0:02

Hello and welcome to Noon Conference,

0:03

hosted by M R I Online Noon Conference connects the global radiology community

0:08

through free live educational webinars that are accessible for all and is an

0:13

opportunity to learn alongside top radiologists from around the world.

0:16

We encourage you to ask questions and share ideas to help the community learn

0:20

and grow.

0:22

You can access the recording of today's conference and previous noon conferences

0:25

by creating a free m r I online account.

0:28

You can also sign up for a free trial of our premium membership to get access to

0:32

hundreds of case-based microlearning courses across all key radiology

0:36

subspecialties. Today we are honored to welcome Dr.

0:40

Emily Ambinder for an interactive live case review,

0:43

digital breast tomosynthesis and tomosynthesis guided biopsy. Dr.

0:48

Ambinder completed her radiology residency and breast imaging fellowship at

0:52

Johns Hopkins Hospital. She specializes in all aspects of breast imaging,

0:57

including screening, diagnostics and procedures, utilizing mammography,

1:01

ultrasound and m r i.

1:03

Her research interests include improving access to breast imaging and new

1:07

technologies for early detection of breast cancer.

1:10

We're thrilled she's here today to share her ex expertise in this subject.

1:14

At the end of the lecture, please join Dr.

1:16

Ambinder in a q and a session where she will address questions you may have on

1:20

today's topic.

1:21

Please remember to use the q and a feature to submit your questions so we can

1:25

get to as many as we can before our time is up. With that,

1:28

we are ready to begin today's lecture. Dr. Ambinder, please take it from here.

1:33

Hi everybody. Thank you so much for that intro, intro, uh, introduction.

1:37

I'm Emily Ambinder. I'm a breast radiologist at Johns Hopkins.

1:40

I'm really honored to have been invited to be here today.

1:43

I wanna thank Modality and M r I online for, um,

1:47

allowing me to give this lecture and for helping me put the, um,

1:49

presentation together. I have, um,

1:54

I have no disclosures. Um, this is just a, an outline for the talk. I know it's,

1:58

it's a case-based lecture, but I am gonna start with, um,

2:00

a little bit of a didactic section on tosis.

2:04

Then we'll move to some screening and diagnostic cases. Um,

2:08

I'll briefly talk about utilization of tomosynthesis and then move towards, uh,

2:13

tomosynthesis guided biopsy and tomosynthesis guided biopsy cases.

2:19

So digital breast tomosynthesis, or D B T was, um,

2:23

approved by the F D A in 2011. So with D B T,

2:27

we acquire multiple images of the breast,

2:29

which are then reconstructed into thin image slices that can be viewed

2:33

individually. The resulting image is quasi 3d.

2:37

It allows us to see a lot more detail than our traditional 3D mammograms. And,

2:41

um, I wanna point out that this is quasi 3d and often will,

2:44

will interchange the term 3D mammogram with D B T,

2:47

but it's not a true 3D mammogram.

2:49

We're not taking perpendicular slices of the breast like you would have in a CT

2:53

scan. We're taking angled images across the breast, and this is a, um,

2:59

an image kind of that, that's demonstrating that.

3:01

So this is from the Hologic website, but the blue circle represents the breast.

3:05

And you can see in a mammogram that that is compressed between the detector

3:10

and the compression board, which are in green.

3:13

The x-ray tube at the top and red will rotate around the

3:17

patient and take these angled images, and the images are then reconstructed.

3:23

Um, so you can scroll through the individual slices.

3:28

Um, so what are the benefits of tomosynthesis? So it's really a win-win.

3:31

So when we are doing screening mammography with digital breast tomosynthesis,

3:35

we find that we have a lower recall rate by having fewer false positives.

3:40

We have a higher cancer detection rate by finding more true positive.

3:43

So it's higher sensitivity and higher specificity. There's,

3:46

there's not that many, um, technologies that will improve both of these,

3:51

uh, metrics. Um, I can't help myself, but I just show the,

3:54

the calculations for sensitivity and specificity.

3:57

It's just something really important to, um, understand when talking about, um,

4:01

especially screening exams. So sensitivity, uh,

4:04

in order to improve that would be by making sure that we're really finding all

4:08

of the true positives and minimizing our false negatives. Um,

4:11

so that's gonna be an improved cancer detection rate with specificity.

4:15

We really, um, want to limit our false positives.

4:18

So that's what we're doing by decreasing our, our recall rate.

4:24

Um, so how does the recall rate get, uh, decreased using tomos?

4:28

And this is will as I'll,

4:29

I'll show in several cases we're really able to mitigate our uncertainties due

4:32

to overlapping breast tissue when we're using tomosynthesis.

4:37

Um, there are, you know, lots of different numbers kind of thrown up.

4:39

I think generally we accept that the screening recall rate is decreased by about

4:42

15% when we're using, uh, D B T for screening mammography.

4:47

So what about increased cancer detection? Well, with, with D B T,

4:49

we're also able to see more detail in the breast,

4:52

and studies have shown that we have, um,

4:54

an improved cancer detection of invasive cancer,

4:57

specifically by up to 40% when we're doing screening mammography using

5:01

tomosynthesis. Um, it is actually been shown to be,

5:04

be beneficial in all breast tissue density categories,

5:07

but it's particularly helpful in dense breast tissue. Um,

5:12

so now I'll start with some cases. So here's our, our first case.

5:14

This is a patient who had a, her screening mammogram with, um,

5:18

just field digital mammogram. So she did not have tomosynthesis,

5:21

and I'm gonna just leave this for a second.

5:22

I want just have you take a look at it and see if you see any findings that

5:26

might be, um, worth recalling.

5:32

So this patient, um,

5:34

was noted to have two asymmetries on her right MLO view.

5:39

I just have a zoomed in view. This is still that 2D mammogram,

5:42

the full field digital mammogram without tomosynthesis. And, um,

5:46

they, these two different findings were identified. Uh,

5:50

so the patient was recalled for a, a, a callback mammogram. At our institution,

5:55

we always do callback mammograms with tomosynthesis.

5:57

So I have here the screening mammogram on the left showing those two

6:02

asymmetries. And then we have the, um, tomosynthesis mammogram on the right.

6:07

And I'm just gonna scroll through it. And I think, um, do you, to start,

6:10

just kinda keep your eyes on the lower part of the breast where we saw that,

6:13

that lower asymmetry. And when I'm scrolling through,

6:18

I see overlapping fibro ular tissue.

6:21

I see these lines that are crossing in that area of the breast,

6:25

but I'm not seeing any discrete mass. I don't see any distortion. Uh, um,

6:30

and,

6:31

and so that finding that we saw on the 2D mammogram just represents overlapping

6:35

fibro tissue. Similarly, when,

6:38

if you kind of look and now focus more on that retro alar part of the breast

6:42

where we saw that, that asymmetry right behind the nipple,

6:46

now that I'm scrolling through using the tomos and thisis slices, that is, um,

6:51

appears more continuous with the rest of her dense breast tissue.

6:54

There is no discrete mass, there's no distortion, and that finding, again,

6:58

also represents her normal fibro glandular tissue.

7:01

So this is a patient who was recalled from screening mammogram for um,

7:04

asymmetries, but if she had had her screening mammogram with tomosynthesis,

7:08

she likely would not have, uh, needed to be recalled.

