 Welcome to new conferences hosted by MRI online in response to the changes happening around the world right now in the shutting down of in-person events We have decided to provide free daily new conferences to all radiologists worldwide today. We're joined by dr. Carolyn de benedictus She is an associate professor of radiology for the University of Massachusetts medical school in addition She has the roles of vice chair of for education and radiology residency program director Reminded that there will be time at the end of this hour for a Q&A session Please use the Q&A feature to ask all of your questions and we'll get to as many as we can before our time is up That being said, thanks so much for joining us today. Dr. de benedictus. I will let you take it from here Wonderful. Thank you. Okay. So if everyone can see that so today, I'm going to talk to you guys about breast intervention Um, I have no disclosures So I think it's important to know the history of breast biopsies in order to fully understand why we have some of the techniques we have So originally surgeons That when they were unable to palpate a lesion that was detected on mammogram They really had no way of moving it removing it Precisely, so they had to remove large amounts of tissues to get the pathologic diagnosis And a lot of the times these pathologic conditions were benign as these women had large surgical deformities That were kind of unnecessary So it led radiologists and surgeons to find a new way to do this and the first image study intervention to aid in Breast Batsy was needle localization The patient still required surgery and still required anesthesia but we could use imaging to place the wire into the Mammographic finding and allow them to remove significantly less breast tissue So this was the first way that we were able to use image guidance to do A less invasive intervention um When needle needle localizations were the initial diagnosis for a while But then they were replaced by pineal aspiration and eventually by core biopsy So why do we need histologic diagnosis the space mammography's ability to detect lesions in the breast There's a great overlap in the imaging of parents of benign and malignant lesions because of this We need psychology or histology to diagnose the definitive diagnosis as being benign or malignant One concern people have with percutaneous biopsies is when we used to do surgical biopsies We'd have the whole lesion to look at and so you could see the entire lesion You didn't worry about what if you got a spot, you know that was benign in this lesion and there's also a cancer there um So we really worried about that. So we wanted to look at the positive predictive value of breast biopsies So the positive predictive values the number of examinations it takes to find cancers that were found and the positive predictive value of mammography The positive predictive value for mammographically detected lesions increases with patients by age It's 10 to 15 percent at age 40 and up to 50 percent at age 79 so The older you are the more likely a lesion detected on mammography is going to be a cancer And the goal is to increase the positive predictive values of biopsies and to have less benign biopsies And we want to do this because we don't want to but we want to do this so that we don't have too many false positives But we also want to make sure we're not missing cancer. So we're always going to have some false positives Because we don't want to miss cancers So sensitivity is the number of cancers ultimately diagnosed in a screening program and for most screening programs That's green the average population of women ages 40 to 80. They'll detect six to ten cancers for a thousand women's screens And of the cancers detected by screening mammography 30 percent are gcis 50 percent are invasive ductile carcinoma less than one centimeter And less than 20 percent have positive lymph nodes So what you want to learn from these steps is that screening works That if the the majority of patients who get screened roughly 80 percent will have a stage one or less breast cancer Which is not true for the population that isn't screened where 75 percent of deaths That occur in breast cancer patients are in the population that is not regularly screened So of all biopsies about 20 percent of biopsies you perform in an imaging center are positive for malignancy But that means 80 percent are benign and that's a useful statistic to know When you go into talk to a patient who needs a biopsy the important thing for them to know is most of the biopsies We do are benign But we also have to catch those malignancies those 20 percent of malignancies because those patients 80 of those patients who are diagnosed off imaging Have early stage cancer So needle versus surgical biopsies. So image guided core biopsies has become the standard diagnostic technique for all breast lesions Core needle biopsy has been shown to be very accurate. However, there's always a problem of sampling error However, it's typically pretty low and why does this happen? It's because needles can't remove the entire lesion And a design result can actually be a result of missing the cancer with sampling technique And that's why we usually document images of our needles directly through the lesion and also we can Do our vaginal views to show in two planes that our needle is through the lesion And this is why because of this sampling error and this small risk of sampling error that when we get high risk lesions like 88 and papillomas and Complex closing lesions we do a surgical excision And this is to exclude the possibility of sampling error in that we just got the edge where there's a vh But it's really a lesion of dcis. And so that's why with these higher risk lesions We do surgical excision of course open surgical box Here remains the gold standard pathology because you're Examining the entire lesion. But that being said the most common way we do biopsies is by core needle right now So how can we reduce sampling error? So it was really important as I said to use imaging well To confirm that the placement of the needle is in the center of the lesion and to confirm that you've used different You've sampled different parts of the lesion Again, the bigger the bore of the core needle device or if you use vacuum assisted devices The false the false positive the false negative rate actually decreases So you can reduce your sampling error with a larger bore needle and using vacuum assistance Of course the problem with larger bore needles is you can get more bleeding So one of the benefits of core needle biopsy over surgery will clearly it's less invasive There's fewer complications specifically. There's less complications from anesthesia Because core needle biopsies require only local not general anesthesia and they're smaller to no scars from core needle biopsies So these are definitely the benefits So sometimes you still need a surgical excision after core needle biopsy and why would this be? Well, we