Dr Richard Harries Consultant Radiologist Diana, Princess of Wales Hospital Grimsby

1. Assessment of breast microcalcification with stereotactic guidance using the Spirotome Biopsy Needle. Comparison with other biopsy devices Dr Richard Harries Consultant Radiologist Diana, Princess of Wales Hospital Grimsby

2. Breast tissue sampling • Aspiration cytology • Core biopsy (14 -18G, Tru-Cut etc) • Mammotome (11G, 8G) • Spirotome (11G)

3. Macro-biopsies - advantages • More reliable – fewer failures • Larger samples – better histological assessment • Tumour markers • Molecular biology • Genetic expression

5. Macro-biopsies - disadvantages • Larger samples – more tissue removal • Difficulty assessing margins at surgery – more extensive surgical removal • Clip migration • Tumour cell migration? • More haematoma complications • Reduces breast conserving surgery

6. Ideal Biopsy Needle Characteristics • Accurate targeting of lesions • Large samples • Minimum tissue damage • Quick and easy to use • Good patient acceptance • Minimum complications • Cheap!

7. What was I using? • Mammotome VAB – until about 2001 • Spirotome needle subsequently So why not compare them?

9. Spirotome system

12. Spirotome system

15. Sample population

16. Procedure • Siemens Mammomat Upright stereotaxis • Spirotome 11G • Lidocaine & adrenaline • Faxatron specimen radiology

20. Data Collection • Date • Operator • Start/Finish Times • Number of Cores + Cores with Calcification • Clip Marker • Histology • Further Management • Complications

21. Patient Questionnaire • Scale of 1 – 5 • FEAR • PAIN • OVERALL REACTION TO PROCEDURE • No pain at all 1 2 3 4 5 Very painful

22. Results - Length of procedures Average length of procedure = 48 minutes 60% of procedures (27/45) took less than 45 minutes

23. Results - Microcalcification • 45/46 patients’ samples (98%) contained microcalcification • 107/148 samples yielded calcification (73%)

24. Samples with calcification Number of microcalcification-containing cores per total number of cores

25. The number of expected specimen with microcalcification (solid line) is related to the total number of cores (horizontal axis). The upper and lower 95 % confidence intervals are depicted as dotted lines. Beyond 4 cores there is no increase in expected specimen with microcalcification.

26. Number of Cores per patient • Number of cores <5 83% (38/46) • Mean number of cores = 3.2 per patient • VAB – minimum 6 cores recommended • Many practitioners routinely take 20+

27. VAB vs. Spirotome Stereotactic biopsies *Ambrogetti et al 2003; Pfleidere et al 2009

28. Results - Histology 43/46 examinations yielded positive histology

29. Further Management • 3 patients (B1/B3) → VAB • 3 patients with invasive cancer → mastectomy • 1 patient with invasive cancer → WLE

30. Results - Complications • None know of (1 patient fainted but procedure was completed)

31. Complications – VAB • Simon et al (1999) • 71 lesions U/S guided • 5 (7%) bled beyond 10 minutes • 1 (1%) vasovagal episode • Harries …purely anecdotal • ≈ 5 years experience, ≈ 250 patients • Several haematomata requiring surgical treatment • Many vasovagal attacks requiring interruption of procedure

32. Results – Acceptability Scores Patient acceptability

33. Results – Acceptability Scores Acceptability scores <4 Fear - 84% (32/38) Pain - 92% (35/38) Overall - 83% (31/38)

34. Spirotome - Summary • Simpler and cheaper than VAB systems • High positive yield with fewer samples • Less traumatic • More acceptable to patients • Can reach lesions VAB cannot