J-Y Séror

Centre Duroc Paris 6

www.imagerieduroc.com

Interventional

Senology

State of the art

« Israeli-French Breast Cancer Update »Prevention, Detection and Treatment, a Multidisciplinary approach

Interventional Senology

Diagnostic and therapeutic

State of art - Limits - Complications

Nearly 1 woman out of 6 will need a breast biopsy

during her life.

The medical imaging techniques improvement will

contribute to increase the number of biopsies.

Interventional senology : State of the art

• BI-RADS 5 VPP > 95%

• BI-RADS 4 VPP > 3% - 90%

• BI-RADS 2 : Non Indication

• BIRADS 3 VPP < 3% : short-term follow-up was a reasonable and

likely management alternative to excisional biopsy for non palpable lesions

detected with screening mammography that could be considered probably

benign by virtue of their imaging characteristics.

Diagnostic Biopsy : Indications & Objectives

The pre-therapeutic knowledge of the histologicaldiagnosis at least 60% of the infra-clinical lesions.

Nodules , MicrocalcificationsSurdensities +/- spicular

Which weapons ?

FNA (Fine Needle Aspiration Biopsy)

CB (Core Biopsy)

VAB (Vacuum Aspiration biopsy)

Stereotaxy , Ultrasound ,MRI …

Fine Needle Aspiration Biopsy (cytology)?

Cysts evacuation (painful, disturbing)

A very well tolerated and reliable technique, without anesthesia, not expensive,

well adapted for screening experimented cytologist

Axillary nodules

Se 0.927 (95% [CI]) 0.921 to 0.933)

Sp 0.948 (95% [CI] ) 0.943 to 0.952)Ying-Hua Yu & Al BMC Cancer 201246 studies

Masses with a benign aspect (BIRADS 3)

Needles from 22 to 27 G, by capillarity , without local anesthesia

Indications

The cytology principle : • no infiltrative diagnosis,• lobular and Ductal differentiation not always possible

Limits and contre indication

Insufficient material : under estimation 10 - 27%

Dependant operator, dependant reader

Microcalcifications: 50% of the samples are not sufficient

Non-diagnostic procedure need to Complete the diagnosis with a Core biospy

Fine Needle Aspiration Biopsy (cytology)?

Cytology with atypias :Medularry carcinoma

Size 12 mm RH- Cer2 B2+

Benign cytologyFibroadenoma

BIRADS 3,BIRADS 4 An alternative to the short-term follow up:

Hypo-echogenic pre prothetic noduleFNAB under ultrasound.

Visibility of the hyper echogenic needle spot in the nodule : Fibroadenoma

Exploration of the axillary lymph nodes :

Which ganglions do you have to puncture?

Houssami N & Al Annals of Surgery 2011 Méta-analyse 31 studies N=6166

17,6% avoid the Sentinel Lymph Nodes and orientation towards the Axillary Lymph Nodes DissectionNO

Sampling if at least 1 malignancy suspicion criterion of a ganglion

1. Global or localized cortex thickening2. Rounded shape3. Hilum partial or total disappearance

Sampling to be made at the same time as the

breast biopsy

6 mm

Under ultrasound : VPP 98 % Specificity sensibility : 92 to 98%

False negatives : 0 – 4% 7 % of Re biopsy (operator dependant)

Core Biopsy 14 Gauge (16 G Se 92%)

6 mm

Number of samples ( 2-3 minimum) (70% for 1 sample vs 95% for 3)

Type [lobular vsDuctal (DCIS or IDC) ], Grade (SBR), Proliferation index

Receptors (RH), Her2 [ Reliability +++ IHC study for RH and HER2

fixation 8h min and 48h max on biopsies (GEFPICS 2010)

Benign / Malignant diagnosis

Breast Lesions staging (multifocal , multicentric, bilateral)

Prognostics factors, tumoral profile

Core Needle biopsy : confirmation BENIGN / MALIGNANT

Limits and difficulties of Core Needle Biopsies under ultrasound

Small size lesions ?

3 -4 mm ? Visibility

Small size lesions, difficult to localize due to the

surrounding tissue lack of contrast

Deep lesions

Interpretation

•Radio clinical discrepancy

•Histological complexity of the lesions +++ (Important fibrosis, inflammatory reactions)

Risk of under estimation

«volume tissue removal for DIAGNOSTIC »

Limits

Heywang –Kobrunner S , The breast Journal 2009

re-biopsy rate 7% and 23 % malign lesions

Limits and difficulties of Core Biopsies under ultrasound

Place clip if any question of difficulty identifying lesion in future

–Neoadjuvant therapy planned: Mass may shrink or resolve

–Subtle finding

–Facilitate correlation with mammography

–Post-clip CC and 90° lateral mammograms

Limits and difficulties of Core Biopsies under ultrasound

• Most feared complication(s)

–pneumothorax (< 0.1%) –large delayed hematoma (< 1%)

• Other complications

–local pain (common, mild, transient) –acute significant hematoma (< 1%)

• Occurs in < 1% of cases

–infection (rare)

Core Needles Biopsies : complications

Philpotts LE & Al , Am J Roentgenol. 2003

Diagnostic BiopsyVacuum aspiration biopsy or core needle biopsy under ultrasound ?

