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488
Complications
What are the most common
complications of image-guided
breast biopsies?
Bleeding, and less
frequently infection and
persistent pain.
How can we avoid a pneumothorax
during the US-guided breast
biopsy?
Placement of the needle
parallel to the chest wall.
What are the complications of
breast cancer ablation?
Skin burns and mass
formation at the probe site.
Landmark Research
Tomkovich KR.Interventional radiology in the diagnosis and
treatment of diseases of the breast: a historical review and
future perspective based on currently available techniques.
American Journal of Radiology, 2014;203:725-733. https://doi.
org/10.2214/AJR.14.12994
Kreb DL, Looij BG, Ernst MF, etal. Ultrasound-guided
radiofrequency ablation of early breast cancer in a resection
specimen: lessons for further research. Breast 2013;22:543-7.
https://doi.org/10.1016/j.breast.2012.11.004
Nguyen T, Hattery E, Khatri VP.Radiofrequency ablation
and breast cancer: a review. Gland Surgery 2014;3(2):128-135.
https://doi.org/10.3978/j.issn.2227- 684X.2014.03.05
Garcia-Tejedor A, Guma A, Soler T, etal. Radiofrequency
ablation followed by surgical excision versus lumpectomy for
early stage breast cancer: a randomized phase II clinical trial.
Radiology 2018;00(0):1-7. https://doi.org/10.1148/
radiol.2018180235
Toshikazu I, Shoji O, Shinji N, etal. Radiofrequency abla-
tion of breast cancer: a retrospective study. Clinical Breast
Cancer 2017;18(4):e495-500. https://doi.org/10.1016/j.
clbc.2017.09.007
M. J. Uceda and S. Khan
https://t.me/med1917
489
Sabel MS, Kaufman CS, Whitworth P, etal. Cryoablation of
early-stage breast cancer: work-in-progress report of a multi-
institutional trial. Ann Surg Oncol 2004; 11:542–549. https://
doi.org/10.1245/ASO.2004.08.003
Manenti G, Scarano AL, Pistolese CA, et al. Subclinical
breast cancer: minimally invasive approaches. Our experience
with percutaneous radiofrequency ablation vs. cryotherapy.
Breast Care (Basel) 2013; 8: 356–360. https://doi.
org/10.1159/000355707
Simmons RM, Ballmar KV, Cox C, etal. A phase II trial
exploring the success of cryoablation therapy in the treat-
ment of invasive breast carcinoma: results from ACOSOG
(Alliance) Z1072. Ann Surg Oncol 2016 Aug;23(8):2438-45.
https://doi.org/10.1245/s10434- 016- 5275- 3
Common Questions
What is the BI-RADS classification?
BI-RADS
1 Normal
Annual mammogram
BI-RADS
2
Benign Annual mammogram
BI-RADS
3
Probably benign Short-term 6months’
follow-up
BI-RADS
4
Suspicious Tissue sampling
BI-RADS
5
Highly suspicious Tissue sampling
BI-RADS
6
Known biopsy-proven
malignancy
Treat accordingly
How can we identify the location of breast lesions in
mammography?
36 Breast Oncology
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490
Medial
Lateral
Superior
Inferior
MLOCC
Who is a high-risk
patient?
BRCA positive (including untested
first-degree relatives), history of chest
radiation, risk model ≥20%.
What are the
screening
recommendations for
high-risk patients?
Mammography (preferably
Tomosynthesis) and MRI.
What is the best time
of the menstrual cycle
to perform a breast
MRI?
7–14days.
What is a “pancake
breast”?
Breast that compresses <2cm. This is a
specific contraindication for stereotactic
biopsy.
What is the best
method for follow-up
after breast cancer
ablation?
MRI breast with contrast.
What devices are
available for RFA in
the breast?
Covidien Cool Tip, Integra Elektrotom
HiTT, Boston Scientific LeVeen, and
Angiodynamics Starburst.
M. J. Uceda and S. Khan
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491
What is the relevant
data supporting the
use of RFA in early-
stage breast cancer?
In 2013, Kreb etal. analyzed the results
of cryoablation in 20 lesions ≤1.5cm.
Complete cell death of the target was
reported in 85% of lesions. In 2017, a
retrospective study in Japan evaluated
386 patients and obtained ipsilateral
breast tumor recurrence free (IBTR)
rates of 97%, 94%, and 87% for
tumors ≤1cm, 1.1–2.0cm and >2cm,
respectively.
