Die bildgebende Früherkennung des Mammakarzinoms ist eine zentrale Säule der onkologischen Versorgung und trägt wesentlich zur Senkung der brustkrebsspezifischen Mortalität bei. Bevölkerungsbezogene Screening-Programme auf Basis der Mammographie sind etabliert, weisen jedoch insbesondere bei dichtem Brustdrüsengewebe relevante Limitationen auf. Ziel dieses CME-Beitrags ist es, den aktuellen Stand der bildgebenden Früherkennung, Primärdiagnostik und Beurteilung des Therapieansprechens beim Mammakarzinom darzustellen. Neben Mammographie und digitaler Brusttomosynthese werden ergänzende Verfahren wie Ultraschall, automatisierter Brustultraschall, kontrastmittelgestützte Mammographie und Magnetresonanztomographie kritisch bewertet sowie die zunehmende Rolle der künstlichen Intelligenz in der Mammadiagnostik eingeordnet.

Biomarkers are integral to modern breast cancer management by providing essential information for prognosis and treatment selection. This review presents the 2026 update of the recommendations of the Arbeitsgemeinschaft Gynäkologische Onkologie (German Gynecological Oncology Group, AGO) on therapy-relevant prognostic and predictive biomarkers. The recommendations are based on a structured evaluation of the most recent and clinically relevant evidence using the AGO grading system to support decision-making in routine clinical practice.

The German Guideline Committee (AGO: Working Group on Gynecologic Cancers) updated its yearly recommendations on the diagnosis and treatment of breast cancer in March 2026. Chapters on oncological and oncoplastic-reconstructive surgery are coordinated with the Working Group for Plastic, Aesthetic, and Reconstructive Surgery in Gynecology (AWOgyn). The most important changes include the ommission of sentinel lymph node biopsy (SLNB) and preffered axillary staging in patients with node-positive breast cancer undergoing neoadjuvant chemotherapy (NACT). Targeted axillary dissection (TAD) is endorsed as the method of choice [AGO ++] in patients converting from cN + to ycN0 status, and other de-escalated techniques (SLNB, target lymph node biopsy [TLNB]) are also possible options [AGO +]. Following NACT, ALND is indicated only when macrometastatic disease is detected in the sentinel and/or in the target lymph node.

The Breast Committee of the Arbeitsgemeinschaft Gynäkologische Onkologie (German Gynecological Oncology Group, AGO) presents the 2026 update of the evidence-based recommendations for the diagnosis and treatment of patients with locally advanced and metastatic breast cancer.

ABSTRACT Background As the data on BRCA1/2‐associated breast and ovarian cancer prevalence after prophylactic surgery has not been exhaustively investigated yet, we aimed to evaluate the cancer prevalence in a single center cohort of BRCA1 and BRCA2 carriers after conducting prophylactic mastectomy, as well as prophylactic bilateral salpingo‐oophorectomy (PBSO) respectively. Methods We included 875 women that were tested positive for a germline variant in the BRCA1/BRCA2 gene (gPV) between 2002 and 2022 at the Center of Hereditary Breast and Ovarian Cancer of the Technical University Munich Germany. Mean follow up was 7.2 years (range 0–44 years; 95% CI: 6.70 to 7.70). We differentiated breast and/or ovarian cancer diseased (n = 643) and non‐diseased BRCA1/2 carriers (n = 232). Results Our analysis confirmed the effectiveness of prophylactic surgeries in genetically predisposed women with a gPV in the BRCA1/2 gene. We observed no breast cancer after prophylactic bilateral mastectomy, 2 contralateral breast cancer diseases after contralateral prophylactic mastectomy and 1 extraovarian serous adenocarcinoma after PBSO. Within the entire study collective, a total of 293 have undergone PBSO, with 6 women having an incidental finding of ovarian cancer and STIC respectively (=2.0%; 1.7% gBRCA1 and 0.3% gBRCA2). Our data suggests that, particularly regarding ipsilateral secondary cancer (ISC), higher oncological safety can be achieved through mastectomy rather than breast‐conserving surgery (BCS). In the group of patients who had a second breast cancer and were treated with BCS during their first cancer, 18.3% showed an ISC. Within the patients who were first treated with a mastectomy, only 4.3% showed an ISC. Conclusions Prophylactic surgeries demonstrate high oncological effectiveness in gPV BRCA1/2 carriers. In particular, mastectomy may provide greater protection against ISC compared with BCS. Further studies will have to be conducted to compare ipsilateral cancer prevalence after breast‐sparing surgery and mastectomy.

