Breast MR biopsy. I Thomassin-Naggara, A.Jalaguier-Coudray, J Chopier
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1 Breast MR biopsy I Thomassin-Naggara, A.Jalaguier-Coudray, J Chopier
2 Background EUSOBI When a radiologist perform a MR breast imaging he has to be able to realize or to be apart of a network who is able to realize MR biopsy European regulations : Team with an experience in percutaneous core biopsy and in MRI More than 50 procédures/year with 10 under MRI Learning curve : 15 procedures (EUSOBI) 2 Heywang-Köbrunner SH, Eur J Radiol. 2009
3 Indications BI-RADS 4 or BI-RADS 5 lesion not seen on mammography and breast ultrasonography BI-RADS 3 lesion in a specific context (proven associated cancer in the same or in contralateral breast, high-risk women BRCA1/2) 3
4 Indications MR imaging abnormality without any target on conventional imaging (2 nd look mammography and ultrasonography) DCIS A NMLE>2cm associated with calcifications = PPV>90% of malignancy 4 Thomassin-Naggara et al. Radiology 2011
5 Breast MR biopsy : Is it technically accurate? Success rate Main studies Technical success rate Fisher, /389 (96%) Perlet, /538 (96%) Gebauer, /42 (100%) Orel, /85 (100%) Liberman, /98 (97%) Lehman, /38 (100%) 5 Fisher Rofo 2009, Perlet Cancer 2006, Gebauer Act Radiol 2006, Orel Radiology 2006, Liberman AJR 2005, Lehman AJR 2005
6 Breast MR biopsy : Is it technically accurate? Failures 6 Failure rate : 10-15% Causes : Accessibility Bleeding Vanishing lesion Background enhancement Glandular density Size <1cm Over compressed breastt Low experience Cancer rate: 2% Recommandation : Short follow up Diagnostic MRI The day of the biopsy, 1 month later Axial T1 fat-suppressed early contrastenhanced subtracted MRI RSNA 2013 Trop and Thomassin-Naggara et al.
7 Breast MR biopsy : Is it technically accurate? Malignancy rate Main studies Malignancy rate Fisher, /365 (27%) Perlet, /517 (27%) Gebauer, /42 (26%) Orel, /85 (61%) Liberman, /98 (25%) Lehman, /38 (37%) 7 Fisher Rofo 2009, Perlet Cancer 2006, Gebauer Act Radiol 2006, Orel Radiology 2006, Liberman AJR 2005, Lehman AJR 2005
8 Tenon Hospital Experience n Malignat Borderline Benign ACR ACR ACR (angiome) n Malignat Borderline Benign Mass 21 24% (5) 14% (3) 62%(13) Non Mass like enhancement 88 19% (17) 10% (9) 71% (60) 8
9 Breast MR biopsy : Is there any risk? 9 Usual secondary effects (50%) : Hematoma Air in the cavity Secondary effect with interruption of the procedure (10%) : Bleeding Vaso-vagal reaction Pain Rare effects (1%) : Infection Hyperventilation Liberman AJR 2005 Permet Cancer 2006 Hauth Eur radiol 2010 Mahoney JMRI 2008 Perretta breast radiology 2008
10 Routine clinical case MRI : Extension of an invasive lobular carcinoma Report Left breast: BI-RADS 2 Right breast : BI-RADS 6 : Proven malignant lesion Another mass of 15 mm in UEQ, BI-RADS 4c Strategy: Distance with index cancer : 4 cm 2 nd look ultrasound Percutaneous biopsy under sonography with a marker : non contributive Breast MR biopsy BI-RADS 6 BI-RADS 4c BI-RADS 4c 10
11 MR machine : 1,5 T Step 1 : Positioning Dedicated breast coil (ideally the same than for breast MR diagnosis) A biopsy guidance system compatible with the breast coil and tissue sampling device (compression with a grid) 11 Procubitus, Head outside from the coil
12 Lateral access Coil 12 Medial access
13 Step 2 : Localization After breast compression with the grid Positionning a cube visible on T1 sequence (Parafin or vitamin D) 13
14 Step 2 : Localization Positionning of the cube is reported in a schema The patient goes in the coil Cube Schema 14 Cube positionned on N 18
15 Step 2 : Localization High resolution T1 DCE-MR sequences with Fat saturation in Sagittal or Axial plane Before injection After injection on 3 phases with : Complete dose: 0.2 ml/kg with 20 ml saline, débit 2 à 3ml/s (No reinjection at the end of the procédure) 15
16 T1FS gadolinium in sagital plane 16 Find the target ++++
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34 BI-RADS 6 BI-RADS ACR4 c Indication of breast MR biopsy 34
35 Step 2 : Localization Objective : To localize the target in comparison with the cube Lésion ACR4 c A biopsier sous IRM 35 Lésion ACR6 Biospiée sous écho
36 BI-RADS 4 c Breast MR biopsy target 36
37 Projection of BI-RADS 4 c Breast MR biopsy target 37
38 Projection of BI-RADS 4 c Breast MR biopsy target 38
39 Projection of BI-RADS 4 c Breast MR biopsy target 39
40 Projection of BI-RADS 4 c Breast MR biopsy target 40
41 Projection of BI-RADS 4 c Breast MR biopsy target 41
42 Projection of BI-RADS 4 c Breast MR biopsy target 42
43 Projection of BI-RADS 4 c Breast MR biopsy target 43
44 Projection of BI-RADS 4 c Breast MR biopsy target 44
