Outline. Image Guided Percutaneous Breast Procedures. Your Role. Percutaneous Biopsy. Disadvantages Percutaneous Biopsy

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1 Outline Image Guided Percutaneous Breast Procedures Hong P. Pham, M.D. Los Angeles Kaiser Permanente Medical Center Benefits of Percutaneous biopsy technique Stereotactic guided core biopsy Ultrasound guided core biopsies Fine Needle Aspiration/Cyst Aspiration MRI guided biopsy Rad-Path Correlation Your Role Percutaneous Biopsy Physician Patient Technologist Pathologist Large core needle biopsy 9 G to 14 G In past, smaller gage and open biopsy US / Mammography / MRI Spring loaded Vacuum Assisted Modality that best depicts lesion Equipment Advantages of Percutaneous Biopsy No cosmetic deformity; fast recovery Minimal mammographic alteration Minimal time for biopsy and result Cost reduction of 25-50% vs surgical biopsy Decreased physician visits Standard of Care Disadvantages Percutaneous Biopsy Inadequate samples: 2% Cains. AJR 1994; 163:317 6% Dronkers. Radiology 1992; 183:631 9% Parker. Radiology 1990; 176:741 Problem of the past Small gauge and non spring loaded, non vacuum etc Now with larger spring loaded and vacuum assisted devices=surgical biopsy 92-99% sensitive and % specifity 1

2 Contraindications Inability of the patient to cooperate for the procedure Inability of the patient to consent for the procedure Allergy to local anesthetic Coagulopathies, including: Hematologic disorders Drug induced Inaccessible location Before Biopsy: Complete Work up Diagnostic Mammogram and/or US required Screening call back? Palpable concern? BIRADS 4 or 5 Contra-indications or difficulities? Patient intolerance? Complete diagnostic work up Lesions that should not undergo biopsy include: BI-RADS 2: benign Lesions better assessed with shortterm, e.g. six month, follow-up Abscess Mastitis BIRADS 3 CC ML BI-RADS 3: Probably Benign < 2% likelihood of malignancy short interval (6 month) follow up / 2 yr stability Biopsy results in a low positive predictive value for biopsy recommendation and inappropriately inflates the cost of screening. Needle biopsy can be useful in patients with a high anxiety level or unlikely or unable to undergo follow-up. 2

3 BI-RADS 4: Suspicious Percutaneous biopsy is most useful for these lesions differentiate those requiring surgery from those which are definitely benign If benign and concordant with imaging 6 mt f/u Potential sampling error Appropriate followup for this group after benign biopsy has been controversial. Studies suggest poor patient compliance with a 6 month followup recommendation. Goodman. AJR 1996; 170:89 BI-RADS 5:Highly suggestive of malignancy Percutaneous biopsy still useful Surgical planning Staging; lumpectomy vs mastectomy axillary lymph node dissection Treatment options for chemotherapy Receptor status Consent Infection rare Bruising expected Bleeding rare; typically self limited Sampling error; need to still go on to surgical excision Consent for clip Very rare 0-3% Hematoma infection, Pneumothorax Vasovagal Implant rupture Complications Complications Tumor spread during biopsy? Tumor cell displacement Up to 1/3 show displacement on biopsy No increased rate of recurrence after appropriate treatment Outside of tumor environment Host immune response Radiation/chemotherapy 3

4 Stereotactic Core Biopsies Sweden 1977 stereotactic guide FNA USA first stereo unit 1986 First core needle biopsy 1990 Indications Suspicious BIRADS 4/5 calcifications Nonpalpable masses, Architectural distortion, Asymmetry on one view Stereo Technique Prone table; breast compression Scout; stereo pairs Localization X, Y, Z planes and transmitted Needle calibrated Skin cleansed, anesthesia, skin nick Needle advanced in front of lesion (pre-fire), fire (post-fire) Sample, specimen radiograph Clip and post clip stereo and mammogram Stereo Targeting Accurate pre-fire position Accurate post-fire position Errors in Targeting Errors in Targeting X-axis error: needle is to the right of lesion Y-axis error: needle is inferior to lesion Left Stereo Right Stereo Left Stereo Right Stereo 4

5 Errors in Targeting Errors in Targeting Z-axis error: need is too proximal to lesion Left Stereo Right Stereo X +Y axis error Left Stereo Right Stereo Lateral view Number of samples? 9 gage vacuum assisted device 8-12 samples good to get calcs, but tissue around calcs Concentrate on areas of concern 12 Clip Placement Typically place clip to mark most biopsies Possibility of total removal of the lesion. Follow up or localization for treatment 4 Lateral view Post-clip Mammogram After compression is released, relationship of the clip to the biopsy site can be altered. Relationship of the clip to the biopsy site should be documented with a post-biopsy mammogram at the end of the biopsy procedure. Was lesion sampled? Post-biopsy changes on the mammogram are transient, often vanishing with days. Asymmetry and Architectural Distortion Difficult to localize Small field of view of stereotactic window Localizing identical site on stereo pairs may be more difficult without calcs or defining marker Some areas of distortion may be best visualized sonographically. These lesions might be most accurately diagnosed with wire localization and surgical biopsy. 5

