Nice saint paul. biopsies mammaires, L.Rotenberg 2015
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Recommandations Nice Saint Paul 2015. Pre analytique biopsies mammaires. Breast biopsy pre analytic
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Nice saint paul. biopsies mammaires, L.Rotenberg 2015
- 5. Breast lesions imaging • Screening, detec2on or diagnosis : • Mammography – Full Digital Mammography – 3D Digital Breast Tomosynthesis • Sonography – High frequency probe – Doppler – elastography • MRI – 1,5 or 3T magnet – Morphologic and dynamic study, perfusion – Diffusion – Spectroscopy-MRI • Goal = evalua2on for a risk : BIRADS classifica2on
- 9. Very suspicious lesion for malignancy § fine needle aspiraKon : no more or senKnal lymph nodes § Core biopsy 16 or 14 G § histology, HR, Her2... § Suspicious for recidive § aier surgery § aier radiotherapy Bi-Rads 5 to 6
- 10. Frederick R. Margolin1 Jessica W. T. Leung1,2 Richard P. Jacobs1 Susan R. Denny1 Percutaneous Imaging-Guided Core Breast Biopsy: 5 Years’ Experience in a Community Hospital, AJR:177, September 2001
- 11. • Histological diagnosis by the pathologist always mandatory • No histological diagnosis on imaging ! – However, diagnosKc hypotheses and indicaKons of acKon to be taken are welcome Breast lesions imaging
- 12. Birads 1 screening Birads 2 screening Birads 3 Follow up except high risk Birads 4 a Follow up except progressive or high risk Birads 4 b,c LCB or VABB diagnosis Birads 5/6 LCB or VABB diagnosis ou stategical
- 13. MODALITÉS TECHNIQUES DU PRÉLÈVEMENT BIOPSIQUE : reco 2009 • En cas de calcificaKons : • macrobiopsie par voie percutanée uKlisant un système à aspiraKon • microbiopsie par voie percutanée si macrobiopsie techniquement non réalisable. • En cas de masses palpables et radiologiques • Micro par voie percutanée. • Si impossibilité technique de réaliser une biopsie percutanée : • biopsie chirurgicale
- 14. Wallis M et al. EJR 2007 American College of Radiology Reston 2003 Perry EJC 2001 According to the guidelines of the European Society of Breast Imaging (EUSOBI), up to 90% of suspicious breast lesions (BI-RADS™ 4 and 5) should undergo most effective percutaneous biopsy before further treatment is planned.
- 15. Minimal Invasive Interventions US StereotacKcal MRI Others FNAC - - - - LCNB +++ - - - VABB +++ +++ +++ - Intact ++ ++ - - Marking +++ +++ +++ Free Hand Galactoscopy
- 16. Interventional Methods Fine Needle Aspiration Cytology (FNAC) Britton PD The Breast 1999; 8:1-5 Sonography FNAC CNB N = 2,673 1,851 SensiKvity 83,1 96,7 Specificity 84,0 98,7 Meta - analysis: 31 Studies ( n = 17,108 Cases)
- 17. Possibilities of Assessment Interventional Methods FNAC (Fine Needle Aspiration Cytology) FNAC is inadvisable as a standard method.