7:19

So this is another, um, screening mammogram.

7:24

And again, I'm gonna leave this up for a minute, see if you can see any, um,

7:27

abnormalities on here.

7:35

So I'm just opening up the,

7:37

just showing the m l O and CC views of the left breast now.

7:41

And I'm gonna circle the findings. So this is the finding.

7:44

I do think you can see it on her. These are the reconstructed, um, uh,

7:48

synthesized mammogram images. So this is a 2D picture,

7:50

but it's reconstructed from our tomosynthesis slices. And we see this,

7:56

um,

7:57

focal as symmetry or a small speculated mass in the upper central breast

8:03

so that we can see it on the 2D images.

8:05

I wanna now show it on the 3D images and just show how much more, um,

8:09

clear it is that there is a speculated mass with some associated distortion.

8:14

So just pause it here. So I'm gonna circle it,

8:18

it's right here. And then on the MLO view, similarly,

8:23

as I scroll through, I'm gonna pause right here.

8:29

And you can see this, um, this speculated mass in the, while it's,

8:34

it is visible on the 2d, it becomes much more obvious on the tomos.

8:38

And this is images when you're scrolling through it that this does not represent

8:41

overlapping fibro angular tissue like in the first case,

8:45

but instead represents a true finding.

8:50

So we, um, we do spot compression views. These are, these are, um,

8:54

the 2D Spock compression views. And again,

8:57

I do think you can see the finding here,

8:59

but it becomes much more obvious and much more easy and much easier

9:04

to really, um,

9:06

see the morphology of it when we're scrolling through on the 3D slices. So

9:11

again, there's the, on the 2d and here, I think on the cc it's most, uh,

9:16

it's easiest to see.

9:17

So we see the small speculated mass in the upper central breast.

9:21

So when we see a small a finding like this on a, on a mammogram,

9:26

we wanna see if we can find it on ultrasound because ultrasound is really the

9:29

preferred way to do biopsies if we're able to see the finding on ultrasound.

9:32

So I always think, I always look at the finding and try to localize it using,

9:37

um, the mammogram. So I know where on the ultrasound to look.

9:40

So this is in the upper, in the upper outer left breast. So we go to ultrasound,

9:45

we're gonna look in the kinda upper, upper central, upper outer breast.

9:48

And we saw this small mass at that location.

9:52

It's at the 12 o'clock position, three centimeters from the nipple.

9:57

And there is a, a,

9:58

a small irregular hypoechoic mass with angular margins. Um,

10:03

this looks kind of a similar shape, uh, as that uh,

10:07

mass that we saw in mammogram seems to be in the right right position.

10:11

So what we would choose now to do the biopsy using ultrasound.

10:14

So here's images from our ultrasound guided biopsy of that mass. Um,

10:19

so our first image, we see just the,

10:21

our biopsy needle lining up before the mass in our second image.

10:24

We've now fired. It's gone through the mass. So we usually take several samples.

10:28

I'm just showing images of one of them. And we place a biopsy clip.

10:32

And it's really important for these types of cases to place a biopsy clip

10:35

because we wanna make sure that this finding on her ultrasound is truly a match

10:40

for that mammographic finding.

10:42

So here is our post clip mammogram showing that,

10:47

uh, biopsy clip, um, in the,

10:52

in the upper central left breast. And I'm just gonna pull up, um,

10:56

her initial screening mammogram so that we can just look at the positioning and

11:00

we do see, so first I have the CC views and I see that biopsy clip here,

11:06

and that's right in the,

11:07

the the same spot where we saw that initial mass on her mammogram. Similar.

11:11

Similarly, I have the showing the mass on the lateral view, and again,

11:14

it's in the same spot as our initial finding on her mammogram.

11:17

So I feel confident that that ultrasound finding is truly a correlate for the

11:21

mammographic finding. I know my clip is well positioned. Um,

11:25

this did turn out to be an invasive mammary carcinoma with ductal and lobular

11:30

features. Um, it measured six millimeters in the,

11:34

in the material center pathology.

11:41

Here's our next case. So here's a screening mammogram.

11:52

I'm, I'm just showing the side that had the finding.

11:58

So this patient was recalled from screening mammogram for a focal asymmetry in

12:02

the inner central posterior right breast. So these are the,

12:07

the reconstructed CVU images.

12:09

And I'm gonna now scroll through the tomos and thisis slices.

12:15

And I think this is a tough finding. You know,

12:17

I do see that there is an asymmetry there, but I do, I do think that I,

12:21

I see interspersed fat within it that makes me think that it could just be her

12:25

normal fibro glandular tissue here on the, the lateral view.

12:29

The same thing when I'm scrolling through it,

12:31

that finding blends in with the tissue where I, I think it's,

12:36

it might just be her normal tissue, but she, she was recalled,

12:38

so we did additional spot compression views.

12:40

And the spot compression views with tomosynthesis are really helpful to show

12:43

that that just represents normal overlapping breast tissue. So here's, um,

12:47

the 2D spot compression views and here's our 3D images. And, um,

12:52

as I scroll through, I,

12:55

all I can see is her normal overlapping fibro glandular tissue.

12:58

When I follow the individual lines,

13:01

they are around fat lobules representing the fibro glandular tissue,

13:05

but I don't see a discrete mass or any area of architectural distortion.

13:09

So this was a, any symmetry that was recalled in with,

13:12

they're an additional Spock impression images,

13:15

we are able to confirm that this did not represent a true pathology.

13:33

So this is a, another screening mammogram, an asymptomatic patient,

13:39

and I think this is a really tough case to see on, um, a 2D mammogram.

13:44

I think it's, you know, on our, our high quality, um, image,

13:49

uh, screens that we use in breast imaging,

13:51

I think it is possible to see it on a, on your, on the 2D mammogram,

13:54

but it probably on the laptop that you're looking at,

13:56

it's gonna be very subtle here. I'm gonna zoom in on the,

14:00

on the side so you can at least see the side.

14:02

I'm gonna leave it for a second and see if any,

14:05

anybody is able to identify an abnormality here.

14:16

So this is a, a,

14:17

a subtle architectural distortion in the upper slightly inner right

14:21

breast.

14:25

So while I think very subtle on the 2D image,

14:30

I'm now gonna show it on this, on the 3D image,

14:32

and I think it's much less subtle here. So let me

14:37

pause so I can circle it. So here's the distortion.

14:43

It's very hard to see on her on the 2D image,

14:46

but the 3D really allows us to scroll through

14:51

and see that that's tr that's a true distortion in her breast that needs to be

14:55

further evaluated.

15:00

This is, um, I think this finding is easier to see on her, um,

15:04

CC view than the MLO view,

15:11

but I'm just gonna help, um, show you where to look with your eyes.

15:15

So if you keep your eyes here,

15:16

I'm gonna kind of scroll back and forth through there.

15:25

And I think you can appreciate how the breast tissue is distorted in that upper

15:29

part of the breast. So this patient was,

15:34

this was a screening mammogram. This patient was recalled.

15:38

We did spot compression views.

15:43

Here is our SP compression, um, CC view.

