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Is radiology replacing the scalpel: Advances in minimally invasive techniques Dr Steven Allen Consultant Breast Radiologist Breast Imaging Lead, Royal.

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Presentation on theme: "Is radiology replacing the scalpel: Advances in minimally invasive techniques Dr Steven Allen Consultant Breast Radiologist Breast Imaging Lead, Royal."— Presentation transcript:

1 Is radiology replacing the scalpel: Advances in minimally invasive techniques Dr Steven Allen Consultant Breast Radiologist Breast Imaging Lead, Royal Marsden Hospital, Sutton Specialist Advisor to NICE on breast interventional procedures

2 Radiological Breast Intervention Diagnosis (biopsies) Diagnosis (biopsies) Therapy Therapy

3 Fine Needle Aspiration Insufficient material retrieved for definitive diagnosis Insufficient material retrieved for definitive diagnosis Interpretation is highly dependent on skill of cytopathologist Interpretation is highly dependent on skill of cytopathologist Cannot distinguish in situ versus invasive carcinomas Cannot distinguish in situ versus invasive carcinomas Difficult to distinguish atypical ductal hyperplasia from low- grade DCIS or low-grade invasive ductal carcinoma Difficult to distinguish atypical ductal hyperplasia from low- grade DCIS or low-grade invasive ductal carcinoma New Best practice diagnostic guidelines for patients presenting with breast symptoms* New Best practice diagnostic guidelines for patients presenting with breast symptoms* *Willett et al. Best practice diagnostic guidelines for patients presenting with breast symptoms. Nov

4 Fine Needle Aspiration-Uses Where core biopsy not technically possible Where core biopsy not technically possible Lymph nodes Lymph nodes Complex cysts Complex cysts Radiologically benign, young women Radiologically benign, young women Clotting issues Clotting issues Local anaesthetic allergy Local anaesthetic allergy

5 Why do we need breast needle biopsy? Definitive benign diagnosis avoids unnecessary surgery Definitive benign diagnosis avoids unnecessary surgery Knowledge of the type and extent of malignancy influences choice of treatment Knowledge of the type and extent of malignancy influences choice of treatment ADH or Ductal carcinoma in situ? ADH or Ductal carcinoma in situ? Ductal carcinoma in situ or invasive disease? Ductal carcinoma in situ or invasive disease? Invasive tumour type - eg lobular Invasive tumour type - eg lobular Invasive tumour grade Invasive tumour grade Oestrogen receptor status Oestrogen receptor status Other tumour markers Other tumour markers Tumour genetics Tumour genetics

6 Problems with core biopsy False negatives on core (2-10%, mainly calcifications) False negatives on core (2-10%, mainly calcifications) Trend to increasing size of biopsy sample to minimize this Trend to increasing size of biopsy sample to minimize this BUT cheap ( approx £15 per needle, £50 per case versus £150 per needle, £500 per case) BUT cheap ( approx £15 per needle, £50 per case versus £150 per needle, £500 per case)

7 Automated 14g core biopsy deals with more than 90% of cases Very large core biopsy techniques have been developed to deal with the rest and also to help solve diagnostic problems

8 Tissue volume MethodAverage weight MethodAverage weight 14g core17mg 11g VAB 100mg 7g VAB300mg Liberman L. AJR 2000; 174:

9 Vacuum Assisted Biopsy In USA probably overperformed In USA probably overperformed Increasing in Europe where probably still underperformed Increasing in Europe where probably still underperformed The role is extending (MRI, therapy?) The role is extending (MRI, therapy?)

10 When should vacuum assisted biopsy be used? Indications : Very small mass lesions Very small mass lesions Equivocal or failed core biopsy Equivocal or failed core biopsy Architectural distortions Architectural distortions Microcalcifications Microcalcifications Papillary and mucocele like lesions Papillary and mucocele like lesions Diffuse non-specific abnormality Diffuse non-specific abnormality Complex cysts and abscesses Complex cysts and abscesses Excision of benign lesions Excision of benign lesions Malignant disease ?? Malignant disease ??

11 VAB effects Will detect more ADH, LCIS Will detect more ADH *, LCIS Will detect more DCIS, Invasive cancer Will detect more DCIS, Invasive cancer* * Reduced surgical biopsy rate Reduced surgical biopsy rate Better preoperative surgical and medical treatment planning Better preoperative surgical and medical treatment planning * Winchester et al. Arch Surg 2003: 138(6); * * Kettritz et al. Cancer 2004: 100(2);

12 VAB - risks Haematoma rates are actually low*, and not significantly different to core biopsy Haematoma rates are actually low*, and not significantly different to core biopsy Pain?** Pain?** Clip migration Clip migration *Lai, et al. Vacuum-assisted large-core breast biopsy: complications and their incidence. Can Assoc Radiol J Aug;51(4): **Szynglarewicz, et al. Pain experienced by patients during minimal-invasive ultrasound-guided breast biopsy: Vacuum-assisted vs core-needle procedure. EJSO, Feb 28, Epub

13 VAB - technique

14

15

16 EnCor (SenoRx )

17

18

19 EnCor Built in headlights illuminate the biopsy area Built in headlights illuminate the biopsy area Choice of sample patterns that continuously repeat Choice of sample patterns that continuously repeat

20 EnCor

21

22 ATEC (Suros surgical)

23 Vacora

24 VAB systems - comparison of attributes AttributeVacoraMammotomeSuros AtecEncor X-ray and US MRI Directional SampleSingleMultiple MethodCutting Scissor Sharpness RetrievalOpen Closed Vacuum controlX ProgrammableX X LavageXX AnaestheticX Sample size Volume in 1min Probe offset X

