0:00

Finally, let's talk about radiologic pathology concordance

0:04

after ultrasound guided biopsy.

0:06

This is obviously the same process

0:09

after any image guided biopsy.

0:13

Your first correlation is going to happen

0:15

before you even get the pathology back,

0:17

and that you're gonna look at the clip,

0:19

you're gonna look at the original area

0:21

of concern on the mammogram and or the ultrasound,

0:25

and make sure, um, that you have sampled the correct area.

0:28

When you get the results, you're gonna correlate it

0:31

with the expected pathology.

0:32

So we must always have that in mind before we do a biopsy.

0:37

We have monthly rad path conferences for areas, um,

0:42

lesions that we felt, uh, either potentially discordant

0:46

or interesting or we just want to, um,

0:48

look at the pathology.

0:49

Um, ourselves.

0:51

If you do feel that the lesion is discordant,

0:54

you can re-biopsy it.

0:56

You can send them for surgical excision

0:59

and rarely you might do a short interval follow up if your

1:04

level of suspicion for malignancy was low.

1:07

But generally, um, that is not gonna be recommended.

1:11

Here's an example of a discordant biopsy.

1:15

Um, in this case, the lesion was identified here

1:20

by ultrasound

1:22

and on the mammogram as a little spiculated

1:26

hypoechoic mass.

1:28

It was felt that it was, um, adequately biopsied

1:31

with a core needle technique.

1:33

And, um, unfortunately on the post-procedural mammogram,

1:38

you can see that the clip is actually kind

1:41

of a significant distance from the lesion.

1:44

The biopsy came back as being some non-specific type of, uh,

1:49

fibrotic tissue.

1:50

Um, she was re-biopsied using a vacuum technique,

1:53

and this was an invasive ductal carcinoma.

1:56

Just want to reinforce a little bit about Mr.

1:59

Guided, Mr directed ultrasound guided biopsies.

2:03

Um, and I did mention previously these leashing positions

2:06

may vary significantly between MR

2:09

and ultrasound as the patient turns from supine to prone

2:13

and they can be in different quadrants.

2:15

So for this reason, you need

2:16

to have extremely careful correlation pre-op.

2:20

Um, in terms of the position of the lesion, its depth,

2:24

its shape, its size surrounding tissue,

2:26

and I would generally speaking, we don't send, um, patients

2:31

who have non mass enhancement

2:32

or very small lesions for ultrasound

2:35

unless the, the small lesion is very superficial in a small

2:39

breast and we think we can identify it.

2:41

And so when in doubt, do an MR guided biopsy.

2:45

If you do do it by ultrasound, you need

2:48

to have very careful post biopsy correlation

2:51

for both the clip position and the pathology.

2:54

And it's, these can be challenging to kind of look at

2:56

because you are looking at, um, very

2:58

Different representations of the patient

3:00

between mammography and mr.

3:03

You can consider doing a post biopsy,

3:05

MRI if there is questionable concordance.

3:08

Um, I usually wait till the path is back

3:11

and we often do the, these are done in our institution

3:14

as a freebie

3:15

and we just do a limited non-contrast, sagittal

3:19

and axial image to see where the clip is, um, compared

3:22

to the original lesion.

3:24

Um, that could be very helpful.

3:27

Here's an example of a non concordant biopsy.

3:30

Uh, this was a patient who had this lesion here

3:36

in the medial, um, right breasts, um, by ultrasound.

3:41

They found something that they felt was concordant.

3:43

This was the only lesion they found in the medial breasts,

3:46

or I think, you know, looking at his, this at 11 o'clock,

3:50

um, probably wasn't in the right place.

3:52

She had a, um, non-specific biopsy, came back.

3:57

We sent her for a non-contrast, sagittal

4:00

and axial limited sequence.

4:02

Um, Mr you can see the clip clearly here,

4:06

and when you compare it to the original lesion, you can see

4:09

that that really is not in the right place.

4:11

It was not the same lesion.

4:13

Uh, she then underwent a very challenging MR.

4:17

Guided biopsy, which did show a malignancy.