Interventional Radiology : Useful for All and Always ? Dr S. Murgo CHU Tivoli, La Louvière,...

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Transcript of Interventional Radiology : Useful for All and Always ? Dr S. Murgo CHU Tivoli, La Louvière,...

IInterventional nterventional RRadiology : adiology : UUseful for seful for

AAll and ll and AAlways ?lways ?

IInterventional nterventional RRadiology : adiology : UUseful for seful for

AAll and ll and AAlways ?lways ?

Dr S. Murgo

CHU Tivoli, La Louvière, BelgiqueHôpital Erasme, Bruxelles,

Belgique

Dr S. Murgo

CHU Tivoli, La Louvière, BelgiqueHôpital Erasme, Bruxelles,

Belgique

IntroductionIntroductionIntroductionIntroduction

ScreeningScreening Many benign lesions Many benign lesions indistinguishable from cancerindistinguishable from cancer

Previously open surgical biopsiesPreviously open surgical biopsies (OSB) for (OSB) for asymptomatic benign lesions were often asymptomatic benign lesions were often necessarynecessary

Quick development ofQuick development of percutaneaous percutaneaous biopsies biopsies for BIRADS 4 and also 5for BIRADS 4 and also 5 with often a with often a lack of scientific validationslack of scientific validations some some controversiescontroversies

Potential advantagesPotential advantagesPotential advantagesPotential advantages

Less invasive,Less invasive, less expansiveless expansive techniques that techniques that avoid:avoid: surgerysurgery for benign lesions for benign lesions surgsurgery in 2 timesery in 2 times

Percutaneaous biopsy may avoid per-Percutaneaous biopsy may avoid per-operative histological analysisoperative histological analysis that may that may destruct small lesionsdestruct small lesions

Potential drawbacksPotential drawbacksPotential drawbacksPotential drawbacks

Epithelial displacementEpithelial displacement (FNA, CNB > VACB): (FNA, CNB > VACB): No evidence of biologic significance No evidence of biologic significance No No of the recurrence rate after BCS of the recurrence rate after BCS But some displaced cells associated with DCIS can sometime But some displaced cells associated with DCIS can sometime

mimic IDCmimic IDC for pathologist. for pathologist.

Risk of missed cancersRisk of missed cancers good good knowledge of knowledge of limitationslimitations

Interventional Interventional RadiologyRadiologyInterventional Interventional RadiologyRadiology

Includes:Includes:

GGuidewire uidewire LLocalizationocalization

RRadioadioFFrequencyrequency

Fine Needle AspirationFine Needle Aspiration

Core Needle BiopsyCore Needle Biopsy

Large Core Needle BiopsyLarge Core Needle Biopsy

Main Mammographic Main Mammographic Signs Signs Main Mammographic Main Mammographic Signs Signs

MMassass

AArchitectural rchitectural DDistorsionistorsion

MMicrocalcificationsicrocalcifications

Mass: Mass: with irregular / stellate with irregular / stellate outlineoutlineMass: Mass: with irregular / stellate with irregular / stellate outlineoutline

DD:DD: Radial scar, complex sclerosis lesion, invasive Radial scar, complex sclerosis lesion, invasive carcinoma (usually grade I or II), fat necrosis, granular carcinoma (usually grade I or II), fat necrosis, granular cell myoblastoma,…cell myoblastoma,…

FNA ? FNA ? 10 % of C1 10 % of C1 (not enough cells)(not enough cells) CNB CNB

False negative: False negative: 6-7%6-7% (1)(1) C2 no value C2 no value PPV of C3 : 55 % if suspect 83% PPV of C3 : 55 % if suspect 83% (2)(2)

PPV of C4 : 96 % if suspect 98.5 % PPV of C4 : 96 % if suspect 98.5 % (2)(2)

PPV of C5PPV of C5 >> 99.4 %99.4 % (2)(2) invasive carcinoma ? invasive carcinoma ?