25 Vacuum assisted excision Increasing use to excise benign lesions in a piecemeal fashion as an alternative to surgery Increasing use to excise benign lesions in a piecemeal fashion as an alternative to surgery Cannot give margin status on excision Cannot give margin status on excision Newer devices are very automated allowing most procedures to be performed in <30 minutes Newer devices are very automated allowing most procedures to be performed in <30 minutes Significant time, cost, morbidity benefits Significant time, cost, morbidity benefits

26 Vacuum assisted excision Benign lesions such as fibroadenomas * Benign lesions such as fibroadenomas * Recurrence rate may be higher for lesions >2cm Recurrence rate may be higher for lesions >2cm Papillary lesions Papillary lesions All B3 lesions without atypia* * All B3 lesions without atypia* * Lymph nodes? Lymph nodes? Cancers? Cancers? *Grady et al, Breast J 2008, 14(3): * Grady et al, Breast J 2008, 14(3): * * Tennant et al, Breast 2008, 17(6):546-9

27 The Intact Breast Lesion Excision System (BLES) Controller & Vacuum Source Handle & Disposable Wand

28 The Intact BLES Developed in USA in 2001, the INTACT breast lesion excision system (BLES) has a unique capability of obtaining a single large biopsy sample using radiofrequency cauterisation Developed in USA in 2001, the INTACT breast lesion excision system (BLES) has a unique capability of obtaining a single large biopsy sample using radiofrequency cauterisation It has been used extensively in the USA as an equivalent large biopsy device to current vacuum assisted systems (>40,000 cases!). It has been used extensively in the USA as an equivalent large biopsy device to current vacuum assisted systems (>40,000 cases!). At least equivalent diagnostically to VAB devices* At least equivalent diagnostically to VAB devices* *Sie et al, Multicenter Evaluation of the Breast Lesion Excision System, a Percutaneous, Vacuum-Assisted, Intact-Specimen Breast Biopsy Device. Cancer 107:5

29 Intact BLES Excision

30 Goal using The Intact BLES Excision of lesion in one piece Best possibility of clear margins

31 The Intact BLES

32

33 Specimen radiograph

34 The Intact BLES RMH have had this since 2007 and are the second centre outside the USA RMH have had this since 2007 and are the second centre outside the USA Approved as a biopsy device by appropriate committees Approved as a biopsy device by appropriate committees However due to its of obtaining a single large sample, we have almost exclusively used this in an attempt at whole lesion excision However due to its of obtaining a single large sample, we have almost exclusively used this in an attempt at whole lesion excision Most of our patient group have been referred from the NHSBSP, and we have attempted to perform complete excision biopsy in removing small breast lesions with a margin * Most of our patient group have been referred from the NHSBSP, and we have attempted to perform complete excision biopsy in removing small breast lesions with a margin * *Allen SD, Nerurkar A, Della Rovere GU. The breast lesion excision system (BLES): a novel technique in the diagnostic and therapeutic management of small indeterminate breast lesions? Eur Radiol Jan 15.

35 The Intact BLES Many borderline (high risk) lesions can be completely excised without surgery in a short well tolerated outpatient procedure * Many borderline (high risk) lesions can be completely excised without surgery in a short well tolerated outpatient procedure * The results very much represent what can be achieved during the early stages of using this new technique The results very much represent what can be achieved during the early stages of using this new technique Complementary to VAB as an alternative therapy to surgery for small breast lesions Complementary to VAB as an alternative therapy to surgery for small breast lesions * Whitworth PW. Intact Percutaneous Excision (IPEX) for Definitive Diagnosis of High-Risk Breast Lesions. Ann Surg Oncol Oct;18(11):3095. Epub 2011 Sep 9

36 The Intact BLES NICE have now approved this as a large biopsy device NICE have now approved this as a large biopsy device The potential of this technique may grow further as wand technology/unit experience improves The potential of this technique may grow further as wand technology/unit experience improves Current wand sizes/yield limit excision of many lesions Current wand sizes/yield limit excision of many lesions A 30mm wand has been in use in selected centres >6/12 A 30mm wand has been in use in selected centres >6/12 ?whole cancer excision ?whole cancer excision

37 30mm wand

38 Thermal Ablation Radiofrequency ablation Radiofrequency ablation Cryoablation Cryoablation Laser therapy Laser therapy High Intensity focused ultrasound (HIFU) High Intensity focused ultrasound (HIFU) All require a probe to be inserted into the tumour under image guidance (usually ultrasound) All require a probe to be inserted into the tumour under image guidance (usually ultrasound) Margins, margins, margins Margins, margins, margins

39 Thermal Ablation

40 RF Ablation RF ablation most fashionable RF ablation most fashionable Small, centrally sited, low grade tumours, elderly patients Small, centrally sited, low grade tumours, elderly patients Low level of evidence Low level of evidence Almost invariably combined with surgery* Almost invariably combined with surgery* *Imoto S, et al. Breast Apr;18(2):130-4

41 RF Ablation ?neoadjuvant RFA combined with immunologically active cytokines (IL-7 and IL-15) in mice induced immune responses to tumors, inhibited tumor development and lung metastasis * RFA combined with immunologically active cytokines (IL-7 and IL-15) in mice induced immune responses to tumors, inhibited tumor development and lung metastasis * RFA combined with other treatment deliveries? RFA combined with other treatment deliveries? *Habibi M, et al. Breast Cancer Res Treat Apr;114(3):

42 Conclusions Biopsies are getting larger! Biopsies are getting larger! Core biopsy and even FNA still maintain a role Core biopsy and even FNA still maintain a role As with other fields of interventional radiology, the breast interventionalist is finding a role extension in the therapy of benign and now malignant breast disease As with other fields of interventional radiology, the breast interventionalist is finding a role extension in the therapy of benign and now malignant breast disease

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