0:00

Challenge number 14, uh oh, your software has collapsed.

0:06

So various types of targeting software out there.

0:09

Um, they, uh, they're pretty good.

0:12

They, some of them are a little easier to use than others

0:15

and people get very comfortable with them.

0:17

And then for some reason you are in the middle

0:19

of your study, the images won't transfer from you

0:22

for you, you don't know what to do.

0:24

You are ing about the contrast is washing outta the patient,

0:28

you know, as you speak, the patient's getting agitated.

0:31

You need to know how to do a manual biopsy.

0:34

So if you're gonna do this along with me, um,

0:38

these are these PDF sheets that were downloadable for you.

0:43

So I'm gonna teach you how to do a manual biopsy, a manual,

0:47

sorry, manual biopsy, a manual targeting breast biopsies.

0:49

And to be honest, I can do this as fast as

0:53

I can use the software to find it.

0:55

By the time I've remembered how to use the software,

0:56

if we've had a long gap between mi guided biopsies,

1:00

like we're at the moment with COVID for some reason,

1:03

and really this is all you need to do,

1:04

you've gotta calculate how deep, how deep the lesion is.

1:08

You've gotta identify which grid square the lesion is

1:12

relative to the grid square that you have

1:14

that little fiducial marker image in that goes in there.

1:19

And then you want to identify

1:21

where within the particular square,

1:24

on the grid you are going

1:25

to be placing the needle into which of those holes.

1:27

And it's really as simple as that.

1:29

So I, if you don't have one of these as specific

1:32

to your needle

1:34

and your grid, I would highly recommend that you get one.

1:37

I'm just showing ATech 'cause this is the, uh,

1:39

particular one that you're using.

1:41

And I have one of these sheets

1:43

with me pre-prepared on every patient.

1:47

I do an MR guided biopsy

1:48

and if the software goes down, which it does, I would say,

1:51

you know, one in 10 times, um,

1:55

I can flip over to doing this.

1:56

Um, and very, very little downtime occurs.

1:59

So you want to make sure that on this sheet, first of all,

2:03

that you get the right sheet.

2:04

There are two of these sheets.

2:06

There's one that is lateral, lateral,

2:08

right breast or medial left.

2:10

And there's one that is lateral left breast or medial right?

2:13

So you wanna make sure you have the right grid

2:16

when you start the study.

2:18

Before you start scanning, make sure that the technologist

2:21

or yourself has marked where

2:24

that little Mr enhancing BB fiduciary marker has been, um,

2:28

placed within the grid.

2:30

And all of the automated

2:33

softwares use some kind of a marker.

2:34

Sometimes it goes into one set, um, grid position.

2:38

Sometimes it be put wherever the technologist wants

2:40

and I tell them to put it close to,

2:42

but not necessarily right at the lesion.

2:44

But you know, if your lesion's,

2:46

you think your lesion's gonna be up here posteriorly,

2:49

you probably don't wanna put them down.

2:50

The fiducial bout down in F three

2:52

because then it's gonna be miles away.

2:55

And then really what you're doing is playing battle

2:59

As one of my residents pointed out.

3:02

So you've got your fiduciary marker, you've got your sheet,

3:06

and this is the other side.

3:07

So this is the same.

3:08

This is the lateral right medial left,

3:13

and this is lateral left medial right.

3:14

Make sure you have the right grid or you're really

3:15

gonna get yourself confused.

3:18

So here we are, we're gonna walk through it.

3:20

So we have a patient who has a lesion that's in the lateral

3:23

and upper part of her right breast.

3:26

And I'll often just kind of sketch where I think it's going

3:29

to be on this to give the text an idea.

3:32

So in this case, I would think

3:33

that this is gonna be around B two.

3:35

So I would just put a little marker. It doesn't matter if

3:36

you're not exactly on.

3:39

So we're gonna go through a series of grid images.

3:41

So this is the post gadolinium

3:44

sagittal image in this patient.

3:46

And I'm at the slice that the, um, lesion is at.

3:50

We see enhancing nicely here.

3:52

So we do two things while we're at this.

3:54

We put an XA little take, bring the cursor up on the screen

3:58

and hold and put the cursor over the lesion.

4:02

At the same time. We're going to mark the depth,

4:05

which in this case the localization is 79.7.

4:08

So write that down. So on this grid back here,

4:12

you'll see it says depth of target here.

4:16

So you want to put the 79.7 here,

4:18

the depth of the grid face.

4:20

I'll show you how we find that. So here's our cursor.

4:23

We keep the cursor in the same spot,

4:25

like I'm keeping my arrow, um, on the computer here.

4:29

Let's keep disappearing

4:31

and we scroll back until we get to the grid.

4:34

Keep going, keep going, keep going.

4:38

Now there's the grid appears usually on three slices.

4:42

1, 2, 3.

4:44

And so I usually take, well,

4:46

1, 2, 3 coming out of it there.

