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Is radiology replacing the Is radiology replacing the scalpel:scalpel:
Advances in minimally Advances in minimally invasive techniquesinvasive techniques
Dr Steven AllenDr Steven AllenConsultant Breast RadiologistConsultant Breast Radiologist
Breast Imaging Lead, Royal Marsden Hospital, Breast Imaging Lead, Royal Marsden Hospital, SuttonSutton
Specialist Advisor to NICE on breast Specialist Advisor to NICE on breast interventional proceduresinterventional procedures
Radiological Breast Radiological Breast InterventionIntervention
Diagnosis (biopsies)Diagnosis (biopsies) TherapyTherapy
Fine Needle AspirationFine Needle Aspiration Insufficient material retrieved for definitive Insufficient material retrieved for definitive
diagnosisdiagnosis
Interpretation is highly dependent on skill of Interpretation is highly dependent on skill of cytopathologistcytopathologist
Cannot distinguish Cannot distinguish in situin situ versus invasive versus invasive carcinomascarcinomas
Difficult to distinguish atypical ductal hyperplasia Difficult to distinguish atypical ductal hyperplasia from low-grade DCIS or low-grade invasive ductal from low-grade DCIS or low-grade invasive ductal carcinomacarcinoma
New “Best practice diagnostic guidelines for New “Best practice diagnostic guidelines for patients presenting with breast symptoms”*patients presenting with breast symptoms”**Willett et al. Best practice diagnostic guidelines for patients presenting with breast symptoms . Nov 2010. www.rcrbreastgroup.com/Documents/BBCDiagnosticGuidelines.pdf
Fine Needle Aspiration-Fine Needle Aspiration-UsesUses
Where core biopsy not technically Where core biopsy not technically possiblepossible
Lymph nodesLymph nodes Complex cystsComplex cysts Radiologically benign, young womenRadiologically benign, young women Clotting issuesClotting issues Local anaesthetic allergyLocal anaesthetic allergy
Why do we need Why do we need breast needle biopsy?breast needle biopsy? Definitive benign diagnosis avoids Definitive benign diagnosis avoids
unnecessary surgeryunnecessary surgery Knowledge of the type and extent of Knowledge of the type and extent of
malignancy influences choice of treatmentmalignancy influences choice of treatment ADH or Ductal carcinoma in situ? ADH or Ductal carcinoma in situ? Ductal carcinoma in situ or invasive Ductal carcinoma in situ or invasive
disease?disease? Invasive tumour type - eg lobularInvasive tumour type - eg lobular Invasive tumour gradeInvasive tumour grade Oestrogen receptor statusOestrogen receptor status Other tumour markersOther tumour markers Tumour geneticsTumour genetics
Problems with core Problems with core biopsybiopsy
False negatives on core (2-10%, mainly False negatives on core (2-10%, mainly calcifications)calcifications)
Trend to increasing size of biopsy sample Trend to increasing size of biopsy sample to minimize thisto minimize this
BUT cheap ( approx £15 per needle, £50 BUT cheap ( approx £15 per needle, £50 per case versus £150 per needle, £500 per case versus £150 per needle, £500 per case)per case)
Automated 14g core biopsy deals Automated 14g core biopsy deals with more than 90% of caseswith more than 90% of cases
Very large core biopsy techniques Very large core biopsy techniques have been developed to deal with have been developed to deal with
the rest and also to help solve the rest and also to help solve diagnostic problemsdiagnostic problems
Tissue Tissue volumevolume
MethodMethod Average Average weightweight
14g core14g core 17mg17mg
11g VAB11g VAB 100mg100mg
7g VAB7g VAB300mg300mg
Liberman L. AJR 2000; 174: Liberman L. AJR 2000; 174: 1191-11991191-1199
Vacuum Assisted BiopsyVacuum Assisted Biopsy
In USA probably overperformedIn USA probably overperformed Increasing in Europe where probably still Increasing in Europe where probably still
underperformedunderperformed The role is extending (MRI, therapy?)The role is extending (MRI, therapy?)
When should vacuum When should vacuum assisted biopsy be assisted biopsy be
used?used?Indications :Indications : Very small mass lesionsVery small mass lesions Equivocal or failed core Equivocal or failed core
biopsybiopsy Architectural distortionsArchitectural distortions MicrocalcificationsMicrocalcifications Papillary and mucocele like Papillary and mucocele like
lesionslesions Diffuse non-specific Diffuse non-specific
abnormalityabnormality Complex cysts and Complex cysts and
abscessesabscesses Excision of benign lesionsExcision of benign lesions Malignant disease ??Malignant disease ??
