Diagnosis - technique - equipments


What examinations to do, when, to that age and with what frequency

The lines it drives some American Cancer Society for women asintomatiche (women that don't introduce suspicious symptoms for carcinoma of the breast) they foresee:

Some authors don't share this formulation; there is particularly who sustains the utility, also in the band of age from the 30 a 40 years, to perform the visit senologica with annual lilt rather than every three years.

Other authors think the utility, particularly in the band of age from the 30 a 40 years, to perform an ecotomografia of the breast with annual lilt. [<A>]

The woman that instead introduces a symptom of whatever type to load of the breast should immediately turn to the proper medical curante; these provvederàs to the visit senologica and eventually to recommend further diagnostic checks: mammografia e/o ecotomografia.


Autopalpazione

With a careful examination of his/her own breast, a woman can learn to know his/her normal structure of it and to understand when some change is verified.

It is important that the autopalpazione is correctly performed, once a month and always in the same period.

The women in fertile age can perform her/it some days after the term of the menstrual cycle, when the breast is less brim and aching.

The women in menopause can perform her/it the first day of every month.

THE ALTERATIONS TO BE SOUGHT DURING THE AUTOPALPAZIONE ARE:

If they are underlined one or more than these alterations, it is necessary to turn as soon as possible to the physician expert, for a correct diagnostic evaluation.

AUTOPALPAZIONE DURANTE THE PREGNANCY

The women have to continue to perform the autopalpazione during the whole period of the pregnancy, so as it is important that in this period is monthly visited by the physician expert, preferably always the same, in way that the comparison of possible new alterations is easier.

The goal is that to avoid, during the pregnancy, the diagnostic delay and therefore carcinomas in the advanced stadium.

AS TO PERFORM THE AUTOPALPAZIONE

It is important to look and to feel both the breasts and the cable ascellare.

It is necessary to employ the polpastrellis of the three central fingers (index, middle, ring finger) and not the point.

The in demand time various according to the dimensions of the breasts, as a rule they are enough 15-20 minutes a month.

They are had to follow three different schemes to examine the mammary gland:

to examine the breast creating some concentric rings that you/they are closed in a spiral, departing from the external quadrants to finish in the area of the nipple,

to examine the breast with some vertical movements covering the whole area,

to examine the breast “for quadrants”, with movements from the inside to the outside and vice versa

When the breast is palpated following one of the schemes sovradescritti, it needs to practice three different levels of pressure (light, moderate and strong) and of the small circular massages.

Don't lift the fingers during the palpation, to avoid not to examine an area.

It is preferable to perform the autopalpazione in a warm environment or during the shower, in such way that the mammary fabric is relaxed. The cold can determine a contraction of the breast and the nipple, such from the examination to make difficult.

To look (inspection)

You/he/she must have done before to a mirror in a well illuminated place, in four following passages:

These manoeuvres allow to underline alterations of form and dimensions of the breasts, cutaneous retrazioni, alterations of form and position of the nipple, redness or other irregularities of the skin.

To feel (palpation)

You/he/she can be effected both in the erect position and in the supine position.

The breast can also be examined under the shower; the skin lubricated by the soap makes the palpation easier.

To bring the right arm behind the head. Using the left hand, to examine the right breast and the cable ascellare omolaterale, trying to notice the presence of possible new knots following the three schemes of palpation that have been described in precedence.

In the same way, to examine the left breast.

To lie down himself/herself/themselves with a pillow or a towel under the right shoulder and to bring the right hand behind the head. To check with the hand damages the whole breast and the cable right ascellare.

To repeat for the breast controlaterale.

AREAS TO BE EXAMINED WITH PARTICULAR CARE

Naturally it is important to appraise the whole breast with the maximum care, remembering however himself/herself/itself that around halves the tumors it rises up in the overcome-external quadrants, in proximity of the cable ascellare.

EVALUATION OF THE NIPPLE

Around a bystander of the tumors it rises up in the area behind the nipple.

And' necessary to compress the nipple and to appraise the possible secretion of liquid, that if it is yellow or greenish it is normal. Contrarily, if it is dark or frankly ematico is to signal to the proper curante.

To carefully palpate the whole breast.

To also examine with care the region of the cable ascellare.

To compress the nipple to underline the possible presence of a secretion.

To look at himself/herself/themselves before to a mirror both with the lifted braccias, both with the braccias supported on the sides, to appraise a cutaneous alteration or of the nipple.


It visits senologica

The clinical examination of the breasts can be divided in three phases: anamnesis, inspection and palpation.

