0:00

So as well as selecting the correct biopsy device,

0:03

you also have to select the appropriate clip

0:07

to be left at the biopsy site.

0:10

I cannot emphasize too strongly

0:13

that if you do a biopsy, you must leave a clip.

0:17

Uh, we do get referrals in from outside sometimes

0:21

where they say, well, you know,

0:23

it's this four centimeter mass,

0:25

so I don't need to leave a clip in it.

0:26

Of course you can find it afterwards,

0:28

but yes, you can find it

0:30

until they're given neoadjuvant therapy, which an awful lot

0:33

of patients with larger tumors are given nowadays,

0:36

in which case that mass is gonna vanish

0:39

and you need that clip

0:40

because they frequently go on to a subsequent lumpectomy.

0:44

If you are biopsying more than one lesion within a single

0:48

breast, you must place clips of different shapes

0:52

and you must identify which shape

0:55

is placed at which lesion.

0:57

As we've described in the earlier video, you've got

1:00

to have consistent lesion labeling,

1:03

and it'd be very clear where that lesion is,

1:07

and then subsequent what clips involved with it.

1:09

It is very, very challenging for subsequent radiologists

1:13

who may be dealing with that patient

1:15

and subsequent surgeons.

1:17

If that is not clear, if you may be needing ultrasound

1:21

for later localization, which is in the case

1:23

of most auxiliary nodes,

1:25

or if perhaps your inner center has limited resources

1:29

and you cannot perform a, uh, mammographic guided needle

1:34

or seed localization, um, then you must

1:38

put in a clip that will be visible by ultrasound.

1:41

Um, there are various options for this.

1:43

Some have hydroscopic gels within them.

1:46

Some have more complex shapes which are visible

1:49

by ultrasound, but make sure that you have clips available

1:53

that are of different shapes

1:55

and some that are visible by ultrasound later.

2:00

As far as you can, particularly with larger lesions, try

2:03

and center it in the lesion.

2:04

This is particularly important for patients

2:06

who then undergo neoadjuvant chemotherapy.

2:09

You want that to have been in the central

2:10

lesion, not on the periphery.

2:12

You must confirm clip positions with the exception

2:15

of the auxiliary clips, which you usually can't see

2:18

with an MLCC post biopsy mammogram,

2:22

and then correlate those with your pre-procedural imaging

2:25

to make sure you biopsy the right thing

2:27

and is the clip at the appropriate position?

2:29

Sometimes they don't deploy

2:30

and you have to go back in and do it again.

2:33

You should document the clip type and shape,

2:35

and you should document any clip displacement

2:38

from the primary lesion.

2:40

Clearly in your notes, as I said,

2:43

there are many different clips

2:44

of different shapes available from each

2:46

of the manufacturers.

2:48

I would highly recommend that you get a chart like this,

2:52

that you, uh, leave it up in your mammo room

2:54

because it can be very helpful to use these

2:57

specific names of

2:58

These clips in your reports,

3:00

and particularly when you get them from, uh,

3:03

you get patients coming in with mammograms,

3:05

with clips on them from outside institutions

3:08

and you're doing, uh, second opinions on them, for example,

3:10

or you're doing procedures on them, you can make sure

3:13

that you are using the correct terminology.

3:16

And here's just an example of placing

3:19

a clip in a lesion.

3:21

In this case, this is an olive in a pork loin,

3:25

but I think it just demonstrates you putting the clip in

3:27

and you can see it nicely.

3:28

You should always document image

3:31

of the clip after it's been placed.

3:33

This is a patient who had a large auxiliary node,

3:37

has undergone a full course of neoadjuvant chemotherapy.

3:41

And you can just see here this clip,

3:44

and this is what's called a twirl clip.

3:46

This particular one that has been placed

3:49

and you can still see the clip clearly within the tissues,

3:52

despite the fact that the auxiliary node has been, uh,

3:55

completely resolved by the chemotherapy.

3:59

This was a clip that was placed in a large breast mass

4:02

that underwent neoadjuvant chemotherapy as well.

4:05

In this case, this was one of the ones

4:08

that has a colloidal gel within it that absorbs fluid.

4:12

This particular one's called a hydro mark,

4:14

and you can see it again clearly within the, uh,

4:18

soft tissues of the breasts,

4:19

the mass itself has completely resolved.

4:22

And here's just another example of what these, uh, clips

4:26

that have this, uh, colloidal gel

4:28

surrounding them look like.

4:30

Um, many months out, they can be, they're visible

4:33

for at least four to six months out.

4:36

They often look like little cysts

4:38

with the echogenic clip within them.

4:40

And this is just looking at it longitudinally

4:42

and then cross-sectionally.