0:00

Let's go over some further specifics related

0:03

to vacuum assisted breast biopsies.

0:06

So what are the some of the advantages

0:08

of vacuum assisted breast biopsies?

0:10

Well, they're gonna result in larger biopsy samples.

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You're gonna get less sampling error.

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These devices are generally either nine gauge

0:19

or 12 gauge as opposed to 14 gauge for a core biopsy device.

0:23

And that this is a particularly

0:25

of advantage when you are biopsying small masses

0:28

or complex solid

0:29

and cystic masses where you really want to get good sampling

0:32

of the solid component.

0:34

And when you're sampling breast calcifications,

0:37

it also means that potentially you can excise small masses

0:40

such as papillomas

0:41

or small fiber adenomas so they can be therapeutic,

0:45

not just diagnostic.

0:47

In those situations, they are excellent for

0:50

posterior lesions are explained in a little bit.

0:53

They are very sharp

0:55

and so they can go in very easily in dense breasts.

1:00

And in my experience, they are much faster biopsy technique.

1:04

They do, however, come with some disadvantages.

1:06

Uh, larger samples means you have potential

1:08

for more hemorrhage at the biopsy site.

1:11

So larger hematomas, they are more expensive

1:15

and there is the potential for significant chest wall injury

1:19

or in pneumothorax.

1:21

If you're not very careful about how you insert these, uh,

1:23

particularly as they are very sharp, you wanna look at

1:26

that tip the whole way through.

1:28

The needles can be relatively unwieldy

1:31

or heavy Radiologists who have small hands may find

1:35

that a little bit more challenging.

1:36

Um, particularly the TE devices.

1:38

We always make sure that the cords are lying on the patient,

1:43

uh, rather than dragging,

1:44

which can make it much more difficult to hold the devices

1:48

and you can't see posterior to the needle.

1:51

So you've gotta take that into account.

1:54

So let's just go over the basic vacuum biopsy technique.

1:57

You're gonna want to make sure that you anesthetize all

1:59

around the lesion, particularly if it's a small lesion,

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as it will suck that tissue down.

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And particularly behind the lesion as you see,

2:07

that's generally where we place the needle.

2:09

Sometimes we place it to the side of the lesion.

2:11

If the lesion is very shallow, you want to make sure

2:14

that you're not going to be sucking any skin down into

2:17

that needle as you could potentially produce quite a

2:20

significant skin defect.

2:22

In my experience, at least with the 12 gauge devices, uh,

2:25

you can just watch this very carefully.

2:28

I'll show you some little tips and tricks for that later on.

2:31

If it's a larger area they're biopsying,

2:33

you can just go into the center of it and you may

2:36

or may not need to use an introducer with this technique.

2:40

I personally don't use one other.

2:42

People prefer them as they feel

2:43

that it's easier to put clips in.

2:45

This diagram just demonstrates the area that you are going

2:49

to want to include in your anesthetic field.

2:52

I find that they need a little bit more local anesthetic

2:55

than a regular core needle device.

2:57

Uh, you may want to use

2:59

A longer stiff needle to be able to get to some

3:03

of the more distant areas to obtain adequate anesthesia,

3:07

particularly if it's a deep lesion.

3:10

So you're going to want to insert the device very carefully,

3:13

making sure that you can visualize the tip at all times.

3:17

I said these devices are very sharp

3:20

and they will penetrate deep into the chest wall if you

3:24

don't keep an eye on them.

3:25

So you're gonna want to place it the tip just

3:28

beyond the lesion so

3:29

that the lesion is within the biopsy chamber.

3:33

You'll see the ring down effect from that,

3:35

which I'll show you in a minute, um,

3:37

before you start to do your biopsy.

3:40

So if you're using a tethered device, you are then going

3:43

to keep the pedal depressed until you're done usually,

3:46

or keep the button on if a non tethered device taking about

3:49

six to 12 biopsies

3:50

and you just gently rotate that device between biopsies.

3:54

So if you're posterior the lesion that's three through 12

3:57

through nine o'clock, I'll show you a diagram in a minute

4:00

and make sure that that lesion is being drawn down into the

4:03

chamber and adequately sampled at the end.

4:06

If you've got a tether unit, you're going to lavage

4:09

to make sure all specimens are in the container

4:11

and then disconnect the saline doing a dry vac just

4:15

to clean the cavity and make sure there isn't a

4:17

significant hematoma there.

4:19

This is how the biopsy chamber is going

4:21

to appear once you place the device and open it.

4:25

This is the ring down artifact that you see posterior.

4:29

You can see here the step off for that cavity.

4:32

The needle tip is here.

4:34

This is a little tiny lesion sitting here within

4:37

the biopsy cavity.

4:39

And here is just a little center clip

4:41

of the multiple biopsies being taken through that lesion.

4:45

You can see the, uh, chamber closing each time

4:49

and the vacuum effect as that tissue is being pulled down.

4:53

Your biopsy device will have some kind of an indicator.

4:56

It might be a flat side on the device or a raised line

5:01

or raised dots that you can put your fingers on

5:04

or your thumb on so you know

5:06

in which direction you are pointing the biopsy chamber.

5:10

So, um, this is just a demonstration where you are going

5:13

to have the, this is cross sectional through the image

5:16

and through the needle where you're going

5:19

to have your needle here placed underneath with the biopsy

5:22

chamber pointed upwards towards the lesion.

5:25

Or if you're coming from the side, that flat side,

5:28

the biopsy chamber is going to be pointed laterally

5:33

and you then rotate your needle from side to side, uh,

5:36

gradually taking sequential biopsies to get good sampling

5:39

of the lesion, demonstrating it here from

5:42

below and from the side.

5:43

And that lesion will gradually get drawn

5:45

down into the chamber.

5:47

If you have any questions about positioning,

5:49

you can always turn, uh, perpendicular from instead

5:52

of being longitudinal along the needle so

5:54

that you are across

5:56

The needle to just sort of see where your chamber is

5:59

and confirm the lesion is indeed being drawn

6:02

down into the chamber.

6:04

You of course, always want to place a clip

6:06

after biopsies as a convention.

6:08

Couple of ways of doing this, you can take out the device

6:11

and place it through the introducer

6:13

or there are, uh,

6:15

multiple different methods depending on your device

6:17

to place it through the device sheath.

6:20

Um, some of these may need specialized side deploy clips

6:24

to prevent retention in the needle.

6:26

Or what I commonly do is it's very clear

6:28

where the biopsy cavity is.

6:30

Uh, you often got some air artifact there,

6:32

you can just manually place it into the

6:35

cavity following the biopsy.

6:37

Couple of troubleshooting hints.

6:39

Uh, with these vacuum devices, as I said

6:41

before, you want to make sure

6:43

that skin is not drawn down into the device.

6:46

Um, as you will make a significant defect, you might want

6:49

to come from the side

6:51

or, uh, inject a good bleb of local anesthetic

6:55

between the lesion and the skin to make sure

6:57

that it is sufficiently posterior.

6:59

Sometimes very hard lesions will not biopsy if this happens.

7:03

Doesn't happen very often.

7:05

Change to a core biopsy device

7:07

and if you're not getting any biopsies coming back into the

7:10

chamber with a tethered device, you might want

7:13

to just check there is adequate saline flow.

7:15

That's usually the problem. If there is no clip seen on your

7:19

post-procedural mammogram, it usually means it came out

7:21

with a device and in which case just go back

7:24

and replace it manually.

7:25

Under ultrasound guidance, as I said,

7:27

you can virtually always see that cavity pretty well.