talked about if it's a high risk lesion That's one reason but the other reason is we have to make sure that the pathology results are concordant with the imaging If they're not concordant with the pathology So if we see a speculated mass on imaging and it comes back Fibrocystic tissue that worries us because we thought that should have been a cancer So in this case, we would recommend surgical excision to rule out sampling error And it's always important to review all of your imaging In light of the pathology into the denture biopsy reports with regard to concordance And anytime there's a question of concordance, you should always defer to surgical excision, which is the gold standard So we talked a little about core needle biopsy But we also had talked about between when we started doing surgical excisions and localization To core needle biopsy there was fine needle aspirations And so for a while, this is what people used and this involves using a fine needle Which is usually 21 to 25 gauge and putting it into a lesion with active suction In an effort to aspirate the cells FNA is very successful because breast cancer cells tend to be less cohesive and break off more easily than normal tissue And as cytologies advance, we can even get receptors from this now way back when Cytology methods were not as advanced and we weren't able to get receptors But now we can even get receptors most receptors off of on FNA And it's very very sensitive from the ligament cells Um and now even It can even tell us something about type and grade but not as much as a corneal biopsy And that's why we always now default that we have the Technology to corneal biopsy. How are there still lesions that we can't get by corneal biopsy because they're close to an implant Close to the chest wall all sorts of reasons So you can still use fine needle aspiration on masses that are not amenable to corneal biopsy So where are some of the advantages and disadvantages of fine needle aspiration? Well, again, we talked about it's virtually atraumatic. You're using a really small bore needle It's very simple to perform and a cytologist can actually interpret it immediately You can have on-site cytopath whereas when you do a corneal biopsy requires at least 48 hours of fixation and staining before pathologists can review it The disadvantages are it's very skill dependent not only on the person doing procedure, but the cytologist Who's interpreting it? um, again, we can't get all the information we really like to get about cancers from FNA So again, we'll go back to corneal biopsy Which is now our our standard of care for initial sampling of lesions in the breast And it involves removal of actual intact pieces of tissue that can be analyzed histologically and this is why it's better than an FNA for getting the full information about the tissue You're sampling because we're getting an actual core of tissue instead of just a few cells Core core biopsy devices range anywhere from from nine gauge to 18 gauge um, and the most commonly one at least we use where I am is a 14 gauge And the nice thing is it leaves the skin intact without need for suturing unlike a Exitional biopsy where you end up having sutures and scarring so advantages Pathologists need no specialized training to interpret the sample. Whereas a cytologist has additional training above a pathologist It's less traumatic than surgical excision and it's relatively inexpensive to perform Disadvantages again, like we talked about there is the risk of sampling errors And again the larger the bore device you use the less Sampling error there is however, then you can get more complications So it's a real balance of using a bore that gets its adequate sampling without too many complications such as hemorrhage and infection So which lesions do we biopsy and how so any lesion with an imaging appearance that's associated with a greater than 2% risk of malignancy Goes to biopsy, right? So anything with a less than 2% risk of malignancy biopsy is traditionally a byred 3 which is a probably benign finding and we follow it But once we've reached that 2% risk marked by morphology, that's when you'd bring them to a core needle biopsy And you want to choose a biopsy technique where you can see the image the best See the lesion the best so if the best place you could see it was on ultrasound You want a biopsy and an ultrasound if the best place you can see it is under mammography You're going to biopsy it under mammography m r etc So what are the types of image guided corneal biopsies? We do so we do Stereotactic or mammographic guided biopsies. We do m r guided biopsies We do ultrasound guided biopsies and we also do 3d stereotactic biopsies So what's a regular mammographic stereotactic biopsies? So what this is is it's a mammographic guided biopsy and it involves the patient laying on a table with their breast hanging through a hole and underneath this table is a mammogram machine essentially and the breast if you can see with my arrow This is the detector here and the breast is against the detector in compression and we have a camera here The nice part of this is that the patient can't see the needle. So this is really great for patients who are afraid of needles However, it's not great for patients with limited mobility because as you can see they have to get up on this table and lie on their back Patients with spinal fusions, especially cervical spinal fusions can have a real difficult time with this. However, we can do upright stereobiopsies as well as 3d stereobiopsies as well So again at our institution, we use a low-rad prone stereotactic biopsy tables. There's many different Erasions of this. We also operate machines that can easily be attached to hyalogic units or other uses The patient lies prone on the table as I said with the breast through a hole and we put the breast in compression to hold it still So how do you pick an approach for a stereotactic biopsy? So you want to come from the shortest distance from the skin So it's important to look at the mammographic views to see see in the MLO and see Where the shortest distance to the skin is Once you make that decision, you now need to look at the orthogonal view on which you'll be viewing the lesion To see if you can see it. So if you're going to come from If you decide you're going to come from below that means you're going to be looking at the cc view So you want to look at the cc view and if it's hard to see those calcifications on the cc view That's not the smartest distance. Even though it's the shortest the direction even though it's the shortest distance It's not the smartest because you can't buy up to what you can't see So visualization always comes the shortest distance, but you want to start off aiming to use the shortest distance If the visualization is okay in that approach So we do a lot of pre-procedure imaging once the patient's in compression We have scout views and this is to find the target and so the goal is to have the target centered