15:49

And again, I, I do think that that finding is, it's possible to see it on the,

15:53

the reconstructed 2D view, but it becomes much more, um,

15:58

obvious on the 3D view, um, when we're scrolling through tomosynthesis.

16:02

So let me again pause here.

16:03

So the finding is is right here and the slightly inner breast

16:20

and the slightly inner breast. So here's that finding right here.

16:24

Similarly in the MLO view, I think it's,

16:26

it's very difficult to see it on the reconstructed 2D view. Um,

16:31

but on the, um,

16:34

tomosynthesis places and we're able to scroll through the finding,

16:36

I'm just gonna draw your attention right here to keep your eyes here as I'm

16:40

scrolling through,

16:44

we can appreciate that the breast is distorted there.

16:48

So this is in the upper slightly inner right breast.

16:52

We're gonna do a targeted ultrasound to try to find a correlate.

16:57

So here's our ultrasound. This is at the right breast one o'clock position.

17:01

So that's in the upper inner quadrant,

17:02

which is what we would expect to ha where we'd expect to see that finding.

17:05

And we see this, um,

17:07

hypo coic mass with some speculated margins. Um,

17:11

our last image here shows, um,

17:14

internal vascularity kinda at the margins of this mass. Um,

17:17

so because we were able to see an ultrasound correlate,

17:20

we did an ultrasound guided biopsy. Um, but very importantly, uh,

17:23

we wanted to make sure we placed a biopsy clip because again,

17:25

we wanna make sure that that that ultrasound finding is truly a correlate for

17:30

the mammographic art architectural distortion.

17:33

So here's our biopsy clip again in that upper inner right breast. Um,

17:38

I'm just gonna show the CC view cause I think that's where we can see the

17:41

finding easiest. So here's our biopsy clip,

17:44

and that was where the distortion was on our initial screening mammogram.

17:47

And so we, that clip was well-positioned,

17:50

it was po well-positioned in the MLO view also.

17:52

And so we feel confident that the sonographic finding is truly a correlate for

17:57

the mammographic finding. Um,

18:00

the pathology for this was an invasive ductal carcinoma,

18:03

histologic grade two of three with associated D C I S,

18:11

another screening mammogram.

18:15

This was a case that was, uh,

18:18

recalled for a possible arch architectural distortion in the right breast.

18:22

So sometimes we'll we'll see on a, a full view,

18:26

an area that we question whether it's real, it's truly distorted or not.

18:29

We wanna have them come back to take a closer look. So this was, um,

18:33

identified by the radiologist reading the screening mammogram.

18:39

I'm gonna show now the 2D images. I'm gonna scroll through and see if we can

18:45

appreciate any distortion. I'm gonna circle,

18:48

this is where the finding was on her, on the 2D image,

18:53

but when I'm scrolling through now on the 3D imaging

18:58

and I'm following individual lines, I can scroll in and out of that area.

19:01

And there's not any single slice that I can pause on where I see a true

19:06

architectural distortion. So I think what, you know,

19:10

what we saw on that initial 2D mammogram was, uh,

19:14

just the summation of normal overlapping tissue.

19:17

We did a Spock impression view also.

19:19

And similarly we see normal overlapping fibro glandular tissue.

19:23

There's no area that I can pause on that where I see a true architectural

19:27

distortion. So this is another example of, of how, um,

19:33

of how, uh, there are some, there are many findings that with,

19:37

with a tomosynthesis we can, uh,

19:40

clarify as being normal tissue and not pathology without requiring a biopsy.

19:47

We did an ultrasound at this area. Um, we showed normal,

19:50

normal breast tissue and the patient was, um, returned to screening. Um,

20:02

this is a, the, the next case, I just have a CC view. I have the, um,

20:07

reconstructed 2D mammogram on the left and then, uh,

20:10

the tomosynthesis image on the, the right. And I think this is just a good,

20:14

a good example showing this patient has this a very dense breast tissue,

20:17

particularly in the kinda central two outer breast. Um,

20:21

but it's hard to see if there's anything in there. I mean,

20:23

I think you can sort of make out that there might be an edge like where my mouse

20:26

is here, but it's very hard to,

20:28

to make out because the death breast tissue is so dense here.

20:32

But let me show you, when I scroll through on her 3D mammogram,

20:37

it becomes much more clear that there is a mass in the retro aerial or breast,

20:43

um, and potentially even multiple MA and in a even multiple masses.

20:47

So I can see this edge here representing one mass.

20:50

There's another one slightly more outer in the breast.

20:55

Um, you know, when you look, go back and look at that 2D mammogram,

20:57

I think I can see where those masses are,

21:00

but they're very hidden by the dense breast tissue around it.

21:03

And the 3D mammogram,

21:05

the tomos and the cyst places really allow us to scroll through and,

21:09

and tell for sure that there are some findings in this breast that need to be

21:12

further evaluated. Um, so this patient was, um,

21:16

had an ultrasound done and, and luckily that these represented simple cysts,

21:20

she had several, um,

21:21

simple cysts in that outer retro alar and part of the breast,

21:25

which correlated with the mammographic masses.

21:34

So just shifting gears briefly. So I'm def I'm, um,

21:37

I have a interest in access to breast imaging and,

21:42

um, you know, part of that is the util utilization of breast imaging.

21:45

So our group did a,

21:46

a study recently looking at the utilization of tomosynthesis,

21:51

um, at our own institution. So we started, uh,

21:54

doing breast tomosynthesis in 2013. And we,

21:59

um, we found that although insurance, most insurances do cover it,

22:03

not all of them do. And we saw that there were, we,

22:06

we were hypothesizing that there were disparities in who was actually having

22:09

their screening mammograms performed with tomosynthesis.

22:12

And this is what we found in that study. So when starting in April, 2013,

22:16

when we first started doing screening mammograms with 2013,

22:21

with that tomosynthesis, we saw a pretty dramatic increase in utilizations from,

22:26

um, 19% in the first year up to about 90%, um, currently.

22:31

But at all the time periods, we saw differences based on, uh,

22:34

patient's race with a, a disparity between, um, white patients having, uh,

22:38

being more likely to have their, um,

22:40

screening mammogram performed with tomosynthesis compared to black and Asian

22:44

patients. So, and this just highlights that there is, uh,

22:47

definitely work to be done to make sure that this modality is available for all

22:51

patients.

22:57

I'm going to, um, move towards, uh,

23:00

tobo and the CIS guided biopsy now for the second part of the lecture.

23:09

Um, so before we can talk about tomos, and this is guided a biopsy, we need to,

23:13

uh, make sure everyone's on the same page with stereotactic biopsy.

23:16

So historically, uh,

23:17

mammographic findings that did not have a sonographic correlate have always been

23:20

biopsied with stereotactic guidance. Um,

23:24

so with stereotactic biopsies, we take a paired image.

23:27

These are two images that are taken out of, um,

23:30

plus and minus 15 degrees from the the scout image.

23:34

And that that's used to determine the position of the finding, um,

23:37

specifically the depth of the finding.

23:42

But now we've been doing all of these mammograms with, with, um, tomosynthesis,

23:48

and there are many findings that are only seen or best seen with

23:52

tomosynthesis. And so what do we do about those? So before we had, um,

23:57

the ability to do tomosynthesis guided biopsies, that was a,

24:00

it was really a problem, try to figure out what we should do.

