 And I thank you so much for your attention and if anybody has any questions, we have a few minutes remaining where I will answer questions. I see there's a couple already. So I'll go ahead and start going through those but feel free to keep adding them if you have any other ones. So our first question is are you using vacuum assisted biopsy device and what is the gauge. So for our, at our institution for our ultrasound guided biopsies, we do not use vacuum assisted biopsy device. For our stereotactic or Thomas and this is kind of biopsies we do use a vacuum assisted biopsy device. And it's a a nine gauge needle for our ultrasound guided biopsies we typically use a 14 sometimes an 18 gauge biopsy device. So my next question is, did you try hydro mark clip after stereo biopsy and did you notice migration. So that's a great question so we use hydro mark clips for our ultrasound guided biopsies and we really like it especially for cases that we need to localize in the future so the hydro mark clips are really well seen on ultrasound. We do not use them right now for stereo tactic biopsy or for MRI guided biopsy. I was concerned about migration I know I think our rep has said that the newer ones have have less migration but I will say right now we are not using those we're using other other types of clips. Although I think that there is benefits to those hydro mark clips to allow that because it would allow us to be able to do localizations. Using ultrasound potentially, especially for really deep findings. So my next question here is, is it fair to say that most beneficial of dbt is architectural distortion. I would say that the benefits of dbt are really two fold so one is identifying more cancers and those are often architectural distortions but they may be developing asymmetries. There are still even masses that are obscured by the surrounding breast tissue can be better seen with Tomo synthesis. And, and but I think that that category of improved cancer detection is definitely a benefit of dbt and part of that is our realtor distortion but I don't think all of it. The benefit of dbt however is the decrease recall right and I showed I showed a few cases where we can see that the that by using Thomas and this is we were able to clarify that a finding that looks possibly suspicious on a 2d mammogram really just represented normal overlapping breast tissue. I have struggled to stereo a deep calcification in the lower inner quadrant any tips so deep findings are are challenging sometimes with I'm stereotyping biopsies. There's definitely a lot of positioning tips. I think it's, it's, you know, sometimes you can try to have the patient put their arm through the table if you're in a prone position. Sometimes it'll out to get further back I would try both the CC and lateral view sometimes to try to get further back. And we're very lucky that we have multiple sites and some of our sites have a prone table and some have an upright table. And I find that that there are some cases where one or the other can help me get further back in a to get a lesion. And that is a challenge and I'm stay at those really posterior posterior calcifications. Sometimes it's just not possible, and we've definitely had cases where we are unable to do a biopsy and we will instead localize it and the patient will go straight to surgery but we really try to try to minimize that. The next question is, what do you specifically write in the Thomas and this report is a different from the mammogram report. We have a line that we include in our mammogram report stating that Thomas and this was used as part of the exam. It's just a one line that's added to the mammogram report. The next question is, do you have the facility to place a Tomo guided clip without doing a biopsy. So I guess the question is we have the facility I mean technically we would be able to do that we have, I think done that on very rare occasions. But that is very infrequent layer surgeons have a strong preference to have the pathology before taking the patient to surgery. So we haven't found a need to place clips without doing a biopsy on on very many occasions, we would usually do the biopsy and then place a clip there so that we would have an answer and and know what the pathology was before. Before a patient goes to surgery. And then the next question is, is there a scenario where stereo tactic biopsy is superior to Thomas and this guy at a biopsy, I currently only do 3d biopsy but was wondering in which scenario to consider 2d biopsy. I, you know, I showed I think that I've been really switching to doing more and like to doing just about all of my calcification biopsies even with Thomas and this is because I feel like it's, I can do the biopsy quicker. And I'm taking fewer images but I will say that there are there are some calcifications that are kind of subtle like some of those more amorphous calcifications where I feel like the 2d images, help me see the finding better. Because I, I might do a 2d biopsy. I think it's also helpful to have both possibilities so it's, it's, you know, sometimes I'll go back and forth where maybe I'll do my scout image with 3d but then my pre image I'll want to do as a stereo tactic pair, in order to better see the calcifications if I feel like they're somewhat obscured after giving the numbing medicine. I haven't done a full case using just serotactic in a while, but I will say I will definitely take serotactic images to help me sometimes for, especially for subtle calcifications. And the next question is to use Thomas and this is regularly for every case or in a few selected so we use. So