0:00

Now we talked previously about how

0:02

to position the patient adequately depending on

0:04

where your lesion is,

0:06

but you also have to decide where you are going

0:09

to enter with your needle.

0:11

And this is obviously incredibly important

0:13

for doing a successful biopsy.

0:16

Here's some general rules.

0:18

Um, as we said before, you wanna position the patient

0:21

to make the breast as flat as possible

0:23

and as tor as possible, you want to avoid going across

0:27

the nipple if you possibly can.

0:29

This is a very sensitive area.

0:31

It's also quite vascular

0:32

and it's often quite difficult to get your needle through,

0:35

um, immediately behind the nipple.

0:37

You don't want to really be coming from

0:40

above IE from the head end of the patient

0:43

because you're gonna end up

0:44

with your elbow in the patient's face,

0:47

particularly in young patients.

0:49

Try and avoid going through the cleavage if you can, just

0:52

to avoid putting a scar there.

0:54

Some's obviously gonna depend on whether you're right

0:56

or left-handed, and it's absolutely going to depend on

0:59

how visible the lesion is in different planes.

1:03

You're kind of working with these different factors.

1:06

As I said before, I'm very right hand dominant,

1:09

so these guidelines are, uh, you know, referring to me,

1:12

but you may feel they're helpful.

1:14

Um, so generally speaking, I'm gonna be going from

1:17

below just demonstrating this in a lateral lesion.

1:21

Similarly, for a lesion in the lower outer quadrant,

1:24

if a lesion is immediately above the nipple,

1:27

I'm either gonna be coming slightly lateral to the nipple

1:30

or be coming slightly medial to the nipple.

1:33

And I'm gonna kind of play around

1:34

and see which seems most comfortable to me

1:37

and which I'm gonna see the lesion best.

1:39

And then upper inner quadrant lesions, I can come from below

1:43

as I can for lower inner quadrant lesions.

1:47

When you initially mark the patient's skin

1:49

with both a lesion and the skin entry side, as I said

1:52

before, you need to be able to visualize a couple

1:55

of things to work this out.

1:56

First of all, you wanna be able to see your needle.

1:58

So if you're gonna be going in at a steeper than 45 degree

2:02

angle, particularly

2:03

with a core needle device rather than the vacuum needle

2:07

device we'll talk about later for deep lesions, um,

2:09

more than about 45 degrees,

2:11

you're not gonna see it very well.

2:13

You also gotta think about your needle throw,

2:15

whether this is a one centimeter throw

2:18

or a two centimeter throw to see where that tip's going.

2:21

To end up. Thinking about the safety,

2:24

you obviously don't want to go into the chest wall.

2:26

You obviously don't want to go in the skin

2:28

and you want to avoid any large vessels.

2:31

So as we said before, put doppler on,

2:33

make sure there aren't vessels in your angle of approach.

2:38

The face of most linear transducers

2:41

that we use in breast is about five centimeters,

2:43

and generally you can make your needle insertion site pretty

2:46

close to the edge of that transducer, which really helps

2:50

with needle visualization.

2:52

But as I said, you've really gotta look at

2:54

where the lesion is

2:55

and what your biopsy angle's going to be,

2:57

and you have to kind of mentally

2:58

Visualize that throw.

3:00

So for pretty superficial lesion, this is fine

3:04

for a slightly deeper lesion, and this may be fine as well.

3:07

You see that our angle between our needle

3:11

and our transducer is still less than 45 degrees,

3:14

but when you go to a deeper lesion,

3:17

then this can end up being a problem.

3:19

Now, not only are we not gonna see that needle very well,

3:22

but you run the risk of going into the chest wall.

3:26

So in these patients, you're gonna have

3:27

to move your entry site to get a more superficial angle.

3:32

So something like this, you can also

3:35

increase your pressure on your probe, which is going

3:38

to make the breast thinner

3:39

and hence the lesion closer to the transducer.

3:43

And that can often mean that you can move that needle closer

3:46

to the transducer and have less breast to have to go across.