Luc Rotenberg : US guided vacuum breast biopsy and minimal Invasive Interventional procedures

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Minimal Invasive Interventional
procedures in breast lesion
Luc Rotenberg, Grégory Lenczner, Jean Guigui,
Catherine Bèges, Henri Ouazan

RPO – ISHH

Clinique Hartmann-CMC Ambroise Paré

26-27 bdVictor Hugo

92200 Neuilly Sur Seine - France

dr.rotenberg@radiologieparisouest.com

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US guided Breast interventional
procedures:
What possible, what feasible ?

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Minimal invasive diagnosisMinimal invasive treatment ?
•  Benign lesion
•  Malignant lesion ?

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Local Treatment
Surgery / Minimaly treatment US procedures

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Breast Intervention: How I Do It
Mary C. Mahoney, Mary S. Newell, Cincinnati, Altlanta
Radiology, 2013, Vol.268: 12-24, 10.1148/radiol.13120985
S  Written informed consent is required before all breast interventions
S  The risks explained to the patient include bleeding and infection
S  Anticoagulation is a relative contraindication to all biopsies
S  patients are usually asked to discontinue therapy for a short time prior to the
biopsy
S  The patient should be informed of the potential benefits of the biopsy
S  including avoidance of surgery with benign results
S  preoperative confirmation of malignancy, which allows definitive surgical treatment in one
surgical setting
S  Tailored prebiopsy counseling may better prepare women for percutaneous breast
biopsy and improve their overall experience.

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Minimal Invasive Interventions
Methods - Overview
Methods - Comparison
Risk and complications
Tumor cells after
Intervention
Reimbursement
pricing
Preconditions for

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Preconditions for Minimal Invasive Interventions:
Complementary Breast Diagnostic
Clinical Examination Mammography Sonography
Radiological
Special X-Rays
Color Doppler
Sonography MRI

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Breast Biopsy : Ultrasound
Why Ultrasound Guidance?
•  Real-time imaging of the breast
•  Patient is lying on their back
•  Ultrasound has excellent contrast resolution
•  Cost effective
•  Non-ionizing
•  Portable

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S  Side
S  Size
S  h x L x l
S  Location
S  Quadrant
S  Radius zone
S  Distance to the nipple
Balistic target tracking
•  US
•  RX
•  MRI

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•  Side
•  Size
•  h x L x l
•  Location
•  Quadrant
•  Radius zone
•  Distance to the
nipple
S  Deep / cutaneous plane
US balistic target tracking

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S  Vacuum assisted devices
S  Mammotome
S  1995, 11 et 8 g
S  Vacora (Bard)
S  2003, 10 g
S  2007, 14 g
S  Atec (Suros - Hologic)
S  2007, 12 g 9 g
S  Seno RX (Bard)
S  2009, 10 g, 7 g
S  Intact 2009
S  Large core devices
S  16 g
S  14 g
S  Single use devices +++
S  Other biopsy devices
S  Spirotome & Coramate
(Medinvents)
S  2007, 14 et 9 g
S  Celero (Hologic)
S  2008 12 g
S  Finesse (Bard)
S  2010 14 g
Choice of the Needle

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Possibilities of Assessment
Vacuum Assisted Breast Biopsy
Interventional Methods
VABB
Directional Vacuum - Assisted Breast Biopsy

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§ local anesthesia
§ external procedure
§ Explanation +++
§ Time 15 to 40 mn
Breast biopsy
14 G 11 G 10 G 8 G
17 mg 95 mg 160 mg 300 mg

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Indications for diagnostic representative or
ablative Vacuum - Biopsy (VABB) /US
1.  After Large Core Needle Biopsy (LCNB) and suspicion of breast cancer (BI-RADS®
4c / 5, missmatch / discordance of the results of diagnostic imaging and histology)
2.  Suspicious lesions (BI-RADS® 4 / 5) diameter ~ 5 mm
3.  Resection of definitely benign, but symptomatic findings or High risk patients
1.  symptomatic Fibroadenoma
2.  recurrent symptomatic cysts
4.  Intraductal / intracystical proliferations : singulary Papilloma, complex cyst
5.  Neoadjuvant Chemotherapy
6.  Suspiscious of local recurrence
7.  Hazardous or dangerous location : deep, superficial, implants…

