At present, the incidence of breast diseases is high, especially breast cancer has ranked first among gynecological malignant tumors in recent years, which seriously threatens women’s physical and mental health, and its early diagnosis is especially important.
1.Physical examination
It is the first step in the diagnostic work, and the clinical examination by an experienced specialist is even more informative than other examinations such as imaging examination. The physical examination mainly consists of visual examination and palpation. If a specialist pays attention to some minor abnormalities of the breast, such as abnormal nipple overflow, limited glandular thickening of the breast not related to the menstrual cycle, areolar edema, localized skin eczema of the breast, etc., together with careful palpation, early detection and correct diagnosis of breast diseases can be achieved. The first step is to observe the symmetry of both breasts, whether the nipples are sunken or elevated, whether the skin is sunken, and whether there is a “dimple sign” or an “orange peel appearance”. The patient is then placed in a lying position for palpation, and the four quadrants are examined with the fingers in sequence, with the fingers placed flat for palpation. The presence and size of the mass, smoothness of the surface, mobility, texture, and whether it is adherent to the skin and chest wall are determined. Then check the lymph nodes in both axillae.
2.X-ray examination
Mammography began in the 1960s and has been developed to a mature level. It is characterized by high diagnostic accuracy, relatively low cost and easy operation, and some patients can also be punctured for biopsy. It is still recognized as the imaging method of choice for breast disorders. Intramammary masses are more common in breast cancer. The radiographic signs are: irregular shape of the masses with lobulated, stellate or brush-like edges and haptic. Microcalcifications play an important role in the diagnosis of breast cancer. Foreign reports show that up to 50% of breast cancers with calcifications are found on X-ray, including those with and without lumps, and up to 70% of pathological sections. However, mammography has the disadvantages of missing masses near the chest wall, poor contrast of dense breast masses and failure to detect small masses. The advent of high-definition mammography, the use of ultra-microfocal magnification and image display devices and data post-processing has improved the sensitivity and accuracy of diagnosis. The sensitivity, specificity and accuracy of conventional mammography machine and digital mammography machine in diagnosing breast cancer are 82.4%, 87.3%, 80.7%, 84.1%, 81.5% and 86.1%, respectively. Although the improvement of sensitivity, specificity and accuracy of digital mammography for breast cancer diagnosis is not yet significant, it reduces the number of camera positions and exposures and shortens the examination time compared with traditional mammography.
3.Ultrasonic examination
In the past decade, due to the application of high-resolution ultrasound instruments and high-frequency probes, breast ultrasound has developed considerably, and currently ultrasound can detect lesions of 0.5 – 1 cm in size. It provides good imaging data for understanding the site, size, cystic solidity, benign and malignant nature of breast lumps, and the presence of metastasis, which can provide valuable information. The ultrasound diagnostic compliance rate of breast cancer is 83.3%, and the diagnostic compliance rate of benign breast masses is 69.0%. Color flow Doppler can help detect the blood flow in and around the mass, which is helpful in differentiating benign and malignant masses. However, when the lesion is small, especially when it is combined with more obvious other breast diseases, the value of judging benign and malignant tumors is limited.
4.Computed tomography
Computed tomography (CT) of breast disease is similar to mammography, but it has the advantage of showing certain signs, and the high-density resolution of CT and thin cross-sectional scans can detect lesions as small as 0.2 cm. Therefore, CT is becoming more and more important in the diagnosis of breast diseases, especially in the diagnosis of breast cancer. CT examination can accurately show the shape, size and location of the primary lesion of breast cancer, as well as the degree of infiltration of the lump into the skin and chest wall, and the presence of enlarged lymph nodes in the axilla, parasternal and mediastinal areas, which is of great value in the preoperative staging or postoperative evaluation of breast cancer. Since the iodine uptake capacity of breast cancer tissue is significantly higher than that of normal breast tissue, contrast-enhanced CT scan can help to detect occult breast cancer and help to distinguish its benign and malignant nature according to the increase of CT value in the lesion area. The CT value is usually increased to help differentiate benign from malignant. In general, an increase in CT value of 25 – 45 HU or higher, and an increase in CT value of at least 46 HU, is highly suspicious of malignancy. However, some abscesses, fibroadenomas, and reactive lymph node hyperplasia have an increase in CT value greater than 44 HU after enhancement. in addition, in the high prolactin and high progesterone state, the iodine uptake capacity of the breast tissue increases, so enhanced scans cannot be performed within 1 week before the end of menstruation to identify a few lesions. It is worth mentioning that there are false positives, i.e. a few benign tumors may also have more significant enhancement. At the same time, CT scan is expensive; its spatial resolution is low, and it is not easy to show microcalcifications, which is an important sign to distinguish benign and malignant breast tumors; CT scan has a large amount of radiation, and it is not preferred due to the sensitivity of young women to X-rays and the relatively low incidence of malignant breast lesions.
