 Dr. Rashmi, we can't hear you, sorry. You'll have to unmute yourself. Can you hear me now? Yeah. Yeah, thank you so much. Yeah, thank you so much, Dr. Gauri and the organizing committee for giving me opportunity to be here, especially Dr. Shilpa Ladd, who invited me for this talk. So I'm going to speak on ultrasound guided breast intervention. So breast intervention is equally important as diagnostic tool, like we are encouraging breast screening program for early detection of breast cancer. So unless you are able to prove them in the form of tissue diagnosis, there is no use. So I request everyone who is attending here to start doing some kind of breast intervention so that you're able to give the tissue diagnosis to the treating clinician. So it's very important. You can learn from your seniors if you don't have in your own hospital, you can learn from area who are doing major number of biopsies and affinities. It is very simple. And I'm sure the more you do, you will have better experience and definitely you can master in this. So, slant, okay. Now ultrasound is the most preferred method for breast intervention. The most important cause because it does not have radiation compared to the mammography CT scan and other tools. So every clinician, they are very concerned about this. So definitely ultrasound, if the legion is seen on ultrasound, it's always better to do an ultrasound guidance. It is widely available in every corner of the country. It is real time imaging. So you can always position the patient according to your convenience. And it is more cost effective compared to the mammography and tomosynthesis. We can do FNAC or fine needle aspiration biopsy. We can do core biopsy. We can place the clip under ultrasound guidance. We can also put via localization of the mass. And the most recent one is the vacuum-assisted breast biopsy or vacuum-assisted breast lump excision. Both are very important nowadays because everyone wants accurate diagnosis and more sample for the diagnosis. So coming to the fine needle aspiration, cytology and biopsy, it is the simplest technology to do breast intervention. The most common cause for this that the patient presents with painful lump which is cystic. FNSA is required for symptomatic relief. It has several disadvantage that there is no patient preparation required. There is less complication compared to the biopsy. And sensitivity and specificity of picking up malignancy is very high, 83 to 90%. So you are able to tell whether patient has got mass which is having malignant cells or not. But you're not able to give them the histological diagnosis or the molecular diagnosis. Again, for the microbiological assessment, you need fluid for aspirated fluid for the gram stain and AB stain or any other microbiological analysis. So again, fine needle aspiration is very important for the microbiological assessment. So indication, as I told you, symptomatic cysts very important to do FNSA. A patient has got abscess for the microbiological analysis. Post-operative seruma patient has undergone surgery and she has developed some collection which is causing her problem. Again, you can do ultrasound guided aspiration from the seruma. Lymph node, most of the time you will have to find needle aspiration just to say whether they have got malignant cells or not. But sometimes you may have to do biopsy as well. And sometimes if you are not able to perform the biopsy, then clinicians may ask you to do FNSA from the suspicious solid lesion. So again, FNSA is very important whether the mass has got malignant cells or not. It is very simple technology. You just need a syringe. If the mass is superficial, you can get away with the syringe with the attached needle. But if the mass is deep, you have to use the spinal needle. The pathologists recommend either you use 22-gauge needle or 23-gauge needle. But sometimes if the collection is thick, you may use 20-gauge or 21-gauge needle. Once you get the aspirin, you have to transfer this through the slide. You can make this smear yourself. Most of the time you won't have pathologists accompanying you to prepare the slides. So this is the bottom one which has got the aspirate on the slide. And this is another slide you have to use to make the smear. You can go perpendicular to this or along the smear. So like how you are comfortable, you can make it yourself. After making the smear, you have to transfer it to the fixating agent. What fixation is used is the ethanol that is 95% ethanol ethyl alcohol. You also have to have five to six dry slides so that if pathologists want some other stain, they can prepare from that. Or if they want some microbiological assessment, they can prepare from that like gram stain, gene wheels and stain. For AB stains, they can make from it. So you have to send at least five to six wet slides in the ethanol and five to six dry slides so that if pathologists or microbiologists, they want to make another stain, they can make from the dry slides. So finally, aspiration is not sufficient for the histological diagnosis. If you want to grade the tumor, again, it is not sufficient. If you want to have molecular analysis like ERPR, HER2 or K67 status, again, you need to do biopsy. FNAC for the benign also, many times you won't get the diagnosis. You can just say there is malignant cells or not. Most of the time you need to do biopsy to get the complete diagnosis of the benign pathology as well. So along with malignancy and benign pathology, if you want to get the