Nice saint paul. biopsies mammaires, L.Rotenberg 2015

LucRotenberg–RPO-ISHHCliniqueHartmann-CMCAmbroiseParé

26-27bdVictorHugo92200NeuillySurSeine-France

dr.rotenberg@radiologieparisouest.com

PréanalyKquesurlesbiopsiesetprélèvements

Niveauxdepreuve

Leniveaudepreuvecorrespondàlacota2ondesdonnéesdelali4ératuresurlesquellesreposentlesrecommanda2onsformulées.Ilestfonc2ondutypeetdelaqualitedesétudesdisponiblesainsiquedelacohérenceounondeleursrésultats;ilestspécifiepourchacunedesméthodes/interven2onsconsidéréesselonlaclassifica2onsuivante:NiveauA

Ilexisteune(des)méta-analyse(s)«debonnequalite»ouplusieursessaisrandomisés«debonnequalite»dontlesrésultatssontcohérents.

NiveauBIlexistedespreuves«dequalitecorrecte»:essaisrandomisés(B1)ouétudesprospecKvesourétrospecKves(B2).Lesrésultatsdecesétudessontcohérentsdansl'ensemble.

NiveauCLesétudesdisponiblessontcriKquablesd’unpointdevueméthodologiqueouleursrésultatsnesontpascohérentsdansl'ensemble.

NiveauDIln'existepasdedonnéesouseulementdessériesdecas.

PréanalyKquesurlesbiopsiesetprélèvementsRéalisaKonetcondiKonnementdelabiopsieenpréanalyKque

1.   Unebiopsieréféren2elleestelleindispensableavantpriseenchargedelésionmammairesuspecte?

Breastlesionsimaging

•  Screening,detec2onordiagnosis:•  Mammography

–  FullDigitalMammography–  3DDigitalBreastTomosynthesis

•  Sonography–  Highfrequencyprobe–  Doppler–  elastography

•  MRI–  1,5or3Tmagnet–  Morphologicanddynamicstudy,perfusion–  Diffusion–  Spectroscopy-MRI

•  Goal=evalua2onforarisk:BIRADSclassifica2on

BI-RADS

BreastImagingReporKngandDataSystem

2ndfrenchediKon4thamericanediKon

IndicaKons

Probablybenignmalignancy0,2à5%

§ Followup§ NobiopsyindicaKonexceptedfor:

§ HighriskpaKent§ BRCAmuta*on

§ synchronouscancer § Impossiblefollowup§ Cancerophobia

Bi-Rads3

suspiciouslesionmalignancy5to95%

BiopsyindicaKon

4a?

Bi-Rads4

Verysuspiciouslesionformalignancy

§  fineneedleaspiraKon:nomoreorsenKnallymphnodes

§  Corebiopsy16or14G§  histology,HR,Her2...

§  Suspiciousforrecidive§  aiersurgery§  aierradiotherapy

Bi-Rads5to6

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

•  Histologicaldiagnosisbythepathologistalwaysmandatory

•  Nohistologicaldiagnosisonimaging!

–  However,diagnosKchypothesesandindicaKonsofacKontobetakenarewelcome

Breastlesionsimaging

Birads1 screening

Birads2 screening

Birads3 Followupexcepthighrisk

Birads4a Followupexceptprogressiveor

highrisk

Birads4b,c LCBorVABBdiagnosis

Birads5/6 LCBorVABB

diagnosisoustategical

MODALITÉSTECHNIQUESDUPRÉLÈVEMENTBIOPSIQUE:reco2009

•  EncasdecalcificaKons:•  macrobiopsieparvoiepercutanéeuKlisantunsystèmeàaspiraKon

•  microbiopsieparvoiepercutanéesimacrobiopsietechniquementnonréalisable.

•  Encasdemassespalpablesetradiologiques•  Microparvoiepercutanée.

•  Siimpossibilitetechniquederéaliserunebiopsiepercutanée:

•  biopsiechirurgicale

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.

Minimal Invasive Interventions

US StereotacKcal MRI Others

FNAC - - - -

LCNB +++ - - -

VABB +++ +++ +++ -

Intact ++ ++ - -

Marking +++ +++ +++FreeHand

Galactoscopy

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)

Possibilities of Assessment

Interventional Methods FNAC (Fine Needle Aspiration Cytology) FNAC is inadvisable as a standard method.

