PURPOSE IMAGE-GUIDANCE MODALITIES IMAGE-GUIDED BREAST BIOPSY. US-Techniques. Ultrasound. US guided NLOBB. TH. Helbich

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1 IMAGE-GUIDED BREAST BIOPSY PURPOSE TH. Helbich Department of Radiology Division of Molecular & Gender Imaging Medical University of Vienna Imaging techniques Interventional procedures Quality management (QM) IMAGE-GUIDANCE MODALITIES Ultrasound Ultrasound Stereotactic Imaging MR - Imaging US-Techniques US guided NLOBB Guidance systems Free hand technique 1

2 Real time imaging US-guided 14G Core-Needle Biopsy 5 core samples! STEREOTACTIC SYSTEM Stereotactic localization Designed: Calculate the position of a lesion within breast horizontal (x) Localize the position vertical (y) depth (z) m n Röhre l Brust Film b b* a x x a* Bolmgren et al. AJR 1977 Stereotactic localization Stereotactic guided NLOBB Scout view 0 Angled view + 15 Angled view - 15 (n=1115) Lesion miss rate: 1% Riedl et al. Radiology

3 STEREOTACTIC SYSTEMS STEREOTACTIC EQUIPMENT Prone position Dedicated system for prone position Add on systems to mammography STEREOTACTIC SYSTEM Sitting position STEREOTACTIC SYSTEM Decubitus position Courtesy G. Welle Courtesy G. Welle STEREOTACTIC SYSTEM Decubitus position STEREOTACTIC SYSTEM Decubitus position Courtesy G. Welle Courtesy G. Welle 3

4 STEREOTACTIC SYSTEMS Pros and Cons MRI- of the breast Room Costs Patient comfort Motion Vasovagal reaction Workspace Time Accuracy Prone Upright Wunderbaldinger et al AJR 2002 Second Look US: 30-40% MRI- guided Helbich T. JMRI 2001 Control scan shows coaxial needle in correct position up to 15 samples 4

5 Wire localization Miss-rate: 0,9% Riedl et al. Radiology 2001 Fine Needle Aspiration BX (FNAB) Fine Needle Aspiration BX (FNAB) PROS: CONS: Fast Demand on Zyto-pathologists Low Missing costsinformation about invasion Low Specificity Few material (37%) False negative results (31%) Grant et al. Mayo Clin Proc 1986 Radiology 1993 Stereotactic guided biopsy 14g - LCB 11g - VAB 5

6 US-guided 14G Large Core- Needle Biopsy VALIDATION STUDY 14G US-Guided BIOPSY false negative rate low, alternative to open biopsy 1352 lesions 1) 1.6 % 2420 lesions 2) 2.4 % 1) Schüller et al. Radiology ) Youk et al. AJR 2008 PROBLEM 14G US-Guided BIOPSY Underestimation rate: High-risk lesions (4-8%) (ADH, LN, atypical papilloma, radial scar) 1352 lesions 1) U-rate 31 % 2420 lesions 2) U-rate 27% Upgrade to cancer PROBLEM 14G US-Guided BIOPSY Benigne papilloma Upgrade to cancer -25% (5.6%) Upgrade higher >1cm, >50 years, BIRADS 4b,c,5; 3cm from nipple OPEN BX NECESSARY 1) Schüller et al. Radiology ) Youk et al. AJR 2008 Youk et al. Radiology 2011 Relation between needle size and diagnosis VACUUM ASSITED BIOPSY PROS: More tissue improves diagnosis No increase in complication rate Improved diagnosis of ADH, DCIS CONS: High costs 6

7 VACUUM ASSITED BIOPSY Tissue sampling Mammotome Ethicon Surgery 11- and 8- gauge Minimum of 15 tissue samples per lesion FALSE NEGATIVE RATE 14-g LCBB: 8 % 11-g VABB: 3.3 % VACUUM ASSITED BIOPSY UNDERESTIMATION OF DCIS!! LCBB: 20% VABB: 11% Significant improvement in the diagnosis Pfarl et al AJR 2002 Jackman et al. Radiology 2001 Global Language How to solve problems? Quality management BI-RAD System: 1: negative 2: benign 3: probably benign (cancer rate < 2 %) 4: suspicious 5: highly suggestive of malignancy 6: verified malignancy Intervention 7

8 EUSOMA - Guidelines GUIDANCE AND TYPE OF LESION In 90% BIRADS 4 or 5 lesions needle biopsy should be performed Ultrasound: solid lesions, rarely calcifications prior to open breast biopsy EUSOMA 2001 GUIDANCE AND TYPE OF LESION Stereotactic: calcifications, solid lesions: not seen on US, hardly accessible MRI: lesions only seen on MRI SKILLS: personal favorite learning curve: all BX methods: > 20 procedures first 50 biopsies: surgical verifications EUSOBI; Wallis et al ER 2007 CALCIFICATIONS Informed consent VACUUM BIOPSY German English Turkish Croatian Serbian 8

