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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3892_Библиотеки_им_академика_М_И_Перельмана
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S. Khan and M. J. Uceda
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479© Springer Nature Switzerland AG 2022
R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_36
Evaluating Patients
What are the
recommendations for
breast cancer screening
in women?
Recommendations differ between the
United States Preventive Services Task
Force (USPSTF) and the American
Cancer Society (ACS);
USPSTF
Age 40–49: Decision to screen should
be an individual one (Grade C).
Age 50–74: Screen every 2years
(Grade B).
Age ≥75: No recommendation
(insufficient evidence).
Chapter 36
Breast Oncology
MonicaJ.Uceda andShajiKhan
M. J. Uceda (*) · S. Khan
Department of Radiology, Presence Health St. Francis Hospital,
Evanston, IL, USA
e-mail: monica.uceda-arriola@presencehealth.org; shaji.khan@
presencehealth.org
(continued)
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480
ACS
Women 40–44 can begin annual
screening mammography.
Women 45–54 should undergo annual
screening mammography.
Women ≥55 can transition to every-
other- year screening OR continue
annual screening mammography.
Women should continue screening
mammography as long as their overall
health is good and they have a life
expectancy of 10years or longer.
Women at any age should not rely on
breast examination for breast cancer
screening.
What are the
most suspicious
mammographic
findings?
Irregular mass with obscured, indistinct
or spiculated margins, pleomorphic
or fine linear branching calcifications,
developing asymmetry, architectural
distortion, skin thickening, nipple
retraction and lymphadenopathy.
What are the most
suspicious sonographic
findings?
Round lesion, non-parallel and/
or irregular margins (angular),
posterior shadowing, hypoechoic, not
circumscribed, internal vascularity and
lymphadenopathy.
What benign lesion can
appear suspicious on
ultrasound?
A scar can appear non-circumscribed
and demonstrate posterior acoustic
shadowing, as well as spiculated
margins.
What is the work-up of
a palpable mass?
Diagnostic mammogram and breast
ultrasound.
What are ultrasound
features of
fibroadenoma?
Parallel, oval, hypoechoic lesion with
circumscribed margins and no posterior
features.
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BIRADS-3; 6-month follow-up is
necessary to show stability.
Reasons to biopsy:
Interval growth
Patient anxiety
High likelihood of losing the patient
during follow-up
What is the value of
breast MRI?
Screening for high-risk patients and
evaluating cancer extension.
What is a “second
look” ultrasound?
Targeted ultrasound of a corresponding
area of abnormal enhancement on MRI.
What additional
imaging modalities
can be used for further
evaluation?
Breast-specific gamma imaging (BSGI)
and positron emission mammography
(PEM).
High Yield History
What is the
incidence of
breast cancer
in the United
States?
126.5 per 100,000 women and 1.1 per 100,000.
It is the most common cancer in women
independent of race or ethnicity.
What is the
mortality of
breast cancer
in the United
States?
20.3 per 100,000 women and 0.3 per 100,000
men. The mortality rate has recently decreased
by 39% due to improved treatment and early
detection.
What is the
average age at
diagnosis?
62years old, with most cancer deaths in
women ≥50.
(continued)
36 Breast Oncology
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What are the
risk factors?
Older age, personal history, family history,
BRCA1/BRCA2 genes, radiation to chest
<30years old, white race, obesity, nulliparous,
early menarche, late menopause, hormone
replacement therapy, smoking and dense
breasts.
What are
symptoms of
breast cancer?
Palpable mass, lymphadenopathy, skin
thickening and nipple retraction. In the case
of inflammatory breast cancer: peau d’orange,
redness and swelling.
Indications/Contraindications
What are the methods
available for image-
guided breast biopsies?
Stereotactic interventions, US-guided
interventions, MR-guided breast
biopsy, and the new vacuum-assisted
nuclear medicine breast biopsy
techniques.
What are common
contraindications for
the image-guided breast
biopsy?
Bleeding disorders, uncooperative
patient, morbid obesity.
What are the indications
for the stereotactic
biopsy?
Newly diagnosed suspicious
microcalcifications seen on
mammography or digital
tomosynthesis classified as BI-RADS
4 or 5
Suspicious lesions seen best
in mammogram or without an
ultrasound correlate
What are the indications
for the US-guided breast
biopsy?
Any lesion definitely identified as
suspicious by ultrasound.
What are the advantages
of the US-guided breast
biopsy?
Real-time visualization, shorter
procedural time, patient’s comfort,
and no radiation.
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What are the indications
for the MR-guided breast
biopsy?
Suspicious lesions only visualized with
MRI.
What are the techniques
available for breast
cancer ablation?
Radiofrequency ablation (RFA) and
cryoablation.
Which lesions could
be best treated with
ablation?
Breast cancer single lesions ≤1.5cm
and histologically different from
invasive lobular carcinomas.
Relevant Anatomy
What are the three zones of
the breast in mammography?