Possibilities of Assessment Interventional Methods (Ultrasound) LCNB

Autom. Large Core Needle Biopsy

Large Core Needle Biopsy (LCNB)

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%

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.“

Possibilities of Assessment Vacuum Assisted Breast Biopsy

Interventional Methods VABB Directional Vacuum - Assisted Breast Biopsy

Indications for diagnostic representative or ablative Vacuum - Biopsy (VABB)

1. StereotacKcguidance

2. MRIguidance

§ localanesthesia§ externalprocedure§ ExplanaKon+++§ Time15to40mn

Breastbiopsy

14G 11G 10G 8G17mg 95mg 160mg 300mg

Post contrast image of lesion Confirmation of obturator location near lesion

Post biopsy image

MacrobiopsiesousIRM

auteur année typeNbrelésions(nbrepaKents)

Tempsmoyen

unique mulKple%

complicaKon%

succès%

cancer

Libermanetal. 2003 VA 27(20) 49 35 69 1(4) 26/27(96) 8/27(30)

Lehmanetal 2005 VA 38(28) 50 39 61 38/38(100) 15/38(40)

Oreletal 2005 VA 85(75) 30-60 0 85/85(100) 52/85(61)

Fast MRI-Guided Vacuum-Assisted Breast Biopsy: Initial Experience Laura Liberman & alDepartment 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 & alDepartment 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 & alDepartments of Radiology and Pathology and Laboratory Medicine, University of Pennsylvania Medical Center, 3400 Spruce St, Philadelphia, PA 19104. Radiology 2005, 10.1148

MacrobiopsiesousIRM

Indications for diagnostic representative or ablative Vacuum - Biopsy (VABB) /US

1.  AierLargeCoreNeedleBiopsy(LCNB)andsuspicionofbreastcancer(BI-

RADS®4c/5,missmatch/discordanceoftheresultsofdiagnosKcimaging

andhistology)

2.  Suspiciouslesions(BI-RADS®4/5)diameter~5mm

3.  ResecKonofdefinitelybenign,butsymptomaKcfindingsorHighriskpaKents1.  symptomaKcFibroadenoma

2.  recurrentsymptomaKccysts

4.  Intraductal/intracysKcalproliferaKons:singularyPapilloma,complexcyst

5.  NeoadjuvantChemotherapy

6.  Suspisciousoflocalrecurrence

7.  HazardousordangerouslocaKon:deep,superficial,implants…

PréanalyKquesurlesbiopsiesetprélèvementsRéalisaKonetcondiKonnementdelabiopsieenpréanalyKque

2. Existe-t-ilunnombreminimaldeprélèvementsnécessaireaudiagnos2cenfonc2ondelalésion,dutypedebiopsieetdumodedeguidagechoisis(per2nencedel’échan2llonnage)?

03/01/16

S  Vacuumassisteddevices

S  MammotomeS  1995,11et8g

S  Vacora(Bard)S  2003,10gS  2007,14g

S  Atec(Suros-Hologic)S  2007,12g9g

S SenoRX (Bard)•  2009,10g,7g

S  Intact2009

S  Largecoredevices

S  16gS  14gS  Singleusedevices+++

S OtherbiopsydevicesS  Spirotome&Coramate

(Medinvents)S  2007,14et9g

S  Celero(Hologic)S  200812g

S  Finesse(Bard)S  201014g

ChoiceoftheNeedle

03/01/16

RöFo 175; 94 - 98 (2003)

Discussion VABB

•  Underestimation rate ADH, DCIS, ALH, LCIS…

– Not eliminated with VABB

»  >> PPV : malignant »  >> NPV : benign

–  Surgical indication : paradigme and guidelines

DCISRogerJ.Jackman&al,RadiologyFebruary2001218:497-502

Stereotac2cBreastBiopsyofNonpalpableLesions:Determinantsof

DuctalCarcinomainSituUnderes2ma2onRates

•  DCISunderes2ma2onratesbybiopsydevicewere–  20.4%(76of373)atlarge-corebiopsy–  11.2%(107of953)atvacuum-assistedbiopsy(P<.001)

•  24.3%(35of144)ofmasses•  12.5%(148of1,182)ofmicrocalcifica2ons(P<.001)•  andbynumberofspecimensperlesion

–  17.5%(88of502)with10orfewerspecimens–  11.5%(92of799)withgreaterthan10(P<.02).

