Breast MR biopsy I Thomassin-Naggara, A.Jalaguier-Coudray, J Chopier
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
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
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
Breast MR biopsy : Is it technically accurate? Success rate Main studies Technical success rate Fisher, 2009 365/389 (96%) Perlet, 2006 517/538 (96%) Gebauer, 2006 42/42 (100%) Orel, 2006 85/85 (100%) Liberman, 2005 95/98 (97%) Lehman, 2005 38/38 (100%) 5 Fisher Rofo 2009, Perlet Cancer 2006, Gebauer Act Radiol 2006, Orel Radiology 2006, Liberman AJR 2005, Lehman AJR 2005
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.
Breast MR biopsy : Is it technically accurate? Malignancy rate Main studies Malignancy rate Fisher, 2009 106/365 (27%) Perlet, 2006 138/517 (27%) Gebauer, 2006 11/42 (26%) Orel, 2006 52/85 (61%) Liberman, 2005 24/98 (25%) Lehman, 2005 14/38 (37%) 7 Fisher Rofo 2009, Perlet Cancer 2006, Gebauer Act Radiol 2006, Orel Radiology 2006, Liberman AJR 2005, Lehman AJR 2005
Tenon Hospital Experience 2009-2012 n Malignat Borderline Benign ACR3 4 0 1 3 ACR4 101 20 12 69 ACR5 4 3 0 1 (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
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
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
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
Lateral access Coil 12 Medial access
Step 2 : Localization After breast compression with the grid Positionning a cube visible on T1 sequence (Parafin or vitamin D) 13
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
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
T1FS gadolinium in sagital plane 16 Find the target ++++
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BI-RADS 6 BI-RADS ACR4 c Indication of breast MR biopsy 34
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
BI-RADS 4 c Breast MR biopsy target 36
Projection of BI-RADS 4 c Breast MR biopsy target 37
Projection of BI-RADS 4 c Breast MR biopsy target 38
Projection of BI-RADS 4 c Breast MR biopsy target 39
Projection of BI-RADS 4 c Breast MR biopsy target 40
Projection of BI-RADS 4 c Breast MR biopsy target 41
Projection of BI-RADS 4 c Breast MR biopsy target 42
Projection of BI-RADS 4 c Breast MR biopsy target 43
Projection of BI-RADS 4 c Breast MR biopsy target 44
Projection of BI-RADS 4 c Breast MR biopsy target 45
Projection of BI-RADS 4 c Breast MR biopsy target 46
Grid on the breast compressed Projection of BI-RADS 4 c Breast MR biopsy target Cube 47
Breast Schema On MR images Entrance point Breast schema During MR biopsy Cube 48
Step 2 : Localization We need to calculate the depth of the lesion from the skin : substraction (93.7-66.2 : 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
Step 2 : Localization x and y Breast MR biopsy entrance point 50 Z (depth) Z = 27mm
Step 3 : Samples Material : MR-compatible tissue sampling device (<11G) Xylocaine (20cc) Betadine Trocar tip Needle guide 51 Visible MR obturator
Step 3 : Samples Topical anaesthesic: Breast MR biopsy Entrance point 52
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
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
Step 3 : Samples 55
End of the procedure of biopsy Minimum number of samples : 18 56
Step 4 : Quality insurance To mark the biopsy site with a marker To perform a control sequence 57
Usefulness of T2* sequence to visualize the marker
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
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
After removing the foam of the coil Apocrine metaplasia
Tips and tricks Small breats : Use a technique «Wonderbra» to pump the breast Use a «biopsy cover» to limit cutaneous lesion Cover 62
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.
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
Breast MR biopsy Of a segmental NMLE 65
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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 2007. 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 2007. 71
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
A 34 years old women, MR screening, BRCA mutation
Pathology : Fibrosis Normal breast parenchyma with fibrosis with acini without any atypia Courtesy A.Jalaguier, IPC
MR follow up (6 monthes later)
Biopsy under sonography Invasive ductal carcinoma
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
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