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implants
CLI
VABB (Suros 9g, Seno Rx 7 ou 10g)

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Post Minimal Invasive Therapy
assessment
J8-J15

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At an histopathological
benign result there should be
performed an imaging control
after 6 months

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Interactive Case Review of Radiologic and Pathologic Findings from
Breast Biopsy: Are They Concordant? How Do I Manage the Results?
Christopher P. Ho, MD, Jennifer E. Gillis, MD, Kristen A. Atkins, MD, Jennifer A. Harvey, MD, and , Brandi T. Nicholson, MD
University of Virginia Heath System, Chalottesville, Va. Radiographics, Volume 33-4 , 2013
S  To successfully perform a minimally invasive breast biopsy
S  it is important to not only be familiar with the technique
S  but also with how to determine radiologic-pathologic concordance
S  and the appropriate treatments for patients after the procedure
S  When reviewing pathologic results for concordance
S  it is important to ensure that microcalcifications are identified in the
histologic specimen
S  and the specific pathologic diagnosis is consistent
S  with the morphologic characteristics seen at mammography
S  and the pretest probability of malignancy.

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Interactive Case Review of Radiologic and Pathologic Findings from
Breast Biopsy: Are They Concordant? How Do I Manage the Results?
Christopher P. Ho, MD, Jennifer E. Gillis, MD, Kristen A. Atkins, MD, Jennifer A. Harvey, MD, and , Brandi T. Nicholson, MD
University of Virginia Heath System, Chalottesville, Va. Radiographics, Volume 33-4 , 2013
S  At the follow-up examination
S  both the histologic and imaging findings should be revisited
S  and the mass should be assessed at mammography or US to ensure that it is stable
S  If it has grown in size or its morphologic characteristics have changed
S  If calcifications increase in number or extent or the mass changes
S  Increases in size or its features become more suspicious
S  appropriate action should be taken
S  Excision is typically recommended
S  If the lesion is stable at follow-up examination
S  the patient may return to the general screening population

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Discussion
S  Underestimation rate
ADH, DCIS, LCIS
S  Not eliminated with VABB
S  >> PPV : malignant
S  >> NPV : benign
S  Surgical indication

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Roger J. Jackman & al, Radiology February 2001 218:497-502
Stereotactic Breast Biopsy of Nonpalpable Lesions: Determinants of Ductal
Carcinoma in Situ Underestimation Rates
S  DCIS underestimation rates by biopsy device were
S  20.4% (76 of 373) at large-core biopsy
S  11.2% (107 of 953) at vacuum-assisted biopsy (P < .001)
S  24.3% (35 of 144) of masses
S  12.5% (148 of 1,182) of microcalcifications (P < .001)
S  and by number of specimens per lesion
S  17.5% (88 of 502) with 10 or fewer specimens
S  11.5% (92 of 799) with greater than 10 (P < .02).
S  DCIS underestimations increased with lesion size
1.9 times more frequent with masses
than with calcifications
1.8 times more frequent with LCB than
with VAB
1.5 times more frequent with 10 or fewer
specimens per lesion than with more
than 10 specimens per lesion.

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Projektpartner
1.  Fraunhofer-Institut für Integrierte Schaltungen IIS, Erlangen,
Kohr et al. Radiology 255: 723 - 730 (2010)
N = 991; N = 147 cases of atypia
The upgrade rate is significantly higher when ADH involves at
least three foci.
Surgical excision is recommended even when ADH involves
fewer than three foci and all mammographic calcifications
have been removed, because the upgrade rate is 12%.
Wagoner et al. Am J Clin Pathol 131: 112 - 121 (2009)
N = 123;
Patients with ADH restricted to fewer than 3 foci may not need
surgical excision, especially when the mammographic
abnormality is completely removed by VAB.