4:50

And I usually take the middle one in this case

4:55

and I now work out which slice position.

4:59

97.7 is the grid face.

5:03

So your grid face, you see it on three slices by the dent.

5:06

Once we go further back than that, you'll see

5:09

that we are going

5:11

out the patient.

5:15

So there's my grid face, 97.7, write

5:19

that on your sheet as well.

5:21

The next thing I need to do is I need to work out

5:24

this in this square here that I can see my grid.

5:29

Where is the x? And I can see it's in the top right hand

5:32

corner of that X on the sagittal image display.

5:35

You see, here's the top right hand corner.

5:37

My entire square is like this.

5:40

So I say, so top right corner,

5:41

I know it's the top right hand corner.

5:43

And then I scroll back

5:45

until I can see the fiducial marker that's been put in.

5:49

And you can see that fiducial markers there.

5:51

And I wanna work out where my square

5:55

is relative to the

5:56

Square that has a fiduciary marker right in the middle.

6:00

So I can see from this,

6:01

I'm just gonna go back and forth a little bit.

6:04

Here's a square that has a fiduciary marker in

6:07

here's a square which was here.

6:09

Here's a square that has my, um, lesion in.

6:13

So I can tell that I'm one square

6:16

towards the patient's head.

6:17

Okay, fiduciary markers.

6:19

Here I am in this square.

6:23

Here I am one square towards the patient's head.

6:26

I'm in the top right hand corner.

6:30

I then do a series of axial images

6:32

and I check, do a double check for my depth.

6:34

And I measured my depth from

6:36

what I feel is skin surface here.

6:38

The grid face made it 19 millimeters

6:40

when I measured it here.

6:43

So now we take our grid, we said

6:45

that on the image view we were gonna be one square back

6:49

towards up towards the patient's head.

6:51

And we were going to be in the top right hand corner,

6:54

which would put us here, which is the corner

6:56

of C five with B six.

6:59

So I put a little marker there, I go on the image view.

7:03

I know I was in the top right hand corner right there.

7:08

I look at that number there.

7:09

And you can see that says C five.

7:10

I go to C five on the patient view.

7:13

I could see here I was one C.

7:17

So I go one C there and we're gonna be right here.

7:21

And you can look and say your C five would B six,

7:24

C five would B six, it's battleships.

7:26

Okay C five would B six.

7:28

So I know my depth

7:30

because I measured it off the axial image.

7:32

I also can subtract here

7:36

my target depth from my distal grid depth.

7:41

I get 18 millimeters. I know my depth is 18 millimeters.

7:44

I know I'm going in square C five,

7:47

I know I'm going in the upper right hand corner of it.

7:50

And so this is, um, a different patient

7:52

with a a different grid system.

7:54

Here. You're gonna go in, see the patient, you're gonna say,

7:58

all right, I'm going, I need

7:59

to be 1, 2, 3, 4, 5, 6 from the patient's head.

8:03

I need to be 3 1, 2, 3 from the patient's.

8:08

Um, three from the patient's chest wall.

8:12

I'm gonna put my needle block right in there

8:15

and I'm gonna go in that top right hand corner.

8:17

And I always have a second person

8:19

behind me holding the sheet, double checking what I'm doing.

8:24

So I get them to read it aloud. I read it aloud.

8:27

They check it. They say check you're in the right place.

8:29

You don't wanna stick it in the wrong place. It's, it's bad.

8:31

You have to start all over again.

8:34

Your depth as you remember, you're going

8:36

to set on the cannula usually has some

8:39

kind of a little rubber bug.

8:41

Um, with this particular system,

8:44

your depth measurement is the proximal side.

8:47

The hubs up here, the tip of it's down here

8:49

and that's where the 35 is.

8:51

Be very careful you check

8:53

with your manufacturer because some

8:54

Of them it's on the other side.

8:56

So, which is actually more difficult

8:58

because you can't see that side so well,

9:00

I prefer the ones that have this.

9:03

So this is our pre gad.

9:06

This is when we've put the fiducial in.

9:10

Here's our lesion. Now this particular fiducial,

9:13

there are two types of fiducials.

9:14

One of them have bright markers, which this one does.

9:18

That marks the entire biopsy cavity.

9:19

So I know my cavities here to here, lesions in the middle.

9:23

Other ones I showed you previously are dark.

9:27

And the tip of the dark point

9:29

should be the middle of the lesion.

9:30

So this one, the lesion goes in the middle

9:32

of the bright other ones I showed you previously.

9:35

The dark fiducial should be right at the tip of the lesion.

9:38

And then post biopsy, we have a nice fluid cavity there,

9:42

which will develop into a nice heat

9:43

hematoma if I don't suck it out.

9:45

But I can tell that I've got that lesion.

9:47

I actually don't vac dry, as I said until

9:49

after I've placed, um, after I've done this post image.

9:53

'cause I like to see the cavity.