- 18. Possibilities of Assessment Interventional Methods (Ultrasound) LCNB Autom. Large Core Needle Biopsy
- 19. Large Core Needle Biopsy (LCNB)
- 20. Large Core Needle Biopsy (LCNB) Author Year SensiKvity Specificity Parker 1991 100 % 100 % Schulz-Wendtland 1994 / 1998 98 % 100 % Brivon 1997 89 % 89 % Heywang-Köbrunner 1997 / 1998 98 % 100 % Taki 1997 89 % 95 % Fornage 1999 100 % 100 %
- 21. Interventional Methods LCNB Verkooijen HM, Peeters PH, Buskens E et al. Br J Cancer 2000; 82: 1017-1021 Meta - analysis: 5 Studies ( n = 865 Cases) „ The False Rate of 2.6 ( 8 / 307 maligne Diagnosis) – LCNB with a high sensitivity (97%) and specificity (94%) is an excellent alternative in contrast to the wire marking.“
- 22. Possibilities of Assessment Vacuum Assisted Breast Biopsy Interventional Methods VABB Directional Vacuum - Assisted Breast Biopsy
- 23. Indications for diagnostic representative or ablative Vacuum - Biopsy (VABB) 1. StereotacKc guidance 2. MRI guidance
- 24. § local anesthesia § external procedure § ExplanaKon +++ § Time 15 to 40 mn Breast biopsy 14 G 11 G 10 G 8 G 17 mg 95 mg 160 mg 300 mg
- 25. Post contrast image of lesion Confirmation of obturator location near lesion Post biopsy image Macrobiopsie sous IRM
- 26. auteur année type Nbre lésions (nbre paKents) Temps moyen unique mulKple % complicaKon % succès % cancer Liberman et al. 2003 VA 27 (20) 49 35 69 1 (4) 26/27 (96) 8/27 (30) Lehman et al 2005 VA 38 (28) 50 39 61 38/38 (100) 15/38 (40) Orel et al 2005 VA 85 (75) 30-60 0 85/85 (100) 52/85 (61) Fast MRI-Guided Vacuum-Assisted Breast Biopsy: Initial Experience Laura Liberman & al Department of Radiology, Breast Imaging Section, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY 10021. AJR 2003; 181:1283-1293 Clinical Experience with MRI-Guided Vacuum-Assisted Breast Biopsy Constance D. Lehman & al Department of Radiology, University of Washington Medical Center, 1959 NE Pacific, Seattle, WA 98195. Mayo Clinic, 4500 San Pablo Rd., Jacksonville, FL 32224. AJR 2005; 184:1782-1787 MR Imaging–guided 9-gauge Vacuum-assisted Core-Needle Breast Biopsy: Initial Experience Susan G. Orel & al Departments of Radiology and Pathology and Laboratory Medicine, University of Pennsylvania Medical Center, 3400 Spruce St, Philadelphia, PA 19104. Radiology 2005, 10.1148 Macrobiopsie sous IRM
- 27. Indications for diagnostic representative or ablative Vacuum - Biopsy (VABB) /US 1. Aier Large Core Needle Biopsy (LCNB) and suspicion of breast cancer (BI- RADS® 4c / 5, missmatch / discordance of the results of diagnosKc imaging and histology) 2. Suspicious lesions (BI-RADS® 4 / 5) diameter ~ 5 mm 3. ResecKon of definitely benign, but symptomaKc findings or High risk paKents 1. symptomaKc Fibroadenoma 2. recurrent symptomaKc cysts 4. Intraductal / intracysKcal proliferaKons : singulary Papilloma, complex cyst 5. Neoadjuvant Chemotherapy 6. Suspiscious of local recurrence 7. Hazardous or dangerous locaKon : deep, superficial, implants…
- 29. 03/01/16 S Vacuum assisted devices S Mammotome S 1995, 11 et 8 g S Vacora (Bard) S 2003, 10 g S 2007, 14 g S Atec (Suros - Hologic) S 2007, 12 g 9 g S Seno RX (Bard) • 2009, 10 g, 7 g S Intact 2009 S Large core devices S 16 g S 14 g S Single use devices +++ S Other biopsy devices S Spirotome & Coramate (Medinvents) S 2007, 14 et 9 g S Celero (Hologic) S 2008 12 g S Finesse (Bard) S 2010 14 g Choice of the Needle
- 30. 03/01/16
- 32. RöFo 175; 94 - 98 (2003)
- 33. Discussion VABB • Underestimation rate ADH, DCIS, ALH, LCIS… – Not eliminated with VABB » >> PPV : malignant » >> NPV : benign – Surgical indication : paradigme and guidelines
- 34. DCIS Roger J. Jackman & al, Radiology February 2001 218:497-502 Stereotac2c Breast Biopsy of Nonpalpable Lesions: Determinants of Ductal Carcinoma in Situ Underes2ma2on Rates • DCIS underes2ma2on rates by biopsy device were – 20.4% (76 of 373) at large-core biopsy – 11.2% (107 of 953) at vacuum-assisted biopsy (P < .001) • 24.3% (35 of 144) of masses • 12.5% (148 of 1,182) of microcalcifica2ons (P < .001) • and by number of specimens per lesion – 17.5% (88 of 502) with 10 or fewer specimens – 11.5% (92 of 799) with greater than 10 (P < .02). • DCIS underes2ma2ons increased with lesion size 1.9 Kmes more frequent with masses than with calcificaKons 1.8 Kmes more frequent with LCB than with VAB 1.5 Kmes more frequent <10 or fewer specimens per lesion than with ≥ 10 specimens per lesion.