Anamnesis:

It has the purpose to furnish information around the presence of factors of risk and symptoms.

It is necessary to pick up relative information to a possible positive familiarity for carcinoma of the breast, to the age of appearance and disappearance of the menstrual cycle, to the age of the first pregnancy, to the nursing, to the dietary regime, to the pregresses biopsies and to the continuous hormonal therapies.

They analyzes, therefore, the characteristics of the possible symptoms, what the swelling, the mastodinia and the secretion from the nipple.

Inspection:

The patient is sat and you/he/she is observed under different conditions: with the braccias lifted above the head, with the tense superior limbs in before and the flexed bust and while is managing a pressure of the hands on the sides.

It needs to analyze the form, the dimensions, the symmetry and the profile of both the breasts, they appraise you, therefore, the skin (color, edema, retrazione, swelling) and the nipple (retrazione, deviation and presence of excoriations).

Palpation:

In this phase of the clinical examination both the breasts are palpated, the prolongations ascellari, the cables ascellari, the furrows sottomammari, the pits above and sottoclaveari.

The patient is examined first from session and subsequently in the supine position.

To examine the quadrants mediate them of the breast and the furrow sottomammario the braccias of the woman you/they must be brought along the sides, while for the evaluation of the external quadrants and the cable ascellare the braccias must be lifted.

Initially the physician uses only the point of the fingers to be able to notice possible variations of temperature of the skin and the presence of edema. Subsequently it employs for the palpation the whole hand, to flat, for an evaluation more elegant.

If I/you/he/she am us of forehead to a swelling, it needs to define its form, the dimensions, the borders, the consistence, the mobility in comparison to the deep plans and to the surrounding fabrics and the possible dolorabilità.

> The visit is completed with the palpation of the nipple and the areola, for the evaluation of ispessimenti e/o nodularità. With a delicate spremitura of the nipple can be put in evidence a possible secretion.


Mammografia

What it is

The mammografia is an examination radiologico that, using rays x, it allows a very accurate study of the breasts.

As it is performed

Currently the examination is performed employing an equipment devoted radiologica, the mammografo.

mammografo

The breast is positioned on a special support and tablet through a dish in material plastic says presser.

You/they are performed, of base, two projections (skull-caudale and oblique mediolaterale) for every breast: in total they are gotten therefore four radiographies.

Further additional projections can be performed when necessary. The acquisition of the images lasts, for every projection, little seconds. Altogether the investigation hard 10-15 minutes.

Projection skull-caudale Oblique projection

Medicines are not administered and you/he/she are not used mean of contrast.

Not some preparation is necessary before the examination; some form of anesthesia is not effected. At the end of the examination the woman can immediately leave the center; not a period is necessary of observation neither to be accompanied.

When it is performed

In the women with the present menstrual cycle still it is opportune to perform the examination in the first halves the cycle, because it is the period in which the breast is less tense and therefore more easily compressible. Besides in this phase it is possible to exclude a possible pregnancy.

In the women in phase postmenopausale is generally possible to perform the investigation in whatever moment.

Instructions

During the execution of the examination it is important to bring with if the whole relative documentation to diagnostic investigations senologiche performed in precedence. You/they could be of fundamental importance for the physician radiologist for a possible comparison.

The compression of the breast is irrinunciabile for a correct execution of the examination; it is advisable to distrust investigations performed without suitable compression of the breast.

You mark radiologici of tumor

The principals signs radiologici of tumor is constituted by the presence of opacity to more irregular borders, areas of distorsion parenchimale, starry lesions, asymmetries, microcalcificazioni.

Limits of the mammografia

The mammografia is the most important examination for the diagnosis of the carcinoma of the breast. Nevertheless the methodic one, although notably improved during the years, it is not able to recognize the totality of the lesions mammary neoplastiche: in the casuistic more recent it has brought him since 10 to the 20% of tumors not diagnosed with the mammografia; the causes can be related to the same tumor (too low intrinsic contrast towards the surrounding fabrics), to the scarce quality of the mammografia, to the missed recognition from the radiologist. The limits of the mammografia are particularly serious the women with a so-called breast "dense", in which the presence of a mammary gland of elevated radiopacità prevents a suitable study and makes difficult, if not impossible, the recognition of the signs radiologici of the tumor.

The most greater limitation to the resolution of these problems is in the same nature of the formalities with which the image is gotten mammografica: in the traditional system, in fact, the acquisition, the examination and the file of the image are all assembled in an only object, the film radiografica, with impossibility therefore to separately optimize the single procedures.


