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III. КЛИНИЧЕСКИЙ СЛУЧАЙ
УДК 618.19-006-076
STEREOTACTIC BREAST BIOPSY:
TECHNIQUE AND RESULTS
ABOUT THE AUTHORS
Rakhimzhanova Raushan Ibzhanovna -honored worker of the Republic of Kazakhstan, PhD, professor, head of radiology Department named after Z.H. Hamzayev in Astana Medical University.
Abdrakhmanova Zhanar Sagatbekovna - PhD, head of radiology and Radiation Therapy Department in Medical University of Astana.
Suleimenova Danara Muratovna - MD, radiologist, in the radiology department in Astana city Oncological Center, Astana. E-mail: danara27@mail.ru. Phone: 87015559095.
Keywords:
breast cancer, biopsy, mammography
Rakhimzhanova R.I., Suleimenova D.M., Aitbay G.S., Tleuf D.B., Avtaykina T.F.
JSC "Medical University Astana" "Oncological center" of Astana city
Medical Center Hospital of President's Affairs Administration of the RK, Astana, Kazakhstan
Summary
Breast cancer represents a serious public health problem of any modern country. Kazakhstan is no exception. According to statistical data, about four thousand cases of breast cancer in Kazakhstan are registered each year, about 20% of which are diagnosed in late (III-IV) stages [1]. Over the past decades, breast cancer has reached a leading position in the structure of oncologic pathology, and the incidence of this type of neoplasm has a tendency to steady growth [2]. At the same time, thanks to the introduction of new methods of treatment of breast cancer, in particular targeted and new chemotherapeutic drugs, timely diagnosis can not only increase life expectancy, but also significantly improve its quality [3]. In addition, 90% of patients with breast cancer in stage I have indications for organ-preserving surgery, which in turn reduces the disability of patients of working age, and has a positive economic effect [4].
Сут безшщ стереотаксикалык биопсиясы: техникасы жэне нэтижелер1
АВТОРЛАР ТУРАЛЫ
Рахимжанова Раушан Ибжанкызы -, Казакстан Республжасыньщ ецбек сщрген кайраткерi, м.р.д., профессор, Астана Медицина университетin академик Ж.Х. Хамзабаев атындаFы радиология кафедрасыныц мецгерушм.
Сулейменова Данара Мураткызы - Астана каласыныц онкологиялык орталькыныц сэулел'1 диагностика бвл!мтщ рентгенолог дэргерг Электронды пошта: danara27@ mail.ru. Телефон: 87015559095.
Туйш сездер
сут без обыры, биопсия, маммография
Рахимжанова Р.И., Сулейменова Д.М., Айтбай Г.С., Тлеуф Д.Б., Автайкина Т.Ф.
АО «Медицинский университет Астана» ШЖК, «Онкологиялык орталыш» МКК
КР Президент! 1с Баскармасы Медициналык орталык Ауруханасы, Астана каласы, Казакстан
Ацдатпа
Со^ы жылдары сут бeзi катeрлi itiri ауруы онкологиялык аурулардыц алды^ы сатысында т±р. Барлылык жер-лерде скрининглк жуйен eнriзreлi сут безшщ катeрлi itiri ерте сатысында аныктауFа септюн типз'ш отыр. Ол болжамдарды жаксартып, наукастардыц вм'р суру узактьшн арттырады. Сонымен бiрre, юшкентай байкалмайтын СБ1 формалары онколог дэрireрлeр тактикасына кедерп келт'руде. Сут бeзiнiщ катeрлi iшн ерте сатыда (insitu) аныктау уш 'н стереотаксикалык трепанбиопсия тэсШ оцтайлы.
Стереотаксическая биопсия молочной железы: техника и результаты
ОБ АВТОРАХ
Рахимжанова Раушан Ибжановна -Заслуженный деятель Республики Казахстан, д.м.н., профессор, заведующая кафедрой радиологии им. академика Ж.Х. Хамзабаева Медицинского университета Астана.
