0:00

We do an awful lot of axillary node biopsies

0:03

and those can be quite challenging.

0:06

Recent research, including the sound trial,

0:09

have really reduced the, uh, need

0:12

to do sentinel node biopsies

0:15

and particularly axillary dissections in a lot of patients.

0:18

But that does mean

0:19

that we have modified the protocol at our institution so

0:24

that if a patient has a significantly suspicious lesion,

0:27

we will scan the axilla at the time of diagnostic imaging

0:31

and we are likely to go ahead

0:33

and biopsy, uh,

0:35

the most suspicious node if there is one present at the time

0:39

of biopsying at the primary lesion.

0:41

We must leave a clip in this case,

0:43

and this must be an ultrasound visible clip.

0:46

As we discussed previously,

0:49

there are several different morphological abnormalities

0:51

that may suggest metastatic involvement

0:53

to the auxiliary lymph nodes.

0:55

Uh, loss of the normal fatty hilum, um,

0:59

with the lymph node becoming more round,

1:01

rather more uniform is very suspicious.

1:04

Um, particularly suspicious is extension outside

1:08

of the lymph node with loss of

1:11

that normal sharp cortex into the surrounding breast.

1:14

Parenchyma. The lymph node may be diffusely thickened,

1:18

and usually, uh,

1:19

three millimeter single cortical thickness is taken

1:22

as the upper limit to normal.

1:23

Now, note that this is the least

1:27

helpful suspicious feature

1:29

unless it is marked as frequently.

1:31

These are reactive.

1:33

And then you may have little focal cortical nodules

1:36

or thickening either within the hilum or externally.

1:42

Now, it is really important in these cases

1:44

that you biopsy the nodules as these are by far more likely

1:48

to be the positive metastatic areas rather than elsewhere

1:51

within the cortex.

1:55

So here are a couple of examples.

1:57

Uh, the one on the left with focal cortical thickening

2:02

and the one on the right with a cortical nodule.

2:06

And again, these are the areas that you want to be biopsying

2:09

and you can see that, you know,

2:11

biopsying this normal lymph node tissue

2:13

here would not be helpful.

2:15

So while these lymph node biopsies a challenge, well,

2:18

you know, they're often quite deep.

2:20

They can be difficult to visualize the nodes

2:22

and visualize the needles.

2:24

Um, especially in patients who are larger

2:26

and have fatty axxis.

2:28

Um, you may be at in a fairly steep angle making

2:31

that needle visualization difficult and not infrequently.

2:35

Unfortunately, they're close to large vessels or nerves.

2:38

Um, particularly the auxiliary artane vein

2:40

that obviously you don't want a biopsy.

2:42

Um, these lymph nodes tend

2:44

to be quite mobile when you're trying

2:46

to get needles into them.

2:47

They may be quite vascular and bleed more, and then

2:51

because, uh, they may have a fairly heterogeneous tumor foci

2:55

within them, um, that the false negative rate is,

2:58

Uh, not insignificant.

3:01

What are some of the potential solutions?

3:03

Adding harmonics can help you visualize the nodes

3:07

as it tends to make the nodes appear, uh, more hypo

3:12

or koic relative

3:13

to the normal fatty brass tissue in that area.

3:16

You can insert the needle further from the lesion to try

3:20

and get a shallower angle.

3:21

Um, you are always pretty much gonna be using a from below.

3:25

Sagal approach to these are quite difficult to biopsy

3:28

with any other approach.

3:30

Consider using lidocaine with epinephrine.

3:32

It seems to be a particularly vascular lesion.

3:35

You may want to use a smaller needle, a 16 gauge

3:39

or an 18 gauge.

3:40

You know, remembering, of course you do have increased

3:42

sampling issues with this, and I not infrequently end up

3:45

using an open needle approach with these if they are close

3:49

to vascular structures.

3:50

But the, I do find that these nodes tend

3:53

to push away from the needle,

3:54

so they can be quite challenging

3:56

to biopsy when you're going in

3:58

with an open needle rather than spring deploying it.

4:00

And I usually do fewer samples,

4:03

so I'm usually probably only gonna do two

4:05

or three biopsies of a lymph node.

4:08

Beyond that, they, we tend to get a lot more hemorrhage.

4:11

The risks are greater with, uh, declining, um,

4:14

advantages of doing more samples.

4:17

And here's an example of a lymph node biopsy.

4:20

This is a, a lymph node that had sort

4:22

of two fairly prominent cortical bumps on it.

4:26

And you can see that we've biopsied, uh, successfully

4:28

through one of those bumps.