6 23 mm needle throw {-----Z = 20 mm-----} Compression = 50mm Pull back needle 5 mm prefire Too Thin/Deep Compresses too thin (negative stroke margin) Create big wheal of anesthesia Aim short and fire, advance Reverse compression paddle Too Close to the skin Use half sample Stroke Margin=[50 20] [23 5]=12 THIN BREAST OR VERY DEEP LESION Close to Chest Wall Sling for Arm Through Technique Lo Rad Reversed Paddle Ultrasound Guided biopsy Spring Loaded US Biopsy Devices Easy, quick, lower cost No radiation Real time visualization Better patient comfort/preference Spring load vs. Vacuum Assisted Physician only vs. Physician and Sonographer 6

7 Ultrasound guided core biopsy Technique Physician only vs. Physician and Sonographer Patient position key to quick and smooth procedure Never advance needle w/o visualizing the tip Must align transducer and needle Entry Site: Depends on lesion depth False impression of needle tip Elevate deep lesions/parallel to Chest wall Special scenarios Tiny lesion Your first biopsy maybe your best shot Leave clip? Correlates with mammographic abnormality Leave clip and check post biopsy mammogram Hematoma May have to reschedule and rebiopsy 7

8 Number of Samples?? Risk of underestimation US-guided 14-gauge Core-Needle Breast Biopsy: Results of a Validation Study in 1352 Cases Radiology SAMPLES Personally 4-6 samples Fine Needle Aspiration Large core needle biopsy preferred Axillary lesions and lymph nodes Cyst aspiration attempted but lesion is solid Breast too thin to accommodate core biopsy probe Differentiation of invasive vs in situ not important, e. g. recurrence post conservation Cytologist or cytopathologist on site FNA Equipment Small gauge needle (21-25 G) Short, rapid, stabbing motion Vacuum generated 10 or 20 cc syringe Some use IV tubing to connect syringe to needle or a gun adapter Release before needle withdrawn from lesion Aspiration: Fluid Analysis Cytology analysis If red with new blood or rusty with old blood 6782 aspirations only 5 papillomas If lesion has suspicious imaging pattern, e.g. intracystic papillary lesion Green, gray, clear, and white fluid contents are not associated with malignancy. Risk for false positive and atypia Ciatto Acta Cyto 1989 MRI Guided Biopsy MRI Guided Biopsy Newest and increasing used Lesion detection different than Mammo/US Detects neovascularity Requires IV contrast Requires cooperation of mammography and MRI technologists Hands-Free mounted 8

9 MRI guided Biopsy MRI guided biopsy Identification of appropriate grid box 1. Identify lesion Identification of appropriate grid box 1. Identify lesion 2. Mark lesion Identification of appropriate grid box 1. Identify lesion 2. Mark lesion 3. Scroll to grid image Identification of appropriate grid box 1. Identify lesion 2. Mark lesion 3. Scroll to grid image 4. Relate vit E to appropriate box 9

10 The cheat sheet MRI guided biopsy HEAD NIPPLE Vit E CHEST WALL FEET Rad-Pathology Correlation Concordance: Imaging adequate explained by pathologic findings Benign Histology Concordant: 6 month followup 2% false negative (cancer at biopsy site within 2 yrs) Non-concordant: Repeat biopsy/surgical excision Up to 64% incidence of carcinoma when rebiopsied Rad-Pathology Correlation Surgical biopsy indicated ADH, lobular neoplasia (ALH), papillary lesions, phyllodes, radial scar, mucinous lesion. Pathologist recommendation Repeat needle or surgical biopsy indicated BI-RADS 5 non-concordant lesion Missed lesion Pathologist recommendation Lee Radiology 1999 Summary Percutaneous image guided biopsy is standard of care Safe, cost effective and widely available Many options and modalities available Success requires planning and cooperation of radiologist and technologist CASES 10

11 48 year old woman with new breast mass on mammo. How would you biopsy? 1. Aspirate fluid 2. FNA mass 3. Core mass under sono guidance 4. Core mass under stereo guidance Core biopsy diagnosis is ductal atypia. Patient management recommendation is: 1. Routine mammogram in one year 2. Six month followup 3. Refer for high risk screening 4. Repeat core biopsy 5. Surgical biopsy Core biopsy of this lesion is reported at DCIS. Is this diagnosis concordant? 1. Yes 2. No 3. Maybe This 7 mm cluster of pleomorphic microcalcifications was recommended for biopsy. Patient refuses surgery. How should the biopsy be performed? 1. Sono guided FNA 2. Sono guided core 3. Stereotactic core 4. Stereotactic core with clip placement 5. Patient should be convinced to have surgery Screening mammo detected calcifications with mammo and stereo biopsy specimen radiograph Histology of core: ductal hyperplasia How do you manage this patient? 1. Routine followup in one year 2. Six month followup 3. Repeat core biopsy 4. Surgical excision screening mammo mag sono Sono guided biopsy of this new, slightly spiculated mass is reported as fibrocystic change. How do you manage this patient? 1. Routine annual followup 2. Six month followup 3. Repeat core biopsy 4. Surgical biopsy 11

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