Echo-histological “acino-ductal analysis”. Preliminary results

Ultrasound in Med. & Biol. Vol. 14, Sup. i, pp. 89-95, 1988 Printed in the U.S.A.

ECHO-HISTOLOGICAL

"ACINO-DUCTAL

Michel

Centre

de

Radiologie,

95 rue

ANALYSIS".

TEBOUL,

de

0301-5629/88 $3.00 + .00 (c) 1988 Pergamon Press plc

Preliminary

results.

M.D.

Courcelies,

75

017

PARIS,

France.

ABSTRACT : Echo-histological "ACINO-DUCTAL ANALYSIS" allows a display of lesions based on anatomo-physio-pathology, their micro-sampling for inistologica! evaluation by interventionnal echography, and their direct visual observation by intra-ductaI echo-guided endoscopy. This combination complements other means of i n v e s t i g a t i o n a n d s h o w s an u n e q u a l e d p o w e r (if diagr~c~sis by using the two most efficient means of diagnosis for ~aiignancies : detection of cellular abnmormalities and observance of evolutioz~ o v e r t i m e . YEY WORDS : Breast Breast echo-guided

ultrasound. Echo-Histological "ACINO-DUCTAL punctures and biopsies. Breast intra-ductal

ANALYSIS". endoscopy.

akimbo during examination of upper lobes, and arms raised with hands over head for examination of l o w e r lobes. We began examinations by observing the ductai system of a lobe, from the nipple to the extremity of the lobe. Then we observed the next ductal systems and so on, by rotating around the nipple. In that way, we have been able to identify intra-lobar ductal divisions, lateral and terminal branchings, and lobules. Additionally we could study the surrounding connective tissue. Therefore, we have been able to observe the ductal and lobular distribution in the lobes, and consequently to study the epithlial tissue inside the breast. This innovation gave us a highly efficient means of a n a l y s i s of t h e b r e a s t . A s there is a correspondence between waterpath and real time signs, we made an easy transposition from waterpath symptomatologySo, w i t h i n a few months, the "ACINO-DUCTAL A N A L Y S I S "a l l o w e d us t o : I. Differentiate the areas of epithelial tissue (hypo-echogenic) from the areas of connective t i s s u e (more e c h o g e n i c ) . 2. Recognize the ductal and lobular structures inside the lobes, 3. Identify normal aspects and some variations, 4. Detect epithelial alterations down to millimetre dimensions, 5. Observe associated connective modifications, 6. Visualize aspects of different

ACINO-DUCTAL ANALYSIS is a mixed echographic and histological method r~; e v a l u a t i o n of mamary epithelium which allows possible observation of epithelial tissue, estimation of a d jacent connective tissue, recognitior~ of a b n o r m a l i t i e s and assessment oT their histological nature. The elm of this a p p r o a c h is t h e o b s e r ration of t h e i n t r a - l o b a r e p i t h e l i a l ~borization and of the adjacent connective tissue. For that purpose, we u s e d an O C T O S O N 4 . 5 M H z d e v e l o p e d by K o s s o f f a n d al. ( A U S O N I C S ) , a n d a T O S H I B A 100, 7 . 5 MHz. (Ref 1 t o 9). For waterpath sonography, patients were lying in prone position with the breast floating freely in t h e water. We performed rotational scans around the n i p p l e in o r d e r t o i m a g e ducts and lobes. However, poor resolution and the non-rectilinear c:ourse of the ducts made this study inacurate, For real time examinations, we used the 7.5 MHz linear array probe, 6,5 cm l o n g , 525 cm s c a n n i n g f i e l d , with a "SONAR-AID" p l a s t i c o f f s e t . Ducts and lobules were reasonably discernable. The contact of the linear probe improved t h e i r d i s p l a y by straightening, more o r l e s s , t h e course of the ducts which became observable for practically the complete length of the probe. When ducts overlaped or were deviated, they could be followed dynamically and individually. During examinations, patients were examined in upright position for an easier rotation of the body, with arms

89

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diseases of t h e b r e a s t : D y s p l a s i a s , Hyperplasias (fig. 1), benign neoplasms (papillomas, fig. 2), malignant neoplasms (ductal and ] o b u l a r , fig. 3 & 4). ?. Display a graphic representation of lesions based on t h e i r a n a t o m o physio-pathology.

