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Using ultrasound to assist the treatment of femoropopliteal CTO
S28
Ultrasound in Medicine & Biology
atherectomy, including assessment of the effectiveness of plaque removal and identification of vessel wall damage. IVUS imaging is simple, quick and safe to use during endovascular interventions and can provide unique information that can supplement standard angiographic imaging and help optimise treatments. Using ultrasound to assist the treatment of femoropopliteal CTO Richard Allan Senior Vascular Sonographer, Flinders Medical Centre, Bedford Park, SA, Australia Chronic total occlusions (CTO) represent some of the most difficult lesions to treat with endovascular techniques. Crossing the occlusion is a critical step because successful crossing of the lesion must be achieved before treatment can be initiated. Sub-intimal crossing has been a mainstay of endovascular techniques but limits the treatment options available to the interventionist. Luminal crossing is more challenging but provides an opportunity to use adjunctive techniques such as atherectomy that may improve the effectiveness of angioplasty. Conventional imaging methods, such as duplex ultrasound and CTA, have significant limitations for assessing these lesions prior to treatment. In particular the interventionist has no information regarding the presence of vascular micro-channels within these lesions that may provide a path through the occluded lumen and so allow successful luminal crossing. Imaging of micro-channels within CTO has been demonstrated in animals but there are currently no non-invasive means of identifying these structures in humans. In an observational study, we have performed contrast-enhanced ultrasound (CEUS) on 37 patients with femoropopliteal CTO and identified micro-channels in 34 cases (92%). Most micro-channels had a linear configuration and this was associated with a higher rate of complete or partial luminal crossing compared with mixed or tortuous configurations. Identification of micro-channels with CTOs may be useful for planning of the optimal crossing method. We have also investigated the use of conventional ultrasound to directly guide a specialized crossing device through CTOs. Guidance of attempted luminal crossing is currently performed using angiography however this imaging is unable to image the occluded section, limiting ability to guide the crossing wire or device through the lesion. Crossing of CTO using a specialized crossing device was attempted in 56 cases, with ultrasound guidance used in 31 cases and angiographic guidance in 25 cases. There was a significantly higher rate of partial or complete luminal crossing when ultrasound guidance was used. This resulted in a higher rate of atherectomy and a lower rate of secondary stenting compared to angiographic guidance. This experience suggests that ultrasound may have a role in the treatment of CTO both by providing information about the nature of the CTO prior to treatment and by improving the rate of luminal crossing.
SESSION 6D: BREAST Ethnicity and characteristics of triple negative breast cancer (TNBC) Sudhir Vinayak Chair, Radiology Department, AGA Khan University Hospital, Nairobi, Kenya, Africia Studies of the prevalence of hormone receptor status; ER/PR/ HER2 in breast cancer from Sub Saharan Africa (SSA) are fraught with inconsistencies. There are multitude of reasons for these inconsistencies but the most prominent are inadequate breast biopsy material, small sample sizes, poor histopathology services and suboptimal handling of specimens. As an example, ER/PR/HER2 receptors for breast cancers are not part of the routine assessment for breast cancer
Volume 45, Number S1, 2019 and testing is only available in a couple of centers across the entire country. Variability in Radiology, Surgery and laboratory methodology and interpretation makes comparison between data difficult. Available data shows a huge variability in the prevalence of TNBC within the sub-Saharan region. This is due to these factors and almost all suggest a much higher incidence of TNBC compared to the West. Core biopsy as a diagnostic tool is only available in academic or subspecialty hospital settings. Most diagnoses are based on tissue obtained by Fine Needle Aspiration (FNA). Given these constraints, making comparison between breast cancer data from the developed and developing world should be interpreted with caution. As part of a larger funded study investigating the prevalence of Triple Negative Breast Cancer (TNBC) in Kenya, we organized a multidisciplinary workshop for participants from ten provincial health care facilities, all of whom are involved in providing breast cancer care. We sought to provide an overview of TNBC and importance of appropriate tissue collection and handling, identifying gaps in diagnostic processes, suggested remedial strategies and provided hands on training. We describe our experience, impact and outcome of this workshop. Our aim was to accurately determine the histologic type and prevalence of ER/PR/HER2 using standardized methodology of ultrasound guided core biopsies. During the workshop, we trained Physicians how to perform