Documentation:
,PDJLQJ 5HYLHZ • Review films, include mammography and ultrasound • Review reports
– never perform a biopsy without the original films and reports
• Determine type of biopsy and the approach to the biopsy
Biopsy choices
• Fna
– Complex cysts – When its probably fluid – Least invasive – Poorest percent of diagnosis – Usually can not differentiate between DCIS or invasive
Biopsy choices
• Core
– Cancers – Better yield than fna – Can differentiate between invasive and noninvasive – Leaves undisturbed for sentinel node mapping
Biopsy choices
• Sono localization excision
– Eliminates radiologist – Can be performed in office – Removes lesion completely – Can even take margins for malignant lesions
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 dilemmas
• Remove lesion, leave clip and repeat mammo
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
Documentation:
)LOPLQJ
• Pre-Biopsy
– replicate diagnostic ultrasound to include the size of the lesion and its location
• During Biopsy
– image the probe in place with the lesion at the beginning of the biopsy and at the end of the biopsy
• Post Biopsy
– new baseline mammogram
» CC view and 90 degrees lateral » images with tissue marker
Documentation:
%LRSV\5HSRUW
• Very detailed, include specifics of biopsy procedure • History • Procedure • Pathology • Follow-up • Dictate CPT code
DQG QXPEHU RI WLVVXH VDPSOHV
,QFOXGH SDWLHQW SRVLWLRQLQJ SUREH SODFHPHQW DQHVWKHVLD SODFHPHQW RI WLVVXH PDUNHU
My customized report
5LFKDUG $ /RSFKLQVN\ 0')$&6
1$0(BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
,1',&$7,216
Documentation:
)ROORZXS5HFRPPHQGDWLRQV
• Concordance
– Specific Benign
• Six (6) month follow-up
• Discordance
– Unsatisfactory procedure – Discrepancy between mammography and pathology – Rebiopsy or needle localization excision
– Non-Specific Benign
• Six (6) month follow-up
– Atypia/ADH/LCIS
• Excision
– Malignant
• Excision
Documentation:
&RPPXQLFDWLRQRI5HVXOWV • Dictate and phone or FAX report to referring physician • Discuss findings with patient • Arrange surgery for those with an atypia or malignant biopsy result • Decide about surgery for discordance
Documentation:
3DWLHQW&RPPXQLFDWLRQ
• Benign
– Specific or Non-Specific Ideally, send a certified letter as a reminder for a six (6) month follow-up examination Arrange for surgery
• Atypia or Malignant
Documentation:
3K\VLFLDQ&RPPXQLFDWLRQ • Communicate personally on the telephone and through a dictated report • Pathology report sent to physician by FAX and by mail
Ultrasound-Guided Breast Biopsy
(TXLSPHQWDQG7HFKQLTXH
Scheduling the Patient
• 60-minute time slot • No aspirin products • Stop Coumadin three days prior and check PT • Bring films with reports to exam • Wear shirt top and bra
Review of Diagnostic Work-up
• At the time of patient arrival • Review films with reports • Determine type of biopsy and approach
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 syringe • Slides and fixative prepared so the material doesn’t dry out later • Apply limited gel to sono area and prep needle site with alcohol • I use ordinary 21ga 1.5inch needle – • If looks thick =18ga
FNA: Complex cyst
• Complex cyst within dense tissue
FNA: Complex Cluster Cysts
• Complex mass - 1
FNA: Complex Cluster Cysts
• Complex mass - 2
FNA: Complex Cluster Cysts
• Complex mass - 3
FNA: Thick cyst - 1
• Pt with multiple cysts and one hypoechoic mass.
