 Hello, and welcome to noon conferences hosted by MRI online response to the changes happening around the world right now and the shutting down of in person events. You decided to provide free daily noon conferences to all radiologists worldwide. Today, we're joined by Dr. Carolyn De Benedectis, who is an associate professor of radiology at the University of Massachusetts medical school. In addition, she has the roles of vice chair for education and radiology residency program director. A quick reminder, there'll be time at the end of the hour for a Q&A session. Please use the Q&A feature to ask your questions and we'll get to as many as we can before our time is up. That being said, thank you so much for joining us today. Dr. De Benedectis, I'll let you take it from here. All right, so some of you might have been able to join me for my first breath intervention lecture where we covered some parts of breath intervention. Today, we're going to cover ultrasound guided procedures. Thomas and the Cincinnati biopsies need a localization and savvy scout localization to sum up procedures and breast imaging. So what are the most common ultrasound guided procedures? Well, we can do a lot under ultrasound and it's honestly my preferred way if I can to do biopsies. I think it's more comfortable for the patient. Let's take more skill in the radiologist part, but it's quicker. The patients are happier and it takes less time. So the things we do under ultrasound guidance are final aspirations of both masses within the breast as well as axiolins notes. We can aspirate this. We can do core needle biopsies and we can do needle localization or savvy scout localization. Transducer selection. So when you're doing ultrasound guided procedures, you want to make sure you have a high frequency transducer at least 7.5 megahertz or higher. You want to focus on the near field to a depth of three to five centimeters and you want to make sure it's a linear array transducer. This is an example of a linear array transducer. So it's not that body transducer you guys use for your other rotations that's curved. This is flat. Before you do the biopsies, you want to make sure that the patient has been asked for an NSAID clavate for five days. If they're on Covenin, they must be up long enough at my institution. The rule is for an INR to be 1.2 or less. Again, you need to check with your specific institution on what they do. You want to stop heparin or lobenox at least 24 hours before. The one thing I drill and drill and drill into my residence is before you even start the procedure to identify the pectoralis muscle on the screen. Sometimes it might be so deep that it's not even in the image. So what I always tell them to do is have the test increase the depth so that they are guaranteed that that pectoralis muscle is far, far away. Because, honestly, the only time you can really do significant harm to a patient during a breast procedure is during an ultrasound biopsy if you violate the pectoralis muscle and puncture the pleura of the lung. You can cause a pneumothorax. So it's really important that the first thing you always do prior to starting a procedure is to identify the pectoralis muscle. You need to remember that objects and distances appear greater than they actually are. The image is magnified. And we went over the pneumothorax warning. So this is what I usually do. The first time I have a resident do a procedure is I will bring up an image from a ultrasound of biopsy we're doing. From that ultrasound, the pre-procedure ultrasound, I will have them identify all of the structures. So it's really important that you know the structure. So this is the skin here. And then here's our mass. This is all tissue here. But then this is the pectoralis muscle here. It's hypoachroic with some echogenic striations within it, okay? Right there. And then this echogenic line with dirty shadowing behind it is the pleura. Now this looks like it's really far apart, but the truth is this is a matter of centimeters. So you have to be really careful. So here this is when the procedure has already began. And you can see the needle coming in here. And notice that the needle is flat. You'd always rather to come in shallower than come into steep and end up within the pectoralis muscle or worse within the lung. So you want to make sure you explain the procedure prior to starting. I always take the patients through every single step from cleaning them off to numbing them to the biopsy itself, to placing the clip as well as any post-procedure mammograms that will occur. I always explain the risk. We include pain bleeding infection routinely. For pain, I just tell them that it's at any point they have pain. They have every right to tell us to stop and we want to know and we'll give them more numbing medicine. And that makes them feel a lot less anxious. And then bleeding is really a hematoma. I tell them it's really not like you're going to bleed to death. That it's more like you can get a large hematoma and these can last up to two months and can cause cosmetic discoloration. Infection, the rate of infection is less than 2%. Pneumothorax and chest tube I don't routinely consent for unless there is a reason to. For example, if I have a super, super, super thin patient or I've had patients that literally there's the skin, the mask and the chest wall, you know, I will consent them for that. But you really should never cause a pneumothorax, you need a chest tube. And then if the patients have implants, I always, always, always consent for implant rupture. And I actually, when we used to have paper, now we're all electronic, I used to actually have an initial right next to the word implant rupture in the wrist so that it was clear it's been explained to them. Again, give the patient the opportunity to ask questions and make sure you address all of them. This is a super important part of doing breast procedures. Patient positioning, you want to make sure they're supines. So, you know, we've all learned that it's always better to take your time to position the patient so that you feel you have the best and safest approach than to just be like, oh, it's okay, I'll make do because that's how problems happen. So you want to make sure the patient's supine you want to roll the patient on a wedge away from the side of the biopsy so that the, you know, the breast is falling and the pack is planting down. You want to have their arm up over their head. The way they would purchase a breast physical exam, and you may need to turn the structure to the opposite side so that you're not reaching across the patient you always want to have the breath that you're doing the procedure on closest to you. So proper positioning of the patient would be like this, the ultrasound should be on the opposite side from the breast you're doing the procedure on. Whether you hold the probe or the tech holds the probe, it should still be on the opposite side. And then you should be closest to the breast you're doing the procedure on. So you really want to make sure you've looked at the images before you start the procedure. This is the most important thing in all image guided procedures you want to localize, locate the image on the lesion. Sorry, locate the lesion on the image. You also want to make sure you've read the diagnostic reports early to make sure you're biopsying the correct lesion a lot of patients have multiple different lesions and you want to make sure you're biopsying the correct one. When you actually get in there and you put the probe on before you put the