Technology as a force for improved diagnosis and treatment of breast disease

Abstract

Increasing numbers of women are seeking evaluation of screen-detected breast abnormalities, and more women with breast cancer are living with the consequences of treatment. Improved technologies have helped to individualize diagnostic evaluation and treatment, improve efficacy and minimize morbidity. This article highlights some of these technologies. Superior imaging techniques have improved breast cancer screening and show promise for intraoperative surgical guidance and postoperative specimen evaluation. Digital mammography improves the sensitivity of mammography for women younger than 50 years with dense breasts, and tomosynthesis may improve specificity. Magnetic resonance imaging provides sensitive delineation of the extent of the disease and superior screening for women with a greater than 25% lifetime risk of breast cancer Minimally invasive techniques have been developed for the assessment of intraductal lesions, biopsy of imaging abnormalities, staging of the axilla and breast radiotherapy. Ductoscopy facilitates intraductal biopsy and localization of lesions for excision, sentinel lymph node biopsy is becoming standard for axillary staging, and intraoperative radiotherapy has the potential to reduce treatment time and morbidity. Three-dimensional imaging allows correlation of final histology with preoperative imaging for superior margin assessment. Related techniques show promise for translation to the intraoperative setting for surgical guidance. New classifications of breast cancers based on gene expression, rather than morphology, describe subtypes with different prognoses and treatment implications, and new targeted therapies are emerging. Genetic fingerprints that predict treatment response and outcomes are being developed to assign targeted treatments to individual patients likely to benefit. Surgeons play a vital role in the successful integration of new technologies into practice.

Fig. 1

Ductoscope used for the assessment of intraductal lesions. The ductoscope (Fibretech) contains several channels, including a light source, video camera and biopsy channel, which allows saline to be flushed down the duct to aid its passage and the aspiration of fluid for cytology.

Fig. 2

Correlation between imaging histology and 3-dimensional (3-D) reconstruction for comprehensive margin assessment. Whole-mount sections in series are digitally scanned. Each whole-mount section may be compared with slices imaged by micro-computed tomography (CT). The CT and digital images are then coregistered to allow 3-D reconstruction. Photograph courtesy of Dr. Gina Clarke.

Fig. 3

Intraoperative radiotherapy illustration of the Intrabeam unit (A) on its own, (B) in place with the applicator within the breast lumpectomy cavity and (C) in use with a tungsten shield over the breast.