45 Projection of BI-RADS 4 c Breast MR biopsy target 45
46 Projection of BI-RADS 4 c Breast MR biopsy target 46
47 Grid on the breast compressed Projection of BI-RADS 4 c Breast MR biopsy target Cube 47
48 Breast Schema On MR images Entrance point Breast schema During MR biopsy Cube 48
49 Step 2 : Localization We need to calculate the depth of the lesion from the skin : substraction ( : 27mm) ou simple mesurement on reformatted image BI-RADS 4c Breast MR biopsy target External side of the breast with the grid 27 mm 49
50 Step 2 : Localization x and y Breast MR biopsy entrance point 50 Z (depth) Z = 27mm
51 Step 3 : Samples Material : MR-compatible tissue sampling device (<11G) Xylocaine (20cc) Betadine Trocar tip Needle guide 51 Visible MR obturator
52 Step 3 : Samples Topical anaesthesic: Breast MR biopsy Entrance point 52
53 Step 3 : Samples Cutaneous section To put the cube in the grid Adjust the depth of the lesion : 27 mm under the skin According to constructor needles : SenoRx : adding 20 mm Bard : adding 10 mm Mammotome : adding 0 mm To put the trocar inside the breast 53
54 Step 3 : Samples When the position is well: It s necessary to replace the trocart by a MRI visible obturator (high T1FS) DCE MR sequence to check the position 54
55 Step 3 : Samples 55
56 End of the procedure of biopsy Minimum number of samples : 18 56
57 Step 4 : Quality insurance To mark the biopsy site with a marker To perform a control sequence 57
58 Usefulness of T2* sequence to visualize the marker
59 Technical challenges Sternal edge of breast coil * Localization of lesions Posterior lesion or axillary lesion Axial T1 fat-suppressed early contrast-enhancedmri Lateral approach is sometimes the only one issue Internal and superior approach are usually more difficult to realize. Visualization of lesions MR Biopsy - introductor in place Vanishing lesion Impossibility to confirm sampling 59 RSNA 2013 MR post-biopsy - introductor in place
60 Tips and tricks Depth lesion: To put the arms along the body To remove the foam of the coil To elevate the opposite side to down the breast in the coil 60
61 After removing the foam of the coil Apocrine metaplasia
62 Tips and tricks Small breats : Use a technique «Wonderbra» to pump the breast Use a «biopsy cover» to limit cutaneous lesion Cover 62
63 Screening MRI Tip and thricks pad Technical tip Padding around the least supported breast surfaces can help provide stability during the procedure. Axial T1 fat-suppressed early contrastenhanced subtracted MRI MR Biopsy - introductor in place History: 53 year old high-risk woman. MR biopsy of a 7 mm enhancing mass in anterior central left breast. Challenge: The anterior location of the lesion results in little breast support far anteriorly. A pad was placed to maintain the breast in place, and a blunt tip needle was used to avoid damage to the inner breast skin surface. Histology: Inconclusive histology. No follow-up available. Technical tip Use of a blunt tip needle is indicated for sampling of lesions close to the far surface of the breast to avoid skin damage. RSNA 2013 Trop and ThomassinNaggara et al.
64 Tips and techniques CAD system Actual position of the cube Precise localization of the entrance point 64 Depth of the target Schema to insert biopsy device
65 Breast MR biopsy Of a segmental NMLE 65
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71 Patho radiological correlation: Underestimation rate Higher than those under stereotactic guidance About 38% in case of ADH at MR biopsy versus 20% with stereotactic biopsy Liberman et al. AJR Understimation is partially due to a partial sampling of target lesion 342 biopsied benign lesions 24 discordant lesions(7 %), with 6 cancers (30%) These lesions was more frequently simply sampled than removed Lee et al. AJR
72 How to follow patients after breast MR biopsy? Few data Radial scar MSK hospital : 177 benign biopsied lesions 8 increased during follow up. 17 re-biopsied et 4 were malignant Good radiopathological correlation is crucial 72 Systematic follow up 5 months if benign Liberman L et al.. AJR 2007 Li J, Dershaw DD, et al. AJR 2009
73 A 34 years old women, MR screening, BRCA mutation
74 Pathology : Fibrosis Normal breast parenchyma with fibrosis with acini without any atypia Courtesy A.Jalaguier, IPC
75 MR follow up (6 monthes later)
76 Biopsy under sonography Invasive ductal carcinoma
77 Take home messages A coil Only for MR lesion not seen on conventional imaging Be careful : If benign results, follow up at 5 months +++ A grid Psychological take care Better results! A cube
78 Thank you for your attention
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