us guided breast biopsy
TRANSCRIPT
7/28/2019 Us Guided Breast Biopsy
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Ultrasound-Guided Breast
Biopsy'RFXPHQWDWLRQ
%LRSV\7HFKQLTXH
Grateful appreciation to Richard A. Lopchinsky, MD,
FACS and Nancy H. Van Name, RDMS, RTR, and
Marlene Kattaron, RDMS
©2000 UIC All Rights Reserved.
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Documentation:,PDJLQJ 5HYLHZ
• Review films, include mammographyultrasound
• Review reports– never perform a biopsy without the
original films and reports
• Determine type of biopsy and the app
t th bi
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Biopsy choices
• Fna– Complex cysts
– When its probably fluid
– Least invasive
– Poorest percent of diagnosis
– Usually can not differentiate between Dinvasive
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Biopsy choices
• Core– Cancers
– Better yield than fna
– Can differentiate between invasive and
noninvasive
– Leaves undisturbed for sentinel node ma
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Biopsy choices
• Sono localization excision– Eliminates radiologist
– Can be performed in office
– Removes lesion completely
– Can even take margins for malignant les
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Biopsy choices
• Mammotome– Newest technique
– Best diagnostic yield
– 5mm incision
– Remove benign lesions completely
– Leave a clip for small ca’s to help OR– Solve mammo/sono diagnostic dilemma
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Documentation:,QIRUPHG&RQVHQW
• Explanation of the biopsy procedure
• Possible alternatives to the biopsy
procedure
• Risks of the biopsy procedure
• Signature of the patient and a witness
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Documentation:)LOPLQJ
• Pre-Biopsy– replicate diagnostic ultrasound to include
the lesion and its location
• During Biopsy– image the probe in place with the lesion a
beginning of the biopsy and at the end of
• Post Biopsy– new baseline mammogram
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• Very detailed, include specifics of bioprocedure
• History
• Procedure
• Pathology
• Follow-up
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My customized reportFinal Summary Section
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Documentation:)ROORZXS5HFRPPHQGDWLRQ
• Concordance– Specific Benign
• Six (6) month follow-up
– Non-Specific Benign• Six (6) month follow-up
– Atypia/ADH/LCIS
• Excision
– Malignant
i i
• Discordance– Unsatisfactory
procedure
– Discrepancy bmammograph
pathology
– Rebiopsy or n
localization ex
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• Dictate and phone or FAX report to
referring physician
• Discuss findings with patient• Arrange surgery for those with an aty
malignant biopsy result
• Decide about surgery for discordance
Documentation:&RPPXQLFDWLRQRI5HVXOWV
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• Benign
– Specific or Non-Specific
Ideally, send a certified
letter as a reminder for a six
(6) month follow-up
examination
• Atypia or M
Arrange for sur
Documentation:3DWLHQW&RPPXQLFDWLRQ
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• Communicate personally on the
telephone and through a dictated rep
• Pathology report sent to physician byand by mail
Documentation:3K\VLFLDQ&RPPXQLFDWLRQ
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Ultrasound-Guided Brea
Biopsy
(TXLSPHQWDQG7HFKQLT
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Scheduling the Patient
• 60-minute time slot• No aspirin products
• Stop Coumadin three days prior and PT
• Bring films with reports to exam
• Wear shirt top and bra
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Review of Diagnostic Work
• At the time of patient arrival
• Review films with reports
• Determine type of biopsy and approa
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Biopsy techniques
• All techniques– Preliminary sono with limited gel
– Mark crosshairs – usually in radial and
antiradial
• If not using needle guide
– Approach through least amount of breast tissue
– Parallel to chest wall
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FNA Technique
• Need a biopsy gun – to hold a 20cc sy• Slides and fixative prepared so the m
doesn’t dry out later
• Apply limited gel to sono area and pr
needle site with alcohol
• I use ordinary 21ga 1.5inch needle –
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FNA: Complex cyst
• Complex cyst within dense tissue
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FNA: Complex Cluster Cy
• Complex mass - 1
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FNA: Complex Cluster Cy
• Complex mass - 2
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FNA: Complex Cluster Cy
• Complex mass - 3
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FNA: Thick cyst - 1
• Pt with multiple cysts and one hypoechoic
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FNA: Thick cyst -2
• “Mass” likely to be thick cyst
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FNA: Thick cyst - 3
• Try FNA with 18 gauge needle
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Core Technique - 1
• Automated core required for breast. Mfor thyroid
– Much better yield and much less pain w
automated
• Give 2-3cc 2% lidocaine with epi in s
tract, and below lesion• Sterile tray: 11 blade trocar gauze
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Core Technique - 2
• Prep skin and use 11 blade to nick sk• Introduce trocar just proximal to lesio
photo
• Remove inner cannula and replace wi
biopsy instrument
• Warn patient of loud noise
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Core Technique - 3
• Remove trocar sheath• Have patient hold pressure while proc
specimen
• Wash area with peroxide, apply Bioc
and pressure dressing
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Core biopsy: Apocrine lined
• 32 yo with newly diagnosed mass• “Mass” will frequently disappear after 1st
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Core biopsy: Cellular FBA
• 46 yo with new mass with slightly irregula
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Core biopsy: Cellular FBA
• Pre and post biopsy
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Core Biopsy: Fat NecrosNew mass after TRAM flap
• 42yo developed new mass in skin flap aboTRAM 9 months after surgery
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Core Biopsy: Fat NecrosPostreduction
• 24yo post reduction mammoplasty• Mass may disappear as fat leaks out needle
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Core biopsy: Cancer diagno
• New mammo mass leads to a sono evaluati• Ill defined, taller than wide, posterior shad
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Core biopsy: Cancer diagno