in the window And you want to check to see if there's any vessels large vessels by you want to make sure you can see it well and That it's centered if you have a lot of trouble if you have trouble finding it another way you can Do it is you can actually use the mammogram a regular mammogram machine to help you you can get the lesion Calcification or math or whatever it may be Visualize under Mamo and put a bb on it to help locate localize it and then go back to the stereo room If you can't find the target You usually will cancel the biopsy you don't want to clearly try to biopsy sign you can't see nor can you Biopsy sign you can't see so what happens when we cancel biopsies? Well, there's two there's two options Usually if we've gotten to the point where we want to biopsy our suspicion of malignancy is enough that we'll recommend excision however, if you think the Suspicion malignancy is pretty close to two percent or or there or very low in general you can do a six month follow-up So let's assume that we can see our target, which is great So now once we've had our scout image where we can see our target now We have to do what we call a stereo pair and what this is is we take two images 15 degrees apart in the opposite direction from From midline and this allows us to get the data so that the computer system can calculate the coordinates So once we get the stereo pair we target the images on we target on the images and We get the x y and z coordinates Then we check the coordinates to make sure the actual biopsy is feasible So some things we want to look at here is we have a A notch at the top and there's a notch over to this side, which is to the left of the screen in which case We want to make sure that we see where that is so that when we need to move the calcifications like here We want to move them into the center. We know this is the lateral breath And so we want to move it that way so very important from there we want to Get the scout image once we get our scout image up here. We take the stereo pair, which is 15 degrees in each direction and then we want to Take a picture of the needle just anterior to the calcification Before we fire it where the notch will open And we want the tip of the needle to be at the calcifications for the pre fire images and we want the Calcifications to be within the trough or the opening on the post images And you can see here this is the ideal positioning So there's coordinates There's the x which is the horizontal plane the y which is the vertical plane and when you set the coordinates The at least in my practice the technologists will zero the machine and then target the machine These are set for you So I normally if everything's going well with the biopsy I won't touch my x and y coordinates Z is the depth now the depth the radiologist controls That's the needle going into the skin And it's important when you see the z before you do any of your biopsy to make sure depending on your machine the machine I use That there's seven millimeters A seven millimeter stroke margin because our when we fire the needle or open the trough It will go seven meter millimeters forward and we want to make sure That our compression is within seven millimeters of our z so we don't go through the other side of the breath Again, this is device dependent and you always want to check with your Institution what your stroke margin is on your machine You also want to check the coordinates because sometimes you'll look and it you'd be firing outside of the skin Which means the lesion is too superficial You can adjust the coordinates for this or you can use a half trough Where they close half the trough or some systems you sign called a petite needle Which has a smaller trough and you want to make sure you're not sampling the skin because that can cause healing issues if you sample the skin so as you can see here You'll this is one of the views you'll have when you've gotten your coordinates And the compression is usually above and our compression is 42 So we want to make sure the z is at least seven millimeters less than the compression and here the z is 14.1 and our compression is 42 so we're fine. We have no issues here and we can safely do our procedure This is a great example from a propane book of stroke margin Um, and what it is so you can see a good stroke margin means that when you fire the needle The lesion is in the trough and the needle is still within the other side of the breath And insufficient stroke margin if you fired the needle would go through the other side of their breath And it's it's poor for him. Of course, no one's going to die from it But you know, you really don't want to do it. It'll cause the patient a lot of pain Now there'll be another site that needs to heal So you really don't want to do this So stereotactic biopsy devices the one we use at our institution is a 10 gauge vacuum-assisted biopsy device by seros There's one. There's a serocillera or a bar of center x that we've used There's also a nine gauge mammatome, which isn't used as much anymore, but some places still use And it allows you to sample with vacuum. So what'll happen is the trough will open Suction will happen via the vacuum and it will suck the tissue in once the tissue is sucked in a cutting device comes over And cuts the sample and it shoots back into the specimen collection area You can use a regular setting or a dense so on my machine that I use our regular setting allows for seven millimeters of suction Our dense setting allows for 14 millimeters of suction. So if the breath is very dense You can use the dense setting But I also do it if I'm having real trouble getting close to the lesion Of course, you want to get as close to the calcifications of the asymmetry as you can But sometimes due to coordinates and the body habit of some things you can't so the dense setting can also help you out with that And then we place a micro marker through the device at the end Which is really important because that'll allow us to mark the area Um safely if we ever need to find it again because sometimes you do take out the entire lesion calcifications or asymmetry So when we numb for um A stereotactic biopsy you have to do a skin wheel at a funny angle So I will usually bend the lidocaine needle to about a 45 degree angle as shown here So that I can easily make a nice skin wheel so the patient doesn't feel anything This is just a nice image of a stereotactic biopsy where we have the calcifications within the trough The needle rotates some needles rotate on their own other needle other needles you rotate manually so that you're going to sample 360 degrees Usually about six samples. We use a clock So usually they do the evens 12 to 4 And then after you place the clip you'll see this image. So what happens you put the clip introducer into the Needle and you'll deploy the clip and then you'll rotate The biopsy device 180 degrees So as you can see here the trough is inferior and the clip is superior because what you don't