(1)(1) Lau. The breast Journal 2004; 10: 487Lau. The breast Journal 2004; 10: 487(2)(2) Bulgaresi. Breast cancer Res Treat 2006; 97 (3):319-21Bulgaresi. Breast cancer Res Treat 2006; 97 (3):319-21

CNBCNB

Mass: CNBMass: CNBMass: CNBMass: CNB

(1)(1) Koskela. Radiology 2005; 236: 801-9Koskela. Radiology 2005; 236: 801-9

14 g – with 3 samples in the target

Mass: Mass: with well-defined with well-defined outlineoutlineMass: Mass: with well-defined with well-defined outlineoutline

DD:DD: Cyst, FA, hamartoma, lymph node, phyllodes Cyst, FA, hamartoma, lymph node, phyllodes tumor, invasive carcinoma (high grade), papillary tumor, invasive carcinoma (high grade), papillary lesions, mucinous carcinoma, medullary carcinoma, lesions, mucinous carcinoma, medullary carcinoma, abscessabscess

UltrasoundUltrasound1 - Typical cyst, harmatoma, or LN 1 - Typical cyst, harmatoma, or LN STOP STOP

2 – « Typical FA » 2 – « Typical FA » different schools: different schools: Follow-up ?Follow-up ? Not palpableNot palpable 0-2 % of malignancy (mean: 0-2 % of malignancy (mean: 1.4%1.4% - Lower for young women - Lower for young women (< 30 yo))(< 30 yo))

Triple test with FNA ?Triple test with FNA ? Negative predictive value: Negative predictive value: 100% 100% (1)(1) but … false positive !but … false positive !

CNBCNB the best testthe best test to exclude a breast cancer ! Especially for large lesion and old women to exclude a breast cancer ! Especially for large lesion and old women (> 60 % of carcinoma after 60 yo)(> 60 % of carcinoma after 60 yo)

(1)(1) Lau. The breast Journal 2004. 10: 487Lau. The breast Journal 2004. 10: 487

? FA ?

6 mo follow-up6 mo follow-up FNAFNA CNBCNB

ChangeChangeNo change after 2 y

No change after 2 y

Not palpableNot palpable98.6 % of benign lesions 98.6 % of benign lesions (1)(1)

0.026% 0.026% of of missed cancers missed cancers

(after 3 years) (after 3 years) (2)(2)

CNBCNB

16 % of cancers16 % of cancers

86.1 % of T0N0M0 or T1N0M0 86.1 % of T0N0M0 or T1N0M0 (2)(2)

C1C1

C2C2

C3 C3

10-15 % 10-15 % CNB CNB (3)(3)

99.9 % B99.9 % B

0.1% M 0.1% M (7% of 1.4% (7% of 1.4% BC)BC)

7-8 % 7-8 % CNB CNB (4)(4)

Best test

Best test

NPV NPV 100 % 100 %

PPV > 98 % PPV > 98 %

(3 samples in the target)(3 samples in the target)

(1)(1) Sickles. Radiol Clin NorthSickles. Radiol Clin North. . Am 1995; 33:1123-1130.Am 1995; 33:1123-1130.

(2)(2) SicklesSickles. . Radiology 1999;Radiology 1999; 213:11-14.213:11-14.

(3)(3) Wells. EU guidelines for non-operative diagnostic procedures. 2004Wells. EU guidelines for non-operative diagnostic procedures. 2004

(4)(4) Lau. The breast Journal 2004; 10: 487Lau. The breast Journal 2004; 10: 487

Tabar. Radiol Ciln North Am. 2000; 38(4):625-651Tabar. Radiol Ciln North Am. 2000; 38(4):625-651

FA ?

