7.2 Staging Workup: When to Use MRI, CT, Bone Scan & PET

CBCN Certified Breast Care Nurse Exam

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1 Introduction: The CBCN Exam

CBCN Exam Facts, 2026 Blueprint & Study Plan

2 Chapter 1: Breast Health, Examination & Benign Conditions (Care Continuum)

1.1 Breast Anatomy, Vascular Supply & Hormonal Physiology 1.2 Clinical Breast Examination & Breast Awareness Education 1.3 Benign Breast Conditions, Mastalgia & Fibrocystic Changes

3 Chapter 2: Screening, Breast Density & Special Populations (Care Continuum)

2.1 Screening Modalities, Breast Density & Pharmacologic Risk Reduction 2.2 Screening & Breast Health in Special Populations

4 Chapter 3: Cancer Risk Assessment & Genetics (Care Continuum)

3.1 Proliferative Lesions, Atypia & High-Risk Benign Pathology 3.2 Breast Cancer Risk Models (Gail, Tyrer-Cuzick, Claus, BRCAPRO) 3.3 Hereditary Cancer Syndromes & Genetic Evaluation

5 Chapter 4: Patient Navigation, Surveillance & Survivorship (Care Continuum)

4.1 Patient Navigation, Barriers to Care, Social Determinants & Interprofessional Collaboration 4.2 Survivorship Care Planning, Surveillance Intervals & Recurrence Monitoring 4.3 Secondary Prevention, Physical Activity, Nutrition & Wellness Guidance

6 Chapter 5: Carcinogenesis & Diagnostic Evaluation (Diagnosis and Staging)

5.1 Carcinogenesis: How Breast Cancer Develops and Spreads 5.2 Clinical Assessment, Diagnostic Imaging & BI-RADS Categorization 5.3 Breast Biopsy Modalities & Image-Guided Localization Techniques

7 Chapter 6: Pathology, Biomarkers & Genomic Testing (Diagnosis and Staging)

6.1 Histopathology: In Situ Carcinomas & Invasive Carcinoma Subtypes 6.2 Receptor Biomarkers (ER, PR, HER2, Ki-67) & Molecular Subtypes 6.3 Multigene Genomic Assays & Recurrence Risk Stratification

8 Chapter 7: Clinical & Pathologic Staging (Diagnosis and Staging)

7.1 AJCC TNM Staging System (Anatomic vs Prognostic Staging) 7.2 Staging Workup: When to Use MRI, CT, Bone Scan & PET

9 Chapter 8: Breast Surgery, Axillary Staging & Reconstruction (Treatment Modalities)

8.1 Breast-Conserving Surgery, Margin Standards & Mastectomy Techniques 8.2 Axillary Staging: Sentinel Lymph Node Biopsy vs. Axillary Dissection 8.3 Post-Mastectomy Reconstruction & Oncoplastic Surgery

10 Chapter 9: Radiation Therapy & Chemotherapy (Treatment Modalities)

9.1 Radiation Therapy: Whole Breast, Chest Wall, Regional Nodal & Partial Breast Irradiation 9.2 Neoadjuvant vs. Adjuvant Chemotherapy Principles & Standard Regimens

11 Chapter 10: Endocrine, HER2-Targeted & Novel Systemic Therapies (Treatment Modalities)

10.1 Endocrine Therapy: SERMs, Aromatase Inhibitors, Ovarian Suppression & SERDs 10.2 HER2-Targeted Monoclonal Antibodies, Antibody-Drug Conjugates & Kinase Inhibitors 10.3 CDK4/6 Inhibitors, PARP Inhibitors & Immune Checkpoint Blockade 10.4 Trop-2 Antibody-Drug Conjugates, PI3K/AKT/mTOR Inhibitors & New Oral SERDs

12 Chapter 11: Specific Conditions & Special Populations (Treatment Modalities)

11.1 Triple-Negative Breast Cancer: Treatment Considerations 11.2 HER2-Positive Breast Cancer: Treatment Considerations 11.3 Inflammatory Breast Cancer & Paget Disease of the Nipple 11.4 Phyllodes Tumors & Breast Angiosarcoma 11.5 Treatment Considerations for Special Populations

