Interventional Radiology : Useful for All and Always ? Dr S. Murgo CHU Tivoli, La Louvière, Belgique Hôpital Erasme, Bruxelles, Belgique.
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Slide 1
Slide 2
Interventional Radiology :
Useful for All and Always ?
Dr S. Murgo
CHU Tivoli, La Louvière, Belgique
Hôpital Erasme, Bruxelles, Belgique
Slide 3
Introduction
Screening Many benign lesions indistinguishable
from cancer
Previously open surgical biopsies (OSB) for
asymptomatic benign lesions were often necessary
Quick development of percutaneaous biopsies for
BIRADS 4 and also 5
with often a lack of scientific validations some controversies
Slide 4
Potential advantages
Less invasive, less expansive techniques that avoid:
surgery for benign lesions
surgery in 2 times
Percutaneaous biopsy may avoid per-operative
histological analysis that may destruct small lesions
Slide 5
Potential drawbacks
Epithelial displacement (FNA, CNB > VACB):
No evidence of biologic significance
No of the recurrence rate after BCS
But some displaced cells associated with DCIS can sometime mimic
IDC for pathologist.
Risk of missed cancers good knowledge of
limitations
Slide 6
Slide 7
Interventional Radiology
Includes:
Guidewire Localization
RadioFrequency
Fine Needle Aspiration
Core Needle Biopsy
Large Core Needle Biopsy
Slide 8
Main Mammographic Signs
Mass
Architectural Distorsion
Microcalcifications
Slide 9
Slide 10
Mass: with irregular / stellate outline
DD: Radial scar, complex sclerosis lesion, invasive carcinoma
(usually grade I or II), fat necrosis, granular cell
myoblastoma,…
FNA ?
10 % of C1 (not enough cells) CNB
False negative: 6-7% (1) C2 no value
PPV of C3 : 55 % if suspect 83% (2)
PPV of C4 : 96 % if suspect 98.5 % (2)
PPV of C5 > 99.4 % (2) invasive carcinoma ?
(2)
CNB
(1)
Lau. The breast Journal 2004; 10: 487
Bulgaresi. Breast cancer Res Treat 2006; 97 (3):319-21
Slide 11
Mass: CNB
14 g – with 3 samples in the target
(1)
Koskela. Radiology 2005; 236: 801-9
Slide 12
Mass: with well-defined outline
DD: Cyst, FA, hamartoma, lymph node, phyllodes tumor,
invasive carcinoma (high grade), papillary lesions, mucinous
carcinoma, medullary carcinoma, abscess
Ultrasound
1 - Typical cyst, harmatoma, or LN STOP
2 – « Typical FA » different schools:
Follow-up ? Not palpable 0-2 % of malignancy (mean: 1.4% - Lower for young women (< 30 yo))
Triple test with FNA ? Negative predictive value: 100% (1) but … false positive !
CNB the best test to exclude a breast cancer ! Especially for large lesion and old women (> 60 % of
carcinoma after 60 yo)
(1)
Lau. The breast Journal 2004. 10: 487
Slide 13
? FA ?
6 mo follow-up
No change
after 2 y
0.026% of missed
cancers
Change
CNB
FNA
C1
C2
(1)
CNB
Best test
10-15 % CNB (3)
99.9 % B
0.1% M (7% of 1.4% BC)
NPV 100 %
PPV > 98 %
C3
(after 3 years) (2)
Not palpable
98.6 % of benign lesions
7-8 % CNB (4)
(3 samples in the target)
16 % of cancers
86.1 % of T0N0M0 or T1N0M0 (2)
(1)
Sickles. Radiol Clin North. Am 1995; 33:1123-1130.
(2)
Sickles. Radiology 1999; 213:11-14.
(3)
Wells. EU guidelines for non-operative diagnostic procedures. 2004
(4)
Lau. The breast Journal 2004; 10: 487
Slide 14
Tabar. Radiol Ciln North Am. 2000; 38(4):625-651
Slide 15
FA ?