Traditional Mammografia

The traditional mammografia uses, for the formation of the image, a film radiografica: the radiations ionizzantis sent forth by the pipe radiogeno cross the breast and they go to impress the film, that is developed therefore with a procedure analogous to that employee for the common photographic films.

Up to the years ‘50 the mammary carcinoma was discovered only when it gave clinical signs of its presence, that is, in the big part of the cases, when it became "palpable" from the hands of the physician or the woman; this also happened because of the fact that the study radiologico of the breast didn't give satisfactory results. In the years '60, mainly thanks to the studies of French Charles Gros, the concept was introduced that to perform a correct investigation radiografica of the breast it was necessary to employ a devoted equipment; in that years you/they were produced therefore the first ones "mammografi." It was a true revolution, since the mammografia allowed to recognize lesions of dwarfish dimensions; it became possible to discover the tumor in phase preclinica, when he/she anchors it was in an initial stadium, not "palpable." The technique had all over the world a rapids diffusion; in the years '60 was started, in the United States, the first programs of screening of mass that allowed to confirm, with certain epidemiological data, the value of the methodic one: the periodic execution of the mammografia involved a considerable reduction, in the population, of the mortality for mammary carcinoma. In the years ‘70 also in Italy, in the province in Florence, you/he/she was started the first program of screening mammografico.

Other investigations, in the following years, you/they were introduced in the diagnostic senologica: among the principal ones the xerography, the termografia and the ecotomografia. While the first two have been completely abandoned, the ecotomografia, although as examination of screening cannot be employed, it has a well defined role in the diagnostic mammary today and you/he/she must be uses in support and in association to the mammografia. He/she anchors today insofar the mammografia it is the best disposition investigation for the precocious diagnosis of the carcinoma of the breast and it is the only test that can reduce in meaningful way the number of corpses for such neoplasia.


Digital Mammografia

What it is

The digital mammografia is a new methodic diagnostic that uses, for the formation of the image mammografica, a denominated equipment digital mammografo.

The advent of the digital technology has modified deeply our life and our habits; also in medicine, and particularly in radiology, the use of images gotten with digital techniques is broadly by now entered the daily practice; you are enough to think about the ecografia to the computerized tomography or to the magnetic resonance. In field mammografico, instead, the use of digital techniques is revealed more difficult, particularly because of the characteristics of elevated resolution spatial applications and for the tall costs of the proposed systems. Only recently, in fact, they are become available the first equipments for the study digital radiologico of the breast; their realization has required over ten years of searches (primarily in the United States), and with investments, aside both of public organizations is of private firms of hundreds of million of dollars.

In digital mammografia the film radiografica is replaced by a detettore: this absorbs the rays x transmitted through the breast and it converts their energy in electronic signals, that digitalizzatis come and fixed in the memory of the computer. From the whole these data you/he/she is drawn therefore an image, the digital mammografia, that best man on a monitor to tall definition. From here, after having opportunely been elaborated, you/he/she can be engraved on film through laser printer or memorized in one of the various systems of filing to disposition today, included the CD-ROM.

They are currently to the study different types of digital detettori. The system more used is constituted by a thin panel of amorphous silicon covered by a layer of crystals of ioduro of caesium. The layer of ioduro of caesium acts from scintillatore: it deals with a material that, when struck by rays x, it sends forth bright radiations. The amorphous silicon has the function of fotodiodo, that is it converts the bright signal in electronic signal. Every fotodiodo corresponds to a pixel, that is to the elementary unity of the information. The position of every element is converted in digital information. The detettore measures 19x23 centimeters and every pixel it measures 0.1 millimeters. Other systems in the street of experimentation use memory phosphoruses, CCD, panels to the amorphous selenium.

The advantages of the digital one

The image traditional mammografica is an image on film that, to the peer of a photo, after having been produced it is not more modifiable. Besides the breast is constituted from zones to different density: since these zones will be reproduced in an only image, there will be areas well you represent, and therefore well studiabili, nearby to areas correctly you represent not, too much clear or too much ax, and therefore not correctly studiabili. The digital image can also be elaborate instead from the computer after the formation: you/he/she can opportunely be then modified varying the parameters of contrast, brightness, enlargement etc., the correct visualization of every different area of the breast making so possible. The digital image can be visualized on monitor to tall definition or printed on film through laser printers.

One of the factors that don't allow sometimes to diagnose a tumor to the mammografia it is that the pathological area is endowed with a difference of intrinsic contrast too much low towards the surrounding healthy fabric. Since the digital image can be elaborated after the acquisition, the differences of contrast can be excited, the diagnosis making easier.

