0:01

Okay. So what type of procedure is

0:04

this?

0:07

Open this.

0:13

Up. There's a stereotactic needle localization post ultrasound

0:16

guided procedure or galactogram.

0:22

So this is actually wow kind of

0:25

I'm glad that some people are getting this wrong. So this is actually

0:28

a needle localization procedure and whenever you

0:31

see that alphanumeric grade, you know, it's a needle localization as

0:34

opposed to a stereo which I want to show you after I

0:37

don't think I have it but I will

0:41

Um, so so a patient

0:44

comes in if you don't know this, you're probably going to lose you

0:47

here, but this is good because I want you guys to learn something.

0:50

So if a patient comes in for a needle localization, what's the best

0:53

approach and let's pull up the poll here. Do we

0:56

want to come from lateral for medial from above

0:59

or From Below?

1:03

So this is the CC and this is the mlo.

1:11

Or ml it should be an ml.

1:15

Okay.

1:17

So let's close the poll.

1:22

Okay good. So the two people that answered got

1:25

it, right. So the shortest distance is from lateral.

1:28

So you always want to go for the shortest distance whenever

1:31

you're doing a needle localization or stereotected biopsy always

1:34

wanted to do the shortest distance.

1:36

And and what size needle would you

1:39

use would you use a three five seven

1:42

and a half or 10 centimeter needle?

1:48

We're going to go over all this so you're going to be Pros by the time

1:51

we're done with it.

1:54

Okay good. So the three people I answered it. It got it, right. So

1:57

yeah, you're gonna want to use a five in this case because you want

2:00

it to be long enough. This was four and a half centimeters. We

2:03

wanted to be long enough to get to the lesion but not too much

2:06

longer than that. So you always want to size up a little bit. So

2:09

when it's four and a half you want to use a five and how

2:12

you tell the tech to position the patient.

2:15

This is where I lose everybody. So we're coming from lateral.

2:19

How are we going to position the patient for their

2:22

needle look procedure?

2:26

lmml or CC

2:30

Okay, good. I'm so glad that nobody

2:33

shows the right answer. So it's LM. So

2:36

this is how I remember it so.

2:40

If you're coming from lateral, I think

2:43

that what confuses people is you're you

2:46

think because the shortest skin surface is is on

2:49

the CC. It's from the lateral view, but

2:52

you actually place it like an orthogonal. So

2:55

let me show you how we actually do a

2:59

A needle look so we talked about this and the

3:02

patient comes from needle. Look you want to choose a shorter skin surface and this case

3:05

it's lateral you're using a five centimeter needle and

3:08

you're going to tell the patient the tech to position the patient Ln. So

3:11

I always think of it as a side

3:14

that you're coming from is the letter that you're going to start with. So if

3:17

you're coming from lateral, it's gonna be Ln if you're coming from medial. It's

3:20

going to be ml. So that's easy way to remember it.

3:23

If you're coming from above the patient is going to be positioned in

3:26

CC and you're coming from above same if

3:29

they're coming from below you're gonna position them CC but

3:32

it all matters where the actual alpha numeric

3:35

grid is open versus the receptor.

3:38

So

3:41

If you haven't seen one, I really urge you to see one in person

3:44

because I think it will make a lot more sense. Once you see it

3:47

in person. I always tell my residence to come in and see because when we plan

3:50

for it, so let's talk about this. So This is

3:53

actually a case where I'm coming from lateral. So I'm

3:56

targeting this clip right here.

4:00

so

4:02

so if we're coming from lateral, we're going

4:05

to be positioned LM. We're gonna put our needle in

4:08

we already measured we know that we need a five centimeter needle.

4:11

So we're gonna use a five and

4:14

we're gonna go in all the way. So in this case, I would go and be I'm

4:17

sorry be and a half and one and like

4:20

a quarter. So you basically put your needle in all

4:23

the way.

