Substantial progress has been made in the diagnosis and treatment of primary and metastatic breast cancer in the last 20 years. New technical instruments and laboratory tools have emerged in recent years that expand the options for the study of breast cancer at different stages. Such an improved platform requires a departure from standard approaches and prompts testing of the innovative tools in the workup of women with breast cancer, with the aim of investigating at which stage, in the natural history of breast cancer, they should be applied to optimize clinical management. It is known that the widespread use of routine mammography has led to an increase in the early detection of primary breast lesions that significantly contributes to the decrease of mortality from breast cancer that is now measurable in Europe and North America. The dramatic shift in the stage of breast cancer at diagnosis has been associated with the successful application of less mutilating surgical procedures, with the widespread resort to breast-conserving surgery and, more recently, with avoidance of useless surgical staging of the axillary lymph node status through the use of sentinel node biopsy. In addition, adjuvant and preoperative systemic therapy has been optimized in terms of drug availability and activity and refinement of the criteria for administration, thus significantly contributing to prolongation of survival in women with early breast cancer. The challenge at this time is to define procedures and tools that allow easy characterization of the tumor, its aggressiveness and its pattern of sensitivity/ resistance to drug therapy, so that treatment can be tailored to individual needs rather than to the average risk of the average patient. The technological development of the diagnostic imaging has been impressive in the field of radiology and nuclear medicine allowing for the dependable detection of small lesions. These tools have generated new approaches permitting the successful differential diagnosis of doubtful lesions and the rapid identification of systemic metastases, and are providing a means for the non-invasive characterization of biology of cancer tissue. It is likely that these advances will provide further contributions to the optimization of therapeutic strategies, considering that the metabolic information offered by nuclear medicine procedures, combined with the anatomical data provided by conventional radiological techniques, should find a place in predicting tumor response and monitoring the outcome of patients. It is difficult to formulate conclusive diagnostic guidelines for application in the workup of breast cancer, since while the role of some examinations, such as mammography and US, is well established, that of others, such as MRI and PET, is still a matter of investigations. New technical instruments and laboratory tools have emerged in recent years that expand the options for the study of breast cancer at different stages. Such an improved platform requires a departure from standard approaches and prompts testing of the innovative tools in the workup of women with breast cancer, with the aim of investigating at which stage, in the natural history of breast cancer, they should be applied to optimize clinical management. Assessment may be simplified by evaluating their role: (1) in screening for and in diagnosing of breast cancer; (2) for loco-regional staging; (3) for extensive staging and follow-up; (4) for better characterization of the tumor; (5) for monitoring/predicting patterns of sensitivity or resistance to therapy. Clinical observation is the mainstay of evaluation in each phase of the patient's management, and histopathological analysis is the gold standard for diagnosis, but laboratory tests, radiological imaging and nuclear medicine imaging are assuming a growing role in the workup of patients with breast cancer (Table 22.1).
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