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Hello, my name is Petra Lewis.

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I am the breast section Chief at Dartmouth Health.

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Uh, this is a series

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of videos on ultrasound-guided breast biopsies

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that I hope will not only provide guidance

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to those just learning this procedure,

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but also tips to more advanced practitioners in particular

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when they're doing challenging biopsies.

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We're going to start by talking about some

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of the indications for an ultrasound-guided breast biopsy

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or when a cyst might need to be aspirated.

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So when to do an ultrasound-guided breast biopsy on

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aspiration, well birads four and five lesions.

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In general, this video is not intended

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to be a comprehensive review of breast ultrasound

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and what lesions may fall into those categories.

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Uh, for that you'll have to look

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at some of the other videos.

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Birads three lesions on occasions may need to be biopsied,

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either because the patient requests it

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or the surgeon may request it.

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For example, before patients have, uh,

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neoadjuvant chemotherapy, they may want

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to have these lesions biopsied so they know what to do

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with them if they change

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or they don't change on subsequent imaging.

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If patients need symptomatic relief of large, simple cysts,

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we do frequently aspirate those

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and some complicated cysts need to be aspirated.

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In these videos, I'm only going

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to talk about core biopsies rather than

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fine needle aspirations.

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And why is that? Well, fine needle aspirations,

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they certainly have minimal risk, uh, much less likely

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to have hemorrhage, for example.

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However, they are significantly less sensitive than core

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biopsies with only about 74% sensitivity

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and inadequate samples up to 18% in, uh, multiple series,

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you need to have an onsite cytologist available,

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which is often not convenient.

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To get adequate sampling, you need to prepare slides.

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Core or vacuum biopsies are still low risk.

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They're not minimal risk,

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but they're certainly low risk, much more sensitive,

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about 93% sensitivity

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and a much smaller inadequacy rate, five, 7%.

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You don't have to have an onsite pathologist, you don't have

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to prepare the specimen.

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And these larger specimens allow for hormonal receptor

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analysis, ERPR, her two, as well as genetic analysis.

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So generally speaking, these are going

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to be much more preferred by oncologists.

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So when might we want

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to aspirate a presumed complicated cyst?

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Well, sometimes it's for symptomatic relief if this cyst is

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particularly tender or to relieve patient anxiety,

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particularly if you are planning for them

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to come up for follow-up visits.

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If you're unsure if this is a cyst

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or homogeneous solid mass,

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and in that case you would go onto biopsy if it did not

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aspirate, if it has some atypical features such as a thick

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or an irregular wall,

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although I would highly recommend doing a biopsy

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of the wall in this case rather than aspiration

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as a cytology is often indeterminate

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if there are mixed echogenicity

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contents and it's not clearly

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An RY cyst.

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And then finally, if you suspect infection,

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and I'm gonna talk briefly about cyst aspiration.

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So what do you need for cyst aspiration?

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Now, please know you always consent

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the patient for a biopsy.

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In addition to aspiration,

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we use a five centimeter 18 gauge needle,

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although on occasions you may need a larger bore needle if

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the contents are very viscous.

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Uh, we use a 20 cc syringe attached to, uh,

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just a little short length of tubing.

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And we usually actually have a second person do the

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aspiration while the primary, uh, person inserts a needle.

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Just makes it a little bit easier there.

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Now, what are you going to do with the

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contents of the aspirate?

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So if it's just clear, it's green, it is black, it's white,

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or it's just fluid tinge

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with a little pink stuff from blood, usually

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as the needle passes through the breast tissue,

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just discard it.

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Don't follow it up, don't send it cytology.

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You're gonna regret that you did that

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if it's bloody send for cytology.

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But you must leave a clip at the site

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where you did the aspirate because you've aspirated it.

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And if you have to go back, if it comes back

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as atypical cells, um, rarely, frankly malignant cells,

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you're gonna need to excise it.

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So you're gonna need to find it if it comes back.

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Ent small collections,

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you can just aspirate completely and send for culture.

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Um, large collections, you're going to need

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to put a drain insertion as well as culture.

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Um, and at least in my department,

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that means the patient has to go over

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to interventional radiology for that.

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But if that's something you do in your department, then

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that's fine Treatment, antibiotics

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and close clinical follow-up for reac accumulation.

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If you cannot aspirate the cyst completely

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or it's a failed aspiration, in other words, it's solid,

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just go straight ahead to do the biopsy and leave a clip.

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Now what about if it's not a complicated cyst,

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but it's actually a mixed solid

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and cystic mass as per the a CR Birads lexicon?

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Don't aspirate these, these need to be biopsied.

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I prefer to biopsy these with a vacuum device

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because you really need the solid component biopsied,

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not just the wall.