0:00

So now moving into our biopsy cases, um,

0:06

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

0:10

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

0:14

see if you can identify the abnormality.

0:20

I'm now showing just the, the MLO views, the, um,

0:24

current and the prior, and we see new, uh,

0:29

density in the upper, uh, left breast.

0:33

And this is just the two D view.

0:34

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

0:36

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

0:40

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

0:45

really help to show this. Um, developing finding.

0:55

I'm now showing the tomosynthesis slices.

0:57

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

1:01

distortion in that posterior breast.

1:09

Similarly, on the M l O view, in the upper part of the breast,

1:14

we see this developing asymmetry with associated distortion.

1:25

So the, here's the finding on the M l O view,

1:27

and then here is the finding on the CC view.

1:33

So just like for those cases that I showed earlier,

1:35

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

1:38

Here's the CC and M L O Spock impression views. Um, I think that,

1:43

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

1:48

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

1:52

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

1:57

that's associated. So here,

1:59

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

2:04

I'm gonna scroll back through that finding.

2:12

And then similarly on the m l o view,

2:20

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

2:26

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

2:28

we would recommend doing an a targeted ultrasound.

2:30

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

2:34

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

2:37

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

2:41

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

2:45

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

2:50

this is a CC from above biopsy because the,

2:54

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

2:57

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

3:01

the shortest distance within the breast. Um,

3:04

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

3:09

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

3:14

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

3:19

identified the finding on the tomosynthesis slices,

3:21

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

3:25

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

3:29

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

3:37

This is, um,

3:37

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

3:42

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

3:46

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

3:51

images and where the finding is on those angled images.

3:56

Our middle image here is our pre-fire image.

3:59

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

4:02

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

4:06

a very hard thing to show on a PowerPoint slide,

4:11

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

4:14

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

4:19

um, is often obscured on a post-fire image,

4:23

so I don't always take one. So I don't have a post-fire image here.

4:26

I just have the pre-fire image.

4:33

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

4:37

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

4:42

the area that we, um, saw on the, those full views, uh,

4:47

is the area that was biopsied. Um,

4:49

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

4:52

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

4:55

the biopsy ends up being benign,

4:57

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

4:59

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

5:03

So we put the clip in. We usually do a a three D post clip mammogram.

5:07

I see here. There's a top hat clip right at the right, um,

5:11

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

5:14

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

5:17

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

5:22

So I can see that here.

5:28

Um, so here is our, um, post clip, uh, mammogram.

5:34

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

5:39

asymmetry with distortion in that upper inner, uh, left breast,

5:43

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

5:45

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

5:49

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

5:53

the pathology is at that site. So this case was an invasive

5:56

Lobular carcinoma, grade two, um, measuring 1.1 centimeters in the material.

6:01

So this is a good example. Like I had said in our, in our paper where we, uh,

6:05

looked at all of our, our, uh, architectural distortions, we found most of the,

6:09

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

6:12

So this is an example of an lobular, um,

6:16

that presented as a distortion without a sonographic correlate.