6 mo follow-up6 mo follow-up FNAFNA CNBCNB

ChangeChangeNo change after 2 y

No change after 2 y

Not palpableNot palpable98.6 % of benign lesions 98.6 % of benign lesions (1)(1)

Missed Missed cancers cancers

0.026%0.026% (after (after

3 years) 3 years) (2)(2)

CNBCNB

16 % of cancers16 % of cancers

86.1 % of T0N0M0 or T1N0M0 86.1 % of T0N0M0 or T1N0M0 (2)(2)

C1C1

C2C2

C3 C3

10 % 10 % CNB CNB (3)(3)

99.9 % B99.9 % B

0.1% M 0.1% M (7% of 1.4% (7% of 1.4% BC)BC)

7-8 % 7-8 % CNB CNB (4)(4)

Best test

Best test

NPV NPV 100 % 100 %

PPV > 98 % PPV > 98 %

(3 samples in the target)(3 samples in the target)

(1)(1) Sickles. Radiol Clin NorthSickles. Radiol Clin North. . Am 1995; 33:1123-1130.Am 1995; 33:1123-1130.

(2)(2) SicklesSickles. . Radiology 1999;Radiology 1999; 213:11-14.213:11-14.

(3)(3) Wells. EU guidelines for non-operative diagnostic procedures. 2004Wells. EU guidelines for non-operative diagnostic procedures. 2004

(4)(4) Lau. The breast Journal 2004; 10: 487Lau. The breast Journal 2004; 10: 487

Caution: size , age, other risk factors (BRCA, Caution: size , age, other risk factors (BRCA, family or personal history,...), anxiety and family or personal history,...), anxiety and

reliabilityreliability of the pat. of the pat.

UltrasoundUltrasound3 – Cystic lesion with intracystic growth3 – Cystic lesion with intracystic growth

40 women with 56 papillary lesions: 3 papillary carcinomas, 13 40 women with 56 papillary lesions: 3 papillary carcinomas, 13 papillaryal lesions with carcinoma in situ, 1 atypical carcinoma, 4 papillaryal lesions with carcinoma in situ, 1 atypical carcinoma, 4 sclerosed papilloma, 35 papillomata.sclerosed papilloma, 35 papillomata.

PPVPPV NPVNPV

FNAFNA 31 %31 % 79 %79 %

CNBCNB 100 %100 % 83 %83 %

Lam. AJR 2006; 186(5): Lam. AJR 2006; 186(5): 1322-71322-7

Well-defined massWell-defined massWell-defined massWell-defined mass

Open Surgical Biopsy !

50 50 papillomas on percutaneous biopsypapillomas on percutaneous biopsy (35 VACB – 11G & 15 CNB 14 G) (35 VACB – 11G & 15 CNB 14 G)

Reference standard: OSB and longterm follow-upReference standard: OSB and longterm follow-up

5 (14%) 5 (14%) breast cancersbreast cancers (4 DCIS & 1 inv. carcinoma) (4 DCIS & 1 inv. carcinoma)

6 (17%) 6 (17%) high risk lesionshigh risk lesions (3 ADH, 2 radial scar, 1 LN) (3 ADH, 2 radial scar, 1 LN)

The risk The risk in case of multiple papilloma and with a family history of in case of multiple papilloma and with a family history of breast cancerbreast cancer

Liberman. AJR 2006; 186(5): Liberman. AJR 2006; 186(5): 1328-341328-34

Well-defined massWell-defined massWell-defined massWell-defined mass

Can we totally remove a small benign lesion with LCNB ? …

Open Surgical Biopsy !

Architectural distortionArchitectural distortionArchitectural distortionArchitectural distortion

DD: DD: Involution, radial scar, invasive lobular carcinoma, Involution, radial scar, invasive lobular carcinoma, DCIS(rarely),… DCIS(rarely),…

Radial scar:Radial scar: Fibroelastic center with pseudo-infiltrative tubular structure (DD: Fibroelastic center with pseudo-infiltrative tubular structure (DD: tub car). tub car). In the crown of the RS +/- ADH, ALH, DCIS, LN, … In the crown of the RS +/- ADH, ALH, DCIS, LN, … the risk the risk with with the age and the size the age and the size (1)(1)

- None < 40 yo,- None < 40 yo, rare between 40 & 50 yo, rare between 40 & 50 yo, > 50 yo > 50 yo

- Rare if < 6-7 mm- Rare if < 6-7 mm

(1)(1) Andersen JA, Cancer 1984; 53:2557-2560.Andersen JA, Cancer 1984; 53:2557-2560.