The general output of the system, particularly as it regards the resolution of contrast, it is decidedly superior to the conventional system. This allows to get images of good diagnostic quality with a smaller dose of radiations. Besides, since the images can be elaborated again to the computer, it is also possible possession a good mammografia under non optimal conditions of exposure. Insofar the problem is reduced, common instead with traditional technique, of the repetition of non diagnostic examinations because not correctly statements. You reduces therefore the dose of radiations administered to the women, factor this particularly important in mammografia as the investigation, to be effective to the goals of the prevention, has to be repeated periodically every 1-2 years.

The digital acquisition makes the use of systems of artificial intelligence possible to improve the images and to assist the radiologist in their interpretation; they are in phase of advance experimentation you systematize that allow the analysis of the image and the search, from the computer, of alterations possible expression of mammary neoplasia. Such systems (CAD, Computer Assisted Diagnosis) you/they could be used as aid to the radiologist in the refertazione ("according to reader"), allowing an increase of the effectiveness of the investigation, the reduction of the costs and the possibility from the radiologists of refertare an ampler number of examinations.

The availability of images in digital form allows the creation of complete computer files, comprendenti both the whole clinical news riguardanti the patients is the relative images. You would owe therefore to get a complete computerized clinical briefcase, with advantages over that in the practical management, also for the aspects riguardanti the search and the didactics.

The digital image can finally, be transmitted to distance (other stations of job near hospitals, physicians of base, centers of search, whatever computer connected through net or telephone line) with different possible applications: transmission from the place of execution to the place of refertazione, transmission to centers of reference for consultation, etc. And' possible therefore to effect the mammografia to Turin or to London and to send the gotten images, almost in real time, to New York or to Paris.

In conclusion, the digital technique allows to get images mammografiche of elevated quality, with possibility to discover neoplasie in some non diagnosable cases with traditional technique. The employment of the digital mammografia should involve besides a further advantage for the woman in terms of reduction of the dose of radiations administered. The principal obstacle to the diffusion of this procedure is currently represented by the elevated costs of the necessary equipments: he treats, in fact, of very sophisticated machineries, endowed with an elevated technological content and fruit of years of searches. It is therefore comprehensible as, at least in a first phase, the cost of these instruments is notable.

Charles Gros affirmed: "the mammografia doesn't admit but the perfection." Digital or traditional, the mammografia is an important investigation however, to periodically effect and with the best possible technique, to discover a possible tumor in initial phase and to save, therefore, the life to the woman.


Galattografia

What it is

The galattografia is a particular type of examination radiologico of the breast, effected through middle introduction of contrast radiopaco in the learned galattoforis and following execution of the radiographies.

To what it serves

The galattografia serves to study the learned galattoforis, that is the scholars of the mammary gland through which, during the nursing, milk escapes.

The galattografia can be performed in case of suspicious secretion by the nipple, to discover the possible cause and its center of it in the system duttale.

In this case the investigation can be useful with the purpose to correctly plan a possible surgical intervention.

As it is performed

The procedure divides him in two phases: the middle introduction of contrast in the learned galattoforis and the execution of the radiographies.

And' necessary that the secretion from the nipple, spontaneous or provoked by a light compression, both in action during the examination, with the purpose to be able to individualize with precision the orifice of the learned secernente. You proceeds therefore to the introduction of a small cannula in the system duttale through the individualized orifice, dopodiché is injected, through the cannula, a small middle quantity of contrast.

To this point the radiographies are performed, with technique analogous to the normal MAMMOGRAFIA

The procedure can result in some cases indaginosa for the difficulties to incannulare the scholar.

Generally the examination is not painful for the patient but you/he/she can have been lasting for 30 minutes to a hour.


Ecotomografia

What it is

The ecotomografia is a diagnostic investigation that doesn't use radiations ionizzanti (the rays x) but ultrasounds.

To what it serves

In field senologico the ecotomografia is an examination of fundamental importance for the diagnosis and the characterization of a good part of the pathology mammary nodulare. Besides the ecotomografia allows to drive with great precision the procedures interventistiche (mammary agobiopsia, emptying cysts, positioning retrieved).

Just to motive for his/her importance, the ecotomografia must correctly be performed always, with suitable equipments and with precise indications.

Ecotomografo

As it is performed

The investigation is performed using a devoted equipment the ecotomografo.

The patient prepares him in supine position on a bunk from visit, with the open chest.

The physician that performs the examination pours on the part to examine a small quantity of watery gel, that has the purpose to favor the passage of the ultrasounds from the probe used for the examination to the breast.

