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0:43

Today we're honored to welcome Dr. James Facciola for a

0:46

lecture on overview of ultrasound-guided biopsies.

0:50

Dr. James Facciola completed his radiology residency

0:53

at Temple University Hospital and cross-sectional

0:56

imaging fellowship at Johns Hopkins Hospital.

0:59

At the end of the lecture, join

1:00

Dr. Facciola in a Q and A session where he will address

1:03

any questions you may have on today's topic.

1:05

Please remember to use the Q and A feature

1:07

to submit your questions so we can get to

1:08

as many as we can before our time is up.

1:10

With that being said, we are

1:12

ready to begin today's lecture.

1:13

Dr. Facciola, please take it from here.

1:16

All right, thank you.

1:18

Um, so I hope everyone's doing all right.

1:22

Uh, so today we're gonna talk about, or I'm

1:25

gonna talk about ultrasound-guided biopsy.

1:28

Um, this is just pretty much

1:30

a general quick overview.

1:33

Um, we're not trying to get too specific,

1:35

'cause there's parts within the talk that

1:37

could each probably take up their own hour.

1:40

Um, the objectives are, we'll talk about

1:44

the advantages of ultrasound guidance, um,

1:47

contraindications, general principles, uh, kind of

1:51

how like most of the procedures would proceed.

1:56

Um.

1:57

And then I guess if there's still time, I can go

2:00

over some pitfalls and kind of more advanced kind

2:05

of techniques or imaging like, uh, using contrast.

2:09

Um, so kind of at the beginning, I'd like to

2:14

note that there's, you know, there, there are,

2:17

you can find articles or almost anything, um, to

2:19

support kind of whatever it is you want to do.

2:22

Um, and there's pretty much no consensus on what

2:26

constitutes the, the like, absolute best approach.

2:30

Um, sorry if there's too much noise in the background.

2:33

Um, so as with many parts of medicine, there's

2:37

an interplay between like the art and

2:39

the science of, of, uh, your practice, and

2:42

ultimately there's no substitute for experience.

2:45

Um, so, so a lot of the things that I'll

2:48

say, you know, when possible, I can, I

2:51

point to literature to support those things.

2:53

But a lot of it is gonna come

2:55

down to my own personal experience.

2:57

Um, you know, especially the majority

3:00

of it being here at, uh, Johns Hopkins,

3:02

um, and the way we do things.

3:05

And so local practice patterns can vary.

3:08

Um, like depending on the availability,

3:11

uh, availability of equipment and staff.

3:13

Um, so, you know, if I say something or something

3:16

kind of sounds different from what you do,

3:18

it's, you know, it's not that what you do is

3:21

wrong, um, just because it's different.

3:26

Um, all right, so

3:32

get going.

3:34

All right.

3:34

So why would we, uh, choose

3:37

ultrasound in the first place?

3:39

I mean, so you generally, you can pick between

3:41

ultrasound, um, CT, uh, you can do MR, sometimes even

3:47

PET-guided biopsies or even open surgical biopsies.

3:51

Um, and we're kind of, you know, having to assume

3:54

that the success rates, which are defined as, you

3:58

know, adequate samples and getting true

4:02

positive diagnoses, um, we have to assume that

4:06

those are gonna be the same between the modalities.

4:08

Otherwise, we, you know, if there was one

4:10

that was clearly better than the rest,

4:12

everybody would just be using that.

4:15

Um, so, so the advantage of ultrasound comes

4:19

in the form of other factors that, uh,

4:23

pretty much make it a nearly ideal choice

4:26

for guiding percutaneous biopsies.

4:30

Uh, so the most obvious benefit, and I mean you'll

4:32

hear it anytime we talk about ultrasound, uh,

4:35

is that there's no ionizing radiation, which,

4:38

as compared to the most common alternative

4:40

guidance, uh, which would be CT.

4:43

And of course, you know, as I said before,

4:45

surgical biopsy and MRI-guided biopsy,

4:48

they also lack ionizing radiation.

4:50

But you know, they, they come with increased

4:52

cost and time and other complications.

4:57

Uh, and more importantly, ultrasound guidance

5:00

has been reported to be as safe or safer, um,

5:03

than, you know, other, other methods of guidance.

5:08

Uh, and of course, safer is a relative term,

5:12

'cause we're still putting a needle into the skin

5:15

and potentially taking, uh, pieces of tissue out.

5:18

So there's always a risk inherent

5:21

to any of these procedures.

5:23

Um, but what makes ultrasound a little,

5:26

a little relatively safer is that

5:29

we have the ability to image in real time

5:31

and detect some major vascular structures.

5:34

Um, and you can avoid them by making adjustments to

5:38

the needle course, you know, again, in real time as

5:41

you're watching your needle go through the tissue.

5:44

Um, and then part of that is because, uh, you can

5:48

also perform ultrasound from almost any position,

5:52

you know, thereby allowing you to have the patient

5:54

positioned in, in, uh, the most optimal way that

5:58

will allow you to, to either reach the lesion and

6:01

avoid these structures or bring, uh, bring the lesion

6:06

in a more like favorable position where you could

6:09

better control bleeding if it occurred.

6:12

Um, and, you know, you compare that to something

6:15

like CT, where you're pretty much, I mean,

6:18

I've, I've seen some CT-guided biopsies where

6:21

you could have the patient actually sitting

6:23

up, but it, it's pretty rare to do it that way.

6:24

So they're usually almost always

6:26

lying, either prone or supine.

6:29

Uh, sometimes decubitus, which we can do all

6:31

of that with ultrasound, but we can also

6:34

have them, you know, we can angle the bed more.

6:36

Um, we can put bumps underneath of them to,

6:39

to like bring parts of the anatomy either

6:42

closer or move, move it away if like, a rib

6:45

shadow or something is obscuring a lesion.

6:50

Um, and also like, because we're using, um, real-time

6:57

and pressure, uh, to directly visualize everything and

7:01

we're actually kind of in contact with the patient for

7:03

the entire procedure, you can, uh, use compression to

7:09

decrease the skin-to-target distance,

7:11

um, which always makes things safer.

7:15

You, you always want the lesion

7:17

to be as close as possible to you.

7:19

Um, and then you can also displace,

7:22

uh, any intervening structures, and it's

7:25

less likely that you're gonna be able

7:26

to move a, a blood vessel out of the way.

7:28

You know, usually you would

7:29

just try to steer around that.

7:30

But, um, if there, if there was bowel in the

7:33

way, um, sometimes you, you look at something

7:36

on CT and you think that it would not be

7:39

accessible to percutaneous biopsy, um, if

7:43

you're worried about going through the bowel.

7:45

But with ultrasound, you can, you can really put a lot

7:48

of compression on the abdomen and push a lot of that

7:51

bowel out of the way to the point where, um, you know,

7:54

we've, we've done retroperitoneal lymph node biopsies,

7:58

um, but, you know, assuming the patient's body habitus

8:02

allows you to get that deep, um, 'cause we also have a

8:05

limit on the, the length of the needles we have.

8:09

Um, and then once you've done the biopsy, ultrasound

8:13

also allows you to see, um, almost immediately

8:16

if there are complications such as bleeding.

8:20

I mean, you can see the hematoma develop,

8:21

you can see a jet, uh, on the color Doppler.

8:25

Um, I mean, but that said, not, you

8:27

know, not every, not every episode of

8:29

bleeding is gonna happen right away.

8:30

So, um, but with, again, with ultrasound, it's

8:34

easy enough to just bring them back, um, you

8:37

know, half an hour later or an hour later,

8:39

uh, and you just take another look.

8:41

And since there's no ionizing radiation, you don't

8:43

have to feel guilty about re-scanning them,

8:46

and know kind of all you lost is a little time.

8:49

Um, some other reported benefits that,

8:53

people include for ultrasound is that they

8:55

have increased confidence that the target

8:57

is being biopsied since you can, you know,

9:00

directly see your needle within the lesion.

9:03

Um, and this kind of becomes more

9:05

important when you're biopsying

9:06

really small lesions or, or something in an

9:10

area with a rich neurovascular supply like,

9:13

like the head and neck, if you're doing parotid,

9:15

uh, parotid, like either intraparotid

9:18

lymph nodes, or just some other parotid lesion.

9:23

Um,

9:26

and also ultrasound is more portable or,

9:30

or mobile, which allows biopsies at bedside.

9:34

Um, you know, sometimes patients can't leave the ICU,

9:36

but we can take the ultrasound machine up to them.

