Minimally Invasive Breast Procedures

F. Sperber, M.D. Breast Imaging Center Sourasky Medical Center Tel Aviv University

Percutaneous core breast biopsy - Advantages

Since

a few years ago most of the suspicious clinical or mammographic lesions were diagnosed by surgical biopsy. With time percutaneous core biopsy proved to be efficacy in the diagnosis of breast lesions. Is faster, less expensive than surgical biopsy. Less tissue is removed resulting in no deformity or scaring.

Percutaneous core biopsyAdvantages

Spare surgery in benign lesions (60% of the mammographic findings). Reduce the number of surgical procedures in cases of breast cancer, providing surgery planning. Lumpectomy and sentinel node or axillary dissection as one step procedure in malignant cases. Mastectomy in cases of multifocal-multicentric lesions.

Guidance modalities
Stereotactic

mammographic guidance Ultrasound guidance MRI guidance

Stereotactic mammographic guidance

Stereotactic units are available in two different
configurations : -Add -on units attached to mammography units (sitting position). -Dedicated prone tables ( lying position). Selection of equipment is based on considerations of cost, patient volume and space availability.

Stereotactic mammographic guided

Mammographic Guided BiopsyStereotactic Table

Stereotactic mammographic guided

Advantages Patient motion is eliminated Patient dont see the biopsy less vasovagal reactions Disadvantages: Space Difficult access to lesions close to the chest wall

Stereotactic mammographic guidance: Technique

Enables a lesion to be localized three-dimensionally trough the used of angled images. Localization is done by identifying the site of the lesion in x-axis, y-axis and z-axis. The depth of the lesion (z-axis) is calculated by the shift of the lesion along the x-axis when the tube is tilted in this plane. Standard equally angled views of 150 are used to calculate the location of the lesion. Accuracy in performing the biopsy is dependent on the accurate localization of the same point in the lesion on angled views.

Mammographic guided

Ultrasound guidance
One of the most important applications of breast ultrasound is to guide interventional procedure Most common used technique. Advantages: Non-ionizing radiation. Accessibility to all parts of the breast and axilla. Quicker and no discomfort (no breast compression). Real time visualization of the needle providing accuracy of the targeting. Low cost.

Ultrasound guidance
Disadvantages Most difficult technique to perform. Requires long time of expertise. Slow learning curve.

MRI guided

Always performed after second look ultrasound (fails in > 77%).

MRI compatible devices. Biopsy is performed outside the magnet. Coaxial sheath: Inner stylet Outer cannula

Biopsy Procedure

Fiducial Marker: Small plastic capsule filled with saline and gadolinium or oil. Calculation of x,y,z MRI moved out and the needle guide is adjusted Lidocaine injection Coaxial sheath is inserted, inner stylet is removed MRI table is returned to the magnet Limited axial sequence is performed Site clip

MRI biopsy guidance

Tissue Acquisition Devices - Types and Indications

FNA

( Fine needle aspiration) Core biopsy Vacuum assisted core biopsy Fine needle localization devices

Minimally Invasive Procedures Types & Indications

FNA
Core

Cysts,

Lymph nodes

Needle Biopsy of

Solid

masses

Drainage

collections Fine Needle Localization

Vacuum-Assisted

Abscess

and post surgical collections Pre-Operative

Large
Solid

Core Needle Biopsy

(Mammotome)

masses smaller than 5mm and calcifications

FINE NEEDLE ASPIRATION

Most popular technique of biopsy for breast palpable and nonpalpable lesions.
ADVANTAGES Virtually atraumatic Rare to even cause a hematoma Simple to perform DISADVANTAGES
Extremely dependent on level of cytological interpretation. High percentage of insufficient, material aspirates (34%-40%). Cytology doesnt differentiate between in situ from invasive disease

TECHNIQUE-EQUIPMENT
10-20-30

ml LUER-LOK syringe 21-23-25G needles Needle length 3.6-7.8cm Glass slides 95% alcohol fixative Anesthesia is optional

ASPIRATION TECHNIQUE
After

placement of needle, a syringe is connected. Suction is applied by pulling the plunge of the syringe. Sampling needle should be moved back and forth rapidly within lesion. Needle is angled in multiple directions.

TECHNIQUE FOR F.N.A.

Vertical

or oblique needle insertion. Needle should be oriented perpendicularly to ultrasonic beam. Needle shaft and tip should be visualized during procedure.

FINE NEEDLE ASPIRATION

Pre-FNA

Post-FNA

LYMPH NODE F.N.A.