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Atypical Lobular Hyperplasia and Lobular Carcinoma in Situ at Core Breast Biopsy:
Use of Careful Radiologic-Pathologic Correlation to Recommend Excision or
Observation
Kristen A. Atkins, Michael A. Cohen, Brandi Nicholson, Sandra Rao.
Northwestern Memorial Hospital, Prentice Women’s Hospital, Chicago.
S  By consensus of the physicians involved in the diagnosis and treatment of breast
disease at the University of Virginia, all cases of ALH or LCIS diagnosed at core
needle biopsy receive a recommendation for surgical excision of the biopsy site.
S  with careful pathologic-radiologic correlation, noninvasive ALH and LCIS were not
independent risk factors for worse pathology on excision
S  None of the 43 (95% CI: 0%, 8%) benign concordant cases determined with careful
radiologic-pathologic correlation were upgraded at subsequent surgical excision or
extended imaging follow-up
S  which suggests that arbitrary excision in all cases of ALH or LCIS may not be necessary.
S  In essence, we have reaffirmed the work of Liberman et al , AJR Am J Roentgenol
1999;173(2):291–299
S  LCIS (and we have added ALH) with concordant imaging-histologic analysis need not
undergo surgical biopsy
S  comprehensive communication between the radiologist and pathologist, triaging
of the biopsy results works well and may save many patients from undergoing
surgical excision

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Atypical Lobular Hyperplasia and Lobular Carcinoma in Situ at Core Breast Biopsy:
Use of Careful Radiologic-Pathologic Correlation to Recommend Excision or
Observation
Kristen A. Atkins, Michael A. Cohen, Brandi Nicholson, Sandra Rao.
Northwestern Memorial Hospital, Prentice Women’s Hospital, Chicago.
S  Advance in Knowledge
S  When careful radiologic-pathologic correlation is conducted in the setting of a
breast core biopsy with atypical lobular hyperplasia or lobular carcinoma in situ
S  some women can be safely triaged to observation
S  of the 43 benign concordant cases, none were upgraded at surgery or extended
follow-up (95% confidence interval: 0%, 8%)
S  Implication for Patient Care
S  Focused and complete radiologic-pathologic correlation may obviate
excisional biopsy in patients with benign concordant biopsy findings.
S  Additional validation of this is required before this approach can be universally
applied

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Discussion
to excise or to sample ?
—  Excision for probably benign lesion + clip
S  Birads 3
S  Birads 4a
—  Sample for suspicious or malignant lesion
S  Birads 4 b & c
S  Birads 5 & 6

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Radiofrequency ablation
Alterning electrical current (420-500 kHz)
= Minimally invasive procedure
using a thin electrode needle
Ø Ionic agitation
Ø heating of the surrounding tissue
Ø T> 60°C, Necrosis

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Breast is RF friendly
Volume of ablation for a given quantity of RF energy
S  Lung (13 ± 3.5 mm)
Breast (11.8 ± 3.5 mm)
S  Soft tissue (9.8 ± 1.0 mm)
S  Kidney (7.3 ± 0.6 mm)
Specificity of the breast tissue
- Electric conductivity
- Thermal diffusion
- Low vascularity
Manenti G et al. Radiology 2009
Ahmed M, Radiology 2004

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Drawing illustrates the RF ablation device correctly placed so as to produce a thermal
lesion volume (black outline) that is concentric to the tumor and that encompasses the
tumor and a sufficient margin of noncancerous tissue.
Fornage B D et al. Radiology 2004;231:215-224

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US monitoring to ensure accurate placement of the RF device in the
Geometric center of the tumor to be ablated.

