minimal invasive breast procedure

7/27/2019 Minimal Invasive Breast Procedure

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Minimally Invasive Breast

Procedures

F. Sperber, M.D.

Breast Imaging Center

Sourasky Medical CenterTel Aviv University


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Percutaneous core breastbiopsy - Advantages

Since a few years ago most of the suspiciousclinical or mammographic lesions were diagnosedby surgical biopsy.

With time percutaneous core biopsy proved to beefficacy in the diagnosis of breast lesions.

Is faster, less expensive than surgical biopsy.

Less tissue is removed resulting in no deformity orscaring.


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Percutaneous core biopsy-

Advantages

Spare surgery in benign lesions (60% of themammographic findings).

Reduce the number of surgical procedures incases of breast cancer, providing surgeryplanning.

Lumpectomy and sentinel node or axillary

dissection as one step procedure in malignantcases.

Mastectomy in cases of multifocal-multicentriclesions.


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Guidance modalities

Stereotactic mammographic guidance

Ultrasound guidance

MRI guidance


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Stereotactic mammographicguidance

Stereotactic units are available in two differentconfigurations :

-Add -on units attached to mammography units

(sitting position).-Dedicated prone tables ( lying position).

Selection of equipment is based on considerations

of cost, patient volume and space availability.


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Stereotactic mammographic guided


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Mammographic Guided Biopsy-

Stereotactic Table


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Stereotactic mammographic guided

Advantages

Patient motion is eliminated

Patient dont see the biopsy lessvasovagal reactions

Disadvantages:

SpaceDifficult access to lesions close to the chest

wall


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Stereotactic mammographicguidance: Technique Enables a lesion to be localized

three-dimensionally trough theused of angled images.

Localization is done byidentifying the site of the lesionin x-axis, y-axis and z-axis.

The depth of the lesion (z-axis)is calculated by the shift of thelesion along the x-axis whenthe tube is tilted in this plane.

Standard equally angled viewsof 150 are used to calculate the

location of the lesion. Accuracy in performing the

biopsy is dependent on theaccurate localization of thesame point in the lesion onangled views.


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Mammographic guided


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Ultrasound guidance

One of the most important applications of breastultrasound is to guide interventional procedure

Most common used technique.Advantages:

Non-ionizing radiation. Accessibility to all parts of the breast and axilla. Quicker and no discomfort (no breast

compression). Real time visualization of the needle providing

accuracy of the targeting. Low cost.


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Ultrasound guidance

Disadvantages

Most difficult technique to perform.

Requires long time of expertise.Slow learning curve.


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MRI guided

Always performed aftersecond look ultrasound(fails in > 77%).

MRI compatible devices.

Biopsy is performedoutside the magnet.

Coaxial sheath:Inner stylet

Outer cannula


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Biopsy Procedure

Fiducial Marker: Small plasticcapsule filled with saline andgadolinium or oil.

Calculation of x,y,z

MRI moved out and the needle

guide is adjusted Lidocaine injection

Coaxial sheath is inserted, innerstylet is removed

MRI table is returned to the

magnet Limited axial sequence is

performed

Site clip


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MRI biopsy guidance


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Tissue Acquisition Devices - Typesand Indications

FNA ( Fineneedle aspiration)

Core biopsy

Vacuum assisted core biopsyFine needle localization devices


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Minimally Invasive Procedures Types &

Indications

FNA Cysts, Lymph nodes

Core Needle Biopsy Solid masses

Drainage of

collections

Abscess and post

surgical collectionsFine NeedleLocalization

Pre-Operative

Vacuum-Assisted LargeCore Needle Biopsy

(Mammotome)

Solid masses smallerthan 5mm andcalcifications


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FINE NEEDLE ASPIRATION

Most popular technique of biopsy for breastpalpable and nonpalpable lesions.

ADVANTAGES

Virtually atraumatic

Rare to even cause a hematoma

Simple to perform

DISADVANTAGESExtremely dependent on level of cytological interpretation.

High percentage of insufficient, material aspirates (34%-40%).

Cytology doesnt differentiate between in situ from invasivedisease


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TECHNIQUE-EQUIPMENT

10-20-30 ml LUER-LOK syringe

21-23-25G needles

Needle length 3.6-7.8cmGlass slides

95% alcohol fixative

Anesthesia is optional


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ASPIRATION TECHNIQUE

After placement of needle, a syringe isconnected.

Suction is applied by pulling the plungeof the syringe.

Sampling needle should be moved back

and forth rapidly within lesion.Needle is angled in multiple directions.


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TECHNIQUE FOR F.N.A.

Vertical or obliqueneedle insertion.

Needle should be

orientedperpendicularly toultrasonic beam.

Needle shaft and

tip should bevisualized duringprocedure.


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FINE NEEDLE ASPIRATION

Pre-FNA Post-FNA


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LYMPH NODE F.N.A.


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CORE NEEDLE BIOPSY - CNB

First described in 1982 by Perlinggren,Sweden.