The p o t e n t i a l o f e c h o g r a p h i c a l l y discerning epithelial tissue indicates the possibility of its spatial localization. (ref.lO-11). We h a v e used t h i s p r o p e r t y t o g u i d e micro-samplings for histological evaluation. We systematically recommanded e c h o - g u i d e d p u n c t u r e s i n detected a b n o r m a l i t i e s . With t h e 0 . 6 millimeter axial resolution of the real-time ( s p e c i f i e d by t h e m a n u f a c turer), echo-guiding became more a c c u r a t e and e a s i e r w i t h a TV s c r e e n X 3 magnification (pictures were also magnified X 1.33y second h a l f 1987). Under v i d e o c o n t r o l , we were able to sample c e l l s from inside pathological ducts and groups of lobules. We used 0.9 x 50 mm needles for superficial lesions, 1.2 x 70 mm o r 1 . 4 x i 0 0 mm n e e d l e s for deeper l e s i o n s , 10 cc s y r i n g e s , and a Cameco P i s t o l held by the right hand, the left hand holding the probe on the skin. For intra-ductal samplings, the p r o b e was d i r e c t e d on t h e c o u r s e o f the duct, with the nipple on one side and the l e s i o n u n d e r and n e a r the other side. Punctures were performed at 1 to 2 cm o f the peripheral side of t h e p r o b e . Then the n e e d l e was directed toward the lesion in the s c a n n i n g p l a n e . When the needle tip reached the dilated duct, the drive was modified to follow the course of the duct while a s p i r a t i o n was c a r r i e d o u t . For samplings in larger lesions, we used split screens displaying M mode and real time. The probe was set transversally slightly tilted towards the h e a d w i t h t h e l e s i o n in the middle of the field. Punctures were performed perpendicularly to the p r o b e in c r a n i o - c a u d a l direction When reaching the scanning plane, the needle tip produced an echo displayed as a white line on M mode screen and as a w h i t e s p o t in r e a l time. The needle position was easily a d j u s t e d b y u s e of t h e t a r g e t l i n e . This echo-histological combination proved so r e l i a b l e t h a t we made i t a mixed, single entity : t h e "ACINO DUCTAL ANALYSIS". The d i r e c t a c c e s s to histological i n f o r m a t i o n s g a v e an u n e q u a l l e d power of diagnosis for "ACINO-DUCTAL ANALYSIS", resolving ambiguities and eliminating false positives as biopsies are performed only if/when malignant cells are found or evolution is observed.

Examination of the Breast

T h i s method a l s o complements o t h e r means o f investigation by finding alterations otherwise undetected (hyperplasias, ductal ectasias, micro and gross cystic disease, papillomas, primary malignancies, recurrences); resolving equivocal densities (hyperplasia vs f i b r o s i s ) and equivocal micro-calcifications (adenoslerosis v.s. malignancy); confirming specific aspects; and assisting the surgeon with an adequate operative strategy, by evaluating e x t e n s i o n o f c a n c e r s more c o m p l e t e l y t h a n mammography. This method opens a new f i e l d of intra-epithelial interventionnal echography, e.g. ductal endoscopy (color fig. 7 & 8 : lesions observed by e n d o s c o p i e s p e r f o r m e d t h e 18th o f sept 1987, same t e c h n i q u e as i n t r a ductal sampling, using an Olympus Selfoscope 1717 K), eventually micro-biopsy and removal of intraductal papillomas by analogy with polyps in the colon. Dubious, u n r e s o l v e d cases a r e r e c h e c k e d 4 months l a t e r f o r image comparision and an additional echo-guided puncture. Hence t h e two most important means o f e v a l u a t i o n of malignancies are carried out, namely, detection of cellular abnormalities and o b s e r v a n c e o f an evolution over time. T h i s method i s n o t v e r y t r a u m a t i c and it s h o u l d improve w i t h advances in electronics and micro-surgery equipments. Despite a non-sufficient number o f cases, a f t e r one y e a r o f t e s t i n g , we feel that "Analytic Echography": shows the ability to analyze clinical masses, allows a good maping o f complex pathologies non-analyzable in detail by mammography, indicates a much h i g h e r f r e q u e n c y of papillomas i n o u r s e r i e s (19 f o r 53 Carcinomas i n 1987 = 35 %) t h a n reported by HAAGENSEN (160 for 1669 cancers in 2 5 y e a r s = 9 %) ( r e f . 1 2 ) , displays with reliability small radio-visible spiculated and knobby carcinomas, shows the dual involvment of t h e epithelium ( h y p o - e c h o g e n i c ) and t h e connective tissue (hyper-echogenic) in early cancers, (ref.13), displays 2 patterns of cancers n o n - d i a g n o s a b l e by mammography (no sign or only indeterminate fainted density) : intra-epithelial or mini-invasive primary m a l i g n a n c i e s and r e c u r r e n c e s (ref.14), as h y p o - e c h o g e n i c d e f o r m e d "ducto-lobular" patterns (fig. 5) that were v i s u a l i z e d o n l y on scans performed in acino-ductal axes, i.e. o n l y by A n a l y t i c E c h o g r a p h y , recurrences, as "bushy" diffuse hypo-echogenic patterns (fig. 6). -

-

-

5th International

Table :n :

of

No

:

number

patients: 1987

:

961

: :

ratio Carcinomas

Table .

