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:
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
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
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
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
Interventional Radiology Includes: Guidewire Localization RadioFrequency Fine Needle Aspiration Core Needle Biopsy Large Core Needle Biopsy
Main Mammographic Signs Mass Architectural Distorsion Microcalcifications
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
Mass: CNB (1)Koskela. Radiology 2005; 236: g – with 3 samples in the target
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
? 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
Tabar. Radiol Ciln North Am. 2000; 38(4):
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.
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 !
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 !
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 !
Architectural distortion From Tabar. Practical breast pathology - Thieme 2002: Open Surgical Biopsy !
MicrocalcificationsMicrocalcifications Mammographic appearence of breast cancers
MicrocalcificationsMicrocalcifications Mammographic appearence of calcifications sent to surgery
Vacuum assisted breast biopsy Mammotome ® Vacora ®
Large biopsy SiteSelect ® (ABBI ®) En-bloc ® …
Lateral position - LM On stereotactic guidance
Dedicated table Lorad Fisher
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 %
Post biopsy MG MG of samples To reach a high NPV:
Koskela. Radiology 2005; 236: With CNB, the sensitivity with the number of samples
(1)Lomoschitz. Radiology 2004; 232:897–903 With VACB - 11 G under stereotactic guidance The accuracy increase significantly until 12 samples MicrocalcificationsMicrocalcifications Mass Microcalcification
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
Large cluster of amorphous calcifications: adenosis +/- DCIS ? Tabar. Practical breast pathology - Thieme 2002 Calcifications : undervaluation
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
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
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.