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The Quarterly Journal of Nuclear Medicine 1998 March;42(1):66-80


language: English

Impact of the diagnostic methods on the therapeutic strategies

Greco M., Agresti R., Giovanazzi R.

From the Division of General Surgery “B” Istituto Nazionale per lo Studio e la Cura dei Tumori, Milan, Italy


Over the ­last 25 ­years the diag­nos­tic approach­es and ther­a­peu­tic strat­e­gies of ­breast can­cer ­have dra­mat­i­cal­ly ­changed. The rela­tion­ship ­between diag­no­sis and ther­a­py has grad­u­al­ly ­become ­more com­plex due to the ­ever ­more sophis­ti­cat­ed diag­nos­tic ­tools (mam­mo­graph­ic screen­ing, dig­i­tal mam­mog­ra­phy, magnetic resonan-ce, ­SPECT ­scan and FDG-PET), ­which ­have ­improved res­o­lu­tion lim­its and accu­ra­cy, and ­also due to the dif­fer­ent ther­a­peu­tic plan­ning ­applied to ­breast can­cer in ­these ­years (con­ser­va­tive sur­gery, neo-adju­vant chem­o­ther­a­py, axil­lary dis­sec­tion or not). Thus, in ­this ­paper, we ­have brief­ly ana­lyzed the ­many ­open ques­tions in ­breast can­cer man­age­ment and the clin­i­cal chal­leng­es of ­present diag­nos­tic ­tools in rela­tion to pre-, ­peri- and post­op­er­a­tive phas­es, and to ther­a­peu­tic strat­e­gies in gen­er­al. The ­main ­goal of mam­mo­graph­ic screen­ing is to ­detect ear­ly inva­sive can­cers and to ­treat ­them at the ­first use­ful ­moment. However, at ­which age ­should one ­begin screen­ing, and ­what is the ­impact on over­all sur­vi­val, the ­cost-effec­tive­ness, and, ­most of all, the ­best oper­a­tive ­approach to sus­pect ­lesions? Can dig­i­tal mam­mog­ra­phy ­give a bet­ter qual­ity of imag­ing ­with ­respect to con­ven­tion­al mam­mog­ra­phy? Does unex­pect­ed mul­ti­cen­tric­ity and/or mul­ti­fo­cal­ity, ­which is some­times ­showed by mag­net­ic res­o­nance, ­have any clin­i­cal rel­e­vance? Is ­this tech­nique real­ly bet­ter ­than tra­di­tion­al meth­ods for the iden­tifi­ca­tion of ­local recur­rence? Is scin­ti­mam­mog­ra­phy ­able to ­improve the low diag­nos­tic accu­ra­cy of mam­mog­ra­phy on non-pal­pa­ble ­breast ­lesions? Moreover, at ­present, the ­need for axil­lary dis­sec­tion and its ther­a­peu­tic and stag­ing val­ue is deep­ly debat­ed: how­ev­er, clin­i­cal detec­tion of axil­lary metas­ta­ses is not a reli­able diag­nos­tic ­tool and ­there are no con­ven­tion­al radio­log­ic tech­niques to be ­used: recent­ly nucle­ar med­i­cine imag­ing has pro­vid­ed var­i­ous approach­es, ­such as ­SPECT ­scan ­with dif­fer­ent trac­ers, FDG-PET, or lym­phos­cin­tig­ra­phy ­with gam­ma ­probe sen­ti­nel biop­sy: ­there are not ­only method­o­log­ic but ­also phy­lo­soph­ic dif­fe­ren­cies in ­using ­these tech­niques. Neo-adju­vant chem­o­ther­a­py has ­allowed a dra­mat­ic reduc­tion of pri­mary ­breast can­cer ­with a replan­ning of the sur­gi­cal ­approach to ­large ­breast ­tumours but, at the ­same ­time, has ­posed new ques­tions ­such as the ade­qua­cy of diag­nos­tic pre- and per­i­op­er­a­tive reval­u­a­tion. Finally, ­does post­op­er­a­tive fol­low-up ­take advan­tage of inten­sive diag­nos­tic pro­grams and are ­there ther­a­peu­tic mar­gins ­which ­would ­improve sur­vi­val of ­patients ­with met­a­stat­ic dis­ease? This ­paper is an ­attempt to ana­lyze the ­answers giv­en in the literature. Nevertheless, at ­present, ­this mat­ter is glo­bal­ly in ­progress and a sci­en­tif­ic ­debate ­will pro­vide, in the ­near ­future, a new prom­is­ing sce­nar­io for ­breast can­cer man­age­ment.

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