9:39

Um, and I mean, I know there are, you know,

9:41

there are portable CT and MRI scanners, but

9:45

they're much less practical, uh, when you're

9:48

talking about doing like an inpatient biopsy.

9:55

All right.

9:57

Um, so I didn't really give a list

10:01

of like true indications there.

10:03

I mean, there are lists published out there.

10:05

Um, I've just found that in general, we, we,

10:12

when we get a request for a biopsy, um, for better or

10:16

worse, it, it usually gets done one way or another.

10:19

Um, sometimes even, you know, despite our

10:22

protests that it doesn't need to be done.

10:25

Um, you know, we often get cases referred from outside

10:28

institutions, um, and when someone else has

10:31

told them that they need a biopsy, then, you know,

10:35

it's, it's hard to convince 'em that they don't.

10:37

Um, so I guess the way, the way I think of

10:39

it is more like the only, the only real,

10:44

um, concern is if there are reasons that

10:47

we can't or shouldn't do the biopsy.

10:49

Not so much is,

10:51

um, if it's like a textbook indication for biopsy.

10:58

Um, all right.

11:01

And, and we also do here, we do a lot of research

11:05

biopsies, um, where the diagnosis is already known.

11:08

Um, but they need a lot of tissue, um, for,

11:13

sometimes repeatedly, um, to do these, you know,

11:16

immunohistochemical and molecular analysis.

11:20

Um, so in that sense, you know, there's,

11:25

there's really no way getting around it.

11:26

So, um, at that point you just have to

11:30

decide what's the safest and kind of

11:32

best way to be able to get that tissue.

11:35

Um, and, and here we have kind of a unique

11:39

setup, uh, so that our ultrasound biopsy service

11:42

is separate from interventional radiology.

11:45

Um, like, we often get, either they refer cases

11:48

to us that they think should be done with ultrasound,

11:50

or, you know, we'll look at it and say if, if we

11:53

can do it or not, and if we think it needs CT.

11:56

Um, because there are, there are times when

11:58

we won't be able to do it with ultrasound.

12:00

Uh, and then, so if we think they need to be done

12:03

by CT, then it goes to interventional radiology.

12:06

Um,

12:09

so, you know, I've seen plenty of times where,

12:15

where, you know, we don't

12:16

really think we can get to it.

12:18

Um, and when we think we can't, someone

12:22

else is gonna end up doing it anyway.

12:24

And because, you know, ultrasound's

12:28

pretty much, it's cheaper and like, no radiation,

12:32

um, basically there's no harm in trying.

12:34

So at the very least we can bring the patients down

12:36

and, and take a look at it, um, just to see if we're

12:39

able to find a safe way to, uh, approach the target.

12:46

Um, so some, I mean, sometimes you, you, you

12:49

don't know just by looking at it if it's gonna

12:52

be able to be biopsied, uh, using ultrasound.

12:56

Um, but for the most part, if, if you can

12:58

see it, then you should be able to biopsy it.

13:03

Um, so adding ultrasound doesn't really introduce

13:09

any special contraindications other than those

13:11

that would apply to any biopsy in general.

13:16

And the most important of those are gonna

13:18

be uncorrectable coagulopathies and, uh, the

13:22

inability to either see the lesion or, you know,

13:26

avoid critical structures that would increase

13:29

the risk of bleeding, um, or damage to any, any

13:33

other organs that are in the way or, you know,

13:36

cause like a bowel perforation or something.

13:40

Um, so we use the 2019 Society of

13:43

Interventional Radiology consensus

13:47

guidelines for assessment of bleeding risk.

13:50

Um, so, you know, when that update came out, it

13:52

kind of restratified patients into, instead of

13:56

a three-tiered, low, moderate, and high risk,

13:59

it's now just low risk and high risk, um, with,

14:03

with low risk procedures being superficial,

14:06

um, so like thyroid and lymph node biopsies.

14:11

And the high risk group includes solid

14:13

organ and deep non-organ biopsies

14:16

like, um, retroperitoneal lymph nodes.

14:20

So basically anything intraperitoneal,

14:22

retroperitoneal, or, you know, deep in the

14:25

pelvis, um, are considered high risk, where bleeding

14:29

can be difficult to identify and control, you

14:33

know, without kind of going to embolization.

14:38

Um, so that, I guess the exceptions to that,

14:41

are a paracentesis and thoracentesis,

14:43

which even though they'd be intraperitoneal,

14:46

are still considered low-risk procedures.

14:49

Um, and, and also now the guidelines for

14:51

withholding anticoagulation and antiplatelet

14:54

medications were revised so that, uh,

14:57

we no longer withhold most of

14:59

these prior to a low-risk procedure.

15:01

So, especially like the most common thing is

15:04

people on like a, take a baby aspirin or something

15:07

every day, and, you know, they'll wanna cancel

15:10

a thyroid biopsy because they had an aspirin.

15:12

And we, so we don't, we don't really

15:14

have to worry about that anymore.

15:17

Um,

15:20

and then so, but for high-risk procedures,

15:22

you know, you still follow that.

15:25

Um, and those, I mean, there's

15:26

like a whole list of that.

15:27

So those withholding and reinitiation

15:29

recommendations, um, those can easily

15:32

just be found by looking up the, uh,

15:34

SIR guidelines.

15:37

Um, so since the, the other contraindication,

15:44

um, I kind of keep saying is that if I'm not

15:47

able to safely identify or access the lesion,

15:52

and a lot of that has to do with the

15:54

patient being able to cooperate with the scan.

15:58

Um, sometimes it's just, you know, you

16:01

can't get ribs out of the way to see it.

16:03

Um, sometimes the patient can't take, take a deep

16:06

breath, so, you know, you can't get

16:08

the, like, the liver to come down into the field

16:11

of view from underneath the ribs if their,

16:14

um, lungs are all atelectatic and it's just, it's

16:17

kind of risen up, uh, underneath the rib cage.

16:23

Um, and that's kind of where, like a lot

16:27

of times, you can get a lot of help

16:28

from your experienced sonographers.

16:30

They, they come and, uh, their experience really

16:33

helps, um, get you into these, kind of find, find

16:39

ways to see these lesions that you might not

16:43

be able to do yourself, or, or, you know, a less

16:47

experienced sonographer wouldn't be able to do.

16:49

So that's why some of our most

16:51

experienced, uh, sonographers are the

16:53

ones that do the biopsies with us.

16:56

Um, and kind of all that, all that stuff

17:01

also mainly refers to core needle biopsy,

17:04

um, because that's got a known higher risk

17:08

of, uh, bleeding and potential damage.

17:12

Um, 'cause we also, basically, whenever we're gonna

17:15

do a core, we also do fine-needle aspiration.

17:19

Um, I mean, you can do

17:21

that pretty much almost

17:22

anywhere, and you can pretty much hit

17:24

almost anything and not really do any damage.

17:27

Um, so for the most part, I'm fine,

17:31

uh, even when they ask me to try some

17:34

crazy thing, I'm okay even attempting

17:36

an FNA, a fine-needle aspiration of it.

17:39

Um, but, you know, we might have to draw

17:43

the line at doing cores if, you know,

17:45

depending on the path we're able to get.

17:49

Um, and I guess, and it, it's also, a lot of this

17:54

comes down to your own experience and, um, comfort

17:58

with doing these procedures, um, and potentially

18:01

managing complications if they were to occur.

18:05

Um, so sometimes, we'll, you know, we'll throw

18:08

the ultrasound probe on and, you know, we can't

18:12

find any window where there's not a, like a,

18:14

in the liver, for instance, there's not

18:16

a portal vein crossing in front of it.

18:19

Um, or the lesion is very vascular,

18:22

and people kind of start to get a

18:24

little nervous about bleeding.

18:26

Um, and in a lot of these cases,

18:29

kind of earlier, um, when I was a newer

18:32

attending, you know, I would, I would defer

18:36

them and say that they should be done by CT.

18:39

And then you go and see that, you know,

18:42

they do a non-con CT for guidance.

18:44

Um, and it's not that any of those

18:47

vessels or anything are gone.

18:49

They're, I mean, they're still there.

18:50

You just don't see them, uh, because you don't

18:52

have the contrast, and you still go through 'em.

18:55

I mean, and I guess the difference is that

18:59

because of the way we're set up, um, you know, IR

19:03

is typically better equipped to deal with

19:06

those complications, which is one reason why we

19:10

don't really feel bad sending patients to IR

19:13

for a CT-guided biopsy.

