0:00

Challenge number nine.

0:02

Okay. Anybody want to biopsy this in this patient

0:04

with saline implants?

0:08

Not me. Thanks. So, um,

0:12

lesions in patients

0:13

with implants are a significant challenge

0:16

depending on where they are.

0:17

There. You can do some of these by Mr.

0:20

Um, we could not do this one,

0:22

we could not see it by ultrasound.

0:25

And we, um, decided that we really didn't want

0:29

to biopsy this and we just followed it in six months

0:31

and it went away, thankfully.

0:34

So obviously for implants we're gonna use ultrasound

0:37

or stereotactic biopsy for preference.

0:40

Um, MR is really last resort here.

0:44

Um, so what are we going to do?

0:45

We want to be able to displace it outta the,

0:48

the implant away from the needle track.

0:51

So we're going to use a similar sort

0:53

of implant displaced techniques

0:55

that we use when we're doing stereotactic

0:58

biopsies on these patients.

1:00

And you know, this is one you really want to have.

1:03

If you have your MR texts usually position patients for, um,

1:06

MR guided biopsies, I would highly recommend

1:08

that you bring one of your mammo texts over from the mammo

1:11

department to do it because they have the experience of, um,

1:15

obtaining implant displaced views.

1:18

Now remember the vacuum effect, in other words,

1:21

you don't want your vacuum needle if the chamber is facing

1:24

towards the implant to suck in the implant

1:28

and make a big hole in it.

1:30

You know, generally speaking,

1:31

it's not great if your patient comes in a C cup

1:34

and she goes out an A cup,

1:35

she's not gonna be real happy with you.

1:37

You'll know if you've done it

1:39

because it's going to make a very loud sucking noise

1:41

and you are going to see saline

1:43

or silicon disappearing up your vacuum device.

1:47

I always consent for implant collapse.

1:50

You need, even if you're miles away from the implant,

1:53

you wanna be able to consent for it.

1:55

When we place the needles,

1:57

I'll show you in a diagram at the moment, we want

1:59

to have our chamber directed always away from the implant.

2:02

So you want to put the needle in posterior to the implant,

2:07

you can do an mr guided needle lo excision.

2:10

The same risks have arise,

2:11

but they're probably slightly smaller.

2:13

And every now and then, the only way you can biopsy it is

2:16

to perforate the implant.

2:18

And I have done that.

2:20

Um, I've done it in patient where they've known

2:22

that they're going to have to have the implant replaced,

2:24

that there are high risk of this being a malignancy

2:27

and they're comfortable with that decision.

2:29

And obviously you want to have the plastic surgeons involved

2:32

and the patients see a plastic surgeon

2:34

before you have to do that.

2:37

So here's a patient with an implant

2:39

that's not displaced on the diagnostic study.

2:42

We have two lesions, one here, more anterior,

2:44

one here, more posterior.

2:46

The text done a good job of displacing the implant out

2:50

of the region of the grid,

2:51

but we're still not able to get at

2:53

that little blue lesion here.

2:54

We can now, however, biopsy the red lesion. However, we're

2:58

Going going to put our needle in posterior to the lesion

3:02

and we're going to biopsy towards the nipple.

3:04

We're gonna be very careful that we don't turn that chamber

3:07

around and start biopsying towards the chest wall

3:10

because the vacuum may suck it in

3:12

and you will make a big hole in that implant.

3:16

So putting it here in this case, I've used a petite needle

3:21

because, um, many of these patients, obviously

3:23

for the reasons that they've had implants placed,

3:25

have very little natural breast tissue.

3:28

And once you do the implant displaced views,

3:30

the breast is going to be very thin.

3:32

It may only be two and a half

3:33

or three centimeters at that width.

3:37

And using the small chamber with a blunt, um, distal end

3:41

to it is going to prevent you producing unnecessary trauma.