Introduction

It is an unquestionable fact that the progress that has taken place in recent years in the early diagnosis of neoplastic pathologies of the breast is primarily connected with the technological progress of diagnostic imagery, in primis mammograms and ultrasound, the preferred tests for breast pathologies.

Digital technology has profoundly influenced both procedures and their current evolution is strongly based on the evolution of computer technology. The digital mammogram is currently taking its first significant ‘steps’ forward, thanks to the introduction of amorphous selenium and photo-stimulant phosphorous imaging plates, which with the 4th generation have reached the threshold of 20 pixel/mm. Ultrasound is making great use of volume acquisition methods thanks to the processing capability of available hardware (echo3d). Experience teaches that the former is not an alternative to the latter or vice versa but rather that their integration is crucial and fundamental to reach a correct diagnosis. We will discuss the advantages of the three-dimensional ultrasound in detail (considering the dedicated thematic aspect of the text) but, where necessary, we shall not hesitate to refer to the x-ray method.

Malignant pathologies

We shall discuss the most common, especially those where an integration of diagnostics and the three-dimensional ultrasound can represent an important turning point in imaging interpretation.

Non infiltrating ductal carcinoma

This is the most tangible proof of the importance of mammograms in screening. Its most common x-ray signs are the widespread micro-calcifications that cannot be viewed in large percentages by an echography as it is difficult to differentiate them from the hyperechoic microstructures of the glandular parenchyma. In its early stages, this neoplasia does not display any true focal points of echo-structural alteration and for this reason it would appear that the pathology remains within the realm of x-ray procedures.
The high percentage of multi-focal varieties of the illness, and the ability of the echo 3D to analyse the more sensitive coronal planes in noting alterations of structural homogeneity and multicentric distribution with respect to traditional longitudinal and transversal scans directed to the small area of echo-structural alteration, make the echo 3D and irreplaceable tool in assessing the extent of the illness.

Infiltrating ductal carcinoma

This is the most frequent percentage-wise. The now classic radiological sign is the “famous” stellar radiopacity frequently associated with “granular” micro-calcification. X-ray diagnosis is frequently as simple as it is complex to establish the actual extent. We normally limit ourselves to measuring the maximum diameter of the radiopaque nucleus, obtaining results that can be later contrasted by anatomopathologic responses.

And this is where the 3D ultrasound comes in, in a decisive and innovative manner, with respect to traditional ultrasonography.

The multiplanar technique makes it possible to identify the ductal path taken by the illness and measure its real extension. According to the results obtained, the echometric evidence closely approaches the histological response.

3D ultrasound aimed at the ductal infiltration plane has great capacity to identify compromised ducts. They appear clearly hypoechoic and ectatic with respect to surrounding structures and it is not difficult to observe the homogeneous areas around them, indicating the spreading of the illness. Since a different surgical conduct must be associated with the extreme precision of the diagnosis, we may state that further development of tri-dimensional models, displaying a faithful coherence with the actual condition of the anatomic section being studied, provides information that is extremely useful in establishing the extent of the illness in terms of spatial definition of the lesion.

Carcinoma in situ

In diagnostic terms, this is considered as the “the true early diagnosis”.
Almost totally lacking in positive mammographic indications, it is the pathology in which diagnostic integration plays a crucial role.
Diagnosis is strictly histological, but the scan is certainly the most sensitive among the imaging methods available.
It highlights minimal parenchymal distortions and echostructural alterations.
In this case the scan is strongly associated with the operator, something that is reduced by the use of echo 3D.
It is the multiplanar method that most helps to reach a decision concerning the area in doubt, thanks to the greater number of images available.
The echo-guided biopsy thus consequently becomes the additional and only step forward when negative mammogram results do not allow for a stereotaxic approach.