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Consultant Breast Radiologist

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Presentation on theme: "Consultant Breast Radiologist"— Presentation transcript:

1 Consultant Breast Radiologist
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) Therapy

3 Fine Needle Aspiration
Insufficient material retrieved for definitive diagnosis Interpretation is highly dependent on skill of cytopathologist Cannot distinguish in situ versus invasive carcinomas 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”* *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 Lymph nodes Complex cysts Radiologically benign, young women Clotting issues Local anaesthetic allergy

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

6 Problems with core biopsy
False negatives on core (2-10%, mainly calcifications) 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)

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 Method Average weight 14g core 17mg 11g VAB 100mg
Liberman L. AJR 2000; 174:

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

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

11 VAB effects Will detect more ADH *, LCIS
Will detect more DCIS, Invasive cancer* * Reduced surgical biopsy rate Better preoperative surgical and medical treatment planning Of the 65 patients who underwent open biopsy for ADH in this series, only 83% had an accurate diagnosis. A diagnosis of ADH by stereotactic core needle biopsy should be followed by an open excisional biopsy. Stereotactic vacuum-assisted breast biopsy in 2874 patients: a multicenter study. Twelve percent of patients with DCIS proved to have invasive carcinoma. Seventy-three percent of the patients had benign lesions. Only 1 false-negative result was encountered (negative predictive value, 99.95%). Minor side effects were reported to occur in 1.4% of patients and 0.1% of patients required a subsequent intervention. Scarring relevant for mammography was rare among patients (i.e., 0.3% of patients had relevant scarring). * 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 Pain?** Clip migration 297 patients between Sept. 18, 1997, and Mar. 30, 1999, were evaluated. Complications associated with VALCBB were assessed at the time of the procedure and in the post-procedure period. Adverse outcomes included pain, bleeding or bruising, and hematoma. Complications were also classified in terms of minor, significant, and major severity. RESULTS: VALCBB yielded non-minor (i.e., significant and major) complication rates of 3.9% during the procedure and 3.6% in the post-procedure period, with only 2 complications (vasovagal-induced seizure and migraine) that required treatment. Median pain score 3 vs 6 with VAB!! *Lai, et al. Vacuum-assisted large-core breast biopsy: complications and their incidence. Can Assoc Radiol J Aug;51(4):232-6. **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



16 EnCor (SenoRx™)



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

20 EnCor


22 ATEC (Suros surgical)

23 Vacora

24 VAB systems - comparison of attributes
Vacora Mammotome Suros Atec Encor X-ray and US MRI Directional Sample Single Multiple Method Cutting Scissor Sharpness + +++ Retrieval Open Closed Vacuum control X  Programmable  Lavage Anaesthetic Sample size Volume in 1min ++ Probe offset

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

26 Vacuum assisted excision
Benign lesions such as fibroadenomas * Recurrence rate may be higher for lesions >2cm Papillary lesions All B3 lesions without atypia* * Lymph nodes? Cancers? Of 69 lesions treated, 52 were available for follow-up. The median follow-up period was 22 months, with a range of 7 to 59 months. At 6 months, there were no fibroadenoma recurrences. Follow-up sonography demonstrated recurrences in 13 lesions distributed across eight patients. The overall recurrence rate was 15% (8/52) with an actuarial recurrence rate of 33% at 59 months. All of the recurrences were in lesions which were larger than 2 cm in size at initial presentation. Our data suggest that the mechanism of recurrence is the regrowth of retained lesion fragments too small to be detected by ultrasound--not the incomplete excision of all imaged lesion evidence. Despite successful percutaneous excision, fibroadenomas do recur. Lesions smaller than 2 cm in size, so treated, do not need additional therapy or surveillance. Fibroadenomas larger than 2 cm are prone to recurrence and require additional treatment. To assess whether vacuum-assisted excision (VAE) is a safe alternative to surgery in the treatment of breast lesions of uncertain malignant potential (B3) in which no atypia is present on needle core biopsy (NCB). Forty two VAE procedures were performed for B3 lesions. Twenty four (57%) were papillary lesions. Eighteen (43%) were radial scars. Two patients (4.7%) were upgraded to carcinoma at VAE. Two patients with papillary lesions went on to develop cancer in the same breast (at 24 and 41 months post VAE). No cancer developed in the radial scar group. Eight patients (19%) had surgery - four for carcinoma, two for radial scars missed at VAE excision and two for symptomatic papillomatosis. Follow-up mammography after VAE of radial scars often showed residual distortion. VAE can be a safe alternative to surgery in the treatment of B3 lesions without atypia, providing thorough multidisciplinary discussion has taken place. RW satisfaction paper clin rad. Some pain and haematoma at 1 week only * Grady et al, Breast J 2008, 14(3): 275-8 * * Tennant et al, Breast 2008, 17(6):546-9

27 The Intact™ Breast Lesion Excision System (BLES)
The breast lesion excision system represents an innovative advance in breast biopsy technology. Handle & Disposable Wand Controller & Vacuum Source

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 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* Of the 742 breast lesions, 34 displayed ADH upon biopsy with the BLES device. Two patients did not receive open surgical biopsy. Of the 32 patients who had open surgical excision, 3 (9.4%) had DCIS or invasive cancer. There were 119 diagnoses of DCIS upon biopsy with the BLES device. Four patients did not receive open surgical biopsy. Of the 115 patients who had open surgical excision, 6 (5.2%) had invasive cancer. *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


33 Specimen radiograph

34 The Intact BLES RMH have had this since 2007 and are the second centre outside the USA 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 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 * Of the 742 breast lesions, 34 displayed ADH upon biopsy with the BLES device. Two patients did not receive open surgical biopsy. Of the 32 patients who had open surgical excision, 3 (9.4%) had DCIS or invasive cancer. There were 119 diagnoses of DCIS upon biopsy with the BLES device. Four patients did not receive open surgical biopsy. Of the 115 patients who had open surgical excision, 6 (5.2%) had invasive cancer. *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 * 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 *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
The potential of this technique may grow further as wand technology/unit experience improves Current wand sizes/yield limit excision of many lesions A 30mm wand has been in use in selected centres >6/12 ?whole cancer excision

37 30mm wand

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

39 Thermal Ablation

40 RF Ablation RF ablation most fashionable
Small, centrally sited, low grade tumours, elderly patients Low level of evidence Almost invariably combined with surgery* T1N0 breast cancer patients with no extensive intraductal components RFA-related adverse events were observed in nine patients: two with skin burn and seven with muscle burn. Twenty-six patients (87%) showed pathological degenerative changes in tumor specimens with H&E staining. In 24 of the 26 cases (92%) examined by NADH diaphorase staining, tumor cell viability was diagnosed as negative. RFA proved to be reliable and feasible in clinical stage I breast cancer, with no extensive intraductal components. Randomized clinical trials are needed to compare RFA with BCS. *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 other treatment deliveries? *Habibi M, et al. Breast Cancer Res Treat Apr;114(3):

42 Conclusions Biopsies are getting larger!
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


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