Сулейменова Данара Муратовна -врач рентгенолог отделения лучевой диагностики онкологический центра г. Астаны. Электронный адресс: danara27@ mail.ru. Телефон: 87015559095.
Ключевые слова:
рак молочной железы, биопсия, маммография
Рахимжанова Р.И., Сулейменова Д.М., Айтбай Г.С., Тлеуф Д.Б., Автайкина Т.Ф.
АО «Медицинский университет Астана» ГКП на ПХВ «Онкологический центр»
Больница Медицинского центра Управления Делами Президента РК, г. Астана, Казахстан
Аннотация
За последние десятилетия рак молочной железы (РМЖ) вышел на лидирующую позицию в структуре онкологической патологии, и заболеваемость данным видом новообразований имеет тенденцию к неуклонному росту. Благодаря повсеместному внедрению скрининга на раннее выявление рака молочной железы, увеличивается количество пациенток с РМЖ,диагностированным на ранней стадии. Это улучшает прогноз и увеличивает продолжительность жизни больных. Вместе с тем, верификация малых непальпируемых форм РМЖ представляет собой тактическую проблему для врачей онкологов. Одним из методов верификации рака молочной железы на нулевой стадии (insitu) является стереотаксическая трепанбиопсия молочной железы, которая обладает рядом преимуществ.
Thanks to the national screening program for the early detection of breast cancer, introduced in Kazakhstan since 2011, the diagnosis of this disease at the preclinical stage became a reality. At the same time, the verification of small non-palpable forms of breast cancer is still a significant tactical problem for oncologists [5]. However, with the introduction into practice of a modern arsenal of diagnostic tools and manipulations, this task found a solution. The ideal method for verifying the diagnosis of breast cancer is one that has sufficient sensitivity and specificity, allows a specialist to take enough material for a pathomorphological and immunohisto-chemical analysis, is fast, inexpensive, safe for the doctor and patient [6]. Such methods include core need biopsy (or gun biopsy) and vacuum aspiration biopsy, which can be carried out under the guidance of visual diagnostic methods-ultrasound or mam-mography. One of the methods of verifying breast cancer at the stage 0 (in situ) is a stereotactic gun biopsy. This method has been introduced in Astana oncologic center since March 2015.
Diagnostic possibilities of morphological methods of verifying breast cancer at the preoperative stage have been investigated in numerous studies [7,8,9], but many authors do not agree on the algorithm, the procedure, the indications for it, and the diagnostic characteristics of the technique.
Aim of the study
To develop a comprehensive algorithm for conducting stereotactic breast biopsy; To analyze the results of stereotactic gun biopsy in Astana onco-logic center from March 2015.
Materials and methods
Stereotactic gun biopsy was carried out on the mammographic unit Siemens Mammomat Inspiration with a special stereotactic attachment.
Puncture and sampling of the material was carried out using an automatic biopsy system Bard Monopty, needles 14G, 10, 13 and 15 cm long. The indications for this interventions were grouped microcalcifications, local architecture distortion, not detectable by ultrasound.
Ninety six patients with mammographically suspicious, non-palpable lesions underwent stereotactic breast biopsy from March 2015 to October 2016.
Patients were divided into two groups: 1- with lesions, detected by the national screening program (screening patients), 2-with lesions, detected by diagnostic mammography. The second group included both primary patients and breast cancer patients after complete treatment course. The results of histological examination are available for all patients.
The number of patients in the first group was fifty one, with age varying from 50 to 60 years.
The second group consisted of forty six patients. The age of the patients ranged from 35 to 71 years, with a mean age 56 years.
In eighty seven (90%) patients out of the total number of women (ninety six patients) the indications for biopsy were clustered microcalcifications of different types. Four (4.5%) patients had a local architectural distortion, and five (5.5%) patients had local star-like fibrosis on mammography as an indication for biopsy. All women underwent ultrasound breast examination, including the "MicroPure" mode for the visualization of microcalcifications, where microcalcifications were detected in 62 (64%) patients. However, considering the clinical protocols, the biopsy was performed under the control of mammography. In nine patients with an architectural distortion and a local fibrosis, these changes were not clearly visualized on sonography.