19:15

But, you know, the reality is that

19:18

like everything you biopsy is probably

19:20

gonna have some degree of vascularity.

19:22

Um, and, you know, you're pretty much always

19:26

gonna end up hitting a vessel, and you

19:28

often end up seeing a little bit of pneumobilia

19:32

when you're doing liver biopsies.

19:34

Um, for the most part, it all just

19:36

resolves on its own without any lasting effect.

19:45

Alright, so, uh, complications are divided into

19:52

major and minor, with major complications defined

19:55

as those requiring admission to the hospital,

19:58

uh, an increased level of care, prolonged

20:00

hospitalization, permanent adverse sequelae, or death.

20:04

Um, while minor complications

20:06

are those that may require

20:08

either, you know, nominal therapy or a

20:12

short hospital stay, uh, for observation.

20:17

Um, then they're also thought about, um,

20:20

in terms of generic and organ-specific.

20:24

So generic complications are those that

20:26

kind of apply to, to, uh, any procedure.

20:30

You know, everybody, you get used to doing consents,

20:33

you know, either as a resident doing IR or if you

20:37

did like a surgical intern year, you get the whole

20:40

bleeding, infection, you know, damage to surrounding

20:43

structures, unintended organ or nerve injury.

20:47

Um,

20:50

those, it's the, the rates kind of depend on how

20:53

big of a date range you, you look up, like earlier

20:57

complication rates could range from 0 to 8.3%.

21:00

Now a lot of them are either 4% or less.

21:05

Um, and oddly enough, the spleen was

21:09

reported to have the highest and lowest

21:12

rates of complication, which was mainly bleeding.

21:15

Um, and that was probably just because

21:17

it wasn't done very frequently.

21:19

So, you know, one bad case can

21:21

throw off the numbers, um, or one good

21:25

case can make it look really good.

21:28

Um, but yeah, so the, the next organs,

21:32

the organs with the next highest rates of

21:36

complication were renal biopsies for

21:40

non-targeted, um, you know, basically just looking

21:44

for medical renal disease, and liver biopsies.

21:51

Um, so clinically significant bleeding is

21:53

infrequent.

21:55

Um, although it's known that the relative

21:58

bleeding risk increases with larger needles,

22:02

um, use of cutting needles, and the vascularity

22:05

of the organ or the lesion biopsied, um, like,

22:10

you know, the kidneys and kidney lesions in

22:13

non-targeted renal biopsies, they bleed a lot.

22:16

Usually you kind of expect it.

22:20

Uh, and then, you know, hypervascular

22:21

lesions again, like RCCs, um, anything,

22:28

that's the main one we worry about.

22:30

Um, so like Gelfoam embolization of biopsy

22:33

tracts is a pretty common practice, um,

22:37

the idea is to reduce the chance of bleeding.

22:40

Um, I know there's, there's probably

22:43

a lot of anecdotal reports there.

22:44

I mean, there have been some studies, um,

22:47

but it hasn't been anything, it hasn't

22:50

been definitely proven to decrease, um,

22:53

the incidence of significant bleeding.

22:56

So we, we don't do it.

22:58

And I mean, I don't, I don't think we have

23:00

an unusually high rate of bleeding

23:03

after any of the procedures.

23:06

So, I mean, sometimes you kind of,

23:08

sometimes you wish you had it.

23:11

Um, but just the way our department's

23:14

set up, we don't, we don't even have Gelfoam

23:16

in the room, Gelfoam in the room.

23:18

So, um, so it's basically, it's not necessary.

23:22

You could do it if you want, but it's not necessary.

23:26

Um, and then, you know, we throw infection in

23:28

there because we're breaking the skin barrier

23:30

and putting in needles and anything foreign.

23:33

So there's always a chance,

23:34

theoretically, of infection.

23:36

Um, but, you know, we

23:38

prepare a sterile site.

23:40

Um, every, all the needles we use are, you know,

23:43

one-time use and disposable, um, and sterile.

23:46

So the real risk of infection

23:49

is exceedingly rare.

23:52

Um, I've never seen one, I mean,

23:56

not from us in five or six years.

23:58

I, I don't think we've ever seen one.

24:00

Um, the riskiest one would probably

24:02

be the transrectal prostate biopsies,

24:04

which we don't do as many of those anymore.

24:07

But, um, those are the ones

24:09

that have the highest chance,

24:10

'cause you're going through the bowel.

24:15

Right.

24:16

Um,

24:19

so that, those are the

24:21

generic complications: bleeding,

24:23

infection, unintended organ injury.

24:27

Um, organ-specific complications are

24:31

those that are associated or most commonly

24:33

associated with biopsy of specific sites

24:36

or organs, such as pneumothorax or

24:41

hemoptysis after a lung or pleural biopsy.

24:45

Um, I mean, pneumothorax has also been

24:48

reported to occur during liver biopsies,

24:53

depending on if you have to choose an

24:56

intercostal approach versus a

25:59

completely subcostal approach.

25:02

Um, and then you can also get,

25:06

um, and you expect hematuria after

25:10

renal or prostate biopsies.

25:14

Um, but usually it's not,

25:16

it's not significant bleeding.

25:19

Um, and then a final kind of, it's

25:23

considered a complication even though it,

25:25

we don't really see it that much anymore.

25:28

Probably because we stopped

25:30

biopsying most of the tumors

25:32

that are associated with it.

25:33

But, um, you can have tract seeding, um,

25:37

which, the estimated range is from 0.3 to 4%.

25:44

Um, and most of the available data

25:46

deals with, uh, biopsy of HCC.

25:50

Um, and then it's also been noted to happen

25:53

with RCC, but again, these are kind of two

25:56

lesions that we mainly don't go around biopsying.

26:00

Um, the imaging diagnosis is generally

26:03

enough, although we do sometimes end up having to

26:06

biopsy them when there's kind of, if a patient has

26:10

multiple primaries and they're trying to figure out

26:12

which treatment the patient needs to be on, which

26:16

one's working, which one isn't, um, which, or which

26:19

cancer's responding, or if there truly is a

26:24

reason to suspect that it's not

26:27

whatever it classically looks like.

26:30

Um,

26:34

alright,

26:35

so,

26:38

all right.

26:38

So it's kind of like a quick

26:41

rundown of how the procedures go.

26:43

Um, and there's pretty much just

26:48

a basic outline, but it's also how I think most

26:51

people do it and how most procedures are gonna go.

26:55

Um, so we obviously begin by reviewing the

27:00

prior images to try and identify the area,

27:03

uh, that we're interested in, find the lesion.

27:06

Um, then our sonographers go in and,

27:09

you know, we show them on either a CT or a

27:12

prior ultrasound where it is, and they go in

27:15

and they find it, they try to find a safe path.

27:19

Sometimes they bring us multiple options,

27:21

um, and they ask us to help decide.

27:23

I mean, ultimately it is our decision,

27:25

uh, about what the best path is.

27:28

Um, but we value their input and

27:32

their experience in kind of figuring out how, you

27:34

know, if the patient's gonna be able to lie in a

27:37

certain position for a long period of time,

27:40

um, or if they're gonna be able

27:43

to hold their breath or not after kind

27:44

of watching them while they're scanning.

27:47

Um.

27:48

And so this is also when you would, uh,

27:50

decide if you're gonna use the linear

27:53

transducer or the curved transducer.

27:56

Um, generally you'd wanna use the linear

27:59

transducer as much as you can, but, uh,

28:02

the problem is, it mostly can only be used for

28:04

superficial procedures, which, you know, we do

28:06

a lot of thyroid and superficial lymph nodes.

28:10

Um, but you'd like the resolution

28:13

that you get with the linear probe, it just

28:16

sometimes you can't get that deep in the,

28:18

you can't see that deep in the liver or, or the

28:21

retroperitoneum with the linear transducer.

28:24

So you have to go for the curved, um, which

28:26

kind of, you know, makes everything look more

28:29

zoomed out, a little more blurry.

28:32

Um, but otherwise you're not gonna see the needle.

28:40

Um,

28:43

so.

28:45

Let's see.

28:47

So yeah, the, and that's all.

28:49

This is also where your approach, um, a lot

28:52

of our sonographers will, like,

28:54

try to avoid going intercostal, um, because

28:57

it's more uncomfortable for the patient.

29:00

Um, your vision is, uh, a lot more,

29:04

you have a lot more artifact in the way

29:05

that can obscure the lesion and your needle.