core biopsies, thereafter store and transport biopsy samples. Results: A total of 301 cases of breast cancer were included in the study. Invasive ductal carcinoma (NOS) was the most common histologic type (84.2%). ER positivity was seen in 72.8%, PR in 64.8% and HER2 in 17.6% of all cases. Triple negative breast cancers (TNBC) constituted 20.2 % of the cases. There was a significant association between receptor status and histologic grade (p<0.001) and statistically significant trend of increasing pathological stage of tumor (pT) associated with TNBC (p=0.020). Conclusions: We present a definitive prospective analysis of IHC data from a single center and demonstrate that prevalence of ER/PR/ HER2 receptor status from SSA is comparable with that in the West, which contradicts previous reports. Breast imaging in difficult women Merran McKessar Mater Imaging, Sydney, NSW, Australia Breast imaging can be hard to get right. You can take a beautiful set of images at 2,4,6,8,10 and 12 o’clock in both breasts, documenting normal tissue, and miss the cancer completely. You can simply “miss” the cancer in your survey, or perhaps misinterpret scanned tissue. Breast imaging is operator dependent, and you are the operator. Your ability to provide accurate assessment depends on knowing what you are looking for, your ability to interpret normal from abnormal, and documenting that information accurately. Performing breast ultrasound requires knowledge of anatomy, an understanding of the wide range of normal appearance, and the spectrum of benign, atypical, suspicious and malignant findings superimposed upon this wide range of normal. What can make breast ultrasound difficult includes patient factors such as age, mobility, breast size and density, and history prior surgery or treatment. Lack of information regarding these factors, and even patient demeanour, may also cause difficulty. The reason for breast examination is paramount: Is this a diagnostic examination or a screening study? Is there a history of prior benign, atypical or malignant pathology? Is there an MRI or mammography finding requiring correlation? Is there a clinical lump or symptom that is causing concern? Is the referring doctor’s clinical concern the thing that is worrying this woman?
Ultrasound in Medicine & Biology
atherectomy, including assessment of the effectiveness of plaque removal and identification of vessel wall damage. IVUS imaging is simple, quick and safe to use during endovascular interventions and can provide unique information that can supplement standard angiographic imaging and help optimise treatments. Using ultrasound to assist the treatment of femoropopliteal CTO Richard Allan Senior Vascular Sonographer, Flinders Medical Centre, Bedford Park, SA, Australia Chronic total occlusions (CTO) represent some of the most difficult lesions to treat with endovascular techniques. Crossing the occlusion is a critical step because successful crossing of the lesion must be achieved before treatment can be initiated. Sub-intimal crossing has been a mainstay of endovascular techniques but limits the treatment options available to the interventionist. Luminal crossing is more challenging but provides an opportunity to use adjunctive techniques such as atherectomy that may improve the effectiveness of angioplasty. Conventional imaging methods, such as duplex ultrasound and CTA, have significant limitations for assessing these lesions prior to treatment. In particular the interventionist has no information regarding the presence of vascular micro-channels within these lesions that may provide a path through the occluded lumen and so allow successful luminal crossing. Imaging of micro-channels within CTO has been demonstrated in animals but there are currently no non-invasive means of identifying these structures in humans. In an observational study, we have performed contrast-enhanced ultrasound (CEUS) on 37 patients with femoropopliteal CTO and identified micro-channels in 34 cases (92%). Most micro-channels had a linear configuration and this was associated with a higher rate of complete or partial luminal crossing compared with mixed or tortuous configurations. Identification of micro-channels with CTOs may be useful for planning of the optimal crossing method. We have also investigated the use of conventional ultrasound to directly guide a specialized crossing device through CTOs. Guidance of attempted luminal crossing is currently performed using angiography however this imaging is unable to image the occluded section, limiting ability to guide the crossing wire or device through the lesion. Crossing of CTO using a specialized crossing device was attempted in 56 cases, with ultrasound guidance used in 31 cases and angiographic guidance in 25 cases. There was a significantly higher rate of partial or complete luminal crossing when ultrasound guidance was used. This resulted in a higher rate of atherectomy and a lower rate of secondary stenting compared to angiographic guidance. This experience suggests that ultrasound may have a role in the treatment of CTO both by providing information about the nature of the CTO prior to treatment and by improving the rate of luminal crossing.