The probe ecotomografica is made to flow on the breast; the image that is gotten you/he/she is visualized in real time on the monitor of the ecografo.

During the investigation some are acquired images that have the purpose to document happens him execution of the examination and the possible presence of meaningful finds.

Indications

The ecografia mammary it is an investigation that always makes integral part of an iter of diagnostic senologica.

The investigation must be precedes always from an accurate anamnesis and from the vision of possible precedents (mammografia or ecotomografia).

In many cases this methodic is complementary to the mammografia. In fact the ecografia has an inferior sensibility and a greater specificity of the mammografia; this means that allows a good tipizzazione of a lesion, but, above all if the lesion is of small dimensions, not he/she always succeeds in noticing her/it. Contrarily, the mammografia is able to underline a greater number of lesions, but it is always not able to characterize her.

In the young woman, of inferior age a 30 years, the ecografia is performed as first-quality investigation, if I/you/he/she see us the presence of a palpable knot; if the characteristic ultrasonografiches of the found lesion are suspicious, the study is completed by a mammografia and eventually from an agobiopsia.

In the woman of superior age a 30 years, in case of palpable knot, it is advisable to make to precede the ecografia from a mammografia however, in consideration of the increased risk, in this band of age, of mammary carcinoma.

It is opportune, besides, to perform the ecografia in all the patients, also asintomatiche as diagnostic completion of a mammografia in which a lesion has been underlined or however an alteration of the glandular structure.

The investigation ecotomografica also represents a methodic first-quality for the revaluation of the dimensions of a tumor after chemotherapy neoadiuvante and to confirm the diagnosis and to appraise the evolution of a flogosi or a post-traumatic alteration.

The ecografia represents, besides, a guide for the collecting bioptico and for the positioning of it retrieved for the location preoperatoria of non palpable lesions.


Biopsy

Execution of a biopsy
with ecotomografia

What it is

The biopsy of the breast consists in the collecting of some cells or a fragment of fabric and in the following analysis anatomopatologica of the withdrawn material.

Types of biopsy and strumentario

Different types of biopsy of the breast exist according to the type of needle that is used for effecting the collecting.

The simplest is the agoaspirato, that is the collecting of some cells of the suspicious zone through a thin needle; of this term some synonymous ones exist: agobiopsia with thin needle, FNAB (End Needle Aspiration Biopsy), cytological collecting.

For the execution of the agoaspirato a needle of inclusive caliber is used between 21 and 27 Gauge (the needle from 21 Gauge is the common needle of the syringe).

Another type of methodic, very used in USA and employee in Italy, is for a while mostly the biopsy with jerky needle, CNB (Core Needle Biopsy), collecting microistologico; you/he/she deals with the collecting of a small frustule of plotted from the suspicious zone through a particular device generally denominated jerky needle.

Gun for biopsy with jerky needle

Particular techniques of biopsy exist, finally also these in street of expansion, that uses sophisticated equipments and on purpose produced for effecting mammary collectings of big dimensions. The equipments most common, in this last group, Mammotone is denominated, MIBB, Have.

Methodic guide

Three different techniques of execution of the collecting exist according to substantially the methodic guide, that is of the methodic one that allows to individualize the exact center of the lesion and to address the select needle for the collecting.

Technique to free hand: the lesion is individualized by the hand of the physician.

Technique with guide ecotomografica: to individualize the lesion and to drive the collecting is used an ecotomografo.

Technique with guide stereotassica: it uses for the centratura of the lesion an equipment particular radiologica, the so-called stereotassi. Of such instruments exist more versions, lists among them for formality of formation of the image (analogical or digital) and for position of the patient (sat or prone).

Choice of the methodic guide

The choice of the methodic guide depends on numerous variable; the principal ones are the characteristics of the lesion, the type of needle that he intends to use, the type of equipments that you/they are had available the personal preferences of the operator.

The technique to free hand can be used only obviously with palpable lesions. Less and less used by now, you/he/she is performed only generally on lesions of big dimensions and employing needles of small caliber.

The technique with guide ecotomografica is generally the preferable techniquenerally the preferable techniqusiveness. It is the most diffused technique, also for the ample availability of the equipments necessary ecotomografiche. It is also besides more commonly the technique employee because good part of the lesions that you/they need agobiopsia is visible to the ecotomografia.

The necessary equipments for the collecting with guide sterotassicas are relatively a little diffused. In case of visible lesion only to the mammografia and not to the ecotomografia (for instance the microcalcificazionis), the choice of the guide stereotassica is forced.

Technique of execution

The technique of execution is different according to the methodic guide and of the type of employed needle.