24:02

So these patients were either, um,

24:06

recommended to have go straight to surgery and we would use, um,

24:09

tomosynthesis to localize the finding. Um,

24:11

and then they would do a surgical excision. Um, or we'd also, uh,

24:15

sometimes we would evaluate these findings further with M R I, um,

24:19

but if the M R I is negative, you're still left with this, um,

24:21

this finding that hasn't been, um, that has not been fully resolved.

24:26

So luckily, tomos and this got added biopsy was, um,

24:31

was started to be used. And this allows us to biopsy findings that are either,

24:35

uh, best seen or only seen on tomos. And this is imaging. Uh,

24:40

so our group started, started doing this and we had a lot of success with it.

24:43

There were some early studies that with high technical success,

24:46

they showed shorter procedure times. Um,

24:49

but after we had done this for some time,

24:51

we thought there was still limited data in the literature and it was reasonable

24:54

for us to, uh, look at our own experience to try to help, um,

24:58

to help show whether this has been a successful, successful or not. So, uh,

25:03

most of the cases of tomosynthesis guided biopsy were for architectural

25:06

distortions. So that was the first project that we did. We, um,

25:10

looked at all of our cases of architectural distortions that did not have a

25:13

sonographic correlate and we're biopsied with tomosynthesis guidance.

25:18

Um, this was, uh, published in a j r a few years ago. Uh,

25:22

the study included 151 unique architectural distortions

25:27

without a sonographic correlate. We found that, um,

25:31

19% of that cases were malignant, 32% were high risk,

25:35

and 49% were benign. Uh,

25:38

most of these malignant lesions were invasive carcinomas, and interestingly,

25:42

most of the invasive carcinomas were lobular, which is, um, overall less,

25:47

much less common than, um, ductal, which is the,

25:49

the most common type of invasive breast cancer. The high risk lesions, uh,

25:53

most often represented radial scars or complex rosing lesions.

25:58

And I think this just emphasizes that we really wanna make sure that these

26:02

distortions, even if they don't have a sonographic correlate,

26:04

are bios seed since 19% of them represented malignancies and another 32%

26:09

represented high high risk lesions. Um,

26:14

we did a follow up, very similar study looking at developing asymmetries.

26:17

These are not distortions, but, um, our are still suspicious findings. Um,

26:21

again, that did not have sonographic correlates. Um, this was, um,

26:25

published a couple of years ago in radiology,

26:28

and we included 85 developing asymmetries, did not have a sonographic correlate,

26:32

and we found a very similar, um,

26:36

malignancy rate of 20%.

26:38

And almost all of those malignancies were invasive carcinoma. So again,

26:41

this highlights the importance of biopsying these findings, which are,

26:45

are suspicious on mammography even if they don't have a sonographic correlate.

26:54

So now moving into our biopsy cases, um,

26:59

I'm showing here a, a prior mammogram and a new mammogram.

27:04

I'm just gonna leave this up for a few seconds so that you can take a look and

27:08

see if you can identify the abnormality.

27:19

I'm now showing just the, the MLO views, the, um, current and the prior,

27:26

and we see new, uh, density in the upper, uh,

27:30

left breast. And this is just the 2D view.

27:33

I'm gonna show the 3D views where we can do a better job of,

27:35

of evaluating whether it's it's distorted or, or not. But here's the CC view,

27:40

and I think that the two ccs next to each other can, uh,

27:44

really help to show this. Um, developing finding.

27:54

I'm now showing the tomos and the SI slices.

27:56

So here's the CC view when we see this developing asymmetry with artificial

28:00

distortion in that posterior breast.

28:13

Similarly on the MLO view in the upper part of the breast,

28:18

we see this developing asymmetry with associated distortion.

28:29

So the here is the finding on the MLO view,

28:31

and then here is the finding on the CC view.

28:36

So just like for those cases that I showed earlier,

28:38

this patient had a full workout. So we did Spock impression views,

28:41

here's the CC and MLO Spock impression views. Um, I think that,

28:46

I think you can see that there is a, an asymmetry, a focal asymmetry on the, um,

28:51

these reconstructed C view images. But on the tomosynthesis images,

28:56

I think we can really appreciate that there is an architectural distortion, um,

29:00

that's associated. So here,

29:03

I'm just gonna circle it with my mouse here so you can see where I'm looking and

29:07

I'm gonna scroll back through that finding. And

29:21

then similarly on the m l o view,

29:31

we can appreciate that there's a distortion in that upper part of the breast.

29:37

So like the cases I showed earlier, this, um,

29:39

we would recommend doing an a targeted ultrasound.

29:41

So we did the ultrasound and just showed normal breast issue. We didn't,

29:45

could not find a a, a mass that correlated with that finding,

29:48

but this was a suspicious finding. Um, we wanted to make sure we biopsied it.

29:52

So we recommended doing a, um, tomosynthesis guided biopsy.

29:56

So here are our images from the tomosynthesis guided biopsy. So,

30:01

um, this is a CC from above biopsy because the,

30:05

the finding was in the upper part of the breast, but more centrally on the cc.

30:08

So we generally choose the direction that's going to make the needle have to go

30:12

the shortest distance within the breast. Um,

30:15

the first picture here is our scout view. So on the scout view,

30:20

I'm gonna scroll through the finding and find on which slice I can best,

30:25

um, see the distortion. When I've, um,

30:30

identified the finding on the tomosynthesis slices,

30:32

I'm gonna click on it and our software will then give us coordinates.

30:36

So the X and the Y are gonna be based on where on the image I'm clicking.

30:40

Our Z axis is going to be calculated by which slice I'm clicking on.

30:48

This is, um,

30:49

different from the stereotactic cases where we take angled images and then, um,

30:53

the computer software will use geometry to determine how, what,

30:57

what the Z axis is or how far in we have to put the needle by using those angled

31:02

images and where the finding is on those angled images.

31:07

Our middle image here is our pre-fire image.

31:10

So I always take a pre-fire image and we wanna show that that needle is lined up

31:13

just, um, at the, the lesion. I think that this is, um,

31:17

a very hard thing to show on a PowerPoint slide,

31:22

but I see the finding here and I see my needle approaching the finding.

31:25

This is in the pre-fire position. Um, the finding,

31:31

um, is often obscured on a post-fire image, so I don't always take one.

31:35

So I don't have a post-fire image here, I just have the pre-fire image.

31:44

Um, we always wanna put a biopsy clip in. So similar, similar to the, uh,

31:49

ultrasound biopsies. That clip is really helpful to make sure that the, the, um,

31:53

the area that we, um, saw on the flow's full views, uh,

31:58

is the area that was biopsied. Um,

32:00

it's also helpful for localization when the patient goes to,

32:03

if the patient needs to go to surgery. Um, even if the,

32:06

the biopsy ends up being benign,

32:08

it's helpful to know where it was that we took those biopsy samples.

32:10

So we don't in the future, um, feel the need to biopsy it again.

32:14

So we put the clip in. We usually do a, a 3D post clip mammogram. I see here.

32:19

There's a top hat clip right at the right, um,

32:22

at the area of artificial distortion. After I place the clip,

32:26

I usually pull my needle back a little bit to make sure that there's separation,

32:29

so I can really see the biopsy clip separate from my biopsy needle.