SESSION 6D: BREAST Ethnicity and characteristics of triple negative breast cancer (TNBC) Sudhir Vinayak Chair, Radiology Department, AGA Khan University Hospital, Nairobi, Kenya, Africia Studies of the prevalence of hormone receptor status; ER/PR/ HER2 in breast cancer from Sub Saharan Africa (SSA) are fraught with inconsistencies. There are multitude of reasons for these inconsistencies but the most prominent are inadequate breast biopsy material, small sample sizes, poor histopathology services and suboptimal handling of specimens. As an example, ER/PR/HER2 receptors for breast cancers are not part of the routine assessment for breast cancer
Volume 45, Number S1, 2019 and testing is only available in a couple of centers across the entire country. Variability in Radiology, Surgery and laboratory methodology and interpretation makes comparison between data difficult. Available data shows a huge variability in the prevalence of TNBC within the sub-Saharan region. This is due to these factors and almost all suggest a much higher incidence of TNBC compared to the West. Core biopsy as a diagnostic tool is only available in academic or subspecialty hospital settings. Most diagnoses are based on tissue obtained by Fine Needle Aspiration (FNA). Given these constraints, making comparison between breast cancer data from the developed and developing world should be interpreted with caution. As part of a larger funded study investigating the prevalence of Triple Negative Breast Cancer (TNBC) in Kenya, we organized a multidisciplinary workshop for participants from ten provincial health care facilities, all of whom are involved in providing breast cancer care. We sought to provide an overview of TNBC and importance of appropriate tissue collection and handling, identifying gaps in diagnostic processes, suggested remedial strategies and provided hands on training. We describe our experience, impact and outcome of this workshop. Our aim was to accurately determine the histologic type and prevalence of ER/PR/HER2 using standardized methodology of ultrasound guided core biopsies. During the workshop, we trained Physicians how to perform core biopsies, thereafter store and transport biopsy samples. Results: A total of 301 cases of breast cancer were included in the study. Invasive ductal carcinoma (NOS) was the most common histologic type (84.2%). ER positivity was seen in 72.8%, PR in 64.8% and HER2 in 17.6% of all cases. Triple negative breast cancers (TNBC) constituted 20.2 % of the cases. There was a significant association between receptor status and histologic grade (p<0.001) and statistically significant trend of increasing pathological stage of tumor (pT) associated with TNBC (p=0.020). Conclusions: We present a definitive prospective analysis of IHC data from a single center and demonstrate that prevalence of ER/PR/ HER2 receptor status from SSA is comparable with that in the West, which contradicts previous reports. Breast imaging in difficult women Merran McKessar Mater Imaging, Sydney, NSW, Australia Breast imaging can be hard to get right. You can take a beautiful set of images at 2,4,6,8,10 and 12 o’clock in both breasts, documenting normal tissue, and miss the cancer completely. You can simply “miss” the cancer in your survey, or perhaps misinterpret scanned tissue. Breast imaging is operator dependent, and you are the operator. Your ability to provide accurate assessment depends on knowing what you are looking for, your ability to interpret normal from abnormal, and documenting that information accurately. Performing breast ultrasound requires knowledge of anatomy, an understanding of the wide range of normal appearance, and the spectrum of benign, atypical, suspicious and malignant findings superimposed upon this wide range of normal. What can make breast ultrasound difficult includes patient factors such as age, mobility, breast size and density, and history prior surgery or treatment. Lack of information regarding these factors, and even patient demeanour, may also cause difficulty. The reason for breast examination is paramount: Is this a diagnostic examination or a screening study? Is there a history of prior benign, atypical or malignant pathology? Is there an MRI or mammography finding requiring correlation? Is there a clinical lump or symptom that is causing concern? Is the referring doctor’s clinical concern the thing that is worrying this woman?