All microcalcinates were classified according to the system presented by the author LeGal [10]: Typel. Ring-shaped
Type 2. Round, regular shape, symmetrical Type 3. Dusty, very small Type 4. Point, irregular shape Type 5. Wormlike, tree-like. Reflect intraductal necrosis.
It is necessary to distinguish the types of microcalcifications on mammography, because it affects the cancer detection rate. The probability of detecting breast cancer with various calcifications ranges from 1% to 96%
Image 1
Mammographic stereotactic system
Image 2
Classification of microcalcifications (from E.Fondrinier et al., 2002)
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Image 3
Probability of detection of breast cancer depending on the type of microcalcifications
Sixteen (63.5%) of the patients had type 4, three (3.1%) had type 5, seventeen (17.7%) had type 3, and fifteen (15.6%) had 1 or 2 types of microcalcifications.
By the number of microcalcifications the patients were divided into those with more than 20 microcalcifications per 1 sq. cm (seventeen per-sons-17.7%), and who had less than 20 microcalcifications per 1 sq. cm (seventy nine patients-82.3%).
Results
Technique of the biopsy
We developed a clear technique for carrying out this manipulation, which allows us to draw an informative sample from an accurately targeted point.
were taken and reviewed by the radiologist. Once the radiologist identified the abnormality on mammogram (we used printed version in our study),the study begins with marking the mammogram in a direct projection. We made the markings manually. A straight line is drawn from the nipple, a perpendicular is drawn from it to the site of interest. The distance between the marks is measured accurately in centimeters. The main thing at this stage is to use mammogram, which is printed in full size. Next, the marking of the breast was made. A mark is placed in the place of the proposed puncture.
Then, breast was compressed and held in position throughout the procedure. The breast is compressed such that the target mark is present within the open window of the compression paddle. A scout view is obtained, providing localization of the lesion in the x- and y-axes. Stereotactic images are then obtained 15° from midline in both the positive and negative directions.
By shifting the shadow of the lesion relative to the center of rotation, the coordinates of the location of the target are calculated. At the workstation, the radiologist selects the point, from which the sample will be taken. The doctor can target any smallest point of interest, including a very compact
Image 4
Marking a breast
Image 5
Image acquisition
j
group of microcalcifications. Radiologist can set up to 6 goals, the biopsy attachment will move consistently from the first to the last goal. After selecting the appropriate biopsy needle, the stereotactic paddle moves to the puncture site. After anesthetizing the skin with a solution of local anesthetic through a special guide, the biopsy needle is inserted all the way down to the stop.
Accurate needle placement is confirmed by obtaining additional pre- and postfire paired stereotactic images. Then, a "fire" is carried out, and the sample is taken, which is then placed into a container with formalin.
This procedure (with the exception of anesthesia) is repeated 4-5 times for each new sample.
After the procedure, an aseptic bandage and an ice pack is applied to the puncture site for up to 15 minutes. The whole procedure takes about 20 minutes.
Results of stereotactic breast biopsy in Astana oncologic center
Informative material sufficient for pathomor-phological examination was obtained in ninety two (95%) of ninety six cases.
In fifteen (15.6%) patients, the material, although it was informative to exclude the diagnosis of breast cancer, was defined by pathomorpholo-gists as "scarce".
Infiltrative adenocarcinoma was diagnosed in four (4.1%) of the examined women.
Breast cancer in situ was detected in six (6.2%) cases.
The number of microcalcifications was significantly higher in patients with histologically confirmed breast carcinoma (p<0.05). In nine (53%) of seventeen patients with the number of microcalcifications more than 20 per 1sq. cm, breast cancer was diagnosed, while in the group with the number of microcalcifications less than 20 per sq.cm, breast cancer was detected only in one (1,2 %) patient.
In sixty seven (70%) patients, fibrocystic changes (proliferative and non-proliferative variants), local fibrosis, intraductal papillomatosis, and other benign pathological changes were diagnosed.