32:33

So I can see that here.

32:44

So here is our, um, post clip, uh, mammogram.

32:49

So when I see that that biopsy clip is right in that area of developing

32:54

asymmetry with distortion in that upper inner, uh,

32:57

left breast right in the spot that I expect it to be. So I,

33:00

I feel confident that I biopsy that's the correct finding, um,

33:04

and that my pathology is gonna, is going to represent what, um,

33:08

the pathology is at that site.

33:10

So this case was an invasive lobular carcinoma grade two, um,

33:14

measuring 1.1 centimeters in the material. So this is a good example.

33:17

Like I had said in our, in our paper where we, uh, looked at all of our, our,

33:22

uh, architectural distortions, we found most of the,

33:24

the cancers were invasive carcinomas and more than half were invasive lobular.

33:28

So this is an example of an invasive lobular, um,

33:31

that presented as a distortion without a sonographic correlate.

33:39

Um, here's, uh, the next case. This is a, this a tricky case. This was a, um,

33:43

showing the left, this is actually an X CCL L view, so an exaggerated CCC view.

33:47

So you can see the outer breast well and, um, an MLO view.

33:52

Um, so this patient has lots of, of surgical eclipse from a prior lumpectomy,

33:57

but she was noted to have a new, um,

34:00

a new focal asymetry at the lumpectomy site,

34:03

and I think it's better seen on our spot views.

34:06

So I'm just gonna go to the spot views here,

34:08

but you can see there's a small mass or focal asymetry here in the upper,

34:13

upper outer left breast. Very posterior depth. Um,

34:17

this is new compared to prior exams.

34:18

The patient had had this lumpectomy many years ago. Uh,

34:23

and so it was considered suspicious. It's a ti uh, very, very small finding.

34:26

But regardless, we still recommended doing an ultrasound. Oh,

34:29

lemme just go ahead and show the, our tomosynthesis slices here.

34:34

So here is on the, on that X C C L view,

34:38

you can see this very small

34:43

mass.

34:47

And here's our MLO view,

34:59

and we can see that mass on the MLO view also. And again,

35:04

this was new compared to her prior exam, so it was considered suspicious.

35:11

We did an ultrasound. Um,

35:12

and this one we do not able to find a sonographic correlate for that finding.

35:18

So a new, a new finding at a lumpectomy site, um, it's considered suspicious.

35:22

We wanna make sure we biopsy.

35:23

And so this is another great example of where we can use, um,

35:27

tomosynthesis guided biopsy. So here is our, um,

35:30

our scout image of our tomosynthesis guided biopsy. And this was challenging,

35:34

it was very posterior in the breast. Um,

35:39

and it took a while, you know, to get, to find the area. But, um,

35:45

we, um, we found this asymmetry here. Um,

35:50

and so this was what targeted for biopsy. So we did the biopsy and like I have,

35:53

um, repeatedly said, we placed a clip to, uh, to,

35:58

uh, mark where it was that we took the biopsy from.

36:00

So we did that post clip mammogram, and we saw the biopsy clip.

36:05

But as we looked at the, the case after doing it,

36:07

we saw that she still had that small mass in the upper outer,

36:11

outer breast, further posterior from where we had biopsied. So we,

36:16

we spoke with the patient and she actually was willing to just have another

36:19

biopsy done that day. So she came back to the, um, biopsy table.

36:23

We did another scout image here.

36:28

And here's my, here's the biopsy clip from the first biopsy.

36:32

And at the very, very back of the screen,

36:36

we saw this other mass here.

36:42

So it was, it was, it was close, but if you remember from our first biopsy,

36:44

this was at the very back of our, of our biopsy window.

36:47

It's a small window that we're able to look at, um, where we had biopsied.

36:52

Uh, so with this, this other area was not in our initial biopsy window.

36:57

We then biopsied the second area. Um,

37:00

on that same day we put another biopsy clip in,

37:03

and that was in the correct area on her post clip mammogram.

37:07

We got our pathology back a few days later.

37:09

That first biopsy site was benign breast issue with associated rare

37:14

microcalcifications. That second spot when we had her come back and, uh,

37:18

biopsy the initially, uh,

37:21

describe suspicious finding represented in invasive ductal carcinoma,

37:25

moderately differentiated with mu mucinous features measuring five millimeters

37:29

and the results of associated microcalcifications. Um, so I think, um,

37:33

this just a great example of why we wanna make sure we're,

37:35

we're looking at that post clip mammogram image and, um, making sure that the,

37:40

the finding, um, whichever modality it's being biopsied with, uh,

37:44

really is, uh, matches up with our initial mammographic finding.

37:55

What about tomosynthesis guided biopsy of calcifications? So, um, you know,

37:59

I've,

38:00

we talked about stereotactic guidance before using that plus and minus 15 degree

38:03

images to localize the, the finding. And, um, although, you know,

38:08

I've only talked about biopsying like distortions and asymmetries, um,

38:11

really that was primarily, that's been primarily used to biopsy calcifications.

38:15

Uh, but in our,

38:17

once we started doing using 3D biopsy for these other findings,

38:21

we also started using it for back calcifications. And anecdotally, we,

38:25

I think people in our group really enjoyed using it. They felt like it was,

38:27

it was quicker. We took fewer images. There had been, um,

38:31

some studies on the use of it, but there hadn't been very many.

38:34

So we decided to, to look at our own experience with, um, tomos,

38:38

and this is guided biopsy of calcification. So this was a, a paper published,

38:42

um, pretty recently this past year, um,

38:45

in a j r where we looked, we compared our, um,

38:49

diagnostic mammography guided biopsy or,

38:51

or the traditional stereotactic biopsy with tomosynthesis guided biopsy for

38:55

suspicious breast calcifications. Uh, we included, uh,

39:00

over 1300 biopsies in their research study.

39:04

And we found that we,

39:06

we performed almost three quarters of our biopsies using tomosynthesis guidance

39:11

and only about a quarter with stereotactic only guidance.

39:14

And I think that really speaks to just the, our radiologists were getting,

39:17

were very comfortable using TOMOS and Thisis guidance and,

39:20

and felt like it was working well for them. When we compared these two groups,

39:24

the tomos and Thisis guidance group with the stereotactic guidance group,

39:27

we found that the procedure time and the number of exposures was significantly

39:32

lower when we used homos and the CIS guidance compared to the stereotactic

39:36

guidance. And it was statistically significant.

39:39

We did not show any difference between biopsy outcomes or high-risk leg lesion

39:43

upgrade rate. You know,

39:44

we wanna make sure that we're still diagnosing as many similar numbers of

39:47

cancer. Similar, we're not under, um,

39:51

under diagnosing cancers or finding, um,

39:54

that more of our high risk lesions are being upgraded,

39:56

but we didn't find any differences in those outcome metrics.

40:01

Um, so with that in mind, I wanna, um, next show a case of,

40:07

um, suspicious calcification.

40:08

So here are magnification views of grouped course heterogeneous

40:13

calcifications in the upper outer left breast.

40:20

So unlike all of the other cases I've shown, calcific uh,

40:23

calcifications are best visualized on ma um, on magnification views.

