US Guided Interventional Procedures

Introduction to Ultrasound-Guided Biopsy

I limited this talk somewhat.

I usually blather on for an hour about all the cool things we can do with ultrasound intervention, including cyst aspiration, abscess drainage, needle oaks, fiducial placements, all the various things we can do.

But I'm gonna limit this to just biopsy and talk about two main decisions that we have to make.

And then I'm gonna just say a little bit about technical mistakes that I see people make, but I'm not gonna get too much into the technique, but mostly I wanna talk about choosing the right method of guidance for a biopsy in the modality and device.

Types of Guidance and Instruments

So there are three types of guidance, stereo attacks, ultrasound, MRI guess if you have, molecular imaging, some of them allow you to do biopsies that way as well, but I don't have that.

And then three types of instruments, FNA core biopsy.

And there are two kinds. One stage and two stage fires.

And then vacuum assisted biopsy, which can be directional or 3, 360 degrees.

So basically just two main decisions that I want to talk about.

What's the best method of guidance for certain applications and what's the best instrument to use for alt sound guidance?

Indications for Image Guidance

Any sort of mass, whether it's solid or mixed cystic and solid intraductal poplar lesions, palpable lesions.

You might think that's paradoxical, but I mean, people miss lesions that are palpable because there's overlying fibrous tissue and they put the needle into the overlying fibrous tissue.

Even palpable lesions should be done with image guidance and most asymmetries, most architectural distortions, most MRI abnormalities and some calcifications.

So, it's a very long list and I'll give you reasons why we might do calcifications under all sound later.

Choosing Guidance Modality

I have it well illustrated, but there won't be time to show all the illustrations of why stereo guidance, of course for cation occasionally as symmetry when there's no alt on correlator or occasional architectural distortion when there's no alts on correlate and MR guidance, whenever we can't find the lesion on second look alt sound.

But more importantly, if we see something and we're not a hundred percent sure it's the lesion, that we're seeing on mr, we should still do the biopsy under MR guidance.

So, it includes two categories.

We can't see it at all, or we see something, but we're not a hundred percent sure that's it.

There's no point in doing ultrasound biopsy and then finding out it's a different lesion and having to go do an MR biopsy as well.

Preference for Ultrasound Guidance

In general, we prefer ultrasound guidance whenever possible.

Why? It's faster, it's easier, it's cheaper, and it's truly real time.

I hate both stereo and Mr Biopsies.

When you fiddle with the, you look at the images and you fiddle with the needle and you go have to wait for five minutes and look at the pictures again.

You fiddle around some more and you go back and look at the pictures.

I mean, I don't like that. I like to do it in real time in three dimensions.

And that's ultrasound.

We can see complicating structures in real time.

So I can see if there's a big artery in the way that I might wanna, move out of the way with lidocaine or do a more limited biopsy to try to avoid it.

And we can see, complications in real time.

So if I'm developing a hematoma, I can put thrombin in or stop and do compression immediately 'cause I can see it happening in real time.

Whereas in the other modalities, I only found out after the fact that there's some complication occurring.

Applications of Ultrasound Guidance

So these are all the things we can do with alt sound.

And all I'm gonna talk about is biopsy and marker placement, post biopsy hematoma evacuation, and post biopsy pseudo aneurysm thrombosis.

Why do I care about that? Because I think if we wanna take something away from the surgeon, we need to put on our big boy and big girl pants and take care of our own problems.

If we cause a problem, don't call it, don't go cry into the surgeon to fix it for you.

Do it yourself. You could, you have the ability to do that.

So really I'm talking about the big two, the method of guidance and biopsy device.

And I'm talking about philosophy and I'm talking about a little bit about mistakes people make and about complications and how to handle them.

So truly real time, stereo and Mr are not get comfortable.

Technique for Ultrasound-Guided Biopsy

You know, I like to sit whenever possible.

Sometimes the lesion is positioned where I can't sit it, I'm tall enough, even on a left-sided lesion, I can just lean over the table.

But if you're shorter, you may have to go to the opposite side of the table and work from the left side for the left breast.