histological diagnosis, you have to go ahead and do the core biopsy. Now the core needle biopsy, it is just like FNAC, but you are going to use thicker needle. You can see this is the automatic gun which is supplied by the bar. You can see this is the 14 gauge gun. So in breast commonly, this is recommended. This is the 14 gauge green one. Many times you will, you can get away with the 16 gauge itself. If the mass is hard, better to use the 14 gauge needles. But if it is firm to soft, you can use 16 gauge itself. Now it is an outpatient procedure. You have to do on the local anesthesia because you're going to cut some amount of tissue. So it's better to give local anesthesia. Where do we perform this core needle biopsy? If the patient has got biopsy four or five months, definitely you are going to do the core biopsy because diagnostic yield is very high for almost 98 to 99% time. You will be correct in diagnosing the disease. Byreds three sometimes you have to decide depending on the patient's anxiety. Many times in byreds three, there is 2% chance of malignancy for a few patients that may not be sufficient to give them relax. They want to relieve their tension. So if patient wants or the clinician wants or if you think that patient cannot come for the short term follow up after six months in that condition also for byreds three lesion, you can go ahead and do the biopsy. And patient for the mutation analysis or molecular testing or ISC examination, again, you have to perform the core biopsy. So byreds four and five must, you have to do core biopsy. Byreds three, depending on the condition of the patient whether they want or clinician wants from you, if their clinical suspicion is high, still you have given byreds three, clinician may ask you to go ahead with the core biopsy. Do we prepare the patient? So make sure that you explain the biopsy procedure in detail to the patient, get the written informed consent because it is a minimally invasive technology. There is chances of some complications, we have to explain to the patient that there is chances of minimal bleeding after the procedure, which will subside in few days. So like all the pros and cons you have to explain to the patient. You check whether patient is on any blood thinner or not. If patient is on blood thinner like a clopidogrel you have to stop for four to seven days prior to the biopsy or you can check the INR, it should be less than 1.5. And if you are checking the platelet counts it should be above 50,000. Now this is the equipment you need. You need ultrasound with high resolution linear probe. This is the dressing set, you need this. This is the sterile gloves, betadine. This is the sterile cloths just to make that area sterile so that it doesn't get contaminated. You need the 16 gauge or 18 gauge or 14 gauge gun to get the tissue. And along with this, you need 2% of xylokene because this is going to cut some amount of tissue. You have to give some local anesthesia. So we use xylokene 2%. And then along with this you are going to transfer the sample to the 10% buffered for formalin. So this is very important. You have to have this by side so that you can transfer the sample immediately to the formalin where it is taken to the pathology. Now how we perform. So once you have identified the mass on the ultrasound you give the local along the track how you're going to introduce the needle to the mass. So most of the time you will end up doing needle. It should go parallel to the chest wall or parallel to the skin or parallel to the mass so that you get the longest length of the mass for the biopsy. You should not go perpendicular. Perpendicular if you go, you may hit the chest wall or pectoralis muscle which may be very painful. So you give the local anesthesia, make a small nick and the needle track should be parallel to the skin or the chest wall. You can get four to six scores. You transfer all the course to the 10% buffered for formalin. And then it hand over to the pathologist. So this is how you do. First you identify the mass, give local anesthesia, give a small skin prick and then you introduce your needle. The needle should be at the edge of the mass so that it can travel through the mass. Once you shoot, it has to go further two centimeters. Now after doing the biopsy, you apply a good manual compression for five to six minutes. You have to do entire procedure under asepsis so that it doesn't get infected. Apply a good compression and then you apply a good compression bandage which can be kept for 24 to 48 hours. Instruct the patient about the post biopsy sequelae about a pain and bruise which will subside in few days. And then avoid any intense physical exertion after doing the biopsy. If patient still feels some pain, you can prescribe some NSAIDs or any painkillers for few days. If you have done this procedure in the asepsis condition, you don't need to prescribe any antibiotic. Sometimes they may need painkiller, that's all. Now next investigation is the tissue market placement or clip placement. So what we place, there is the ultra clip here. This is the ribbon shape which is easily available and this clip is inserted within this pen-like needle. So this is inbuilt inside this needle's tip and there is a push button. So once you identify the mask, you have to introduce the needle in the center of the mask and once you are in the correct position, you just press this push button and the clip inside, this is the ultra clip which is inside, it will get detached from