VAB effectsVAB effects
Will detect more ADH Will detect more ADH *, LCIS, LCIS Will detect more DCIS, Invasive cancerWill detect more DCIS, Invasive cancer* * Reduced surgical biopsy rateReduced surgical biopsy rate Better preoperative surgical and medical Better preoperative surgical and medical
treatment planningtreatment planning
* Winchester et al. Arch Surg 2003: 138(6); 619-22
* *Kettritz et al. Cancer 2004: 100(2); 245-51
VAB - risksVAB - risks
Haematoma rates are actually low*, and Haematoma rates are actually low*, and not significantly different to core biopsynot significantly different to core biopsy
Pain?**Pain?**
Clip migrationClip migration
*Lai, et al. Vacuum-assisted large-core breast biopsy: complications and their incidence. Can Assoc Radiol J. 2000 Aug;51(4):232-6.
**Szynglarewicz, et al. Pain experienced by patients during minimal-invasive ultrasound-guided breast biopsy: Vacuum-assisted vs core-needle procedure. EJSO,. 2011 Feb 28, Epub
VAB - techniqueVAB - technique
EnCor (SenoRxEnCor (SenoRx™) ™)
EnCorEnCor
Built in Built in headlightsheadlights illuminate the biopsy illuminate the biopsy areaarea
Choice of Choice of sample sample patternspatterns that that continuously repeatcontinuously repeat
EnCorEnCor
ATEC (Suros surgicalATEC (Suros surgical))
VacoraVacora
VAB systems - comparison of VAB systems - comparison of attributesattributes
Attribute Vacora Mammotome Suros Atec Encor
X-ray and US
MRI
Directional
Sample Single Multiple Multiple Multiple
Method Cutting Cutting Cutting Scissor
Sharpness + + + +++
Retrieval Open Open Closed Closed
Vacuum control
X
Programmable
X X
Lavage X X
Anaesthetic X
Sample size
Volume in 1min
+ ++ +++ +++
Probe offset X
Vacuum assisted excisionVacuum assisted excision
Increasing use to excise benign lesions in Increasing use to excise benign lesions in a “piecemeal” fashion as an alternative to a “piecemeal” fashion as an alternative to surgerysurgery
Cannot give margin status on excisionCannot give margin status on excision Newer devices are very automated Newer devices are very automated
allowing most procedures to be performed allowing most procedures to be performed in <30 minutesin <30 minutes
Significant time, cost, morbidity benefitsSignificant time, cost, morbidity benefits
Vacuum assisted excisionVacuum assisted excision
Benign lesions such as fibroadenomas Benign lesions such as fibroadenomas ** Recurrence rate may be higher for lesions Recurrence rate may be higher for lesions
>2cm>2cm Papillary lesionsPapillary lesions All B3 lesions without atypiaAll B3 lesions without atypia* ** * Lymph nodes?Lymph nodes? Cancers?Cancers?
** Grady et al, Breast J 2008, Grady et al, Breast J 2008, 14(3): 275-8 14(3): 275-8
* * Tennant et al, Breast 2008, * * Tennant et al, Breast 2008, 17(6):546-917(6):546-9
TheThe Intact Intact™ ™ Breast Lesion Breast Lesion Excision System (BLES)Excision System (BLES)
Controller & Vacuum Source
Handle & Disposable Wand
The Intact BLESThe Intact BLES Developed in USA in 2001, the INTACT breast Developed in USA in 2001, the INTACT breast
lesion excision system (BLES) has a unique lesion excision system (BLES) has a unique capability of obtaining a single large biopsy capability of obtaining a single large biopsy sample using radiofrequency cauterisationsample using radiofrequency cauterisation
It has been used extensively in the USA as an It has been used extensively in the USA as an equivalent large biopsy device to current vacuum equivalent large biopsy device to current vacuum assisted systems (>40,000 cases!).assisted systems (>40,000 cases!).