Cutting needle fits in automated spring-

loaded biopsy gun.

Most accurate results with 14-gauge.

Needle consists of inner tissue sampling

needle and outer cutting needle.


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CORE NEEDLE BIOPSY - CNB

17mm tissue slot is located4mm from end of innerneedle.

Prebiopsy position , outerneedle covers innerneedle.

Inner needle is advancedforward, moving tissueslot within lesion.

Outer needle slides overinner needle, cutting atissue sample and securingit in slot.

Throw short &

long (15/22mm)

Throw short &long (15/22mm)

Trigger Safety device


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DISPOSABLE SEMIAUTOMATICBIOPSY NEEDLE

Stylet

Hub

Main part

Plunger


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CNB - TECHNIQUE

Patient in supine position.

Skin disinfection with alcohol or polydine.

Probe is disinfected with alcohol

Probe may be covered with sterile plasticsheath.

Sterile gel or alcohol should be used ascoupling agent.

Local anesthesia.

Skin incision, 2-3mm.


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Needle placement with ultrasoundguidance - TECHNIQUE

Transducer is placedon patients skin so

both lesion and pathof needle are visible.

Needle position is

documented withlongitudinal andtransverse scans.


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Ultrasound guidance-Technique


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Core Sampling

5 or more cores require reinsertion andrepositioning of needle.

Visual inspection of samples.


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CNB - TECHNIQUE

Specimen placed informalin and sent for

histologicaldiagnosis.

5-10 minutescompression.

Bandaging applied.


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Advantages of Core Biopsy

96%-100% concordance between CNB

and surgery.No insufficient samples.

Histological tissue diagnosis allows

differentiation of IDC from DCIS.


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Disadvantages of Core Biopsy

Multiple insertions and removal of the needle.

Later samples composed predominantly of

blood.May be nondiagnostic in small lesions

Retrieval of calcifications is difficult

Incomplete characterization of ADHand DCIS


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COMPLICATIONS AND RISKS

Fainting.

Hematoma 6-30%.Seeding of needle track by malignant

cells.


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Vacuum-Assisted Mammotome

Histology Large, contiguous tissue samples

Less precise targeting requiredbecause of vacuum assistance

Ability to place a marker at the biopsy site

Sutureless

Single insertion


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Vacuum-Assisted Biopsy:Advantages

Suction of the blood out of the biopsycavity.

Only one insertion of the needle.

Larger specimen- 11G or 8G.


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Vacuum-Assisted Biopsy:Advantages

Significant improvement in the retrieval ofcalcifications

Vacc m assisted biops


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Vaccum assisted biopsy:Advantages

Clip Placement

More accurate characterization of ADH and DCIS,DCIS and IDC.

Reduction in the underestimation of ADH andDCIS comparatively to core biopsy.


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NEEDLE LOCALIZATION FOR BREASTEXCISIONAL BIOPSY- F.N.L.

Designed to direct the surgeon toappropriate site within breast, insuring

accurate removal of suspicious lesion.Less commonly used for diagnostic

purposes only when accurate needle

sampling was not achieved


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HOOKWIRE SYSTEMS


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HOOKWIRE SYSTEMS

M hi Fi N dl


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Mammographic Fine NeedleLocalization

S fi Fi N dl


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Sonografic Fine NeedleLocalization

EXCISED SPECIMEN


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EXCISED SPECIMEN

Two-view magnifiedspecimenradiograph.

US specimen in masses

visualizedsonographically


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Minimally invasive technique in Breast

Cancer Treatment: The Future

Stereotactic excision with vaccum assistedcore biopsy

Criotheraphy monitored by ultrasound

Laser ablation/focused ultrasound

Radiofrequency monitored by ultrasound


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Cryotheraphy

Advantages

- Is easy visualizedwith ultrasound.

- Painless.- Can be used for

masses near theskin.


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Intracellular Ice Formation

Very high freezing rates

Within a few millimeters of the cryoprobe

Ice crystals cause mechanical injury to cellularorganelles and membranes.


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Extracellular Ice Formation

Solution Effects-Majority of iceball experiences lower freezing rates

-Ice formed outside the cell hyperosmolarity.

-Osmotic dehydration and shrinkage of the cell.-Damage to enzymatic machinery, destabilization of cell

membranes.


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Delayed Ischemic Damage

Dominant killing mechanism results in uniformnecrosis.

Endothelial cells comprising the microvasculatureare very susceptible to direct damage.

Microvasculature endothelial destruction resultsin post-thaw platelet aggregation and subsequentvascular stasis.

Within hours and days following cryoablation

ischemic damage occurs throughout thepreviously frozen volume.


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Conclusions

Minimal invasive procedures became 1/3 of thediagnostic work in breast imaging.

Team work approach is essential for further

management of the breast cancer patient.

The traditional approach to surgical marginsmay be replaced in the very near future by

minimally invasive treatment techniques of theprimary tumor.

minimal invasive breast procedure

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