14 G Automatic Biopsy Gun (n =181) 11 G Mammotome ( n= 100)

Similar results : Missed cancers, Complications, re biopsy

Percutaneous excisionsSurgical excisional Biopsy : GOLD STANDARD

DIAGNOSTIC comparable surgerySe 94% to 100% Sp 96% to 98%

MORBIDITYImmediate Complications < 2%

LOWER ECONOMIC COSTS: 45% à 82% ++

Percutaneous ExcisionVacuum aspiration Biopsy under ultrasound guidance

Macrobiopsy with aspiration under ultrasound 7 Gauge

OUT-PATIENT PROCEDURE / UNDER LOCAL ANAESTHESIA

Fibroadenomas(Careful ,pain is not due to the FA)

BI-RADS 3 nodulesRemoval : Dg and TTT

Size < 3cm

Needles 7G – 11 G

Palpables or not palpables

Indications and results Percutaneous Excision by VAB under ultrasound

Parker 2001, Fine 2002, Johnson 2002, Baez 2003, Sperber, 2003, March, 2003, Alonso, 2004, Povoski, 2007, He, 2008, Grady, 2008, Tagaya, 2008, Gulf, 2008, Grady, 2008, Thurley, 2009, Yom, 2009, Kim, 2010, Slanetz, 2010, Wang, 2009-11, Lou 2011, Wang, 2012

Young women with multiples nodes

Diagnosis before the exeresis

Diagnosis or Treatment : complete immediate excision > 73%

Percutaneous Excision : Limits of Vacuum biopsies under ultrasound ?

Papillary lesions?? : under estimation 5 %

Isolated benign papilloma : isolated

lesion, peri-areolar topography in pre or perimenopause +++

Youk JH & Al Radiology. 2011

After the node complete exeresis

The under-estimation risk

becomes very low even equal to zero

Grady I & Al J Am Coll Surg. 2005

Complex Fibro-adenomas

BI-RADS 4 & 5 nodesNode size> 3cm

Technically not feasable

• Breast size• Localization

Fibro-adenomas ? Quick growth

Non Elective Indications of Removal by Vacuum aspiration biopsy under ultrasoundParker 2001, Fine 2002, Johnson 2002, Baez 2003, Sperber, 2003, March, 2003, Alonso, 2004, Povoski, 2007, He, 2008, Grady, 2008, Tagaya, 2008, Gulf, 2008, Grady, 2008, Thurley, 2009, Yom, 2009, Kim, 2010, Slanetz, 2010, Wang, 2009-11, Lou 2011, Wang, 2012

Histology with atypicals

Vacum Aspiratiuon Biopsy under ultrasound : Follow-up and complications

Hematoma: 3 to 10% Skin damage : 0,6%

Residual lesion up to 31%

But decrease after 2 years

• Incidence of Scar : 2 – 4,3%Follow up : difference residual lesion and scarring (2years)

• Recurrence 15% to 59 months ( Grady 2008 )

6 month 1 year 2 year

Microcalcifications +++ 97% of the indications for macrobiopsy under stereotaxy

Avoided surgery 53,1 %

Useful surgery > 70 %

Seror JY et Gynecol Obstet Fertil. 2000

Dg Precision = 98.6 %

Microcalcifications Biopsy : V.A.B.BiopsyWhat benefits for the patient ?

Number of samples : 12 with 11 G 6 -8 with 7 – 8 GaugeGuidelines from the European Society of Breast Imaging Eur Radiol , 2007

Feasibility : The team experience

Limits

No complication 83.3 %

Hematoma : 7.4%

No disturbing scar on the follow-up mammographies (6-12 months)

Post biopsy pain 24 h (7%)

Slight Cervical pain

Complications after Vacuum biopsy

Dressing allergy

The significant, hemorrhagic or infectious complications rate after biopsy is very low, inferior to 5 %.

Post VAB ++ 3,9 % of complications per-procedure and 3,6 % for post-procedure

• The accent should be put on stopping the platelet-inhibiting drugs 10 days before the interventional procedure.

