jean yves seror : interventional senology diagnostic and therapeutic : state of art - limits -...
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J-Y Séror
Centre Duroc Paris 6
www.imagerieduroc.com
Interventional
Senology
State of the art
« Israeli-French Breast Cancer Update »Prevention, Detection and Treatment, a Multidisciplinary approach
Interventional Senology
Diagnostic and therapeutic
State of art - Limits - Complications
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Nearly 1 woman out of 6 will need a breast biopsy
during her life.
The medical imaging techniques improvement will
contribute to increase the number of biopsies.
Interventional senology : State of the art
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• BI-RADS 5 VPP > 95%
• BI-RADS 4 VPP > 3% - 90%
• BI-RADS 2 : Non Indication
• BIRADS 3 VPP < 3% : short-term follow-up was a reasonable and
likely management alternative to excisional biopsy for non palpable lesions
detected with screening mammography that could be considered probably
benign by virtue of their imaging characteristics.
Diagnostic Biopsy : Indications & Objectives
The pre-therapeutic knowledge of the histologicaldiagnosis at least 60% of the infra-clinical lesions.
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Nodules , MicrocalcificationsSurdensities +/- spicular
Which weapons ?
FNA (Fine Needle Aspiration Biopsy)
CB (Core Biopsy)
VAB (Vacuum Aspiration biopsy)
Stereotaxy , Ultrasound ,MRI …
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Fine Needle Aspiration Biopsy (cytology)?
Cysts evacuation (painful, disturbing)
A very well tolerated and reliable technique, without anesthesia, not expensive,
well adapted for screening experimented cytologist
Axillary nodules
Se 0.927 (95% [CI]) 0.921 to 0.933)
Sp 0.948 (95% [CI] ) 0.943 to 0.952)Ying-Hua Yu & Al BMC Cancer 201246 studies
Masses with a benign aspect (BIRADS 3)
Needles from 22 to 27 G, by capillarity , without local anesthesia
Indications
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The cytology principle : • no infiltrative diagnosis,• lobular and Ductal differentiation not always possible
Limits and contre indication
Insufficient material : under estimation 10 - 27%
Dependant operator, dependant reader
Microcalcifications: 50% of the samples are not sufficient
Non-diagnostic procedure need to Complete the diagnosis with a Core biospy
Fine Needle Aspiration Biopsy (cytology)?
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Cytology with atypias :Medularry carcinoma
Size 12 mm RH- Cer2 B2+
Benign cytologyFibroadenoma
BIRADS 3,BIRADS 4 An alternative to the short-term follow up:
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Hypo-echogenic pre prothetic noduleFNAB under ultrasound.
Visibility of the hyper echogenic needle spot in the nodule : Fibroadenoma
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Exploration of the axillary lymph nodes :
Which ganglions do you have to puncture?
Houssami N & Al Annals of Surgery 2011 Méta-analyse 31 studies N=6166
17,6% avoid the Sentinel Lymph Nodes and orientation towards the Axillary Lymph Nodes DissectionNO
Sampling if at least 1 malignancy suspicion criterion of a ganglion
1. Global or localized cortex thickening2. Rounded shape3. Hilum partial or total disappearance
Sampling to be made at the same time as the
breast biopsy
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6 mm
Under ultrasound : VPP 98 % Specificity sensibility : 92 to 98%
False negatives : 0 – 4% 7 % of Re biopsy (operator dependant)
Core Biopsy 14 Gauge (16 G Se 92%)
6 mm
Number of samples ( 2-3 minimum) (70% for 1 sample vs 95% for 3)
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Type [lobular vsDuctal (DCIS or IDC) ], Grade (SBR), Proliferation index
Receptors (RH), Her2 [ Reliability +++ IHC study for RH and HER2
fixation 8h min and 48h max on biopsies (GEFPICS 2010)
Benign / Malignant diagnosis
Breast Lesions staging (multifocal , multicentric, bilateral)
Prognostics factors, tumoral profile
Core Needle biopsy : confirmation BENIGN / MALIGNANT
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Limits and difficulties of Core Needle Biopsies under ultrasound
Small size lesions ?
3 -4 mm ? Visibility
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Small size lesions, difficult to localize due to the
surrounding tissue lack of contrast
Deep lesions
Interpretation
•Radio clinical discrepancy
•Histological complexity of the lesions +++ (Important fibrosis, inflammatory reactions)
Risk of under estimation
«volume tissue removal for DIAGNOSTIC »
Limits
Heywang –Kobrunner S , The breast Journal 2009
re-biopsy rate 7% and 23 % malign lesions
Limits and difficulties of Core Biopsies under ultrasound
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Place clip if any question of difficulty identifying lesion in future
–Neoadjuvant therapy planned: Mass may shrink or resolve
–Subtle finding
–Facilitate correlation with mammography
–Post-clip CC and 90° lateral mammograms
Limits and difficulties of Core Biopsies under ultrasound
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• Most feared complication(s)
–pneumothorax (< 0.1%) –large delayed hematoma (< 1%)
• Other complications
–local pain (common, mild, transient) –acute significant hematoma (< 1%)
• Occurs in < 1% of cases
–infection (rare)
Core Needles Biopsies : complications
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Philpotts LE & Al , Am J Roentgenol. 2003
Diagnostic BiopsyVacuum aspiration biopsy or core needle biopsy under ultrasound ?