40:26

The tomosynthesis is not typically helpful in evaluating them,

40:33

but, um, we did do the bi this biopsy using tomosynthesis guidance.

40:37

So similar to the other cases,

40:39

we have our initial scout image where we take a tomosynthesis, um,

40:45

a set of tomosynthesis images through the area. Um, here are our calcifications.

40:51

Uh, it's important to,

40:53

to scroll above and below the area that you're intending to biopsy to make sure

40:57

there's not a vessel in the way. And that's, um,

40:59

something that's very helpful with tomosynthesis that you're able to do that to

41:03

see for sure that whether or not there are biopsies above and below the finding

41:09

here is our pre-fire image.

41:14

And I see my biopsy device lined up just in front of those calcifications.

41:17

I'm making sure that they didn't move when I did my, um,

41:20

numbing medicine and placed my biopsy device in

41:32

after I took the samples. We place a biopsy clip.

41:37

Here's the biopsy clip. We see again, it's right,

41:39

it's lined up exactly where those calcifications had been.

41:42

I pulled back my needle a little bit to make sure to see separation between the

41:45

biopsy clip and the biopsy needle.

41:51

We biopsy see calcifications while we're still in the room with the patient.

41:54

We take a stereo, a, a, uh,

41:56

specimen radiograph to confirm that the m f calcifications have been removed in

42:01

order to come up with a a definite answer.

42:03

So here's our specimen radiograph showing, uh,

42:05

representative calcifications in the specimen. And,

42:10

um, this,

42:11

this did represent ductal carcinoma in situ grade two to three out of three.

42:25

Um, so in in summary, uh,

42:28

digital breast tomosynthesis has really changed breast imaging in the past, uh,

42:32

decade or a little bit more than a decade now. Um,

42:34

we see improved recall rate and improved cancer detection rate,

42:38

and we're also at able to buy findings using tomosynthesis guidance,

42:42

which is very exciting. And this is, um, more of an evolving area.

42:46

Um, I wanna thank you so much for your attention. Um,

42:51

if anybody has any questions, we have a few minutes remaining where I will, um,

42:55

answer questions. I see there's a couple already. Um, so I'll go ahead and, um,

43:00

and start going through those, but feel free to keep,

43:02

keep adding them if you have any other ones. So, um, our first question is,

43:06

are you using vacuum assisted biopsy device and what is the, the gauge?

43:10

So for our, um, at our institution, for our ultrasound guided biopsies,

43:15

we do not use vacuum assisted biopsy device for our, um,

43:19

stereotactic or tomosynthesis guided biopsies,

43:22

we do use a vacuum assisted biopsy device. Um,

43:25

and it's a a a nine gauge needle for our ultrasound guided biopsies.

43:29

We typically use a 14, sometimes an 18 gauge biopsy device.

43:36

Um, the next question is, um,

43:38

did you try hydro mark clip after stereo biopsy and did you notice migration?

43:44

Um, so that's a, a great question.

43:46

So we use hydro mark clips for our ultrasound guided biopsies. Um,

43:50

we really like it, especially for, um,

43:51

cases that we need to localize in the future.

43:54

So the hydro mark clips are really well seen on ultrasound. Um,

43:59

we do not use them right now for steri tactic biopsy or for M R I guided biopsy.

44:04

Um, there is was concern about migration. I know I think our,

44:07

our rep has said that the, the newer ones have have less migration,

44:10

but I will say right now we are not using those, we're using other,

44:13

other types of clips. Um, although our,

44:15

I think that there is benefits to those Highmark clips to allow that because it

44:19

would allow us to be able to do localizations, um,

44:24

uh, using ultrasound potentially, especially for really deep findings.

44:32

Um, our next question,

44:38

Let me see.

44:42

So one of the questions here is,

44:43

is it fair to say that most beneficial of D B T is architectural distortion?

44:48

Um, I would say that the, the benefits of of D B T are really twofold to,

44:53

one is identifying more cancers and those are often architectural distortions,

44:57

but they may be developing asymmetries, um, as well,

45:03

even masses that are, uh,

45:06

obscured by the surrounding breast tissue can be better seen with tomosynthesis.

45:10

Um, and, but I,

45:12

I think that that category of improved cancer detection is definitely a benefit

45:17

of D B T and part of that is arter health distortion,

45:19

but I don't think all of it. I think another benefit of D B T,

45:22

however is the decreased recall rate. And I showed a few, I showed a few cases,

45:27

um, where, um, we could see that the, that, um,

45:30

by using tomosynthesis we were able to clarify that a finding that looked

45:35

possibly suspicious on a 2D mammogram really just represented normal overlapping

45:39

breast tissue.

45:46

Lemme see.

45:48

So there's a question about, um,

45:49

tomosynthesis and elastography and I will say I don't really know the answer to

45:53

that. I have not done any work with elastography and we don't routinely do

45:57

elastography on our, um, in breast imaging at our institution.

46:05

The next question is, I have struggled to stereo a deep calcification in the,

46:09

um, lower inner quadrant. Any tips? So deep, um, findings are,

46:14

are challenging sometimes with, um, stereotactic biopsies.

46:17

There's definitely a lot of positioning, um, tips. Uh,

46:22

I think it's, it's, you know, sometimes you can try to have the,

46:25

the patient put their arm through the table if you're in a prone um, position,

46:30

um, sometimes it'll allow to get further back. I would, um,

46:34

try both the CC and lateral view sometimes to try to get further back. Um,

46:39

if we are very lucky that we have, uh,

46:41

multiple sites and some of our sites have a prone table and some have an upright

46:44

table, and I find that,

46:46

that there are some cases where one or the other can help me get further back in

46:50

a, to get a, a lesion. Um,

46:53

but it is a challenge sometimes to get those really posterior,

46:56

posterior calcifications. Um, sometimes it's just not possible.

47:00

And we've definitely had cases where we are unable to do a biopsy and we will

47:04

instead localize it and the patient will go straight to surgery,

47:06

but we really try to try to minimize that.

47:12

Um, the next question is, um,

47:14

what do you specifically write in the tomo report?

47:17

Is it different from the mammogram report? Um, we have a, a,

47:22

a line that we include in our mammogram report stating that tomo and thisis was

47:26

used as part of the exam. It's just a one line that's added to the,

47:29

the mammogram, um, report.

47:34

The next question is,

47:37

do you have the facility to place a tomo guided clip without doing a biopsy?

47:44

Um, so I guess the question is we have the facility, I mean,

47:46

technically we would be able to do that. We have, um,

47:49

I think done that on very rare occasions. Um,

47:53

but that is done very infrequently.

47:54

Our surgeons have a strong preference to have the pathology before taking the

47:58

patient to surgery. Um, so we haven't found a need to, to place, um,

48:02

clips without doing a biopsy on, on very many occasions. We would, um,

48:07

usually do the biopsy and then place a clip there so that we would have an

48:10

answer and, um, and know what the pathology was before,

48:15

um, before a patient goes to surgery.

