0:00

Doing safe and successful breast biopsies is all about

0:03

seeing that needle all of the time.

0:06

So this is hopefully gonna give you some little tips

0:09

and tricks on how to maintain needle visibility.

0:13

The plasticity of the breast is both our friend and our foe.

0:17

It means that we can do things in with breast biopsies

0:20

that you certainly wouldn't be able to do in the liver,

0:22

for example, but it does mean that lesions move in a way

0:26

that you don't see the move in the liver.

0:28

So here are some tricks that might help you

0:31

increase the probe pressure.

0:32

This is really going to narrow the depth

0:34

of the lesion on the breast.

0:36

It's gonna help you with your needle

0:38

or angle as I described in a previous video, and try

0:41

and keep less than 45 degrees

0:43

between the probe surface and the needle.

0:47

You want to reduce the field depth as much as possible.

0:50

So you wanna be able to see the lesion, you wanna be able

0:53

to see the stroke margin beyond it,

0:55

but you don't need to necessarily be seeing five

0:58

centimeters deep.

1:00

So reduce that field depth

1:01

so you have everything within the field of view

1:03

that you need, but not stuff

1:04

that you don't need is out of it.

1:06

It's gonna improve your resolution.

1:08

I wanna put the focal zone kind of in the mid imaging field

1:12

and I'm gonna show you a couple of maneuvers, hill towing

1:15

and L pass that can help you with needle visibility,

1:18

particularly in deep lesions.

1:21

The more parallel the needle is to the face

1:23

of the transducer, the easier it's going to be

1:27

to see the greater that angle between the transducer

1:31

and the needle, the more difficult it's going to be to see.

1:34

So the heel towing approach is to reduce that angle,

1:39

making the probe more parallel to the needle.

1:44

And effectively what you're doing is you are just digging

1:48

the side of the probe into the breast

1:50

as you can see like this, to be able

1:52

to make it more parallel to the needle

1:54

and you'll be amazed at how much more visible

1:57

the needles are going to be if you use this maneuver.

2:01

For reasons of patient confidentiality, I'm going

2:03

to demonstrate some of these tips

2:05

and tricks in these sequential videos, uh,

2:08

using my friend the pork loin.

2:10

Um, so sorry about the kind of meaty stuff here,

2:12

but I think it demonstrates quite well.

2:15

So what I'm doing here is I'm just digging in the side

2:18

of the probe that's away from the needle entry site

2:21

and that's gonna make,

2:22

as I demonstrated in the prior diagram, more parallel

2:26

to the needle and much more visible.

2:28

This is a video clip from, uh, my friend the pork loin.

2:32

Again, just showing that as I do that heel to approach,

2:36

you can see the needle going from very difficult

2:38

to visualize to very easy to visualize.

2:42

Now a lot of modern ultrasound machines also have something

2:46

called beam steering.

2:48

And effectively what this is doing is it changes the angle

2:51

of the ultrasound beam as it comes outta the transducer face

2:55

from being perpendicular to the transducer face, such as

2:58

Here to non perpendicular

3:03

to the transducer face,

3:05

but more perpendicular to the needle, meaning

3:08

that we can see it a lot better.

3:10

I've had mixed success with this.

3:12

I think it's probably depends on your confidence

3:16

and expertise and also the machine involved.

3:19

I'm gonna show you an example on the following slide.

3:22

So the image on the left is, uh, in a patient

3:25

where we have no beam steering on

3:28

and I have a fairly steep angle.

3:30

This is actually the needle here

3:32

and you can see that it's really not very visible at all.

3:35

Now we've turned on the right, the beam steering on,

3:39

it's gonna come up with a little indicator of the angle

3:43

that the beam is at.

3:44

There's usually a couple of options for this angle.

3:47

Some of them are completely variable, some

3:48

of them just give you a shallow and deep option

3:51

and, um, I haven't changed anything else

3:53

other than the beam steering.

3:54

And now you can see that needle quite well.

3:57

One of the problems I have is they tend

3:59

to look a little sparkly.

4:00

It's a little bit more difficult sometimes to see the tip,

4:03

but I think it is a useful technique, particularly

4:07

with deep lesions.

4:09

I can demonstrate something now

4:10

that I call an L-shaped path.

4:13

Um, I use this a lot when I'm going for deep lesions to try

4:17

and improve my visualization

4:20

of the needle when they could be at relatively steep angles

4:23

and also mean that I can do my skin entry site much closer

4:26

to the transducer

4:28

and again, avoid transversing, a lot of breast.

4:31

So what I effectively do is I'm gonna go straight down

4:35

just a couple of centimeters.

4:37

You obviously do this in a very controlled manner,

4:40

straight down, not directed towards a lesion.

4:42

And then I'm going to leverage my transducer pressing, um,

4:47

down with my probe usually.

4:49

So it's now directed towards a lesion.

4:51

It's a little bit difficult to describe in diagrams.

4:55

This is something you need to kind of try for yourself,

4:57

but go down and then leverage across.

5:00

And again, you are kind of using the BLE breast plasticity,

5:04

uh, to our advantage here.

5:07

And here we are back to the pork loin.

5:09

Just trying to demonstrate myself, uh, doing this.

5:12

You see, I go down, leverage across,

5:14

and then go across to get at the lesion.