Breast ultrasound has been established for many years as an important method in addition to mammography for clarifying breast findings. The goal of the Best Practice Guidelines Part III of the DEGUM breast ultrasound working group is to provide colleagues working in senology with information regarding the specific medical indications for breast ultrasound in addition to the current ultrasound criteria and assessment categories published in part I and the additional and optional sonographic diagnostic methods described in part II. The value of breast ultrasound for specific indications including follow-up, evaluation of breast implants, diagnostic workup of dense breast tissue, diagnostic workup during pregnancy and lactation, and the diagnostic workup of breast findings in men is discussed. Each section after the general information section contains a description of specific pathologies followed by a short summary and DEGUM recommendations for the particular indications. The latest S3 guidelines and AGO guidelines were taken into consideration.

Breast cancer has the highest prevalence in the world, and thus, most countries have screening programs which aim to detect the cancer onset early. In these screening programs, negative studies dominate the dataset. Unsupervised anomaly detection promises to take advantage of the negative studies by using it to detect abnormalities as cancer or signs of cancer onset. In this study, we evaluate an anomaly detection method for cancer prediction (1-year ahead) on a MRI dataset of a high risk cohort with BRCA1 and BRCA2 gene mutations. As the approach fails to predict cancer risk on the dataset, we investigate the intrinsic behavior of the method. Our analysis reveals, that the reconstruction based method might only detect high intensity anomalies and that the reconstruction quality is highly correlated with noisy patterns in the image patches.

Breast cancer is the world's most prevalent cancer type. Risk models predicting the chance of near future cancer development can help to increase the efficiency of screening programs by targeting high risk patients specifically. In this study we develop machine learning models for predicting the 2 year risk for breast cancer and current breast cancer detection. Therefore, we leverage feature sets based on background parenchymal enhancement (BPE), radiomics and breast symmetry. We train and evaluate our models on longitudinal MRI data from a German high risk screening program using random forests and 5-fold cross validation. The models, which are developed similar to prior work for breast cancer risk prediction, have low predictive power on our dataset. The best performing model is based on BPE features and achieves an AUC of 0.57 for 2 year breast cancer risk prediction.

The German Guideline Commission (AGO: Working Group on Gynecologic Cancers) updated its recommendations on the diagnosis and treatment of breast cancer in March 2025. Chapters on oncological and oncoplastic-reconstructive surgery are coordinated with the Working Group for Plastic, Aesthetic, and Reconstructive Surgery in Gynecology (AWOgyn). The most important changes include the incorporation of INSEMA and SOUND trial results into the guidelines. In patients with low-risk characteristics, defined as age ≥50 years, postmenopausal status, hormone receptor-positive/HER2-negative subtype, tumor grading G1-2 with a maximum preoperative size of 2 cm, and unsuspicious axillary ultrasound and clinical examination, the sentinel lymph node biopsy (SLNB) can be omitted if breast-conserving surgery and whole-breast irradiation are planned. In patients with 1-2 macrometastatic sentinel lymph nodes (SLNs) undergoing a mastectomy and postoperative irradiation, completion axillary lymph node dissection (ALND) is no longer recommended. After neoadjuvant systemic therapy (NST), ALND is recommended if the targeted axillary dissection (TAD) shows macrometastases in the sentinel and/or in the target lymph node (the node that was marked and had a macrometastasis in the biopsy before NST). Patients with isolated tumor cells in the sentinel and/or target lymph node should not receive ALND after NST. In case of ypN1mi status, the decision to perform a completion ALND should be made on a case-by-case basis. Oncoplastic surgery is safe and may replace a mastectomy in select cases.

Nipple discharge affects over 80% of women at some point in their lives, with malignancy detected in up to 23% of cases. This review highlights the shift from traditional surgical approaches to advanced imaging techniques, which enhance diagnostic accuracy and reduce unnecessary procedures. Diagnosis begins with a thorough medical history and physical examination to assess the need for imaging. Physiological nipple discharge, which is bilateral, multiductal, and non-spontaneous, typically requires no imaging. Conversely, pathological nipple discharge (PND), characteristically unilateral, uniductal, and spontaneous, requires imaging to rule out malignancy. Bloody PND is frequently associated with breast cancer, and up to 12% of non-bloody PND cases also involve malignancy. For women over 40 years, the first-line imaging modality is full-field digital mammography (FFDM) or digital breast tomosynthesis (DBT), usually combined with ultrasound (US). Men with PND undergo FFDM/DBT starting at age 25 years due to their higher risk of breast cancer. For women aged 30-39 years, US is the first assessment tool, with FFDM/DBT added, if necessary, while US is preferred for younger women and men. When initial imaging is negative or inconclusive, magnetic resonance imaging (MRI) is useful, often replacing galactography. With its high sensitivity and negative predictive value of almost 100%, a negative MRI can often obviate the need for surgery. Contrast-enhanced mammography (CEM) offers a viable alternative when MRI is not feasible. Although invasive, ductoscopy helps identify patients who may not require duct excision. This review consolidates the latest evidence and proposes an updated diagnostic algorithm for managing PND effectively. CRITICAL RELEVANCE STATEMENT: Effective management of nipple discharge requires recognising when imaging tests are needed and selecting the most appropriate diagnostic technique to rule out malignancy and avoid unnecessary interventions. KEY POINTS: First-line imaging for pathological nipple discharge (PND) assessment includes ultrasound and mammography. MRI is recommended for patients with PND and negative conventional imaging. A negative MRI is sufficient to justify surveillance rather than surgery. Contrast-enhanced mammography (CEM) is an alternative when MRI is unavailable or contraindicated.