want to happen is when you pull the Needle out the clip to get stuck back in the trough and get pulled out again So if the if the trough is upside down or 180 degrees rotated you prevent this from happening So I always joke with my residents that stereotactic biopsies are pretty easy. It's kind of like a dance and memorizing the steps Um, and so when stereotactic biopsies are go well, they are really easy And I say 95 to 98 of the times they're really easy. It's just memorizing the steps, you know making sure you're checking everything um, but when When things go wrong in stereo or there's an issue stereos are really really really hard So, um, sometimes the breast is too thin And in that case you have trouble with your stroke margin. And so there are ways you can help this You can you can use bolsters made from foam or towels or other materials to give the breast a bulge You can also tape and wrap around the breast near the chest wall to push tissue anterior and sometimes that will work Sometimes we have lesions that are too close to the chest wall And we can't get the breast to fall into the hole enough to be visualized and on the detector In this case, we can put the patient's arm through the hole with the breast And that'll lower the patient's body into the hole and allow more of the breast to be visualized on the detector Sometimes we have issues that the needle is is too far from the lesion And sometimes the lesion can move when we fire it. So sometimes we push the needle out of the lesion out of the way when we fire it Um, and so sometimes what you have to do is position the trough below or above the lesion instead and just sample through those areas Again, if you ever can't get the positioning correctly you cancel the biopsy So sometimes you can't solve these problems that are listed here with the solutions I have and in which case the biopsy gets canceled and you decide to either excise if the risk of malignancy is high Or do a short interval follow-up if you think the risk of malignancy is relatively low After we do the biopsy we get a specimen radiograph And this is to ensure that we have an adequate number of calcifications or we have the lesion samples Now with asymmetries and masses done on stereo It's really hard to confirm in a specimen radiograph But calcifications are really easy to confirm in a specimen radiograph So what we do is we x-ray the the specimens and we make sure that there's an adequate number If we don't see any calcifications or we don't feel there's enough calcifications. We can always rebiopsy the area So this is an example of a specimen radiograph And you can see these cores of tissues in a petri dish and we can see some of the calcifications within it So micro markers during stereo. So before we place the micro marker We always want to look at a full field mammogram in the breast replaced in a micro marker to make sure that there are not Additional micro markers in the breast if there are other micro markers in the breast from prior biopsies We want to make sure we use a different type of micro marker If you're doing two biopsies at the same time, you want to make sure you're placing two different micro markers Real important thing to remember when placing the micro marker is it stays in the breast And it can be a knitus of infection if it gets contaminated So you really want to be very careful to keep the tip of your micro marker introduced or covered until you're absolutely ready to place Place the the micro marker and you want to make sure when you go to put The micro marker introduced or into the needle. It does not touch anything except the needle You ideally you like to place the micro marker in the center of the lesion And it's important to remember that the micro marker introducer is longer than the biopsy device in some cases So post clip mammography after biopsy will confirm placement of the clip You want to make sure that the clip corresponds with the original mammographic finding whether it's um ultrasound, uh, whether i'm sorry, whether it's a mass or calcifications and sometimes you can get Migration due to accordion effects when we release the breast out of compression. We can get suction along the Track of the biopsy and it can move and hopefully there's some residual lesion left if this does happen so that we So that we know Where the lesion was and we can find it for localization if need be if it's malignant or high risk So these are some examples of biopsy clips. So here is this is an ultrasound biopsy introducer here Not the stereo one, but a stereo one is it's somewhat similar but the whole point is that the micro marker is within the needle and there's a plunger whether it's the ultrasound device plunger or a Stereo plunger device, which looks a little different that plunges it out and there's different shapes Here's a ribbon. Here's a wing. Here's a coil Um, and those little white things are mainly holders for it And then you can see they're very radio opaque and easy to see and we joke with our patients that these are like breast jewelry or breast Sling, um And they're very easy to see and the patient can't feel them the patient can't see them Um, a surgeon within the breast can't feel them and it's important to note They these are made of surgical steel and titanium Which is good because um, very few patients have allergy to them most most clips do not contain nickel I think there might still be one or two Out there that do but you can read the packaging to ensure it doesn't because a lot of people have nickel allergies Um, but these stay in there and they rarely cause the patient's problems And the nice thing about the surgical steel and titanium is they call it's less blooming artifacts than other metals on MRI So if these patients have to get MRIs, it's not an issue So let's talk about that clip migration I talked about so here are the Calcifications in this patient in the medial right breast on the cc that were targeted After biopsy we can see the post biopsy changes in the medial breast, but we also see that the clip migrated Migrated medially and so this can happen. So the important thing to do with this is if you get clip migration you want to You want to Do pre magnification views if the patient needs excision of the original lesion and see if there are Calcifications remaining so that you can then localize those calcifications and you can leave the clip in And it's really important to document if there's clip migration in your report. So when they go to protocol the biopsy Um, you don't have to the patient the clinician protocoling knows. Oh, there was clip migration I need to look for calcifications and not the Clip so now we'll move on to emmergated biopsy So we're only going to cover a few types of biopsies today because there's two parts to this lecture Um, but we'll start with this for now So for emmergated biopsies Um, we do these for lesions only seen under MRI So what we'll do is when we do an MRI we will have a Second look ultrasound if we