Minimally Invasive Breast Minimally Invasive Breast ProceduresProcedures

F. Sperber, M.D.F. Sperber, M.D.

Breast Imaging CenterBreast Imaging Center

Sourasky Medical CenterSourasky Medical Center

Tel Aviv UniversityTel Aviv University

Percutaneous core breast Percutaneous core breast biopsybiopsy- - Advantages Advantages► Since a few years ago most of the suspicious Since a few years ago most of the suspicious

clinical or mammographic lesions were clinical or mammographic lesions were diagnosed by surgical biopsy.diagnosed by surgical biopsy.

► With time percutaneous core biopsy proved With time percutaneous core biopsy proved to be efficacy in the diagnosis of breast to be efficacy in the diagnosis of breast lesions.lesions.

► Is faster, less expensive than surgical Is faster, less expensive than surgical biopsy.biopsy.

► Less tissue is removed resulting in no Less tissue is removed resulting in no deformity or scaring.deformity or scaring.

Percutaneous core biopsy-Percutaneous core biopsy-AdvantagesAdvantages Spare surgery in benign lesions (60% of the Spare surgery in benign lesions (60% of the

mammographic findings).mammographic findings). Reduce the number of surgical procedures in Reduce the number of surgical procedures in

cases of breast cancer, providing surgery cases of breast cancer, providing surgery planning.planning.

Lumpectomy and sentinel node or axillary Lumpectomy and sentinel node or axillary dissection as one step procedure in malignant dissection as one step procedure in malignant cases.cases.

Mastectomy in cases of multifocal-multicentric Mastectomy in cases of multifocal-multicentric lesions.lesions.

Guidance modalitiesGuidance modalities

►Stereotactic mammographic guidanceStereotactic mammographic guidance►Ultrasound guidanceUltrasound guidance►MRI guidance MRI guidance

Stereotactic mammographic Stereotactic mammographic guidanceguidance Stereotactic units are available in two different Stereotactic units are available in two different

configurations :configurations :

--Add -on unitsAdd -on units attached to mammography attached to mammography units (units (sitting positionsitting position).).

--Dedicated prone tablesDedicated prone tables ( ( lying position).lying position). Selection of equipment is based on Selection of equipment is based on

considerations of cost, patient volume and considerations of cost, patient volume and space availability. space availability.

Stereotactic mammographic Stereotactic mammographic guided guided

Mammographic Guided Mammographic Guided Biopsy-Stereotactic TableBiopsy-Stereotactic Table

Stereotactic mammographic Stereotactic mammographic guidedguided

AdvantagesAdvantages

Patient motion is eliminatedPatient motion is eliminated

Patient don’t see the biopsy less Patient don’t see the biopsy less vasovagal reactions vasovagal reactions

DisadvantagesDisadvantages::

SpaceSpace

Difficult access to lesions close to the Difficult access to lesions close to the chest wallchest wall

Stereotactic mammographic Stereotactic mammographic guidance: Techniqueguidance: Technique► Enables a lesion to be Enables a lesion to be

localized three-dimensionally localized three-dimensionally trough the used of angled trough the used of angled images.images.

► Localization is done by Localization is done by identifying the site of the identifying the site of the lesion in x-axis, y-axis and z-lesion in x-axis, y-axis and z-axis.axis.

► The depth of the lesion (z-The depth of the lesion (z-axis) is calculated by the shift axis) is calculated by the shift of the lesion along the x-axis of the lesion along the x-axis when the tube is tilted in this when the tube is tilted in this plane. plane.

► Standard equally angled views Standard equally angled views of 15of 1500 are used to calculate are used to calculate the location of the lesion.the location of the lesion.

► Accuracy in performing the Accuracy in performing the biopsy is dependent on the biopsy is dependent on the accurate localization of the accurate localization of the same point in the lesion on same point in the lesion on angled views.angled views.

Mammographic guidedMammographic guided

Ultrasound guidanceUltrasound guidance

► One of the most important applications of breast ultrasound is to guide interventional procedure

► Most common used technique. Advantages:► Non-ionizing radiation.Non-ionizing radiation.► Accessibility to all parts of the breast and axilla.Accessibility to all parts of the breast and axilla.► Quicker and no discomfort (no breast Quicker and no discomfort (no breast

compression).compression).► Real time visualization of the needle providing

accuracy of the targeting. ► Low cost.Low cost.

Ultrasound guidanceUltrasound guidance

Disadvantages

Most difficult technique to perform.Most difficult technique to perform.

