0:00

There are lots of different devices available

0:04

to do ultrasound guided breast biopsies.

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So how do you decide on the appropriate one?

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Now, I'm not gonna be talking about name brands here

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for um, obvious reasons.

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You may need to try different brands of equipment

0:19

to see which you like.

0:20

And I'm be talking more about generalities.

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You must have a linear transducer to do these.

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Well, a minimum of 12 megahertz.

0:30

Uh, we use an 18 megahertz.

0:33

Generally we rarely go to a 12

0:34

and there's somebody has very big breasts.

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Here are some of the options available

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for different breast biopsy needles,

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and you may have one that you tend to use as your workhorse

0:47

and then use some other variants for specific lesion types

0:51

that we will be talking about in later talks I've just

0:54

highlighted in yellow are sort

0:56

of workhorse needles that we use.

0:59

We don't actually have just one that we use

1:01

as different practitioners prefer different types,

1:04

sometimes dependent on the size of their hands

1:07

and whether the buttons are in a convenient position.

1:10

The gauge for core needles is typically 14, 16, or 18.

1:14

We tend to use 14.

1:16

Most of the time they can be between nine

1:19

and 14 centimeters long.

1:21

Most have a two centimeter throw,

1:23

some have a one centimeter throw

1:26

and some have a more variable throw, um,

1:28

that you can set at the time your biopsy, which is handy.

1:32

Uh, the vacuum needles come in both tethered

1:35

and non tethered versions.

1:36

Tethered meaning, uh, you have a separate piece of equipment

1:40

that provides a vacuum similar to you do in, uh,

1:43

stereotactic biopsies where non tethered is there.

1:46

Everything is within the device itself.

1:48

And again, they come in several different sizes.

1:52

Nine, 12, and 14.

1:55

Now you can either use a separate introducer

1:58

that you insert first

2:00

or not most, uh, needles come with the option

2:03

of an introducer or not.

2:05

Some of it's an individual preference.

2:07

I tend to use an introducer, you know, 95% of the time.

2:11

I do think it's easiest

2:12

for multiple biopsies is you only really gotta get

2:15

to the lesion once and then it makes it much easier.

2:18

Um, if you have residents that you are training,

2:22

I certainly prefer to do it.

2:23

It does speed up the procedure quite considerably with them.

2:26

Very important to my mind.

2:28

It does reduce the potential for seeding along a tract.

2:31

Um, patients are not infrequently concerned about that,

2:34

but it does need to be sharp.

2:36

For dense breasts is a larger gauge

2:38

and it can be quite difficult to get into dense breasts.

2:41

So what's ivanti not using introducer. Smaller incision.

2:45

The needle may be a little easier to get in,

2:49

although personally I've not found this

2:50

to be a, a huge problem.

2:52

I do sometimes not use an introducer if I have a very

2:56

shallow lesion or a challenging

2:58

Lesion, such as a patient who has implants

3:00

or perhaps a patient who's, uh, had a mastectomy

3:04

and I'm looking for a skin recurrence

3:08

or a superficial recurrence in them.

3:10

We just not got a lot of breast tissue and I may not use it

3:13

and just do it freehand in that case, which is fine.

3:17

So, as I said, I'm not going to discuss

3:20

or recommend specific manufacturers.

3:22

It is very individual, as I said,

3:24

you know, you've gotta try 'em out.

3:26

You've gotta see where the firing button is.

3:29

Is that in a comfortable position to you or not?

3:32

Um, is it something that feels too unwieldy?

3:35

There are certain types that just not comfortable for me

3:38

because I had a prior thumb fracture, so I,

3:40

I can't get my thumb in the right place.

3:42

So try out different ones.

3:44

You know, generally speaking, they all take good biopsies.

3:47

So it really is a, a matter of personal preference.

3:50

And similar for vacuum devices.

3:52

So here we have the tethered device.

3:57

We use a tethered device

3:58

because we have that equipment available.

4:01

If you don't have that equipment available,

4:02

then you may look at an untethered device.

4:05

Some of 'em are a little large and unwieldy.

4:07

Some of them can be quite expensive,

4:09

although none of them to be honest, to that cheap.

4:11

Uh, so what depend on what resources you have available.

4:15

So other than personal preference

4:18

or institutional availability, here are some

4:21

of the things you wanna think about when you're deciding

4:23

what device you are going to use

4:25

that are the ones you have available for you.

4:27

Well, it's gonna depend on the lesion size,

4:29

whether it's a subtle lesion, um,

4:31

that may help you decide whether you want to do core biopsy

4:35

or vacuum assisted biopsy.

4:36

Is it solid? Is it cystic? Is it mixed cystic and solid?

4:40

Where is it in the breast? Is it very posterior?

4:43

Is it close to the skin?

4:45

And I'm gonna be talking about these specific examples in

4:48

more subsequent videos.

4:49

Um, do you need to have very large samples?

4:52

In which case you may want

4:53

to think about using a vacuum device.

4:55

So unique calcifications

4:57

or they want to do special pathology tests on it.

5:00

So if it's a patient undergoing research studies,

5:03

sometimes is it a very vascular lesion

5:05

or is it very close to large vessels?

5:08

Does a patient have implants? Do they have a thin breast?

5:10

These are all sort of things that as you gain experience

5:14

with biopsying, different types

5:15

of lesion will help you decide

5:17

what device you might want to use.

5:20

So when might you want to use a vacuum device

5:22

through rather than a core needle?

5:23

These are my general guidelines. Very small lesions.

5:26

If you know, if you're biopsying a four,

5:28

five millimeter mass with a 14 gauge needle,

5:32

it can be sometimes very difficult to kind of, you know,

5:34

you're chasing around the breast like an olive

5:36

and a martini glass with a cocktail stick.

5:38

This, um, where you can take a vacuum biopsy needle,

5:41

put it right under it, suck a thing up, you know,

5:43

you've got that little mass.

5:45

So very small lesions are gonna veer towards that

5:48

mixed solid and cystic masses.

5:50

As I've said before, definitely I would recommend

5:53

using a vacuum device.

5:54

Once you pop that cystic

5:56

Component of it, you might not see the mass at that point,

6:00

so you wanna make sure that you get the whole lesion.

6:02

Very posterior lesions.

6:03

I'll talk about in a subsequent video,

6:06

particularly in patients who have large breasts.

6:08

If they're very ill-defined

6:10

and you think they might get obscured

6:12

by putting the local anesthetic in,

6:14

sometimes I will do a vacuum device on that

6:17

to make sure I've got good sampling if I wanna have

6:19

calcifications in my sample because the samples are bigger

6:23

and you tend to do more.

6:24

And then sometimes to avoid, um, later surgery,

6:27

you can do excisional biopsies

6:29

with the larger vacuum devices such as papillomas

6:33

or small fibroadenomas.

6:36

So here are two examples of, uh, mixed, solid

6:41

and cystic masses

6:42

that I would preferentially use a vacuum assisted

6:46

biopsy for if I could.

6:48

And here's an example

6:49

of a vacuum assisted biopsy being performed of a lesion,

6:53

which is both very subtle and ill-defined

6:56

and very posterior in a fairly large breast.

7:01

Uh, you can see it just right here.

7:03

It's just this little hypoechoic thing here sitting in the

7:07

chamber of the needle.