6 mo follow-up
No change
after 2 y
Missed cancers
Change
CNB
FNA
C1
C2
3 years) (2)
(1)
CNB
Best test
10 % CNB (3)
99.9 % B
0.1% M (7% of 1.4% BC)
NPV 100 %
PPV > 98 %
C3
0.026% (after
Not palpable
98.6 % of benign lesions
7-8 % CNB (4)
(3 samples in the target)
16 % of cancers
86.1 % of T0N0M0 or T1N0M0 (2)
Caution: size , age, other risk factors (BRCA, family or
personal history,...), anxiety and reliability of the pat.
(1)
Sickles. Radiol Clin North. Am 1995; 33:1123-1130.
(2)
Sickles. Radiology 1999; 213:11-14.
(3)
Wells. EU guidelines for non-operative diagnostic procedures. 2004
(4)
Lau. The breast Journal 2004; 10: 487
Slide 16
Slide 17
Well-defined mass
Ultrasound
3 – Cystic lesion with intracystic growth
40 women with 56 papillary lesions: 3 papillary carcinomas, 13 papillaryal lesions
with carcinoma in situ, 1 atypical carcinoma, 4 sclerosed papilloma, 35
papillomata.
PPV
NPV
FNA
31 %
79 %
CNB
100 %
83 %
Lam. AJR 2006; 186(5): 1322-7
Open Surgical Biopsy !
Slide 18
Well-defined mass
50 papillomas on percutaneous biopsy (35 VACB – 11G & 15 CNB 14 G)
Reference standard: OSB and longterm follow-up
5 (14%) breast cancers (4 DCIS & 1 inv. carcinoma)
6 (17%) high risk lesions (3 ADH, 2 radial scar, 1 LN)
The risk in case of multiple papilloma and with a family history of breast cancer
Liberman. AJR 2006; 186(5): 1328-34
Open Surgical Biopsy !
Can we totally remove a small benign lesion with LCNB ? …
Slide 19
Slide 20
Architectural distortion
DD: Involution, radial scar, invasive lobular carcinoma,
DCIS(rarely),…
Radial scar:
Fibroelastic center with pseudo-infiltrative tubular structure (DD: tub car).
In the crown of the RS +/- ADH, ALH, DCIS, LN, … the risk with the age
and the size (1)
- None < 40 yo, rare between 40 & 50 yo, > 50 yo
- Rare if < 6-7 mm
Open Surgical Biopsy !
(1)
Andersen JA, Cancer 1984; 53:2557-2560.
Slide 21
Architectural distortion
Open Surgical Biopsy !
From Tabar. Practical breast pathology - Thieme 2002: 104-5
Slide 22
Slide 23
Microcalcifications
Mammographic appearence of breast cancers
Masses with calcif
17%
Calcifications
19%
Masses
64%
Slide 24
Microcalcifications
Mammographic appearence of calcifications sent to
surgery
Casting
19%
Crushed stone
45%
Powdery
36%
Slide 25
Microcalcifications
Casting calcifications (fine, linear, branching): plasma cell
mastitis, DCIS grade III.
Crushed stone calcifications (pleomorphic, heterogenous): Fat
necrosis, FA, cysts, DCIS grade II/III, Lobular neoplasia
(rarely).
Powdery calcifications (amorphous, indistinct): sclerosing
adenosis, cysts, DCIS grade I/II.
Wells. EU guidelines for non-operative diagnostic procedures. 2004
Slide 26
Microcalcifications: CNB
(1)
Koskela. Radiology 2005; 236: 801-9
Slide 27
Vacuum assisted breast biopsy
Mammotome®
Vacora®
Slide 28
Large biopsy
En-bloc
SiteSelect
(ABBI ®)
®
®
…
Slide 29
On stereotactic guidance
Lateral position - LM
Slide 30
Dedicated table
Lorad
Fisher
Slide 31
Slide 32
Microcalcifications
VACB > CNB with a higher NPV and less technical failures
Meta-analysis: 35 studies – minimal invasive breast biopsy after
screening:
12 VABB, n = 5119
25 CNB, n = 6236
Reference standard: open surgery or longterm follow-up
VACB
CNB
Overall agreement
with reference
97.3 %
93.5 %
Technical failure
1.5 %
5.7 %
Non diagnostic
samples
0%
2.1 % (23 % of BC)
FN : 3.8 %
Fahrbach. Arch gynecol obstet 2006; 274(2):63-74
Slide 33
To reach a high NPV:
MG of samples
Post biopsy MG
Slide 34
With CNB, the sensitivity with the number of samples
Koskela. Radiology 2005; 236: 801-9
Slide 35
Microcalcifications
With VACB - 11 G under stereotactic guidance
Mass
The accuracy increase significantly until 12 samples
Microcalcification
(1)
Lomoschitz. Radiology 2004; 232:897–903
Slide 36
Calcifications : undervaluation
Vacuum-assisted devices, larger gauge biopsy needles,
and greater number of cores were associated with a
higher NPV.
