2 Interventional Radiology : Useful for All and Always ? Dr S. MurgoCHU Tivoli, La Louvière, BelgiqueHôpital Erasme, Bruxelles, Belgique
3 IntroductionScreening 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 advantagesLess invasive, less expansive techniques that avoid:surgery for benign lesionssurgery in 2 timesPercutaneaous biopsy may avoid per-operative histological analysis that may destruct small lesions
5 Potential drawbacks Epithelial displacement (FNA, CNB > VACB): No evidence of biologic significanceNo of the recurrence rate after BCSBut some displaced cells associated with DCIS can sometime mimic IDC for pathologist.Risk of missed cancers good knowledge of limitations
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 ? CNBLau. The breast Journal 2004; 10: 487Bulgaresi. 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, abscessUltrasound1 - Typical cyst, harmatoma, or LN STOP2 – « 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 palpable98.6 % of benign lesions (1)6 mo follow-upFNACNBNo change after 2 yChangeC110-15 % CNB (3)Best test99.9 % B 0.1% M (7% of 1.4% BC)C2NPV 100 %PPV > 98 %(3 samples in the target)CNB0.026% of missed cancers(after 3 years) (2) C37-8 % CNB (4)16 % of cancers86.1 % 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. 2004Lau. 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 palpable98.6 % of benign lesions (1)6 mo follow-upFNACNBNo change after 2 yChangeC110 % CNB (3)Best test99.9 % B 0.1% M (7% of 1.4% BC)C2NPV 100 %PPV > 98 %(3 samples in the target)CNBMissed cancers0.026% (after3 years) (2) C37-8 % CNB (4)16 % of cancers86.1 % 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. 2004Lau. The breast Journal 2004; 10: 487Caution: 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 growth40 women with 56 papillary lesions: 3 papillary carcinomas, 13 papillaryal lesions with carcinoma in situ, 1 atypical carcinoma, 4 sclerosed papilloma, 35 papillomata.PPVNPVFNA31 %79 %CNB100 %83 %Lam. AJR 2006; 186(5):Open Surgical Biopsy !
18 Well-defined mass50 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 cancerLiberman. 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 mmOpen Surgical Biopsy !Andersen JA, Cancer 1984; 53:
21 Architectural distortion Open Surgical Biopsy !From Tabar. Practical breast pathology - Thieme 2002: 104-5
32 MicrocalcificationsVACB > CNB with a higher NPV and less technical failuresMeta-analysis: 35 studies – minimal invasive breast biopsy after screening:12 VABB, n = 511925 CNB, n = 6236Reference standard: open surgery or longterm follow-upVACBCNBOverall agreementwith reference97.3 %93.5 %Technical failure1.5 %5.7 %Non diagnostic samples0 %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 samplesPost 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 MassMicrocalcificationWith VACB G under stereotactic guidanceThe accuracy increase significantly until 12 samplesLomoschitz. 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 requiredMagenthaler. Am J Surg 2006; 192(4):534-7Mahoney. AJR 2006; 187(4):949-54Lomoschitz. Radiology 2004; 232:897–903
37 Calcifications : undervaluation Large cluster of amorphous calcifications: adenosis +/- DCIS ?Tabar. Practical breast pathology - Thieme 2002
38 MicrocalcificationsTo avoid missed cancer, a open surgical biopsy is required after percutaneous biopsy:When none or a small number of calcifications are removedFor large cluster of amorphous calcifications (adenosis +/- DCIS ?)For an histological diagnosis of ADH, ALH, and LN
40 ConclusionsIR is very useful and efficient BUT not for all and always !The knowledge of the limitations of each techniques nb of missed cancersConfrontation 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 discordantSurgical excision is necessary for some histological benign lesions: ADH, ALH, LN, radial scar, papillary lesions, possible phyllode tumor
41 ConclusionsFurther 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.
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