Vacuum-assisted breast biopsy using computer-aided 3.0 T- MRI guidance: diagnostic performance in 173 lesions

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1 Vacuum-assisted breast biopsy using computer-aided 3.0 T- MRI guidance: diagnostic performance in 173 lesions Poster No.: C-2870 Congress: ECR 2017 Type: Scientific Exhibit Authors: A. Pozzetto, L. Camera, I. Baglio, Q. Piubello, C. Cavedon, S. Montemezzi; Verona/IT Keywords: DOI: Breast, Interventional non-vascular, Computer applications, MR, CAD, Percutaneous, Vacuum assisted biopsy, Diagnostic procedure, Computer Applications-Detection, diagnosis /ecr2017/C-2870 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 19

2 Aims and objectives To estimate the accuracy and underestimation rates of Magnetic Resonance Imaging (MRI)-guided vacuum assisted breast biopsy with a 8-9 or 11 Gauge needle for diagnosis of suspicious breast lesions detectable at 3.0 Tesla. The results were compared to histopathological examination of surgical specimens for malignant cases. Page 2 of 19

3 Methods and materials Between October 2011 and August 2016, 173 suspicious breast lesions (168 Patients) detected with a 3.0T MRI scanner, classified as MRI BI-RADS 3, 4 or 5, underwent computer-assisted MRI-guided localization (Dynacad, Invivo corp.) and vacuum assisted biopsy (Fig. 1-3). Target lesions were localized by a seven channel breast array coil outfitted for biopsy and a dedicated diagnostic workstation. After calculating localization co-ordinates, sampling was performed using a MRI compatible needle (8, 9 or 11G) (Fig. 4-5). At the end of procedure a marker was placed in the biopsy site, confirmed by MRI scans; (Fig. 6). The study protocol used was: 3D FFE (sagittal) - Fiducial Markers detection; Gadobenate dimeglumine based CE; 3 phases T1-THRIVE 3D FAT SAT (axial) for target localization; 1 phase T1-THRIVE 3D FAT SAT (axial) for target confirmation and marker confirmation (Fig.7). Page 3 of 19

4 Images for this section: Fig. 1: 3.0 T MRI scanner and localization grid. Fig. 2: Introducer localization set. Page 4 of 19

5 Fig. 3: Automated core vacuum collection system. Page 5 of 19

6 Fig. 4: Fiducial Markers detection and Computer-assisted MRI-guided localization system (Dynacad, Invivo corp.). Fig. 5: Vacuum assisted biopsy procedure. Page 6 of 19

7 Fig. 6: Marker placed in biopsy site, later confirmed by MRI scans. Page 7 of 19

8 Fig. 7: T1-THRIVE 3D FAT SAT (axial) with Gadobenate dimeglumine for target localization; T1-THRIVE 3D FAT SAT (axial) for target confirmation and marker confirmation. Page 8 of 19

9 Fig. 8: Sample collection after biopsy. Page 9 of 19

10 Results All the procedures were technically successful. There were only rare minor complications as 2 hematomas, 1 case of bleeding, 1 skin laceration and 1 punture to the opposite side of breast. There were 115 "mass like" lesions (mean lesion size: 10 mm) and 58 "non mass like" lesions (mean lesion size: 25 mm). The MRI indications were: pre operatory staging (98 patients), middle-high risk (30 patients) and variance/inconsistency between mammography and US imaging (45 patients). The pathological results showed 73 (42,2 %) benign lesions (B1, B2), 39 (22,5%) atypical, probably benign (B3), 1 (0,6%) suspicious for malignancy (B4) and 60 (34,7%) tumors (B5) (Fig. 9). Histopathologic examination revealed: 60 malignant lesions (30 ductal carcinoma in situ, 14 invasive ductal carcinoma, 10 invasive lobular carcinoma and 6 rare histotypes as tubular, mucinous and histiocytoid carcinoma); 39 high-risk lesions (8 papilloma, 12 lobular intraepithelial neoplasia, 13 atypical ductal hyperplasia, 6 radial scar) and 74 benign lesions (Fig ). Regarding the 98 Patients underwent breast MRI for preoperative staging, we found 49 suspicious omolateral multicentric lesions of which 51% were malignant and 49 suspicious controlateral lesions, of which 26,5 % were malignant. In particular, among the omolateral multicentric lesions 14 (28,6%) were benign lesions, 9 (18,4%) were atypical probably benign, 1 (2%) were suspicious for malignancy and 25 (51%) were malignant; on the other hand, among the 49 controlaterl suspiciuos lesions 23 (47%) were benign lesions, 13 (26,5 %) were atypical probably benign, and 13 (26,5%) were malignant (Fig. 12). Concerning the 75 Patients underwent breast MRI not for preoperative staging, 33 (44%) were benign lesions, 20 (26,7%) were atypical probably benign lesions and 22 (29,3%) were malignant lesions (Fig.13). Among this group, there were 30 middle - high risk women, in which, at histopatologic examination, 17 (56,7%) benign lesions, 10 (33,3%) atypical probably benign lesions and 3 (10%) malignant lesions were founded (Fig. 14). Page 10 of 19