13 Chapter 12: Symptom Management & Supportive Care (Nursing Practice)

12.1 Acute Chemotherapy Toxicities, Supportive Regimens & Oncologic Emergencies 12.2 Lymphedema Pathophysiology, ISL Staging & Complete Decongestive Therapy (CDT) 12.3 Musculoskeletal Toxicities, Bone Health & Vasomotor/GSM Relief 12.4 Complementary & Integrative Modalities 12.5 Cancer Rehabilitation: Physical, Occupational & Pelvic Floor Therapy

14 Chapter 13: Oncologic Emergencies (Nursing Practice)

13.1 Oncologic Emergencies I: Spinal Cord Compression, Hypercalcemia, Tamponade & SVC Syndrome 13.2 Oncologic Emergencies II: Hypersensitivity & Anaphylaxis, Sepsis, Pleural Effusion & Thromboembolism

15 Chapter 14: Professional Practice, Clinical Trials & Self-Care (Nursing Practice)

14.1 Professional Practice: Guidelines, Ethics, Legislation, Outreach & Accreditation 14.2 Clinical Trials in Breast Oncology 14.3 Nurse Self-Care: Compassion Fatigue, Burnout, Moral Distress & Substance Use

16 Chapter 15: Psychosocial Dimensions of Care (Psychosocial Dimensions)

15.1 Psychosocial Distress, Coping, Grief & Palliative Care 15.2 Culture, Spirituality, Sexual & Gender Identity, Age & Healthcare Disparities 15.3 Family & Caregiver Dynamics 15.4 Altered Body Image 15.5 Reproductive & Sexual Health

7.2 Staging Workup: When to Use MRI, CT, Bone Scan & PET

Key Takeaways Explain This Topic AI

Routine systemic imaging with CT, bone scan, or PET is not recommended for asymptomatic clinical stage I to II breast cancer because metastases are rare and false positives are common.

Systemic staging with contrast CT of the chest, abdomen, and pelvis plus a bone scan, or FDG PET/CT, is recommended for clinical stage III disease, inflammatory breast cancer, or symptoms or labs suggesting metastasis.

Symptom-directed imaging matches the complaint: bone pain or rising alkaline phosphatase prompts a bone scan, abnormal liver tests prompt abdominal imaging, and neurologic symptoms prompt brain MRI.

Tissue expanders with magnetic ports are an MRI safety hazard, so nurses screen every patient for implants and devices before MRI.

Last updated: September 2026

The Baseline Workup

For every newly diagnosed invasive breast cancer, the core workup includes:

History and physical examination, including nodal basins and menopausal status.

Bilateral diagnostic mammography, with ultrasound of the breast and axilla as needed.

Pathology review with histologic type, grade, ER, PR, and HER2.

Genetic counseling and testing when criteria are met, fertility counseling for patients of reproductive age, pregnancy testing when relevant, and distress screening.

Laboratory tests such as a complete blood count and comprehensive metabolic panel with liver tests and alkaline phosphatase, used mainly to guide treatment or when systemic imaging is being considered.

The CBCN outline separates clinical and pathologic staging (covered in the AJCC section) from additional studies : MRI, bone scan, CT, and PET.

When Systemic Imaging Is Not Indicated

For asymptomatic clinical stage I and II disease, NCCN and the ASCO Choosing Wisely list recommend against routine CT, bone scan, or PET. Distant metastases are found in only a small fraction of these patients, while incidental findings (liver cysts, lung nodules, degenerative bone changes) trigger anxiety, delay, extra biopsies, and radiation exposure. Tumor markers are also not used to stage early breast cancer.

When Systemic Imaging Is Indicated

Situation Typical imaging

Clinical stage III (for example T3 N1, any N2 or N3, or T4) Contrast CT of chest, abdomen, and pelvis plus bone scan, or FDG PET/CT

Inflammatory breast cancer Full systemic staging; about one third have metastases at diagnosis
Bone pain or elevated alkaline phosphatase Bone scan (or FDG PET/CT)
Abnormal liver tests, abdominal symptoms, or abdominal findings Contrast CT or MRI of the abdomen
Pulmonary symptoms Contrast CT of the chest
Neurologic symptoms Contrast-enhanced brain MRI

Many teams also stage selected stage II patients with high nodal burden or aggressive biology who are starting preoperative therapy. Brain MRI is not routine in asymptomatic early disease.