FNA: Thick cyst -2
• “Mass” likely to be thick cyst
Core Technique - 1
• Automated core required for breast. Manual for thyroid
– Much better yield and much less pain with automated
• Give 2-3cc 2% lidocaine with epi in skin, tract, and below lesion • Sterile tray: 11 blade, trocar, gauze, Bioclusive, few gtts saline, core device
Core Technique - 2
• Prep skin and use 11 blade to nick skin • Introduce trocar just proximal to lesion – photo • Remove inner cannula and replace with biopsy instrument • Warn patient of loud noise • Take 4-6 cores depending on yield. Use saline to keep specimens moist
Core Technique - 3
• Remove trocar sheath • Have patient hold pressure while processing specimen • Wash area with peroxide, apply Bioclusive, and pressure dressing
Core biopsy: Apocrine lined cyst
• 32 yo with newly diagnosed mass • “Mass” will frequently disappear after 1st pass
Core biopsy: Cellular FBA -1
• 46 yo with new mass with slightly irregular border
Core biopsy: Cellular FBA -2
• Pre and post biopsy
Core Biopsy: Fat Necrosis
New mass after TRAM flap
• 42yo developed new mass in skin flap above TRAM 9 months after surgery
Core Biopsy: Fat Necrosis
Postreduction
• 24yo post reduction mammoplasty • Mass may disappear as fat leaks out needle
Core biopsy: Cancer diagnosis-1
• New mammo mass leads to a sono evaluation • Ill defined, taller than wide, posterior shadowing
Core biopsy: Cancer diagnosis-2
• Core biopsy followed by definitive therapy
Core Biopsy: Infiltrating Ca
Lesion close to chest wall - 1
• New mass noted at edge of mammogram • Appears to invade muscle
Core Biopsy: Infiltrating Ca
Lesion close to chest wall - 2
• Lesion lifted off muscle with lidocaine and cored
Sono localization technique
• • • • • • Localize lesion with sono and prep skin Insert Localization needle through mass Advance hook to just beyond mass Remove needle Continue as if it were a palpable mass bx Specimen can be sono’ed in water bath if necessary
Sono Localized Biopsy:
Ductal Ectasia
• Discrete microlobulated mass •Sono guided excison
Sono Localized Biopsy:
Fibroadenoma
• Small somewhat irregular hypoechoic mass • FNA - atypical cells
Sono Localized Biopsy:
Infiltrating Ductal Ca
• 6mm hypoechoic, “round”, somewhat irregular mass - wire localization for excision
Approach to Biopsy
• Mammotome® 11 gauge • Relative contraindications:
– multiple lesions – implants – very deep lesions (depends on approach angle) – anxious and frightened patients
Correct Angle Parallel to Chest Wall
Important: Poor angle placement
Deep Lesions
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 posterior oblique • Ipsilateral arm is elevated and placed behind the head • Locate lesion with ultrasound imaging and mark the skin • Cleanse skin with betadine and drape • Offer patient virtual reality glasses
The Mammotome®
Biopsy Tray—Set-up
• Sterile gloves • (Tuberculin syringe, 25ga needle with 1% lidocaine) • 6 cc syringe with 22 (or 25) ga needle and lidocaine with epinephrine • 12 cc syringe with sterile saline for flushing needle • Sterile gauze • Tweezers with formalin bottle • Unexposed x-ray film for microcalcifications
The Mammotome®
• Locate lesion with ultrasound using sterile lubricant • Skin wheal of lidocaine • 6 cc deep anesthesia with epinephrine
– elevate the lesion with the anesthesia
• Skin nick • Elevate rear end of Mammotome® and advance the probe
The Mammotome®
• Monitor the position of the probe during advancement • When at lesion depth, go horizontal and advance the aperture (bowl) under the lesion
The Mammotome®
Opening of chamber placed under lesion, parallel to chest wall
MicroMark® Placement
• • • • Vacuum biopsy cavity Introduce marker and deploy Rotate aperture and remove probe Begin manual compression
Obtaining Hemostasis
• • • • • • Manual compression for fifteen (15) minutes 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
– Pressure dressing locally or wrap
Expectations After the Biopsy
• Possible mild discomfort or bruising • Possible excessive bleeding
– contact physician
• Pathology report available in forty-eight (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 cancelled cases Surgery for all ADH, cancer, radial scar, and LCIS Wound check Six (6) month follow-up imaging
Common Mistakes
• Uncomfortable for the physician performing the 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 probe • Poor monitoring of the tip of the probe • Compression not maintained during the biopsy procedure
Common Mistakes
• Never biopsy down • Use anesthesia to elevate the lesion off of the chest wall • Use the gravity to allow the lesion to fall into the aperture • Place tissue marker to confirm mammographic location of lesion
Practice, Practice, Practice
RECIPE Turkey Breast a la Georgian-Smith
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 residents, fellows, and attendings. Also, it may be frozen and used again!