Aristida Colan-Georges - Atlas of Full Breast Ultrasonography

Springer International Publishing Switzerland 2016

Aristida Colan-Georges 1

(1)

Keywords

The only method of diagnosis of the breast ductal pathology used in the past and still recommended is galactography/ductography of the breast, considered as an underused procedure that often helps define the cause of unilateral, single-pore, spontaneous nipple discharge []. It is recommended to search papilloma or carcinomas that can be responsible for nipple discharge and to help guide accurate surgical intervention. Galactography is useful because it refers to ducts, but it has some inconvenient facts:

With regards to performance, galactography/ductography is as limited for the breast diagnosis as the urography for the urinary system, or barium meal for the upper digestive tube.

The breast pathology was redefined by T. Tot and L. Tabar, which developed the theory of the sick lobe [] and demonstrated by numerous pathologists. The explanation of the origin of the sick lobe in the embryonic life is nevertheless unbelievable, because there is not any small embryonic or fetal model of the breast with little lobes, similar to the embryonic cartilaginous model of the bones, for example, or an embryonic branching tracheal-bronchial tree; indeed, the newborn has a not divided mammary bud, and the branching process during thelarche is progressive: initially the homogeneous bud becomes heterogeneous, and then the main ducts appear at the periphery and are surrounded by the simultaneously growing glandular stroma; in the next stage, the secondary segmental ducts develop and finally appear in the lobules, with the terminal ductules and the acini. If the moment of the origin of the sick lobe seems to be thelarche, it is possible to be determined by the amount of hormonal and neural receptors or by a mutation of the responsible genes during the cellular multiplication. The sick lobe could be determined even later, related to pregnancy, dishormonal pathology, substitution hormonal therapy, or other unknown factors. We find this explanation concordant with the statistically risk factors for breast malignancies such as precocious thelarche, late pregnancy, birth control pills, or postmenopausal substitution therapy.

The greatest value of the sick lobe theory consists in removing the concept of breast cancer as a lump; thus, the radical excision of the whole sick lobe should theoretically represent the best conservative curative intervention. This is sustained by the fact the mammary lobes may overlap, but there are not directly communications between their ductal-lobular trees, so the cancer is spreading initially via the lobar tree inside the same lobe before to extend to the surrounding lobes or other tissues. For achieving this target, we need a technique of imaging able to visualize the anatomy of the breast lobe, and the only technique that is noninvasive, in real time, operator independent, and accessible for all is the ductal echography (DE) imagined by M. Teboul and his collaborators and further developed by promoters such as D. Amy.

In 1995, the first Atlas of Ultrasound and Ductal Echography of the Breast, by Michel Teboul and Michael Halliwell, was published []. This was a best seller, the ductal approach became more familiar, and many specialists from Europe, Japan, and the USA became adepts of this method.

M. Teboul sustained his method in Congresses and Conferences such as The 13th International Congress on the Ultrasonic Examination of the Breast, April 68, 2003 []. It seems the American College of Radiologists was more conservator, because it is easier to learn a new technique than to change an old, well-known technique with another newer, even better one. This is an observation of one of the most active promoters of DE, Dominique Amy, who worked formerly in DE at the Francophone Center of Formation in the USA, of Aix-en-Provence, coordinated by the University of Nimes, France.

However, we can read many publications about breast US that are referring of the radial and antiradial scans in classical breast US, but used as complementary targeted scans, after the classical longitudinal and transversal scans; this approach has as goal to find the lesion , while DE intends to analyze the breast anatomy , because only searching the whole forest, we are able to localize, recognize and characterize all its trees as normal elements, and thus we become able to detect all the abnormal changes. By using DE, it proves a feasible diagnostic procedure of the subcentimeter breast carcinoma, as presented by Amy at the 13th International Congress on the Ultrasonic Examination of the Breast: Thanks to its systematic anatomical analysis its a perfectly reproducible technique and moreover it became interpretable by everyone .

In the studies of Amy, 2003 [], with 1400 files analyzed, focused on the lesions of 45 mm to 10 mm, DE was evaluated in comparison with mammography. There were classified three categories of cases:

Contrary to certain publications, this author never met a mammographically visible lesion which was not detected by US. Moreover, the analysis of the multicentric cancers confirmed and raised the literature data that affirms more than 43% of multiple lesions, this percentage increasing with the new equipment to be above 55%. The very significant number of multifocal cancer (more than 1 out 2), of infracentimetric dimensions, certainly will involve surgical and chemotherapeutic treatment adaptations.

The DE is not a different technique of examination, but an US with another method of acquisition and interpreting the images, based on the anatomy and sustained by the most recent theories of breast pathology. There are some models of the primary site and the spreading ways of ductal and lobular cancers [], which offered a three-dimensional network showing the ductal-lobular system, where the papilloma develops in the main ducts, while the cancers arise in the periphery, in the terminal ductal-lobular specific units (TDLUs). This model explains the branching ductal-lobular system, where several duct systems overlap one another in the same radius of the breast, and may mimic a multilobar simultaneous pathology.