Ultrasound-guided breastinterventional procedures
Salima HIBAT ; C. Balleyguier
Breast interventional procedure
• Considerable progress in recent years
• Precise and accurate diagnosis, Bi RADS 4 & 5
• Bi RADS 3 • High risk patients
• Before pregnancy
• Follow-up impossible
• Anxiety
• By Bi RADS 6 Lesion
Quality criteria and results
• Rates of false negatives and underestimates must be evaluated and limited.
• Percentages recommended by EUSOBI : • false negative for cancer on percutaneous biopsy: < 2%
(acceptable < 5%);• diagnosis of cancer in situ on biopsy, classified as invasive after
surgery: < 5% (acceptable < 15%);• diagnosis of border lesions on biopsy, classed as invasive
cancer after surgery: < 10% (acceptable < 25%). • Percutaneous biopsies :
• help limit the number of surgical procedures by increasing the positive predictive value of surgery (which was lower than 50% before the use of such biopsies)
• lowering the number of revisions for insuffi- cient margins
Various procedures
• Ultrasound-guides fine needle biopsies
• Micro biopsy :• Ultrasound guidance• Stereotactic guidance
• Vacuum biopsy :• Stereotactic guidance• Ultrasound guidance• Tomosynthese guidance• MRI guidance
• One-pass-en-bloc excision :
• Intact ® System
• Pre operative targeting• Stereotactic guidance• Ultrasound guidance• Tomosynthese guidance• MRI guidance
Specific initial training / regular practice
• at least 20 procedures per type of guidance, with histological verification and checking by a specialist, before being able to work alone;
• to maintain a sufficient degree of competence subsequently, 25 procedures per year are considered to be necessary
Fine needle biopsy
Fine needle biopsy
• Palpable mass
• Ultrasound-guided:• Parallel
• Perpendicular
• Rapid, inexpensive
• Experience +++
• Capillary technique / Aspiration technique
FNB - Indications
• Cystic lesions: • Typical cyst + pain: aspiration and evacuation
• Atypical cyst
• Masses :• Palpable
• Non palpable :
• Atypical lesion
• Bi RADS 3 lesion by women discovered > 35 yrs
• Lymph nodes
Prerequisites
• Reviewing the case
• Report :• Side
• Quadrant
• Distance nipple
• Skin distance
FNB – Techniques
• Optimal position
• Fine needle: 18 G to 27G.
• +/- syringe
• Local desinfection
• Sterile gloves / ultrasound protection
• No local anesthetic
• No gel : water or antiseptic
FNB - Kalinox
1/ FNB- Palpable mass
Capillary technique
Aspiration technique
2/ Ultrasound-guided FNB
• 2 Techniques for approaching the lesion
• Parallel
• Perpendicular
a) Parallel technique
• Needle approaches the skin parallel to the long axis of the probe 10-20mm
• Advantages : • Needle visible trough its course
• Less risks to go to deep
• Inconvenients : • Longer way
Grumbach 2002
• Perpendicular to the probe
• Advantage :• Shorter way
• Inconvenients : • Only the extremity is visible as a very attenuating
echogenic spot ( tip echo)
• Major risk of complications
b) Perpendicular technique
Grumbach 2002
• Aspiration in a syringe
• Bacteriological analysis
• Onto a slide
3/ FNB +/- aspirationCystic lesion
Grumbach 2002
• Verify needle position
• Capillarity +/- aspiration
• Back and forth movements rotating about it own axis
• 2 FNB per mass
• By bloody aspiration , repeat
4/ US-guided FNBMasses
N. Poté, Beaujon
Grumbach 2002
FIBROADENOMA
DCIS
5/ FNB Lymph node, perpendicular approach
5/ FNB : Parallel approach
Jalaguier-Coudray JFR 2010
Ultrasound-guided core needle biopsy
Indications
• Histologically confirmation of malignancy :• Before neo adjuvant chemotherapy +++
• Multifocal ?
• Bilateral ?
• Grade, Hormon receptors
• Histologically confirmation of benignity:• To avoid unnecessary surgery
Advantages
• High sensibility et specificity (97 %, 95 %)
• Determinate the initial surgical or medical treatment
• Protocol for detecting the sentinel lymph nodes or lymph nodes can be set up
Indications
• By non conclusive FNB
• Recommandations ANAES (2003) : • At least 80 % diagnoses before the surgery
• Better surgery planification
• No particular precautions regarding hemostasis :• But careful with anticoagulants
• Sterile bandage with compression
• Material : Needle 16 G (1,3mm) ou 14 G (1,6mm)
• Automatic guillotine type system• 15 mm to 25 mm
• 3 - 5 samples / lesion
Technique
Apesteguia, Insight Imaging 2011
Apesteguia, Insight Imaging 2011
N. Poté, Beaujon
Prerequisites
• Reviewing the case
• Report :• Side
• Quadrant
• Distance nipple
• Skin distance
• Local desinfection, asepsis
• Local anesthetic (10ml Lidocaine +/- 1,5 ml bicarbonate)
• Skin incision at the entry with a scalpel
• Needle : contact with the lesion
• Image documentation before and after deployement
• Compression after deployement
• Adhesive band ou Steristrips®
Technique
Tipps
• Choose the best positioning and introduction point
• Place the lesion at the medial / lateral third of the image
• Skin incision not to close from transducer
• Skin marking
• Never move at the same time needle and transducer
N. Poté, Beaujon
Grumbach 2002
Superficial lesion
Left approach
• Entry site further from transducer
• Shaft parallel to chestwall : pneumothorax
• +/- small sliding , sweeping motions to “catch” the lesion
• +/- anesthetic injection to push the lesion from chestwall
Deep lesion
Escolano 1999
Pre pectoral lesion
Jalaguier-Coudray JFR 2010
Same axe needle and transducer
Never move the both at the same time
Co-axial
Jalaguier-Coudray JFR 2010
• Dilemma between• Lowest rate of false negatives
• Leave some lesion for the pre operative targeting
• Fishman, Radiology 2003; 226: 779-782• False negative30% (1sample), 8% (2 sample), 4% (3 sample),
0% (4 sample)
Number of samples
Images C. Vermersch
Sample
• Collection tube with formaldehyde solution
Sampling
Lymph nodes
FNB +++
Hiroyuki, radiographics 2007
Semi automatic core needle preferred
Hiroyuki, radiographics 2007
Vessels +++
Hiroyuki, radiographics 2007
Hiroyuki, radiographics 2007
INTACT ® system
• Large core biopsy and tumor destruction
• Ultrasound or mammography guided
• One-pass-en-bloc excision
INTACT ® System
Do we have to biopsy BI RADS 3 lesions?
• No, normally :• Cancer by BI RADS 3 < 2 %
• Eventually if :• Follow up difficult
• BI RADS 3 and pregnancy
• BI RADS 3 et BI RADS 6 lesion
• Familiary history
• Anxiety
Pre operative targeting
M.H Dilhuidy Bergonié Bordeaux
Surgical position- arm 90 °
Skin marking
Complications
• FNB : less invasive• Pneumothorax
• Core needle biopsy :• Hematom
• Pneumothorax
• Infection
• Allergy
7 mm
Perpendicular approach
Perpendicular approach
5 mm
Perpendicular approach
Perpendicular approach
Pre targeting After targeting
Perpendicular approach
• Perpendicular approach
• Skinny patient
• Deep lesion
Conclusion
• FNB : fast, inexpensive
• Cystic lesions
• Not sufficien cells for analysis
Conclusion
• Core needle biopsy : more invasive but less false negative
• Complications : pneumothorax +++
• Training necessary