0:01

I'd like to go through one case to show from beginning

0:04

to end how I approach these biopsies.

0:07

So we're putting everything together right now.

0:11

One of the most important thing is planning

0:15

before the procedure is ever done.

0:17

The first step is going to be at the time

0:19

of the diagnostic evaluation

0:21

when the radiologist should specifically mention

0:25

which modality is recommended

0:29

when I'm scheduled to do procedures, and we may have 10

0:32

or 11 in a day the day before or a couple of days before.

0:37

I'm going to go through all of those cases.

0:41

For each one, I review all of the images.

0:44

I go back to the beginning.

0:46

So even the screening mammogram, I'll start there.

0:50

I'll look at all of the images, not just

0:53

to determine whether

0:54

or not I agree with the target that was recommended

0:57

for biopsy, but are there additional findings

1:00

that may require additional imaging or sampling?

1:05

And this is important to know in advance.

1:07

You don't wanna any surprises the day of the biopsy.

1:10

And also if there's additional imaging that needs

1:12

to be done, you wanna try to get that done

1:14

before the day of the biopsy.

1:17

By reviewing the images, you can determine whether

1:20

or not you agree with the modality

1:22

that was recommended for biopsy.

1:25

We also determine what approach we want,

1:27

whether it's superior, inferior, medial, or lateral, whether

1:32

or not we're going to use tomosynthesis or stereotaxis.

1:37

Do I need to change the needle that I'm going to use?

1:39

Do I need a petite, do I want to come

1:42

with a lateral arm approach?

1:44

And what do I think is the most likely diagnosis?

1:47

This is somewhat time consuming,

1:49

but very important to go through all of these steps prior

1:51

to the day of the biopsy.

1:54

The day of the biopsy, everything's

1:56

already been figured out.

1:57

You just need to communicate with your technologist.

2:00

What's the approach, the technique

2:02

and which needle you would like.

2:04

Also, go over the images with the technologist

2:06

to know they know exactly what the biopsy target is.

2:11

As I mentioned, I review all the images from the beginning.

2:15

So this patient was scheduled

2:16

for a mammographic guided core biopsy earlier this month.

2:21

Going back to the screening images, I see a group

2:24

of calcifications in the right upper outer quadrant

2:27

and a posterior depth.

2:28

She had also already had multiple prior biopsies

2:32

in both breasts.

2:33

Uh, Mr Guided ultrasound guided,

2:38

she was called back for diagnostic evaluation

2:41

of those calcifications.

2:43

I know they don't, uh, project very well here,

2:46

but the circle is showing you that there is a group,

2:48

small group of calcifications there.

2:51

These are new, these need to be biopsied.

2:55

Part of planning for a procedure is to determine which

2:59

Approach in this particular, uh, patient

3:03

the calcifications are in the upper outer quadrant.

3:05

This on the right is a CC magnification view.

3:08

And on the left an ML magnification view.

3:11

So these are closest to the lateral skin,

3:13

and we usually choose the,

3:15

the shortest distance for the approach.

3:17

However, there are times where we may modify the approach.

3:22

Um, one reason could be visibility of the target.

3:25

Sometimes calcifications are better seen on

3:29

one view than another.

3:30

And even though they may be a long distance, you may want

3:34

to come from a different direction.

3:37

Also, I consider where the needle entry site

3:40

and subsequent scar would be.

3:43

And I try to avoid

3:46

producing a scar on the medial

3:48

or superior breast if I have a choice.

3:52

Um, some patients do scar more significantly than others,

3:56

such as patients who form keloids.

3:58

So I'd rather bury the skin changes if I can.

4:03

Another thing to consider for the approach is whether

4:05

or not you would traverse large vessels going

4:08

to your target from a particular direction.

4:12

The choice of needles depends on your facility

4:14

and the manufacturer in my facility.

4:17

Um, we only have one gauge available. It's a nine gauge.

4:21

We do have different lengths of trough, uh, available

4:24

with this manufacturer that we use,

4:26

and we have two available, the regular

4:29

and the trocar petite, uh, not the blunt tip petite.

4:34

Going back to the, uh, patient

4:36

that I biopsied earlier this month, on the day

4:39

of the procedure, I communicated with the technologist

4:42

that I wanted a lateral approach.

4:45

Um, I was not going to use the lateral arm approach

4:48

where the needle was parallel to the plaintiff compression.

4:52

Um, just a standard approach from lateral

4:55

with a standard needle with a two centimeter trough.

4:59

And I wanted to use tomosynthesis rather than stereotaxis.