for screening exams we would like to use it for all patients but unfortunately there are a few insurance companies still in the state of Maryland that don't cover Tomo synthesis so we do about 90% of our screening mammograms with Tomo synthesis. But that has increased over the past decade, dramatically, but we're kind of right around, we've been 90% now for the last few years. We call patients back, we do, we do Tomo synthesis for all of those recalled mammograms unless they're for calcifications when it's not necessary but we do all of the call back mammograms with Tomo synthesis because we find it to be very helpful in order to to limit our need for biopsies for findings that we could clearly see are just overlapping tissue with the Tomo synthesis. Our next case, our next question is how many cases in your, in your study had a normal study on Tomo biopsy. So I think you're referring to the the architectural distortion paper and the developing asymmetry paper so. So all of those patients had an ultrasound exam that was negative. All of them had a finding on their, their 3D mammogram that was considered suspicious and had a biopsy done in both of those cities, 20% of them turned out to be about 20% turned out to be cancer. So the 80, the other pieces were not were not cancers. So the majority of those cases did not turn out to be cancers but 20% is a, is a high enough number to definitely justify doing a biopsy for them, you know we usually buyer as for is anything over a 2% risk of breast cancer so when we're talking about a pre, a predictive value of 20% then that easily justifies biopsying those findings. The next question is any tips for biopsy in a small breast and yeah this can be can be challenging you know we have the petite needle which usually you can, it will allow you to do a biopsy up to I think it's 2.3 centimeters of thickness but they're definitely patients who have even smaller so there are some things that you can do to help you so you can give lots of dummy medicine to kind of create a little bit more breast tissue to use there is and when doing the when you're localizing you can remember that you're going to be taking. You're not, you don't have to exactly click on the finding when you're doing the biopsy you can click in front of it or behind it in order to allow your whole. The, the biopsy needle to be buried and have instead of the finding being exactly in the middle of your of your target could be towards the beginning or the end and that can be helpful to help to get the needle totally buried. On top of there being you know our normal needle and then there's a petite needle there's also a blunt tip needle that can be used for very small mall brassy have to have to get order that and have it separately but that's another option to be used for small breasts. I think also another another thing that I found helpful is being able to go back and forth between the CC and the lateral view sometimes want a patient will compress differently in one view versus the other and it might be a little bit thicker in one view to help you do the biopsy. The next question is what should you suggest Tomo synthesis or contrast enhanced mammography and I'm very biased because we do not do contrast enhanced mammography at my institution so I would definitely pick Tomo synthesis. I also don't think it's one or the other. I think they are both, you know I think pieces that that use contrast enhanced mammography are also doing Tomo synthesis. Tomo synthesis has a lot more data behind it and is a more universal modality than contrast enhanced mammography if you're only going to have one or the other. But there's a lot of exciting research coming out on contrast mammography so I'm excited to kind of see where that where that goes and where that's going to fit into our cancer work up. So there we have increased detection of micro calcifications I assume that is referring to with Tomo synthesis and I don't think so I don't know that calcifications necessarily have improved detection. I think that the benefits of Tomo synthesis are more specific for invasive micro invasive carcinomas which are usually not just calcifications. I think that there have been studies that have shown both both for that so I don't. I don't know all of the data that have on my head but I would say the benefit of Tomo synthesis is not necessarily for increased detection of micro calcifications but more for like masses and distortions and asymmetries like I talked about before. You know the next question is whether there's an absolute indication for Tomo synthesis and and no I don't think the answer right you know currently standard of care is is either 2d or standard full field digital mammogram or Tomo synthesis so we do think that there is there is sufficient studies to say that Tomo synthesis is has improved recall rate and cancer detection. But the standard of care is really for either modality and it's much more important for a patient to get a mammogram with either one than to not get one to then to not get one or to choose one or the other so I would definitely encourage patients to get a screening mammogram and if they can get it with Tomo synthesis I would always pick that but I would not say that there is an absolute indication for that. The next one is how do you encounter complications bleeding during or after the biopsy how do you handle it so you know whatever we're doing a biopsy there is definitely a risk for for bleeding. That's probably the most common complication that we that is the most common complication we see and you know I find that holding pressure is is almost always