Non-Palpable Breast Lesions- Diagnosis and Treatment

study the the of patients with non-palpable breast Material and Methods: The authors present the diagnostic and the results of the treatment of patients with non-palpable breast lesions. They were hospitalized at Department of Surgery in Nitra since until 2017 and we used SNOLL method or wire guided excision under ultrasound control or digital stereotaxic. Results: Since 2014 until 2017 there were 122 patients diagnosed with non-palpable breast lesions at Department of Surgery of our hospital. 76 (62,3%) of these patients were diagnosed with carcinoma. Wire Guided Localization was performed in 99 (81,1%) patients, sentinel node was found in 41 (33,6%) patients, using of the SNOLL method. From all of the patients the reoperation was conducted in 4 cases (3,3%) for close or positive margin status and in 3 cases (2,5%) for false negative perioperative sentinel biopsy. Conclusion: The technique combining 99mTc-MAA (albumin-macro aggregate marked by 99Technecium) and nanocoloid is reliable localization method for nonpalpable lesions and sentinel nodes. SNOLL is practical and oncological safe technique of excision subclinical lesion in combination with sentinel biopsy. Situ; Lobular Carcinoma in Situ; Pleomorphic Carcinoma Carcinoma Sentinel Nanometre; ml: Millilitre; Nanomolar; MBq- Megabecquerels; Cubic Centimetre Non-Palpable Breast

formation of cancer, but the extent of risk is necessary to connect with pre-existing individual risk factors of every patient [1,2]. At the last decades, the incidence of non-palpable lesions of breast is increasing, because of mammography and another exact imaging methods [3][4][5]. As a result of this fact, there is the decrease of number of neoplasions and reduction of their spreading into the axillar lymphatic nodes [6,7]. Using of mammographic screening improvement of its sensitivity increase capture ratio of subclinical lesions. Ratio of non-palpable lesions in the time of diagnosis is 25-30% in countries with function screening programme [7].
With increasing diagnostic of non-palpable lesions at the early stadium, correct and complex treatment process is more important.
Successful intraoperative localization of non-palpable lesion is necessary for surgeons because of complete excision during the one intervention without extensive excision of healthy tissue.

Histopathological Types of Carcinomas in Situ
There are two types of preinvasive carcinomas, which are different of their features and clinical meaning.   of abnormal cell growth that increases a person's risk of developing invasive breast cancer later on in life-both form ductal and lobular. Higher risk of incidence is not only in the place of LCIS but in every area of both breasts. Treatment strategy is not only operative, but also in primary or secondary prevention. Some findings report, that subgroup with atypical nucleuses pleomorphic type (PLCIS), could be straight cancer precursor [8].
Character of growing and spreading is important for treatment and prognosis of DCIS. Faverly´s study of mastectomy preparations shows that DCIS is in 90% spreading single centre (lesion of one quadrant / distance between two focuses >4cm) but can grow also multifaceted (lesions in more separated focus in one quadrant) and discontinued-especially low-grade lesions. Multicentre growth was detected in one case of 60, in 30 cases (50%) was reported discontinued growth. These lesions formed more than 70% low grade carcinomas. Opposite of this, 90% of HG-DCIS growth typical continues [9,10]. Reliable prognostic and predictive markers of DCIS are missing. That's why the information's on molecular-genetic level and histopathological parameters are important prognostic meaning of regional relapse. For the management of DCIS grading of lesions is also very important. Precisely histological examining is necessary not only for determination of diagnosis, but also for treatment [11,12].  Advantage of mammography is ability to find out microcalcifications, which follow carcinoma in 30%. With systematic mammography it is possible to decrease mortality ( Figure 3) [13]. Today the core-cut biopsy is gold standard in preoperative diagnostics of non-palpable lesions of breast. During the core-cut biopsy roller of tissue is taken without damage of architect of tissue. It is using special needle, which is attached to mechanic target unit. Suitable calibre of needle is 14G and 16G. By biopsy of clear focus, it is necessary to take 3-4 samples, but by biopsy of unclear focus it is important to take 5-10 samples. [8] Today, there are many methods of preoperative localization of breast lesions. They have to fulfil some basic conditions. Golden standard is localization of nonpalpable lesion with wire (WGL-wire guided localization) (Figures 4 & 5). This technique was introduced by Dodd in 1965. Another modification was technical or shape character of wire (Frank, Homer, Kopans) [14]. By European guidelines for quality of screening and diagnostic of breast cancer the peak of wire must be in maximal 10mm distance from the centre of lesions in minimal of 90% of patients.