The Breast Committee of the Arbeitsgemeinschaft Gynäkologische Onkologie (AGO; German Gynecological Oncology Group) presents the 2025 update of the evidence-based recommendations for the diagnosis and treatment of patients with locally advanced and metastatic breast cancer (mBC).

Introduction: Pre-therapeutic histologic diagnosis through image-guided core needle biopsy (CNB) or vacuum-assisted biopsy (VAB) for suspicious breast findings is a standard procedure. Despite the moderate risk of bleeding, a significant proportion of patients are on temporary or permanent anti-coagulation therapy (ACT) or anti-platelet therapy (APT). Currently, there are no established guidelines for managing biopsies in such patients, leading to varying approaches in clinical practice. Methods: An online survey was conducted among all members of the breast ultrasound working group at the German Society for Ultrasound in Medicine (DEGUM) and the working group for breast diagnostics at the German Radiology Society (DRG). It included n = 51 questions about individual risk perception of biopsy-related bleeding complications and the specific management of biopsies on ACT/APT. Results: A total of 332 experts participated, with 51.8% reporting the absence of a standardized management plan for breast biopsies on ACT/APT. Concerning specific ACT/APT medications, the survey revealed discrepancies in risk perception and management: The majority preferred discontinuing medication with directly acting oral anti-coagulants (DOACs; CNB: 66.9%; VAB: 91.1%), phenprocoumon (CNB: 74.9%; VAB: 96.7%), or therapeutic heparin (CNB: 46.1%; VAB: 72.7%). However, there was a lower inclination to discontinue acetylsalicylic acid (ASA; CNB: 15.2%; VAB: 50.3%) or prophylactic heparin (CNB: 11.9%, VAB: 36.3%). Conclusion: Breast biopsies for patients on ASA or prophylactic heparin are deemed safe and part of standard clinical practice. However, despite available feasibility studies, conducting breast biopsies on ACT medications such as DOACs or phenprocoumon appears feasible only for a minority of experts.

PURPOSE:The identification of internal mammary lymph node metastases and the assessment of associated risk factors are crucial for adjuvant regional lymph node irradiation in patients with breast cancer. The current study aims to investigate whether tumor contact with internal mammary perforator vessels is associated with gross internal mammary lymph node involvement. METHODS AND MATERIALS:We included 297 patients with primary breast cancer and gross internal mammary (IMN+) and/or axillary metastases as well as 230 patients without lymph node metastases. Based on pretreatment dynamic contrast-enhanced magnetic resonance imaging, we assessed contact of the tumor with the internal mammary perforating vessels (IMPV). RESULTS:A total of 59 patients had ipsilateral IMN+ (iIMN+), 10 patients had contralateral IMN+ (cIMN+), and 228 patients had ipsilateral axillary metastases without IMN; 230 patients had node-negative breast cancer. In patients with iIMN+, 100% of tumors had contact with ipsilateral IMPV, with 94.9% (n = 56) classified as major contact. In iIMN- patients, major IMPV contact was observed in only 25.3% (n = 116), and 36.2% (n = 166) had no IMPV contact at all. Receiver operating characteristic analysis revealed that "major IMPV contact" was more accurate in predicting iIMN+ (area under the curve, 0.85) compared with a multivariate model combining grade of differentiation, tumor site, size, and molecular subtype (area under the curve, 0.65). Strikingly, among patients with cIMN+, 100% of tumors had contact with a crossing contralateral IMPV, whereas in cIMN- patients, IMPVs to the contralateral side were observed in only 53.4% (iIMN+) and 24.8% (iIMN-), respectively. CONCLUSIONS:Tumor contact with the IMPV is highly associated with risk of gross IMN involvement. Further studies are warranted to investigate whether this identified risk factor is also associated with microscopic IMN involvement and whether it can assist in the selection of patients with breast cancer for irradiation of the internal mammary lymph nodes.

