2. Interventional Radiology : Useful for All and Always ?
Dr S. Murgo
CHU Tivoli, La Louvière, Belgique
Hôpital Erasme, Bruxelles, Belgique

3. Introduction
Screening  Many benign lesions indistinguishable from cancer
 Previously open surgical biopsies (OSB) for asymptomatic benign lesions were often necessary
 Quick development of percutaneaous biopsies for BIRADS 4 and also 5
 with often a lack of scientific validations  some controversies

4. Potential advantages
Less invasive, less expansive techniques that avoid:
surgery for benign lesions
surgery in 2 times
Percutaneaous biopsy may avoid per-operative histological analysis that may destruct small lesions

5. Potential drawbacks Epithelial displacement (FNA, CNB > VACB):
No evidence of biologic significance
No  of the recurrence rate after BCS
But some displaced cells associated with DCIS can sometime mimic IDC for pathologist.
Risk of missed cancers  good knowledge of limitations

7. Interventional Radiology
Includes:
Guidewire Localization
RadioFrequency
Fine Needle Aspiration
Core Needle Biopsy
Large Core Needle Biopsy

8. Architectural Distorsion
Main Mammographic Signs
Mass
Architectural Distorsion
Microcalcifications

10. Mass: with irregular / stellate outline
DD: Radial scar, complex sclerosis lesion, invasive carcinoma (usually grade I or II), fat necrosis, granular cell myoblastoma,…
FNA ?
 10 % of C1 (not enough cells)  CNB
 False negative: 6-7% (1)  C2 no value
 PPV of C3 : 55 % if suspect 83% (2)
 PPV of C4 : 96 % if suspect 98.5 % (2)
 PPV of C5 > 99.4 % (2)  invasive carcinoma ?
 CNB
Lau. The breast Journal 2004; 10: 487
Bulgaresi. Breast cancer Res Treat 2006; 97 (3):319-21

11. Mass: CNB 14 g – with 3 samples in the target
Koskela. Radiology 2005; 236: 801-9

12. Mass: with well-defined outline
DD: Cyst, FA, hamartoma, lymph node, phyllodes tumor, invasive carcinoma (high grade), papillary lesions, mucinous carcinoma, medullary carcinoma, abscess
Ultrasound
1 - Typical cyst, harmatoma, or LN  STOP
2 – « Typical FA »  different schools:
Follow-up ? Not palpable  0-2 % of malignancy (mean: 1.4% - Lower for young women (< 30 yo))
Triple test with FNA ? Negative predictive value:  100% (1) but … false positive !
CNB the best test to exclude a breast cancer ! Especially for large lesion and old women (> 60 % of carcinoma after 60 yo)
Lau. The breast Journal : 487

13. (3 samples in the target)
? FA ?
Not palpable
98.6 % of benign lesions (1)
6 mo follow-up
FNA
CNB
No change after 2 y
Change C1
10-15 %  CNB (3)
Best test
99.9 % B
 0.1% M (7% of 1.4% BC) C2
NPV  100 %
PPV > 98 %
(3 samples in the target)
CNB
0.026% of missed cancers
(after 3 years) (2)
 C3
7-8 %  CNB (4)
16 % of cancers
86.1 % of T0N0M0 or T1N0M0 (2)
Sickles. Radiol Clin North. Am 1995; 33:
Sickles. Radiology 1999; 213:11-14.
Wells. EU guidelines for non-operative diagnostic procedures. 2004
Lau. The breast Journal 2004; 10: 487

14. Tabar. Radiol Ciln North Am. 2000; 38(4):625-651

15. (3 samples in the target)
FA ?
Not palpable
98.6 % of benign lesions (1)
6 mo follow-up
FNA
CNB
No change after 2 y
Change C1
10 %  CNB (3)
Best test
99.9 % B
 0.1% M (7% of 1.4% BC) C2
NPV  100 %
PPV > 98 %
(3 samples in the target)
CNB
Missed cancers
0.026% (after
3 years) (2)
 C3
7-8 %  CNB (4)
16 % of cancers
86.1 % of T0N0M0 or T1N0M0 (2)
Sickles. Radiol Clin North. Am 1995; 33:
Sickles. Radiology 1999; 213:11-14.
Wells. EU guidelines for non-operative diagnostic procedures. 2004
Lau. The breast Journal 2004; 10: 487
Caution: size , age, other risk factors (BRCA, family or personal history,...), anxiety and reliability of the pat.

17. Well-defined mass Ultrasound Open Surgical Biopsy !
3 – Cystic lesion with intracystic growth
40 women with 56 papillary lesions: 3 papillary carcinomas, 13 papillaryal lesions with carcinoma in situ, 1 atypical carcinoma, 4 sclerosed papilloma, 35 papillomata.
PPV
NPV
FNA
31 %
79 %
CNB
100 %
83 %
Lam. AJR 2006; 186(5):
Open Surgical Biopsy !

