Nice saint paul. biopsies mammaires, L.Rotenberg 2015
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Transcript of Nice saint paul. biopsies mammaires, L.Rotenberg 2015
LucRotenberg–RPO-ISHHCliniqueHartmann-CMCAmbroiseParé
26-27bdVictorHugo92200NeuillySurSeine-France
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
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