9 0. Positioning 1. Stereotactic localization Scout view 0 Angled view + 15 Angled view Local anaesthesia Superficial anaesthesia: 5 ml Xylocain 1% Deep anaesthesia: 5 ml Xylocain 1% + Dilution with 0,5 ml Natriumbicarbonat 8,4% 3. Insertion of the Needle 4. Prefire-views

10 5. Tissue sampling 6. Specimen radiography 7. Clip placement 7. Clip placement ALMOST ALWAYS 8. Compression After biopsy compression of approx. 15 min Compression bandage Clinical control if necessary PATHOLOGY WORK - UP Information for pathologist Patient name BIRADS Copy of MG- report and MG Copy of specimen radiography Calcs. in separate vials 10

11 WORK -UP PATHOLOGIST SOP:Result (BIRADS4) Non - frozen sections 4 HE slices (minimum) Histopathologic diagnosis plus BENIGN 6 MONTH FOLLOW-UP HIGH RISK SUSPICIOUS (BIRADS 4) MALIGNANT INADEQUATE OPEN BIOPSY THERAPY RE-BIOPSY recommendations (B-classification) High risk: ADH, Atypia.., Radial scar, LCIS, ALH SOP: Result (BIRADS 5) 9. Follow-up MG in benign cases (6, 12 Mo.) SUSPICIOUS (BIRADS 5) BENIGN HIGH RISK MALIGNANT INADEQUATE OPEN / RE- BIOPSY OPEN BIOPSY THERAPY RE-BIOPSY High risk: ADH, Atypia.., Radial scar, LCIS, ALH QUALITY STANDARDS Testing of equipments (weekly annually) - according to EUSOBI Testing of physicians - # of procedures - # of cancers diagnosed - # of complications requiring treatment DOCUMENTATION FOR QUALITY ASSURANCE Pooling and report of DATA: -underestimation of high-risk lesions -FN-rate -FP-rate - Re-biopsy-rate - complication rate 11

12 : Results 11-gVAB BIOPSY Validation study; prone units Mammotome 11- gauge Pfarl G al. AJR gVAB BIOPSY Results for prone units 11-gVAB BIOPSY Upgrade from ADH to DCIS or IDC 24% NPV 99,9%; Scarring on MG in 0.3% Kettritz U et al. Cancer 2004 VACUUM ASSITED BIOPSY VACUUM ASSISTED BIOPSY 9-g VACORA (BARD) Suros (ATEC) 9-gauge Vacora (BARD) 9-gauge 12

13 9g-Vacuum Biopsy with SUROS SUROS: How does it work? Sampling takes 4.5 sec / target Sampling max. 30 sec for all targets Closed system all specimens are collected in one chamber Combination of lavage and constant aspiration VAB BIOPSY 9 versus 11-gauge ADH UPGRADE RATE; n=991 ADH to DCIS: 21% Breast Lesion Excision System (Intact ) An innovative advance in breast biopsy technology 9-gauge: 21% 11-gauge: 20% Eby P et al. AJR 2008 One-Person Handheld Procedure Same System Can Be Used With: Any stereotactic system Ultrasound guidance Breast Lesion Excision System (Intact ) 13

14 Larger Specimen Weight Clinical Evidence of Concordance Rates cm cm cm 3.0 grams 2.1 grams 1.1 grams All sample sizes are retrieved using one device. Intact specimen samples are available in three sizes: 12 mm, 15 mm, and 20 mm. DCIS Upgrades ADH Upgrades Complete Excision of ADH at Bx Intact Mammotome 5 of 110 (4.6%) 3 of 32 (9.4%) 21 of 32 (65.6%) Fewer Subsequent Surgeries Due to: 1. Fewer upgrades 2. Complete excision of the lesion at biopsy 15 of 112 (13.4%) 11 of 30 (36.7%) 10 of 30 (33.3%) p = 0.03 p = 0.01 p = 0.02 Source: Sie A. Paper presented at: Radiological Society of North American Scientific Assembly and Annual Meeting; November 27-December 2, 2004; Chicago, Ill. Advantages of Breast Lesion Excision System (Intact ) vs. Core Needle Biopsy Intact specimen, thus better preservation of architecture More definitive diagnosis (improvement in concordance rates or a reduction in diagnostic upgrades) One-pass specimen collection in seconds Easier targeting of lesion Greater correlation of histology with imaging VAB BIOPSY false negative rate low, alternative to open biopsy Stereotactic 1) -3 % US / MRI-guided 2) -3 % 1) Pfarl et al. AJR ) Memarsadeghi et al. RöFo 2001 Interventional breast procedures VAB BIOPSY Diagnostic procedure and NOT a therapeutic one Reiner C et al. European Radiology

15 Screening / Cancer detection Needle Breast Biopsy Costs 15