And it's occasionally for a real lateral lesion or a real inferior lesion, I might do that.

But generally I do everything from the right side, the right breast, I'll do sitting.

I may have to stand to do the left breast from the right side, but being tall, I can do that.

You need to adjust the room so that you're looking straight ahead.

So I have the, I have the monitor swung over the bed.

It's better if you have a separate monitor hanging from the ceiling that you can look straight across at.

But I have the tech move the feet of the table around so that when I do the biopsy, I'm looking at the screen.

Nothing makes you more uncoordinated than doing this.

The minute you look over your shoulder, you're uncoordinated.

That is an uncoordinated position.

So take the time to set the room up.

So you're looking straight ahead.

I like an underhanded grip. Why?

It's not just preference.

When I do overhanded grip, I'm using very strong big muscles.

Yeah, they're strong, but they fatigue quickly and they're not very coordinated.

When I do it underhand, I'm using the fine muscles, which are incredibly coordinated and they, it doesn't get fatiguing.

I can hold the probe like this for hours and not get fatigued.

If I hold a probe like that, I'm dripping sweat on the patient because it's exhausting to hold your arms out like that.

Now I think that women with small hands and small wrists sometimes have to hold it overhand 'cause they just don't have the wrist strength to put it through fibrous tissue this way.

But us big guys with big wrists and strong arms, we can, we can put it in this way and do it that way.

So perhaps there's some physical differences between men and women that require you to do it overhand.

But an underhand grip is far more coordinated.

Little muscles are highly coordinated and they don't fatigue.

Big muscles are strong, but they fatigue quickly and they're not very coordinated.

Maintain the needle parallel to the axis of the transducer.

Optimize the angle of incidence between the beam and the needle by healing and towing the transducer using spatial compounding or trapezoid.

So you can pick up the needle earlier and use hydro dissection to create workspace when you need it.

And don't look at the beam till the needle's far or don't look at the screen till the needle's far enough to be in the beam.

Common Technical Mistakes

The biggest mistake I see people make is they get out of parallel the needle's this way, and the probe is this way because they're looking at the screen too early.

Watch your hands till the needle is far enough to be into the beam and then look up.

And once you're in the, once you're in the beam, you're gonna stay in the beam.

But it's hard to get in the beam if you start outta the beam.

So I don't like the short angle approach.

Obviously with the coops, you're firing at the chest wall, but you don't see the needle the whole way.

And it, it's just a silly way to do it.

I mean, I know Laslow does his cy aspirations that way, but I, I think it's a bad way.

Don't do it. Go along the long axis.

And you want to sort of heal and toe your probe to create a better angle of incident.

You wanna be as close to 90 degrees to the needle as possible.

Spatial compounding is an electronic form of healing and towing the probe.

So spatial compounding will help you see the needle better.

Trapezoid, or virtual convex or whatever the manufacturer happens to call its version of trapezoid, will let you pick up the needle about a centimeter earlier.

So you get it in the beam quicker.

You can get it on course quicker. And this is what you want.

You want to be in the, in the, in the beam from the end and from the top of the probe.

You wanna be centered on the probe.

This is what I see most often when I do hands-on.

People get out a plane very, very quickly.

And the best way to do that is to look over your shoulder.

The minute you do that, you're gonna be out a plane.

You can't coordinate yourself looking like this.

Get yourself turned like this so you can stay on plane.

There are some people who actually do better when they go along the long axis to the probe.

And so if you're better that way, I'm not gonna criticize you.

You know how you do it best, but what you do is you wanna stay in the plane the whole way.

So I'm saying when the needle's not in the beam yet, don't look at the screen, watch your hands and make sure that the probe stays parallel.

Don't even look at the screen till you estimate that the needle is far enough in that the tip of it is within the alt beam.

Then as soon as it's in the ultrasound beam, don't look back at your hands anymore.

Then you just watch on the screen.

So probably the biggest mistake I see people make is they look at the screen before the needle's in the beam and then they never get in the beam.

And then they're going, I can't see the needle.

They look like a jittery baby who needs magnesium.

That's not what you wanna do.

