1. Minimally Invasive Breast Procedures F. Sperber, M.D. Breast Imaging Center Sourasky Medical Center Tel Aviv University

2. 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.

3. Percutaneous core biopsy- Advantages  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.

4. Guidance modalities ► Stereotactic mammographic guidance ► Ultrasound guidance ► MRI guidance

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

6. Stereotactic mammographic guided

7. Mammographic Guided Biopsy- Stereotactic Table

8. Stereotactic mammographic guided Advantages Patient motion is eliminated Patient don ’ t see the biopsy less vasovagal reactions Disadvantages: Disadvantages: Space Space Difficult access to lesions close to the chest wall Difficult access to lesions close to the chest wall

9. 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 15 0 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.

10. Mammographic guided

11. 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.

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

13. 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

14. 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

15. MRI biopsy guidance

16. Tissue Acquisition Devices - Types and Indications ► FNA ( Fine – needle aspiration) ► Core biopsy ► Vacuum assisted core biopsy ► Fine needle localization devices

17. Minimally Invasive Procedures Types & Indications ► FNA ► Cysts, Lymph nodes ► Core Needle Biopsy ► Solid masses ► Drainage of collections ► Abscess and post surgical collections ► Fine Needle Localization ► Pre-Operative ► Vacuum-Assisted Large Core Needle Biopsy (Mammotome) ► Solid masses smaller than 5mm and calcifications

18. FINE NEEDLE ASPIRATION Most popular technique of biopsy for breast palpable and nonpalpable lesions. ADVANTAGES ADVANTAGES Virtually atraumatic Virtually atraumatic Rare to even cause a hematoma Rare to even cause a hematoma Simple to perform Simple to performDISADVANTAGES Extremely dependent on level of cytological interpretation. High percentage of insufficient, material aspirates (34%-40%). Cytology doesn ’ t differentiate between in situ from invasive disease

19. 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

20. 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.

21. 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.

22. FINE NEEDLE ASPIRATION Pre-FNA Post-FNA

23. LYMPH NODE F.N.A.

24. CORE NEEDLE BIOPSY - CNB ► First described in 1982 by Perlinggren, Sweden. ► Cutting needle fits in automated spring- loaded biopsy gun. ► Most accurate results with 14-gauge. ► Needle consists of inner tissue sampling needle and outer cutting needle.

25. CORE NEEDLE BIOPSY - CNB ► 17mm tissue slot is located 4mm from end of inner needle. ► Prebiopsy position, outer needle covers inner needle. ► Inner needle is advanced 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

26. DISPOSABLE SEMIAUTOMATIC BIOPSY NEEDLE Stylet Hub Main part Plunger

27. 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.

28. Needle placement with ultrasound guidance - TECHNIQUE ► Transducer is placed on patient ’ s skin so both lesion and path of needle are visible. ► Needle position is documented with longitudinal and transverse scans.

29. Ultrasound guidance-Technique

30. Core Sampling ► 5 or more cores require reinsertion and repositioning of needle. ► Visual inspection of samples.

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

32. Advantages of Core Biopsy ► 96%-100% concordance between CNB and surgery. ► No insufficient samples. ► Histological tissue diagnosis allows differentiation of IDC from DCIS.

33. 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 and DCIS

34. COMPLICATIONS AND RISKS ► Fainting. ► Hematoma 6-30%. ► Seeding of needle track by malignant cells.

35. 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

36. Vacuum-Assisted Biopsy: Advantages ► Suction of the blood out of the biopsy cavity. ► Only one insertion of the needle. ► Larger specimen- 11G or 8G.

37. Vacuum-Assisted Biopsy: Advantages  Significant improvement in the retrieval of calcifications

38. 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.

39. 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

40. HOOKWIRE SYSTEMS

42. Mammographic Fine Needle Localization

43. Sonografic Fine Needle Localization

44. EXCISED SPECIMEN Two-view magnified specimen radiograph. US specimen in masses visualized sonographically

45. Minimally invasive technique in Breast Cancer Treatment: The Future ► Stereotactic excision with vaccum assisted core biopsy ► Criotheraphy monitored by ultrasound ► Laser ablation/focused ultrasound ► Radiofrequency monitored by ultrasound

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

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

48. 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.

49. 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.

50. 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.