0:01

Patients who have very dense breasts and

0:04

or have very mobile lesions can be a particular

0:07

challenge in the breast.

0:08

As I said, the mobility

0:09

of the breast tissue is both our friend and our foe.

0:12

In this case, it's definitely our foe.

0:15

So in these patients it can be very difficult

0:17

to get in the introducer or the needle.

0:21

Um, particularly in young patients,

0:23

I found this to be a challenge.

0:25

So what can you do? You do have

0:27

to apply more force than you may be comfortable with.

0:30

But when you're applying that force,

0:32

really look at your hands

0:33

and look at the image to see the direction

0:36

that you are applying that force.

0:38

Is it gonna be in a safe direction?

0:40

So if you overshoot a little bit during the insertion,

0:44

is it all gonna be fine, still well within breast tissue

0:46

or might you be going towards the chest wall?

0:48

And it's a little unnerving sometimes to do these, so

0:52

it can be quite uncomfortable to patients, um, as well

0:54

as unnerving to them if they see that you're kind

0:57

of really struggling to shove that needle in.

1:00

So there are some modified techniques I'm gonna show you,

1:02

um, such as what I call, shoot and slide.

1:06

Now you really can improve the safety when you're trying to,

1:09

you know, push a little harder than average

1:11

with these techniques by modifying your hand grip.

1:14

This is not a safe hand grip.

1:16

This is the overhand hand grip I'm showing you on the left

1:19

with a core device on the right with a, um,

1:21

vacuum assisted device.

1:23

But it's the same problem when you've got your hand over,

1:27

you have much more freedom of movement to be able to,

1:29

you know, if it's suddenly the resistance goes to be able

1:32

to go into far.

1:34

So I would highly recommend that for all biopsies.

1:37

Um, you use this underhand grip

1:39

or more of a pen grip, um, to go in

1:42

because then the side

1:44

of your hand is resting against the patient

1:47

and you really have very little freedom of movement in terms

1:49

of wrist rotation as to how far you might overlo

1:54

in these patients with dense tissue or mobile lesions.

1:58

You can also use the side of your hand

2:01

that's holding the transducer, so kind of pressing down

2:04

with your, uh, fourth and fifth digits

2:08

and the side of your hand so

2:09

that you are pairing a little counter pressure

2:11

to stop things moving.

2:13

So I developed a technique that I call, shoot and slide

2:16

'cause I'm not seeing it, uh, described formally anywhere

2:18

else in patients who have that very dense pressed parenchyma

2:22

that you feel you're using undue force.

2:25

Uh, you do need an introducer to be able to do this.

2:28

So what I'm gonna do is I will inter, uh,

2:30

put the introducer in as far as I feel that I can, um,

2:34

safely do without undue force.

2:37

And you can see here I am a, a significant distance, um,

2:40

with the tip here from my lesion here.

2:45

I'm then gonna put the needle in, I'll deploy the needle

2:48

directed towards the lesion, realizing

2:50

that it might not reach the lesion as it hasn't.

2:53

Here you can see that the, uh, tip is actually, um,

2:57

just slightly

2:59

Proximal to the lesion here.

3:04

The important thing is then step three,

3:07

which is you advance the introducer over the needle.

3:10

So you're kind of using it like a coaxial technique.

3:13

And I find what I do usually is I just rotate

3:17

that introducer, um, push it forward

3:19

and it's gonna slide beautifully over the needle with no,

3:23

you know, no resistance whatsoever.

3:25

You then remove the needle, take your sample out,

3:28

I toss it in the pot, you know, knowing

3:30

that probably hasn't even got the lesion in it.

3:32

And then when you put the needle back in,

3:34

your introducer is now in the perfect position

3:37

and your second throw is gonna

3:39

go straight through the lesion.

3:42

And here we are back to our friend Mrs.

3:44

Pork loin, and I'm just showing you that technique.

3:47

So, um, as I said

3:49

before, you're going to deploy that needle,

3:52

then you're gonna slide that, introduce a ride over it,

3:56

and now it's in a great position.