If you can't see it, just stop and then work from there.

So you don't move both things at once.

My preference is if I see the needle and I don't see the lesion, or if I see the lesion and I don't see the needle, I go out and I find the tip of the needle and I find out which way I'm off.

Then I slide my transducer back to where it goes through the skin.

So I want my transducer lined up between the lesion and the skin puncture site, and then I rock my needle back online and I may have to, to pull it back a little if I'm in too far.

And then I, I advance.

So I only move one thing at a time and I prefer to move the transducer first.

Find, line it up with the entry point and the lesion and then move my needle back online after that.

If it's in fatty tissue, usually it can just bend it right back online.

If it's in fibrous tissue, you may have to pull it back and redirect it to get it back online.

'cause the fibrous tissue's too firm.

Another mistake I see people make is they dig in the end of the probe near the needle puncture site.

And that creates a terrible angle of incidents.

It's almost zero degrees and everything in imaging should be done at 90 degrees.

So you wanna dig in the opposite end of the probe.

You wanna dig in the end away from the needle, to create a better angle of incident.

And then you can also pry the hub of the needle down.

But you want to create as close to a 90 degree angle of incident.

You don't have to necessarily, you don't have to come in way over here at 90 degrees and go through more breast tissue, but you can manipulate the needle to create, you can manipulate both the probe and the needle to create a better angle of incident so you see the needle better.

Role of FNA in Breast Biopsy

Is there a role for FNA in the breast?

Now, I would say generally no.

The possible exception is absolutely limb loads.

And I wouldn't, I wouldn't make any other, exceptions.

I don't see any reason to do FNA in the breast.

Yeah, you might have a great cytopathologist, but you're still gonna have too high an insufficient rate compared to core biopsy.

And you can't tell invasion from DCIS.

You may see there's malignant cells, but you don't know whether it's invasive or not.

It just doesn't make any sense in this day and age in the United States to do FNA, for, for breast lesions, for lymph nodes, for to see if they're positive.

I think it's okay, but I wouldn't use it on a breast lesion.

Core Biopsy Devices

Large core devices, there's two stage fire devices where they both fire at once and there's one stage fire devices or where they, two stage fires, one at a time.

You can pre redeploy the inters stylet and then just fire only the outer needle.

And I like that for really critical positioning.

I like it in the axi because I wanna know where the tip is gonna wind up.

And if I do that in the axi, I don't have to worry about going too high up and hitting the axillary artery or anything.

And for very superficial lesions, when I don't want to get skin with a vacuum biopsy, I'll go with a, a core device where I can pre re-deploy the aperture.

And if there's a big artery, say right next to the lesion, I can pre-position my aperture so I can see that I'm not gonna get the artery, and avoid the hematoma that way.

The one stage fire device I use most of the time when I'm doing a core, they just fire the inner and outer aperture so fast that it seems it's really two stages, but it seems like one you don't really preposition the aperture.

The, the lesions where I can pre redeploy the inner, stylet and then fire only the outer cannula include the achieve the teal, the hologic soro and the in red.

And I, I've used the Teo, I don't like that one very much.

The achieve has a problem in that the grips are on the top and bottom instead of the sides.

So for the axilla, when you wanna get really flat, sometimes that thumb handle hits on the chest wall.

The n rat is pretty nice. I like that one.

And the Hologic Soros nice, but it's big.

It's 12 gauge and many times for an ary lymph node, 18 is all I need.

So, probably what I use the most often is the achieve, but the, the thumb and finger holders are kind of mispositioned there.

I don't use an introducer sheath, but if you like it, fine, I'll tell you why I don't like it.

Now the important thing to remember about the core biopsy device is you, most of you probably think that the inners stylet with the can with the, aperture comes straight out through the lesion.

It doesn't, it is intentionally designed to have this bevel drive it away from the bevel.

Usually you've got the aperture up so you can see the aperture, and so it, it dives down and then as the outer sheath comes over, so it dives down and as the outer sheath comes over, it pulls it back up and that's how it traps tissue.

And this is the reason on small rock hard lesions like six millimeter grade one IDCs, I don't care how good you are, you're gonna miss the lesion.

