What is the recommended approach for staging breast cancer prior to surgery?

Preoperative Staging of Breast Cancer

The recommended approach for staging breast cancer prior to surgery includes clinical examination, bilateral mammography, ultrasound of breasts and regional lymph nodes, pathological examination of core needle biopsy, and selective use of additional imaging based on risk factors, with comprehensive radiological staging reserved for patients with advanced disease or planned neoadjuvant therapy 1.

Initial Diagnostic Evaluation

Clinical Assessment

• Complete personal medical history
• Family history of breast/ovarian and other cancers
• Physical examination including bimanual palpation of breasts and regional lymph nodes
• Performance status assessment
• Menopausal status evaluation (measure serum estradiol and FSH if unclear)

Laboratory Tests

• Full blood count
• Liver and renal function tests
• Alkaline phosphatase
• Calcium levels

Core Imaging

• Bilateral mammography
• Ultrasound of breasts and regional lymph nodes (depending on local expertise)

Pathological Assessment

Core Needle Biopsy

• Obtain core needle biopsy (preferred) or fine needle aspiration before any surgical procedure 1
• Pathological examination should include:
  • Histologic type and grade
  • Determination of estrogen receptor (ER) status
  • Progesterone receptor (PgR) status
  • HER2 receptor status by IHC or FISH/CISH test 1

Risk-Stratified Additional Imaging

MRI Indications (Selective Use)

MRI is not recommended as a routine procedure but may be considered in specific scenarios 1:

• Dense breast tissue, especially in young women
• Familial breast cancer associated with BRCA mutations
• Positive axillary lymph node status with occult primary tumor
• Suspected multiple tumor foci
• Invasive lobular carcinoma 2
• Aggressive tumor biology (triple negative or HER2-positive) 2

Additional Staging for Higher Risk Patients

For patients with any of the following, additional investigations are recommended 1:

• Planned preoperative (neoadjuvant) systemic therapy
• Clinically positive axillary nodes
• Large tumors
• Clinical signs, symptoms, or laboratory values indicating possible metastases

These additional investigations include:

• Chest X-ray
• Abdominal ultrasound
• Bone scintigraphy

Important Considerations

Staging Efficiency

• Early stage (N0) breast cancer patients do not benefit from comprehensive radiological staging 1
• Selective use of MRI can help identify additional disease not seen on conventional imaging in high-risk patients 2

Multidisciplinary Approach

• Treatment planning should involve a breast surgeon, radiologist, pathologist, medical and radiation oncologists 1
• This team should integrate local and systemic therapies and their sequence

Sentinel Node Biopsy

• Sentinel node biopsy is the recommended procedure for surgical staging of the axilla for patients with clinically node-negative (cN0) breast cancer 1
• Should only be performed in centers with documented experience and accuracy 1

Common Pitfalls to Avoid

1. Overuse of MRI in low-risk patients, which may lead to unnecessary procedures
2. Underutilization of staging investigations in high-risk patients
3. Failure to obtain core needle biopsy before surgical procedures
4. Inadequate assessment of receptor status, which is crucial for treatment planning
5. Using the same guidelines for MRI-detected multicentric cancer foci as for clinically detected disease, which may lead to unnecessary mastectomies 3

By following this evidence-based, risk-stratified approach to preoperative staging, clinicians can optimize treatment planning while avoiding unnecessary procedures and potential overtreatment.