find a lesion And if we cannot see the lesion under second look ultrasound and the lesion is a greater than 2 chance of malignancy will recommend an emmergated biopsy So the patients will come in and they'll lay in the MRI. We give them contrast We localize the lesion which we can target manually or via a CAD system And and then we biopsy it and so the first thing I'd like to do is orient everyone with the biopsy kit and the components of it So this is an operator and this operator has some air within the tip that causes blooming artifacts And this goes through the needle so that we can see the blooming artifact where the target would be We then have a grid and this goes within one of the Bigger grid boxes and I'll go back a second. So this is the grid used for compression So the patient's on their stomach in the coil and we put the grid here Either lateral or medial in the breast depending on where the lesion is and there's these big grid boxes and then this is one of those little grids and you put it in the big grid box where the Needle is going to go where the lesion is. So that's what that's for. This is the this is the needle That helps us get through the skin And then here we have the sheets for the needle So the needle goes into the sheet And we use the needle to get the blunt tip sheet into the skin into the To the depth we want and then we remove the needle and only leave the sheath in then the operator goes into that sheet There's a little black donut. I guess you would call it And we use this to mark the depth So when you do your calculations on where your lesion is it's going to give you a depth and you want to mark The depth with this with this black donut so that you don't go into the breast further than the donut and so that you're at the correct depth This is an image from a MRI corneal biopsy. We can see the patient is lying prone here. We have They order here heart breast that's not being biopsied and here's the breast in compression Notice how it has this odd rectangular shape. That's because it's in compression And we can see the signal void here. That is the operator and the biopsy device within the The breast so once you've completed the biopsy It's the same as a regular biopsy where we Vacuum-assisted biopsy is just like a stereo. That's why I kind of do these two together a stereo is a vacuum-assisted biopsy device Usually nine or ten gauge. It's the same here. It rotates around via suction takes multiple of these core biopsies Once you have all of the core biopsies usually about six to 12 depending on how much you want Then you will um, send them off to pathology For stereo biopsies as well as emergated biopsies post biopsy. It's really important to hold pressure specifically For these two biopsies even more than an ultrasound got a biopsy because you're using a larger bore needle which causes more bleeding MRI biopsies of all the biopsies tend to cause the most bleeding And that's because the time it takes so what happens with an MRI biopsy is we put the patient in the In the biopsy in the mr We give them contrast the images Then we take them out. We find out we target everything We then put the needles in the devices into the targeted then we image again to confirm Then we take them out then we biopsy the area then we put them back into confirmed placement of the clip So there's a lot of lag between the biopsy and when pressure is held And so they tend to get bigger hematomas So it's really important to really hold pressure at least five to ten minutes Sometimes with mr biopsies we hold up to 15 minutes to decrease the amount of hematoma. Why do you want to decrease hematoma? Well, if there's too large hematoma What will happen is It will delay surgery for a breast cancer because it's hard for them to To do a Surgery if there's a large hematoma in addition if you use savvy scouts for your pre-surgery localization Hematoma is really the only absolute contra indication to using a savvy scout because it hinders reflection of the signal from the probe To be received by the reflector So you really want to make sure you minimize the amount of hematoma Then we usually clean the area off if there's been a nick I know in our institution We use a nick for a stereo but not for a mr biopsy But if there has been a nick or if it's a large four needle you can use dairy strips and then a bandage We usually give them ice as well to decrease swelling Our post procedure instructions include you don't want them to do any heavy lifting or activity for or heavy activity for 24 to 48 hours because what happens there is the breast will move and I always Can I always talk about a scab on your knuckle, right? So if you get a cut on your knuckle and you start bending your finger The scab keeps breaking and it'll bleed and that's what happens if they do things to make the breast move whether it's Heavy activity with that arm or heavy lifting It can the scab can break in it will bleed and patients get very freaked out. I mean everyone No one I don't even like to see myself bleeding at home, right? No one wants to see a wound. They have bleed at home Um, so we always tell them to take light activity to prevent that For pain we recommend telling not only because um, we don't want aspirin or NSAIDs because they cause bleeding Patients who have hat were on chronic aspirin or NSAID therapy. We tell them to stop them Five days before really that's for aspirin NSAIDs can be 48 hours before Um, and then they can restart them within 48 hours We tell them 20 minutes of ice on and off. We usually tell them to use frozen peas and wrap it in a towel So it's not applied directly to the skin And that helps with the swelling and discomfort we tell them to wear a supportive soft bra usually like a sports bra um So that they feel better when they're sleeping and it supports the breast Shower in the morning. No baths are swimming for five days. They can take the bandage off the next day But we usually if they have dairy strips tell them to let them fall off on their own if they haven't Um remove them one week another important thing to tell your patient How long it's going to take for them to get the pathology for us is three to five business days at our site And they will receive it from the referring clinician So you want to tell them how long it's going to take for them to receive it You might tell them who they're receiving it from And then we always tell them if they have not heard from their doctor by day five to follow up with their Doctor to make sure nothing gets lost in the shuffle of paperwork and now epic inboxes and things like that We also give them the instructions on when to call your doctor after a biopsy So we tell them if there's bleeding fever you want to give them a call if there's any concerning symptoms like Discharge your drainage from the site or anything like that. We also tell them to call their physician if the pain is getting too severe as well So one really important part of your post biopsy Post biopsy procedure