That bevels gonna hit the lesion and bounce off.

And there's a 6% false negative rate with core biopsy and lesions under 10 millimeters, especially rock hard grade one and grade twos because that's the way the device is designed to work.

In fact, there have been technical articles in the yellow and gray journal showing that if you bend this, if you put it out and bend it more, you get better specimens.

So that's how it works. It dives and then the outer cannula pulls it back up and that's how it traps tissue.

So it's not a matter that you're not coordinated.

I know everybody thinks they never miss, but people miss because that's how the core device is designed to capture tissue.

It's designed to dive and that bevel will hit a rock hard six millimeter cancer.

It'll bounce off it and go deep every time.

Well the other reason, the other mistake I see people make is they'll take multiple shots right through the center of the lesion.

You want to canvas the lesion.

So I might take my first one through the center lesion, but then I'll intentionally move up to 12 and over to nine and over to six and over to three.

I don't always get five specimens.

Sometimes I'll get three or four. Depends on good.

My specimens are if they're good sinkers or not.

But you don't want to go back through the center.

And this is the reason I don't like the outer cannula.

In a fatty breast, you can use an outer cannula and probably still canvas the lesion.

But when you're putting an outer cannula through fibrous tissue, you're just going back through the center every time.

And whenever I've done that, I just get mush on the second and third and fourth biopsies.

I mean my first specimen's, all I get really the rest is just mush.

'cause it keeps driving the needle back into the center of the lesion.

And you wanna canvas the whole lesion.

So this is how it works.

You fire out and then the thing dives and then the outer candidate comes and traps tissue and you take it off or it automatically accumulates it and you deploy your marker.

This is just a real time of a two, two, a one stage fire where it's firing both things at once.

And this is a marker of deployment.

We, we put a marker in absolutely everything.

I'm not gonna say too much about the markers 'cause I'm trying to keep this down to 30 minutes, but we mark everything under the new ECMS regulations that's gonna be bundled and we're not gonna get specific reimbursement.

Is that gonna affect whether I use marker?

I hope not, but it may not be my choice.

Some two bit bureaucrat may tell me I can't use markers anymore, but I mark everything, because it helps me read the screening mammograms and follow up years.

That's the main reason I like to mark benign lesions.

People do a lot of insurance and doctor shopping and sometimes it's not up to them.

It's, they get their work, insurance through work and the guy at work changes insurance every year.

If he can save 10 bucks with a different carrier and the the insurance company they get next year forces 'em to go somewhere else and then they went this year or vice versa.

So you get a lot of people where you don't have the previous mammograms, but if you see a cluster of calcs with a clip there, or if you see a, a solid nodule with a clip in it, you know it's already been biopsied and you just call it birads two on the mammogram and go on.

So it helps you read mammograms, clip and everything.

Vacuum Assisted Biopsy

Now for small lesions, that's where I don't really like the core device.

I really prefer vacuum.

Here's a lesion just under the skin and here we're just coring it with a regular pathy device.

Here's a lymph node and here I pre deployed the 18 gauge, achieve needle.

And so you can see here's the lymph node, here's my aperture shown by the arrows.

The tip of the needle is right here.

So I'm only firing the outer cannula.

So there's no question where my tip is gonna be after I fire.

It's gonna be exactly in that same position 'cause only the outer sheath is firing.

So here it is after I fire and there's my tip in exactly the same position.

So when you're, when safety is a concern, when you're up in the axilla and you don't want to get a nerve or an artery when you're, right near a big artery, that huge artery that comes outta the upper outer quadrant, or if you're right or near the nipple or under the skin, you want precise control.

Predeployment the aperture is a great thing to do.

And I always use it for all axillary nodes and I just go with a small needle only using 18 for axillary nodes.

That's always been sufficient.

Now, the vacuum assisted device, we have single sample multiple insertions.

That's where you put the needle in and you get a specimen.

You have to take the needle out to get the specimen out, then you have to put it in again and take it out.

To me. These devices are sort of disingenuous.

They were devised to get a vacuum charge for what's really a core device.

