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Worldwide breast cancer has the highest incidence of all malignancies in women. Although the incidence has increased, mortality has decreased during the last two decades [1]. This reduction in mortality is largely due to early detection of malignancies in screening and to better and more personalized therapies [2]. Mammography is the primary screening imaging modality. This technique, however, has limitations in terms of sensitivity (39–86 %) and specificity (88–94 %), depending on age and breast density [3, 4]. Therefore, ultrasound is used in addition to mammography to increase diagnostic accuracy [5]. Mammography is scored in five categories according to the American College of Radiology (ACR) Breast Imaging Reporting and Data System (BI-RADS): category 1, negative; 2, benign finding; 3, probably benign; 4, suspicious finding (chance of malignancy 2–95 %); and 5, highly suggestive of malignancy (chance of malignancy >95 %) [6]. The guideline for non-invasive diagnostic tests for breast abnormalities of the Agency for Healthcare Research and Quality (AHRQ) in the USA states that for BI-RADS 1 and 2 no further work-up is required. The work-up for BI-RADS 4 and 5 requires an invasive procedure (biopsy). The diagnostic work-up of a BIRADS 3 lesion (chance of malignancy 5 cm), clinical symptoms or laboratory values suggesting the presence of metastases [9, 10]. In the case of proven breast cancer, imaging modalities can have an added value not only to determine the extent of the disease but also to characterize the primary and metastatic breast lesions. Non-invasive modalities are increasingly implemented in standard care to support breast cancer diagnosis, staging and evaluation. However, the role of several potential imaging investigations has not yet been fully established and existing international guidelines are lagging behind these developments. The purpose of this editorial is to provide guidance for the application of (developing) imaging techniques in (1) the non-invasive work-up of breast lesions and (2) staging and characterization of advanced breast cancer. M. D. Dorrius Department of Radiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands

Breast cancer: a new imaging approach as an addition to existing guidelines