• Core biopsy followed by definitive therapy
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Core Biopsy: Infiltrating CLesion close to chest wall - 1
• New mass noted at edge of mammogram• Appears to invade muscle
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Core Biopsy: Infiltrating CLesion close to chest wall - 2
• Lesion lifted off muscle with lidocaine and
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Sono localization techniqu
• Localize lesion with sono and prep sk• Insert Localization needle through ma
• Advance hook to just beyond mass
• Remove needle
• Continue as if it were a palpable mas
• Specimen can be sono’ed in water ba
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Sono Localized Biopsy:Ductal Ectasia
• Discretemicrolobulated mass •Sono guided e
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Sono Localized Biopsy:Fibroadenoma
• Small somewhat irregular hypoechoic mas• FNA - atypical cells
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Sono Localized Biopsy:Infiltrating Ductal Ca
• 6mm hypoechoic, “round”, somewhat irregmass - wire localization for excision
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Approach to Biopsy
• Mammotome®
11 gauge• Relative contraindications:
– multiple lesions
– implants
– very deep lesions (depends on approach
– anxious and frightened patients
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Correct Angle
Parallel to Chest Wall
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Important: Poor angle placement
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DeepLesions
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Patient Consent
• Describe the procedure, the
alternatives, the risks and the benefits
• Sign general consent form• Review allergic and menstrual history
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Patient Preparation
• Position in the contralateral posterioroblique
• Ipsilateral arm is elevated and placed
behind the head• Locate lesion with ultrasound imaging and
mark the skin
• Cleanse skin with betadine and drape
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The Mammotome®
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Biopsy Tray—Set-up
• Sterile gloves
• (Tuberculin syringe, 25ga needle with 1% lidocai
• 6 cc syringe with 22 (or 25) ga needle and lidocai
epinephrine
• 12 cc syringe with sterile saline for flushing needl
• Sterile gauze
• Tweezers with formalin bottle
• Unexposed x-ray film for microcalcifications
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The Mammotome®
• Locate lesion with ultrasound using slubricant
• Skin wheal of lidocaine
• 6 cc deep anesthesia with epinephrine
– elevate the lesion with the anesthesia
• Skin nick
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The Mammotome®
• Monitor the position of the probe
during advancement
• When at lesion depth, go horizontal advance the aperture (bowl) under the
lesion
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The Mammotome®
Opening of chamber placed under les
parallel to chest wall
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Obtaining samples:
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The Mammotome®
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MicroMark ® Placement
• Vacuum biopsy cavity
• Introduce marker and deploy
• Rotate aperture and remove probe• Begin manual compression
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Obtaining Hemostasis
• Manual compression for fifteen (15) minut
• Steri-strip place on incision
• Ice pack in the bra for four (4) hours
• Pressure dressing for complicated cases
• Follow-up sheet completed
• Emergency contact telephone numbers
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Post Biopsy Care
• Ice pack in the bra for four (4) hours• Analgesic without aspirin
• No vigorous exercise for twenty-four (24)
hours
• Steri-strip over the incision
• Emergency contact telephone numbers• Hematoma
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Expectations After the Bio
• Possible mild discomfort or bruising• Possible excessive bleeding
– contact physician
• Pathology report available in forty-ei
(48) hours
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Pathology Reports
• Verbal report next morning
• Determine concordance with ultrasound imaging
• Inform the patient of results
• Case is dictated after final pathology report
• Six (6) month follow-up for all benign and cancel
• Surgery for all ADH, cancer, radial scar, and LCI
• Wound check • Six (6) month follow-up imaging
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Common Mistakes
• Uncomfortable for the physician performing t
biopsy or for the patient
• Poor positioning of the ultrasound system
• Skin incision not long enough or deep enough• Entry site too far away from the transducer
• Improper alignment of the transducer and the
• Poor monitoring of the tip of the probeC i t i t i d d i th bi
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Common Mistakes
• Never biopsy down• Use anesthesia to elevate the lesion o
of the chest wall
• Use the gravity to allow the lesion to
into the aperture
• Place tissue marker to confirmhi l ti f l i
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Practice, Practice, Practi
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RECIPE
Turkey Breast a la Georgian-Sm
1 turkey breast with sternum
1 jar olives with pimentos
1 jar maraschino cherries
optional: capers, grapes, pearl onions
1. Warm up ultrasound machine.
2. Leave turkey skin intact but remove legs.
3. Stuff turkey “lesions” between muscle planes
Serves: excellent practice for resident
f ll d tt di
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Mammogram Pre-Biopsy
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Sonogram Pre-Biopsy
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Skin Incision Point Marking
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Anesthesia Delivery
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Skin Incision
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Mammotome Hand HeldIntroduced
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Mammotome Hand Hel
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Mammotome Software
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Mammotome Hand Hel
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Sample Retrieval
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Specimen Collection
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Cavity Post Biopsy
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MicroMark Tissue Marker Placement
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MicroMark Introducer
(PHUJLQJIURP0DPPRWRPH
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Post Biopsy Bandage