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MR images show visualization and segmentation of the RF ablation–induced lesion in three
perpendicular planes (left to right: axial, sagittal, coronal).
Manenti G et al. Radiology 2009;251:339-346

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Close-up view of the specimen in a shows the
well-defined tumor in the center of the ablation zone

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a negative reaction to NADH-
diaphorase stain, which confirmed
the absence of viable tumor cells
after RF ablation

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Axial MR images show successful RF ablation
in 55-year-old woman with breasts with a
dense glandular pattern.
Manenti G et al. Radiology 2009;251:339-346
Images show residual enhancement in 66-
year-old patient with breasts with a fatty
glandular pattern.

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Cryotherapie
S  nonoperable liver metastases from colorectal cancers
S  Cryotherapy uses coldness to achieve tumor destruction
S  Local anesthesia
S  Energy is produced by an external generator composed of an argon or
nitrogen freezing system and a helium heating system
S  Several probes can be used simultaneously for larger tumors
S  The probe is inserted in the center of the tumor under imaging guidance
(US or MRI) through a tiny incision
S  Iceball is created at the needle tip destroying the tumor as well as 5–10
mm of additional breast tissue surrounding the lesion

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Littrup P J et al. Radiology 2005;234:63-72
Iceball

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Cryotherapie
S  During each freeze cycle, temperatures from –185°C to -70°C
S  Tumor destruction in real time under US or MRI.
S  Tumor destruction is the result of cell damage from membrane
rupture during the successive freeze-thaw cycles
S  In the center of the tumor, cells are completely destroyed
S  in the periphery, a necrotic zone of some millimeters with viable
cells is observed
S  cryotherapy ablation zone needs to be larger than the tumor size
to be effective.
S  T < 2 cm

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Implications for breast cancer management
S  The aim of breast conservation surgery
S  to remove the entire tumor
S  achieve negative surgical margins
S  preserve the breast and patient’s body self-image
S  Minimally invasive approaches
S  must offer at least the same advantages as surgery
S  should be at least equivalent to tumor excision with proven
negative surgical margins
S  Minimally invasive ablation techniques may replace
surgical resection in the future
S  If they do, having imaging modalities that can detect
tumor destruction would be essential.

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Patient categories may benefit more from these techniques
S  Elderly breast cancer patients
S  often undertreated
S  worse outcome compared with younger patient
S  minimally invasive approaches may allow these patients with
multiple comorbid conditions to be suitable for local treatments
and be cured
S  neoadjuvant chemotherapy
S  challenge to be overcome in the future by novel and less
invasive approaches
S  Residual disease can potentially be ablated without the need for
surgery in an outpatient setting and can increase quality of life

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S  USBP are essential tools in the diagnosis of nonpalpable
lesions
S  devices used for biopsy have limitations, which lead to
increased failure and underestimation rates for
diagnosing of various breast lesions
S  USBB must be handled cautiously
S  careful interpretation of some histopathologic results is
ensured
S  Complications are rare (<2%) and include hematomas,
persistent bleeding, vasovagal episodes, and wound
infection
USBB can be a useful tool for both the diagnosis and
optimal patient management

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S  Percutaneous image-guided biopsy techniques have replaced
open surgical biopsies
S  considered to be the standard procedure for the diagnosis of
breast cancer
S  None of the ablative techniques described are used alone in
current clinical practice for the treatment of breast cancer and
are used only in study settings.
S  Surgery remains the standard local treatment of breast cancer,
with radiation therapy if needed clinically
S  The value of these treatments compared with traditional open
surgery needs to be confirmed by large prospective studies.
S  In addition, cost-effectiveness and long-term effect on
cosmetic outcomes still need to be investigated.

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S  Balistic consultation
S  Faisability
S  Explanation
S  Concordance +++
S  Device and guidance
S  Success rate : 95 à 98 %
S  Under-estimation :
S  ≈ 10 % VABB , less with Intact
S  ≈ 20 % LCNB
S  = Surgery if boarder line lesion
S  Present & Next Futur :
S  Minimal invasive therapy
S  Benign
S  Malignant ?
Take home

Luc Rotenberg : US guided vacuum breast biopsy and minimal Invasive Interventional procedures

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Luc Rotenberg : US guided vacuum breast biopsy and minimal Invasive Interventional procedures