is to do a pathology. Addendum and it's really important to do this because this allows us to kind of Close the loop on what we're doing. So right the only reason we do breast imaging is really to find cancer not cancer and occasionally Image some infection But for the most part things are either benign or malignant when they're benign. We really don't care what they are Unless it's an infection and so we really want to make sure that no cancers fall through the cracks So when you addendum your biopsies you want to addendum them with pathologic diagnosis so my addendum will usually say pathology colon and then it'll say fibrinoma if it's benign or invasive ductal carcinoma And then you will state if this is malignant high risk atypical or benign because you know We specialize in this and and so we know this but there are some primary cares out there that they don't do Breast imaging and aren't as familiar. So it's really important for you to make it very clear to them Um, is this sign they need to worry about or not? So is it malignant high risk or atypical or benign? And then you need to tell them if it's concordant, right? So you need to state concordance. So I'll usually say you know pathology colon Fibrinoma period these findings are benign and concordant because it was an oval circumscribed mass However, if it comes back fibrinoma, it was a speculated ugly mass. I would say these findings are not concordant And then you'll recommend further intervention if a biopsy is concordant and it's benign You'll recommend whatever follow-up is needed for them depending on their age with mammography if it's a malignancy you will Tell them they need a surgical consultation if it's discordant you will also tell them they need a surgical consultation Um, and then the most important thing is you want to document who you call So you want to give them a call and say, um, you know, if it's cancer Definitely you want to call and say, you know patient X. I did her breast biopsy on Thursday And it came out to be invasive ductal carcinoma. So this is the legged in and concordant and she's going to need um A surgical consultation for removal and then you document who you talk to some places also Document all benign results as well And call all of them. So you just need to be familiar with your institutions policies on this but always document So let's talk some more about concordance because this is really important You really want to make sure your imaging features are consistent with your pathologic diagnosis If not, you want to make sure you recommend excision to rule out sampling error And it's really important that if if you don't feel it's concordant To really recommend excision because I I can tell you I've had a few where I'm like I feel really bad making the patient undergo excision and having anesthesia And that's a big deal and it's expensive and there's risk And I've been so happy I've done it when it's something that I thought was benign What that came back as benign, but I thought was a little Unsettling comes back as a cancer and you feel much better. So don't don't hesitate if you really don't think it's concordant recommend surgical excision Also, make sure it's calcifications or biopsies that you see calcifications are seen in the pathologic specimen So really read the pathology report careful And if it says benign fibrocystic change, but it says It doesn't say anything about calcifications in the specimen. That's a real problem And you really want to call your pathologist. So I have a direct line of communication with my pathologists I know them all by their first name and that's really important as a breast imager because you really want to Help them and they can help you So if if it comes back as benign and there are no calcifications I'd call my pathologist and I say hey Dina I say, you know, I just saw that, you know He said this is benign, but there were no calcifications. You know, there definitely were calcifications in my specimen radiograph Um, maybe we we need to look at it. So sometimes she'll go back and she'll reacquire the specimen and respect it And if there's still no calcifications, that's a problem and you have to recommend either excision of those calcifications or re biopsies And and you want to make sure you're very careful about this Another thing that I think is really important during biopsies is sharp safety. You really want to keep your tray organized and uncluttered If things are overlapping you're at more chance for sticking yourself. I've been stuck a few times. It's not fun Especially if the patient doesn't consent to Having their blood drawn or there's some other compounding thing why they can't and then you have months and months of blood follow-up blood tests So, um, you really want to make sure everything's very organized. You don't want it things overlapping. You want everything, you know Visible. Um, I always have all my sharps facing away from me in one direction Um, if possible use a pad in which you can stick use needles in I also always tell my residents to clean up your own sharps. It is not any type of technologist or Technologist aids job to clean your sharps up You know, you put them down and you know where you put them down and you're less likely to stick yourself Because you know where everything is so I always tell my residents to clean their own sharps up I try to clean my own sharps up all the time as well So now that we've kind of talked about biopsies and some biopsie important things I thought we'd go on to some needle localization If we have time I think we probably have a few minutes To do this this talk tends to run about a full hour. So I didn't realize we had question to answer but right now there's only one question So so let's try to get through a little of needle localization So we talked about this having been the original way that people did biopsies way back when before percutaneous guidance Um, and there's multiple ways to do localizations now the most traditional way which we'll start talking about is a wire localization Um, and this is how it used to be done now. There's all types of um reflectors like I said with scabby scouts scabby scouts, there's um magnetic Ways to do this. There's uh radio nucleotide ways to do it But we'll start with just traditional needle localizations For now So wires placed in a lesion of interest and the wire has a thickening on it And that allows the surgeon if the thickening is centered in the lesion to feel to make non palpable lesions palpable It can be done under any type of imaging guidance at Mamo ultrasound or MRI And normally use a modified cocan's wire or Hawkins wire are the most common and as they said it has a stiffener And it makes non palpable lesions palpable So what comes in the kit is a hollow bore 20 gauge needle along with a wire with some kind of hook and stiffener on it And the wires the needles come in different lengths with corresponding wires So these these are actually the needle lengths, which is