48:23

Um, then the next question is, um,

48:25

is there a scenario where stereo tactic biopsy is superior tooma and the IS

48:30

guide guided biopsy? I currently only do 3D biopsy,

48:33

but was wondering which scenario to consider 2D biopsy? So I,

48:38

I, you know, I showed,

48:39

I think that I've been really switching to doing more and, uh,

48:42

like to doing just about all of my calcification biopsies even with, um,

48:45

tomosynthesis because I feel like it's, I can do the biopsy quicker, um,

48:49

and I'm taking fewer images. But I will say that there are,

48:52

there are some calcifications that are kind of subtle,

48:55

like some of those more amorphous calcifications where I feel like the 2D images

49:00

help me see the finding better. And in those cases, I,

49:04

I might do 2D biopsy. Um,

49:08

I think it's also helpful to have both possibilities. So it's, it's, um,

49:12

you know,

49:13

sometimes I'll go back and forth where maybe I'll do my scout image with 3d,

49:16

but then my pre-image I'll wanna do as a stereotactic pair in order to better

49:21

see the calcifications if I feel like they're somewhat obscured after giving

49:24

the, the numbing medicine. Um,

49:28

I haven't done a full case using just stereotactic in a, in a while,

49:32

but I will say I will definitely take stereotactic images to help me sometimes

49:36

for, um, especially for subtle calcifications.

49:44

Um,

49:44

the next question is use TOMA and the CI regularly for every case or in a few

49:48

selected. So, um, we use, um,

49:52

so for screening exams we would like to use it for all patients,

49:55

but unfortunately there are a few insurance companies still in, um,

49:59

the state of Maryland that don't cover tomosynthesis.

50:02

So we do about 90% of our screening mammograms with tomosynthesis. Um,

50:06

but that has increased, um, over the past decade, um, dramatically.

50:10

But we're kind of right around ni we've been 90% now for the last few years

50:15

helper. When we call patients back, we do, we, um,

50:18

do tomosynthesis for all of those recalled mammograms unless they're for

50:21

calcifications when, when it's not necessary. But, um, we, uh,

50:26

do all of the callback mammograms with tomosynthesis because we find it to be

50:29

very helpful in order to, to limit our,

50:32

our need for biopsies for findings that we could clearly see are,

50:35

are just overlapping tissue with the tomosynthesis.

50:43

Um, our next case, our next question is,

50:47

um, how many cases in your,

50:50

in your study had a normal study on tomo biopsy?

50:55

Um, so I think you're referring to the,

50:58

the architectural distortion paper and the developing asymmetry paper. So, um,

51:03

so all of those patients had an ultrasound exam that was negative. Um,

51:08

all of them had a, a finding on their,

51:11

on their 3D mammogram that was considered suspicious and, and had a biopsy done.

51:15

And, and both of those studies,

51:17

20% of them turned out to be about 20% turned out to be cancer. So the 80,

51:22

the other pa the other cases were not, were not cancers. Um,

51:27

so still the majority of those cases did not turn out to be cancers,

51:30

but 20% is a,

51:31

is a high enough number to definitely justify doing a biopsy for them. You know,

51:35

we usually buy RADS four is anything over a 2% risk of breast cancer.

51:39

So when we're talking about, um, a pre, uh,

51:42

a predictive value of 20%, then that, um,

51:46

easily justifies biopsying those findings.

51:53

Um, the next question is, any tips for biopsy in a small breast? And yeah,

51:56

this can be, can be challenging. You know, we have the petite needle,

51:58

which usually you can, um, it will allow you to do a biopsy up to, I think it's,

52:02

um, 2.3 centimeters of thickness. But there are definitely patients who have,

52:07

um, even smaller breasts and there are some things that, um, you can do to,

52:10

to help you. So, um, you can,

52:15

uh,

52:16

give lots of numbing medicine to kind of create a little bit more breast tissue,

52:20

um, to use. There is, um, when,

52:24

when doing the, when you're localizing,

52:26

you can remember that you're gonna be taking, um, you're not,

52:31

you don't have to exactly click on the finding when you're doing the biopsy.

52:34

You can click in front of it or behind it in order to allow your whole, um,

52:39

the, the biopsy needle to be buried and have,

52:42

instead of the finding being exactly in the middle of your,

52:45

of your target could be towards the beginning or the end.

52:47

And that can be helpful to help to get the needle totally buried, um,

52:51

on top of there being, you know, our normal needle.

52:53

And then there's a petite needle.

52:54

There's also a blunt tip needle that can be used for very small, small breasts.

52:58

So you have to, obviously you have to get order that and have it separately,

53:01

but that's another option to be used for small breasts.

53:06

Um, I think also another,

53:08

another thing that I found helpful is being able to go back and forth between

53:11

the, the cc and the lateral view.

53:12

Sometimes when a patient will compress differently in one view versus the other,

53:16

and it might be a little bit thicker in one view to help you do the biopsy.

53:24

Um, um, the next question is,

53:26

which do you suggest tomosynthesis or contrast enhanced mammography? And I'm,

53:30

I'm very biased because we do not do contrast enhanced mammography at, uh,

53:34

my institution. So I would definitely pick tomosynthesis.

53:36

I also don't think it's one or the other. Um, I think they have both, you know,

53:41

I think pieces that that use contrast enhanced mammography are also doing

53:44

tomosynthesis. Um,

53:46

I think that tomosynthesis has a lot more data behind it, um,

53:50

and is a more universal modality than contrast enhanced mammography if you're

53:55

only gonna have one or the other. Um, but there's a lot of exciting, uh,

53:59

research coming out on contrast mammography,

54:00

so I'm excited to kind of see where that,

54:02

where that goes and where that's gonna fit into our, uh, our cancer workup.

54:11

The next question is whether we have increased detection of microcalcifications.

54:14

I assume that is referring to with tomosynthesis and, and I don't think so.

54:17

I don't know that calcifications, uh, necessarily have improved detection. Uh,

54:21

I think that the benefits of tomosynthesis are more specific for invasive micro,

54:26

uh, invasive carcinomas, which are, are usually not just calcifications. Um,

54:30

but I think that the, there have been studies that have sh shown both, um,

54:34

both for that, so I don't, I don't know all of the data off the top of my head,

54:37

but I would say the benefit of tomos is not necessarily for increased detection

54:41

of microcalcifications, but more for, um,

54:44

like masses and distortions and asymmetries like I talked about before.

54:52

So there another question about contra mammography and I'm gonna, um,

54:55

I think I'm not gonna answer that one now. That's not,

54:57

so we don't do contra mammography. I think there is, um,

54:59

the kind of developing where that's going, where that should be,

55:02

where that should be used, but I don't think I have the,

55:04

probably the most up-to-date answer on that right now. Um, you know,

55:09

the next question is whether there's an absolute indication for tomosynthesis

55:12

and, and no, I don't think the answer right, you know,

55:14

currently standard of care is,

55:16

is either to the standard full field digital mammogram or tomosynthesis.

55:21

So, um, we do think that there is,

55:23

there is sufficient studies to say that tomosynthesis is, um,

55:27

has improved recall rate and cancer detection. Um,

55:30

but the standard of care is really for either modality and it's much more

55:33

important for a patient to get a mammogram with either one than to not get one,

55:38

um, to, than to not get one or to choose one or the other.

55:42

So I would definitely encourage patients to get a screening mammogram. Um,

55:46

and if they, they can get it with tomosynthesis, I would always pick that,

55:49

but I would not say that there is an absolute indication for that.