the needle tip and it will remain there. Once you see that it has been detached, you can withdraw this needle and what remains, this is the clip inside. This is very useful, patient who are going for the new adjuvant chemotherapy. Now diagnosed cases of breast cancer, many patients, they want to go for precise treatment like breast cancer or minimal surgery and the oncologist, they want to place the clip because they want to start the patient on new adjuvant chemotherapy. After giving the new adjuvant chemotherapy, many patients, they are having good response, the tumor may completely resolve what you will see at the end of the new adjuvant chemotherapy clip remains and the entire mask gets completely resolved. So in that case, just before the surgery, because they want to excise the tumor bed, they will ask you to mark the clip where it is and based on that, surgeon will take two centimeter of margin and they'll do the breast-conservative surgery. So nowadays it is very important that you should know how to put the clip, where to put the clip so that oncologists, they don't have to send the case anywhere else and the patient gets the more precise surgery. Another procedure which can be done in adjuvant guidance is the hook wire localization. This is again, there is a needle-like cannula. Inside this cannula, this is the hook wire which is inserted inside, it comes in a set. So you introduce this cannula at the center of the mask or just at the outer edge of the mask. Once you are at the correct site, what you do, this is the hook wire which remains inside this cannula. You push a little bit of this hook so that hook gets detached, it opens up and this J-light, it goes beyond the mask at the outer edge like this and this guide wire you leave inside and just withdraw this outer cannula. So this is like sheath like cannula, it comes out and what remains after placing this hook wire, this is the only wire remains and the wire part of the wire will be hanging outside. You can stick this to the skin so that it doesn't get displaced. So along the wire surgeon goes and they do the very small surgery so it will hardly cause any dysmorphism to the breast. So it is very important nowadays to know all these procedures because everybody is for personalized and precise treatment. After doing the surgery, now the surgeon wants to confirm whether the entire tumor has come out or not. So they will send for the sample mammography or sample ultrasound. You can see here after doing the surgery, the mask and the wire completely has come out so there is nothing remaining inside. So this precise surgery can be done only if you know how to place the hook wire. Now next, which is the last one and this is the most recent entry to the breast intervention. This is the vacuum assisted breast biopsy or where vacuum assisted breast lump excision. This is diagnostic as well as therapeutic investigation where you can provide to the pathologist more amount of tissue for the diagnosis and you can have more diagnostic, better diagnostic yield. So it is again a minimally invasive technique which is more efficient than the core needle biopsy but less invasive than the open surgical biopsy. It can be done under mammography as Shilpa has already shown you that 2D or 3D guided vacuum assisted breast biopsy. It can be done an ultrasound guidance or MR guidance. Now I'm going to talk about ultrasound guided vacuum assisted breast biopsy. So the difference between the core biopsy and the vacuum assisted breast biopsy is the breast biopsy needle size is larger than the core biopsy. It comes into like 10 gauge, 11 gauge and 7 gauge. If you're only using for the diagnostic purpose means you want small amount of tissue you can use 10 gauge or 11 gauge but if you're using for the therapeutic purpose you can use a thicker needle like 7 gauge. So the difference in placement of the needle tip is that in core biopsy you keep in the center like you keep here at the edge so that you can go you can shoot through this center of the mass but in vacuum assisted breast biopsy you keep the needle trough just under the mass or posterior to the mass. So when you start sampling this is the needle this is the trough and this has got a blade here. So once you start sampling this blade keeps cutting and at the same time under vacuum this mass keeps falling under gravity to the trough. So cutting and vacuum collection happening simultaneously like you can see cutting and then simultaneously mass also is falling into the trough and it gets further aspirated under vacuum to the vacuum chamber. So this is the set. This is the vacuum generator. This is monitor which guides you which clock to do the sampling. Sorry to bother you ma'am could you please go to slideshow? I think it's yeah, it's fine. Okay, sorry. Yeah, so you can see here this is the vacuum generator and this is the disposable needle probe set. So entire thing is disposable. It comes in disposable set for each patient you have to use one. For one patient this needle can be used for two, three masses as long as it is cutting and but the same should not be used for the different patients. So this is the disposable needle set here. This is the needle tip you can see it shows up and this is the trough with the cutting needle. This the length is same as for biopsy this is two centimeters. So up to two centimeter it can easily cut and it can be collected in the vacuum chamber and this at the back of the needle probe you can see this is the vacuum chamber