I don't like 'em. I think they were devised for the wrong reason.

They were devised to get better reimbursement for a procedure that's no better than a core biopsy.

The multiple sample, single insertion makes sense.

It's faster, it's more complete.

There's no targeting issues as long as you put it in right the first time.

You can get the whole lesion if you want.

And there are really only three devices that we use that, qualify for that.

And I use all of 'em.

At our previous site we had all three, then the administrator went to sole source.

So we only have one of them now.

But it wasn't our decision, it was an administrator decision.

I liked having all three. This is the single sample, multiple insertion one, it's non-directional.

So this one actually had a, radio frequency tip and that caused a lot of artifact in the tissue.

And the pathologist didn't like it.

I don't even know if this probe still exists.

We didn't use it very often.

Occasionally you would have a, a nodule that was so hard that the core needle would fire out and hit it, but it wouldn't penetrate it, it would just kick back the whole device.

And this was a good device for that.

You could just put it right through the center of the lesion 'cause of the radio frequency tip and then get a real big specimen that would, it came out in a roll, but you could just lay it out in a nice thin specimen.

So it was really nice. But about the only time I ever used it was those rock hard lesions when the, when I got recoil, with the core needle off it, what we used most of the time is directional vacuum assisted biopsy.

The typical way you position it is with the aperture below the lesion.

You don't target the center of the lesion.

You go underneath it. And I use this for solid masses.

A centimeter or less complex cysts.

We now call those complex mixed cysts and solid lesions.

Intraductal papillary lesions attempted a removal of large birads three lesions.

If a patient tells me I'm gonna have surgery if you don't take this out, I say, okay, I'll take it out.

So I let it up to the patient.

When I give her a choice, I say, this is birads three, you have two choices.

We can biopsy this or follow it.

Now I'm perfectly comfortable following it, but it'll have to be followed for two years.

If you choose biopsy, I'm happy to do that.

You just have to let me know. It's your decision.

I don't know whether you're gonna wake up at AM in cold sweat, but the second choice I give 'em is I can just biopsy this and we can leave it there.

Or I can try to take it all the way out.

I don't offer that for lesions over three centimeters, but up to three centimeters I'll offer them the choice of removal.

Most people with non palpable lumps are happy to just have it cord and diagnosed as benign, but people with palpable lesions are more likely to choose.

I want it out. And then of course any suspicious enhancement on second, that were looking, where we found a lesion in second ultrasound, obviously you don't wanna put the, the probe in on top with the aperture down 'cause who knows what you're gonna run into behind the lesion.

You can't see the lesion. It's wider than the beam so it obscures the lesion.

You don't know if there's an artery there, you're getting into the implant or the chest wall.

You really don't wanna do that.

And you get some of the same problems if you put it in the center.

It really needs to be deployed deep to the lesion with the aperture up.

And then you have precise control and you watch the aperture.

You can see the cutter, you can see the vacuum suck the lesion in.

You can see the cutter come across and you can monitor, the lesion as you biopsy and or decide to remove it.

So again, here are the DVAB devices, the mammotome, the Encore, and the AEC petite and also, the a AEC Eros or the Petite Eros.

And some, devices allow you to use half aperture.

The petite is a half aperture.

Instead of 20 millimeters it's 10.

But some of the devices would let you choose a smaller aperture.

And again, you might do that when there's a big artery next to a lesion or when it's a tiny lesion that you think you can get with a half aperture or a petite instead of an atec.

I do that for small papillo.

I might do it for small six millimeter lesions, I'll use a half aperture.

If something's close to the skin and I'm starting to get indentation from the skin from the vacuum.

There are two approaches you can, come in from the side instead of the bottom.

You can hydro dissect the skin away.

And the third choice is just to go to smaller aperture where it's less likely to in dent and biopsy the skin.

Here's a small lesion.

Here's the vacuum device under it.

You can see the aperture because you get ring down artifact off the vacuum hole.

So the aperture goes from here to here and there it's removed in a marker's place, but notice that the skin is indented.

So this is a problem when you're dealing real near the skin.