- 35. ADH Peter R. Eby, Jennifer E. Ochsner, Wendy B. DeMartini & al, Frequency and Upgrade Rates of Atypical Ductal Hyperplasia Diagnosed at Stereotactic Vacuum-Assisted Breast Biopsy: 9- Versus 11-Gauge. AJR 2009; 192:229–234
- 36. ADH Prevalence RJ Jackman, RL Birdwell, DM Ikeda, Atypical Ductal Hyperplasia: Can Some Lesions Be Defined as Probably Benign after Stereotactic 11-gauge Vacuum- assisted Biopsy, Eliminating the Recommendation for surgical exision ? Radiology 2002; 224:548–554
- 37. Radial Scars R. James Brenner, Roger J. Jackman, Steve H. Parker & al, Percutaneous Core Needle Biopsy of Radial Scars of the Breast: When Is Excision Necessary? AJR:179, November 2002 • Carcinoma was found at excision in – 28% (8/29) of lesions with associated atypical hyperplasia – 4% (5/128) of lesions without associated atypia • In the la4er group, carcinoma was found at excision in – 3% (2/60) of masse – 8% (3/40) of architectural distorKons – 0% (0/28) of microcalcificaKon lesions • Malignancy was missed in – 9% (5/58) of lesions biopsied with a spring-loaded device LCB – 0% (0/70) of lesions biopsied with a direcKonal vacuum-assisted device VABB – 8% (5/60) of lesions sampled with less than 12 specimens – 0% (0/68) sampled with 12 or more specimens • Lesion type, maximal lesion diameter, and type of imaging guidance (stereotac2c or sonographic) were not significant factors in determining the presence of malignancy • CONCLUSION: Diagnosis of radial scar based on core needle biopsy is likely to be reliable when – no associated atypical hyperplasia – biopsy includes at least 12 specimens (VABB) – mammographic findings are reconciled with histologic findings. – If miss a criteria, excisional biopsy is indicated
- 38. Projektpartner 1. Fraunhofer-Institut für Integrierte Schaltungen IIS, Erlangen, Kohr et al. Radiology 255: 723 - 730 (2010) N = 991; N = 147 cases of atypia The upgrade rate is significantly higher when ADH involves at least three foci. Surgical excision is recommended even when ADH involves fewer than three foci and all mammographic calcifications have been removed, because the upgrade rate is 12%. Minimal Invasive Interventions Wagoner et al. Am J Clin Pathol 131: 112 - 121 (2009) N = 123; Patients with ADH restricted to fewer than 3 foci may not need surgical excision, especially when the mammographic abnormality is completely removed by VAB.
- 39. Lobular carcinoma in situ/atypical lobular hyperplasia on breast needle biopsies: does it warrant surgical excisional biopsy? A study of 27 cases O’Neil M, Madan R, Tawfik OW, Thomas PA, Fan F. Ann Diagn Pathol 2010;14(4):251–255 • 3163 breast core needle biopsies were retrieved from the surgical pathology files between 2003 and 2009 • among them, 56 (1.8%) cases were iden2fied with a diagnosis of ALH or LCIS • Eleven cases were excluded because of the presence of a concurrent more severe lesion in the biopsies that mandated excision • The remaining 45 cases contained only ALH or LCIS – 27 had surgical excision follow-up – In the surgical excision specimens, 5 (19%) of 27 (11% of 45) cases showed more severe lesions or were "upgraded » • 3 invasive ductal carcinomas • 1 invasive lobular carcinoma • 1 ductal carcinoma in situ • Histologic features of the lobular neoplasia on the core were found to have no predicKve value for a more severe lesion in the subsequent excision • We suggest that pa2ents with LCIS/ALH on core needle biopsy should be considered for surgical excision to rule out a more significant lesion regardless of the histologic features.