29:08

Um, and as we said before, there is a risk of

29:12

pneumothorax depending on how high up you go

29:16

and what kind of angle you approach from.

29:21

Um, all right.

29:23

So, so after you get everything, you know, you

29:24

have the patient positioned, um, you know, you've

29:27

found the lesion, you've got the patient positioned.

29:30

We do the informed consent.

29:31

Um, just pretty standard.

29:33

I mean, we, we have papers printed out with it, so you

29:36

just kind of go over it with the patient and have them

29:38

sign, um, and give 'em a chance to ask any questions.

29:42

Most people don't.

29:44

They tend not to have that many questions,

29:46

probably just they're nervous

29:47

and they don't really know what to ask.

29:48

But, um, so then we prep the sterile field.

29:53

So we use, you know, chlorhexidine or Betadine.

29:56

Uh, you put a drape over the area.

29:58

Most of the drapes that come with our kits

30:00

have that little hole in the center that

30:03

they can use the ultrasound probe through.

30:08

Um, and then we start with, uh, the numbing.

30:12

And so here we only use, uh, local anesthetic, right?

30:16

A lot of places use, um, they may

30:18

do conscious or moderate sedation.

30:21

Um, we just, for whatever reason, I

30:24

guess, I don't know if it's historical,

30:26

but we've just never done that.

30:28

It's most of our, um, most of our

30:31

cases are outpatient procedures.

30:33

Um, and they can go home almost, you

30:35

know, depending on what they have done,

30:36

they can go home almost right away.

30:37

And also the, the not using sedation makes it

30:42

so you don't have to have them, uh, fast for kinda

30:45

a longer period of time than they would otherwise.

30:50

Um, so it's fine to use it if, if you're

30:55

set up for the monitoring and everything.

30:57

Um, but we, we find that just using local anesthetic

31:01

usually works really well for most people.

31:04

Um, you can usually get them numbed up pretty well.

31:07

We just use 1% lidocaine without epi.

31:10

Um, we start, you know, we make a skin wheel

31:12

right over the area where you're, where you

31:15

think you're gonna be, um, inserting the needles.

31:19

And then under ultrasound guidance, we,

31:23

once the skin is numbed, we go deeper.

31:25

And depending on where you're going, if you're

31:27

going, you know, through the, like intra-

31:29

abdominally, you would numb the peritoneum.

31:32

Um, if you're going for like the liver or

31:36

thyroid or kidney.

31:38

Um, we then make like a, a pocket on the capsule.

31:44

So we kind of have like, almost like three

31:46

different layers of, uh, local anesthetic.

31:49

And like I said, for most people,

31:51

that seems to work just fine.

31:54

Um, but worst is, you know, once it wears

31:57

off, people describe things as like a

31:58

dull ache, like someone punched them.

32:02

Um, but most of them are up and, uh, walking

32:03

around probably like an hour after the procedure.

32:08

Um, so once we get the, once we get the

32:11

lidocaine in, uh, we start by doing fine needle

32:15

aspiration, um, which we put on a slide and give

32:18

it to a either cytotechnologist or pathologist.

32:22

Kind of depends on who's there that day.

32:25

Um, we're lucky enough to have them available for all

32:27

the biopsies, um, and we use them except for

32:31

like abscess drainages or non-targeted liver biopsies.

32:35

Um, and you know, we, we like it because

32:39

they can tell us if our site is good.

32:42

Um, you know, if we think we're in something

32:45

that looks weird on ultrasound, um, they

32:48

can tell us if the cells— I mean, we've had

32:51

times when we think we're in a mass and they

32:54

tell us it just looks like normal liver.

32:56

Um, so we go looking for other targets at

32:59

that point, but you know, they, they tell

33:01

us if it's adequate and when we have enough.

33:05

Uh, and then we, we also rinse the needles in a,

33:09

we have something called Hank's solution.

33:12

It's pretty much just essentially saline

33:14

with some other, uh, inert stuff in it.

33:19

Um, and they can use that later to make a cell block,

33:22

um,

33:22

or send it for flow cytometry if we're like

33:25

biopsying a lymph node looking for lymphoma.

33:29

Um, so once, uh, the cytologists or

33:33

the pathologists have looked at it and tell

33:35

us we're, we're in a good spot, um, you

33:38

know, we will move on to the core biopsy.

33:41

Uh, except for basically thyroid

33:44

nodules and parotid glands.

33:45

Uh, those we usually only do FNAs for.

33:48

It's, I mean, it's all we usually need.

33:51

Um, but pretty much everything else

33:53

goes on to a core as long as it's,

33:55

you know,

33:56

at least a centimeter.

33:57

'Cause that's the smallest size

34:00

throw that we have for the needles we use.

34:04

But otherwise, as long as we can

34:07

get to it, we pretty much core everything.

34:09

Um, and usually it's three to four cores, but

34:13

we also regularly obtain up to six cores, um,

34:17

when it's specified for a research protocol.

34:20

And that can be six 18-gauge,

34:22

two-centimeter cores.

34:25

So that's, I mean, that's a lot of, uh,

34:27

a lot of tissue, a lot of cores,

34:30

sometimes painful, sometimes bloody, but

34:34

usually no major complications from that.

34:37

Um, all right.

34:40

Uh, and then afterwards for

34:42

superficial procedures, um,

34:47

patients are typically allowed to leave,

34:50

um, pretty much by the time the nurse

34:53

explains their discharge instructions.

34:55

Um, and then for the deeper biopsies

34:58

like, um, liver, either solid organs or

35:02

anything retroperitoneal, we watch

35:05

the patients for a minimum of one hour.

35:07

Um, and they go over to the recovery area

35:09

where they're monitored by the nursing staff.

35:13

And, you know, they're, they're watching

35:15

for, you know, any sort of changes in

35:18

their vital signs or any increasing pain.

35:20

Anything that, um, might lead us

35:23

to think that they're bleeding.

35:26

Um, but most people are, by the time the

35:29

hour is up, most people are ready to leave.

35:32

Um, and if we're, if, if we're truly concerned about

35:38

them, it's easy enough to just re-scan them with the

35:42

ultrasound, take a look, see if anything's going on.

35:45

Um, if you don't see anything,

35:47

then they're usually good to go.

35:48

If, if you see something that worries you,

35:50

then next step would be to do a CT and

35:53

get a full view of what may be going on.

35:58

Um, alright.

36:03

Alright.

36:03

So that's like the, the main

36:06

overview of the procedure.

36:08

Um, so then as far as actually using the

36:11

ultrasound, uh, I wish I could figure out

36:15

how to get videos, uh, videos to work.

36:18

'Cause it would be a lot easier to

36:19

illustrate things with the videos.

36:20

But, um, basically you have, you have a

36:24

couple or two, two main options, right?

36:27

You can hold the, the ultrasound

36:29

probe yourself, uh, and the needle.

36:32

I mean, you, you'll always be holding the needle,

36:34

but you can hold the ultrasound probe yourself,

36:38

um, and basically do it, do it all yourself.

36:41

You, you angle the probe, you keep track

36:44

of your needle, you guide the needle.

36:46

Um, and you can either use the

36:50

needle freehand or with a guide.

36:53

Um, I think most people that want to do

36:56

it this way wouldn't use a guide anyway.

36:58

Um, and it's probably the most often

37:01

done way of doing these biopsies.

37:03

I mean, that's like, it's the

37:04

way I trained in, in residency.

37:08

Um, you know, there's like, it's kind of an

37:14

something like you feel good knowing that

37:16

you can do it, but that doesn't necessarily

37:19

mean it's always the way you should do it.

37:22

Um, you know, for people who are really good

37:25

and experienced and have that coordination,

37:28

um, it's usually pretty easy for them to keep

37:32

track of their needle, keep to be able to see

37:34

it the whole time, um, and to kind of move the

37:38

probe and their needle in the same direction.

37:41

Um, but for people who don't, who haven't had that

37:44

experience, it can be a pretty steep learning curve.

37:47

Um, and it actually ends up being taking a longer

37:52

usually, um, while people are learning to do it.

37:55

Um, 'cause they'll, they'll be losing sight of their

37:57

needle all the time and they'll have to always.

38:00

Be correcting and searching for the needle.

38:02

So initially it, you know, takes longer.

38:05

Um, sometimes it leads to, you know, a lot more sticks

38:08

because the, I mean, this is kind of from the, from

38:12

the perspective of training residents, um, you know,

38:15

they, they get in there and then they can't find

38:17

the needle at all, and then they have to come out.