14 G Automatic Biopsy Gun (n =181) 11 G Mammotome ( n= 100)
Similar results : Missed cancers, Complications, re biopsy
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Percutaneous excisionsSurgical excisional Biopsy : GOLD STANDARD
DIAGNOSTIC comparable surgerySe 94% to 100% Sp 96% to 98%
MORBIDITYImmediate Complications < 2%
LOWER ECONOMIC COSTS: 45% à 82% ++
Percutaneous ExcisionVacuum aspiration Biopsy under ultrasound guidance
Macrobiopsy with aspiration under ultrasound 7 Gauge
OUT-PATIENT PROCEDURE / UNDER LOCAL ANAESTHESIA
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Fibroadenomas(Careful ,pain is not due to the FA)
BI-RADS 3 nodulesRemoval : Dg and TTT
Size < 3cm
Needles 7G – 11 G
Palpables or not palpables
Indications and results Percutaneous Excision by VAB under ultrasound
Parker 2001, Fine 2002, Johnson 2002, Baez 2003, Sperber, 2003, March, 2003, Alonso, 2004, Povoski, 2007, He, 2008, Grady, 2008, Tagaya, 2008, Gulf, 2008, Grady, 2008, Thurley, 2009, Yom, 2009, Kim, 2010, Slanetz, 2010, Wang, 2009-11, Lou 2011, Wang, 2012
Young women with multiples nodes
Diagnosis before the exeresis
Diagnosis or Treatment : complete immediate excision > 73%
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Percutaneous Excision : Limits of Vacuum biopsies under ultrasound ?
Papillary lesions?? : under estimation 5 %
Isolated benign papilloma : isolated
lesion, peri-areolar topography in pre or perimenopause +++
Youk JH & Al Radiology. 2011
After the node complete exeresis
The under-estimation risk
becomes very low even equal to zero
Grady I & Al J Am Coll Surg. 2005
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Complex Fibro-adenomas
BI-RADS 4 & 5 nodesNode size> 3cm
Technically not feasable
• Breast size• Localization
Fibro-adenomas ? Quick growth
Non Elective Indications of Removal by Vacuum aspiration biopsy under ultrasoundParker 2001, Fine 2002, Johnson 2002, Baez 2003, Sperber, 2003, March, 2003, Alonso, 2004, Povoski, 2007, He, 2008, Grady, 2008, Tagaya, 2008, Gulf, 2008, Grady, 2008, Thurley, 2009, Yom, 2009, Kim, 2010, Slanetz, 2010, Wang, 2009-11, Lou 2011, Wang, 2012
Histology with atypicals
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Vacum Aspiratiuon Biopsy under ultrasound : Follow-up and complications
Hematoma: 3 to 10% Skin damage : 0,6%
Residual lesion up to 31%
But decrease after 2 years
• Incidence of Scar : 2 – 4,3%Follow up : difference residual lesion and scarring (2years)
• Recurrence 15% to 59 months ( Grady 2008 )
6 month 1 year 2 year
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Microcalcifications +++ 97% of the indications for macrobiopsy under stereotaxy
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Avoided surgery 53,1 %
Useful surgery > 70 %
Seror JY et Gynecol Obstet Fertil. 2000
Dg Precision = 98.6 %
Microcalcifications Biopsy : V.A.B.BiopsyWhat benefits for the patient ?
Number of samples : 12 with 11 G 6 -8 with 7 – 8 GaugeGuidelines from the European Society of Breast Imaging Eur Radiol , 2007
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Feasibility : The team experience
Limits
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No complication 83.3 %
Hematoma : 7.4%
No disturbing scar on the follow-up mammographies (6-12 months)
Post biopsy pain 24 h (7%)
Slight Cervical pain
Complications after Vacuum biopsy
Dressing allergy
The significant, hemorrhagic or infectious complications rate after biopsy is very low, inferior to 5 %.
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Post VAB ++ 3,9 % of complications per-procedure and 3,6 % for post-procedure
• The accent should be put on stopping the platelet-inhibiting drugs 10 days before the interventional procedure.
