0:01

Biopsies can be won or lost.

0:04

Um, at the time of patient positioning,

0:06

if you get the patient positioning all wrong,

0:09

you're gonna set yourself up for failure

0:11

because you're always,

0:13

you may be fighting a dependent breast

0:15

in a very mobile lesion.

0:16

So let's talk at length on how to

0:19

position the patient correctly.

0:21

There are multiple different factors which will affect

0:24

how you position your patient

0:26

to perform an ultrasound guided breast biopsy.

0:28

There's some things related to the patient, you know,

0:30

they've gotta be comfortable.

0:31

If they can't stay comfortable for the 10

0:33

or 15 minutes that will take you, um, then

0:35

that is obviously gonna be an issue.

0:37

They need to feel that they're appropriately covered.

0:40

Uh, they're not too exposed.

0:42

They may have limited mobility in their arms or shoulders.

0:46

Very commonly, it is uncomfortable for patients

0:49

to keep their arm elevated for a protracted period,

0:51

or it may be their hip or their knee.

0:54

Um, so they're not comfortable lying on their side

0:56

or they may be short of breath if you lie them flat.

0:59

So you've gotta take all of these things in account.

1:02

Make them as comfortable as possible.

1:03

May mean that their head has to be elevated a bit.

1:06

You may need to put a pillow between their knees

1:08

and we'll talk about pillows behind the arms in a moment.

1:11

There are also some factors dependent on you.

1:15

Are you left or right handed?

1:17

Dominance, can you easily do biopsies in both?

1:20

I happen to be very strongly right hand dominance.

1:23

If I can do a biopsy with my right hand,

1:25

that's how I'm gonna do it.

1:27

If you have longer arms rather than shorter,

1:29

that's gonna depend on how you can reach over a patient,

1:32

as does your height.

1:35

There are factors to do with the patient's breasts,

1:37

which may depend on how large

1:39

and how mobile their breast is,

1:40

because generally speaking, you're gonna want

1:42

to reduce the redundancy as much as possible

1:46

and the mobility of the breast.

1:47

So as much as you can make that breast stretched as flat

1:50

as possible in the area that you're gonna biopsy,

1:53

that's really gonna help you.

1:55

What about the lesion? Well, you wanna reduce the depth of

1:58

that lesion in that patient's breast as much as possible.

2:01

Make it as visible as possible,

2:03

and also obviously to provide safe biopsy approaches

2:08

relative to the chest wall, the skin, the nipple, and so on.

2:11

So all of these things really need to be taken into account

2:14

before you ever put a needle to skin.

2:17

So the following are my personal recommendations.

2:20

Now, take into account here I'm five seven.

2:24

I often have an inch or two heel and I have quite long arms.

2:27

And so that may affect, um, what I can do, particularly

2:31

with left-sided lesions that may not be comfortable for you.

2:35

We have a biopsy in my department who's about five foot

2:38

tall, if that, and she uses a different approach than I do.

2:42

So see what works best for you.

2:45

Now note that all the following images are being

2:48

photographed from the foot of the patient.

2:50

Now, generally speaking, it is gonna be much easier if you

2:53

are on the opposite side to the ultrasound scanner.

2:57

It's gonna be much easier if you're just looking across the

2:59

breast at the scanner.

3:01

Then you've got your neck crooked round

3:02

unless you're an owl.

3:04

So things that we're going to need, you're going

3:07

to need a wedge pillow to be able

3:09

to position patients obliquely,

3:12

and you're gonna want to have a pillow behind their arm

3:14

with their arm raised, generally speaking, if they can do

3:18

that, because it's going to make the breast less dependent.

3:21

I'm gonna go through each

3:22

of the different lesion positionings

3:24

and how I position the patient, at least as a first off.

3:27

I may roll them around a bit more depending uh,

3:30

what the lesion looks like when I image it,

3:32

but this is kind of where I start.

3:34

So for a medial lesion, the patient is going

3:37

to be pretty flat.

3:39

Uh, may not be completely flat, it depends on

3:41

how large their breast is.

3:42

But again, what I'm aiming to do is to make the area

3:46

of the breast that has the lesion as parallel to the floor

3:50

as possible and as tort as possible.

3:53

Now, for a right lateral lesion,

3:55

I'm gonna roll them up a little bit more.

3:58

I'm gonna put that wedge behind them.

4:00

How much I roll them depends on how lateral the lesion is.

4:03

The more the further out it is,

4:06

the steeper, I'm gonna roll them up.

4:09

So for a right auxiliary lesion, they're going to be,

4:12

you know, pretty much in a left lateral decubitus position.

4:17

Again, I'm gonna be wanting to come in from this direction,

4:20

so I'm gonna put that as horizontal as I can make it.

4:24

Now for an inferior lesion, I will probably want

4:27

to have the patient as flat as possible,

4:29

and in some cases, such as this lady

4:32

who had a fairly large breast

4:34

and may tape their breast up again to get it out of the way

4:38

so you're not fighting the dependency

4:40

of the breast while you're trying to come in from below.

4:43

Again, this is gonna depend on the patient and their breast.

4:46

We're gonna talk about two different alternatives

4:48

for left breast lesions, particularly left lateral lesions.

4:52

So left medial breast lesions.

4:53

Again, the patient's pretty flat

4:55

or they may be just tilted just a tad towards you.

4:59

Now for me, and again, remember, I I'm a fairly tall woman.

5:03

I'm gonna roll them up into a right lateral decubitus, uh,

5:07

position, how steep I put them.

5:09

It's gonna depend on where this lesion is.

5:11

If it's all the way over here, they're gonna be pretty much

5:13

to cube and I can comfortably reach that

5:15

with an appropriate table height

5:17

and it still means that I'm coming from below.

5:20

Um, and uh, remember I said I was fairly

5:23

right-handed dominance.

5:24

So that's a very comfortable position to come in for me.

5:29

And again, for a left auxiliary lesion,

5:31

they're now gonna be completely right lateral decubitus.

5:34

You make sure that they're comfortably wedged with

5:37

that wedge pillow, their arms up comfortably over the head.

5:40

If they're not comfortable and you start,

5:41

they're not gonna be comfortable a few minutes later.

5:45

Now this is an alternate method of positioning

5:48

for left breast lesions, particularly left lateral lesions.

5:52

One of our providers preferreds to do this, uh,

5:55

she is our shorter

5:56

Radiologists and I think she finds this more comfortable

5:59

than, um, leaning over the patient.

6:01

For me, it means I would have to change to my left hand.

6:04

So I don't find that comfortable.

6:06

And it also means that the technologists have to flip, um,

6:10

the patient around, um, sometimes flip the stretch

6:13

around depending on your stretcher when they're going

6:15

between right and left sided lesions

6:18

with different patients.

6:19

But you may find this more comfortable.

6:21

If you do, that's great.

6:22

So, you know, again, we're just coming up your,

6:25

this time you flip the patient

6:27

so their head is on your right.

6:29

Um, as you are facing the ultrasound scanner rather than

6:32

your left, and you're gonna be using a left-handed approach

6:37

for this, it's pretty difficult

6:38

to do a right-handed approach.