where the sample gets aspirated and collected. Okay, so this is the entire set. Now, where we perform we can use this as a diagnostic investigation when the legion is very small like five to 10 mm then many times if you do four biopsy or FNAC it may give you false negative results. So in small cases again it is very important to use the vacuum because this will not only give you diagnostic if it is benign it gives you therapeutic benefits as well and you're going to provide the sample in total so pathologist also will be happy the diagnostic yield will be almost 100%. So small lesion if you have vacuum better to go ahead with the vacuum assisted breast biopsy. In cases where patient has already undergone with the core needle biopsy but there is radiological pathological discordance again if you want to have better diagnosis you can go ahead with the vacuum because this will give you better diagnostic yield. And then again in B3 masses the pathologist have reported as high risk lesions or indeterminate lesion which has got indeterminate malignant potential like ADH, radial scar, atrial lesions again they can have associated DCIS or malignant pokai. So these cases again, Vav is very important because you're going to provide the entire mass for the diagnosis. So chances of missing any underlying malignance is very less. So for small lesions, sub-centimeter lesion B3 masses or high-risk lesions again vacuum assisted breast biopsy scores over the core needle biopsy. Now coming to the therapeutic again it is used for the if it is proven case or very typical of benign lesions like fibroidinomas and papillomas you can use Vav directly for the excision for the biopsy as well as for the therapeutic purpose again, the patient has got wrist abscess which has got very thick collection difficult to aspirate the entire pus then in that case also you can use Vav and you can provide entire abscess for the diagnostic as well as for the therapeutic. Now, how do we do? So same as you do for the core needle biopsy you take the informed patient consent patient position in supine or lateral oblique depending on your convenience and the patient convenience make sure that patient is comfortable position because it is little longer procedure compared to the core needle biopsy and then you give local anesthesia here you give local anesthesia 2% xylokin with the diluted adrenaline, okay? So this is very important because we add little bit of adrenaline because it stops the bleeding now you are going to do continuous cutting so chances of bleeding is more so if you're going to do Vav you add diluted adrenaline 1 ml it is sufficient to the 2% xylokin you give 15 to 20 ml of local anesthesia at the site of biopsy along the needle track and around the mass so that it doesn't bleed much you give a small skin incision because needle size is thicker than the core needle biopsy size of skin incision little bigger 3 to 5 mm if the mass is deep the incision the skin incision you make little away from the probe so that you can get more horizontal approach I'll show you how it is done so needle should be placed just under the mass push it to the mass so that needle and the mass falls automatically into the trough then you start sampling after doing the sampling you apply compression once you remove the needle make sure that there is no mass left there is no collection if there is any collection you can vacuum that collection that area should be completely clean once you have assessed that then you can apply the compression with the pump for 5 to 10 minutes and then you apply a tight compression bandage and then of the specimen if you think there is calcification you can go ahead and do the sample specimen mammography so that you can be sure that calcifications are out and then you can do the unilateral mammogram just to confirm if you are placing clips sometimes entire mass will be out and the patient wants to be sure that that area has been completely clean for medical legal purpose in benign condition also you should place a clip after doing the procedure and for malignancy again if there is no residual tumor left in that area better to place a clip though it increases a little bit of cost but it's it's much better if you place a clip so that later on for follow up it is very useful so this is the mass which has been identified on the ultrasound this is typical fibroidinoma if you have core biopsy before doing the lab well and good but it is so typical that it can't be anything else you can do FNSE just to make an entry that you're doing for the benign lesion and then you give a local anesthesia at the site of the needle track you can see the needle track is going to be under the mass so you have to give local anesthesia how you're going to enter behind the mass so this is the local anesthesia needle track you can see it is going just push it to that and then you give a small skin trick two through three mm or three to five and depending on the needle size and then you introduce your needle through the skin entry and then make sure that your needle tip is just under the mass it is entering it is posted to the mass and then you can start cutting you can see here this is very small video just I have done yesterday so like just I asked sister to send that quality is not that good but you can see this is the mass and you can see this is needle that this truck is just posted to the mass okay and you can see as it is being cut it is falling on the truck right you can see here so