•  DCISunderes2ma2onsincreasedwithlesionsize

1.9KmesmorefrequentwithmassesthanwithcalcificaKons

1.8KmesmorefrequentwithLCBthanwithVAB

1.5Kmesmorefrequent<10orfewerspecimensperlesionthanwith≥10specimensperlesion.

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

ADHPrevalence

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

RadialScarsR. 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

•  Carcinomawasfoundatexcisionin–  28%(8/29)oflesionswithassociatedatypicalhyperplasia–  4%(5/128)oflesionswithoutassociatedatypia

•  Inthela4ergroup,carcinomawasfoundatexcisionin–  3%(2/60)ofmasse–  8%(3/40)ofarchitecturaldistorKons–  0%(0/28)ofmicrocalcificaKonlesions

•  Malignancywasmissedin–  9%(5/58)oflesionsbiopsiedwithaspring-loadeddeviceLCB–  0%(0/70)oflesionsbiopsiedwithadirecKonalvacuum-assisteddeviceVABB–  8%(5/60)oflesionssampledwithlessthan12specimens–  0%(0/68)sampledwith12ormorespecimens

•  Lesiontype,maximallesiondiameter,andtypeofimagingguidance(stereotac2corsonographic)werenotsignificantfactorsindeterminingthepresenceofmalignancy

•  CONCLUSION:Diagnosisofradialscarbasedoncoreneedlebiopsyislikelytobereliablewhen

–  noassociatedatypicalhyperplasia–  biopsyincludesatleast12specimens(VABB)–  mammographicfindingsarereconciledwithhistologicfindings.–  Ifmissacriteria,excisionalbiopsyisindicated

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.

Lobularcarcinomainsitu/atypicallobularhyperplasiaonbreastneedlebiopsies:doesitwarrantsurgicalexcisionalbiopsy?Astudyof27casesO’NeilM,MadanR,TawfikOW,ThomasPA,FanF.AnnDiagnPathol2010;14(4):251–255

•  3163breastcoreneedlebiopsieswereretrievedfromthesurgicalpathologyfilesbetween2003and2009

•  amongthem,56(1.8%)caseswereiden2fiedwithadiagnosisofALHorLCIS•  Elevencaseswereexcludedbecauseofthepresenceofaconcurrentmore

severelesioninthebiopsiesthatmandatedexcision•  Theremaining45casescontainedonlyALHorLCIS

–  27hadsurgicalexcisionfollow-up

–  Inthesurgicalexcisionspecimens,5(19%)of27(11%of45)casesshowedmoreseverelesionsorwere"upgraded»

•  3invasiveductalcarcinomas•  1invasivelobularcarcinoma•  1ductalcarcinomainsitu•  Histologicfeaturesofthelobularneoplasiaonthecorewerefoundtohaveno

predicKvevalueforamoreseverelesioninthesubsequentexcision

•  Wesuggestthatpa2entswithLCIS/ALHoncoreneedlebiopsyshouldbeconsideredforsurgicalexcisiontoruleoutamoresignificantlesionregardlessofthehistologicfeatures.

AtypicalLobularHyperplasiaandLobularCarcinomainSituatCoreBreastBiopsy:UseofCarefulRadiologic-PathologicCorrelaKontoRecommendExcisionorObservaKonKristenA.Atkins,MichaelA.Cohen,BrandiNicholson,SandraRao.NorthwesternMemorialHospital,PrenKceWomen’sHospital,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.

•  AdvanceinKnowledge–  Whencarefulradiologic-pathologiccorrelaKonisconductedinthese�ngofa

breastcorebiopsywithatypicallobularhyperplasiaorlobularcarcinomainsitusomewomencanbesafelytriagedtoobservaKon

•  ofthe43benignconcordantcases,nonewereupgradedatsurgeryorextendedfollow-up

•  ImplicaKonforPaKentCare–  Focusedandcompleteradiologic-pathologiccorrelaKonmayobviate

excisionalbiopsyinpaKentswithbenignconcordantbiopsyfindings–  AddiKonalvalidaKonofthisisrequiredbeforethisapproachcanbe

universallyapplied

AtypicalLobularHyperplasiaandLobularCarcinomainSituatCoreBreastBiopsy:UseofCarefulRadiologic-PathologicCorrelaKontoRecommendExcisionorObservaKonKristenA.Atkins,MichaelA.Cohen,BrandiNicholson,SandraRao.NorthwesternMemorialHospital,PrenKceWomen’sHospital,Chicago.Radiology,2013,Vol.269:340-347,10.1148/radiol.13121730

Discussion

toexciseortosample?