• Taking over of the heparin in case of anti-coagulant treatment

« Decrease of the under estimation by increasing the number of samples, and bigger hematoma risk

Complications after Vacuum biopsy

Interest of the 7 or 8 Gauge needle ( vs 10 or 11 G)

Post biopsie j 8

HISTO : MFK

Bénin , Significatif et concordant

ACR4

Results management : Radio histological concordance +++

Benign histology : Micro cysts with secretory metaplasia

Benign Significant Concordant result BIRADS 2

Benign Non significant or Non concordant result Mutdisciplinarydecision(Short-term follow-up (6 months) , New Biopsy ( 5%) , surgical excisional biopsy)

BIRADS 4

ADH prevalence ADH underestimation

Year n % N %

Liberman 1998 12/112 11 1/10 10

Meyer 1999 - 1/9 11

Burak 2000 45/851 5 6/46 13

Darling 2000 - 16/86 19

Andrales 2000 90/1081 8 9/62 15

Philpons 2000 - 6/26 23

Cangiarella 2001 9/160 6 2/8 25

Jackman 2002 131/1964 7 22/104 21

Pandelidis 2003 37/134 3 5/37 14

Wincherster 2003 77/1750 4 11/65 17

Under estimation

(10 – 25%)

Hyperplasia with

Atypias

Surgical biopsy recommended

* Lobularneoplasias

* Papillarylesions

* Radial scars

Why the fact of performing a VABB has an impact on surgery :

healthy margins and operating time?

Liberman L, et al. AJR. 2001

139 women

calcifications:

BIRADS 4 and 5

Women with a diagnosed cancer

% of a one-time surgery

Surgical biopsy (n=50)16.2%

(6/37)

Biopsy under stereotaxy

(n = 89 )

71.4%(55/77)

p = 0.0000001

% healthy margins Immediatesurgical biopsy

Pre-operatory biopsy

Liberman 1997 63 % 92 %

Jackman 1996 53 % 91 %

Clip migration after a macrobiopsy :13 to 21% of the cases.

In case of clip migration, the exeresis rate in positive margin can reach 50%

Brenner RJ & Al Am J Roentgenol 2001;

Rosen EL & Al Radiology 2001

Burbank F & Al Radiology 1997

Kass R & Al Am J Surg. 2002

« Clip migration »

Limits

6 cm6 cm

Microbiopsy or macrobiopsy with aspiration The limits of biopsies by fragmentation : MONOBLOC EXCISION

BLES (Breast Lesion Excision System

Intact® BLES System ® Lesion Capture (RF)

BLES (Breast Lesion excision system) Intact System under ultrasound

Immediate intraoperative or post-biopsy complications (8.2%) of the procedures. The most common immediate complication was hemorrhage that was minor and controlled by applying external pressure only (n = 6). Moreover, three patients suffered hemorrhage that required deep skin sutures while two patients developed a skin burn around the incision site

Late complications (12.6%). More specifically, delayed wound healing was encountered in seven

cases, minor hematoma in five and wound infection in four, one of which required administration of antibiotics

Complications of percutaneous stereotactic vacuum assisted breast biopsysystem utilizing radio frequency

European Journal of Radiology 82 (2013) 623– 626

N = 134

N= 166 Intact procedures

AFTER SURGERY n INCOMPLETE REMOVAL

COMPLETE

REMOVAL

COMPLETE REMOVAL OF

INVASIVE

( ONLY DCIS)

PAPILLOMA 1 1

ATYPICAL LESIONS 9 7 77% 2 23%

HDA 4 3 1

HLA 2 2

Flat epithelial Atypiia 2 1 1

LIN2 1 1

CARCINOMA 36 23 63,8% 12 33,3% 1 (2,7%)

DCIS 27 16 59,3% 11 40,7%CCI 7 5 71,4% 1 14,3% 1

CLI 2 2

Total 46 31 67,4% 14 30,4% 1 (2,2%)

CIC Marges saines

CIC Marges positives

Tomosynthesis

Mrs B.. 79 years old under heparin (Cardiac surgery contra indication)

CRP : Complementary radiotherapy follow up at 6 months

Radiographie prélèvement Intact

Healthy margins : 3 mm

Tubular carcinoma 5 mm Very well differenciated

•Feasability

•Surgical resumption of atypias and small cancers with healthy margins

(lack of recul and insufficient studies)

• BLES Complementary technique to VABB with aspiration

• Today : excellent diagnostic precision (less under estimation)

Balance after 10 years of exper ience : D iagnost ic or therapeut ic

Limits

• Therapeutic perspectives• Atypical hyperplasias and small size cancers :

Complete percutaneous excision vs therapeutic surgery

Biopsies under RMI

Biopsies under ultrasound or stereotaxy possible in 50% to 80% of the cases if a MRI abnormality not detected initially under ultrasound or mammography

DeMartini & al. Utility of Targeted Sonography for Breast Lesions That Were Suspicious on MRI. AJR 2009;192:1128

Development limited by the technical , organizational and economic constraints

J-Y Séror

Centre Duroc Paris 6

www.imagerieduroc.com

Interventional

Senology

State of the art

Interventional Senology

Diagnostic and therapeutic

State of art - Limits - Complications

« Israeli-French Breast Cancer Update »Prevention, Detection and Treatment, a Multidisciplinary approach