How does RFA
compare to
lumpectomy in early-
stage breast cancer?
A very recent prospective randomized
clinical trial with 40 subjects
demonstrated RFA is effective for
local tumor control and that tumor-free
margins were obtained more often with
RFA than with lumpectomy.
How many freeze/
thaw cycles are
recommended
when performing
cryoablation?
Two freeze/thaw cycles are recommended
for complete treatment.
What devices
are available for
cryoablation in the
breast?
Sanarus Visca-2 system and Ice-Cure
Medical IceSense-3 system.
What is the relevant
data supporting the
use of cryoablation
in early-stage breast
cancer?
A phase II clinical trial in 2017 evaluated
86 patients and 87 stage I breast cancer
lesions. When multifocal disease outside
of the targeted cryoablation zone was
not defined as an ablation failure, 92%
of the treated cancers had a successful
cryoablation. Littrup etal. analyzed 22
lesions in 11 patients and there were no
local recurrences in 18months follow-up
after cryoablation.
(continued)
36 Breast Oncology
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492
How does
cryoablation compare
to lumpectomy in
early-stage breast
cancer?
A multicenter non-randomized clinical
trial is being conducted to evaluate the
potential use of cryoablation instead of
resection in small breast tumors (FROST
trial). The accrual goal is 220 patients and
the lesions included are ≤1.5cm without
nodal extension. The primary endpoint is
complete tumor ablation and secondary
endpoints include IBTR rate, breast
cosmesis, and adverse events.
Further Reading
Brant W, Helms C, Vinson E.Fundamentals of diagnostic radiology.
4th ed. Lippincott Williams & Wilkins; 2007. p.536–67.
D’Orsi CJ, Sickles EA, Mendelson EB, Morris EA, et al. ACR
BI-RADS® atlas, breast imaging reporting and data system,
American College of Radiology. Reston, VA; 2013.
Garcia-Tejedor A, Guma A, Soler T, etal. Radiofrequency ablation
followed by surgical excision versus lumpectomy for early stage
breast cancer: a randomized phase II clinical trial. Radiology.
2018;00(0):1–7.
https://doi.org/10.1148/radiol.2018180235.
Klein J, Brant W, Helms C, Vinson E. Fundamentals of diagnostic
radiology. 4th ed. Lippincott Williams & Wilkins; 2009.
Kreb DL, Looij BG, Ernst MF, etal. Ultrasound-guided radiofre-
quency ablation of early breast cancer in a resection specimen:
lessons for further research. Breast. 2013;22:543–7.
https://doi.
org/10.1016/j.breast.2012.11.004.
Lanza E, Palussiere J, Buy X, et al. Percutaneous image-guided
cryoablation of breast cancer: a systematic review. J Vasc Interv
Radiol. 2015;26:1652–7. https://doi.org/10.1016/j.jvir.2015.07.020.
Mainiero MB, Moy L, Baron P, et al. ACR appropriateness criteria
breast cancer screening. J Am Col Radiol. 2017;14(11):s383–90.
https://doi.org/10.1016/j.jacr.2017.08.044.
Manenti G, Scarano AL, Pistolese CA, et al. Subclinical breast
cancer: minimally invasive approaches. Our experience with per-
cutaneous radiofrequency ablation vs. cryotherapy. Breast Care
(Basel). 2013;8:356–60. https://doi.org/10.1159/000355707.
Mauro M, Murphy K, Thomson K, Venbrux A, Morgan R.Image-
guided interventions. 2nd ed. Elsevier; 2014. p.1152–60.
M. J. Uceda and S. Khan
https://t.me/med1917
493
Nguyen T, Hattery E, Khatri VP. Radiofrequency ablation and
breast cancer: a review. Gland Surg. 2014;3(2):128–35. https://doi.
org/10.3978/j.issn.2227-
684X.2014.03.05.
Noone AM, Howlader N, Krapcho M, et al. (editors). SEER
Fast Stats, 1975–2015. Age-adjusted SEER incidence and mor-
tality rates, 2010–2015. National Cancer Institute. Bethesda,
MD. Accessed on April 19, 2018. https://seer.cancer.gov/fast-
stats/
, 2018.
Sabel MS, Kaufman CS, Whitworth P, et al. Cryoablation of
early-stage breast cancer: work-in-progress report of a multi-
institutional trial. Ann Surg Oncol. 2004;11:542–9. https://doi.
org/10.1245/ASO.2004.08.003
.