CORE NEEDLE BIOPSY - CNB

First

described in 1982 by Perlinggren, Sweden. Cutting needle fits in automated springloaded biopsy gun. Most accurate results with 14-gauge. Needle consists of inner tissue sampling needle and outer cutting needle.

CORE NEEDLE BIOPSY - CNB

17mm tissue slot is located 4mm from end of inner needle. Prebiopsy position , outer needle covers inner needle. Throw short & Inner needle long is advanced (15/22mm) forward, moving tissue slot within lesion. Outer needle slides over inner needle, cutting a tissue sample and securing it in slot.

Throw short & long (15/22mm)

Trigger

Safety device

DISPOSABLE SEMIAUTOMATIC BIOPSY NEEDLE

Stylet

Hub

Main part

Plunger

CNB - TECHNIQUE
Patient

in supine position. Skin disinfection with alcohol or polydine. Probe is disinfected with alcohol Probe may be covered with sterile plastic sheath. Sterile gel or alcohol should be used as coupling agent. Local anesthesia. Skin incision, 2-3mm.

Needle placement with ultrasound guidance - TECHNIQUE

Transducer

is placed on patients skin so both lesion and path of needle are visible. Needle position is documented with longitudinal and transverse scans.

Ultrasound guidance-Technique

Core Sampling
5

or more cores require reinsertion and repositioning of needle. Visual inspection of samples.

CNB - TECHNIQUE

Specimen placed in formalin and sent for histological diagnosis. 5-10 minutes compression. Bandaging applied.

Advantages of Core Biopsy

96%-100%

concordance between CNB and surgery. No insufficient samples. Histological tissue diagnosis allows differentiation of IDC from DCIS.

Disadvantages of Core Biopsy

Multiple

insertions and removal of the needle. Later samples composed predominantly of blood. May be nondiagnostic in small lesions Retrieval of calcifications is difficult Incomplete characterization of ADH and DCIS

COMPLICATIONS AND RISKS

Fainting. Hematoma

6-30%. Seeding of needle track by malignant cells.

Vacuum-Assisted

Mammotome

Histology Large, contiguous tissue samples Less precise targeting required because of vacuum assistance Ability to place a marker at the biopsy site Sutureless Single insertion

Vacuum-Assisted Biopsy: Advantages

Suction

cavity. Only one insertion of the needle. Larger specimen- 11G or 8G.

of the blood out of the biopsy

Vacuum-Assisted Biopsy: Advantages

Significant improvement in the retrieval of

calcifications

Vaccum assisted biopsy: Advantages

Clip Placement

More accurate characterization of ADH and DCIS, DCIS and IDC. Reduction in the underestimation of ADH and DCIS comparatively to core biopsy.

NEEDLE LOCALIZATION FOR BREAST EXCISIONAL BIOPSY- F.N.L.

Designed

to direct the surgeon to appropriate site within breast, insuring accurate removal of suspicious lesion. Less commonly used for diagnostic purposes only when accurate needle sampling was not achieved

HOOKWIRE SYSTEMS

HOOKWIRE SYSTEMS

Mammographic Fine Needle Localization

Sonografic Fine Needle Localization

EXCISED SPECIMEN
Two-view magnified specimen radiograph.

US specimen in masses visualized sonographically

Minimally invasive technique in Breast Cancer Treatment: The Future

Stereotactic

core biopsy Criotheraphy monitored by ultrasound Laser ablation/focused ultrasound Radiofrequency monitored by ultrasound

excision with vaccum assisted

Cryotheraphy
Advantages

Is easy visualized with ultrasound. - Painless. - Can be used for masses near the skin.
-

Intracellular Ice Formation

Very high freezing rates Within a few millimeters of the cryoprobe Ice crystals cause mechanical injury to cellular organelles and membranes.

Extracellular Ice Formation

Solution

Effects

-Majority of iceball experiences lower freezing rates

-Ice formed outside the cell hyperosmolarity. -Osmotic dehydration and shrinkage of the cell. -Damage to enzymatic machinery, destabilization of cell membranes.

Delayed Ischemic Damage

Dominant killing mechanism results in uniform necrosis. Endothelial cells comprising the microvasculature are very susceptible to direct damage. Microvasculature endothelial destruction results in post-thaw platelet aggregation and subsequent vascular stasis. Within hours and days following cryoablation ischemic damage occurs throughout the previously frozen volume.

Conclusions
Minimal

invasive procedures became 1/3 of the diagnostic work in breast imaging. Team work approach is essential for further management of the breast cancer patient. The traditional approach to surgical margins may be replaced in the very near future by minimally invasive treatment techniques of the primary tumor.