- 40. Atypical Lobular Hyperplasia and Lobular Carcinoma in Situ at Core Breast Biopsy: Use of Careful Radiologic-Pathologic CorrelaKon to Recommend Excision or ObservaKon Kristen A. Atkins, Michael A. Cohen, Brandi Nicholson, Sandra Rao. Northwestern Memorial Hospital, PrenKce Women’s Hospital, Chicago. Radiology, 2013, Vol.269: 340-347, 10.1148/radiol.13121730 Flow diagram of total number of cases partitioned into radiologic and histologic concordance or discordance. IC = invasive carcinoma.
- 41. • Advance in Knowledge – When careful radiologic-pathologic correlaKon is conducted in the seƒng of a breast core biopsy with atypical lobular hyperplasia or lobular carcinoma in situ some women can be safely triaged to observaKon • of the 43 benign concordant cases, none were upgraded at surgery or extended follow-up • ImplicaKon for PaKent Care – Focused and complete radiologic-pathologic correlaKon may obviate excisional biopsy in paKents with benign concordant biopsy findings – AddiKonal validaKon of this is required before this approach can be universally applied Atypical Lobular Hyperplasia and Lobular Carcinoma in Situ at Core Breast Biopsy: Use of Careful Radiologic-Pathologic CorrelaKon to Recommend Excision or ObservaKon Kristen A. Atkins, Michael A. Cohen, Brandi Nicholson, Sandra Rao. Northwestern Memorial Hospital, PrenKce Women’s Hospital, Chicago. Radiology, 2013, Vol.269: 340-347, 10.1148/radiol.13121730
- 42. Discussion to excise or to sample ? — Excision for probably benign lesion + clip • Birads 3 • Birads 4a — Sample for suspicious or malignant lesion • Birads 4 b & c • Birads 5 & 6
- 43. To Excise or To Sample the Mammographic Target: What Is the Goal of Stereotac2c II-Gauge Vacuum- Assisted Breast Biopsy? Laura Liberman, Jennifer B. Kaplan, Elizabeth A. Morris, Andrea F. Abramson, Jennifer H. Menell and D. David Dershaw AJR 2002;179: 679-683 Complete excision rather than sampling of mammographic target was associated with : • lower frequencies of discordance and ductal carcinoma in situ underesKmaKon • no other advantage or disadvantage • Among cancers in which the mammographic target was excised, surgery revealed residual cancer in almost 80%.
- 45. Biospsie contribuKve et concordante • Avant • ConsultaKon BalisKque et de faisabilité • ExplicaKons et consentement éclairé • Pendant • Technique • ÉchanKllonage • FixaKon et CR pour anapath • Après • ConsultaKon J8-J15 +/- imagerie • Concordance radio-anatomopathologique • Courrier prescripteur incluant CAT • RCP
- 46. Breast IntervenKon: How I Do It Mary C. Mahoney, Mary S. Newell, CincinnaK, Altlanta Radiology, 2013, Vol.268: 12-24, 10.1148/radiol.13120985 • Wri4en informed consent is required before all breast interven2ons • The risks explained to the pa2ent include bleeding and infec2on • An2coagula2on is a rela2ve contraindica2on to all biopsies – paKents are usually asked to disconKnue therapy for a short Kme prior to the biopsy • The pa2ent should be informed of the poten2al benefits of the biopsy – including avoidance of surgery with benign results – preoperaKve confirmaKon of malignancy, which allows definiKve surgical treatment in one surgical seƒng • Tailored prebiopsy counseling may be4er prepare women for percutaneous breast biopsy and improve their overall experience.