Simmons RM, Ballmar KV, Cox C, etal. A phase II trial exploring
the success of cryoablation therapy in the treatment of invasive
breast carcinoma: results from ACOSOG (Alliance) Z1072.
Ann Surg Oncol. 2016;23(8):2438–45. https://doi.org/10.1245/
s10434-
016- 5275- 3.
Smith RA, Saslow D, Sawyer KA, etal. American Cancer Society
guidelines for breast cancer screening: update 2003. Ca Cancer J
Clin. 2003;53:141–69.
Tomkovich KR.Interventional radiology in the diagnosis and treat-
ment of diseases of the breast: a historical review and future per-
spective based on currently available techniques. Am J Radiol.
2014;203:725–33. https://doi.org/10.2214/AJR.14.12994.
Toshikazu I, Shoji O, Shinji N, et al. Radiofrequency ablation
of breast cancer: a retrospective study. Clin Breast Cancer.
2017;18(4):e495–500. https://doi.org/10.1016/j.clbc.2017.09.007.
36 Breast Oncology
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Part V
Hepatobiliary
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497© Springer Nature Switzerland AG 2022
R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_37
Evaluating thePatient
What are the common
biliary interventions which
interventional radiology
may offer patients?
Percutaneous transhepatic
cholangiography (PTC) and biliary
drainage (PTBD), percutaneous
biliary stent placement, and
percutaneous cholecystostomy
(PC).
Chapter 37
Percutaneous Biliary
Interventions
JacobJ.Bundy, JeffreyForrisBeechamChick,
andRaviN.Srinivasa
J. J. Bundy (*)
Department of Radiology, Wake Forest Health,
Winston Salem, NC, USA
e-mail: Jbundy@wakehealth.edu
J. F. B. Chick
Department of Interventional Radiology, University of Washington,
Seattle, WA, USA
R. N. Srinivasa
Department of Radiology, Division of Interventional Radiology,
University of California- Los Angeles, Los Angeles, CA, USA
(continued)
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498
What are the common
causes of benign biliary
obstruction?
The flow of bile may be
disrupted by either benign or
malignant causes. Benign biliary
obstructions are commonly
caused by migrated cholelithiasis
(gallstones) into the common bile
duct (choledocholithiasis), benign
stricture formation following
invasive procedures, and strictures
related to chronic inflammation
secondary to chronic pancreatitis
or primary sclerosing cholangitis.
What are the common
causes of malignant biliary
obstruction?
Malignant biliary obstructions
are commonly caused by
pancreatic adenocarcinoma,
cholangiocarcinoma, lymphoma,
and metastases from another
primary neoplasm.
What are the physical
signs and symptoms
associated with biliary tree
obstruction?
Jaundice, bilirubinuria (darkening
of the urine), acholic stool, pruritus,
anorexia, nausea, and fatigue.
What are the laboratory
studies which are indicative
of a biliary obstruction?
The typical cholestatic pattern
observed during a biliary
obstruction include elevation in
the serum bilirubin (conjugated
hyperbilirubinemia), elevation of
the serum alkaline phosphatase
out of proportion to the serum
aminotransferases, and elevated
gamma-glutamyl transpeptidase.
J. J. Bundy et al.
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499
What imaging studies are
useful in the evaluation
of suspected biliary
obstruction?
Transabdominal ultrasonography
(US) is a common imaging
modality used in the early
evaluation; however,
overlying bowel gas may
limit extrahepatic bile duct
evaluation. Magnetic resonance
cholangiopancreatography
(MRCP) and computed
tomographic cholangiography offer
cross-sectional anatomic models to
evaluate the level of obstruction.
What is the role of
endoscopic retrograde
cholangiopancreatography
(ERCP) in the evaluation of
biliary obstruction?
ERCP is the preferred method
of biliary intervention as it
allows for simultaneous diagnosis
and treatment of biliary
obstructions. Altered anatomy
(Roux-en-Y gastric bypass and
hepaticojejunostomy) and high
bile tree obstructions (obstructions
proximal to or involving the
confluence of the left and right
hepatic ducts), however, are
generally more amenable to
percutaneous interventions.
High Yield History
What is Charcot’s
triad? Reynold’s
pentad?
Charcot’s triad refers to the three
classical features associated with
cholangitis; right upper quadrant pain,
fever, and jaundice. Reynold’s pentad
adds mental status changes and sepsis
or hypotension to the clinical findings
suggestive of cholangitis.
(continued)
37 Percutaneous Biliary Interventions
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