needle in you want to put Doppler color Doppler on the lesion and the area around the lesion to make sure there's no large vessels in the path of the biopsy device. So just do your best to avoid those to avoid hematoma. Again, always double check the lesions relation to the pectoralis muscle and ensure you are far away from it. So just quick things on local anesthesia. We, at my institution, we use 1% buffer lidocaine we use when we see a bicarb to every 10 species of lidocaine. Not always possible. There's been shortages of bicarb over the last few years, but it is nice if you can buffer it, it's things less for the patient. I always tell my residents you always want to have a skin wheel, a good size skin wheel that leads to a lot of patient comfort because if you move the needle, they don't keep getting a stick in the skin if the skin is numb. Then you want to numb the path up to the lesion. I also tell them to numb around the lesion either above or below. We say to use the hydro dissection technique if the lesion is too close to the pectoralis muscle or the skin, and I'll show you what that is, but it involves dumping a nice pile of lidocaine either inferior or superior to the lesion depending on where you need more space to kind of create space, a virtual space between the lesion and the other area that you do not want to go through with the needle. If there's significant vascularity in the lesion, you can use lidocaine with epinephrine. Epinephrine causes vasoconstriction in the lesion and will decrease bleeding. What are the pros? Well, when you're there, there's less bleeding and you feel better, right? The radiologist feels better because we're not seeing a lot of bleeding. What's the cons? When the epinephrine lays off, you can get delayed bleeding and the patient is now out of the office and having bleeding. So I tend not to use lidocaine with epitone on ultrasound-guided procedures because of this, but if something's really vascular, I will do it to decrease the chance of an immediate post-biopsy hematoma. If you are going to use it, I always do a quick screen for any major cardiac issues. Again, if you're not using a lot, it's a minimal amount of epinephrine and it shouldn't be an issue, but again, always screen for anything, especially allergies, et cetera. Usually when patients aren't being monitored, the traditional teaching is you only want to use up to 30 cc's of lidocaine total for a procedure in the same day. You know, there's varying opinions on this. Is this the safest thing to do to be like really sure you're not going to have an adverse event, right? Because lidocaine tend to have cardiac toxicity, of course. But sometimes it's just not possible now because our imaging is so much better. Sometimes we're biasing two and three lesions. It's not more an abreast and sometimes 30 cc's doesn't cut it. But you should try to stay as close to this as you can when possible while still maintaining patient comfort. So this is a hydro dissection technique I was telling you guys about. Mainly we use it to create space between the pectoralis muscle and a lesion. However, you can also use it if the lesion is too close to the skin to make sure you don't go through the other side of the skin. So what you want to do is you want to aim your needle right at the perfect corner where you get a nice angle between the lesion and the pectoralis muscle. And then you just want to dump a ton of lidocaine there. And what it should do is it should create a tissue plane. It should hydrate that between tissue planes and create a temporary pillow almost between the lesion and the pectoralis. And this just gives you a little more room. So when we do ultrasound by this aspiration, you can use any size needle you want. It just depends on the thickness of the fluid. So if you see simple fluid start with your 21 or your 20. However, if you see a lot thicker fluid you'll probably want to upgrade to your 16 or 18 and sometimes it's really, really thick. And this is all even use a 13 gauge introduce your needle from the bar biopsy device to to suck the fluid out. When you aspirate the fluid from assist aspiration you want to know the color and amount. Again, always staying parallel to the chest wall. At our institution we just guard fluid unless it's frankly hemorrhagic or dark maroon or dark brown. Generally hemorrhagic fluid can assist can be due to a papillary carcinoma in the wall. Normally you'll see a mural nodule it's very rare to aspirate assist that doesn't have a mural nodule or a really thickened wall. But if you ever do aspirate frankly hemorrhagic fluid the safest thing is to send it to psychology. So why don't we send the other colors of fluid to psychology. We don't because a lot of times assist is sitting around with this fluid in it a long time and you can get false atypia as a result because these cells have kind of been sitting in this fluid for a while and kind of start to look funky. And even though they're not really a typical they look a little funny and so a cytologist can't call them normal. You always want to aspirate assist completely if you can and on post biopsy images you want to confirm that it's resolved. If for any reason assist does not aspirate completely you want to convert to core biopsy. Because then there's a worry that this is not just a simple benign system or simple complicated system. Sometimes you may need post aspiration films if there was a mammographic correlate to ensure that mammographic correlate resolved. If you ever actually aspirate assist that you thought was a mammographic correlate and the mammographic correlate persists then you need to move to stereotactic biopsy of the mammographic correlate if it's worrisome. So here's a typical assist aspiration you take your needle this was probably you know a 20 gauge or 18 gauge you put it into the system you suck out the fluid and then you document the post assist aspiration how there's no fluid left. Recurrent breast is 40% of breasts that are going to recur by two years recurrence of assist due to the presence of cancer on the wall is extremely rare. There's no scientific reason to re aspirate honestly you should only be aspirating simple for two reasons one you need to resolve a mammographic finding and you're unsure if the system fully correlates with it or to the patient a significant pain or just comfort from the pain. Honestly, otherwise you should just leave simple this alone. Some surgeons may if it recur ask you to core the wall. That's up to the surgeon. It's not playing I recommend. However, if you do have a complex this which has real modularity or thickened wall. There's no question that you should core it. It's not a complex this complicated this and simple this can be aspirated and if they fully resolve your fine but complex this should always be court ultrasound guided FNA. Again, we talked about this they can be used on a axillary lymph node or solid lesion that's too close to nipple implants or other things like the chest wall to safely do it. I actually did one of these I had a patient that was close next to me who had implants that were quite large in and there was very little space between the lesion and implants so I FNA that instead of court it. The way I perform is I use 21 gauge needle with a syringe and perform active suction the entire time using the syringe as I'm FNA. I usually do three passes and I put it inside a light and send it to psychology. This is an example of an FNA in a lymph node. So this is the big lymph node with lymph node you want to make sure you're