Impact of the diagnostic methods on the therapeutic strategies

Over the last 25 years the diagnostic approaches and therapeutic strategies of breast cancer have dramatically changed. The relationship between diagn osis and therapy has gradually become more complex due to the ever more sop histicated diagnostic tools (mammographic screening, digital mammography, m agnetic resonance, SPECT scan and FDG-PET), which have improved resolution Limits and accuracy, and also due to the different therapeutic planning app lied to breast cancer in these years (conservative surgery, neo-adjuvant ch emotherapy, axillary dissection or not). Thus, in this paper, we have brief ly analyzed the many open questions in breast cancer management and the cli nical challenges of present diagnostic tools in relation to pre-, peri- and postoperative phases, and to therapeutic strategies in general The main go al of mammographic screening is to detect early invasive cancers and to tre at them at the first useful moment. However, at which age should one begin screening, and what is the impact on overall survival, the cost-effectivene ss, and, most of all, the best operative approach to suspect lesions? Can d igital mammography give a better quality of imaging with respect to convent ional mammography? Does unexpected multicentricity and/or multifocality, wh ich is sometimes showed by magnetic resonance, have any clinical relevance? Is this technique really better than traditional methods for the identific ation of local recurrence? Is scintimammography able to improve the low dia gnostic accuracy of mammography on non-palpable breast lesions? Moreover, a t present, the need for axillary dissection and its therapeutic and staging value is deeply debated: however, clinical detection of axillary metastase s is not a reliable diagnostic tool and there are no conventional radiologi c techniques to be used: recently nuclear medicine imaging has provided var ious approaches, such as SPECT scan with different tracers, FDG-PET, or lym phoscintigraphy with gamma probe sentinel biopsy: there are not only method ologic but also phylosophic differencies in using these techniques. Neo-adj uvant chemotherapy has allowed a dramatic reduction of primary breast cance r with a replanning of the surgical approach to large breast tumours but, a t 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 m argins which would improve survival of patients with metastatic disease? Th is paper is an attempt to analyze the answers given in the literature. Neve rtheless, at present, this matter is globally in progress and a scientific debate will provide, in the near future, a new promising scenario for breas t cancer management.