But there is always some underevaluated lesions: ADH,
ALH, LN, DCIS (16-31 %) OSB is required
Magenthaler. Am J Surg 2006; 192(4):534-7
Mahoney. AJR 2006; 187(4):949-54
Lomoschitz. Radiology 2004; 232:897–903
Mahoney. AJR 2006; 187(4):949-54
Slide 37
Calcifications : undervaluation
Large cluster of amorphous calcifications: adenosis +/- DCIS ?
Tabar. Practical breast pathology - Thieme 2002
Slide 38
Microcalcifications
To avoid missed cancer, a open surgical biopsy is required
after percutaneous biopsy:
When none or a small number of calcifications are
removed
For large cluster of amorphous calcifications (adenosis
+/- DCIS ?)
For an histological diagnosis of ADH, ALH, and LN
Slide 39
Slide 40
Conclusions
IR is very useful and efficient BUT not for all and always !
The knowledge of the limitations of each techniques nb
of missed cancers
Confrontation of the cytological and histological results with
the PE and medical imaging studies in a multidisciplinary
approach !
Repeat biopsy is necessary if histological and imaging finding are
discordant
Surgical excision is necessary for some histological benign lesions:
ADH, ALH, LN, radial scar, papillary lesions, possible phyllode tumor
Slide 41
Conclusions
Further work is necessary to optimize criteria for patient
selection, to develop and define the role of new
technologies.
Complete removal of the mammographic target does not
ensure complete excision of the histological process
Further investigation is necessary to determinate in which
lesion, complete removal of the target is advantageous.
Slide 42
Slide 43
Slide 44
Slide 2
Interventional Radiology :
Useful for All and Always ?
Dr S. Murgo
CHU Tivoli, La Louvière, Belgique
Hôpital Erasme, Bruxelles, Belgique
Slide 3
Introduction
Screening Many benign lesions indistinguishable
from cancer
Previously open surgical biopsies (OSB) for
asymptomatic benign lesions were often necessary
Quick development of percutaneaous biopsies for
BIRADS 4 and also 5
with often a lack of scientific validations some controversies
Slide 4
Potential advantages
Less invasive, less expansive techniques that avoid:
surgery for benign lesions
surgery in 2 times
Percutaneaous biopsy may avoid per-operative
histological analysis that may destruct small lesions
Slide 5
Potential drawbacks
Epithelial displacement (FNA, CNB > VACB):
No evidence of biologic significance
No of the recurrence rate after BCS
But some displaced cells associated with DCIS can sometime mimic
IDC for pathologist.
Risk of missed cancers good knowledge of
limitations
Slide 6
Slide 7
Interventional Radiology
Includes:
Guidewire Localization
RadioFrequency
Fine Needle Aspiration
Core Needle Biopsy
Large Core Needle Biopsy
Slide 8
Main Mammographic Signs
Mass
Architectural Distorsion
Microcalcifications
Slide 9
Slide 10
Mass: with irregular / stellate outline
DD: Radial scar, complex sclerosis lesion, invasive carcinoma
(usually grade I or II), fat necrosis, granular cell
myoblastoma,…
FNA ?
10 % of C1 (not enough cells) CNB
False negative: 6-7% (1) C2 no value
PPV of C3 : 55 % if suspect 83% (2)
PPV of C4 : 96 % if suspect 98.5 % (2)
PPV of C5 > 99.4 % (2) invasive carcinoma ?