taking the samples from the cortex which is hypocoic, not the echogenic. Highland, and that's very important that you take yourself from the cortex because that's where the cancer will be. So ultrasound guided corneal biopsy. There are multiple devices. Again, this is the real one you have to be careful with. Okay, this is the one procedure. Yeah, the FNA you could cause injuries to but this is the one where if you're going to cause an injury is going to be during the core biopsy with the spring loaded device. So there are plenty of spring loaded biopsy devices we use 14 gauge most commonly. There's the Bard monopsy. There's the achieve there's the vacuum assisted devices that are 14 gauge called the finesse. There's also a 12 gauge vacuum device from salaro or the finesse. Most of these have a throw. For example, the Bard monopsy is the one I'm going to talk about today because it's the one I use. It has a 2.2 centimeter grow. It has a one point XM sorry that's a type of it should be a 1.9 centimeter drop. And the total length of the needle vary. We use a 10 centimeter total length needle. It also comes in 13 and 15 but we only stock the 10 centimeter. So it's really important to read your package and understand understand the total length of the needle and which one you're using. Some devices can be deployed so that there is no throw two examples are the achieve in the salaro but there's also other devices that do it as well. And those can be used if you don't if you're if you're nervous about having a throw that you may be too close to other structures such as an implant or the pectoralis muscle or large vessel or something like that. I tend to not like this as much because I tend to find that I end up pushing FNA at that point, because a lot of times the masses are too difficult to fear with this already deployed needle, but it's a good thing to try first you can try to get a court and not FNA it. Most of these come with 13 gauge introducers or if there are 12 gauge they come with an 11 gauge introducer. And you use that so that you're only going through the skin one. So this is what I use and I'm just showing you the one I use this does not mean it's the best or the only one. There is definitely multiple devices that you can use. But this is a backfire spring loaded bar monopsy. What you do is you cock it twice clockwise using this green circle and then the green the light green circle at the back is the trigger to fire it. What happens here are. It's cocked like this and when you do the initial when you when you press the back button what happens is the trust brings out 2.2 centimeters from the distance when it was totally fully cocked and then this this sheet then cuts over it so that you end up with a core. And it all happens instantaneously. So I'll just invite about these I don't use skin incisions for 14 gauge devices. There are some exceptions if I'm close to an implant or close to the pack and I'm afraid the force I need to get through the skin could accidentally get me too far I will use a skin neck. You want to position the tip of the needle just proximal to the lesion if you talk to your pathologist and I really urge anyone that does breast intervention you should get to know your pathologist. You should really be close with your breast pathologist and you should talk to them about what they need, because your goal is not just to get the sample for the patient, your goal is to get the best sample for the patient so that the most accurate pathologic read can be performed. So I talked to pathologists pretty much through my fellowship and and being an attending to always ask them what they want and what most pathologists have told me is they don't want only the lesion tissue. They want you to have some of the normal tissue, the transition or capsule, and then the lesion, and that way they can make the best pathologic diagnosis. So you don't want to be within the lesion necessarily you want to be just proximal to it. Again, always make sure you're parallel to the chest wall. And if you can't be parallel to the chest wall you always want to make sure you're at least 2.2 centimeters from the pectoralis muscle how do you do that. Well you're going to put the needle into the device, and then you're going to have the technologist measure from the tip to the pectoralis muscle. I always tell my residents I just round up to 2.5 just to make myself feel better. So I know I have a little wiggle room. You need to make sure the needle is within the lesion after each biopsy what we do at my institution is we take one image in the plane of the biopsy and then we take an orthogonal image at least once and document it. The ACR guidelines do not say that you have to take this orthogonal image it's recommended but not required so for ACR certification if your institution does that. I don't need this image but I think it's great because if you get this cordon path, then you can show the pathologist and the breast surgeon hey I was right in the middle of it. Here's your orthogonal lesion. It's clear, the orthogonal image is clear I was in there. It's discordant. You know, I don't think rebiopsy is worth it. I think this needs an excision. At my institution we do a minimum of three to four cores with a 14 gauge or two to three cores with a 12 gauge. This is just an image of ultrasound guided biopsy from actually my one of the fellow. And you can see the pectoralis muscles down here the skin is up here it was a little deep I could not get completely parallel, but you can see my ectogenic needle going through my hypocoic mass and I'm well far away from the pectoralis muscle and pre level. So the specimen you can place the specimen directly in saline or on a saline so tell the pad, and then place it in formalin it's really important that you do not get the needle into formalin and then put it back into the patient. Every institution does this differently and what you guys are going to learn is some of you as residents rotate through different sites in different hospitals, some of you don't. So the ones of you that do, you know, it's really important that you ask each site, when they put a clear solution out in a cup, what is it, you want to make sure it's not formalin. Okay. Clearly it's helpful pad is always safe, but if they give you a couple of fluid and you want to make sure it's not formalin and don't assume just because one place gives you saline that all places give you saline right. We acquired a new hospital where I worked and I went to this new site for the first time to do a biopsy, and there was a specimen cup with clear fluid in it. I took the specimen out of the, you know, I took the needle out of the patient I opened the specimen I was just about to put it back in the patient and I thought, huh, let me just double check. I mean, who would ever tell me that, you know, put my needle in formalin. I said is that formalin and they said yes. So thank God I hadn't put the needle back into the patient. And from then on, you know, I asked them for a saline assessment cup full of saline that they could then pour the formalin into, or it's helpful pad. So it's really important to ask, especially when you're transitioning from residency to a new fellowship or from fellowship to a new attending job. There's a form of specimen rating graph on lesions if there were calcifications in the lesion. Again, if there were no calcifications on mammography within a lesion, this step isn't necessary, but if there were, it can be a nice way to confirm you've gotten calcifications and the