three centimeters five centimeters seven and a half centimeters and 10 centimeters and The reason we have different lengths is you know, even though you're trying to get the shortest length from the skin Sometimes that shortest length can be up to 10 centimeters And then there are wires that correspond to each of these needles that come with the kit So this is a traditional needle localization wire. It's a hollow bore 20 gauge needle And we have a A wire sorry wire This is a I think this is a modified modified copans wire And there's a hash mark on it and you can see the stiffener here and you can see the hook The hook helps keep this in place so it doesn't slide back out and as I said this stiffener Will allow a non-capital lesion to become palpable. There is a hash mark There's a single and a dual hatch mark the dual hatch marks up here But we usually bury the wire into the needle once the needle is in place Um to this hatch mark. We usually place the needle 1.5 centimeters past the lesion And by doing that when we bury the Wire to this hatch mark and we unsheath the wire allowing for the hook to bring back out Using the feldinger technique. We remove the needle and what happens is the wire If it's 1.5 centimeters past the tip of the needle here will be centered because the tip from the Hook to the center of the stiffener is 1.5 centimeters. It should be centered in the lesion making a non palpable lesion palpable So what are the indications for needle localization? As we know they used to be done for surgical biopsy, which we still do but usually now we use it for lumbarctomy for proven high risk or cancerous lesions, but you can do it for primary surgical biopsy And we can do localization for lesions not amenable to percutaneous biopsy for excision now with upright stereotactic biopsies MRI biopsies and all these things like that. It's very rare to find saying that's not amenable to percutaneous biopsies But if exists we can use needle localization for that Again, just like with the stereotactic biopsy you want to use it the shortest distance from the skin But you also have to make sure you can see it in mammal We can look from superior inferior in the suit in the cc view We can do medial or lateral in the true lateral view on ultrasound and mr Though we only go medial and lateral due to the image the way we image so you can only come from medial or lateral Again for mammal localizations if we can't see the lesion we localize the micro marker if we know it's in the right spot We can also localize masses under ultrasound or calcifications under mammal The patient's usually sitting unless we have to go from below in which case they're standing in the mammal machine And we have them in compression for the entire procedure You can perform single wire or a two-wire bracket for larger lesions or spans of calcifications So I'll show you an example Of a needle localization and then we'll probably stop here so that we can answer some questions As I said, this is a two-part talk I go into ultrasound guided Biopsies and FNAs as well as other other localization techniques in a second talk So here you can see we use an alphanumeric grid to Localize the lesion so we target here We put a little crosshair here and it would be seven and f Then using the there's a light that allows us to see the crosshairs on the breast at the time And we put the needle so that the hub is directly over the crosshairs and we and we put it into the breast Once it's in the breast we go to an orthogonal view This is your orthogonal view and then we control the depth of the needle And you always want to pull back and never push in Because then you don't know if you're in the right plane anymore So what you want to do is you want to measure from the tip of the needle to the center of the lesion And you know you need to be 1.5 centimeters past the lesion If you're not then you just pull back accordingly. There's little hash marks on the needle You pull back accordingly until you're there once you're at 1.5 centimeters past the center of the lesion You put the wire in you bury it to that first hash mark. I showed you on that prior image And then using seldinger you keep the wire still in place and you pull the needle off When you take the needle off you should see the stiffener right here buried in the lesion And the hook should be just outside the lesion. I think the next slide is the specimen radiograph yet So then you take two films for the Surgeon we mark the nipple and we mark the Entrance of the needle with a BB And then we send those images to the surgeon so they can use it like road map and once they've excised it They will send us a specimen and the specimen usually contains the wire in the target In this case, we would tell them they'll usually call us Well, the patient's still in open and in the or and we'll say well the wire and the clip are here However, the clip is along whatever they'll usually label it either with uh ink or with sutures short and long sutures, but in this case you say, oh, you know Let's say this is the medial margin via the ink color I'll say, you know, the clip is really close to the medial margin You might want to go in and re excise and that's why it's so important to do it with the um With the patient still open in the operating room So that's how a traditional needle localization is and since you know, we have limited time Um, this is a bracket. I'll show you just quickly Uh, so you see so a bracket's kind of like putting parentheses around sign the most common type time we use it It's for spans of calcification and it's just two needle localizations done at the same time And instead of being right in the middle of the target You want to be just on either side of the target again like parentheses So you make sure everything's contained between the two and then you'll get a specimen with two wires and two needles So let's see what questions we have in the last few minutes Let's see Is all right, so I have one question so far and it is elastography useful to reduce sampling error in breast biopsy I rule out necrotic tissue or select a malignant focus Um, I'm an institution that does not use elastography And so I don't have much experience with elastography and biopsy Um, so I'm not really able to answer this question well But you know what we do recommend always is to target different parts of the lesion So if you know what I know about elastography like you said here is it can show more higher risk Areas, you know, if it's necrotic, which you probably don't want to biopsy necrotic tissue, right? Or if there's an area that's more likely to be malignant based on the Elastography features you can target that better. Um, so so in theory from from knowing the basics of elastography It it should help a little however, you still want to always biopsy all parts of the lesion I think that um, I think that would be The smartest thing even with elastography and biopsy like I try to biopsy the superior part the inferior part the