What Each Study Shows

Breast MRI: the most sensitive test for extent of disease in the breast. Useful for occult primary cancer presenting as axillary metastasis, invasive lobular carcinoma, very dense breasts, discrepancies between exam and imaging, Paget disease with negative mammography, and response to neoadjuvant therapy. Routine preoperative MRI has not been shown to reduce re-excision or recurrence and can increase mastectomy rates, so it is used selectively.

Contrast CT: evaluates lungs, liver, nodes, and bone windows. Requires iodinated contrast.

Bone scan (skeletal scintigraphy): a technetium-99m–labeled phosphonate is injected, and images are taken 2 to 4 hours later. It detects osteoblastic activity; purely lytic lesions can be missed, and healing bone after treatment can "flare" and look worse.

FDG PET/CT: shows glucose uptake. Most helpful when standard imaging is equivocal and in stage III or metastatic disease. Low-grade and lobular tumors can have low FDG uptake. If PET/CT clearly shows bone metastases, a separate bone scan can be omitted.

FES PET/CT (fluoroestradiol): an FDA-approved tracer that shows estrogen receptor-positive lesions, used in recurrent or metastatic disease when biopsy is difficult. Patients stop tamoxifen and fulvestrant for a washout period beforehand because they block uptake.

Nursing Preparation and Safety

Study Nursing checks

Contrast CT Contrast allergy history and premedication protocol; kidney function (eGFR); hydration; metformin instructions per policy; IV access

MRI with gadolinium Screen for pacemakers, neurostimulators, aneurysm clips, and tissue expanders with magnetic ports , which are MRI-unsafe; kidney function; claustrophobia plan; prone positioning for breast MRI

Bone scan Explain the 2- to 4-hour wait after injection; encourage fluids and voiding; small radiation dose that clears in urine

FDG PET/CT Fast 4 to 6 hours; check blood glucose (facilities usually proceed when it is under about 200 mg/dL); avoid strenuous exercise for 24 hours; stay warm and still during uptake

Premenopausal patients having breast MRI for screening are scheduled on days 7 to 14 of the cycle to reduce background enhancement; diagnostic staging MRI is not delayed for cycle timing. Always confirm pregnancy status before imaging with radiation or gadolinium.

Helping Patients Understand Staging

Patients often expect "full-body scans" and feel reassured by them. Explain that in early-stage disease scans are more likely to find harmless spots than real cancer, and that treatment decisions come from the tumor's size, nodes, and biology. When scans are ordered, prepare the patient for the possibility of indeterminate findings and the timeline for results.

Restaging: After Neoadjuvant Therapy and at Recurrence

During and after neoadjuvant therapy: clinical examination and breast imaging (ultrasound or MRI) track response and guide surgery. A clip placed in the tumor and in any biopsy-proven node before treatment lets the surgeon find the tumor bed even after a complete clinical response. Systemic imaging is repeated only for new symptoms or signs of progression.

Suspected recurrence: biopsy the first recurrence whenever feasible to confirm breast cancer and retest ER, PR, and HER2, because receptor status changes between the primary tumor and metastases in a meaningful minority of patients and can change treatment. Stage with contrast CT of the chest, abdomen, and pelvis plus bone scan, or FDG PET/CT, and add brain MRI for neurologic symptoms.

Metastatic disease monitoring: imaging every few months, symptom review, and sometimes tumor markers (CA 15-3, CA 27.29, CEA) interpreted together with imaging; a rising marker alone should not change treatment. Tumor markers are not used for surveillance after curative treatment of early breast cancer.

Quick Scenarios

Scenario Imaging decision
1.8-cm node-negative cancer, no symptoms No systemic staging

3-cm cancer with one mobile palpable node (cT2 N1) starting neoadjuvant therapy Systemic imaging often considered; stage III definitely staged

New back pain during adjuvant endocrine therapy Bone-focused imaging (MRI of the spine if cord compression is possible)

Rising liver enzymes on routine labs in a survivor Abdominal imaging
Persistent headaches with nausea on waking Contrast-enhanced brain MRI