Agoaspirato with guide ecotomografica

Not some preventive preparation is necessary before the procedure.

The patient is made to lie down supine on the bunk of the room ecotomografica, with the braccias aloft and the open breast. For some lesions (those in the external quadrants of the breast) you/he/she can be useful to make to rotate the patient on a side.

With the probe ecotomografica is individualized the lesion and is chosen the point of entry of the needle. If possible it is preferable to avoid to sting to level of the nipple and the areola, because to this level the skin is thicker and the manoeuvre can result more painful.

After having disinfected the skin, the interested part is covered with a sterile cloth.

The execution of the local anesthesia generally is not necessary, in how much the procedure is well born; in particular cases (particular dolorabilità of the breast, anxiety, the patient's application) local anesthesia can be performed injecting in the center of the collecting 5 ccs of local anesthetic (Lidocaina to 2%).

To this point the real collecting is begun. Two different formalities of execution exist substantially: to two operators or to single operator. In the case of two involved operators, one deal him with to perform the ecotomografia during the manoeuvre to verify the centratura of the lesion and the progression of the needle, the other one it performs the collecting. In the case of the single operator, all the manoeuvres are developed by an only operator. The procedure to two operators allows greater liberty of movements the physician that performs the collecting. The procedure to single operator allows a best coordination among movements of the probe ecotomografica and of the needle. The choice of the procedure depends on the personal preferences of the operators.

You introduces therefore the needle in the skin: the progression toward the lesion is followed in real time by the probe ecografica. When the lesion is reached it begins the aspiration: this is effected using a devoted equipment (Cytomat) that you/he/she is connected to the needle; in alternative the aspiration can be performed with a simple syringe. During the collecting the needle is made to repeatedly move inside the lesion with a movement of it goes and you come for mostly sampling the suspicious zones.

When it holds him to have withdrawn material enough, the aspiration interrupts him and the needle removes him.

The withdrawn material immediately comes prepared for the examination anatomopatologico. If possible a part of the collecting is examined suffered by the pathologist (so-called judgment of fitness): if these it holds not to have enough material to be able to formulate the diagnosis, the collecting you/he/she can be repeated. If instead the material is held enough, the procedure is finished.

The patient is cleaned, disinfected and cured with a small bandaid.

The procedure is usually very well born, the pain warned by the patients is very modest if it doesn't consent.

At the end of the procedure the patient is generally under good conditions and you/he/she can return home without problems.

Jerky needle with guide ecotomografica

The procedure is very similar to that for the agoaspirato. The phase of preparation is identical. Since a needle of big caliber is used (14 Gs, correspondents to 4 mms) it is advisable to always perform the local anesthesia injecting, with an insuline needle, 5 ccs of local anesthetic in the zone of the collecting. After the local anesthesia a small taglietto is performed (few millimeters) to level of the skin with the point of a scalpel, to allow the entry of the jerky needle. Also in this case the progression of the needle is followed in real time with the probe ecografica. It is necessary to preventively warn the patient that the needle, when it automatically effects the collecting, it provokes a dry noise (note him “release”); this to avoid that, frightened by the sudden noise, brusquely stirs during the procedure. When the point of the needle is correctly positioned in the center of the lesion the collecting it is performed. After the release the needle removes him and is deposited the frustule withdrawn in a test-tube. Also in this case you/he/she can be opportune to immediately examine the withdrawn material making to crawl the frustule on a slide and examining him/it to the microscope. Generally it is advisable to effect at least two or more collectings with the jerky needle.

It is advisable, after the collecting, to manually compress the interested zone for some minutes, to reduce the risk of sanguinamento and a possible hematoma. It is not necessary to suture the skin.

At the end of the procedure the skin is disinfected, a medication is performed with bandaid and is positioned on the interested part a purse of dry ice to cool the zone. Also in this case the procedure is generally well born, few or not at all painful. The patient can reenter to house; a period of rest of some times is advisable. The medication can be removed later the day.

Agoaspirato with guide sterotassica

Two different possibilities of execution exist: technique with stereotassi in sat position and technique with stereotassi in prone position; the choice generally depends on the type of disposition equipment.

For the execution in prone position, the patient has lain down on a special bunk with the breast inserted in a hole of the same bunk.

For the execution in sat position, the patient is made to sit in front of the equipment; the mammografia of centratura is performed with technique analogous to the diagnostic mammografia.

You individualizes the lesion on the performed radiography and they is calculated the coordinates in the space. To this point, always with the compressed and immovable breast, the cutaneous point of entry is individualized and is plunged the ago.Quindi the correct position of the needle it checks him in the lesion with further projections mammografiche, the collecting is finally performed.