lesion. Also, it's important to document the time out of the body from the for the specimen and the time into formula. And again, this is all to help your pathology colleagues get the best diagnosis possible. And then we send it to pathology or if it's a lymph node, we send it to psychology. It's important to know that if you want just psychology, you send it in at least at my institution, we send it in satellite, which I'm assuming is the same for everyone. However, if it's for flow cytometry, my institution likes it in saline or in our PMI or Hank. So it's always important to check with your psychologist. About what solution you should put your, your cores or your FNAs in. So definitely always really, this is why you need that open line of communication with your psychology department, your pathology department to make sure you're getting the best results for your patient. Micro markers. So before placing a micro marker, you want to confirm on the mammogram on the most recent pre procedure mammogram that there are no other micro markers in the same breast. So I always do this before I go into the patient. This is part of my pre procedure image review. So if there is a micro marker in the patient's breast, you want to make sure you select a different type of micro marker for each biopsy that way they can be easily distinguished if localization needs to be done. It's really important to remember that this is going to stay in the patient. And if this is denied, it's going to stay in the patient for a very long time. And it can be a night of infection if it gets contaminated. So I am super OCD. I'm sure it drives my residents crazy how I always do not uncover the tip of the of the introducer for the clip. Do not uncover it until you're ready to put it in the body and then uncover it. Make sure it doesn't touch anything until it gets into the introducer. So really be super careful. I have heard of a case once, not my direct patient, but an institution I was at where a patient had recurrent infection because, you know, the clip was not put in in a sterile way. So it's super important that you are really careful about this. Again, you also want to try to place the micro marker in the center of the lesion. And it's important to remember that it's a plunger device. So you actually want the tip of your, your micro marker introducer to be just proximal to center of the lesion because when you plunge it out, it's going to go a little further. And you always want to make sure you're not too far in the leisure also could plunge out outside of the lesion. The other thing I drill into my residence is it unlike the biopsy device where you can hub it and not worry about going farther than the introducer. This is not that case. The introducer for the micro marker is longer than the biopsy device introducer in most cases. So don't just hub it in there thinking that you're safe and it's going to stop. This could actually end up going to the pectoralis or an implant or something, some place you don't want it. So always remember that and watch, always watch the tip of your introducer as it's coming out of the biopsy introducer sheet to make sure you're not going too far. And then we always do a post clip mammogram to confirm placement of the clip and make sure it correlates with the mammographic finding if there was one. If there was a mammographic finding and your clip doesn't correlate with it, then you might need to do either a stereotactic biopsy of the finding on mammogram if it's concerning enough, or if it's not super concerning, you can do a six month follow up. So these are just an example of the clips. These are just the ones we use in our institution. Again, there are different ones everywhere you use. We call them breast fling and breast jewelry. We call them all sorts of things for the patients. But this is the introducer. And as you can see, there's always a lock. Every introducer is different. Some you turn it and line up to red dots. Some you just remove a sheet. Some you like this one, you have to push this red lock device and then push it and then so it's unlocked so it can go down. It just depends. And then these are them. The most common are ribbons, wings, coils or springs. And different companies have different coils, wings and ribbons. So it's good to say this is a barred coil. This is a, you know, I don't know why I'm blanking on another name. But you want to make sure you give the company sometimes because sometimes there's multiple different coils and they actually have a different appearance depending on the company. So Tomo guided biopsies. So we're moving on. We're now done with ultrasound guided biopsies and we're going to cover ultrasound guided localizations and savvy under those subsequent topics. So Tomo said this is guided biopsies. What's the indication for this? If it's finding is only found on Tomo and you can't biopsy it any other way. There's no ultrasound correlate. It can't be seen on 2D mammography to do a stereo. And this usually for the most part is architectural distortion that we biopsy this way. Not only there can be asymmetries and other things, but I would say of all the Tomo biopsies we do at my institution, over 95% of them are architectural distortions. This can be done upright. The device we have is done upright. And it's stereotypic guided and mammographically guided and we use a 10 gauge vacuum assisted needle. So here's an example of distortion. So this could only be seen on Tomo. We could not see it on the 2D. That's actually a calc, not a clip there. We did an ultrasound, nothing. So now we had to target it. First, you do a scout image to make sure we're in the right area. Then we do prefire images here. As you can see, this is the distortion here and these would be Tomo, but you know, it's hard to show Tomo on on on PowerPoint, but you can kind of see the distortion here as well. And you make sure on the 3D image that you're there. And the way this works is the patient is sitting in a chair the way they would for like a typical needle look. And again, there's a paddle with a open, open paddle that has square that's open just like a needle localization. And there's a biopsy device attached to the Mamo machine, at least in the system we have there's all different types of systems. So once you ensure that the tip is near the lesion, then you fire, you do the biopsy, and then you'll do a post biopsy image here to ensure that you're that everything's in the right spot. And then you deploy a clip. And you're good to go needle localization. So once you biopsied everything. So now we've done stereotactic biopsies Tomo biopsies and ultrasound guided biopsies. Now what do you do if the lesion you biopsy needs to come out, right? And the lesions aren't palpable. And so traditionally, way back when we only did need a localization and the goal here was to place a wire within the lesion of interest that has a thickener in it. And it takes a non palpable lesion and makes it palpable because it's the thickener and the thickener part is localized within the lesion. Then all the surgeon has to do is cut down, feel down for the thickener and it's palpable. And so we know the thickener is in the middle of the lesion. So essentially it makes a non palpable lesion palpable to the surgeon. And this is the only way we did these for many, many years. Actually, my entire training was only need a localization that no other real methods existed, maybe until my fellowship, but maybe not even then. These can be performed under mammographic ultrasonic or MRI guidance. Most of