• Taking over of the heparin in case of anti-coagulant treatment
« Decrease of the under estimation by increasing the number of samples, and bigger hematoma risk
Complications after Vacuum biopsy
Interest of the 7 or 8 Gauge needle ( vs 10 or 11 G)
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Post biopsie j 8
HISTO : MFK
Bénin , Significatif et concordant
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ACR4
Results management : Radio histological concordance +++
Benign histology : Micro cysts with secretory metaplasia
Benign Significant Concordant result BIRADS 2
Benign Non significant or Non concordant result Mutdisciplinarydecision(Short-term follow-up (6 months) , New Biopsy ( 5%) , surgical excisional biopsy)
BIRADS 4
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ADH prevalence ADH underestimation
Year n % N %
Liberman 1998 12/112 11 1/10 10
Meyer 1999 - 1/9 11
Burak 2000 45/851 5 6/46 13
Darling 2000 - 16/86 19
Andrales 2000 90/1081 8 9/62 15
Philpons 2000 - 6/26 23
Cangiarella 2001 9/160 6 2/8 25
Jackman 2002 131/1964 7 22/104 21
Pandelidis 2003 37/134 3 5/37 14
Wincherster 2003 77/1750 4 11/65 17
Under estimation
(10 – 25%)
Hyperplasia with
Atypias
Surgical biopsy recommended
* Lobularneoplasias
* Papillarylesions
* Radial scars
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Why the fact of performing a VABB has an impact on surgery :
healthy margins and operating time?
Liberman L, et al. AJR. 2001
139 women
calcifications:
BIRADS 4 and 5
Women with a diagnosed cancer
% of a one-time surgery
Surgical biopsy (n=50)16.2%
(6/37)
Biopsy under stereotaxy
(n = 89 )
71.4%(55/77)
p = 0.0000001
% healthy margins Immediatesurgical biopsy
Pre-operatory biopsy
Liberman 1997 63 % 92 %
Jackman 1996 53 % 91 %
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Clip migration after a macrobiopsy :13 to 21% of the cases.
In case of clip migration, the exeresis rate in positive margin can reach 50%
Brenner RJ & Al Am J Roentgenol 2001;
Rosen EL & Al Radiology 2001
Burbank F & Al Radiology 1997
Kass R & Al Am J Surg. 2002
« Clip migration »
Limits
6 cm6 cm
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Microbiopsy or macrobiopsy with aspiration The limits of biopsies by fragmentation : MONOBLOC EXCISION
BLES (Breast Lesion Excision System
Intact® BLES System ® Lesion Capture (RF)
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BLES (Breast Lesion excision system) Intact System under ultrasound
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Immediate intraoperative or post-biopsy complications (8.2%) of the procedures. The most common immediate complication was hemorrhage that was minor and controlled by applying external pressure only (n = 6). Moreover, three patients suffered hemorrhage that required deep skin sutures while two patients developed a skin burn around the incision site
Late complications (12.6%). More specifically, delayed wound healing was encountered in seven
cases, minor hematoma in five and wound infection in four, one of which required administration of antibiotics
Complications of percutaneous stereotactic vacuum assisted breast biopsysystem utilizing radio frequency
European Journal of Radiology 82 (2013) 623– 626
N = 134
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N= 166 Intact procedures
AFTER SURGERY n INCOMPLETE REMOVAL
COMPLETE
REMOVAL
COMPLETE REMOVAL OF
INVASIVE
( ONLY DCIS)
PAPILLOMA 1 1
ATYPICAL LESIONS 9 7 77% 2 23%
HDA 4 3 1
HLA 2 2
Flat epithelial Atypiia 2 1 1
LIN2 1 1
CARCINOMA 36 23 63,8% 12 33,3% 1 (2,7%)
DCIS 27 16 59,3% 11 40,7%CCI 7 5 71,4% 1 14,3% 1
CLI 2 2
Total 46 31 67,4% 14 30,4% 1 (2,2%)
CIC Marges saines
CIC Marges positives
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Tomosynthesis
Mrs B.. 79 years old under heparin (Cardiac surgery contra indication)
CRP : Complementary radiotherapy follow up at 6 months
Radiographie prélèvement Intact
Healthy margins : 3 mm
Tubular carcinoma 5 mm Very well differenciated
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•Feasability
•Surgical resumption of atypias and small cancers with healthy margins
(lack of recul and insufficient studies)
• BLES Complementary technique to VABB with aspiration
• Today : excellent diagnostic precision (less under estimation)
Balance after 10 years of exper ience : D iagnost ic or therapeut ic
Limits
• Therapeutic perspectives• Atypical hyperplasias and small size cancers :
Complete percutaneous excision vs therapeutic surgery
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Biopsies under RMI
Biopsies under ultrasound or stereotaxy possible in 50% to 80% of the cases if a MRI abnormality not detected initially under ultrasound or mammography
DeMartini & al. Utility of Targeted Sonography for Breast Lesions That Were Suspicious on MRI. AJR 2009;192:1128
Development limited by the technical , organizational and economic constraints
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J-Y Séror
Centre Duroc Paris 6
www.imagerieduroc.com
Interventional
Senology
State of the art
Interventional Senology
Diagnostic and therapeutic
State of art - Limits - Complications
« Israeli-French Breast Cancer Update »Prevention, Detection and Treatment, a Multidisciplinary approach