18. Well-defined mass
50 papillomas on percutaneous biopsy (35 VACB – 11G & 15 CNB 14 G)
Reference standard: OSB and longterm follow-up
 5 (14%) breast cancers (4 DCIS & 1 inv. carcinoma)
 6 (17%) high risk lesions (3 ADH, 2 radial scar, 1 LN)
The risk  in case of multiple papilloma and with a family history of breast cancer
Liberman. AJR 2006; 186(5):
Open Surgical Biopsy !
Can we totally remove a small benign lesion with LCNB ? …

20. Architectural distortion
DD: Involution, radial scar, invasive lobular carcinoma, DCIS(rarely),…
Radial scar:
Fibroelastic center with pseudo-infiltrative tubular structure (DD: tub car).
In the crown of the RS +/- ADH, ALH, DCIS, LN, … the risk  with the age and the size (1)
- None < 40 yo, rare between 40 & 50 yo,  > 50 yo
- Rare if < 6-7 mm
Open Surgical Biopsy !
Andersen JA, Cancer 1984; 53:

21. Architectural distortion
Open Surgical Biopsy !
From Tabar. Practical breast pathology - Thieme 2002: 104-5

23. Mammographic appearence of breast cancers
Microcalcifications
Mammographic appearence of breast cancers

24. Mammographic appearence of calcifications sent to surgery
Microcalcifications
Mammographic appearence of calcifications sent to surgery

25. Microcalcifications
Casting calcifications (fine, linear, branching): plasma cell mastitis, DCIS grade III.
Crushed stone calcifications (pleomorphic, heterogenous): Fat necrosis, FA, cysts, DCIS grade II/III, Lobular neoplasia (rarely).
Powdery calcifications (amorphous, indistinct): sclerosing adenosis, cysts, DCIS grade I/II.
Wells. EU guidelines for non-operative diagnostic procedures. 2004

26. Microcalcifications: CNB
Koskela. Radiology 2005; 236: 801-9

27. Vacuum assisted breast biopsy
Mammotome®
Vacora®

28. Large biopsy
En-bloc ® …
SiteSelect ®
(ABBI ®)

29. On stereotactic guidance
Lateral position - LM

30. Dedicated table
Lorad
Fisher

32. Microcalcifications
VACB > CNB with a higher NPV and less technical failures
Meta-analysis: 35 studies – minimal invasive breast biopsy after screening:
12 VABB, n = 5119
25 CNB, n = 6236
Reference standard: open surgery or longterm follow-up
VACB
CNB
Overall agreement
with reference
97.3 %
93.5 %
Technical failure
1.5 %
5.7 %
Non diagnostic samples
0 %
2.1 % (23 % of BC)
 FN : 3.8 %
Fahrbach. Arch gynecol obstet 2006; 274(2):63-74

33. To reach a high NPV:
MG of samples
Post biopsy MG

34. With CNB, the sensitivity  with the number of samples
Koskela. Radiology 2005; 236: 801-9

35. Microcalcifications With VACB - 11 G under stereotactic guidance
Mass
Microcalcification
With VACB G under stereotactic guidance
The accuracy increase significantly until 12 samples
Lomoschitz. Radiology 2004; 232:897–903

36. Calcifications : undervaluation
Vacuum-assisted devices, larger gauge biopsy needles, and greater number of cores were associated with a higher NPV.
But there is always some underevaluated lesions: ADH, ALH, LN, DCIS (16-31 %)  OSB is required
Magenthaler. Am J Surg 2006; 192(4):534-7
Mahoney. AJR 2006; 187(4):949-54
Lomoschitz. Radiology 2004; 232:897–903

37. Calcifications : undervaluation
Large cluster of amorphous calcifications: adenosis +/- DCIS ?
Tabar. Practical breast pathology - Thieme 2002

38. Microcalcifications
To avoid missed cancer, a open surgical biopsy is required after percutaneous biopsy:
When none or a small number of calcifications are removed
For large cluster of amorphous calcifications (adenosis +/- DCIS ?)
For an histological diagnosis of ADH, ALH, and LN

40. Conclusions
IR is very useful and efficient BUT not for all and always !
The knowledge of the limitations of each techniques   nb of missed cancers
Confrontation of the cytological and histological results with the PE and medical imaging studies in a multidisciplinary approach !
Repeat biopsy is necessary if histological and imaging finding are discordant
Surgical excision is necessary for some histological benign lesions: ADH, ALH, LN, radial scar, papillary lesions, possible phyllode tumor

41. Conclusions
Further work is necessary to optimize criteria for patient selection, to develop and define the role of new technologies.
Complete removal of the mammographic target does not ensure complete excision of the histological process  Further investigation is necessary to determinate in which lesion, complete removal of the target is advantageous.