the time we use the modified copans wire or Hawkins wire. And as I said, the wires have the stiffener. So the needle that you use to introduce the wire is a 20, 20, a hollow board 20 gauge needles. And there's also a wire with a hook and a stiffener that's associated with the kit. And it comes in multiple links. So it goes by the wire link. And then each wire has the corresponding appropriate links needle within the kit. So I'm sorry goes by the needle length and it has the appropriate wire within the kit. So depending on the distance from the skin to the lesion, you pick the appropriate thing and they come in 357.5 and 10 centimeter needle length. So here we go. I think I started on this at the end of our last lecture. This is that 20 gauge hollow board needle that you see here. And this is your wire. So here's your wire and you can see this part here is thicker. You guys see that. And then there's a hook. So this is the part that you want to bury in the lesion and it's important to note that from the tip of the hook to the center of the stiffener is 1.5 centimeters and that's very important. Because what we do know is if you bury the needle. I'm sorry if you bury the wire at the hub to the first hatch mark. Okay. And then you unsheathe it. You need to have the needle 1.5 centimeters distal to the center of the lesion. Okay, so past the center of the lesion in order for when you want to sheet it. The thickness to be in the center of the lesion. So what you do is you put this needle 1.5 centimeters past the center of your lesion, then you bury the wire within the needle to the first hatch mark. And then you do a double hatch mark further up and once in a while you make a poor decision and you pick too short a needle and you can't quite get there. Then your option is to bury it to the second hatch mark. However, the problem is the needle has a cutting device at the end the wire doesn't and in a fatty breath the wire should go pretty easily without the needle and advanced where you need it. However, if you're in a dense breath sometimes the wire will not go it's not sharp. So that's why you really want to make sure you do great pre procedure planning, and you have the appropriate length needle. So as you can see well you're then when you do use the selling or technique, you hold the wire, and you slowly pull back the needle, keeping the wire in place what will happen is you'll slowly unsheathe the hook. Well then hold the needle and the wire in place so it doesn't fall out. And once you unsheathe the hook is hard to get the wire out and you don't want to have to get it out because it's very uncomfortable for the patient. So indications for needle we do localization for biopsy proven lesions for lumpectomy or excision so if it's a cancer for lumpectomy if it's atypia or a high risk lesion for excision. However, we can also localize lesions that are not amenable for percutaneous biopsy for an excisional biopsy. So approach like all procedures as I cannot stress enough plan plan plan know your procedure know your lesion know what you're doing before you get in there. It's like carpenters say right measure twice cut once right we want to plan twice and only biopsy once. So you want to approach the lesion in the plane where the distance from the skin is the shortest to the lesion. And that's really important. However, if you can't see the lesion, the shortest distance isn't going to help you. So once you decide on the shortest distance, you want to take a look at the lesion in the view that you'll be looking at it. So if you're going to come from superior inferior on Mamo, you want to look at the CC view and you want to say alright the shortest distance is superior. Let me look at the CC view and you look and you say can I see the lesion now if it's a clip is always easy to see a clip, but sometimes if it's calcifications or an asymmetry can be different. And you say oh darn I can't see it well you can't look sign you can't see so in that case, you'd move to the longer distance from the skin, if you can see it better. And then again, with your approaching for medial or lateral you want to look at the true lateral view to ensure you can see the lesion. For ultrasound and MR lobes we only go for medial or lateral. Okay, that's really important to know. So Mamo localization. For Mamo you want to, you can do two things. You can use Mamo localizations for loping a micro marker with inhalation seen on ultrasound. That's not seen on ultrasound. Sorry, you can use it for calcifications or masses that are not amenable to percutaneous biopsy that require pathologic diagnosis. Usually the patient is sitting in it in a Mamo chair. However, if you're going to go from below the patient is standing so below sometimes can be trumps by your patient. If you've got a fainter, let me tell you if you have a fainter or a super nervous nilly, sometimes going from below does not work well. The other time it won't is that the patient has a large abdomen. Then sometimes the abdomen is so large it creates a block the light and you can't get the shadow for the crosshairs. So things to think about with below. I mean you always want to go from the shortest distance but if your patients going to pass out multiple times, and you're not going to be able to do it going from below isn't really worth it. The patient is in compression for the procedure. This can be performed as a single wire. You can also do multiple single wires, or you can do two wires to bracket larger lesions or spans of calcifications. All right, so kind of the look here's what we do we put the breast in compression using an alphanumeric grid, we take a scout film and localize the leash on the image, and then we take the coordinates from the alphanumeric grid, and we localize where the lesion is. So you'll see you'll get like a, a two or something like that. And then we'll use crosshairs to do that on the breast so we can see it, and then we'll num the area. Once you're nice and numb, we place the needle so that the hub of the needle is at the crosshair. So it projects right over the crosshairs. Once that happens, we then reposition the patient in the orthogonal view. So if you start in the CC, you'll move to the 90. And then this is where on the orthogonal view you want to adjust the needle to be 125 centimeters past the lesion. Your goal is probably you always would rather have your needle past the lesion when you go to the orthogonal view, then to have it short of the lesion, because you really want to make sure you're moving in the plane in the correct plane. So you always want to go past the lesion. So I almost always if there's room with compression, get the needle as close to the hub as I can on the initial placement with the crosshairs, and then pull back. So you'd rather pull back on the needle in the orthogonal view than advance. Again, then you're once you're in the right spot and you've taken the images to prove your 1.5 centimeters past the lesion, you're going to put the wire in and deploy to the first hatch mark, then you're going to remove the needle over the wire using a pinch tip pull And then for the OR, we always take at our institution CC and lateral views with with just the wire in place and we also put a BB on the entrance of the wire, and we send it to the OR and that's what our surgeon likes again it's all about communication I can't stress enough. Communicate with your surgeons, find out what they like. Our surgeons also like us to measure the length of the wire outside the body, give them the total length and do the math