Diagnostics and Treatment
Excision must be successful more than in 90% of patients. Other conditions are minimum risk of dislocation during localization and surgery and easy identification during surgery.     In 1998 in Europe oncological institute, Luini introduced alternative method of localization of nonpalpable lesion with the name ROLL (radioguided occult lesion localization) [14]. Principle of this technique is based on localization of nonpalpable lesion by radiopharmaceutical, which is fixed on carrier with high molecular weight. Localization is conducted by ultrasonographical navigation, digital stereotaxy or magnetic resonance imaging. By patients with nonpalpable lesion of breast evaluation of axillar lymphatic node is one of the most important factors, so the biopsy of sentinel node is very necessary [15][16][17][18][19]. Combination of ROLL with biopsy of sentinel node is called SNOLL (sentinel occult lesion localization) and it was introduced by deCicco in 2002 [20]. f) Diminish of operations wound and it is less traumatic [23,24].
In our clinic, we proceed according to this two-days protocol: MBq. Under the USG control, respectively under digital stereotaxy.
Marking of lesions were done by specialists from Izotopcentrum.
94% of lesions were marked in distance from 10mm from the centre of lesion. Nonpalpable lesion and sentinel node were detected by gamma probe during the surgery. Operating preparation was subjected RTG examination for the evidence of lesion and wide of healthy resection border. (Figure 8). In case of the fact, that the safety rim was under 10mm, the perioperative resection was done.
Reoperation was conducted only if the safety rim was less than 3mm in correlation of histopathological examination.

Results
In Surgery department of Nitra´s hospital we operated from    Table   2). It is important to do dispensary of these patients in specialized outpatients' department. We found CIS by 14.8% patients in our group. CIS together with T1 stadium of carcinoma presented 46,05% from all malign cases (76=100%).  Table 2: An overview of benign lesion types of our patients.

Papilomatosis 6
Myofibroblastoma 5 Pseudoangiomatsis stromal hyperplasia 4 Adenomyoepitelioma 3 Study was focused for verification of sentinel node and oncology radicality with using SNOLL [25]. One of the benefits of Sienna+ is that this substance is not radioactive. Therefore, it can be used in outpatients' department or in surgery department without connection with nuclear medicine.

Discussion
There is no need of protection against radioactivity or work with radioactive waste. We can detect substance percutaneous and nodes are brown coloured, what helps by perioperative identification. Indicator in lymphatic node does not underlie quick degradation and is not quickly transporting from node so it is possible to application it with long period before surgery. It can be potentially used by detection of lymphatic nodes by another relevant diagnosis [27]. By concussions of overview studies, radiopharmacological navigated localization obtained many supporters. The reasons are a smaller number of reoperations and better cosmetic effect. Popularity of this method is enhanced with its combination of biopsy of sentinel node. Incidence of CIS dos does not reach 2% in long time period in Slovakia, in screening programmes its incidence raised [28]. Identification of nonpalpable lesions and microcalcifications before surgery is very important by breast carcinoma because early identification requires minimal surgery and minimal multimodal therapy. We can expect minimal incidence of local relapses, higher survival of patients and decrease of mortality. Good cooperation between radiologist, surgeon a pathologist is the guarantee of quality of diagnostic and therapy.
We expect more significant effect in survival of patients with nonpalpable lesions of mammal gland (CIS, tumor in T1a) by using MRI with contrast substance and follow-up mark by guide wire before surgery. SNOLL is very practical modification of ROLL method in practise. With combination of sentinel node detection, it is very useful and oncological safety technique of excision of subclinical lesion [31,32].

Conclusion
In pursuance of our study´s results we can state that detection of sentinel node by using 99mTc-MAA presents reliable method for localization of nonpalpable lesions and sentinel node. SNOLL with combination of sentinel node detection is practical and oncological safety technique of excision of subclinical lesion. Alternative method of localization of sentinel node is method Senti-Mag. Benefit of this method is that substance Sienna+ is not radioactive. Examination of asymptomatic women increases number of nonpalpable malign lesions of breast. Identification of nonpalpable lesion with guide wire still golden standard for its verification in many workplaces in Europe.