(2)
CNB
(1)
Lau. The breast Journal 2004; 10: 487
Bulgaresi. Breast cancer Res Treat 2006; 97 (3):319-21
Slide 11
Mass: CNB
14 g – with 3 samples in the target
(1)
Koskela. Radiology 2005; 236: 801-9
Slide 12
Mass: with well-defined outline
DD: Cyst, FA, hamartoma, lymph node, phyllodes tumor,
invasive carcinoma (high grade), papillary lesions, mucinous
carcinoma, medullary carcinoma, abscess
Ultrasound
1 - Typical cyst, harmatoma, or LN STOP
2 – « Typical FA » different schools:
Follow-up ? Not palpable 0-2 % of malignancy (mean: 1.4% - Lower for young women (< 30 yo))
Triple test with FNA ? Negative predictive value: 100% (1) but … false positive !
CNB the best test to exclude a breast cancer ! Especially for large lesion and old women (> 60 % of
carcinoma after 60 yo)
(1)
Lau. The breast Journal 2004. 10: 487
Slide 13
? FA ?
6 mo follow-up
No change
after 2 y
0.026% of missed
cancers
Change
CNB
FNA
C1
C2
(1)
CNB
Best test
10-15 % CNB (3)
99.9 % B
0.1% M (7% of 1.4% BC)
NPV 100 %
PPV > 98 %
C3
(after 3 years) (2)
Not palpable
98.6 % of benign lesions
7-8 % CNB (4)
(3 samples in the target)
16 % of cancers
86.1 % of T0N0M0 or T1N0M0 (2)
(1)
Sickles. Radiol Clin North. Am 1995; 33:1123-1130.
(2)
Sickles. Radiology 1999; 213:11-14.
(3)
Wells. EU guidelines for non-operative diagnostic procedures. 2004
(4)
Lau. The breast Journal 2004; 10: 487
Slide 14
Tabar. Radiol Ciln North Am. 2000; 38(4):625-651
Slide 15
FA ?
6 mo follow-up
No change
after 2 y
Missed cancers
Change
CNB
FNA
C1
C2
3 years) (2)
(1)
CNB
Best test
10 % CNB (3)
99.9 % B
0.1% M (7% of 1.4% BC)
NPV 100 %
PPV > 98 %
C3
0.026% (after
Not palpable
98.6 % of benign lesions
7-8 % CNB (4)
(3 samples in the target)
16 % of cancers
86.1 % of T0N0M0 or T1N0M0 (2)
Caution: size , age, other risk factors (BRCA, family or
personal history,...), anxiety and reliability of the pat.
(1)
Sickles. Radiol Clin North. Am 1995; 33:1123-1130.
(2)
Sickles. Radiology 1999; 213:11-14.
(3)
Wells. EU guidelines for non-operative diagnostic procedures. 2004
(4)
Lau. The breast Journal 2004; 10: 487
Slide 16
Slide 17
Well-defined mass
Ultrasound
3 – Cystic lesion with intracystic growth
40 women with 56 papillary lesions: 3 papillary carcinomas, 13 papillaryal lesions
with carcinoma in situ, 1 atypical carcinoma, 4 sclerosed papilloma, 35
papillomata.
PPV
NPV
FNA
31 %
79 %
CNB
100 %
83 %
Lam. AJR 2006; 186(5): 1322-7
Open Surgical Biopsy !
Slide 18
Well-defined mass
50 papillomas on percutaneous biopsy (35 VACB – 11G & 15 CNB 14 G)
Reference standard: OSB and longterm follow-up
5 (14%) breast cancers (4 DCIS & 1 inv. carcinoma)
6 (17%) high risk lesions (3 ADH, 2 radial scar, 1 LN)
The risk in case of multiple papilloma and with a family history of breast cancer
Liberman. AJR 2006; 186(5): 1328-34
Open Surgical Biopsy !
Can we totally remove a small benign lesion with LCNB ? …
Slide 19
Slide 20
Architectural distortion
DD: Involution, radial scar, invasive lobular carcinoma,
DCIS(rarely),…
Radial scar:
Fibroelastic center with pseudo-infiltrative tubular structure (DD: tub car).
In the crown of the RS +/- ADH, ALH, DCIS, LN, … the risk with the age
and the size (1)
- None < 40 yo, rare between 40 & 50 yo, > 50 yo
- Rare if < 6-7 mm
Open Surgical Biopsy !