38:19

You just, you know, you, instead of digging

38:21

around with it, you just have 'em come out

38:23

and you have to go back in from the skin.

38:25

So it can lead to more sticks

38:27

that aren't strictly necessary.

38:30

Um, but once you get really good and proficient

38:33

at it, it, it can be the fastest way to do the biopsy.

38:37

Um, especially for superficial

38:40

lesions.

38:42

Um.

38:46

So the, the other way to do it is

38:50

where the sonographer holds the probe

38:52

and you are still holding the needle.

38:54

Um, and in this case, again, you could either

38:57

use the guide or no guide or freehand it.

39:01

Um, but from experience it's definitely harder,

39:07

um, trying to, trying to freehand the needle when

39:11

somebody else is holding the ultrasound probe.

39:13

Um, there's just, you kind of

39:15

lose this proprioceptive feedback.

39:18

Um, and it's, it's a lot harder to, if, if you

39:22

don't go perfectly in line with the transducer,

39:25

you'll end up going outta the imaging

39:26

plane and you'll lose the needle, and then they'll

39:29

try to look for you. But if you're moving

39:32

the needle and they're moving the probe at the

39:33

same time, you're never gonna find each other.

39:35

So, um, it's, if you're gonna have the, the

39:39

sonographer hold the probe, it's probably

39:42

best if you use a guide, um, which kind of ensures

39:46

that the, that the needle is always going in,

39:49

like the optimal angle and in the middle of the,

39:52

uh, the probe so that you can always see it,

39:55

or at least as well as you're gonna be able to,

39:57

when you start getting into deeper, um, biopsies.

40:01

Sometimes there's no way around it.

40:02

The needle just becomes hard to see, mostly

40:04

because it's either obscured by, um, air,

40:07

like in, in the bowel or, uh, the echogenic

40:11

fat can also kinda make it harder to see.

40:16

Um, so

40:21

personally, I, I mean, I used

40:24

to be able to do it freehand.

40:25

I still can, but I definitely prefer

40:30

now having the tech hold the probe.

40:33

Um, and then using the guide to, to do the

40:38

biopsies because some, I mean, when we're

40:39

taking, you know, if we, if we're gonna do.

40:43

Five FNAs and up to six cores.

40:46

Um, it just ends up being much faster, just

40:48

being able to keep the guide, keep the probe

40:52

on, on your target, um, you know, which, which

40:55

would be the sonographer's job to hold it there.

40:58

And then all you, all you're doing is

41:00

going in and out through the guide.

41:02

Um, and it, it ends up being much faster, um,

41:05

if you're not gonna use a coaxial technique,

41:08

um, which is a, we'll get into that in a second.

41:11

Uh, um, so the only downside really of, of

41:16

the guide is that sometimes it limits your,

41:19

uh, your approach or your, the angle you can

41:21

get, because the, the guides are adjustable.

41:25

Um, they kind of, they're all like variations of these

41:28

little things that snap on, uh, to an outer piece.

41:32

Um, and they, they can usually be switched on the

41:35

fly, you know, for the, for the gauge if you need

41:37

to make it, um, accept a larger gauge needle.

41:42

Um, so that's, it's not really an issue.

41:44

It's not like you're stuck using the same

41:45

needle the whole time if you put that on.

41:48

Um, and then these are, so these,

41:50

these are disposable plastic ones.

41:52

So those, you just, you open it up, you use it, it's

41:55

sterile when you open it and you just toss it out.

41:57

They have these metal reusable ones.

41:59

Um, most of them attach, uh, to the side so that it's

42:04

going kinda like longitudinally along the, the probe.

42:10

Um, 'cause that's generally how

42:11

you're gonna see your needle best.

42:12

They do make these ones that, where, where it's kind

42:15

of going right through the, the center of the probe.

42:18

Um, which would, if you were gonna do a, a biopsy

42:23

where you wanted that to be your focal point?

42:25

Um, I don't know.

42:28

I, I've never used that kind.

42:29

I don't, that one just seems, I don't

42:32

think I would like that one as much.

42:33

But, um, you know, they make it, so someone's using it.

42:39

Um, all right.

42:41

And I've also, the other benefit of having the,

42:44

uh, sonographers hold the probe while you do these,

42:47

especially for the, for these deeper biopsies,

42:50

uh, is that they, they can put two hands on it.

42:53

They can give you a lot of compression, you

42:54

know, they can put their whole, like, body weight

42:56

into it, um, which, you know, helps move stuff

43:01

outta the way that you don't want to be there.

43:03

Uh, and it can also help pin down some of

43:06

these lesions that, uh, might wanna move around

43:09

sometimes if you're doing like a mesenteric mass.

43:11

Um, and it, you know, it helps if they can

43:14

really compress it to decrease that, the

43:17

distance and help keep it from moving around.

43:21

Um.

43:25

Uh, also, I guess the other, the other

43:27

benefit is that, you know, that it's, uh,

43:30

going through the same tract all the time.

43:33

Um, like once you numb up one area, there's,

43:36

there's kind of a tendency when you're holding

43:37

the probe until you get really good at it and

43:39

learn to, uh, pin your hand down to kind of

43:44

like use the patient or something as a rest.

43:47

Um, you, especially with all the ultrasound

43:50

gel, and if you're on a curved surface.

43:52

Um, 'cause you're trying to watch the screen

43:54

while you're moving the needle, um, and your hand

43:57

will tend to kind of glide away with the probe.

44:00

Um, and then if you have to kind of

44:03

pull out and restart, you might end up

44:06

in a different spot that you numbed up.

44:07

And when we do it this way, as long as the

44:09

tech doesn't lift the, the probe off, um,

44:12

during, during the biopsy, then we know

44:14

we're always going through the same spot.

44:16

So, and then also,

44:18

you know,

44:18

some of these core, like an 18

44:19

gauge core isn't exactly small.

44:21

So, um, you, I mean, you can see a visible

44:24

hole by the time you've done six of them.

44:26

So if we can minimize the number of

44:28

those we put into like a patient's

44:30

belly or back, um, that's always good.

44:36

Um, all right.

44:37

So main, main things we're doing, oh, sorry.

44:43

All right, so you have fine needle aspiration, which

44:45

is defined as a, you know, it's a thin hollow needle.

44:48

It's 22 gauge, 22 gauge or smaller.

44:51

Um, the main, the main way

44:54

it works is by capillary reaction.

44:56

So you generally, they come with a stylet,

44:59

uh, you insert the needle, pull the stylet

45:02

out, and kind of do a back and forth motion.

45:06

Um, trying to use capillary

45:08

action to, to suck up the cells.

45:10

Um, if you're gonna be, if you're gonna be handing

45:14

them off to cytology for like, on-site evaluation,

45:19

um, we typically don't use a syringe for those.

45:21

Um, 'cause it pulls up more blood into

45:24

the, into the specimen, which can kinda

45:27

make it harder for them to find cells.

45:29

Well, I mean, they'll see cells, but

45:30

they'll be mostly red blood cells.

45:32

So.

45:34

And for most things we use a 25 gauge, uh, needle.

45:38

For thyroid nodules we use, we use 26.

45:41

Um, the idea is that it, like, I mean,

45:43

they can be, they can tend to get bloody.

45:45

Um, and the idea is that the, the thinner

45:48

needle will hopefully pull up less blood

45:51

compared to the number of cells it gets.

45:54

Um, and then so, so we do the aspiration first.

46:00

Um, so they can tell us, you know, like, like we said

46:03

before, if we're in a good area, um, then they also

46:05

can help identify necrosis sometimes and help steer us

46:09

away from a part of the lesion that might, um, might

46:11

be, might not be so great for doing histology on.

46:16

Um, so after, if we're gonna do cores, after the

46:21

FNA, um, we would use pick, you know, we, we only

46:25

have a couple core needles, but in general, core

46:28

devices are going to be a 20 gauge or a larger needle.

46:33

Um, and they normally, I mean, they're, they're

46:38

all typically have some sort of cutting mechanism.

46:41

Um, some of them differ as to whether or not

46:43

it's, um, like semi-automated or automated.

46:48

Um, and whether or not it's a side cutting

46:50

needle versus an end cutting needle.

46:53

Um, some people like to claim one is better

46:56

than the other, but I think whatever you are

46:59

familiar with and comfortable with using,

47:02

um, that's, that's the one to go with.