Boundaries Content
Premammary
zone
Skin to anterior
mammary fascia
Subcutaneous fat, blood
vessels, ligaments of
Cooper. May contain
ectopic ducts and TDLU
Mammary zone Anterior to
posterior
mammary
fascias
Majority of ducts/TDLU,
stromal fat, and stromal
connective tissue
Retromammary
zone
Posterior
mammary fascia
to chest wall
Fat and posterior
suspensory ligaments
What are the layers
identified in breast
ultrasound?
Skin, subcutaneous tissue, glandular
tissue, pectoralis major, and chest
wall.
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Relevant Materials
What is the set-up for
stereotactic breast biopsy?
Dedicated table or digital
mammography unit attachment and
a special chair for positioning.
What size biopsy needles
are utilized?
11-, 9-, 8-, or 7-gauge.
What are the benefits of
vacuum-assisted devices?
Actively drawing tissue into the
biopsy chamber allows for larger and
multiple tissue samples, and increases
diagnostic accuracy.
How do you select the
appropriate device/
technique for US-guided
breast biopsies?
Fine needle aspiration (FNA) for
cystic or mixed lesions and core
needle biopsies (CNB) for solid
lesions.
What are the advantages
or disadvantages of FNA?
Advantages: low cost and likelihood
of hematoma.
Disadvantages: operator-dependent
and inability to differentiate between
DCIS and IDC.
What device options exist
for CNB?
Automated spring-loaded or
vacuum-assisted devices.
What are the advantages
or disadvantages of CNB?
Advantages: higher likelihood of
negative margins during surgery and
ability to perform oncologic markers
with the sample.
Disadvantages: higher cost and
need for multiple re-insertions with
automated devices.
When is a vacuum-assisted
device preferred for CNB?
Suspicion of intraductal papillomas.
What are the available
MRI-guided biopsy
platforms?
Grid system and pillar-and-post
system.
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How is the needle placed
in a grid system?
Orthogonally to the compression
plate.
How is the needle placed
in a pillar-and-post
system?
Accommodates needle angulation up
to 30 degrees.
What are the components
of the introducer set in the
MRI-guided biopsy?
Needle guide, coaxial introducer
sheath, sharp nonferrous inner stylet,
and plastic localizing obturator.
What is the mechanism of
action of RFA?
High-frequency alternating currents
cause thermal coagulation and
protein denaturation of tissues.
What is the advantage
of ablation compared to
surgery?
Minimally invasive procedures and
improved cosmesis.
What is the mechanism of
the action of cryoablation?
Nitrogen or argon gas causes a local
freezing reaction (“ice ball”) which
induces direct cell injury and death
via vasoconstriction.
What are the advantages
of cryoablation?
Can be performed under mild
sedation and local anesthesia.
General Step by Step
How is the patient
positioned for a
stereotactic breast
biopsy?
Prone with the breast positioned
dependently through an aperture in the
table.
What types of
images are taken
before stereotactic
procedures?
+15 and−15 degree images.
What is the best
approach during
a stereotactic
procedure?
1. Select the projection in which the lesion
is best visualized.
(continued)
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2. After initial imaging, the computer
generates x, y, and z coordinates.
3. Place the lesion in the center of the
biopsy chamber of the probe.
What if the lesion is
too superficial?
Advance the probe to a position where the
entire biopsy chamber is just beyond the
skin.
What if the lesion is
too deep?
Reposition the patient.
Why is it important
to obtain a
post-procedure
mammogram?
To confirm the lesion has been biopsied
and identify the biopsy clip.
What size needle is
used for FNA?
22- to 25-gauge needles.
What is the best
approach for FNA?
Several passes through different areas of
the lesion.
What size needle is
used for CNB?
12- to 14-gauge.
What is the best
approach for CNB?
1. Advance device 1–3cm proximal to the
edge of the lesion.
2. Fire into the lesion.
3. Turn the needle and remove.
4. 3–5 passes are needed with automated
spring-loaded devices.
5. Place a biopsy clip.
What is the best
approach to perform
an MRI-guided
breast biopsy?
1. Place the patient prone in an MRI
biopsy coil.
2. Scout images and contrast
administration.
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3. The computer generates x, y, and z
coordinates.
4. Coaxial sheath is inserted through the
stylet.
5. Stylet is removed and obturator is
placed.
6. Remove obturator and VAB is advanced
to obtain samples.
7. Place titanium clip.
What is the use of
a post-biopsy scan
in the MRI-guided
breast biopsy?
Document adequate clip placement,
identify lesion removal, or decrease in size.
If the lesion is not
identified in MRI,
what are the next
steps?
Decrease breast compression, second dose
of contrast, short-term interval follow-up
MRI.
How is RFA
performed?
Probes are placed under US guidance and
ablation is performed under real-time
sonographic visualization. The procedure is
complete when the desired temperature is
obtained.
How is cryoablation
performed?
Cryoprobes are placed under US guidance
and ablation is performed under real-time
sonographic visualization. The “ice ball”
allows for homogenous tissue destruction.
Helium or passive thawing can be applied
after the freezing portion of the procedure.
What is the most
important step on
cryoablation?
Creating an “ice ball” larger than the
tumor in order to ensure negative margins.
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