to show them the wire, the length of the wire inside the body. Remember, your goal here is to make sure the patient gets the best care possible and the surgeon's able to do the best surgery surgery possible. So knowing what the surgeon needs to do the procedure accurately is going to make you a better radiologist and provide better patient care. So here's an example. We have this mask here with architectural distortion and and calcifications in it. You see our alphanumeric grid here so if I was to guess where our crosshairs where they're probably at f and seven. Okay, then we put the needle in to project the shadow of the needle directly over the crosshairs which we did and this is a hub of the needle right here. So now we're going to move to the orthogonal view. Here is the orthogonal view. And like I said, I have the needle and we're past the lesion. So then I'll measure 1.5 centimeters which this looks a little far so I probably pulled back a bit. Then I'm going to put the wire in. Then I'm going to use seldinger text meat to take the needle out and as you can see here, the stiffener is within the lesion and the hook is just distilled to the lesion to hold it in place. And then you can see here it's the post procedure images the CC in the 90. Again, you can see the the wire right at the clip and the mask and the hook just distilled and you can see the BB on the entrance to the skin as well as we usually do a nipple marker to I forgot to mention that. And same here and then when the surgeon send you the specimen, the surgeon is going to send you the specimen and what you want to find in the specimen is the lesion. Or clip depending on what was visible pre surgery and the wire. Now, this is where you serve a vital purpose. Okay. This specimen is not one that you call the OR and you say all good. Close the patient. Our surgeons at our institution wait to hear from us. If you look, the clip and the mass are on the edge of the specimen, which is going to mean either maybe they didn't get the whole lesion or the borders, the margins are going to be close, which would need the patient to have a reassession. So this is where you contribute hugely to patient care. You should get on the phone to your surgeon, you should say, you know, Dr so and so the clip and the math are really close to the X edge. Now, I don't know what happens at your, your institution at ours they ink the different margins so I'll look up. They'll send me a paper that says red is lateral green is inferior blue is superior. So let's say this margin is green, and it's superior I'll say you know Dr larkin, the clip is close to the superior green margin, you should re excise that before closing others will use a short and a long string to orient the lesion. And you can help them that way but this is where you really help your surgeon and provide really good patient care. So you want to always make sure the lesion is in the center of the specimen to ensure that the surgeon got good margins and got the whole lesion. And that's what they rely on you to do remember it's all a team effort. And we all have to play as part of the team with these procedures. Here's an example of a bracket just to show you so this was a span of calcifications that are hard to see projecting on this image with two clips. And so you want to do like parentheses and, and this is perfect or you want to be just outside of both of the clips right you don't want to be within in between the two clips, you want to create parentheses right if you have the word. And you put parentheses around it, you're not going to have the parentheses between the B and the R and the E and the T right, you're going to have it outside to be an outside the T, and you want to do that with a bracket look as well you want it outside of the area of interest whether it's the span of calc, or the clip. So as you can see on the orthogonal view here this is perfect just like parentheses right we're trying to put parentheses around the two clips. And we have it just outside just posterior to one clip and anterior to the other clip. And that is absolutely perfect for the needles and they're 1.5 centimeters just digital solution. We then put the wires in and as you can see here the stiffeners are projecting right where the clips are, and they're just outside of it. And when the surgeon does the specimen radiates, takes out the specimen and sends it to it. It's perfect. This is a perfect specimen. The lesions of interest are in the center of the specimen. We see both lesions of interest are clipped and we also see the wire. So this is perfect. So this is one where you can call your surgeon and you say everything looks great. You're good to close. Ultra sound low. So again we do the ultrasound look when it's clearly visible under ultrasound, i.e. a solid mass. However, it's really important what I do is I always look at the pre biopsy images. I look at how big it is and if it doesn't look very big. I then look at the post biopsy ultrasound images like when they document the clip in there. And I look and if I see solid mass because we've removed some and now there's a clip in there, I will convert to a mammal look. You don't want to look a clip under ultrasound. Some of these new beautifully seen ultrasound. These are some clips that are really meant for ultrasound like the hydra mark and things like that that create assist around them. If you have one of those, maybe it's possible, but I cannot tell you how many times I've been burned saying, oh yeah, I see the clip. I'll just look the clip and then you look on the memo and you're like, oh, I'm so far off and now you need to place another wire. They need to pull the other wire. So the safest thing to do is if you don't see the mask clearly on the post biopsy images or wasn't very big on the pre biopsy images to just convert and look the clip under memo. So why do I like ultrasound look? First of all, the patient is so much more comfortable. There's no compression. There's two kinds are much, much quicker. And of course, there's no radiation exposure. So if you can do it, this is a good way to do it. You want to localize the lesion under ultrasound, then you insert the needle through the largest part of the lesion. Of course, after you've administered lidocaine. And then again, just like with a mammal look, you make sure it's 1.5 centimeters past the center of the lesion and the tech can measure that for you. Then you deploy the wire to the first hatch mark. Again, do seldom here and then get post procedure mammograms. Okay, I remember you're always doing this in the medial or lateral because you want the whole length of the needle to be seen in the in the image. And if you were to do it from superior in here, all you'd be seeing is a dot. And you wouldn't be able to see the whole length of the needle, which would be dangerous and not accurate. So always do it in the medial or lateral again, where the lesion is closest to. As for length of needles, honestly, what I always use, I always use a 7.5 for an ultrasound look, you always need a longer needle than you think for an ultrasound look. However, if the lesion is very superficial, you know, close to the skin, I will go down to a seven to a five. And if the lesion is ever super, super deep, I'll go to the 10. I hate using 10 surgeon pay 10. You know, if you don't have to use a 10 don't use a 10 it's just too long, and they lose, you know, their, their land landmarks and their orientation. So here's an example of an ultrasound look on imaging. So here's my needle approaching my math. So