The procedure, performed with traditional equipments, you/he/she can relatively be long (20-40 minutes) and in some cases annoying, because of prolongs her/it compression of the breast.

If the procedure is performed with digital equipments the times of execution they shorten a lot, with consequent best tollerabilità from the patients.

Jerky needle with guide sterotassica

The procedure is analogous to the agoaspirato; likewise to the guide ecografica, also with guide stereotassica is advisable to perform a local anesthesia and a small cutaneous incision.

Indications to the biopsy

The biopsy of the breast is performed every time that I/you/he/she am necessary to characterize quote-istologicamente a mammary lesion.

Complicanze

In the big part of the cases it doesn't occur any complicanza.

Sometimes a modest dolorabilità is signalled in the center of the collecting that, in some cases, you/he/she can persist some times. Generally some therapy is not in demand.

In some cases you/he/she can form him a hematoma, that is a harvest of blood in the center of the collecting. Almost always the harvest is of small dimensions and, also in this case, it generally is not application therapy.

Complicanze of greater gravity as the pneumotorace (that is the perforation, with the needle, of a lung) they are absolutely exceptional; in these cases it is in demand a suitable medical treatment.

Surgical biopsy

The surgical biopsy consists in the collecting of a part of the suspicious zone through surgical intervention. If possible, it is advisable to remove the whole lesion.

The surgical biopsy is generally performed in that cases in which you/he/she has not been possible to come to a diagnosis certain preoperatoria with the common methodic (mammografia, ecotomografia, biopsy)

In case of non palpable lesion it is necessary to position before the intervention a repere, that is a system that allows the surgeon to identify and to correctly remove the suspicious zone. The principal types of repere are the vegetable coal, the metallic repere, the injection of a tracing radioactive.

System of telepatologia

The biopsy is generally effected in the department of radiology. The contemporary presence of the anatomo pathologist allows the immediate extemporaneous evaluation of the collecting with obvious benefits the management of the patient: in case of non fit collecting, in fact, the manoeuvre is immediately repeated by the radiologist, eventually also more times, up to when the anatomopatologo doesn't hold to have material enough for a diagnostic judgment.

The presence of the anatomopatologo to the session of agoaspirato is important besides for the immediate discussion multidisciplinare in the case.

Nevertheless this involves organizational problems and you costs not indifferent. In fact there is a continuous increase of the application of such performances with necessity to always program a greater number of sessions of mammary agobiopsia. The presence of the anatomopatologo, therefore, coast a lot in terms of time, of appointment and economic. Also for these motives in many centers the constant presence of the anatomopatologo to the sessions of biopsies is not possible.

A possible solution to the problem can be represented by a system of telepatologia, that is from a system able to transmit to distance imagines online of collectings anatomopatologici.

The material withdrawn in progress of agoaspirato is immediately delivered by the radiologist to the technician of laboratory of pathological anatomy that handles the fixation and the immediate coloration.

The prepared slide is positioned on the microscope. The image comes digitalizzata from a television camera connected CCD and from this transmitted in local to the computer in radiology. Here the image appears on the monitor and you/he/she can be analyzed by the present personnel in radiology. From the first posting the image is practically transmitted online in real time to the posting in pathological anatomy. Here the image is analyzed by the anatomopatologo that it establishes the fitness or less than the collecting.

The system not only allows the transmission of the static image, but also of images in movement, therefore with possibility to analyze and to transmit different fields of the slide and to different enlargements. There is besides the possibility of audiocomunicazione, that allows the pathologist to give indications to the personnel that manages the image to the microscope on what fields desires to examine, to what enlargement, that movements to effect.

The audio (and video) two-way communication allows besides I exchange him/it opinions and the discussion of the case between radiologist and pathologist. In the case the pathologist holds the material examined not fit to express a diagnostic judgment, the collecting you/he/she is repeated and the material is examined with the same procedure.

When the pathologist holds to have material enough, the procedure you/he/she is finished.

The system allows the filing of the most meaningful images.

The final result is an optimization of the times and the costs of the personnel with a best and more efficient service offered to the public. It is not negligible, finally, the possibility of cultural enrichment for the radiologist with the learning of the correlation between anatomo-pathological image and radiologica.

The problem of the lymph nodes of the armpit

The cells neoplastiche of the carcinoma of the breast can migrate along the lymphatic streets and to localize himself/herself/themselves to the lymph nodes; the first stations interested linfonodalis are almost always situated to level of the cable ascellare.La stadiazione of such lymph nodes is of fundamental importance for the correct planning of the therapy and for the prognosis of the illness.