4:25

So we put the needle in right where the clip is

4:28

and now all we know is that it's in the same plane is

4:31

it we don't know know where it is or how deep it

4:34

is until we take them out and then we put them in the CC compression

4:37

and then we could actually see where our needle is and

4:40

relation to the the clip in

4:43

the math. So in this case, I really wish I had a better image but you

4:46

can see that the mat that the needle goes beyond the clip and

4:49

the mask and once you confirm that the needles beyond the clip

4:52

in The Mask, then you're gonna hook it you're gonna put the hook

4:55

wire through the needle and the patient goes across

4:58

the whole to surgery with the

5:02

needle and wire in their breasts and then they go to surgery and the

5:05

surgeon takes it out and then they're gonna send you something like this.

5:08

This is called a specimen radiograph. If you've never seen one before

5:11

the patient goes to surgery they take out the

5:14

clip. So when we check us person radiograph, we're looking

5:17

for a few things we're looking for the clip and the wire we're looking

5:21

to make sure that we got the by the math and that you know,

5:24

it's not

5:25

The edge of the margins because we're really going

5:28

for for negative margins and this patient that's going for lumpectomy.

5:31

So this is really how

5:34

you do need a look procedure for my residents come in

5:37

the room with me. You'll make a lot more sense after you see it if you

5:40

haven't seen one in a while.

5:41

So need a localizations are performed when

5:44

the surgeon cannot see or feel the tumor or

5:47

they need a surgical biopsy. Let's say you get atypical ductal

5:50

hyperplasia. They want to take out more tissue. They're going

5:53

to go to the or so we do a needle localization. You can

5:56

do needle localization under any modality where

5:59

you see it best. So if you see it best under mammography because you

6:02

have a clip there. That's one. That's great. You do in our mammogram. I

6:05

like to do it on ultrasound whenever I can because I

6:08

really want to Target that math.

6:10

Um, or you could do it on MRI, but you

6:13

need an MRI compatible needle and wire

6:16

so we don't typically do them here at Cooper.

6:20

These cases are usually performed on the morning of

6:23

the creation surgery. They come to reality immediately before their surgery.

6:26

We put the needle and wire in and then they go straight

6:29

across the hall towards the or they go

6:32

to the or with the needle and wire in the breath that the surgeon removes,

6:35

you know newer Technologies are way better for patients.

6:38

It's all done the same way. But in this

6:41

type of in the newer Technologies here, we use something called

6:44

a radio frequency

6:47

tag, but they also have tags that are magnetic

6:50

or our radioactive. And basically we're

6:53

going to place a little chip a

6:56

little tag right where the the cancer

6:59

is or the thing that needs to be removed and the

7:02

patient can leave with that. We take the needle and wire out

7:05

they just put a clip right where it is and then the surgeon can

7:08

come back a week the patient can come back a week later

7:11

two weeks later kind of indefinitely later. We try

7:14

not to put it in more than a month in advance. But then the surgeon

7:17

when they go to the or the surgeon has

7:20

A receptor whatever it is in our case. They have a radio frequency

7:23

receptor or detector, or you

7:26

can have a magnetic detector or radio a radio

7:29

Radioactive C localization and they find where

7:32

it is in the breast and then they remove it

7:35

and they know they got it because then it you know, it beeps when it's taken out.

7:38

It's kind of like the gamma camera.

7:40

with a sentinel lymph node injection

7:43

And so, you know just to summarize how you

7:46

do need a low procedure. You're going to want to find the shortest skin surface

7:49

and measure the distance needles come in three centimeter

7:52

of five seven and a half or nine. You always want

7:55

to make sure you you know, if you're coming from lateral

7:58

you're going to position them LM. They're coming from medial you're

8:01

gonna position them ML and if you're coming from above or below

8:04

you're gonna position them CC and just simmer on

8:07

that for a little bit think about that. You're gonna

8:10

basically

8:13

find find your target and determine your

8:16

coordinates. You're going to put the needle on straight as straight as

8:19

you can then you're gonna take them out and put them in the other orthogonal directions.

8:22

So if you're in LM, you're gonna put them in CC

8:25

in vice versa if you're in CCR and put them NL or

8:28

Ln you're gonna place the wire through the needle and

8:31

remove and then the patient's gonna go to surgery and you're gonna check this doesn't

8:34

really