this is just posted to the mass and as you keep doing the mass keeps falling on the truck till it gets completely excised okay so and after getting this sampling done under vacuum the entire sample gets collected in the vacuum chamber you can see here this is done and then these samples same like core needle biopsy sample you can transfer this to the 10% formalin and hand over to the pathology another patient quality is not that good of the video low resolution so you can see here again you have this is very important to place the needle just posted to the mass once you're in the correct position the procedure is very simple you can see here keeps on it the needle the sampling is happening it is going and to and fro and keeps cutting at the same time the mass is falling on the truck and it gets aspirated under vacuum into the vacuum chamber so like this you have to continue till you reach to the anterior edge if the mass is just under the skin you can give local anesthesia between the mass and the skin and if the mass is again very close to the chest wall again to make some space you can inject some local anesthesia between the mass and the chest wall so that you don't hurt the chest wall or you don't hurt the skin so this is how it is done so once you're in the correct position it takes around five to 10 minutes to complete the procedure so this is the fibrodenoma this was the pre biopsy and you can see after post-wired what is the outcome you can see there is nothing inside just small collection this is the post-vab area there is no mass at all and the skin is completely scarless there is hardly two mm of skin incision is there which heals within a week so that's why it is called scarless breast surgery for removal of the benign breast lumps you won't be wondering if a lot of research is going on even for malignancy cases as I showed you that you have to place a clip for new adjuvant cases within the mass and after new adjuvant chemotherapy almost entire mass is resolving so doctors may ask you to do for malignant cases as well and already research is going on in many places in UK and US that they are comparing the vab excision versus BCS and so far the results are very encouraging so maybe in few years we may have to do vab excision for malignant cases as well as of now it is only approved for the benign cases so contraindication for the vacuum massage breast up biopsy is there is no absolute contraindication you can go ahead and do for any mass which is less than three centimeter and the relative contraindication is that sometimes patient will be on anticoagulants so they will have more chances of bleeding you put on the color doctor if you see the mass is very vascular in those cases again better to avoid doing vab because chances of bleeding is higher with vacuum assisted breast biopsy and if patient is on any anticoagulant they can stop for few days you can check INR and then you can go ahead and do the vacuum assisted breast biopsy so this case looks pretty benign well circumscribed oval hypocoic mass with central cystic area likely to be fibroidinoma so this is the ideal case for vacuum assisted breast lump excision but when we put the color Doppler the color Doppler showed very highly vascular mass so we abandoned this case for vacuum assisted breast biopsy because we did not want any kind of complication so this was sent for the surgical excision of the mass they can use some other sclerotherapy to control the bleeding but in OP procedure we cannot do all these things so this was sent for the excision so again you have to put color before doing the vab it is very important to avoid any kind of catastrophe in your department so complication rate it is very minimal if you are careful if you have chosen the case very well like if there is no there is minimal vascular probe within the mass you can go ahead and do the vacuum assisted breast lump excision or biopsy so in those cases chances of hematoma is very minimal but if you don't see the on color Doppler and mass has got moderate to high vascularity chances of hematoma is more and if you cut some normal tissue again they will have normal vascularity that also can cause hematoma formation so make sure that you apply a good complication after doing the biopsy for five to 10 minutes so that there is no hematoma formation infection rates are very minimal or it's extremely rare because we do under ASEPSS so chances of infection is very low we don't give them any prophylactic antibiotics so maybe a patient has got pain she's pain sensitive you can prescribe them some NSAIDs so to summarize we have talked about fine needle aspiration biopsy core biopsy, clip and tissue market placement who acquire localization WAP and vacuum assisted breast lump excision under indication contraindication procedure complication and how to manage the complication so this should be sufficient for you so to start with so I think if you have opportunity to perform FNS if you have never done any start doing it I'm sure you can do and as you do more number of cases I'm sure you will do much better job later on, thank you so we are going to start one mentorship program from 15th May onwards so any of you are interested you can send an email to this email address this is email address of breast imaging society of India or you can send message to one of us and we can proceed further so already almost 50% seats are full so if you want to book any place you have to hurry up thank you very much for giving me opportunity