0:00

Now let's focus on selecting the

0:03

appropriate target for biopsy.

0:04

So which lesion or which part

0:06

of a lesion should be biopsied?

0:09

Here's some general guidelines you wanna biopsy the most

0:12

suspicious area.

0:13

So it is a very heterogeneous lesion, uh,

0:16

particularly if it's a mixed, solid or cystic lesion.

0:19

You wanna get the solid portion if it is a lesion

0:23

that appears necrotic.

0:24

Make sure you get the wall.

0:26

You don't want to get just necrotic debris.

0:28

If you're biopsying a cyst, you wanna get the wall of it.

0:31

Again, generally if there are multiple suspicious masses,

0:36

you biopsy all of them, but usually not more than three.

0:41

Um, be very, very careful to differentiate

0:44

between these different lesions

0:46

and use different clips for each lesion.

0:49

If you've got three

0:51

or more lesions, you may want

0:53

to just biopsy the most suspicious or the most distance.

0:58

So if you have a lesion in the upper inner quadrant

1:02

of the breast and multiple other lesions in the upper inner

1:06

quadrant, but also one in the lower outer quadrant,

1:09

you're gonna want to make sure that you have

1:11

that lower outer quadrant lesion biopsy

1:15

as this is really going to affect surgical decision making.

1:18

If you have a satellite lesion, you do not need

1:21

to biopsy that separately.

1:24

Just to confirm the standard nomenclature

1:27

multifocal lesions.

1:28

So when there's more than one lesion within one quadrant

1:30

of the breast multicentric when there's more than one lesion

1:34

within different quadrants of the breast.

1:36

And that differentiation used to be more important

1:38

as multicentric disease used

1:41

to mean the patient was always recommended for a mastectomy

1:44

that's no longer true.

1:45

Uh, patients with multiple lesions, multiple multicentric

1:49

or multifocal lesions may frequently end up now

1:52

having multiple lumpectomies.

1:55

Now, a satellite lesion is different.

1:57

That is when there are additional lesions which are two

2:01

centimeters or less.

2:03

And these don't need to be separately biopsied, as I said,

2:06

they'll be excised at the time, a lumpectomy

2:08

and they won't change the staging or other treatment.

2:13

Now, it is super important for patients

2:16

who have multiple lesions for the clinical management

2:20

that you have strict and consistent name ring.

2:24

Um, I'm gonna give you how we name ours.

2:27

Uh, you can do something similar,

2:29

but as long as you're consistent

2:31

and is very clear, which lesion is which,

2:34

and this same naming convention should be continued

2:38

through further imaging such as MRI, surgical management,

2:42

pathology and so on.

2:43

Do not change lesion one to be lesion two

2:46

at some point during the workup.

2:48

That gets very confusing.

2:50

Um, and I found that our surgeons really

2:51

like this consistency.

2:53

So the way that we name it is,

2:55

we name it separate for each breast.

2:56

So we have right lesion

2:58

One, lesion two, lesion three, and so on.

3:01

And then we would have left lesion one, lesion two,

3:04

and lesion three and so on.

3:06

And for each lesion we have its size.

3:09

What type of lesion is I? Is it a mass?

3:11

Is it a non mass lesion, et cetera,

3:15

radian or clock face?

3:17

And how many centimeters from the nipple?

3:19

So for example, right lesion one, 1.2 centimeter mass,

3:23

12 o'clock four centimeters from the nipple, right lesion,

3:26

two three centimeter calcifications,

3:28

two o'clock five centimeters in the nipple left lesion,

3:32

one 2.3 centimeter nomas lesion, five o'clock,

3:36

two centimeters, the nipple and so on.

3:39

When you're choosing your lesions to biopsy

3:42

and certainly right

3:43

before you do a biopsy, always check for flow.

3:46

Using color doppler, obviously you want

3:48

to avoid large vessels.

3:49

This may affect what lesion you biopsy.

3:51

It may affect or angle you come at them.

3:54

Um, especially those big ones in the ax are good to avoid.

3:57

And sometimes if it's a very vascular lesion, you might want

4:00

to add epinephrine, especially if the patient is on any form

4:04

of antithrombotic therapy.

4:06

And on occasions you might want to reduce the needle size,

4:10

for example, from a 14 gauge to an 18 gauge.

4:14

So just a reminder that the blood flow

4:16

to lesions in the breast can be very affected

4:18

by your transducer pressure.

4:20

Um, this is particularly important with superficial lesions.

4:24

Papillo is the classic example because there's soft tumors

4:27

and you can see here how this papillo,

4:31

there is color flow on both these images,

4:34

but you don't see any flow whatsoever

4:36

where the pressure is being applied

4:39

by the transducer in the left hand image.

4:42

But when you release that pressure suddenly pop,

4:44

that color flow comes back in.

4:46

So just always remember to put minimal pressure on, um,

4:49

before you exclude flow.