The procedure performed more commonly for discovering the presence of cells neoplastiche linfonodali is the surgical removal. The traditional intervention (the so-called emptying of the cable ascellare) it consists in the removal of all the traceable lymph nodes.

Nevertheless the intervention is not performed with therapeutic finality but simply diagnostic of stadiazione; you/he/she has been in fact shown that the complete emptying of the cable ascellare doesn't modify the patients' survival struck by neoplasia. Besides the postoperative complicanzes (as the swelling of the arm) they are relatively frequent. For these motives the search is currently directed toward techniques that allow to know the situation of the cable ascellare in less way invasivo. Among these, the more one currently used is the technique of the "lymph node sentinel". Such technique foresees only the removal of a lymph node; this intervention founds him on the presupposition that during the migration from the primitive lesion, the cells tumoralis go to interest the first lymph node that you/they meet in their journey, the so-called one "lymph node sentinel."

Injection of tracing radioactive for the location of the lymph node sentinel

The intervention of removal of the lymph node sentinel is based on the injection peritumorale of a tracing radioactive that, migrating along the lymphatic streets, you/he/she will go to settle in the first lymph node that she will meet along the lymphatic journey, note the lymph node sentinel. With the aid of a particular probe, the surgeon will be able to individualize the center of the interested lymph node and therefore to remove him/it.

In case of palpable lesion the injection of the tracing radioactive is effected to free hand.

In case of non palpable lesion, instead, the injection is made with guide ecotomografica or stereotassica.

Agoaspirato of the cable ascellare

The study ecotomografico allows to underline, with good sensibility, the presence of lymph nodes to level of the cable ascellare and their aspect.

With guide ecotomografica is possible to perform an agoaspirato, that can furnish important information on the presence of metastasi linfonodali besides. In case of indicative result of the presence of cells neoplastiche, the intervention of the lymph node sentinel can be avoided.


Magnetic resonance (RM)

The mammografia is currently the first-quality investigation for the precocious diagnosis of the carcinoma of the mammella.Le limitations of the traditional mammografia they have nevertheless brought to explore alternative or additional roads: the principal ones are the digital mammografia and the magnetic resonance (RM) of the breast.

The improvements brought in the technology of the magnets and the development of new protocols of image have allowed the RM to prove himself/herself/themselves as a very promising technique for the recognition and the characterization of the mammary lesions. Nevertheless the RM is relatively today still an expensive and a little diffused examination. Its use in the clinical practice is limited therefore to very particular cases, in which the others methodic are not able to arrive to a diagnosis of certainty. The principal indication seems to currently be the study of the integrity of the mammary prostheses. For the execution of the RM of the breast it is necessary to use devoted spools. The examination foresees the middle intravenous injection of contrast.


Nuclear medicine

The principal role of the physician-nuclear investigations in senologia currently concerns the retrieval of the "lymph node sentinel."

The other available investigations as the mammoscintigrafia, don't currently find clinical employment.


CAD (Computer Aided Detection and Diagnosis)

What it is

The CAD is a new methodic experimental that allows the identification and the diagnosis from a computer of the lesions neoplastiche of the breast.

As it works

It is necessary to have images mammografiche in digital form.

In case of mammografie gotten with traditional technique, the films come digitalizzate through a scanner. The images gotten with the new technique of digital mammografia are already obviously available in digital form.

The software of the program is able to analyze the type of breast and to recognize the presence of possible lesions, represented by microcalcificazioni or opacity (detection).

Subsequently the program expresses a judgment on the probability that the found lesion is malignant (diagnosis).

Currently the system is not usable in the clinical practice but it is in progress of experimentation.

It is probable that in the future such system can be of great help to the physician radiologist in the recognition and in the characterization of the carcinoma of the breast.

In Italy a program of CAD is currently in progress of experimentation, denominated Calm (Computer assisted lybrary in mammography) conceived and realized near the INFN in Pisa by the group of the prof. Ubaldo Bottigli; the clinical experimentation happens near some centers of Italian mammografia: Center of senologia in Bari, Radiology University of Udine, Center of screening mammografico Hospital Molinette in Turin.

Electric potential (Electrical Impedance Scanning)

It deals with a methodic that studies the formalities of crossing of the breast from current electric to low intensity.

The investigation allows to get a representation of the based breast on the principle of the different conductivity of the fabric tumorale in comparison to the healthy fabric.

Technology is still in the street of experimentation and to the moment you/he/she has not found clinical use.