Requires long time of expertise. Requires long time of expertise.

Slow learning curve.Slow learning curve.

MRI guidedMRI guided

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

► MRI compatible MRI compatible devices.devices.

► Biopsy is performed Biopsy is performed outside the magnet. outside the magnet.

► Coaxial sheath:Coaxial sheath:

Inner styletInner stylet

Outer cannulaOuter cannula

Biopsy ProcedureBiopsy Procedure

► Fiducial Marker: Small Fiducial Marker: Small plastic capsule filled with plastic capsule filled with saline and gadolinium or saline and gadolinium or oil.oil.

► Calculation of x,y,zCalculation of x,y,z► MRI moved out and the MRI moved out and the

needle guide is adjustedneedle guide is adjusted► Lidocaine injectionLidocaine injection► Coaxial sheath is inserted, Coaxial sheath is inserted,

inner stylet is removedinner stylet is removed► MRI table is returned to the MRI table is returned to the

magnetmagnet► Limited axial sequence is Limited axial sequence is

performedperformed► Site clipSite clip

MRI biopsy guidanceMRI biopsy guidance

Tissue Acquisition Devices - Tissue Acquisition Devices - Types and IndicationsTypes and Indications

►FNA ( Fine –needle aspiration)FNA ( Fine –needle aspiration)►Core biopsyCore biopsy►Vacuum assisted core biopsyVacuum assisted core biopsy►Fine needle localization devicesFine needle localization devices

Minimally Invasive Procedures Types & Minimally Invasive Procedures Types & IndicationsIndications

►FNAFNA►Cysts, Lymph Cysts, Lymph nodesnodes

►Core Needle Core Needle BiopsyBiopsy

►Solid massesSolid masses

►Drainage of Drainage of collectionscollections

►Abscess and post Abscess and post surgical collections surgical collections

►Fine Needle Fine Needle LocalizationLocalization

►Pre-OperativePre-Operative

►Vacuum-Assisted Vacuum-Assisted Large Core Needle Large Core Needle BiopsyBiopsy

(Mammotome)(Mammotome)

►Solid masses smaller Solid masses smaller than 5mm and than 5mm and calcificationscalcifications

FINE NEEDLE ASPIRATIONFINE NEEDLE ASPIRATION

Most popular technique of biopsy for Most popular technique of biopsy for breast palpable and nonpalpable lesions.breast palpable and nonpalpable lesions.

ADVANTAGESADVANTAGES Virtually atraumaticVirtually atraumatic Rare to even cause a hematomaRare to even cause a hematoma Simple to performSimple to perform

DISADVANTAGES DISADVANTAGES Extremely dependent on level of cytological interpretation.Extremely dependent on level of cytological interpretation.High percentage of insufficient, material aspirates (34%-40%).High percentage of insufficient, material aspirates (34%-40%).Cytology doesn’t differentiate between in situ from invasive Cytology doesn’t differentiate between in situ from invasive

diseasedisease

TECHNIQUE-EQUIPMENTTECHNIQUE-EQUIPMENT

►10-20-30 ml LUER-LOK syringe10-20-30 ml LUER-LOK syringe►21-23-25G needles21-23-25G needles►Needle length 3.6-7.8cmNeedle length 3.6-7.8cm►Glass slides Glass slides ►95% alcohol fixative95% alcohol fixative►Anesthesia is optionalAnesthesia is optional

ASPIRATION TECHNIQUEASPIRATION TECHNIQUE

►After placement of needle, a syringe After placement of needle, a syringe is connected.is connected.

►Suction is applied by pulling the Suction is applied by pulling the plunge of the syringe.plunge of the syringe.

►Sampling needle should be moved Sampling needle should be moved back and forth rapidly within lesion.back and forth rapidly within lesion.

►Needle is angled in multiple Needle is angled in multiple directions. directions.

TECHNIQUE FOR F.N.ATECHNIQUE FOR F.N.A..► Vertical or oblique Vertical or oblique

needle insertion.needle insertion.► Needle should be Needle should be

oriented oriented perpendicularly to perpendicularly to ultrasonic beam. ultrasonic beam.

► Needle shaft and Needle shaft and tip should be tip should be visualized during visualized during procedure.procedure.

FINE NEEDLE ASPIRATIONFINE NEEDLE ASPIRATION

Pre-FNA Post-FNA

LYMPH NODE F.N.ALYMPH NODE F.N.A..