medial part You just try to biopsy different sections and again try to avoid anything necrotic because you won't get as good yield out of that Perfect. That's the only question. I see. I don't know if you have any words Opposed to or anything else or if you have a few more slides you want to get through we do so a few minutes left Let me see. Yeah, since we do I just was nervous. I didn't know how many questions we'd have We can talk about ultrasound lobes then for a bit um, so again ultrasound localization is very similar to mammographic localization that we use the same the same tool for a while localization the same Needle and wire system however with ultrasound we're using ultrasound clearly And usually we do things that are only visible under ultrasound like solid masses So you would not localize calcifications under ultrasounds. Um, what are the pros of this ultrasound's much more comfortable for the patient They're lying on their back with their arm behind their head. There's no compression They're usually much happier about that Um, but you know, we do have to still be careful with this take a little more still on the radiologist part with Hand-eye coordination with the probe in the needle and making sure we don't violate the test wall And this was just an image of an ultrasound localization So again, this is that 20 gauge needle coming towards the oval ibococ mass It'll pass through it here Then I measure tip to center of the lesion to make sure i'm 1.5 centimeters through the lesion Then i'll deploy the wire and then this is an image of the wire with its hook With the stifter in the middle of the lesion and again, you'll get that same specimen radiograph just like the mammogram Here it is So we usually will take a post mammogram As well, even if it's an ultrasound lobe to show the stiffeners right at the clip And then you'll get your your specimen like you do for the mammographic localization mr We still have two minutes. These are rarely done They're jump religions that are not accessible for percutaneous mr biopsy guidance And are only seen on MRI As I said, we don't do them very often you have to make sure they need a wire system Which looks the same as your one for mammoth and ultrasounds Is compatible with MRI if they have not been able to Biopsy lesion prior to localization You want to make sure you put a clip at the site right before you deploy your wire Which helps for confirmation in the specimen. Let's see. I see we have another question So let me see here's an example of an mr localization. It looks very similar to the biopsy This is the tip of the needle in the lesion The signal void not very pretty images. Okay, this is ductography. So we'll stop here. Um, and let's see Do you do so I have questions here? I have do you use stereotactic device for hook wire So no, so you you use a regular mammoth You wouldn't use the stereotactic biopsy table for a localization Normally you use a regular mammogram device The difference is you'll use a alphanumeric grid paddle with an opening versus a solid paddle So no, you don't use the actual stereotactic biopsy machine to do the biopsy is to do the uh, wire load placement and then Do you do axilla? Accelerate lymph nodes. I'm not sure what this is referring to We can FNA axillary lymph nodes and yes, you can localize them. So sometimes we have patients who have large Ah, yes, do you do wire localization? Yes. Yes. So Yes, so so for for some patients who have had a positive lymph node, we will clip those at the time of FNA And then we can wire we can use a wire to localize them For surgeons who desire that not all of our surgeons like us to do that But some do so yes, you can do it. You usually you'd clearly do it under ultrasound guidance guidance And it's difficult though. I will say it's not easy and I usually if we're going to place a clip in a lymph node I usually do a coil clip because those are the easiest to see under ultrasound The next question is do you do sentinel node biopsies? So what we do is we do do FNA of axillary lymph nodes if they're in large so so it's I wouldn't so I guess you could call it a sentinel node so sentinel node really refers to The drain the draining node the first draining node of the breast that drains the majority of the breast And really when we're doing imaging, we really can't tell which node that is Usually you have to use blue dye or radionucleotide During surgery to do that. But what we do do is if we see an enlarged lymph node, we buy we FNA it Um, and that way we know If there are positive nodes up front Sometimes that's the sentinel node. Sometimes it's actually not the sentinel node So so that's a little bit of a complicated question But we epinate using a 21 gauge needle. Just like I said, we do FNAs in the first part of the The talk And so someone also asked what is the role of FNA in today's patients with breast cancer? It's surgeon dependent So you have to talk to your breast surgeons and most of the things, you know One of the things I actually love about breast imaging is the collaboration with the surgeons So we talk to our surgeons and what they like us to do is if we see a positive axillary lymph node, they like us to FNA And that allows us them to know ahead of time if there's axillary disease Sometimes we'll have as FNA more than one two because that helps the z11 Criteria as well. So we do do it But again, it's something you like to collaborate with your surgeons about to see what they need to make what they do more efficient Should FNA be a step prior in every breast biopsy? No, no So if if if you can core a breast lesion, you should just core a breast lesion You should always do a core biopsy. It's the best for the pathology It's the best way to get all the receptors all the information about the tumor It's the best way to decrease the time from Diagnosis to surgery and that's the goal, right? So if you do an FNA, you're going to need a core biopsy anyway Most likely if it's malignant and so you're going to want to do a core right up front So no, I would not recommend FNA lesions before core If there's some kind of weird thing With a patient where it can't be coreed or something like that Then you can FNA it up front to see if it's malignant or benign But then if it's malignant most most surgeons and pathologists are going to want a core So it's just smart to do the core up front if it's feasible Looks like that's it for questions Yep, I was about to say the same thing. Uh, so as we bring this to a close I just want to say thank you Dr. Divana Ductis for your time today We really appreciate you joining us and thanks to all of you for participating in this noon conference Or reminder that it will be made available on demand at mryonline.com in addition to all previous new conferences These are made available complimentary and tomorrow join us for a new conference with dr Mark Goslin on thromboembolic disease challenging the conventional wisdoms and algorithms Thank you and have a wonderful day. Thank you