0:00

What's challenge number four?

0:03

Think about this lesion.

0:04

Now here, this is on the diagnostic exam.

0:08

So our grid of our, um,

0:10

biopsy device is usually gonna come out

0:13

to something around here.

0:15

And when you have these extremely postal lateral lesions

0:18

like this, and you can see on the sagittal quite

0:21

how posterior this is right up against the chest wall

0:25

and pectorals muscle, that's not going

0:27

to be in the area that you can biopsy.

0:29

You can't biopsy in most devices above the area of the grid,

0:34

there's a sort of plastic sheet there

0:36

that you just can't go through.

0:39

So what can we do?

0:40

Um, these postal lateral lesions are particularly a problem

0:43

in ladies who have smaller breasts

0:45

because usually in ladies who have larger breasts,

0:48

they fall forward and we often have to take the padding out,

0:51

that by itself, you know, just put a towel

0:53

or something in to make it a little

0:54

more comfortable for the patient.

0:55

But that can help taking the padding out

0:57

of the coil out the table.

1:00

Um, we kind of roll the contralateral side up.

1:03

I'm gonna show you a diagram that'll make that more obvious.

1:05

And then it's really important you let the technologists

1:08

know in advance that they really need to pull

1:11

that posterior lateral tissue down

1:13

and they can do a lot to positioning.

1:16

Um, Mr Techs

1:18

or mammography techs

1:19

who do breast MR positioning really need to learn

1:23

how to do good positioning.

1:24

And we used our mammography techs to teach the Mr Techs,

1:28

and now the Mr Techs, um, can do it by themselves.

1:30

It's not a natural thing for Mr.

1:32

Techs when the positioning other organs to be, you know,

1:36

kind of yanking down and pulling something into a coil.

1:38

The way that you really have to for this,

1:41

when you do your pre gadolinium sagittal image, you want

1:46

to really make sure that that area

1:48

of interest is within the grid.

1:51

So I'm going to look at my landmarks,

1:54

my breast parenchymal landmarks, try

1:57

and guesstimate where I think that lesion's gonna be,

2:00

and then scroll back

2:01

and make sure it's going to be within the grid

2:03

and not outside the grid.

2:04

Because this is the time if you need to reposition, you want

2:07

to do it before you give the gadolinium.

2:09

And if I don't need, if I, um, don't think it's going

2:13

to be within the area, we'll stop the scan,

2:15

the text will go in, they'll play around more, trying

2:17

to get more postal lateral tissue down

2:19

before we start again, when you're doing the biopsy,

2:23

because you're going to be in the top row

2:25

of holes in the grids, I'll show in a minute.

2:27

You normally have to take the, um, the coil out

2:31

and then later place it in

2:33

below the needle when you put them back into scan again.

2:36

And if nothing else works, it's just so postal lateral,

2:39

you don't think that you're gonna be able to get at it

2:41

and it's not visible by any other means.

2:43

Then you can do an mr guided needle lo without the needle

2:47

guide so that you can angle the needle up

2:49

towards the chest wall.

2:51

Now why would I do a needle look like this?

2:53

And I wouldn't do a biopsy like this

2:55

because I'm not that concerned about sticking a,

2:58

You know, 18 gauge needle into, um, somebody's chest wall

3:03

where I am extremely bothered about putting a nine gauge,

3:07

um, catheter into someone's chest wall.

3:09

So you can get away with this.

3:10

You may end up embedding it a little bit in pectorals,

3:12

but that's not such a big deal.

3:15

So just to show you what I meant by rolling up.

3:17

So this is a patient who has a very poster lateral lesion.

3:20

And these, this time, the patient's positioned

3:22

as they should be with their nipples straight.

3:25

This is their grid coming from a lateral approach

3:27

of a right-sided breast lesion.

3:30

And this is with I roll their left side up.

3:32

So we, so we literally just roll them up,

3:34

we put a triangular wedge underneath them,

3:37

the tech will pull that tissue down,

3:39

it rolls a nipple to the other side.

3:41

And you can see now that we look at those images,

3:43

we are within the grid.

3:45

So when I have my sagittal images on this patient

3:49

coming this away, as I scroll back

3:51

through my sagittal images, I'll see

3:53

that I'm within the grid.

3:55

I'm not up here, up here. We can't get at.

4:00

So as I said, that needle block is going

4:03

to be going into the most posterior row

4:06

of the grid like here.

4:08

And so the coil, which is usually up here against

4:11

that po covering up the posterior row, will have

4:13

to be put below it.

4:18

So just to give you an example here.

4:19

So this is a subtraction from the diagnostic study showing a

4:23

poster lateral image in a patient

4:25

with small breasts that we wanted to biopsy.

4:28

And again, on the diagnostic sagittal image,

4:30

you can see it's way back here.

4:31

So this is nowhere near where the grid's gonna be.

4:36

So this is the diagnostic study.

4:38

I just flipped it over to give the same visualization

4:40

as we see when we're doing the biopsies.

4:44

This is the patient in the scanner

4:46

and this is her diagnostic study.

4:48

This is her biopsy study where they've really pulled down

4:51

that lateral tissue, look at the shape of pectorals.

4:53

So the pectorals muscle is nice and smooth here,

4:59

and it's pulled down in a V here, which tells you

5:01

that the technologist has done a really good job.

5:04

Now, actually as it happened,

5:05

this little enhancing thing here was actually

5:08

these vessels here.

5:09

And this lesion did not enhance the time

5:11

of the biopsy study, which we'll talk about later.

5:15

Here's again on the sagittal study from the

5:17

diagnostic study here.

5:19

Now if you look, all

5:21

of this retro glandular fat here was not visible.

5:24

It was all a faced against it.

5:25

So this area here is this tissue here

5:29

and see how things have really been brought forward, um,

5:32

by a good technologist.