What I like to do in these cases is hydro dissect the lesion away from the skin, but I don't use epi there.

I use epi deep but superficial.

I'm gonna inject, lidocaine without epi.

And what I'm gonna do is put enough in there that I expand the space between the skin and the lesion.

And you already have to have your neck in the skin made and be ready to go because the probe pushes that anesthetic out pretty quickly.

But you can create space to work by hydro dissecting the skin away from the lesion.

The other thing you can do is you can just, instead of having the aperture underneath the lesion, you can come in from the side of the lesion and then it won't pull the skin down.

So you can work real near the skin, but you have to use a couple tricks, hydro dissection or come in from the side instead of the bottom.

Then if you're gonna monitor the removal, if you're gonna hydro dissect and you're still gonna come in, behind the lesion, deep to the lesion, you can monitor it in the long axis.

But if you're gonna come in the side of the lesion, you have to monitor it in short axis to the needle because the aperture is gonna be pulling things in from the side.

And you're only gonna be able to see that when you're transverse to the image to the, to the lesion and the needle.

Removing Large Lesions with Vacuum

Now if you're removing a big lesion, it really helps to have a big needle.

The nine gauge sounds big, but when I remove three centimeter fiber adenomas, I like the seven gauge.

The nine gauge sounds great, but it might be 40 specimens in 10 minutes to remove a two centimeter fiber adenoma with a nine gauge, with a seven gauge.

It might be 15 specimens and a minute or two.

So, people get scared by the big gauge, but it's actually more efficient.

I get less bleeding and it's less traumatic and faster to use a bigger needle for removal of fiber adenomas, you can remove pretty large lesions.

This one is 2.2 centimeters.

Here's the vacuum probe underneath it.

Now it's gone and there's just a marker in its place.

And you see there's no hematoma.

This is just a little saline lavage.

Here's a great big lesion. It's so big.

We had to do split screens.

This was in the days when we only had a three and a half centimeter transducer.

So this was, four centimeters, 4.1 centimeters in diameter.

But here we're removing it.

You can see the vacuum holes under the aperture and as we remove it, it's completely gone and there's no hematoma.

So here it is pre here it is post with the clip in its place.

You see there's no mass and no hematoma.

Again, the other view, here's the mass, it's gone.

There's a little clip in its place. There's no hematoma.

I frequently get bigger hematomas removing a five millimeter perrer papilloma than I do, removing a two and a half or three centimeter fiber adenoma.

Most of these fibro adenomas are quite hypovascular and it's pretty easy to take 'em out without getting any bleeding.

Now we talked about how I prefer vacuum for complex mixed system, solid lesions in intrad ductal papillary lesions.

And I showed you examples of that in those two talks.

So I'm not gonna dwell on that anymore. Why white?

Why might we use, vacuum for, ultrasound guided vacuum for, calcifications?

Well, ultrasound can show calc in some cases and we can use ultrasound guidance rather than stereo.

It's cheaper and quicker. Ultrasound biopsy may be possible when stereo can't because a stroke mark margin issues or it's near the chest wall or bleeding worry from a calcified artery that we see right next to the lesion on stereo.

There may be an invasive component that we see that's a a a mass with hard findings that we didn't see.

We may have only seen calcs on the mammogram 'cause there's dense tissue.

There may be noncalcified DSS components much more extensive than we could see on the mammogram.

That's typical for micro papillary DCIS.

We can see a whole quadrant involved with ultrasound, whereas the calcs may involve a tiny part.

There may be positive lymph nodes indicating there's an invasion.

We can look at the lymph nodes in those cases.

And we, with ultrasound and doppler, we can avoid the big hematomas.

Almost all the big hematomas we get these days, they happen after stereo biopsies.

It's pretty rare in this day and age when we really are careful to get a big hematoma after an ultrasound biopsy.

Second Look Ultrasound for MRI Findings

What about second look ultrasound?

Well, there's two categories where we biopsy things mass.

We can core the bigger lesions, DVAB, the smaller lesions.

And how big a vacuum we use depends on the size of the lesion For non mass enhancement, we always use DVV and we almost always go large.