Out of the total number of patients examined, twenty two (23%) patients underwent surgical excision of the lesion: ten with breast cancer underwent radical resection, six women with atypical hyperplasia and six with negative biopsies underwent surgical biopsy.
In six patients diagnosed with atypical hyperplasia, the diagnosis remained the same in five cases, in one case in the surgical material, invasive breast carcinoma was detected.
In patients with preoperative diagnosis of breast cancer, the result of postoperative histology coincided with the initial one in all ten cases.
Image 6
Installation of biopsy needle
Image 7
Sample
There were two (2%) cases of false-negative conclusions after biopsy registered in this study, when the postoperative histology came positive for breast cancer. The remaining seventy four (77 %%) patients with a predictably benign breast pathology were recommended for a dynamic observation in oncologic center.
Thus, the stereotactic biopsy of the non-palpable breast tumor made it possible to identify breast cancer in ten (10%) out of the ninety six examined patients, all cancers registered at stage 0 (6) and T1 (4).
In seventy four patients, this technique allowed to avoid a potentially unreasonable surgical intervention, but close mammographic follow-up at 6 and 12 months is necessary to exclude false-negative results.
There were no major complications reported in this study. Minor complications, stated by the women, included small post-biopsy ecchymosis and tenderness in the place of puncture.
Conclusions
1) Stereotactic gun biopsy is a highly informative diagnostic method that allows the morphological verification of breast cancer at an early stage.
2) The material obtained by stereotactic biopsy, allows identification both histological and im-munohistochemical profile of the tumor before the start of treatment.
References
1. Statistical collection of KazIOR, Almaty, 2016.
2. Kamchen V.B., Turbekova M.N., Epidemiological aspects of the incidence of malignant neoplasms in Kazakhstan. Unique research of the XXI century. 2015- 8 (8): 61-66
3. Boyle P. Breast cancer control: Signs of progress, but more work required // The Breast. $ 2005. -Vol. 17 -P. 429-438
4. V.F. Semiglazov, V.V. Semiglazov, G.A. Dashyan, Problems of surgical treatment of breast cancer. Practical oncology. 2010-11 (№4): 217-220
5. V.F. Semiglazov, VV Semiglazov, Screening of breast cancer. Practical oncology. 2010-11 (№2): 60-65
6. N.M. Fedorov, ON Tsarev, D.D. Nokhrin, A.V. Chizhik, A.D. Nokhrin. Possibilities of various methods of verification of non-palpable mammary tumors under ultrasound control. Tyumen medical journal. 2014-16 (No. 4): 28-30
3) There is s statistically significant association between the number of microcalcifications and probability of detecting breast cancer. The latter is directly proportional to the increase in the number of microcalcifications per unit area.
4) Our experience has shown that the sensitivity increases with the number of samples obtained by biopsy. The optimal number in our conditions is 4 samples. It is crucial to assess the samples visually (fragmentation and a large number of fatty tissues reduce the accuracy of the biopsy) in order to assess the necessity to obtain more samples.
7. F.J. Andreu et al. The impact of stereotactic large-core needle biopsy in the treatment of patients with nonpalpable breast lesions: a study of diagnostic accuracy in 510 consecutive cases. European Radiology 1998- 8: 1468-1474
8. Ying-Hua Yu et al. Diagnostic value of vacuum-assisted breast biopsy for breast carcinoma: a meta-analysis and systematic review. Breast Cancer Research and Treatment. 2010-120(2): 469-479
9. N.M. Fedorov., N.A. Shanazarov, A.A. Sabirov, D.D. Nokhrin, A.V. Chizhik, D.P. Efremov, L.I. Karpova. The role and place of morphological verifications of non-palpable neoplasms in mammary glands. Tyumen Medical Journal. 2011-3,4: 34-35
10. E. Fondrinier, G. Lorimier, V. Guerin-Boblet, AF. Bertrand, C. Mayras, N. Dauver. Breast microcalcifications: multivariate analysis of radiologic and clinical factors for carcinoma. World Journal of surgery. 2002 -26(3):290-296