�  Excisionforprobablybenignlesion+clip

•  Birads3•  Birads4a

�  Sampleforsuspiciousormalignantlesion

•  Birads4b&c•  Birads5&6

ToExciseorToSampletheMammographicTarget:WhatIstheGoalofStereotac2cII-GaugeVacuum-AssistedBreastBiopsy?LauraLiberman,JenniferB.Kaplan,ElizabethA.Morris,AndreaF.Abramson,JenniferH.MenellandD.DavidDershawAJR2002;179:679-683

Completeexcisionratherthansamplingofmammographictargetwasassociatedwith:•  lowerfrequenciesofdiscordanceandductalcarcinomain

situunderesKmaKon•  nootheradvantageordisadvantage•  Amongcancersinwhichthemammographictargetwas

excised,surgeryrevealedresidualcancerinalmost80%.

PréanalyKquesurlesbiopsiesetprélèvementsRéalisaKonetcondiKonnementdelabiopsieenpréanalyKque

3.Leradiologuedispose-ild’argumentspréperetpostbiopsiquesluiperme4antdeconcluresurlecaractèrecontribu2fetconcordantdesesprélèvements?

BiospsiecontribuKveetconcordante

•  Avant•  ConsultaKonBalisKqueetdefaisabilité•  ExplicaKonsetconsentementéclairé

•  Pendant•  Technique•  ÉchanKllonage•  FixaKonetCRpouranapath

•  Après•  ConsultaKonJ8-J15+/-imagerie•  Concordanceradio-anatomopathologique•  CourrierprescripteurincluantCAT•  RCP

BreastIntervenKon:HowIDoItMaryC.Mahoney,MaryS.Newell,CincinnaK,AltlantaRadiology,2013,Vol.268:12-24,10.1148/radiol.13120985

•  Wri4eninformedconsentisrequiredbeforeallbreastinterven2ons

•  Therisksexplainedtothepa2entincludebleedingandinfec2on•  An2coagula2onisarela2vecontraindica2ontoallbiopsies

–  paKentsareusuallyaskedtodisconKnuetherapyforashortKmepriortothebiopsy

•  Thepa2entshouldbeinformedofthepoten2albenefitsofthebiopsy–  includingavoidanceofsurgerywithbenignresults–  preoperaKveconfirmaKonofmalignancy,whichallowsdefiniKvesurgical

treatmentinonesurgicalse�ng

•  Tailoredprebiopsycounselingmaybe4erpreparewomenforpercutaneousbreastbiopsyandimprovetheiroverallexperience.

•  youngerwomenaremoreadverselyaffectedbythebiopsyexperience.

•  ImplicaKonforPaKentCare•  Tailoredprebiopsycounselingmaybeverpreparewomen

forpercutaneousbreastbiopsyandimprovetheiroverallexperience.

PercutaneousBreastBiopsy:EffectonShort-termQualityofLifeKathrynL.Humphrey;JanieM.Lee;KarenDonelan;ChungY.Kong;OlubunmiWilliams;OmosalewaItauma;ElkanF.Halpern;BeverlyJ.Gerade;ElizabethA.Rafferty;J.ShannonSwan;MITMGH,Boston,Radiology2013,10.1148/radiol.13130865