is going to is going to be successful sometimes it's a lot of pressure and for a long time. And if that is the radiologist or maybe there is a tech or tech eight at the institution that can help, but really holding firm continuous pressure until the bleeding stops. You know there are rare complications pseudo aneurysms that can occur I think that's really one off, but most of the time the bleeding really just requires pressure, continuous pressure until it stops bleeding. The next question is how much local anesthetic you give and how often does the target move. I do think this is sort of individual. You know I think, even when I did my my fellowship which is only a few years ago different, the different attendings that I worked with would be definitely inconsistent with how much in anesthetic each person use but I found that the most important thing is, is making sure that the skin is really well numbed. So, I want to give enough lidocaine in the skin to make sure I see a really a skin wheel that's very clear so it's usually about one to two ccs, you know sometimes if, if I end up if my initial injection is a little bit deep I'm not seeing a good wheel I'll put a little bit more in. And then I give deeper numbing medicine lidocaine mix with epinephrine. I usually drop out eight ccs and depending on how dense the breast tissue is and how deep the finding is I'll just slowly inject it in and out and usually give about five or six ccs but it is it is very, very very variable. I find that with that patients do not have symptoms typically during the biopsy but I do tell them if you're feeling anything let me know we can always give you more we are biopsy machine will automatically give additional lidocaine as we're taking the biopsy samples. And eventually we'll warn the patient they might feel like a few seconds of that singing sensation when we're taking the biopsies and that's probably the numbing medicine that's that's going to be that's at an area that wasn't totally numb, not the biopsy needle like causing causing pain and I think that is very helpful for the patients to know. The next question is do you have any data of dbt guided biopsy with implants versus stereo I don't have any data I think it would be interesting to see. You know I think with both you want to make sure that that implant is really pushed back as much as possible and is not in the images. I think I just kind of anecdotally I like using Tomas and this is because I think I can really scroll through the slices and see for sure that I'm not going to hit the be anywhere near the the implant which is with the with the angled images that sometimes it can be a little bit confusing of. If exactly the direction that your needles going whereas with the Thomas and this is you know you're just going straight down through the breast tissue. But I don't have any any specific data on that I think it would be an interesting interesting thing to look at. The next question is. Does needle localization ever helpful in lesions with suspicious. Calcifications. I'm not sure I completely understand that question but we do need a localizations for suspicious calcifications. I don't, we don't typically use Tomas and this is for our localizations usually do them with a upon American grid. But I think I know there's other institutions that are using Tomas and this is more for localizations that's not something that I'm, I'm actually that familiar with. And the next question is in our unit the clip placement has to be through the biopsy needle so on the rare occasion when we need to place a Tomo guided clip. We do not have the equipment to support this which equipment to use to facilitate Tomo guided clip placement. So this is probably a follow up to the question before asking if we have replaced biopsies with their biopsy clips without doing the biopsy. I also I'm not sure that we have a separate equipment I'm not sure there may be things that you can order. I think the very few times that we've done this before we probably had to just open up the biopsy the whole biopsy kit but I'm not actually 100% sure. There's something that you could ask your, your rep about if they would be able to separate and just get them the biopsy, like the introducer piece. But you would need to have a needle in it to get to the site so I'm not sure what you would need to do but I think that's something probably to talk more with your rep about I don't think that we have anything specific that we have different, I think we've just opened up the biopsy kit. The last question is, how do you biopsy lesions close to the skin. It's, you know, I sort of a similar answer I think to like how to biopsy in small breasts and I would say it can be really challenging, it can be really challenging and can be helpful to use the petite device. But if there's a lot of tissue behind you might not need the petite device I think a few things that you can do are to make a really big skin wheel that can add some additional depth for you to have to get the needle totally buried. You can also target slightly past where the lesion is on your stereotactic images, knowing that you're where you're targeting is going to be the middle of your biopsy device. So you don't necessarily need the lesion to be right in the middle so okay if it's closer to the proximal part of the needle. So if you target slightly past it, you can still often biopsy the lesion closer to the skin. So those are some tricks that I've done to try to get these very superficial biopsies, but I do I know they can be definitely be challenging. Well thank you so much for the for the discussion.