**3. Conclusion**

In the era of rapidly developing technology, improvements in mammographic and molecular diagnostics appear promising, keeping up with the progress and corresponding demands raised by therapeutic oncology. The combination of multiple imaging methods (PET/CT, PET/MRI etc.) may concurrently evaluate both morphological and functional parameters and may directly influence the clinical management of patients bearing breast lesions, especially in recurrent or metastatic disease.

Scintimammography on its own is a simple, safe, non-invasive and widely available conventional nuclear medicine technique, which provides valuable multilevel information in the clinical management of breast lesions. The method visualizes the lesion site and also reflects specific biological and functional lesion features, including perfusion, proliferative potential, metabolic activity and receptor status. Thus, scintimammography represents not only a complementary method, but also a study of choice by applying the proper radioligand in the corresponding clinical background. It is noteworthy that the whole-body absorbed radiation dose for scintimammography is equivalent with that of mammography.

Current innovative scintimammographic findings using 99mTc(V)-DMSA and 99mTcsestamibi add to our understanding of the process of malignant transformation, tumor biology and further propound individualized treatment strategy by improving our ability to depict and possibly quantify the therapeutic target, identify drug remission and resistance factors, measure and predict early response and possibly apply novel therapeutics such as 188Re(V)-DMSA or anti-CGRP peptides.

Hence, the clinical impact of the recent scintimammographic findings could be of great value in terms of preoperative evaluation –on a molecular basis– of the extent and the nature of a suspected breast lesion, i.e. extent of the DCIS component in a mixed DCIS+IDC, lesion multicentricity or lymph node involvement. Furthermore, possible chemoprophylactic treatment with tamoxifen, aromatase inhibitors or anti-CGRP peptides in pre-cancerous lesions, or even prophylactic administration of NSAIDs in florid hyperplastic lesions could be considered in patients with diffuse breast uptake patterns on 99mTc(V)-DMSA. Finally, treatment with 188Re(V)-DMSA in cases of advanced disease with osseous and soft tissue metastatic spread could be considered if these lesions are depicted by breast and whole-body 99mTc(V)-DMSA scintigraphy.

#### **4. References**

74 Imaging of the Breast – Technical Aspects and Clinical Implication

conjunction with MRI skin markers. Positron emission mammography (PEM) is conducted by concurrent acquisition using two planar detectors and a traditional mammographic system and its role in screening or diagnosis still constitutes a field under investigation, although it does sustain the potential capability of detecting smaller and less FDG-avid

Finally, other SPECT or PET assessments using proper tracers may determine selection of treatment for breast cancer patients through: a) quantification of the therapeutic target by receptor imaging, radioimmunoscintigraphy and 99mTc(V)-DMSA-depicted cell proliferation in a CGRP-related neo-angiogenic background, introducing e.g. the ER (tamoxifen and letrozole), HER2 (trastuzumab [Herceptin]), EGFR (gefitinib [Iressa]) and angiogenesis factors (bevacizumab [Avastin]), considering that tumor expression may also be examined *in vitro* on biopsy specimens, b) identification of resistance factors, i.e. anti-HER2 MAbdepicted HER2 expression which evokes resistance to hormone therapy, 99mTc-sestamibidepicted P-glycoprotein expression which denotes resistance to chemotherapy (doxorubicin, taxanes) and c) measurement of early response to treatment, as indicated by reduction of cell

In the era of rapidly developing technology, improvements in mammographic and molecular diagnostics appear promising, keeping up with the progress and corresponding demands raised by therapeutic oncology. The combination of multiple imaging methods (PET/CT, PET/MRI etc.) may concurrently evaluate both morphological and functional parameters and may directly influence the clinical management of patients bearing breast

Scintimammography on its own is a simple, safe, non-invasive and widely available conventional nuclear medicine technique, which provides valuable multilevel information in the clinical management of breast lesions. The method visualizes the lesion site and also reflects specific biological and functional lesion features, including perfusion, proliferative potential, metabolic activity and receptor status. Thus, scintimammography represents not only a complementary method, but also a study of choice by applying the proper radioligand in the corresponding clinical background. It is noteworthy that the whole-body absorbed radiation dose for scintimammography is equivalent with that of mammography. Current innovative scintimammographic findings using 99mTc(V)-DMSA and 99mTcsestamibi add to our understanding of the process of malignant transformation, tumor biology and further propound individualized treatment strategy by improving our ability to depict and possibly quantify the therapeutic target, identify drug remission and resistance factors, measure and predict early response and possibly apply novel therapeutics such as

Hence, the clinical impact of the recent scintimammographic findings could be of great value in terms of preoperative evaluation –on a molecular basis– of the extent and the nature of a suspected breast lesion, i.e. extent of the DCIS component in a mixed DCIS+IDC, lesion multicentricity or lymph node involvement. Furthermore, possible chemoprophylactic treatment with tamoxifen, aromatase inhibitors or anti-CGRP peptides in pre-cancerous lesions, or even prophylactic administration of NSAIDs in florid

tumors than the conventional whole-body PET.

proliferation shown by 99mTc(V)-DMSA or 18F-FLT.

lesions, especially in recurrent or metastatic disease.

188Re(V)-DMSA or anti-CGRP peptides.

**3. Conclusion** 


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**4** 

*USA* 

**Digital Mammography** 

Full-field digital mammography has transformed mammography over the past decade. The technology has reached a level of maturity that has caused an increase in its utilization in hospitals and clinics world-wide. This chapter will discuss the advantages and disadvantages of the technology as compared to screen-film mammography, a discussion on the basic physics of digital mammography and the currently available detector technologies. In addition to the technical aspects, this chapter will explore the clinical trials published to date regarding the technology performed compared to screen-film mammography in both screening and diagnosis, and evaluate the various imaging process algorithms that have been applied to digital mammography. Finally, digital mammography's impact on daily

clinical workflow will be discussed along with future directions for this technology.

Digital mammography has become part of everyday clinical practice across much of the developed world. However, I find it interesting that most of the radiologists in training (residents and fellows) have no concept of what "film" is and was to our practice of mammography. They are used to the digital age of computers, personal electronic devices and electronic social networking through the internet. To the present generation, softcopy display in some form is a way of daily life. To others who have devoted their medical career in screening and in the diagnostic evaluation of women for breast cancer, it has and continues to be a learning and transitional process. In order to understand and fully appreciate the advances in mammography technology, it is important to understand the natural history of breast cancer and the challenges and changes that our specialty has

Cancer of the breast is not a new disease. It has been present since ancient times and was documented by the early Egyptians, Greeks, Babylonians and Chinese (Bland, 1998). If a woman presented to her local "healer/physician" with a lump in her breast, treatment may have stemmed from charms and chants to applied ointments or possibly intervention with a knife and hot irons for cauterization. For women, treatment for breast cancer was similar for

It was not until 1913, when Albert Salomon, a German surgeon, evaluated 3,000 mastectomy specimens in a radiology-histological study on comparing the x-ray findings with microscopic pathology that it became evident to evaluate radiography technology for breast cancer detection. In the 1920's and 30's, several attempts to implement radiography for the diagnosis of breast abnormalities were done by O. Kleinschmit, W. Vogel, J. Goyanes, and

**1. Introduction** 

undergone and how it continues to evolve.

centuries and prognosis was generally poor.

Cherie M. Kuzmiak *University of North Carolina* 