- 47. • younger women are more adversely affected by the biopsy experience. • ImplicaKon for PaKent Care • Tailored prebiopsy counseling may bever prepare women for percutaneous breast biopsy and improve their overall experience. Percutaneous Breast Biopsy: Effect on Short-term Quality of Life Kathryn L. Humphrey; Janie M. Lee; Karen Donelan; Chung Y. Kong; Olubunmi Williams; Omosalewa Itauma; Elkan F. Halpern; Beverly J. Gerade; Elizabeth A. Rafferty; J. Shannon Swan; MIT MGH , Boston, Radiology 2013, 10.1148/radiol.13130865
- 48. 03/01/16 • Side • Size • h x L x l • Location • Quadrant • Radius zone • Distance to the nipple BalisKc target tracking • US • RX • MRI
- 49. 03/01/16 • Side • Size • h x L x l • LocaKon • Quadrant • Radius zone • Distance to the nipple • Deep / cutaneous plane US balisKc target tracking
- 50. 03/01/16 Mme A. 40 ans. Atcd KS qsiD 1997. Atcd familiaux. Surv /6 mois M+US/IRM nles en 2010 05/2011 SD CNB 14g : CCI g2
- 51. 03/01/16
- 52. 03/01/16
- 55. Biopsy & pathology • RepresentaKve samples • Rx of samples if μcal • Formol > 12h < 24h : Kme of fixaKon +++ • Histology, RH, Her2 • clinical findings, report
- 56. Specimens XRays
- 57. InteracKve Case Review of Radiologic and Pathologic Findings from Breast Biopsy: Are They Concordant? How Do I Manage the Results? Christopher P. Ho, MD, Jennifer E. Gillis, MD, Kristen A. Atkins, MD, Jennifer A. Harvey, MD, and , Brandi T. Nicholson, MD University of Virginia Heath System, Chalovesville, Va. Radiographics, Volume 33-4 , 2013 • To successfully perform a minimally invasive breast biopsy • it is important to not only be familiar with the technique • but also with how to determine radiologic-pathologic concordance • and the appropriate treatments for paKents aier the procedure • When reviewing pathologic results for concordance • it is important to ensure that microcalcificaKons are idenKfied in the histologic specimen • and the specific pathologic diagnosis is consistent • with the morphologic characterisKcs seen at mammography • and the pretest probability of malignancy.
- 58. • At the follow-up examina2on • both the histologic and imaging findings should be revisited • and the mass should be assessed at mammography or US to ensure that it is stable • If it has grown in size or its morphologic characteris2cs have changed • If calcifica2ons increase in number or extent or the mass changes • Increases in size or its features become more suspicious • appropriate acKon should be taken • Excision is typically recommended • If the lesion is stable at follow-up examina2on • the paKent may return to the general screening populaKon InteracKve Case Review of Radiologic and Pathologic Findings from Breast Biopsy: Are They Concordant? How Do I Manage the Results? Christopher P. Ho, MD, Jennifer E. Gillis, MD, Kristen A. Atkins, MD, Jennifer A. Harvey, MD, and , Brandi T. Nicholson, MD University of Virginia Heath System, Chalovesville, Va. Radiographics, Volume 33-4 , 2013
- 59. Imaging-Histologic Discordance Aier Sonographically Guided Percutaneous Breast Biopsy: A ProspecKve ObservaKonal Study Eun Ju Son, Eun-Kyung Kim, Ji Hyun Youk, Min Jung Kim, Jin Young Kwak, Seon Hyeong Choi, August 22, 2011 • From January 2005 to December 2006, • US-guided 14-gauge automated CNB on 3339 breast lesions and obtained benign results in 2194 cases. • 1588 lesions that were either excised (n = 658) or followed up for at least 2 years (n = 930) aier CNB. • Imaging-histologic discordance was present in 103 of 1588 (6.5%) lesions. • The upgrade rate was – 6.8% (7/103) in discordant lesions – 0.4% (6/1485) in concordant lesions (p < 0.01) • Lesion size, Breast Imaging, ReporKng and Data System (BI-RADS) category and the presence or absence of symptoms was staKsKcally significant between the upgrade and non-upgrade groups in discordant cases (p < .05). • Imaging-histologic discordance is an indica2on for excision because it has a higher upgrade rate than concordant lesions.
- 60. • No imaging specificity for breast lesion • Biopsy histology correlaKon for all Birads 4 and 5 lesions • LCNB : 16 or 14 G ≥ 4 samples • Under-esKmaKon rate for premalignant lesion • ≈ 10 % VABB • ≈ 20 % LCNB • PML refered for surgical excision • VABB under stereotacKc guidance • 11G ≥ 10 samples • 7 G ≥ 6 samples • VABB under US or MRI guidance • No guidelines : target excision or sampling • Concordance • BalisKc consultaKon • Sampling quality : guidance/biopsy device/samples • Birads/histological correlaKon • Follow up or surgical excision indicaKon : RCP Take home message