1

.

: : :

.

.

.

No 2 .

.

.

.

.

.

number of punctures 145

.

lesions

:: ::

Papillomas

: :

:

53

::

19

:

(5.5

100

.

.

.

.

.

%)

and .

.

.

.

:

6

Dg w i t h o u t : punctures :

22

35

results .

.

.

.

.

.

.

of .

.

.

.

%)

78

.

.

o

.

.

.

.

.

.

.

.

. .

.

: : 7 : ......... : : 3

::

: ........

: :

31

: . . . . . . . . . .

::

. . . . . . . . .

:

:

::

47

17

.

.

.

26

(2.3

: :

%

: :

%)

49

:

: :

%

:

.

(2)(4)2 Papill. : :

: : 4 : ........ : : 2

. . . . . . . . .

.

Fibroadenomas

:

punctures

.

:: :: 6 :: ......... :: :: 10 :: ::

: :

(8.1%)

147

echo-guided .

91

: Gross Cysts

: :

%

(2((3): (2)(3): Hyper: ductal : plasias :ectasia :

: . . . . . . . . . . .

53

(1.9

:: ::

%

: . . . . . . . . . .

total

detected

Carcinomas

: 25 : ..........

: . . . . . . . . . . .

of

Examination of the Breast

:

number .

nature

: (1):: :Carcinomas:: : ::

: successful: : 124 : ........... :no material: : 21 : :

and

: :

: .

Congress on the Ultrasonic

.

.

.

.

.

.

.

(5): Gross : Cysts :

.

.

.

.

.

.

..

.

.

.

(6): fibroadenomas

: :

: : 62 : ....... : : 1

: : 19 : .......... : : 4

: : : : :

: . . . . . . . . .

: .......

: . . . . . . . . . .

:

: :

: :

: :

: :

9

15

3

: ........

: . . . . . . . . .

: .......

: . . . . . . . . . .

:

:

:

:

:

:

23

19

78

26

(1) : Punctures always recommanded systematically if any doubt, and performed if accepted by patient or no surgical biopsy already decided. (2) : Punctures recommanded systematically only during the ~irst months to assess diagnosis and recognize different aspects; not performed anymore if simple benign aspects. (3) : Material withdrawn was o f t e n poor. ( 4 ) : same a s ( 2 ) . Papillomas were with adeno-scleroses the main causes of false-positives in waterpath sonography. Punctures are not performed anymore for isolated simple papillomas which are well discriminated from carcinomas by Analytic Echography. Punctures are still recommanded for multiple and papillary shaped papillomatoses, specially if surrounded by hyper-echogenic connective tissue : two mini-invasive papillary carcinomas were diagnosed that way. (5) : Plus 48 cases of micro-cystic disease. Punctures recommanded only for centimetric cysts or associated micro-calcification. (6) : including 1 cysto-sarcoma phyllodes.

Table .

.

.

.

.

No 3 .

.

.

.

.

: .

.

Patterns .

.

.

.

.

.

.

.

of .

.

=

cancers .

=

.

.

~

=

:

total

:

:

53

:

23

(42

%)

:

21

(39

%)

: :

(

%)

: :

primary 38 (71%)

: :

:

recidives 15 ( 2 9 %)

:

:

:

mammography

:

:

:

+

=

28

(52%)

:

:

?

=

14

(26%)

:

:

-

=

11

(21%)

:

stellate

.

: .

.

:

.

..

.

.

.

=

4

:

4

=

=

=

=

=

=

=

=

=

=

=

=

17

(32

%)

:

8

(13

11

(20

%)

: :

&

(11%)

ducto-lobular

2

(

%)

: 6

(11%)

radio-visible 19

=

:

: 2

=

knobby

:

:

=

=

=

=

=

=

=

=

=

=

:Bushy :

5

=

=

=

(

7

%)

: :

not

%)

:

=

=

=

=

: :

:

: 4

=

diffuse

: 5

(

radio-visible

%)

:

:

:

9

:

:

7

:

2

:

1

:

:

1

:

6

:

4

:

Analytic echography dysplays radio-visible malignancies. histologically as intra-epithelial

:

9

:

non radio-visible benign lesions and non Ducto-lobular malignancies were estimated (intraductal) or mini-invasive.