Open Surgical Biopsy !

Architectural distortionArchitectural distortionArchitectural distortionArchitectural distortion

From Tabar. Practical breast pathology - Thieme 2002: 104-5From Tabar. Practical breast pathology - Thieme 2002: 104-5

Open Surgical Biopsy !Open Surgical Biopsy !

Masses with calcif17%

Masses64%

Calcifications19%

MicrocalcificationsMicrocalcificationsMicrocalcificationsMicrocalcifications

Mammographic appearence of breast cancers

Casting19%

Powdery36%

Crushed stone45%

MicrocalcificationsMicrocalcificationsMicrocalcificationsMicrocalcifications

Mammographic appearence of calcifications sent to surgery

MicrocalcificationsMicrocalcificationsMicrocalcificationsMicrocalcifications

Casting calcifications (fine, linear, branching): Casting calcifications (fine, linear, branching): plasma plasma cell mastitis, DCIS grade III.cell mastitis, DCIS grade III.

Crushed stone calcifications (pleomorphic, Crushed stone calcifications (pleomorphic, heterogenous): heterogenous): Fat necrosis, FA, cysts, DCIS grade II/III, Fat necrosis, FA, cysts, DCIS grade II/III, Lobular neoplasia (rarely).Lobular neoplasia (rarely).

Powdery calcifications (amorphous, indistinct): Powdery calcifications (amorphous, indistinct): sclerosing adenosis, cysts, DCIS grade I/II.sclerosing adenosis, cysts, DCIS grade I/II.

Wells. EU guidelines for non-operative diagnostic Wells. EU guidelines for non-operative diagnostic procedures. 2004procedures. 2004

Microcalcifications: CNBMicrocalcifications: CNBMicrocalcifications: CNBMicrocalcifications: CNB

(1)(1) Koskela. Radiology 2005; 236: 801-9Koskela. Radiology 2005; 236: 801-9

Vacuum assisted breast Vacuum assisted breast biopsy biopsy Vacuum assisted breast Vacuum assisted breast biopsy biopsy

MammotomeMammotome®®

VacoraVacora®®

Large biopsy Large biopsy Large biopsy Large biopsy

SiteSelect SiteSelect ®®

(ABBI ®)(ABBI ®)

En-bloc En-bloc ®® ……

LLatateeralral position position - - LMLM

On stereotactic On stereotactic guidanceguidanceOn stereotactic On stereotactic guidanceguidance

Dedicated tableDedicated tableDedicated tableDedicated table

LoraLoradd

FisheFisherr

MicrocalcificationsMicrocalcificationsMicrocalcificationsMicrocalcifications

VACB > CNBVACB > CNB with a higher NPV and less technical failures with a higher NPV and less technical failures Meta-analysis: 35 studiesMeta-analysis: 35 studies – minimal invasive breast biopsy – minimal invasive breast biopsy

after screening:after screening: 12 VABB, n = 511912 VABB, n = 5119 25 CNB, n = 623625 CNB, n = 6236

Reference standard: open surgery or longterm follow-upReference standard: open surgery or longterm follow-up

VACBVACB CNBCNB

Overall Overall agreementagreement

with referencewith reference

97.3 %97.3 % 93.5 %93.5 %

Technical failureTechnical failure 1.5 %1.5 % 5.7 %5.7 %

Non diagnostic Non diagnostic samplessamples

0 %0 % 2.1 % (23 % of 2.1 % (23 % of BC)BC)

Fahrbach. Arch gynecol obstet 2006; 274(2):63-74Fahrbach. Arch gynecol obstet 2006; 274(2):63-74