But if it's a single linear ductile enhancement, we might use a smaller gauge.

But if we see a whole lobe involved with non mass enhancement, we're gonna go with the biggest gauge vacuum we got.

Here's a tiny little mass scene on Mr.

Rapid washout small lesion and al outside.

I can use a small gauge needle there.

Here's the vacuum device under the lesion aperture open lesion gone in a marker to place.

Here's a big previously biopsy, grade three IDC.

We see some na non mass enhancement with, plateau and a little bit of rapid wash out near the nipple.

The coronal reconstruction show it's at nine o'clock medial to a big cyst.

This is gonna look like an implant on ultrasound.

It's so big, it's gonna look like this.

Ductal enhancement is right next to, to a, an implant.

So when we do the alt sound, sure enough, here's the edge of the cyst.

It looks like the edge of an implant, but here's an angular beaded weird looking duct with micro cals in it.

That's the grade 3D CIS that causing the non mass enhancement.

We put our big vacuum probe in, suck it out, and we get grade three multicentric DCIS.

Now, I'm not gonna tell you we do as well with non mass enhancement as mass enhancement as we don't, but we find about 90% of the masses and we probably find about 60% of the non mass enhancement with alt sound.

So just realize you're better at masses than non masses.

But you can, you can do fairly well with second look alts on if you understand DCIS especially,

Hydrodissection for Workspace

there's a old say that neither a lender nor a borrower be, but we can borrow workspace by hydro dissecting.

So here's, here's a fiber adenoma sitting on, an implant.

One way you can do it is to pry. I don't like to do that.

I like to hydro dissect.

I put my anesthetic needle between the lesion and the chest wall or implant and I float the lesion up.

Like you float a ship out a dry dock.

So here's a fibro adenoma sitting on an implant.

I actually have some margin for error 'cause I can see this is a pectoralis muscle, so I'm not right on the implant.

I got pectoralis there as well.

It's always easier when you got a little pectoralis to protect you.

But here's the high anesthetic needle.

It's right in the sulcus between the lesion and the muscle.

And now I've injected all this lidocaine and I floated the lesion up and created this much workspace.

And as long as I've already made my skin neck and created my needle tract, I can get that vacuum needle in there real quick while I still have space.

Get it under the lesion, get my aperture precisely positioned, never turn the aperture down, always have it up and then I can remove the whole lesion.

No problem. The first bite gets most of it.

And then I can remove the whole thing and put my marker in.

Handling Complications

Now here's a case where we created a big hematoma after a stereo biopsy so I can, this patient really wanted something done.

So we just put in a big vacuum probe, vacuumed it out, boom, gone.

So we took care of our own complication from a stereo biopsy.

Here's a place where I made a mistake.

This was when I first started doing vacuum biopsies.

And it was a badge of courage for me to remove the whole lesion, which was stupid, but it's a, it was a birads four B lesion, big artery in front of it.

But I kind of forgot the arteries there.

I said, oh, let's just remove a whole lesion.

And I created this pseudo aneurysm, a classical pseudo aneurysm.

It was Friday afternoon and the surgeon, who's really a nice lady, was going to the mountains to ski.

It's Colorado after all.

And I first called her and she said, no, I'm going to the mountains.

Do I have to do it? And I said, you know what?

No, I've, I've thrombose a bunch of femoral pseudo aneurysms that the cardiologist created.

I'll just take care of it myself.

So here's the pseudo aneurysm real time.

Here's my 25 gauge needle with thrombin.

And I just put it in. I've started to inject about five seconds, about 10 seconds, about 15 seconds.

Then I look around, I've still got a little bit up here.

So I put the needle up there and I inject one last bit of thrombin.

Now it's completely thrombo.

Here it is 24 hours later, seven days after, and 2014 days after.

So, I don't make this mistake anymore.

I watch that artery and I stop short.

I, the badge of courage, of removing lesions is nuts, you know, I mean, if it's a fibro, I know I'm gonna be fairly aggressive, but I'm not gonna create a hemo on a fibro adenoma and cancer.

I gotta remember that my and my goal is diagnosis, not treatment.