5.Magnetic resonance imaging examination
The clinical application of magnetic resonance imaging (MRI) is a revolution in medical imaging, and is a new tomographic imaging method after CT, ultrasound and other imaging means. Due to the different content of organic matter such as water and fat in different tissues such as bone, cartilage, soft tissue and other organs in the human body, the distribution density of protons in normal and diseased environments in the same tissue is different, and there are obvious differences in their relaxation times. Therefore it is of medical importance to study the state of hydrogen atom distribution in the human body and to display it in two-dimensional and three-dimensional high-resolution images of tissues. In most cases, breast cancer has low signal in T1-weighted images, and the signal intensity of the tumor in T2-weighted images depends on the internal tissue composition of the tumor, which is often heterogeneous, with a mixture of high and low signal, while a few cystic lesions have higher signal in T2-weighted images, which can be distinguished from breast cancer. In general, benign lesions are uniformly enhanced with clear borders when enhanced, while breast cancer mostly appears to be heterogeneously enhanced, especially with irregular edges and more pronounced than the center. However, MRI is not yet a routine screening method for breast diseases because of its long time, high cost and poor display of calcification.
6.Milk duct endoscopy
The milk ducts can be divided into internal nipple milk ducts, main milk ducts, branch milk ducts, and terminal milk ducts. Generally, the main milk duct starts to branch after 1cm – 2cm, and most of the milk ducts are 2 branches, but there are also multiple branches with complex directions. Normal milk ducts have smooth walls, slightly pinkish, clear capillaries and smooth lumen. The endoscope is inserted through the breast hole of the nipple overflow, and the image is collected through the cold light source optical system, which can observe the range from 5–6cm from the opening of the nipple duct to the longest 8cm, and then contrast with the clinical and pathology to find the cause of the nipple overflow and provide the basis for reasonable surgery. Breast duct endoscopy can be inserted to the 4th level breast duct, which can diagnose breast cancer at an early stage. Interventional treatment can be performed for some papillomas and chronic inflammation of ducts. Breast duct endoscopy has the advantages of small trauma and high diagnosis rate.
7.Biopsy
(1) Directional breast aspiration biopsy
It is a new technique developed in the 1990s, which is the application of biopsy gun and biopsy needle (14G or 16G) for directional puncture under the stereo of digital imaging technology. Its accuracy is high, with an error of less than 1 mm. A guide wire can also be applied for retention and positioning, which helps in the accurate removal of tiny lesions.
(2) Fine needle aspiration examination
It is currently listed as a routine examination method for breast lumps. In particular, fine-needle aspiration cytology examination is easy, safe and accurate. The accuracy rate is over 80% as reported in domestic and foreign cases.
(3) Minimally invasive rotational mastectomy
The Mammotome is a computer-controlled, vacuum-assisted, high-speed rotary breast therapeutic diagnostic device for minimally invasive treatment or biopsy of breast lumps (tumors) under ultrasound stereotactic guidance. In terms of diagnosis, it greatly improves the diagnostic accuracy of early breast cancer because it is able to perform minimally invasive excisional treatment of the breast under imaging guidance, thus enabling the removal of breast abnormalities that are clinically inaccessible or difficult to remove surgically. In terms of treatment, not only the external scar is small but also the internal scar is small after removal of breast lumps with McMurdo, which has little impact on the diagnosis of recurrence of breast lumps.
In conclusion, there are many other diagnostic tools available for breast diseases, such as: nuclear scan, near infrared scan, etc. Histological examination is the gold standard. The key lies in how to use these methods to improve their early diagnosis rate, taking economy and simplicity as the premise, accuracy and non-invasiveness as the goal, rational application, optimal selection, avoiding unnecessary biopsies, careful analysis of various imaging data, and combining with puncture when necessary can reduce unnecessary surgery.