(1)
Andersen JA, Cancer 1984; 53:2557-2560.
Slide 21
Architectural distortion
Open Surgical Biopsy !
From Tabar. Practical breast pathology - Thieme 2002: 104-5
Slide 22
Slide 23
Microcalcifications
Mammographic appearence of breast cancers
Masses with calcif
17%
Calcifications
19%
Masses
64%
Slide 24
Microcalcifications
Mammographic appearence of calcifications sent to
surgery
Casting
19%
Crushed stone
45%
Powdery
36%
Slide 25
Microcalcifications
Casting calcifications (fine, linear, branching): plasma cell
mastitis, DCIS grade III.
Crushed stone calcifications (pleomorphic, heterogenous): Fat
necrosis, FA, cysts, DCIS grade II/III, Lobular neoplasia
(rarely).
Powdery calcifications (amorphous, indistinct): sclerosing
adenosis, cysts, DCIS grade I/II.
Wells. EU guidelines for non-operative diagnostic procedures. 2004
Slide 26
Microcalcifications: CNB
(1)
Koskela. Radiology 2005; 236: 801-9
Slide 27
Vacuum assisted breast biopsy
Mammotome®
Vacora®
Slide 28
Large biopsy
En-bloc
SiteSelect
(ABBI ®)
®
®
…
Slide 29
On stereotactic guidance
Lateral position - LM
Slide 30
Dedicated table
Lorad
Fisher
Slide 31
Slide 32
Microcalcifications
VACB > CNB with a higher NPV and less technical failures
Meta-analysis: 35 studies – minimal invasive breast biopsy after
screening:
12 VABB, n = 5119
25 CNB, n = 6236
Reference standard: open surgery or longterm follow-up
VACB
CNB
Overall agreement
with reference
97.3 %
93.5 %
Technical failure
1.5 %
5.7 %
Non diagnostic
samples
0%
2.1 % (23 % of BC)
FN : 3.8 %
Fahrbach. Arch gynecol obstet 2006; 274(2):63-74
Slide 33
To reach a high NPV:
MG of samples
Post biopsy MG
Slide 34
With CNB, the sensitivity with the number of samples
Koskela. Radiology 2005; 236: 801-9
Slide 35
Microcalcifications
With VACB - 11 G under stereotactic guidance
Mass
The accuracy increase significantly until 12 samples
Microcalcification
(1)
Lomoschitz. Radiology 2004; 232:897–903
Slide 36
Calcifications : undervaluation
Vacuum-assisted devices, larger gauge biopsy needles,
and greater number of cores were associated with a
higher NPV.
But there is always some underevaluated lesions: ADH,
ALH, LN, DCIS (16-31 %) OSB is required
Magenthaler. Am J Surg 2006; 192(4):534-7
Mahoney. AJR 2006; 187(4):949-54
Lomoschitz. Radiology 2004; 232:897–903
Mahoney. AJR 2006; 187(4):949-54
Slide 37
Calcifications : undervaluation
Large cluster of amorphous calcifications: adenosis +/- DCIS ?
Tabar. Practical breast pathology - Thieme 2002
Slide 38
Microcalcifications
To avoid missed cancer, a open surgical biopsy is required
after percutaneous biopsy:
When none or a small number of calcifications are
removed
For large cluster of amorphous calcifications (adenosis
+/- DCIS ?)
For an histological diagnosis of ADH, ALH, and LN
Slide 39
Slide 40
Conclusions
IR is very useful and efficient BUT not for all and always !
The knowledge of the limitations of each techniques nb
of missed cancers
Confrontation of the cytological and histological results with
the PE and medical imaging studies in a multidisciplinary
approach !
Repeat biopsy is necessary if histological and imaging finding are
discordant
Surgical excision is necessary for some histological benign lesions:
ADH, ALH, LN, radial scar, papillary lesions, possible phyllode tumor
Slide 41
Conclusions
Further work is necessary to optimize criteria for patient
selection, to develop and define the role of new
technologies.
Complete removal of the mammographic target does not
ensure complete excision of the histological process
Further investigation is necessary to determinate in which
lesion, complete removal of the target is advantageous.
Slide 42
Slide 43
Slide 44