0:00

Let's talk briefly about how you select

0:03

what modality you are going to use for a breast biopsy.

0:07

Generally speaking, if you can see a lesion well

0:10

by ultrasound, I would use an ultrasound-guided biopsy.

0:13

If you cannot see it by ultrasound,

0:15

but you can see it stereotactically, EG calcifications,

0:18

you'll do a stereotactic biopsy.

0:21

And if you can only see it on an MRI, in neither of the

0:24

above, you will do an MR guided biopsy.

0:27

There are a few caveats to this,

0:28

however, um,

0:29

sometimes you can have a lesion which is very obvious

0:32

mammographically, but quite subtle by ultrasound.

0:35

Um, architectural distortion is sort

0:36

of the typical example for this.

0:38

And you can be concerned in a situation that when you get

0:41

that local anesthetic in, it's gonna get very obscured.

0:44

And in these cases I would just go straight

0:45

to stereotactic biopsy if that is an option for you.

0:50

There are sometimes you are concerned about the concordance,

0:53

particularly on MRI patients who have non mass enhancement,

0:58

very small lesions or larger breasts.

1:01

You may want to go straight to an MR guided biopsy

1:04

and just skip the second look ultrasound altogether.

1:07

There can be some big differences in

1:09

where a lesion presents when you've got a patient moving

1:12

from the prone position to the supine arm elevated position.

1:17

And in fact, a lesion can appear in a totally

1:19

different quadrant.

1:21

And there's a lot of papers out there about this

1:23

with mammographic lesions.

1:25

You need to be careful. Make sure

1:27

that everything you are seeing on the ultrasound correlates

1:31

well with what you're seeing on the mammogram.

1:34

So how do we decide if the mammographic lesion is the same

1:38

as what you're seeing by ultrasound?

1:40

You need to check the shape.

1:42

If it's irregular on the mammogram,

1:44

it should be irregular on the ultrasound,

1:46

not sharply marginated, you want

1:49

to look at the size of the lesion.

1:51

There can be a little difference when you have some

1:53

compression on the mammogram

1:54

and you don't have that compression on the ultrasound,

1:56

but it should not be more than a millimeter or two.

2:00

You need to know what radiant

2:01

or clock face, it's at distance and nipple.

2:03

We'll talk about a little bit more.

2:05

How deep in the breast are you expecting to see it?

2:08

What are the margins like

2:10

and what is the surrounding parenchyma?

2:12

All of these need to be concordant

2:15

between the mammogram and the ultrasound.

2:18

Let's talk a little bit more about how distance

2:20

and the nipple can be discordant

2:22

between the mammogram and the ultrasound.

2:24

So looking at this red lesion here, well, yep, this is,

2:29

you know, maybe five centimeters from the nipple

2:32

on the mammogram.

2:33

And here on a, the, um, ultrasound kind of fake out here

2:37

of the mammogram, indeed it is also five

2:40

centimeters from the nipple.

2:43

But if we look at this yellow lesion here,

2:46

also five centimeters from the nipple measured

2:49

by the mammogram, it is directly behind the nipple

2:53

when we look by ultrasound.

2:55

Now you need to communicate this very clearly

2:57

to your ultrasonographer when

2:58

They go in and scan and when you back scan to make sure

3:02

that you are looking at one in the same lesion.

3:05

Lesions can also change the orientation between

3:08

how they present on the mammogram.

3:11

Remember, the patient is upright,

3:13

their breast is being pulled forward and compressed,

3:16

and how it can appear

3:18

on the ultrasound when they are lying down, um,

3:22

and their arm is elevated.

3:23

We see this commonly with cysts.

3:27

And here's an example with this particular rather lobulated

3:32

complicated cyst, how it's orientation changes from a more

3:36

perpendicular orientation with the mammogram

3:40

to a more parallel orientation on the supine ultrasound,

3:45

think about what sort of tissue does your lesion live in.

3:48

Is it in the middle of some dense tissue on the mammogram?

3:51

So therefore it's gonna be in the middle

3:53

of dense tissue on the ultrasound,

3:54

or perhaps it's in the middle of more fatty tissue.

3:57

Again, very important you do this correlation.

4:00

There may be some cases where you really try to do it

4:03

by ultrasound, even if perhaps it's better seen

4:06

mammographically or even by MRI, for example,

4:10

very superficial lesions, patients who have implants

4:14

with little native breast tissue, very rich ola areas,

4:18

thin breast, kind of same theme going here,

4:21

and sometimes frail patients who are just not able

4:24

to withstand a stereotactic on Mr.

4:26

Guided biopsy.