CORE NEEDLE BIOPSY - CNBCORE NEEDLE BIOPSY - CNB

►First described in 1982 by First described in 1982 by Perlinggren, Sweden.Perlinggren, Sweden.

►Cutting needle fits in automated Cutting needle fits in automated spring-loaded biopsy gunspring-loaded biopsy gun..

►Most accurate results with 14-gaugeMost accurate results with 14-gauge..►Needle consists of inner tissue Needle consists of inner tissue

sampling needle and outer cutting sampling needle and outer cutting needleneedle..

CORE NEEDLE BIOPSY - CNBCORE NEEDLE BIOPSY - CNB

► 17mm tissue slot is 17mm tissue slot is located 4mm from end located 4mm from end of inner needle.of inner needle.

► Prebiopsy position , Prebiopsy position , outer needle covers outer needle covers inner needle.inner needle.

► Inner needle is Inner needle is advanced forward, advanced forward, moving tissue slot moving tissue slot within lesion.within lesion.

► Outer needle slides Outer needle slides over inner needle, over inner needle, cutting a tissue sample cutting a tissue sample and securing it in slot.and securing it in slot.

Throw short & long (15/22mm)

Throw short & long (15/22mm)

Trigger Safety device

DISPOSABLE SEMIAUTOMATIC DISPOSABLE SEMIAUTOMATIC BIOPSY NEEDLEBIOPSY NEEDLE

Stylet

Hub

Main part

Plunger

CNB - TECHNIQUECNB - TECHNIQUE

► Patient in supine position. Patient in supine position. ► Skin disinfection with alcohol or polydine.Skin disinfection with alcohol or polydine.► Probe is disinfected with alcoholProbe is disinfected with alcohol► Probe may be covered with sterile plastic Probe may be covered with sterile plastic

sheath.sheath.► Sterile gel or alcohol should be used as Sterile gel or alcohol should be used as

coupling agent.coupling agent.► Local anesthesia.Local anesthesia.► Skin incision, 2-3mm. Skin incision, 2-3mm.

Needle placement with ultrasound Needle placement with ultrasound guidance - TECHNIQUEguidance - TECHNIQUE

► Transducer is Transducer is placed on patient’s placed on patient’s skin so both lesion skin so both lesion and path of needle and path of needle are visible.are visible.

► Needle position is Needle position is documented with documented with longitudinal and longitudinal and transverse scans. transverse scans.

Ultrasound guidance-Ultrasound guidance-TechniqueTechnique

Core SamplingCore Sampling

►5 or more cores require reinsertion and 5 or more cores require reinsertion and repositioning of needle. repositioning of needle.

►Visual inspection of samples.Visual inspection of samples.

CNB - TECHNIQUECNB - TECHNIQUE

► Specimen placed Specimen placed in formalin and in formalin and sent for sent for histological histological diagnosis.diagnosis.

► 5-10 minutes 5-10 minutes compression. compression.

► Bandaging Bandaging applied. applied.

Advantages of Core BiopsyAdvantages of Core Biopsy

►96%-100% concordance between 96%-100% concordance between CNB and surgery.CNB and surgery.

►No insufficient samples.No insufficient samples.►Histological tissue diagnosis allows Histological tissue diagnosis allows

differentiation of IDC from DCIS.differentiation of IDC from DCIS.

Disadvantages of Core Disadvantages of Core BiopsyBiopsy

► Multiple insertions and removal of the Multiple insertions and removal of the needle.needle.

► Later samples composed predominantly Later samples composed predominantly of blood.of blood.

► May be nondiagnostic in small lesions May be nondiagnostic in small lesions ► Retrieval of calcifications is difficult Retrieval of calcifications is difficult ► Incomplete characterization of ADH Incomplete characterization of ADH

and DCISand DCIS

COMPLICATIONS AND RISKSCOMPLICATIONS AND RISKS

►Fainting.Fainting.►Hematoma 6-30%.Hematoma 6-30%.►Seeding of needle track by Seeding of needle track by

malignant cells.malignant cells.