my math is right here. Here's my pack right right here is my pack. Here's my flora. Okay, so we're going to come in parallel. We don't want to come into feet. You can see I'm trying to come in as parallel as possible. I then go through my lesion my tech measures 1.5 centimeters from the tip to the center as you can see right here 1.5 to okay I was point two millimeters off. And then I deploy my wire and take out my needle. And as you can see, look at the beautiful hook here, and the stiffener is right in the center of the lesion. This is a perfect look. Sorry, again, you do post procedure mammogram. And again, you'll get a specimen radiograph and you want to ensure the lesion isn't it we're a little close here but I think it was around leaving it was time to see it. But you still tell the surgeon, you know, it looks like you're pretty good. You might be a little close on whatever margin that says MRI look, this is done when the lesion is not accessible for percutaneous ever guided biopsy and can only be seen on MR. This is rarely done. I think I've only done two or three of these and the entire like 10 years I've been practicing. And it's really done and the truth is if you're going to do this, and it wasn't pre biopsies, the lesion, I always place a clip before I put the needle in. And that's so that when they have the specimen radiograph you can confirm it's in the lesion so always drop a clip, even for ultrasound or any other type of look you do if there is no clip present, you really want to drop a clip before you look it. And the other important thing to do is please make sure your localization kit, your needle and wire is MR compatible, right, you always want to make sure you're using an MR compatible needle and wire kit. Again, just like everything else, you'd image first so for MRI that means you're going to admit or contrast, you're then going to target the lesion again it's kind of like a stereotype technique with MR place that micro marker in the lesion if it hasn't already been placed. And then you're going to use your MR compatible localization needle insert at 1.5 centimeters past the enhancing lesion or in this point it'll probably just be a target marker because the enhancement the contrast will probably have washed out by them. Confirm the needle position then deploy the wire remove the needle. Again, additional MR images are done to confirm the needle and yet again. This is just an image as I said I don't have many images. This is actually not from when I personally did, but you know, it looks just like a biopsy the images are not really that great for an MR low. Again, you're coming from medial or lateral. Now we have something amazing, which is just totally. I think in my opinion is made my job so much less stressful on our days. So, when there are needle localization, the patient would come in that day for their needle localization and they already had no our time and we never fail that the first patient of the day would be a fainter and the surgeon would be calling where's my patient there. I'm just screwing up my time and the patient's passing out and I can't get the needle in or the patient's really difficult or the locust really difficult. Yeah, it never fails. This new savvy system is great because you can place the savvy scout. I apologize. Hold on, sorry. You can place the savvy scout anywhere from 30 days to the morning of if you so desired or the day before before the surgery, which means the patient comes in. No one's in a rush. No surgeon is waiting for you and I really like it. Um, so this is a savvy scout system. There is a guide, which is actually it emits ultrasound so that it reflects sound that reflects off the reflector. This is the reflector that you put in the breath. This is the reflector introducer, which kind of looks like a clip introducer. So really putting the savvy scout in is just like putting a clip in. Okay, so it's pretty simple and it's really great. And then you'll confirm we have one of these boxes, the console and the guide in our department and there's also one in the OR. And so we confirm the reflector works. And what happens is just it's kind of like, you know, with a Geiger counter as you get close to radiation at beef, when you get to the reflector this beat. So we will just ensure that it beats and we usually will mark the skin where the where the signal comes. The reflector looks like it's the size of a dime. This is the reflector here, but these are the antenna. So as long as the either span of the antenna is covering the lesion, they can get accurate localization. So what are the indications of contraindications and the same indications as Anita low for pre localization of non public lesion. So the absolute contraindication is a large hematoma at the site of the mass to be localized. You know, sometimes you do a biopsy and the patient gets this big hematoma. The problem is the heme and the blood interferes with signal transmission. So we can't do it until the hematomas results. The other thing is usually you don't want the lesion more than eight centimeters deep from one surface of the breath, because then sometimes it's too deep for the signal to come back. So we can make sure of that too. The other thing is you can undergo MRI in a three T or lower Tesla magnet after this is placed. However, you do get a big artifact from it, not horrible, but I think they should have their staging MR before the savvy scout is placed and that's why we don't place them, even if it looks like a cancer, we usually don't place these at the time of biopsy, because it is better to have your staging MR without the savvy and if you can help it. Modalities are placed and this is just taken directly from the savvy scout website. Again, it can place, it can be placed in the tissue, you know, for greater than 30 days. And it can be done under ultrasound MRI or radiography. So you want to make sure I'm sure they have an MR compatible. I have not done one of these under MR, but I'm sure they have an MR compatible one. Again, you probably you do not bring the guidance box into the MR right to do that outside, but this is just some of the instructions of what you can do, but it is compatible with all image guidance. So this is what it looks like. So I was looking this clip right so is that a and like 11 and a half. So then I put make sure the hub projects directly just like a meal localization over it. We then go to a different the different view, we can see the clip, we can see the device now instead of 1.5 centimeters past the lesion you wanted six millimeters past the lesion okay. So you do it six millimeters and that allows the reflector to be centered over the lesion. Also, if you can you want this to be answered to your clip now the clip is so much smaller than the lesion that if you happen to get it behind it. There's probably, there's probably still a part of the reflector that even though the clip is in front of it is available to get the sound wave, but they technically tell you should try to place an anterior if you can. So there's no chance the clip blocks the signal. And as you can see, I deploy it once it's deployed. Here is the savvy scout reflector here is the clip right anterior to it. Here's the savvy scout reflector here's the clip in the specimen you see the savvy scout reflector and the clip is nice and in the center of the lesion. So this was done accurately ultrasound placement again, just like ultrasound wire localization or clip placement, except this time you need to be six millimeters distal to the center of the