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

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Presentation on theme: "Interventional Radiology : Useful for All and Always ? Dr S. Murgo CHU Tivoli, La Louvière, Belgique Hôpital Erasme, Bruxelles, Belgique Dr S. Murgo CHU."— Presentation transcript:

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

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

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

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

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

8 Main Mammographic Signs Mass Architectural Distorsion Microcalcifications

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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 ? (1)Lau. The breast Journal 2004; 10: 487 (2)Bulgaresi. Breast cancer Res Treat 2006; 97 (3):  CNB

11 Mass: CNB (1)Koskela. Radiology 2005; 236: g – with 3 samples in the target

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) (1)Lau. The breast Journal : 487

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

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

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

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17 Ultrasound 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. PPVNPV FNA 31 % 79 % CNB 100 % 83 % Lam. AJR 2006; 186(5): Well-defined mass Open Surgical Biopsy !

18 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 The risk  in case of multiple papilloma and with a family history of breast cancer Liberman. AJR 2006; 186(5): Well-defined mass Can we totally remove a small benign lesion with LCNB ? … Open Surgical Biopsy !

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

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

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23 MicrocalcificationsMicrocalcifications Mammographic appearence of breast cancers

24 MicrocalcificationsMicrocalcifications Mammographic appearence of calcifications sent to surgery

25 MicrocalcificationsMicrocalcifications 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 (1)Koskela. Radiology 2005; 236: 801-9

27 Vacuum assisted breast biopsy Mammotome ® Vacora ®

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

29 Lateral position - LM On stereotactic guidance

30 Dedicated table Lorad Fisher

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

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

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

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

36 Calcifications : undervaluation n Vacuum-assisted devices, larger gauge biopsy needles, and greater number of cores were associated with a higher NPV. n 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): Lomoschitz. Radiology 2004; 232:897–903 Mahoney. AJR 2006; 187(4):949-54

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

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

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

41 ConclusionsConclusions n Further work is necessary to optimize criteria for patient selection, to develop and define the role of new technologies. n 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.

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