Introduction: Each year the interdisciplinary AGO (Arbeitsgemeinschaft Gynäkologische Onkologie, German Gynecological Oncology Group) Breast Committee on Diagnosis and Treatment of Breast Cancer provides updated state-of-the-art recommendations for early and metastatic breast cancer. Methods: The updated evidence-based treatment recommendations for early and metastatic breast cancer have been released in March 2024. Results and Conclusion: This paper concisely captures the updated recommendations for early breast cancer chapter by chapter.

The Breast Committee of the Arbeitsgemeinschaft Gynäkologische Onkologie (German Gynecological Oncology Group, AGO) presents the 2024 update of the evidence-based recommendations for the diagnosis and treatment of patients with locally advanced and metastatic breast cancer.

Key points: Breast MRI is an essential part of breast imaging The recommendations for performing breast MRI have been updated A table provides a compact and quick overview. More detailed comments supplement the table. The "classic" breast MRI can be performed based on the recommendations. Tips for special clinical questions, such as implant rupture, mammary duct pathology or local lymph node status, are included. Zitierweise Wenkel E, Wunderlich P, Fallenberg E et al. Aktualisierung der Empfehlungen der AG Mammadiagnostik der Deutschen Rontgengesellschaft zur Durchfuhrung der Mamma-MRT. Fortschr Rontgenstr 2024; DOI: 10.1055/a-2216-0782

Metastasis -directed therapy has the potential to improve progressionfree and overall survival in oligometastatic disease (OMD). For breast cancer, however, randomized trials have failed so far to confirm this finding. Because the concept of metastasis -directed therapy in OMD is highly dependent on the accuracy of the imaging modality, we aimed to assess the impact of 18 F-FDG PET/CT on the definition of OMD in breast cancer patients. Methods: Eighty patients with a total of 150 18 F-FDG PET/CT images (between October 2006 and January 2022) were enrolled in this retrospective study at the Technical University of Munich. The inclusion criteria were OMD, defined as 1-5 distant metastases, at the time of 18 F-FDG PET/CT. For the current study, we systemically compared the metastatic pattern on 18 F-FDG PET/CT with conventional CT. Results: At the time of 18 F-FDG PET/CT, 21.3% of patients ( n = 32) had a first-time diagnosis of metastatic disease, 40.7% ( n = 61) had a previous history of OMD, and 38% ( n = 57) had a previous history of polymetastatic disease. In 45.3% of cases, the imaging modality ( 18 F-FDG PET/CT vs. conventional CT) had an impact on the assessment of whether OMD was present. An identical metastatic pattern was observed in only 32% of cases. 18 F-FDG PET/CT detected additional metastases in 33.3% of cases, mostly in the nonregional lymph node system. Conclusion: The use of 18 F-FDG PET/CT had a substantial impact on the definition of OMD and detection of metastatic pattern in breast cancer. Our results emphasize the importance of establishing a standardized definition for imaging modalities in future trials and clinical practices related to metastasisdirected therapy in breast cancer patients.

Recent studies indicate that malignant breast lesions can be predicted from structural changes in prior exams of preventive breast MRI examinations. Due to non-rigid deformation between studies, spatial correspondences between structures in two consecutive studies are lost. Thus, deformable image registration can contribute to predicting individual cancer risks. This study evaluates a registration approach based on a novel breast mask segmentation and non-linear image registration based on data from 5 different sites. The landmark error (mean +/- standard deviation [1st quartile, 3rd quartile]), annotated by three radiologists, is 2.9 +/- 2.8 [1.3, 3.2] mm when leaving out two outlier cases from the evaluation for which the registration failed completely. We assess the inter-observer variabilities of keypoint errors and find an error of 3.6 +/- 4.7 [1.6, 4.0] mm, 4.4 +/- 4.9 [1.8, 4.8] mm, and 3.8 +/- 4.0 [1.7, 4.1] mm when comparing each radiologist to the mean keypoints of the other two radiologists. Our study shows that the current state of the art in registration is well suited to recover spatial correspondences of structures in cancerous and non-cancerous cases, despite the high level of difficulty of this task.

With continuously rising breast augmentation procedures worldwide, there is an increasing clinical need for an early and accurate detection of implant complications. In clinical practice, silicone implants are mainly visualized by silicone-only acquisitions which can be limited by a low signal-to-noise ratio and poor resolution. The present work proposes chemical shift encoding-based multi-echo gradient-echo imaging in combination with a robust graph-cuts-based water-fat-silicone separation. The resulting multi-contrast imaging at high isotropic resolution enables a more precise delineation of the implant capsule and a better evaluation of the implant’s integrity compared to conventional silicone-only acquisition.