lesion. So you want to put your tip six millimeters just, you know, this goes to the center of the lesion and here it's hard to see this one a little further than we had like this is the savvy here. So there's an antenna still in the lesion and that's what matters. And then you can see here is the savvy with the antenna near the lesion. You can also do savvy savvy scout placement just so you know in abnormal axillary lymph nodes it's really important if the patient's going to have neoadjuvant chemo that you place the savvy before chemo. Because once the patient has chemo the lymph node most likely is going to look normal and it's going to be hard to find that node. So this is just an example we place it in the cortex of the lymph node. And you can see the scat savvy here in the hypochoric cortex right here. And then you can see it on the film. Okay, and this helps them for some surgeons. And I'm sure really guarantee that the lymph node that was positive comes out and that they get the correct one note and this helps them with that. And that's it for my talk and I think I tried to leave I actually did not do the Dr. Graham part because I felt it would run over and people really know a few Dr. Graham set much anymore now we do MRI so I felt that I most people would rather me answer a few minutes of questions. And I will answer them. So can we aspirate complicated system are the complications yes you can ask you can absolutely aspirate complicated system that's a good way to ensure that it's a complicated system not a solid mess. The complications are the same as a regular this infection and bleeding. So, same complications. And yeah you can absolutely aspirate that complicated system if you need to resolve a mammographic abnormality, or if you for if you need to just prove it's not solid. If the tip touches the formalin is it possible. No, no to clean it off. No, the safest thing is to get a new needle. The safest thing is if it touches the formalin. If your needle touches the formalin just get a new needle, get a new needle and make sure it doesn't happen again. That's the safest thing I wouldn't try to clean it with alcohol or anything else, I would just get a new needle. Can you discuss performing a Thomas and this is biopsy and the lateral decubitus position for a lesion the lower part of the breath from when a from below approach would be the short distance so so we don't where I am we don't do this in the lateral decubitus ever. We will use the non shortest distance in this case, because we don't have the. We don't have the capability at our site to put a patient in a lateral decubitus position to do this. So what we will do is if it if it should if the shortest distance is from below, we'll then take the second shortest distance. So I can't speak to that as we do not do that. I'm sure there are places that do do it and I'm sure there's somebody who performed it that could answer that for you my apologies that I can't. Let me see if we have some more questions. Here's another one. If you need to use to give local anesthesia, the lesion is deep or near the pectoralis muscle. Good question. So I tend to use it for a regular numbing I use a 25 gauge. If it's deep or near the pectoralis. So if it's near the pectoralis, but the length of a regular 25 is fine. I still use a 25. Okay, if it's deep. What I'll do is I'll numb with the 25 first as far down as I can get and then I'll take a final. I'll use the thinnest final I can find to numb deeper to the lesion. So that's normally what I do. Another one. Which is the correct schedule and localize a mass on ultrasound. I don't fully know what this question is asking. Unfortunately, can you clarify. I'm happy to answer if it's clarified. If you're asking when to do it. You would want to, you can, if you're doing a needle localization, you do it the morning of the surgery. If you're doing a savvy, we usually do it a couple of days or whatever it's convenient for the patient. Usually when they do their preoperative visit. We will usually have them then come for their savvy. I assume that's what you're talking about. And that would be the same for ultrasound or. Mama. So sorry about if I miss under. I hope I understood your question. Another question. Non enhancement. Non enhancing mass biopsy procedure. So. Not quite sure what this question is asking either, but I wonder if what's being asked is what do you do if you see non mass enhancement on an MR. So people have different schools of thought. Non mass enhancement is not likely to be seen on on ultrasound. So right normally when we see mass enhancement on a MRI. We usually do a second look ultrasound see if we can find it on ultrasound and then biopsy it under ultrasound if possible if not we'll do an MR biopsy with non mass enhancement. I rarely do a second look ultrasound unless it's a really large area of non mass enhancement, and even then most likely you're not going to find anything. So for non mass enhancement, I usually go straight to MR guided biopsy. And you, and you do it the same way you do a regular MR guided biopsy. I hope that answers that question. And then hold on there's some chat things I want to make sure I covered them all. Oh, I think we're all set. So yeah. So any other questions. We are heading, we've got about two minutes if there are other questions and I'm happy to take them. All right. Oh wait, here we go. Cost of the savvy scout. So the savvy scout is more expensive than any localization I do not know the exact cost but I do know it's more expensive. We have our MAMO department and our surgeons all decided the cost was worth it for the efficiency. There's other things to there's a magnetic version there's a nuclear there's a radio nucleotide version. So there's all different versions of other non needle non wire localizations and you can compare costs I know the one that involves radioactivity is difficult because there's all as you can imagine all sorts of precautions with that one and God forbid you can't find it and the whole or be locked down. But there's, but definitely these new localization techniques such as savvy magnet scout than the radioactive one those are all more expensive than you need a localization I do not honestly know the exact cost of a savvy scout but it is definitely more expensive than you need a localization. Do you have do you use a clip. I'm sorry, hold on me because this will be our last question because now I think we just hit one o'clock. Do you use a clip with large lesion. Well seen on autism. Yes, I always use a clip. It's just always the safest it's better safe and sorry if if a patient is really losing it over the fact that I'm going to put a clip in them and it's a big lesion and they're like really freaked out then that would be the only exception but I would find it just absolutely safest to to use a clip always and be consistent. Last question, do you have a video on how you do a mammal low hook wire, I don't have a video. Personally, I've never made a video, you know, I've never made a video of me doing a look on a patient. Thank you everybody. I don't want to hold people over but thank you so much. I should bring this to a close. I want to thank you Dr Devin elect this for your time today and thank you all for participating our new conference. A quick reminder is coming to be available on demand at MRI online calm in addition to all the previous Please follow us on social media at the online calm for updates. And tomorrow, please join us for a new conference with Dr Suresh Mukherjee on head and neck. Thank you.