Us Guided Breast Biopsy

7/28/2019 Us Guided Breast Biopsy

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Ultrasound-Guided Breast

Biopsy'RFXPHQWDWLRQ

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Grateful appreciation to Richard A. Lopchinsky, MD,

FACS and Nancy H. Van Name, RDMS, RTR, and

Marlene Kattaron, RDMS

©2000 UIC All Rights Reserved.



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



Biopsy choices

• Fna– Complex cysts

– When its probably fluid

– Least invasive

– Poorest percent of diagnosis

– Usually can not differentiate between Dinvasive



Biopsy choices

• Core– Cancers

– Better yield than fna

– Can differentiate between invasive and

noninvasive

– Leaves undisturbed for sentinel node ma



Biopsy choices

• Sono localization excision– Eliminates radiologist

– Can be performed in office

– Removes lesion completely

– Can even take margins for malignant les



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



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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• 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



• Very detailed, include specifics of bioprocedure

• History

• Procedure

• Pathology

• Follow-up

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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



• 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



• 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

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• Communicate personally on the

telephone and through a dictated rep

• Pathology report sent to physician byand by mail

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Ultrasound-Guided Brea

Biopsy

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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



Review of Diagnostic Work

• At the time of patient arrival

• Review films with reports

• Determine type of biopsy and approa



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



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 –



FNA: Complex cyst

• Complex cyst within dense tissue



FNA: Complex Cluster Cy

• Complex mass - 1











FNA: Thick cyst - 1

• Pt with multiple cysts and one hypoechoic



FNA: Thick cyst -2

• “Mass” likely to be thick cyst



FNA: Thick cyst - 3

• Try FNA with 18 gauge needle



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



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



Core Technique - 3

• Remove trocar sheath• Have patient hold pressure while proc

specimen

• Wash area with peroxide, apply Bioc

and pressure dressing



Core biopsy: Apocrine lined

• 32 yo with newly diagnosed mass• “Mass” will frequently disappear after 1st



Core biopsy: Cellular FBA

• 46 yo with new mass with slightly irregula



Core biopsy: Cellular FBA

• Pre and post biopsy



Core Biopsy: Fat NecrosNew mass after TRAM flap

• 42yo developed new mass in skin flap aboTRAM 9 months after surgery



Core Biopsy: Fat NecrosPostreduction

• 24yo post reduction mammoplasty• Mass may disappear as fat leaks out needle



Core biopsy: Cancer diagno

• New mammo mass leads to a sono evaluati• Ill defined, taller than wide, posterior shad



Core biopsy: Cancer diagno

• Core biopsy followed by definitive therapy



Core Biopsy: Infiltrating CLesion close to chest wall - 1

• New mass noted at edge of mammogram• Appears to invade muscle



Core Biopsy: Infiltrating CLesion close to chest wall - 2

• Lesion lifted off muscle with lidocaine and



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



Sono Localized Biopsy:Ductal Ectasia

• Discretemicrolobulated mass •Sono guided e



Sono Localized Biopsy:Fibroadenoma

• Small somewhat irregular hypoechoic mas• FNA - atypical cells



Sono Localized Biopsy:Infiltrating Ductal Ca

• 6mm hypoechoic, “round”, somewhat irregmass - wire localization for excision



Approach to Biopsy

• Mammotome®

11 gauge• Relative contraindications:

– multiple lesions

– implants

– very deep lesions (depends on approach

– anxious and frightened patients



Correct Angle

Parallel to Chest Wall



Important: Poor angle placement



DeepLesions



Patient Consent

• Describe the procedure, the

alternatives, the risks and the benefits

• Sign general consent form• Review allergic and menstrual history



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





The Mammotome®



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



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



The Mammotome®

• Monitor the position of the probe

during advancement

• When at lesion depth, go horizontal advance the aperture (bowl) under the

lesion



The Mammotome®

Opening of chamber placed under les

parallel to chest wall



Obtaining samples:

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The Mammotome®



MicroMark ® Placement

• Vacuum biopsy cavity

• Introduce marker and deploy

• Rotate aperture and remove probe• Begin manual compression



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



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



Expectations After the Bio

• Possible mild discomfort or bruising• Possible excessive bleeding

– contact physician

• Pathology report available in forty-ei

(48) hours



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



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



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



Practice, Practice, Practi





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

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Mammogram Pre-Biopsy



Sonogram Pre-Biopsy



Skin Incision Point Marking



Anesthesia Delivery



Skin Incision



Mammotome Hand HeldIntroduced



Mammotome Hand Hel

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Mammotome Software

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Mammotome Hand Hel

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Sample Retrieval



Specimen Collection



Cavity Post Biopsy



MicroMark Tissue Marker Placement



MicroMark Introducer

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Post Biopsy Bandage

Documents

Us Guided Breast Biopsy