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Dr. Michael Michell: Intervention- Past, Present and Future

In the 19th century and earlier, the diagnosis of breast disease relied solely on clinical findings. Thus many cancers were large at the time of diagnosis with a high frequency of metastatic spread, the treatment was limited to surgery and the prognosis was often poor. The idea of using percutaneous needle sampling, “explorative puncture” began in the first half of the 19t century. Aspiration was principally aimed at assessing the consistency of the tumour or its connections with underlying structure and to drain fluid content.

The first half of the 20th century saw the development of both x-ray imaging of the breast and fine needle cytology for the diagnosis of breast tumours. Cytological diagnosis of breast lesions was used with considerable success particularly in Scandinavia in the 1970s and 1980s.

The increased use of x-ray mammography for diagnosis and in large scale population based screening programmes together with health education campaigns encouraging women to present early with symptoms and signs of breast disease led to the detection of many small cancers and benign breast lesions and the need to develop accurate and reliable diagnostic techniques. Percutaneous core biopsy using both stereotactic and ultrasound guidance was incorporated into routine practice during the 1990s and has had a dramatic impact on improving the diagnostic accuracy for both non-palpable and palpable breast lesions. During the late 1990s vacuum assisted core biopsy was developed and enabled radiologists to carry out more extensive sampling of breast lesions with minimal discomfort and with no significant complication rates. In current modern practice, diagnostic surgery is rarely required for either benign or malignant breast lesions. The combined use of modern imaging and accurate image guided needle biopsy of breast tumours means that prior to treatment information is available about the tumour type, grade, receptor status and nodal status allowing effective planning of treatment and provision of appropriate information to the patient.

The new generation of vacuum biopsy equipment including the Suros device can be used under x-ray, ultrasound or MRI guidance. Larger volumes of tissue can be safely removed with no discomfort and a very short procedure time, This technology is now being successfully used for the routine percutaneous removal of benign tumours such as fibroadenomas and papillomas thus saving patients surgery. Potential future developments include image guided treatment such as laser therapy, thermal ablation, chemoablation, stereotactic radiotherapy and percutaneous excision.