47:03

I don't think any of them has such a superior

47:06

advantage that it, that it like means you

47:08

should go out and kind of get rid of whatever

47:10

you're using now and get, get something else.

47:14

Um, so we, uh, kind of said before with

47:19

the contraindications, um, there's a

47:23

trend towards increased bleeding as

47:25

you increase the needle gauge size.

47:27

Um, you know, we only use 18 to

47:30

20 gauge needles, um, and the.

47:33

The trend towards increased bleeding was mostly

47:36

seen when you're comparing like a 14 or 16

47:39

gauge needle compared to an 18 or 20 gauge.

47:42

But between 18 and 20 itself, there's, there's

47:45

really nothing that says, you know, 18 is

47:47

always gonna cause more bleeding than or could

47:50

cause more bleeding than a 20 gauge needle.

47:52

So, personally, when, I mean, if I'm gonna

47:55

stick a 20 gauge needle into something,

47:58

I might as well put an 18 in there.

48:00

I mean, you know, you, you get more tissue and

48:04

potentially with fewer punctures if, 'cause

48:07

we, we ultimately rely on the, uh, the cytotechnologist

48:10

or the pathologist to tell us when

48:12

they think there's enough, which I kind of said

48:15

before, that usually ends up being about three

48:17

or four cores, three or four, like full cores, if

48:20

they're, especially if they're two centimeter cores.

48:24

Um, but sometimes they want more.

48:27

Sometimes you can get away with less.

48:30

Um, and a lot of these devices, the, the core biopsy

48:33

needles, um, like they come in different, um, not

48:38

just gauges, but they come in different lengths.

48:40

You know, depending on if you're, if you need your

48:42

needle to go 15 centimeters, um, or 20 centimeters.

48:47

Um, and a lot of them will

48:49

have a, a throw that comes out.

48:51

And it's kind of two, two differences between, between

48:56

these, uh, cutting needles, the side cutting needles.

48:59

Some of them will, when you click the button,

49:01

you'll, you have to cock the, the device.

49:04

Um, you insert the needle, and then when you

49:07

click the button, the kind of like a little

49:09

trough, the, the actual part that, um, it's kind

49:13

of inside the, the outer stylet, it shoots out.

49:17

And then when you, when you pull it back

49:19

in, it, the, the tissue gets cut by, um, by

49:24

the stylet, like moving over the tissue.

49:28

Um, so that, that one, really, the thing to know

49:31

is which type you have, if, if you've got one that

49:34

shoots out from the tip, or if you've got one

49:37

that you advance and then it closes over that tip.

49:41

Um, because if, if you've got one that shoots

49:44

out from the tip, you have to account for

49:46

that when you're placing your needle, that

49:48

you don't, you know, it's gonna shoot out

49:50

either one or two centimeters, um, from where

49:53

the tip of your needle is within the lesion.

49:56

Um, just in case you're in any, uh, critical

49:59

structures nearby that you don't want to hit.

50:03

Um, and there's even ones that

50:04

have three centimeter, um, samples.

50:08

We, we tend to not, we tried using it

50:11

for a while, but we, um, we actually

50:15

had issues with them, um, like that.

50:18

So we, we got rid of them.

50:19

Um, 'cause we had a couple bleeds from

50:21

them, like, which was, and kind of a,

50:26

what's a change from what we're used to.

50:27

So.

50:29

I don't know.

50:30

I don't know if it was something about the

50:31

needle or something about the way we were

50:33

using it, but we, we stopped using them

50:35

and went back to what we were used to.

50:37

Um, but sometimes it does get us in trouble with

50:39

our, uh, pathologist because they, they really

50:43

would want a, they would prefer a 14 or 16 gauge,

50:47

three centimeter liver core, um, especially

50:50

when we're doing these non-targeted biopsies.

50:52

But, um, I mean, it kind of is what it is. We all

50:57

have to make do with the way things are set up.

50:59

Um,

51:02

all right.

51:07

Um, yeah,

51:10

let's see.

51:11

Alright.

51:12

Uh, and that was, this is just, I mean,

51:13

this is like taken easy to find from.

51:16

Radiology Key.

51:17

Um, it's just a little example.

51:21

There's like all these different types of needles.

51:23

This, this is an end cutting needle.

51:25

This one is notched.

51:26

Um, these ones tend to be, uh, aspirating needles.

51:32

Some people like this, this, uh, Francine needle

51:37

because you can, instead of using aspiration or

51:40

capillary action, you can actually push it in

51:42

and out in a twisting motion into the tissue.

51:44

And you can almost make a core out of it without

51:47

actually using a larger gauge core biopsy, um,

51:51

sometimes comes in handy for these like small

51:54

lesions or something that's in a tight area.

51:57

Um, and then all of these are

52:00

different types of core needles.

52:02

Um, you have different.

52:06

Uh, I mean these ones, sorry, the, this

52:08

is the, the side cutting needle or thing.

52:10

This is the part that shoots

52:12

out, uh, from the tip, right?

52:14

This, this is where you would, initially,

52:17

this piece would be retracted into the

52:18

stylet here, or the outer cannula or stylet.

52:23

Um, this is where you would place the tip of your

52:26

needle, and then when you fire it, that shoots out.

52:31

Uh, and then this is an end cutting needle, um,

52:37

that kind of, it pulls the tissue back in as, I

52:42

mean, they, they both do the same thing, supposedly.

52:44

This, um, this type of, this end cutting

52:48

needle produces a fuller, like rounder core.

52:51

Um, but I dunno, I don't think it makes enough of a

52:56

difference to account for the problems we had with it.

52:59

Um.

53:00

So what, you know, you're used to using them,

53:03

and it works for you, then go with that.

53:07

Um,

53:11

all right then, I mean, mostly, um, I just have some

53:18

random examples, um, just to show, oh, wait, sorry.

53:23

Right here.

53:25

All right, so this is just a thyroid.

53:28

Um, again, if I, if I could get pictures to

53:30

work, it would be a lot better because, 'cause

53:32

our, our, uh, sonographers take actual CEC

53:36

clips, uh, of us moving the needles in and out.

53:39

Um, just to document so we can show

53:42

that we were actually in the lesion.

53:43

But, so this is just, uh, an FNA, uh,

53:46

26 gauge FNA of a, of a thyroid nodule.

53:50

And that you can see the actual, uh, that's

53:54

the needle that shows up as a hyperechoic, so this,

53:57

this is the tip right here, not, won't be

53:59

fooled by, uh, the dotted line and the little,

54:02

that's just a little artifact coming off.

54:04

Um, we, we definitely wouldn't be putting the

54:07

needle through, like all the way through the nodule.

54:10

Um, and that's another thing.

54:12

These using the guide, it gives you these

54:14

little depth markers and this trajectory.

54:17

Um, so each of these dots is a centimeter.

54:19

So you, you kind of have an idea, right?

54:21

Like if I was using one of those core, um, biopsy

54:24

devices where it's gonna shoot out one or

54:27

two centimeters from the tip, then I know that I

54:30

have to park the needle kind of one or two of

54:34

these dots away from the back end of the lesion.

54:39

Um, and some of them you can

54:40

adjust the throw manually.

54:44

Ones we use tend to be just pre, preselected.

54:48

Um, but you can, even, even on the superficial,

54:51

it's, it's easier when you have the motion,

54:53

you can see the needle easier. On any one still

54:55

image, it can be a little more difficult.

54:57

Um, but, uh, so yeah,

55:01

that's, that's a

55:03

needle tip.

55:06

Alright.

55:07

Um, so this, right, this is large, uh, liver.

55:13

It's a met from, I mean, they didn't

55:16

know it at the time, but we know now that

55:17

it was from a, uh, pancreatic cancer.

55:21

Um, and so this initially was sent to IR for

55:24

biopsy, which would've been done with CT.

55:26

And I mean, it's perfectly easy to do with

55:29

CT if they wanted to, but it's also so big,

55:32

looks so close to the surface that they

55:34

said this should be done by ultrasound.

55:36

And yeah, so, uh, so they sent it over to us.

55:42

And that's what it looked like on ultrasound.

55:44

And so it looked, I mean, it looks pretty

55:47

cystic on the, on the CT or at least

55:49

necrotic, some of the central areas.

55:53

Um, and then even some of these more echogenic

55:56

areas you would think are solid, even though

55:58

they don't have very much vascularity, kind of

56:00

goes along with the whole thing being necrotic.

56:03

Um, but so this is where we would, uh, do FNAs.