So I don't have to remove the whole lesion, I just have to remove enough to make a diagnosis.

So, in the beginning you may think it's a great thing to remove everything all the time.

It's not necessary. And sometimes it's contraindicated like this.

Decision Criteria for Core vs. Vacuum Biopsy

So how do I decide whether I do core biopsy?

Well for lesions under one centimeter in maximum diameter, I always use vacuum,

for nodules greater than a centimeter.

I just core it in between. It's sort of grab bag.

I tend to do everything under 15 millimeters, but if you wanted to core things over 10, it's fine.

There's virtually no false negatives.

But a lot of data in the literature shows there is a significant single digit false negative rate for lesions under a centimeter with core biopsy for nodules greater than a centimeter for diagnosis.

Again, just core, if it's four a four, four B, four C, or five.

If it's in cystic, I use vacuum.

If it's intraductal, I use vacuum for MR abnormalities, I'll usually use a vacuum.

Although if it's a large mass that I see on ultrasound, I might core it.

For, for, for non mass enhancement, I'll virtually always use a big vacuum device.

And for lymph nodes, I just use a small, usually 18 gauge core.

Sometimes I'll use a 12 gauge core if it's a really huge lymph node, but mostly just 18 gauge.

Why do I vacuum small lesions? Fewer false negatives.

Essentially none. Discordances go away if the lesions completely removed.

If you have four a lesion, you get FCC, you don't know that's discordant, but you may have missed the lesion.

But if you do vacuum, you, you don't miss it.

It makes it harder for the less than excellent pathologist to recommend an unnecessary surgical excision.

If I've taken out a whole papilloma and the dufus recommends, excision when it's not necessary, when he already has the whole thing, I can call him and say, Hey, I know you only took three levels, cut the whole thing and then tell me you need excision because I removed it.

And then some patients want the lesion removed.

So that's another valid reason.

Case Example: Wrong Choices in Guidance and Device

Now I just wanna show you one place that sh that exemplifies wrong choices in terms of method of guidance and types of device.

So I've got a little mammographic lesion that is real and speculated, I wouldn't call it a five, but it's probably a, a high four B, maybe 50 50 and an alt sound, it's more like a five.

It's definitely a small grade one tubular or IDC.

Now this should be vacuum biopsy, this should be ultrasound guidance and vacuum biopsy.

But my young partner, straight out of fellowship, chose a core biopsy.

And remember that the inners stylet is designed to dive, so he's gonna miss deep and there's the lesion and there's the needle.

He missed deep. He thought he was gonna go straight, but because the inners style is designed to dive, it went deep and he missed the lesion.

He got FCC, so this was discordant.

You can't have a birads five, that's FCC, you gotta re-biopsy that.

So we brought the patient back, I guess I had too much vacation and they did spot mags and found some calcs.

And so my other young fellowship trained partner decide she's gonna do a stereo biopsy on the calcs, forgetting that we had a birads five solid nodule there.

So she targets the calcs on stereo and biopsies those.

And there's our cavity, the calcs are gone.

She got the calcs. And again, we got benign FCC.

So now we chose the wrong guidance method.

So we've biopsied this lady twice and we got two discordances.

We got a birads five lesion with two FCC diagnoses.

So we chose the wrong device the first time.

We chose the wrong guidance method the second time.

So finally she has to come back.

It's like goalposts it's goal.

But we didn't wanna, we didn't wanna bracket.

This wasn't a localization procedure.

We didn't wanna bracket the lesion.

We actually wanted a biopsy of the lesion.

So, here she is back again and there's the lesion.

Now we're doing the right guidance method outside.

We're doing the right, method of vacuum assisted biopsy.

And we get the lesion and it's a grade one IDC, and then she has an mr.

And she's got a grade one, ID c on the other side.

So by choosing the wrong guidance method and the wrong device on two separate occasions, we could have missed not one, but two cancers.

So it's just a plea to use the right method.

Conclusion

And so, we'll clip everything.

I won't say any more than that.

And so really choose the rest, the best guidance method and the best device and you'll have better results.

Thank you.