11 All malignant and high-risk lesions were sent to surgery (mastectomy or extensive local excision). Benign lesions and 13 B3 lesions with a mixed histopathology were sent to follow-up (6-12 months). Examination of surgical specimens suggests a rate of underestimation in ADH and DCIS around 5-3% (Fig 15). We identified, as underestimation, only four discordant cases at surgery: two atypical ductal hyperplasia (later DCIS on histopathologic examination); and two cases of IDC previous underestimated as DCIS (Fig.16). All benign lesions and 13 B3 lesions were confirmed by follow-up examinations. No diagnostic overestimation was observed. Page 11 of 19

12 Images for this section: Fig. 9: Histopathologic examination results. Fig. 10: B5 histopathologic examination results. Page 12 of 19

13 Fig. 11: B3 histopathologic examination results. Fig. 12: Histopathologic examination in preoperative staging. Page 13 of 19

14 Fig. 13: Histopathologic examination of Patients underwent breast MRI not for preoperative staging. Page 14 of 19

15 Fig. 14: Histopathologic examination in middle - high risk women. Page 15 of 19

16 Fig. 15: Examination of surgical specimens suggests a rate of underestimation in ADH and DCIS around 5-3%. Page 16 of 19

17 Fig. 16: B3 lesion case of underestimation at surgery, atypical ductal hyperplasia later DCIS on histopathologic examination. Page 17 of 19

18 Conclusion Our experience revealed that 3-T MRI-guided vacuum assisted breast biopsy with 8-9 or 11 G needle is a safe and effective interventional method that enables biopsy of lesions with high accuracy rate and low underestimation. Page 18 of 19

19 References 1. Ferré R et al Diagnostic Performance of MR-guided Vacuum-Assisted Breast Biopsy: 8 Years of Experience. Breast J Jan-Feb;22(1): Liberman L et al Underestimation of atypical ductal hyperplasia at MRI-guided 9 gauge vacuum-assisted breast biopsy AJR 2007 Mar;188: Lee JM et al Underestimation of DCIS at MRI-guided vacuum-assisted breast biopsy AJR 2007 Aug;189: Lee JM et al. Imaging histologic discordance at MRI-guided 9-gauge vacuum-assisted breast biopsy. AJR 2007; 189: Lee JM et al Complete excision of the MRI target lesion at MRI-guided vacuum assisted biopsy of breast cancer AJR 2008 Oct;191: Lourenco AP et al High-risk lesions at MRI-guided breast biopsy: frequency and rate of underestimation AJR 2014 Sep;203: Saladin C et al Lesions with unclear malignant potential (B3) after minimally invasive breast biospy: evaluation of vacuum biopsies performed in Switzerland and recommended further management. Acta Radiol Jul; 57(7): Spick C et al MR-guided vacuum-assisted brest biopsy of MRI-only lesions:a single center experience. Eur Radiol Nov;26(11): Verheyden C et al Underestimation rate at MR imaging-guided vacuum assisted breast biopsy: a multi- institutional retrospective study of 1509 breast biopsies. Radiology: Vol N.3. Dec Page 19 of 19