56:09

Uh, first, and then we'd get it off to the cytotech or

56:13

the pathologist, and, um, they would tell us if we were

56:18

in a good spot or if it was too necrotic or anything.

56:22

So here is, I mean, these ones are

56:25

labeled, so it's easier to know.

56:26

But, um, here's the FNA of the lesion, right?

56:29

Here's the, that's the needle.

56:31

It's always gonna be a little thin echogenic stripe.

56:36

Um, and then here's a core biopsy.

56:39

So this is with it actually fully deployed,

56:41

um, after it's, after it's been fired.

56:43

So here we were targeting these

56:45

more solid appearing areas.

56:48

Um, and obviously the core is a lot

56:53

easier to see just because it's bigger.

56:55

Um, and then some of them actually have, they,

56:57

they can put coatings on them to make them more,

57:00

like, more visible, um, or echogenic while they're,

57:03

while you're looking at 'em doing the biopsy.

57:07

Biopsy.

57:07

Um,

57:11

let's see there.

57:12

So this was, this turned out to

57:16

be a, uh, renal cell carcinoma.

57:19

This one, I mean, looks like it would be

57:21

a good candidate for ultrasound, 'cause

57:22

it looks pretty close to the surface.

57:25

I mean, there is a lot of this tissue

57:27

outside, but that's easy enough to compress.

57:32

Um, and again, these, you know, RCCs tend to bleed.

57:36

Um, but, and also we typically don't biopsy them,

57:42

but it was a kind of an atypical appearance, and, um.

57:47

It was, you know, it looks mostly cystic.

57:49

I don't think there was much enhancement.

57:51

Um, so we ended up biopsying it.

57:56

Um, and let's see.

58:00

All right, so that's just what

58:01

it looks like on the ultrasound.

58:02

You actually, I mean, I mean, you see

58:04

it well enough, but it's kind of not

58:08

maybe quite as well as you would think.

58:10

Right?

58:11

And you also have these, you got these rib

58:13

shadows, um, which some, some patients move

58:16

when they breathe, it moves more or less.

58:19

It's, you just kind of have to watch it and,

58:21

and see how that, how it's gonna work for you.

58:24

Um, so it's not, sometimes you might have to have

58:26

them take that breath hold and hold it in a good

58:28

position and have to get in and get out really quick,

58:31

which is another time when the guide really helps.

58:33

Um, because you don't have to play

58:34

around in case you lose your needle.

58:37

Um, which can be, can happen, right?

58:40

Here's the core.

58:41

Um.

58:43

And so another, the echogenic line.

58:47

But here, I mean, this is, this is another FNA,

58:49

so this was, this would've been done first.

58:52

Um, and that would be the

58:55

tip of the needle right there.

58:57

Um, you can see that you, it's really hard

58:59

to see the kind of the rest of the needle.

59:02

Um, and that's probably due to

59:04

all the surrounding echogenic fat.

59:07

Um, that's kind of matching the, the echogenicity

59:09

of the needle, making it hard to see.

59:21

Um,

59:24

I guess, well, I can skip to this.

59:28

Um, so I mean, I have some other examples.

59:31

It's pretty much a bunch of the same stuff, just

59:33

showing what different things look like on, on a, uh,

59:39

on a, on CT versus the ultrasound.

59:42

I guess if I. Did a more

59:43

focused one on different areas.

59:45

I could, I would go more into

59:47

like how I, how we plan them.

59:50

'Cause I mean, every kind of, every

59:51

approach is kind of, is standardized,

59:53

taking into account a bunch of things.

59:55

Um, you know, how you choose

59:57

to, to approach the lesion.

60:00

Um, so this was just, I mean, an umbilical,

60:03

it was a pancreatic cancer met and we tend

60:05

to get a lot of pancreatic cancers too.

60:07

So it was a pancreatic cancer met that

60:08

it went to the peritoneum and started

60:10

growing into the abdominal wall.

60:13

Um, again, FNA, a little hard to see,

60:16

a lot easier to see in real time.

60:18

Um, and then the core here, core biopsy

60:23

right there, you can see it's like, right.

60:26

So we placed it with the two dots so

60:28

that, that was at kind of the back.

60:30

Um, 'cause this one, right, there's enough of it.

60:33

That was outside of the peritoneum

60:35

that we, there was no need to really go

60:38

intraperitoneal if we didn't have to.

60:40

Um, so we, we'd want it to stop

60:42

kind of, right, right at the edge.

60:48

Uh, uh, so this one was gonna be an example

60:52

of, uh, using contrast or ultrasound contrast.

60:57

And so here's this lady.

60:58

She had, uh, she has a, or I guess a spindle

61:02

cell sarcoma, like a large sarcoma in the pelvis.

61:06

Um, also happened to have

61:08

cirrhosis and, uh, steatosis.

61:12

And there was this kind of incidentally

61:13

noted liver lesion on the CT.

61:17

Um, I think there had been an MRI, but

61:20

either the field of view wasn't, wasn't

61:23

covered fully or they just didn't see it.

61:26

Um, probably I. Probably 'cause there was motion,

61:29

like that's kind of in the tip, so it could have

61:30

been, um, obscured while there was breathing.

61:33

But, um, so then we, we did an ultrasound

61:36

and at first we didn't see anything.

61:39

Um, so we used, uh, fusion, but on the ultrasound

61:44

machine, some of the, the newer machines can do it.

61:47

Um, and we've kind of got, like, one of our

61:49

sonographers is all into the, the new tech stuff.

61:53

So he, he pulled out some programs.

61:56

It's, I think it had like a little app

61:58

that, that you do stuff with an iPad on it.

62:02

Uh, and he fused the CT with the ultrasound and we

62:06

ended up finding this little echogenic thing that

62:10

we were pretty sure corresponded to the lesion.

62:13

Um, and just knowing that because it's echogenic

62:17

and knowing that there was steatosis, um, we

62:21

weren't entirely sure that we wanted the biopsy yet.

62:23

'Cause it's also in kind of a weird spot,

62:26

um, like right along the edge of the

62:28

liver, right and near the gallbladder.

62:31

So it's a good spot for focal fat.

62:34

Um, and it's also not a great spot to be trying to

62:39

biopsy when you don't have very clear margins on it.

62:44

Um, so we gave, uh, the, we gave Lummis

62:47

on, that's the, the agent we used.

62:49

Um, and it turned out that,

62:53

that that area didn't, what was

62:57

that?

63:00

Alright, uh, so that it turned out that

63:02

the area enhanced the same as the liver

63:04

on all, you know, throughout the scan.

63:06

So there was no early

63:07

enhancement, there was no washout.

63:09

Um.

63:11

So we ended up calling it steatosis and

63:13

didn't do a biopsy, but it remains stable

63:16

on, you know, multiple follow-up scans.

63:19

So, um, in this case it helped

63:21

us avoid doing the biopsy.

63:24

Um, but it can also be used, you know, when

63:27

sometimes when the lesions are otherwise

63:29

obscure, either if it's a, if it's enhancing

63:32

relative to the rest of the background, um,

63:34

tissue, it makes it stand out really nicely.

63:36

And even if it's hypo enhancing relative to

63:39

the rest of the tissue, it, it stands out.

63:42

So it can, uh, it can be really

63:43

helpful in identifying, uh, lesions

63:46

that are otherwise not well seen.

63:48

Um, especially in the liver and the kidney.

63:52

Prob the only real problem is that it kind

63:54

of takes a lot of extra time to set up, you

63:57

know, if the patients, most of them don't

63:59

come in with IVs, we have to start the IV.

64:02

Um, you have to mix up the little.

64:04

Microspheres.

64:06

Um, and, you know, you have to, you have to inject

64:10

it a special way so you don't get the bubbles, so you

64:14

don't destroy the bubbles while you're injecting it.

64:16

Um, but it, it can be, it kind of depends

64:20

on how, how the workflow of the day

64:21

is going, but it can be really useful.

64:24

Um, especially if you know ahead of

64:25

time that you're gonna use it, um, then

64:27

you can prepare appropriately for it.

64:31

Um,

64:33

I'm a little over.

64:34

Sorry about that.

64:35

All right.

64:36

So that's, that's it.

64:40

Thank you so much for that awesome presentation.

64:42

Um, you've got a few questions in

64:44

the Q and A if you wanna grab those.

64:46

Oh,

64:48

alright.

64:49

Uh,

64:50

patient.

64:50

Oh, sorry.

64:51

Yeah, you're right.