=

=

=

92

5th International Congress on the Ultrasonic Examination of the Breast

:ucts

Two conglomerates of Iobules Figure 1.

Lobular Hyperplasia.

Sketch i.

Papillomas Figure 2.

Papilloma.

Sketch 2.

Skin flatening ~ Nipple' . ~..

• ...

,.

Ductal carcinoma.

Sketch

/,

-.r.Reparative fibrosis

Neoplasia Figure 3.

....

.~,$~i;~ / " ~ L L ~

<~~,.

3.

Col lagenosis .~..--- - ~ " ._.~

Neoplasia Figure 4.

Lobular carcinoma.

Sketch 4.

i ~~< .

=~ .~f~}.:..

5th International Congress on the Ultrasonic Examination of the Breast

Nipple ____

Neoplasia

Collagenos~s

Figure 5. Deformed ducto-Iobular shape of intra-ep~thellal carcinoma non diagnosable by mammography.

Sketch 5.

Neoplasia N ~

Axillar
Sketch 6.

~Scar

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5th International

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fig.

7

:

Endoscopic view of

an

fig.

8

:

Endoscopic view

a cyst

of

intr-a-ductal

seen

from

Examination

lesion

the

:

duct

:

of

the Breast

5th

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Examination

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Breast

95

Bibliography: 1 - KOSSOFF G., CARPENTER D.A., ROBINSON D.E., et al. (1976): Oct oson, a new rapid general purpose echoscope i__n_nUltrasound in Medicine, eds D.White, R.Barnes, New York, Plenum Press, 1976, vol.2, p.333. -

2 - HARPER A.P., KELLY-FRY E., NOE J.S., BIES J.R., and JACKSON V.P., sound in evaluation of breast solid masses, Radiology, 146: pp.731-736.

-

(1983):

Ultra-

- 3 - KELLY-FRY E. and HARPER P. (1983): Factors critical to highly accurate diagnoses of malignant breast pathologies by ultrasound imaging, in Ultrasound '82, eds R.A.Lerski and P.Morley, pp.415-421, Pergamon Press, Oxford. - 4 - JELLINS J., REEVE T.S. and KOSSOFF G. (1984): Breast by ultrasound, Clin. Diagn. Ultrasound, 12: pp.25-39.

pathology as demonstrated

- 5 - Z R T ~ - F R Y E. (1985): Influences on the development of ultrasound pulsed-echo breast: instrumentation in the U.S., in Ultrasound Mammography, ed P.Harper, pp.l-20, University Park Press, Baltimore. - 6 - McSWEII~IEY M.B. and MURPHY C.H. North Am., 23: pp.157-167.

(1985):

Whole-breast: sonography.

Radiol. Clin.

- 7 - TEBOUL M. (1985): The detection of small breast cancers, in Proc. 4th International Congress on the Ultrasonic Examination of the Breast, eds J.Jellins, G.Kossoff, J.Croll, pp.83-90, Witton Press, Pry. Ltd., Sydney, Australia. - 8 - BASSETT L.W., GOLD R.H., KIMME-SMITH C. eds (1986): Breast ultrasound, Slack, Inc. Thorofare, New Jersey.

Hand-held and automated

- 9 - DEMPSEY P.J. (1988): Breast sonography: Historical perspective, clinical application and image interpretation, in Ultrasound Quarterly, vol.6, no.l, pp.69-90, Raven Press, New York.

- I0 - KOPANS D.B., MEYER J.E., LINDFORS K.K., BUCCHANIERI S.S. (1984): Breast sonography to guide cyst aspiration and wire localization of occult lesions, AJR 1984: 143: pp.489492. - ii - HARPER P., (1985) "The Benefit of Needle Aspiration Biopsies Using Ultrasound Localization Techniques in the Diagnosis and Management of Breast Carcinomas", in Proc. 4th International Congress on the Ultrasonic Examination of the Breast:, eds J.Jellins, G.Kossoff, g.Croll, pp.83-90 Witton Press, Pry. Ltd., Sydney, Australia.

- 12 - HAAGENSEN C.D. (1971): Intra-ducta] ed W.B.Saunders Co., Philadelphia.

papilloma,

13 - GALLAGER S. and MARTIN J. (1969): Early phases cancer, Cancer 24: pp. I170-I178, Dec.1969. -

in Diseases of the Breast,

in the development

p.253,

of breast

- 14 - BARTH V. (1979) : The pre-Jnvasive stage of carcinoma of the breast: and the clinically occult: carcinoma, in Atlas of Diseases of the Breast, pp.83-85, G.Thieme publ., St uttgart.