55:55

Um, see, I think we still have a little bit more time, um,

55:59

a lot of great questions here. The next one is,

56:02

how do you encounter complications bleeding during or after the biopsy?

56:06

How do you handle it? So, you know, whenever we're doing a biopsy,

56:09

there is definitely a risk for, um, for bleeding. Um,

56:13

that's probably the most common complication that we,

56:15

that is the most common complication we see. And you know, I,

56:18

I find that holding pressure is, is almost always is gonna,

56:23

is gonna be successful. Sometimes it's a lot of pressure and for a long time.

56:27

Um, and if that is the radiologist or maybe there's a tech or tech aid at the

56:31

institution that can help. Um,

56:33

but really holding firm continuous pressure until the bleeding stops. You know,

56:37

there are rare complications, pseudo aneurysms that can occur.

56:40

I think that's really one-offs,

56:42

but most of the time the bleeding really just requires, um, pressure,

56:47

continuous pressure, um, until it stops bleeding.

56:54

The next question is,

56:55

how much local anesthetic do you give and how often does the target move? Um, I,

57:00

I do think this is sort of individual. Uh, you know, I think even when I did my,

57:03

my fellowship, which is only a few years ago, different,

57:06

the different attendings that I worked with would be definitely inconsistent

57:09

with how much an anesthetic each person used.

57:11

But I found that the most important thing is,

57:14

is making sure that the skin is really well numbed. So, um,

57:19

I wanna give enough, uh,

57:22

lidocaine in the skin to make sure I see a really a,

57:25

a skin wheel that's very clear. So it's usually about, um,

57:30

one to two ccs. You know, sometimes if, um, if I end up, if I,

57:34

my initial injection is a little bit deep, I'm not seeing a good wheel,

57:37

I'll put a little bit more in. Um, and then I give deeper numbing medicine,

57:41

lidocaine mixed with epinephrine. Um, I usually draw up about eight ccs and,

57:46

uh, depending on how, um,

57:49

how dense the breast tissue is and how deep the finding is,

57:51

I'll just slowly inject it in and out and usually give about five or six ccs.

57:55

But it is, it is very variable. Um, I,

58:00

I find that with that,

58:01

patients do not have symptoms typically during the biopsy, but I do tell them,

58:05

if you're feeling anything, let me know. We can always give you more wem.

58:08

Our biopsy machine will automatically give additional lidocaine as we're taking

58:12

the biopsy samples. Um, so I usually will warn the patient,

58:15

they might feel like a,

58:17

a few seconds of that singing sensation when we're taking the biopsies.

58:20

And that's probably the numbing medicine that's, um, that's going to be,

58:24

that's at an area that wasn't totally numb. Um,

58:27

not the biopsy needle like causing, causing pain. And I think that, um,

58:30

is very helpful for the patients to know. Um,

58:36

the next question is,

58:37

do you have any data of D B T guided biopsy with implants versus stereo?

58:42

I don't have any data. I think it would be interesting to see, um, you know,

58:47

I think with both,

58:47

you wanna make sure that that implant is really pushed back as much as possible

58:51

and is not in the, the images. Um, I think, um,

58:55

I I just kinda anecdotally I,

58:58

I like using tomosynthesis because I think I can really scroll through the

59:02

slices and see for sure that I'm not going to hit the BM anywhere near the,

59:06

the implant, which is with the, with the, um, angled images.

59:09

It sometimes it can be a little bit confusing if,

59:11

if exactly the direction that your needle's going,

59:13

whereas with the tomosynthesis, you know,

59:14

you're just going straight down through the breast tissue. Um,

59:18

but I don't have any, any specific data on that.

59:20

I think it would be an interesting, interesting thing to look at.

59:28

Um, the next question is,

59:31

does needle localization ever helpful in lesions with suspicious

59:37

calcifications? I'm not sure I completely understand that question,

59:42

but we do need localizations for suspicious calcifications. Um,

59:47

I don't, we don't typically use, um, tomosynthesis for our localizations.

59:52

We usually do them with a alphanumeric grid. Um, but I think,

59:55

I know there's other institutions that are using tomosynthesis more for

59:58

localizations. That's not something that I'm, I'm actually that familiar with.

60:03

And the next question is, in our unit,

60:06

the clip placement has to be through the biopsy needle.

60:08

So on the rare occasion when we need to place a tomo guided clip without a

60:12

biopsy, we do not have the equipment to support this.

60:14

Which equipment do you use to facilitate tomo guided clip placement?

60:17

So I think this is probably maybe a follow up to the question before asking if

60:20

we have replaced biopsies with the biopsy clips without doing the biopsy.

60:23

I also am not sure that we have a separate equipment.

60:26

I'm not sure there may be things that you can order.

60:29

I think the very few times that we've done this before,

60:32

we probably had to just open up the biopsy, the whole biopsy kit, but I'm,

60:36

I'm not actually a hundred percent sure. Um,

60:38

I think it's something that you could ask your,

60:39

your rep about if they would be able to separate and just get the, um,

60:45

the biopsy, uh, like the introducer piece. Um,

60:51

but you would need to have a needle in it to get to the site. So I,

60:53

I'm not sure, um, what you would need to do,

60:55

but I think it's something probably to talk more with your rep about.

60:57

I don't think that we have anything specific that we have different,

61:00

I think we've just opened up the biopsy kit.

61:07

Um, I think we're a little bit after one. I'll just do one more,

61:10

one more question. Um, but I really appreciate all of the questions.

61:13

Really great, great discussion here. The,

61:16

the last question is how do you biopsy lesions close to the skin?

61:22

Um, it's, you know,

61:22

I sort of a similar answer I think to like how to biopsy in small breasts and

61:26

it, and I would say it can be really challenge, it can be really challenging.

61:30

Um, could be helpful to use the petite device. Um,

61:35

but if there's a lot of tissue behind, you might not need the,

61:37

the petite device.

61:38

I think a few things that you can do are to make a really big skin wheel that

61:41

can add some additional depth, um,

61:44

for you to have to get the needle totally buried.

61:47

You can also target slightly past where the lesion is on your

61:52

stereotactic images, knowing that your,

61:55

where your targeting is going to be the middle of your biopsy device and you

61:59

don't necessarily need the lesion to be right in the middle.

62:01

So k if it's closer to the proximal part of the needle.

62:05

So if you target slightly past it, you can still, um,

62:08

often biopsy the lesion closer to the skin. Um,

62:13

so those are some tricks that I've done to try to get these very superficial

62:16

biopsies. Um, but I do, I, I know they can be definitely be challenging.

62:22

Um, well thank you so much for the, for the discussion.

62:25

Dr. Ambinder,

62:26

thank you so much for your lecture today and the case review and for everybody

62:29

else for participating in this new conference. It was wonderful.

62:33

You can access the recording of today's conference and all our previous new

62:36

conferences by creating a free m i online account.

62:39

Be sure to join us next week on Thursday, July 20th at 12:00 PM Eastern,

62:44

featuring Dr.

62:44

Steven Rowe for a lecture on PSMA PET Interpretation and applications.

62:49

You can register for this free lecture@mrionline.com and follow us on social

62:53

media for updates on future NOOM conferences. Thanks again and have a great day.