is associated with higher mastectomy rates, possibly due to patient selection for MRI, as tumours on final histology were significantly larger. Fewer re-operations were observed in the MRI group although this was not significant., Advances in Knowledge: Breast MRI performed pre-operatively in HG DCIS is associated with higher mastectomy rates and fewer re-operation rates.

Breast magnetic resonance imaging (MRI) is the technique of choice in detection, local staging, and monitoring of breast cancer; however, breast MRI results in the detection of more indeterminate/suspicious lesions that need to be histopathologically proven to guide patient management than any other breast imaging method. If such abnormalities are not detectable in any of the conventional imaging tools (mammography (MMG) or ultrasound) then an MRI-guided biopsy needs to be performed to obtain a diagnosis. Breast MRI-guided biopsy is a time-consuming and complex procedure that requires specific equipment and experienced, well-trained staff. This review article explores and illustrates the indications, the currently available technologies, and the technique of breast MRI-guided biopsy, and explains the importance of careful imaging review and selection of cases. We correlate the radiological-pathological findings and highlight the impact on patient management in a multidisciplinary setting., (Copyright © 2018 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

Aim: To determine the impact of preoperative axillary ultrasound staging in a screen-detected breast cancer population., Materials and Methods: Ultrasound and needle biopsy staging results alongside reference standard sentinel lymph node biopsy and axillary lymph node dissection were extracted retrospectively from the unit's computer records between 1 April 2008 and 31 March 2015. Axillary staging was compared with final histopathology and treatment., Results: Of the 215,661 screening examinations performed, 780 invasive cancers were diagnosed, which had preoperative axillary staging data, of which 162 (20.7%) were node positive. Thirty-six (4.6%) had a heavy nodal burden (three or more nodes). Ninety (11.5%) had an abnormal axillary ultrasound and axillary biopsy of which 54 were positive for cancer (33.3% of the node positive cases) and triaged to axillary lymph node dissection avoiding a sentinel lymph node biopsy. Of these 22 (40.7%) had neoadjuvant treatment, and 32 (59.3%) proceeded directly to axillary lymph node dissection. The sensitivity of axillary ultrasound and biopsy to detect women with a heavy nodal burden (three or more nodes) was 41.7% (15 of 36); however, 17 (53%) of the 32 women with a positive axillary biopsy had a low burden of axillary disease (two or fewer positive nodes) at axillary lymph node dissection, the mean number of nodes obtained was 14.6., Conclusion: Significant numbers of women are being potentially overtreated or denied entry into positive sentinel node: adjuvant therapy only versus adjuvant therapy and clearance or axillary radiotherapy (POSNOC) because of routine preoperative axillary staging., (Copyright © 2017 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

Aims: To assess the feasibility of undertaking microbubble-guided vacuum-assisted biopsy (VAB) of the sentinel lymph node (SLN) and determine its sensitivity in detecting metastases. Patient experience and the impact of VAB on subsequent axillary surgery were also evaluated., Materials and Methods: Patients with a normal axillary ultrasound or benign core biopsy planned for surgical SLN biopsy were recruited. Part 1 of the study was used to establish the technique of ultrasound microbubble contrast to detect the SLN. In Part 2 microbubble detection of the SLN was followed by 13 G VAB. All patients subsequently had surgical histological correlation., Results: One hundred and thirty-nine patients were recruited: 36 to Part 1 and 103 to Part 2. Of the 100 patients in Part 2 included for analysis, 82 (82%) underwent successful biopsy. Sensitivity for detecting metastases was 58.8% (95% confidence interval: 32.9%, 81.6%). The procedure was generally well tolerated; however, VAB interfered adversely with subsequent surgical SLN biopsy with surgeons reporting moderate or severe interference in 48% of patients and an additional 8.3% with complete failure of SLNB., Conclusion: It is possible to perform VAB of microbubble-detected SLNs. Although the sensitivity for detecting metastases was reasonable, the adverse effect on subsequent surgery was significant., (Copyright © 2017 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

Knowledge of x-ray attenuation is essential for developing and evaluating x-ray imaging technologies. For instance, techniques to distinguish between cysts and solid tumours at mammography screening would be highly desirable to reduce recalls, but the development requires knowledge of the x-ray attenuation for cysts and tumours. We have previously measured the attenuation of cyst fluid using photon-counting spectral mammography. Data on x-ray attenuation for solid breast lesions are available in the literature, but cover a relatively wide range, likely caused by natural spread between samples, random measurement errors, and different experimental conditions. In this study, we have adapted a previously developed spectral method to measure the linear attenuation of solid breast lesions. A total of 56 malignant and 5 benign lesions were included in the study. The samples were placed in a holder that allowed for thickness measurement. Spectral (energy-resolved) images of the samples were acquired and the image signal was mapped to equivalent thicknesses of two known reference materials, which can be used to derive the x-ray attenuation as a function of energy. The spread in equivalent material thicknesses was relatively large between samples, which is likely to be caused mainly by natural variation and only to a minor extent by random measurement errors and sample inhomogeneity. No significant difference in attenuation was found between benign and malignant solid lesions. The separation between cyst-fluid and tumour attenuation was, however, significant, which suggests it may be possible to distinguish cystic from solid breast lesions, and the results lay the groundwork for a clinical trial. In addition, the study adds a relatively large sample set to the published data and may contribute to a reduction in the overall uncertainty in the literature.

The imaging of breast cancer has undergone significant progression in recent years. A multimodality approach is often required, with ongoing developments in mammography, ultrasound, magnetic resonance and nuclear medicine all contributing to breast cancer imaging. Here we review the literature to assess how advances in well-established technologies, such as mammography, have brought added benefits both in terms of diagnostic and practical benefits, as well as allowing the application of derived technologies, such as tomosynthesis and contrast-enhanced mammography. We consider how these newer technologies may fit into clinical practice, both in terms of general population screening as well as use as problem solving tools in specific patient groups, and where the limitations for these may lie. We aim to highlight some of the promising advances in imaging that are still in earlier stages, such as magnetic resonance elastography, as well as reviewing techniques that are already becoming incorporated into clinical practice., (Copyright © 2012 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)