FN : 3.8 %FN : 3.8 %

PPost biopsost biopsy MGy MG

MGMG of samplesof samples

To reach a high NPV:

Koskela. Radiology 2005; 236: 801-9Koskela. Radiology 2005; 236: 801-9

With CNB, the sensitivity with the number of samples

(1)(1) LomoschitzLomoschitz. . Radiology 2004; 232:897–903Radiology 2004; 232:897–903

With VACB - 11 G under stereotactic guidance

The accuracy increase significantly until 12 samples

MicrocalcificationsMicrocalcificationsMicrocalcificationsMicrocalcifications

Mass

Microcalcification

Calcifications : Calcifications : undervaluationundervaluationCalcifications : Calcifications : undervaluationundervaluation

VVacuum-assisted devices, larger gauge biopsy acuum-assisted devices, larger gauge biopsy needles, and greater number of cores were needles, and greater number of cores were associated with associated with a higher NPV.a higher NPV.

But there is always some But there is always some underevaluated underevaluated lesions: ADH, ALH, LN, DCIS (16-31 %) lesions: ADH, ALH, LN, DCIS (16-31 %) OSB is OSB is requiredrequired

Magenthaler. Am J Surg 2006; 192(4):534-7Magenthaler. Am J Surg 2006; 192(4):534-7

Mahoney. AJR 2006; 187(4):949-54Mahoney. AJR 2006; 187(4):949-54

LomoschitzLomoschitz. . Radiology 2004; 232:897–903Radiology 2004; 232:897–903

Mahoney. AJR 2006; 187(4):949-54Mahoney. AJR 2006; 187(4):949-54

Large cluster of amorphous calcifications: adenosis +/- Large cluster of amorphous calcifications: adenosis +/- DCIS ?DCIS ?

Tabar. Practical breast pathology - Thieme 2002Tabar. Practical breast pathology - Thieme 2002

Calcifications : Calcifications : undervaluationundervaluationCalcifications : Calcifications : undervaluationundervaluation

MicrocalcificationsMicrocalcificationsMicrocalcificationsMicrocalcifications

To avoid missed cancer, a open surgical biopsy is To avoid missed cancer, a open surgical biopsy is required after percutaneous biopsy:required after percutaneous biopsy:

When When none or a small numbernone or a small number of calcifications of calcifications are removedare removed

For For large cluster of amorphouslarge cluster of amorphous calcifications calcifications (adenosis +/- DCIS ?)(adenosis +/- DCIS ?)

For an histological diagnosis of For an histological diagnosis of ADH, ALH, and ADH, ALH, and LNLN

ConclusionsConclusionsConclusionsConclusions

IR is very useful and efficient BUT IR is very useful and efficient BUT not for all and not for all and always !always !

The The knowledge ofknowledge of the limitationsthe limitations of each techniques of each techniques nb of missed cancers nb of missed cancers

ConfrontationConfrontation of the cytological and histological of the cytological and histological results with the PE and medical imaging studies in a results with the PE and medical imaging studies in a multidisciplinary approach !multidisciplinary approach !

Repeat biopsyRepeat biopsy is necessary if histological and imaging is necessary if histological and imaging finding are discordantfinding are discordant

Surgical excisionSurgical excision is necessary for some histological benign is necessary for some histological benign lesions: ADH, ALH, LN, radial scar, papillary lesions, possible lesions: ADH, ALH, LN, radial scar, papillary lesions, possible phyllode tumorphyllode tumor

ConclusionsConclusionsConclusionsConclusions

Further work is necessary to optimize criteria for Further work is necessary to optimize criteria for patient selection, to develop and define the role of patient selection, to develop and define the role of new technologies.new technologies.

Complete removal of the mammographic target Complete removal of the mammographic target does not ensure complete excision of the does not ensure complete excision of the histological process histological process Further investigation is Further investigation is necessary to determinate in which lesion, complete necessary to determinate in which lesion, complete removal of the targetremoval of the target is advantageous. is advantageous.