0:00

Just wanna summarize a couple

0:02

of the common procedure errors that I've seen

0:04

that we haven't covered to date.

0:07

And the first one is losing the lesion in the

0:10

middle of their procedure.

0:11

This usually happens with smaller or more subtle lesions

0:16

and, um, frequently after you've given the anesthetic or

0:20

after the first biopsy or two.

0:23

So because of this, make sure

0:25

that your first biopsy is a really good one

0:28

because sometimes that's gonna be the best one.

0:31

If you lose the lesion, look back at your skin marks.

0:35

Um, this is one of the reasons

0:36

that we really wanna make sure that

0:38

that lesion is marked accurately on the skin if you have

0:41

to go back to it, so mark it accurately.

0:44

Sometimes a little bit too much lidocaine ends up, um,

0:47

obscuring things, but if you wait a few minutes,

0:50

sometimes I massage the breast a little bit.

0:53

That can, uh, usually gets absorbed

0:55

and suddenly that lesion will reappear.

0:57

You know, try altering your angle a little bit.

1:00

Um, press with a probe a little bit harder.

1:02

Same with air in the soft tissues, please.

1:06

I can't emphasize enough.

1:08

Make sure that your lidocaine, uh, syringe

1:11

and needles are flushed of air.

1:15

A common mistake I see learners do is they're changing from

1:19

the regular 23 gauge needle to a longer 18 gauge needle

1:24

that we may use to get deeper anesthesia in deep lesions.

1:28

And they forget to flush out that syringe

1:30

and then flush out the needle of air.

1:32

And then all of a sudden you have this wonderful bolus

1:35

of air right where you want to go and you can't see a thing.

1:39

So if this happens to you, massage it

1:42

with a probe, wait a few minutes.

1:44

You may need to come from a different angle in this case.

1:47

And uh, usually it will reappear.

1:50

Hemorrhage is obviously the most common complication

1:53

of an ultrasound guided, uh,

1:55

breast biopsy is usually pretty minor,

1:58

but sometimes it does mean that you have

2:00

to stop the procedure early.

2:02

So time and pressure stops nearly all bleeding.

2:05

I'd like to say it stops all but nearly all.

2:08

So prolonged firm compression.

2:11

If you have hemorrhage, you'll always want to have

2:14

compression on the biopsy site, probably

2:16

for about five minutes after you've done the procedure.

2:19

If it won't stop, you can try injecting some lidocaine

2:23

with epinephrine.

2:25

I have also had to several times inject gel foam

2:28

down the track.

2:30

So I get some, I get the resident to go

2:32

and get some gel phone from interventional

2:34

radiology and we do it.

2:35

And there is rare need

2:37

for operative hemostasis, but it does happen.

2:40

So do check with doppler for active extravasation.

2:43

That's obviously going to, uh, be a much stronger predictor

2:46

of needing operative hemostasis.

2:50

So just to show you what this looks like, this is a patient

2:53

who had a 10 centimeter hematoma.

2:56

Yep, that was one of mine. I'm only

2:58

Showing a very small, this is all hematoma here.

3:01

Um, we had compression for about two hours on this.

3:06

Um, however, there is a persistent active extravasation

3:10

and she had to go to the,

3:12

or even more exciting was this one.

3:14

This was actually after a stereotactic biopsy.

3:16

Not an ultrasound, but could certainly

3:18

occur with an ultrasound.

3:19

And you can see here

3:21

that there is actually a pseudo aneurysm

3:23

with a lovely yin yang sign,

3:25

which occurred following a biopsy

3:27

and she had to go to the or also.

3:30

Now obviously, inadequate sampling can occur

3:33

and needs to be avoided at all cost.

3:37

So false negatives do occur.

3:40

You need to have very good rad path correlation.

3:42

We'll talk about that in a separate talk.

3:45

And these obviously have the potential

3:47

for upgrading at surgery

3:48

or missing a, uh, lesion altogether.

3:51

We mentioned before, necrotic masses.

3:53

Make sure you go for a peripheral biopsy.

3:56

Make sure you're taking enough samples.

3:58

So four plus biopsies or 14 gauge or more.

4:02

Um, if you are using a smaller needle

4:04

and, you know, use a large needle, if you can, try

4:07

and avoid the use of smaller needles,

4:10

unless there is no other option.