At least equivalent diagnostically to VAB devices*At least equivalent diagnostically to VAB devices*
*Sie et al, 2006. Multicenter Evaluation of the Breast Lesion Excision System, a Percutaneous, Vacuum-Assisted, Intact-Specimen Breast Biopsy Device. Cancer 107:5
Intact BLES ExcisionIntact BLES Excision
Goal using The Intact Goal using The Intact BLESBLES
• Excision of lesion in one piece
• Best possibility of clear margins
The Intact BLESThe Intact BLES
Specimen radiographSpecimen radiograph
The Intact BLESThe Intact BLES RMH have had this since 2007 and are the second RMH have had this since 2007 and are the second
centre outside the USAcentre outside the USA
Approved as a biopsy device by appropriate Approved as a biopsy device by appropriate committeescommittees
However due to its of obtaining a single large However due to its of obtaining a single large sample, we have almost exclusively used this in an sample, we have almost exclusively used this in an attempt at whole lesion excisionattempt at whole lesion excision
Most of our patient group have been referred from Most of our patient group have been referred from the NHSBSP, and we have attempted to perform the NHSBSP, and we have attempted to perform complete excision biopsy in removing small breast complete excision biopsy in removing small breast lesions with a margin *lesions with a margin **Allen SD, Nerurkar A, Della Rovere GU. The breast lesion excision system (BLES): a novel technique in the diagnostic and therapeutic management of small indeterminate breast lesions? Eur Radiol. 2011 Jan 15.
The Intact BLESThe Intact BLES
Many borderline (high risk) lesions can be Many borderline (high risk) lesions can be completely excised without surgery in a short completely excised without surgery in a short well tolerated outpatient procedure *well tolerated outpatient procedure *
The results very much represent what can be The results very much represent what can be achieved during the early stages of using this achieved during the early stages of using this new technique new technique
Complementary to VAB as an alternative therapy Complementary to VAB as an alternative therapy to surgery for small breast lesionsto surgery for small breast lesions
*Whitworth PW. Intact Percutaneous Excision (IPEX) for Definitive Diagnosis of High-Risk Breast Lesions. Ann Surg Oncol. 2011 Oct;18(11):3095. Epub 2011 Sep 9
The Intact BLESThe Intact BLES NICE have now approved this as a large biopsy deviceNICE have now approved this as a large biopsy device
The potential of this technique may grow further as The potential of this technique may grow further as wand technology/unit experience improves wand technology/unit experience improves
Current wand sizes/yield limit excision of many lesions Current wand sizes/yield limit excision of many lesions
A 30mm wand has been in use in selected centres A 30mm wand has been in use in selected centres >6/12>6/12
?whole cancer excision?whole cancer excision
30mm wand30mm wand
Thermal AblationThermal Ablation
Radiofrequency ablationRadiofrequency ablation CryoablationCryoablation Laser therapyLaser therapy High Intensity focused ultrasound (HIFU)High Intensity focused ultrasound (HIFU)
All require a probe to be inserted into the All require a probe to be inserted into the tumour under image guidance (usually tumour under image guidance (usually ultrasound)ultrasound)
Margins, margins, marginsMargins, margins, margins
Thermal AblationThermal Ablation
RF AblationRF Ablation
RF ablation most fashionableRF ablation most fashionable Small, centrally sited, low grade tumours, Small, centrally sited, low grade tumours,
elderly patients elderly patients Low level of evidenceLow level of evidence Almost invariably combined with surgery*Almost invariably combined with surgery*
*Imoto S, et al. Breast. 2009 Apr;18(2):130-4
RF Ablation ?RF Ablation ?neoadjuvantneoadjuvant
RFA combined with immunologically RFA combined with immunologically active cytokines (IL-7 and IL-15) in mice active cytokines (IL-7 and IL-15) in mice induced immune responses to tumors, induced immune responses to tumors, inhibited tumor development and lung inhibited tumor development and lung metastasis *metastasis *
RFA combined with other treatment RFA combined with other treatment deliveries?deliveries?
*Habibi M, et al. Breast Cancer Res Treat. 2009 Apr;114(3):423-31.
ConclusionsConclusions
Biopsies are getting larger!Biopsies are getting larger!
Core biopsy and even FNA still maintain a Core biopsy and even FNA still maintain a role role
As with other fields of interventional As with other fields of interventional radiology, the breast interventionalist is radiology, the breast interventionalist is finding a role extension in the therapy of finding a role extension in the therapy of benign and now malignant breast diseasebenign and now malignant breast disease