Vacuum-Assisted Vacuum-Assisted MammotomeMammotome®®

HistologyHistology Large, contiguous tissue samplesLarge, contiguous tissue samples Less precise targeting required Less precise targeting required

because of vacuum assistancebecause of vacuum assistance Ability to place a marker at the Ability to place a marker at the biopsy biopsy

sitesite Sutureless Sutureless Single insertionSingle insertion

Vacuum-Assisted Biopsy: Vacuum-Assisted Biopsy: AdvantagesAdvantages►Suction of the blood out of the biopsy Suction of the blood out of the biopsy

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

Vacuum-Assisted Biopsy: Vacuum-Assisted Biopsy: AdvantagesAdvantages Significant improvement in the retrieval of Significant improvement in the retrieval of

calcificationscalcifications

Vaccum assisted biopsy: Vaccum assisted biopsy: AdvantagesAdvantages

► Clip PlacementClip Placement

► More accurate characterization of ADH and More accurate characterization of ADH and DCIS, DCIS and IDC.DCIS, DCIS and IDC.

► Reduction in the underestimation of ADH Reduction in the underestimation of ADH and DCIS comparatively to core biopsy.and DCIS comparatively to core biopsy.

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

►Designed to direct the surgeon to Designed to direct the surgeon to appropriate site within breast, appropriate site within breast, insuring accurate removal of insuring accurate removal of suspicious lesion.suspicious lesion.

►Less commonly used for diagnostic Less commonly used for diagnostic purposes – only when accurate needle purposes – only when accurate needle sampling was not achievedsampling was not achieved

HOOKWIRE SYSTEMSHOOKWIRE SYSTEMS

HOOKWIRE SYSTEMSHOOKWIRE SYSTEMS

Mammographic Fine Needle Mammographic Fine Needle LocalizationLocalization

Sonografic Fine Needle Sonografic Fine Needle LocalizationLocalization

EXCISED SPECIMENEXCISED SPECIMEN

Two-view magnified Two-view magnified specimen specimen radiographradiograph..

US specimen in US specimen in masses visualized masses visualized sonographicallysonographically

Minimally invasive technique in Minimally invasive technique in

Breast Cancer Treatment: Breast Cancer Treatment: The The FutureFuture

►Stereotactic excision with vaccum Stereotactic excision with vaccum assisted core biopsyassisted core biopsy

►Criotheraphy monitored by ultrasoundCriotheraphy monitored by ultrasound►Laser ablation/focused ultrasound Laser ablation/focused ultrasound ►Radiofrequency monitored by Radiofrequency monitored by

ultrasoundultrasound

CryotheraphyCryotheraphy

► AdvantagesAdvantages- Is easy visualized Is easy visualized

with ultrasound.with ultrasound.- Painless.Painless.- Can be used for Can be used for

masses near the masses near the skin.skin.

Intracellular Ice FormationIntracellular Ice Formation

► Very high freezing ratesVery high freezing rates Within a few millimeters of the cryoprobeWithin a few millimeters of the cryoprobe Ice crystals cause mechanical injury to cellular Ice crystals cause mechanical injury to cellular

organelles and membranes.organelles and membranes.

Extracellular Ice Extracellular Ice FormationFormation

►Solution EffectsSolution Effects--Majority of iceball experiences lower freezing Majority of iceball experiences lower freezing

ratesrates

-Ice formed outside the cell – hyperosmolarity.-Ice formed outside the cell – hyperosmolarity.

-Osmotic dehydration and shrinkage of the cell.-Osmotic dehydration and shrinkage of the cell.

-Damage to enzymatic machinery, -Damage to enzymatic machinery, destabilization of cell membranes.destabilization of cell membranes.

Delayed Ischemic DamageDelayed Ischemic Damage

► Dominant killing mechanism results in uniform Dominant killing mechanism results in uniform necrosis.necrosis.

► Endothelial cells comprising the Endothelial cells comprising the microvasculature are very susceptible to direct microvasculature are very susceptible to direct damage. damage.

► Microvasculature endothelial destruction results Microvasculature endothelial destruction results in post-thaw platelet aggregation and in post-thaw platelet aggregation and subsequent vascular stasis.subsequent vascular stasis.

► Within hours and days following cryoablationWithin hours and days following cryoablation

ischemic damage occurs throughout the ischemic damage occurs throughout the previously frozen volume.previously frozen volume.

ConclusionsConclusions

► Minimal invasive procedures became 1/3 of Minimal invasive procedures became 1/3 of the diagnostic work in breast imaging.the diagnostic work in breast imaging.

► Team work approach is essential for further Team work approach is essential for further management of the breast cancer patient.management of the breast cancer patient.

► The traditional approach to surgical margins The traditional approach to surgical margins may be replaced in the very near future by may be replaced in the very near future by minimally invasive treatment techniques of minimally invasive treatment techniques of the primary tumor.the primary tumor.