64:52

I, I thought I, I thought I wrote that

64:53

somewhere in my notes about the local, the, uh.

64:57

Um, allergy to anesthesia.

64:58

So we, so we have to figure out

65:01

which one that they're allergic to.

65:03

Uh, and we contact the pharmacy and they

65:05

give us recommendations on alternative

65:07

agents that can still be used.

65:09

Um, and that's, that's pretty much just what we do.

65:13

We've, we've never, we've never had an issue where

65:16

we couldn't give any sort of local anesthetic.

65:19

Um, I've heard of like when we, sometimes

65:23

we'll do repeat thyroid biopsies.

65:25

Um, and I've heard a lot of, a lot of

65:27

our patients tell us that when they went

65:29

somewhere else that they didn't get anything.

65:31

They just got ice and then they did the biopsy.

65:34

Um, so they're always amazed when they, when

65:36

we, you know, the, 'cause the anesthetic

65:38

is kind of the worst part of the procedure.

65:40

Um, so people don't believe it at first, and then

65:43

when they're done, they're like, wow, that really

65:44

was, that was the mo that was the worst part.

65:47

Little pinch burn.

65:49

Um.

65:51

So, and we have done, um, we, we used

65:54

to do it more often where we would do

65:57

cases but with, uh, general anesthesia.

65:59

But that was for patients who were already having

66:02

to undergo general anesthesia for some other

66:04

reason, and we just try to coordinate with them.

66:07

Um, so yeah,

66:11

um,

66:15

Post biopsy spleen or renal biopsy.

66:17

So I have actually never biopsied the spleen.

66:22

I tried to get someone to do it.

66:24

I suggested it one time and they sounded

66:25

like they made, they made it sound

66:27

like I was crazy for suggesting that.

66:29

Um,

66:32

I think so, um, renal, it would be the same way.

66:39

Um, like I said, I, I think, I think personally,

66:42

if I had access to the gel foam, I would use it.

66:46

I don't really think there's a reason not to.

66:48

Um, and as much as we like to think, you know, we're

66:51

putting pressure dressings and trying, um, either or

66:55

manual pressure, like realistically the, you know,

66:58

depending on where the area you, you, especially

67:00

if you went intercostal, you're, it's gonna be

67:02

really hard to actually put pressure on that area.

67:05

So I don't really think we're doing

67:06

much when we, when we try that.

67:08

Um, so, uh, the mo I mean, really the most common

67:13

thing is you can just, you just have to watch them.

67:15

Um, if we see a jet at the end of the case and we see

67:18

a little hematoma developing, we'll at the end of the

67:21

hour or even, you know, 30 minutes later, we will, uh.

67:26

We'll check them again with the ultrasound.

67:28

Um, if it looks like it's getting bigger, you know,

67:30

like we send them over to CT and then if it's, if

67:33

it's a significant bleed, you know, they're becoming,

67:35

um, high, like their blood pressure's dropping and

67:38

they're becoming tachycardic, um, then, you know,

67:42

you get an H and H we get them admitted and they,

67:45

they either get observed on with trending hemoglobin

67:48

or, or they get sent to IR for an embolization.

67:51

I mean, usually they'd get a CTA first to I to

67:53

identify active bleeding, but, um, if there was

67:56

bleeding, then they would go to embolization with IR.

67:59

Some, I mean, sometimes IR would use intravascular.

68:02

They would spray gel foam.

68:05

Um, but if it's bad enough they

68:06

could use a, a plug or coils.

68:10

Um, um, and renals.

68:13

1403 01:08:16,694 --> 01:08:16,697 Yeah, renals.

68:18

Renals are we, so we only biopsy the renal masses.

68:23

Um, and nephrology does the, the

68:25

ones for medical renal disease.

68:26

So we see a lot of post biopsy,

68:28

pseudoaneurysms or, or hematomas.

68:30

Um, and it's kind of, it's the same thing.

68:34

Uh, for the most part.

68:35

You just kind of just watch it, make sure any

68:37

underlying coagulopathies, um, are corrected.

68:41

And if it continues to get bigger, they, they'll

68:45

get a, depending on the size or how, I mean,

68:48

if you see an obvious active jet on ultrasound,

68:52

um, you can, you, you can go straight to angio.

68:56

Um, otherwise they'll, they'd get a

68:58

CT and then if it's actively bleeding,

69:00

they'd have, have IR embolize it.

69:04

Um, minimum size to take, or I guess we're

69:07

talking, um, at the same, okay, same question.

69:12

Minimum size, uh, to do core or fine needle.

69:16

So the, so the, I assume the minimum size of.

69:20

Is for the core biopsy.

69:23

Um, that is depending on your,

69:26

what equipment you have available.

69:28

Um, our smallest one that we use

69:31

is we, we call it one centimeter.

69:33

It's technically like 0.75, uh, millimeters.

69:38

So that, that's the smallest piece.

69:41

Um, unless you get a piece that

69:42

fragments, um, generally the, you know,

69:45

the, the pathologist always want more.

69:48

Um, and as far, so that also plays into what

69:52

the smallest size of lesions we can do are.

69:55

Um, so, so for the core, it depends

69:59

where the, where the structure is.

70:01

Like if it's a, um, if it's in like a, it's in

70:06

the axilla or it's something very superficial

70:09

and I'm not worried about anything around it.

70:11

And I don't mind the needle going outside of it and

70:15

getting some of the surrounding fat or whatever's

70:17

there, as long as it's not in a highly vascular area.

70:21

Uh, so in, so in that case, I would, I

70:23

would still biopsy something less than a

70:25

centimeter with our one centimeter, um, core.

70:30

Um, but in, so in other cases when the, the minimum

70:35

size of the lesion is less than your, the throw

70:38

of your core, um, and you're worried about hitting

70:40

something else, uh, in those cases we would either

70:42

just, we would do FNAs, um, and our pathologists

70:46

would, if they really needed more of a, a core.

70:50

Um, so we, because we don't have them, I can't

70:53

use the end cutting needle, but that's where

70:55

you could use, uh, like an FNA with with.

70:58

Cutting end, and you could try to, you

71:01

kind of advance it while twisting it

71:03

and try to almost make a core that way.

71:06

Um, and you could do that for any, like, even probably

71:10

half a centimeter as long as you can see it and it

71:13

hold it in place enough to get the needle into it.

71:16

Um, and then what one of the other things we do

71:18

is, uh, if we run into that situation, um, I'll

71:22

do an FNA and we'll, we'll do multiple FNA

71:24

passes, like, uh, you know, five or six of them.

71:28

Um, and then we put it in the rinse cup and

71:30

they will spin it down into a cell block

71:32

and kind of do like a, a makeshift core,

71:35

um, if they can, if we get enough cells.

71:39

Um, FNA is, so it's not absolutely necessary,

71:44

um, before a core, the combination to get so

71:47

core biopsies have higher diagnostic yield

71:50

than FNA alone, but FNA and core biopsies.

71:55

Have been shown to have an even higher yield.

71:57

So it's best to do them together.

71:59

Um, honestly, there are times when I know

72:03

we're in the lesion 'cause we can see it.

72:06

Um, and like if the Cytotech or pathologist

72:11

is telling us that, you know, they're, they're

72:13

not sure we're in something or, um, you know,

72:16

they're, they're like, you wanna try another area?

72:18

And we're like, no, this is, and

72:19

we're positive this is a lesion.

72:21

Um, so we we're still doing the FNAs in that

72:23

case, but I'm gonna proceed to core anyways.

72:27

Um, I mean as long as we're, we're sure and we know

72:31

where we are, it really hasn't caused any issues yet.

72:33

'cause they're, the majority of what

72:35

they're, um, making a diagnosis on

72:37

is gonna be from those cores anyways.

72:40

All right.

72:40

I think that's all the time

72:41

we have for questions today.

72:43

Uh, Dr. Facciola, thank you so much for your lecture.

72:46

Uh, we really appreciated you participating and,

72:49

uh, hanging on to answer some questions for us.

72:52

Uh,

72:53

I reminder know that you can access the

72:54

recording of today's conference and I'll, and

72:56

all of our other previous noon conferences

72:57

by creating a free MRI online account.

73:00

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73:02

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73:05

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73:08

Be sure to join us next week on Thursday, October

73:10

27th at 12:00 PM Eastern Time for a lecture with

73:13

Dr. Rachel Brim on the high risk breast lesions.

73:17

You can register for that at MRIonline.com

73:21

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73:23

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73:26

Thanks again and have a great day.