ultrasound-guided breast interventional procedures

Ultrasound-guided breastinterventional procedures

Salima HIBAT ; C. Balleyguier

Breast interventional procedure

• Considerable progress in recent years

• Precise and accurate diagnosis, Bi RADS 4 & 5

• Bi RADS 3 • High risk patients

• Before pregnancy

• Follow-up impossible

• Anxiety

• By Bi RADS 6 Lesion

Quality criteria and results

• Rates of false negatives and underestimates must be evaluated and limited.

• Percentages recommended by EUSOBI : • false negative for cancer on percutaneous biopsy: < 2%

(acceptable < 5%);• diagnosis of cancer in situ on biopsy, classified as invasive after

surgery: < 5% (acceptable < 15%);• diagnosis of border lesions on biopsy, classed as invasive

cancer after surgery: < 10% (acceptable < 25%). • Percutaneous biopsies :

• help limit the number of surgical procedures by increasing the positive predictive value of surgery (which was lower than 50% before the use of such biopsies)

• lowering the number of revisions for insuffi- cient margins

Various procedures

• Ultrasound-guides fine needle biopsies

• Micro biopsy :• Ultrasound guidance• Stereotactic guidance

• Vacuum biopsy :• Stereotactic guidance• Ultrasound guidance• Tomosynthese guidance• MRI guidance

• One-pass-en-bloc excision :

• Intact ® System

• Pre operative targeting• Stereotactic guidance• Ultrasound guidance• Tomosynthese guidance• MRI guidance

Specific initial training / regular practice

• at least 20 procedures per type of guidance, with histological verification and checking by a specialist, before being able to work alone;

• to maintain a sufficient degree of competence subsequently, 25 procedures per year are considered to be necessary

Fine needle biopsy

Fine needle biopsy

• Palpable mass

• Ultrasound-guided:• Parallel

• Perpendicular

• Rapid, inexpensive

• Experience +++

• Capillary technique / Aspiration technique

FNB - Indications

• Cystic lesions: • Typical cyst + pain: aspiration and evacuation

• Atypical cyst

• Masses :• Palpable

• Non palpable :

• Atypical lesion

• Bi RADS 3 lesion by women discovered > 35 yrs

• Lymph nodes

Prerequisites

• Reviewing the case

• Report :• Side

• Quadrant

• Distance nipple

• Skin distance

FNB – Techniques

• Optimal position

• Fine needle: 18 G to 27G.

• +/- syringe

• Local desinfection

• Sterile gloves / ultrasound protection

• No local anesthetic

• No gel : water or antiseptic

FNB - Kalinox

1/ FNB- Palpable mass

Capillary technique

Aspiration technique

2/ Ultrasound-guided FNB

• 2 Techniques for approaching the lesion

• Parallel

• Perpendicular

a) Parallel technique

• Needle approaches the skin parallel to the long axis of the probe 10-20mm

• Advantages : • Needle visible trough its course

• Less risks to go to deep

• Inconvenients : • Longer way

Grumbach 2002

• Perpendicular to the probe

• Advantage :• Shorter way

• Inconvenients : • Only the extremity is visible as a very attenuating

echogenic spot ( tip echo)

• Major risk of complications

b) Perpendicular technique

Grumbach 2002

• Aspiration in a syringe

• Bacteriological analysis

• Onto a slide

3/ FNB +/- aspirationCystic lesion

Grumbach 2002

• Verify needle position

• Capillarity +/- aspiration

• Back and forth movements rotating about it own axis

• 2 FNB per mass

• By bloody aspiration , repeat

4/ US-guided FNBMasses

N. Poté, Beaujon

Grumbach 2002

FIBROADENOMA

5/ FNB Lymph node, perpendicular approach

5/ FNB : Parallel approach

Jalaguier-Coudray JFR 2010

Ultrasound-guided core needle biopsy

Indications

• Histologically confirmation of malignancy :• Before neo adjuvant chemotherapy +++

• Multifocal ?

• Bilateral ?

• Grade, Hormon receptors

• Histologically confirmation of benignity:• To avoid unnecessary surgery

Advantages

• High sensibility et specificity (97 %, 95 %)

• Determinate the initial surgical or medical treatment

• Protocol for detecting the sentinel lymph nodes or lymph nodes can be set up

Indications

• By non conclusive FNB

• Recommandations ANAES (2003) : • At least 80 % diagnoses before the surgery

• Better surgery planification

• No particular precautions regarding hemostasis :• But careful with anticoagulants

• Sterile bandage with compression

• Material : Needle 16 G (1,3mm) ou 14 G (1,6mm)

• Automatic guillotine type system• 15 mm to 25 mm

• 3 - 5 samples / lesion

Technique

Apesteguia, Insight Imaging 2011

N. Poté, Beaujon

Prerequisites

• Reviewing the case

• Report :• Side

• Quadrant

• Distance nipple

• Skin distance

• Local desinfection, asepsis

• Local anesthetic (10ml Lidocaine +/- 1,5 ml bicarbonate)

• Skin incision at the entry with a scalpel

• Needle : contact with the lesion

• Image documentation before and after deployement

• Compression after deployement

• Adhesive band ou Steristrips®

Technique

Tipps

• Choose the best positioning and introduction point

• Place the lesion at the medial / lateral third of the image

• Skin incision not to close from transducer

• Skin marking

• Never move at the same time needle and transducer

N. Poté, Beaujon

Grumbach 2002

Superficial lesion

Left approach

• Entry site further from transducer

• Shaft parallel to chestwall : pneumothorax

• +/- small sliding , sweeping motions to “catch” the lesion

• +/- anesthetic injection to push the lesion from chestwall

Deep lesion

Escolano 1999

Pre pectoral lesion


Same axe needle and transducer

Never move the both at the same time

Co-axial


• Dilemma between• Lowest rate of false negatives

• Leave some lesion for the pre operative targeting

• Fishman, Radiology 2003; 226: 779-782• False negative30% (1sample), 8% (2 sample), 4% (3 sample),

0% (4 sample)

Number of samples

Images C. Vermersch

Sample

• Collection tube with formaldehyde solution

Sampling

Lymph nodes

FNB +++

Hiroyuki, radiographics 2007

Semi automatic core needle preferred


Vessels +++


INTACT ® system

• Large core biopsy and tumor destruction

• Ultrasound or mammography guided

• One-pass-en-bloc excision

INTACT ® System

../../../../../AA LUCSCIENCE/PWP/SOFMIS 2009/VAUBAN venderdi/14h45-16h30/5_JEAN YVES SEROR/M8.wmv

Do we have to biopsy BI RADS 3 lesions?

• No, normally :• Cancer by BI RADS 3 < 2 %

• Eventually if :• Follow up difficult

• BI RADS 3 and pregnancy

• BI RADS 3 et BI RADS 6 lesion

• Familiary history

• Anxiety

Pre operative targeting

M.H Dilhuidy Bergonié Bordeaux

Surgical position- arm 90 °

Skin marking

Complications

• FNB : less invasive• Pneumothorax

• Core needle biopsy :• Hematom

• Pneumothorax

• Infection

• Allergy

Perpendicular approach

5 mm



Pre targeting After targeting

• Perpendicular approach

• Skinny patient

• Deep lesion

Conclusion

• FNB : fast, inexpensive

• Cystic lesions

• Not sufficien cells for analysis

Conclusion

• Core needle biopsy : more invasive but less false negative

• Complications : pneumothorax +++

• Training necessary

ultrasound-guided breast interventional procedures

Documents