ESMO recommendations

1. Diagnostics

ESMO recommends a three-pronged diagnostic approach that includes:

• Clinical examination
  
• Diagnostic imaging
  
  • Mammography (bilateral)
    
  • Ultrasound examination of the breast and axilla
    
  • MRI - for specific indications (dense glandular tissue, multifocal disease, BRCA mutation carriers, unclear findings)
    
• Histological confirmation
  

Evaluation of the axilla with ultrasound is mandatory, and a directed biopsy is recommended for suspicious lymph nodes.

2. Biopsy

Core needle biopsy is the method of choice according to ESMO.

Basic principles:

• The biopsy is performed before the start of treatment
  
• Mandatory imaging guidance (US, stereotaxic or MRI)
  
• FNA has a limited role and is not the preferred method for primary diagnosis
  

The pathological assessment should include:

• Histological type and grading
  
• ER and PR status
  
• HER2 status
  
• Ki-67 as an additional prognostic marker
  

3. Surgical treatment of the primary tumor

ESMO endorses organ-sparing surgery (BCS) as the preferred approach when it is oncologically safe.

Surgical options:

• BCS + subsequent radiotherapy - standard in early stages
  
• Mastectomy - at:
  
  • multicentric disease
    
  • large tumour relative to breast volume
    
  • inability to radiotherapy
    
  • genetically high risk or patient choice
    

Reconstructive surgery is an integral part of treatment and can be immediate or delayed.

Resection lines:

• Invasive carcinoma: no ink on tumor
  
• DCIS: recommended free surgical edge ≥ 2 mm
  

4. Sentinel lymph node biopsy (SLNB)

SLNB is the standard for axillary staging in clinically negative axilla (cN0).

Indications according to ESMO:

• Invasive breast cancer at an early stage
  
• DCIS in planned mastectomy
  
• After neoadjuvant therapy in initially negative or downstaged axilla
  

Technique:

• Radioisotope and/or blue dye
  
• The use of ICG fluorescent navigation is permitted
  

Behavior at a positive sentinel node:

• With limited involvement (1-2 nodes), organ-sparing surgery and subsequent radiotherapy → axillary dissection can be avoided
  
• Axillary lymph node dissection is reserved for patients with clinically significant axillary involvement
  

5. Multidisciplinary approach

ESMO stresses the mandatory role of the multidisciplinary team, including:

• surgeon
  
• medical oncologist
  
• Radiation Therapist
  
• image diagnostic
  
• pathologist
  
• geneticist (for hereditary risk)
  

Decisions are made individually, according to tumor biology and patient preference.