• BR 4 and 5 lesions

• Br 3 lesions at patient/surgeon request

• Large simple cysts for symptomatic relief

• Some complicated cysts

FNA 

• Minimal risk

• 74% sensitivity, inadequacy 7-18%

• Need on-site cytologist.

• Slide preparation required

Core/vacuum bx

• Low risk

• 93% sensitivity, inadequacy 5-7%

• Onsite pathologist not needed

• No specimen preparation

• Larger specimens allowing for ER/PR/HER2 and genetic analysis

• Performed for...

  • Sx relief/patient anxiety

  • Cyst vs homogeneous solid mass

  • Cyst w/ atypical features

    • Thick or irregular wall -> bx preferred

    • Mixed echogenicity contents (not apocrine cyst)

  • Suspected infection

• Equipment

  • Always consent for bx in addition to aspiration

  • 5 cm 18G needle (may need larger if viscose)

  • Tubing

  • 20cc syringe

• Key concepts

  • If clear, green, black, white, pink tinged fluid -> discard, no FU needed

  • If bloody -> leave clip, send for cytology

  • If purulent ->

    • Large collection -> insert drain, send for culture

    • Small collection -> aspirate completely, send for culture

    • Tx w/ abx & close clinical FU

  • If incomplete / failed aspiration -> bx/clip

• Mixed solid & cystic masses

  • DO NOT ASPIRATE mixed solid/cystic masses

  • Bx is preferred w/ vacuum device

  • Need the solid component bx'd, not just wall

What modality?

• If you can see it on US -> choose US

• If subtle on US and obvious on mammo  -> choose stereo

  • For architectural distortions; there is a risk of obscuration w/ local anesthetic.

• If NME, small lesions, larger breasts -> MRI

Special cases when US is preferred

• Very superficial lesions

• Implants w/ little native tissue

• Retroareolar lesions

• Thin breasts

• Frail patients

Ask yourself, is it the same lesion?

• Carefully correlate w/ mammo and US

• Check shape, size, radial distance from nipple, depth, margins, surrounding parenchyma

Selecting the appropriate target for bx

• Bx the most suspicious area

  • If mixed solid / cystic lesion -> solid portion

  • Wall of suspected necrotic lesions/thick-walled cysts

• Multiple suspicious masses

  • If </= 3 lesions -> Bx all (careful w/ annotation/clips)

  • If > 3 lesions-> bx most suspicious or most distant

  • Satellite lesions located <2 cm from dominant lesion and do not need to be bx'd separately.

• Naming recommendations

  • Breast side, lesion #; Size, type, radian, cm from nipple

    • Right breast lesion 1: 1.2 cm mass, 12:00, 4 cm FN

• Use of Doppler

  • Always check for flow prior to bx

  • Avoid large vessels, especially in axilla!

  • May need to use lidocaine w/ epinephrine

  • May need to reduce needle size.

  • Put minimal pressure on before you exclude blood flow.

• Review all imaging

  • Confirm bx site and lesion appearance

  • Check for prior clips

• Protocol the procedure

  • Device type, local anesthesia, clip type

• Check for allergies, anticoagulants, contraindications

  • Low platlets <50 per mcL

• Patient consent

  • Bleeding, infection, need to repeat bx

  • Chest wall trauma, milk leak

  • Antithrombotic therapy

    • Counsel patients about increased risk of bruising if on antithrombotic therapy

    • Generally safe to continue especially for 14G bx

      • Baseline INR <2.5 if on coumadin

      • Can use smaller needle

    • Benefit-risk ratio

      • Risk of stroke/other thrombotic event if withhold

      • If withold, usually 3-5 days most agents

        • Consult w/ clinical team

Bx clips

• US needed for later localization of nodes

After placement

• Ensure it is in the center of the lesion by 

  • confirming on ML/CC post bx mammogram

  • Correlating w/ preprocedural imaging

  • Document clip type/shape

  • Document clip displacement

Choosing the entry site and needle approach

• Position patient to make breast as flat as possible to reduce 'wobble'

• Avoid nipple

• Avoid 'from above' and forming cleavage scars

• Avoid elbow in patient's face

• Right vs left-handedness

• May depend on lesion visibilty in different planes

Bx angles

• Needle visibility <45 degrees

• Check needle throw; 1 cm vs 2 cm

• Safety: know where the chest wall, skin and vessels are

PROCEDURE STEPS

• Skin prep

• Anesthesia

• Introducer placement

• Needle placement

• Bx

• Clip placement

• Post bx imaging

Post procedural imaging

• Confirm clip placement and shape for future procedures/imaging

• Correlate w/ original mammo

  • Is it concordant/discordant bx?

• Generally, ML/CC mammograms

• Occasionally omit if young patient, frail patient, or axillary bx

• Only move 1 hand at a time!

• Move each very slowly

• Look at you hands as much as screen

• Needle MUST be parallel and in center of transducer

• Must see total length of needle to predict direction

VERY SUPERFICIAL  LESIONS

DEEP LESIONS / NEAR CHEST WALL

THIN BREASTS / IMPLANTS

DENSE BREASTS & HIGHLY MOBILE LESIONS

AXILLARY NODE BX

HOW TO

• If you don't see your entire needle

  • Look at your hands

  • Adjust your needle to align needle w/ probe

  • Stand more to the left to ensure right arm is parallel with probe.

  • Perform perpendicular pivot

    • Bx is fixed by 2 points: incision and target

    • 2 points always make a line

    • Find target

      • Ensure transducer is perpendicular to chest wall 

      • Pivot transducer by keeping more proximal portion near the needle tip fixed and locate lesion by moving only distal portion of transducer.

      • Look down at your hands

      • Adjust your needle.

  • Do not rock and roll transducer

    • Technique good for dx US to get  better images

    • You will falsely show needle and mass aligned

    • Getting orthogonal images helps to ensure needle is within mass

• Target keeps moving away from you

  • Anchor the breast with you 4th and 5th digits

  • Can ask technologist to apply back pressure to back of breast

• Divot technique 

  • Most often happens when angle is acute to the transducer when bxing deep breast mass

  • Make incision farthest away from transducer as possible

  • Torque down on the needle and on the distal end of the transducer to improve angle of beam. This will cause divots in skin you can see on US.

• Open trough technique

  • needle fired outside of breast

  • Inserted under US to see needle

  • Scoop under target

  • May take some pressure as trough is not as sturdy as cocked needle

  • Method works well for posterior mass near chest wall and fatty breasts (eg axilla)

  • Good for very small masses

  • Some needles have deadspace near the trough which can cause you to not sample the lesion

  • Can also have tech hold prob between samples.

• Blood vessels?

  • Change trajectory to avoid vessels

  • Can also use co-axial needle to cover vessel.

• Mass close to implant?

  • Inject lidocaine posterior to mass to lift mass off implant.

  • Use open trough technique

• Very dense tissue?

  • Make incision closer than you think bc tissue will push away from you

  • May need to biopsy dense tissue proximal to mass in order to get to the mass.

  • Use transducer hand for back pressure