Breast Cancer (Mammary Carcinoma): Diagnostic Tests

Mandatory medical device diagnostics.

  • Mammography (X-ray examination of the breast) – currently the only method that detects precancerous/early stages; examination of both mammaries mandatoryNote: With increased mammographic density, a combination of 2-D and 3-D mammography (tomosynthesis: see below Digital Breast Tomosynthesis (DBT)), with only a slight increase in radiation exposure, can achieve a significant increase in detection rates.
  • Mammary sonography (ultrasound examination of the breast; breast ultrasound) – as a basic diagnostic tool in suspected breast carcinoma; in women < 40 years of age as the diagnostic tool of first choice; but is considered an additional diagnostic tool in unclear findings / recurrences; examination of both mammary obligatoryNote: The current S3 guideline recommends sonography as a complementary examination method outside the high-risk situation.

Optional medical device diagnostics – depending on the results of the history, physical examination and obligatory medical device diagnostics – for differential diagnostic clarification.

  • Digital breast tomosynthesis (DBT); in contrast to conventional digital mammography (2-D), produces a series of 1-mm gapless slices through the entire breast, allowing better delineation of structures without overlap; in addition to 2-D mammography, may reduce the rate of follow-up examinations. Further studies in this regard remain to be seen.The European Society of Breast Imaging states, “DBT improves cancer detection and reduces recall.” EUSOBI, in agreement with 30 national professional societies, sees this method as the future routine procedure for mammography screening.Note: Digital breast tomosynthesis has the potential to be considered the method of choice in the future.
  • Mammary MRI (magnetic resonance mammography (MRM; magnetic resonance imaging – mammary; mammary magnetic resonance imaging; mammary MRI; MR mammography; MRI mammography) – indicated as local staging in lobular breast carcinoma; if necessary. also in the case of unclear findings of mammography or sonography (High sensitivity (percentage of diseased patients in whom the disease is detected by the use of the procedure, ie, a positive finding occurs) 92%; negative MRI excludes tumor.
  • Punch, vacuum, sentinel node, or open biopsy (tissue sample); exceptionally, fine needle aspiration
  • Galactography (contrast imaging of the milk ducts).
  • Elastography of the mamma (to detect pathological (pathological) changes associated with decreased elasticity) (as an adjuvant screening method).

Staging examinations are to be performed pre-therapeutically:

  • For newly diagnosed breast carcinoma from UICC stage II with increased risk and UICC stages III and IV without symptoms of metastasis; staging includes lung, liver and skeleton.
  • In women at higher risk for metastasis and/or with aggressive tumor biology, clinical signs, symptoms, and a planned decision to proceed with systemic chemo/antibody therapy (as whole-body staging)
  • When metastases (daughter tumors) are suspected.
  • Before starting systemic adjuvant (“supportive”) primary therapy/chemo/antibody therapy in the form of:
    • X-ray of the chest (X-ray thorax/chest), in two planes – to exclude lung metastases.
    • Liver sonography – to exclude liver metastases.
    • Skeletal scintigraphy (nuclear medicine procedure that can represent functional changes in the skeletal system, in which regionally (locally) pathologically (pathologically) increased or decreased bone remodeling processes are present) – to exclude bone metastases.
  • In small carcinomas (< 1 cm) and clinically and sonographically negative lymph node status as: Sentinel node biopsy (SLNB).

Operative diagnosis/biopsy (tissue sampling)

This is used to determine dignity (biological behavior of tumors; i.e., whether they are benign (benign) or malignant (malignant)), and in the case of malignancy (“malignancy”), to describe tumor biology and plan therapy. Methods:

  • Punch biopsy (tissue sample): method of choice in the case of
    • Palpable findings
    • Sonographically visible findings
    • Suspicious axillary lymph nodes (see also fine needle aspiration).
  • Vacuum biopsy stereotactic: method of choice for.
    • Microcalcification in mammography
    • suspicious findings in magnetic resonance imaging (MRI).
  • Sentinel lymph node biopsy (Sentinel node biopsy = SNB, SLNB, sentinel lymph node removal) SNB is a diagnostic procedure used to determine the lymph node status of the axilla (armpit) by targeted removal of one or more sentinel lymph nodes. It is used to identify patients in whom further removal of the axillary lymph nodes (axillary dissection, axillary node dissection = AND) can be omitted. In about 70-80% of patients, this method allows limiting the surgical radicality of the axilla. In addition, there are studies indicating that axillary lymph nodes are likely to have low metastatic potential. However, this evidence still requires confirmation. For decades, nodal status (describing whether and, if so, how many lymph nodes are already affected by tumor cells), in which, if possible, 10 or more axillary lymph nodes were the basis for prognostic assessment, was considered the most important parameter for postoperative, systemic, adjuvant, risk-adapted chemotherapy and or hormone therapy. It has now been established that in certain situations it is sufficient to remove only the sentinel lymph node to assess prognosis. The great advantage of SNB is the significant reduction of morbidity/disease incidence (lymphedema, limited mobility, numbness, paresthesia/misfeeling). SNB standard (as of 2014)(1-4):
    • Determination of histologic nodal status (pN status) in invasive breast carcinoma should be performed using sentinel lymph node biopsy (SLNB).
    • SLNB is equivalent to axillary dissection in SLN-negative patients.
    • Axillary dissection should be performed in patients in whom SLN is not detected.
    • In patients who have a positive SLN (macrometastasis), axillary dissection with removal of at least 10 lymph nodes from levels I and II is usually indicated.
    • SLNB is indicated in all patients who have clinically negative lymph node status (cN0) and for whom axillary staging is required.
    • In small (< 2 cm) unifocal breast carcinoma with clinically negative nodal status (cN0) (unremarkable palpation findings (palpation findings), unremarkable sonographic findings in the axilla) can be dispensed with completing lymph node evacuation when the sentinel lymph node is free, or in micrometastases (metastases < 2 mm).
    • SLNB is not indicated in clinically suspected advanced lymph node involvement and tumor-infiltrated lymph nodes.
    • To clarify preoperatively whether lymph node metastasis is indeed present in clinically and/or sonographically abnormal lymph nodes, ultrasound-guided FNA (fine-needle biopsy) or biopsy of the suspicious lymph nodes may be helpful. Histologic evidence of lymph node metastasis precludes the use of sentinel node biopsy.
    • SLND is indicated before neoadjuvant chemotherapy because the detection rate is 99% before and only 80% after.
    • DCIS: Sentinel lymph node biopsy is indicated when mastectomy is performed, or large (near axillary) volumes are resected, so that in case of unexpectedly detected invasion, secondary SLNB is technically no longer possible. It may be considered exceptionally if invasive portions are suspected to avoid a second procedure.
  • Current recommendations for axillary dissection (1-4):
    • Omission of completer lymph node evacuation as an option in the case of
      • T1 or T2 tumors
      • And 1-2 affected sentinel lymph nodes.
      • And breast-conserving surgery
      • And subsequent percutaneous irradiation (tangential irradiation).

    This option should be offered, with data not yet definitively clarified, as the therapeutic benefit of axillary dissection is questioned. A general expansion of the radiation field instead is not advocated. In patients who had positive lymph node status prior to neoadjuvant chemotherapy (therapy administered before planned surgical resection of a tumor), axillary dissection is required after systemic therapy. Axillary dissection may not be required for patients who were sentinel-negative (pN0sn) prior to neoadjuvant chemotherapy.

  • Excisional biopsy: Today, open biopsy (tissue sampling) is used only exceptionally when punch biopsy or stereotactic vacuum biopsy are not possible.
  • Fine-needle aspiration (FNA): fine-needle biopsy is not suitable for clarifying a suspicious finding. It is occasionally used to puncture suspicious-looking lymph nodes in the axilla.

Follow-up

  • Computed tomography (CT) of abdomen and thorax – in patients at high risk of relapse and metastasis.

Recurrence diagnosis after completed breast-conserving therapy (BET).

  • Regular mammography and sonography (mandatory); in case of clinical abnormalities metastasis diagnosis by X-ray thorax, bone scintigraphy, CT, PET or MRINote: 18F-fluorodeoxyglucose (FDG)-PET/CT is superior to other methods including sonography and CT in terms of recurrence detection (detection of tumor recurrence).

Cancer early detection measures (KFEM)

  • ≥ 20 years of age an annual palpation of the mammae (breasts).
  • 50-69 years of age, every 2 years: mammography screening (part of the guidelines for early detection of breast cancer).

Diagnosis of triple-negative breast carcinoma

  • Definition: In triple-negative breast carcinoma, receptors (binding sites) for the hormones estrogen and progesterone and for human epidermal growth factor receptor type 2 (HER2) do not appear on the surface of cancer cells.
  • Frequent occurrence in young women between the thirtieth and fiftieth year of life. Because in this phase of life is usually a higher density of the mammary glands, the tumor is often difficult to delineate on mammography.Triple-negative breast carcinoma is often diagnosed as a palpation finding.
  • Mammographic findings: hyperdense (increased optical density) focal findings with circumscribed margins; typical signs of breast carcinoma (irregular shape, spicules/tumor feet, calcifications) are often absent.
  • Sonographic findings: circumscribed, hypoechogenic space with dorsal sound enhancement (“towards the back”); possibly also central tumor necrosis (death of cells); differential diagnoses: fibroadenoma (benign neoplasm in the mammary gland), cyst or abscess (encapsulated collection of pus).
  • Magnetic resonance imaging findings: approximately 50% of cases show malignancy-typical contrast dynamics with rapid signal increase followed by wash-out; persistent enhancement (signal enhancement of structures after administration of a contrast agent) (approximately 40% of cases); if central tumor necrosis is present, the tumor exhibits ring enhancement (approximately 80% of cases).