03/01/16

•  Side •  Size

•  h x L x l

•  Location •  Quadrant •  Radius zone •  Distance to the

nipple

BalisKctargettracking•  US•  RX•  MRI

03/01/16

•  Side•  Size

•  hxLxl•  LocaKon

•  Quadrant•  Radiuszone•  Distancetothenipple

•  Deep / cutaneous plane

USbalisKctargettracking

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

03/01/16

03/01/16

BreastUSdiagnosKc&balisKc

USBiopsy&WireMarking

Surgery:IDCgrade1,RH+,Her2-

Largecore16gBiopsy Wiremarker

LCB:DCISHighgrade

Biopsy&pathology

•  RepresentaKvesamples•  Rxofsamplesifμcal

•  Formol>12h<24h:KmeoffixaKon+++•  Histology,RH,Her2•  clinicalfindings,report

SpecimensXRays

InteracKveCaseReviewofRadiologicandPathologicFindingsfromBreastBiopsy:AreTheyConcordant?HowDoIManagetheResults?ChristopherP.Ho,MD,JenniferE.Gillis,MD,KristenA.Atkins,MD,JenniferA.Harvey,MD,and,BrandiT.Nicholson,MDUniversityofVirginiaHeathSystem,Chalovesville,Va.Radiographics,Volume33-4,2013

•  Tosuccessfullyperformaminimallyinvasivebreastbiopsy•  itisimportanttonotonlybefamiliarwiththetechnique•  butalsowithhowtodetermineradiologic-pathologicconcordance•  andtheappropriatetreatmentsforpaKentsaiertheprocedure

•  Whenreviewingpathologicresultsforconcordance•  itisimportanttoensurethatmicrocalcificaKonsareidenKfiedinthe

histologicspecimen•  andthespecificpathologicdiagnosisisconsistent

•  withthemorphologiccharacterisKcsseenatmammography•  andthepretestprobabilityofmalignancy.

•  Atthefollow-upexamina2on•  boththehistologicandimagingfindingsshouldberevisited•  andthemassshouldbeassessedatmammographyorUStoensurethat

itisstable

•  Ifithasgrowninsizeoritsmorphologiccharacteris2cshavechanged

•  Ifcalcifica2onsincreaseinnumberorextentorthemasschanges

•  Increasesinsizeoritsfeaturesbecomemoresuspicious•  appropriateacKonshouldbetaken•  Excisionistypicallyrecommended

•  Ifthelesionisstableatfollow-upexamina2on•  thepaKentmayreturntothegeneralscreeningpopulaKon

InteracKveCaseReviewofRadiologicandPathologicFindingsfromBreastBiopsy:AreTheyConcordant?HowDoIManagetheResults?ChristopherP.Ho,MD,JenniferE.Gillis,MD,KristenA.Atkins,MD,JenniferA.Harvey,MD,and,BrandiT.Nicholson,MDUniversityofVirginiaHeathSystem,Chalovesville,Va.Radiographics,Volume33-4,2013

Imaging-HistologicDiscordanceAierSonographicallyGuidedPercutaneousBreastBiopsy:AProspecKveObservaKonalStudyEunJuSon,Eun-KyungKim,JiHyunYouk,MinJungKim,JinYoungKwak,SeonHyeongChoi,August22,2011

•  FromJanuary2005toDecember2006,•  US-guided14-gaugeautomatedCNBon3339breastlesionsandobtained

benignresultsin2194cases.•  1588lesionsthatwereeitherexcised(n=658)orfollowedupforatleast2

years(n=930)aierCNB.•  Imaging-histologicdiscordancewaspresentin103of1588(6.5%)lesions.•  Theupgraderatewas

–  6.8%(7/103)indiscordantlesions–  0.4%(6/1485)inconcordantlesions(p<0.01)

•  Lesionsize,BreastImaging,ReporKngandDataSystem(BI-RADS)categoryandthepresenceorabsenceofsymptomswasstaKsKcallysignificantbetweentheupgradeandnon-upgradegroupsindiscordantcases(p<.05).

•  Imaging-histologicdiscordanceisanindica2onforexcisionbecauseithasahigherupgraderatethanconcordantlesions.

•  Noimagingspecificityforbreastlesion•  BiopsyhistologycorrelaKonforallBirads4and5lesions•  LCNB:16or14G≥4samples•  Under-esKmaKonrateforpremalignantlesion

•  ≈10%VABB•  ≈20%LCNB•  PMLreferedforsurgicalexcision

•  VABBunderstereotacKcguidance•  11G≥10samples•  7G≥6samples

•  VABBunderUSorMRIguidance•  Noguidelines:targetexcisionorsampling

•  Concordance•  BalisKcconsultaKon•  Samplingquality:guidance/biopsydevice/samples•  Birads/histologicalcorrelaKon•  FollowuporsurgicalexcisionindicaKon:RCP

Takehomemessage