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5/27/2014
STEREOTACTIC BREAST BIOPSY
Deborah Thames (R)(M)(QM)
• Diagnostic Radiology /Mammography
All courses offered by AHEC are approved
by a Recognized Continuing Education
Evaluation Mechanism (RCEEM), AHRA (The
Association for Medical Imaging
Management) or ASRT (American Society of
Radiologic Technologists). Courses are
approved in states with independent
approval requirements if the course is being
presented in that state.
• Disclosure of Relevant Financial Interest for
Individuals in Control of Content. AHEC
Financial interest includes but is not limited to
relationships with commercial companies,
manufacturers, or corporations, whose products or
services are related to the subject matter of the
presentation within the prior 12 months.
Please turn off all cell phones and pagers
And be kind to your neighbor and not talk
out Loud in class-Thank You
ABOUT ME
• Work full time at a cancer hospital in Houston, Texas, born in South Dakota
• Done X-rays/Mammography for 18 years
• Taught classes for AHEC for 9 years
• Going to college finish what I started
• Have two sons, daughter-in-law and Grandson Jan 2014 and the only other
estrogen are my two girl dogs
You can get up and use the restroom anytime,
but be discreet please
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IF YOU DIDN’T PRINT OUT YOUR SYLLABUS GO
TO AHECONLINE.COM AND LOOK FOR THIS
SYMBOL AND CLICK ON IT AND FIND TODAY’S
CLASS
IT WILL BE POSTED FOR A FEW WEEKS AFTER
TODAY
Nov 8 1895
Anna Bertha
SOME DISCOVERIES TO REMEMBER
IN THE FIELD OF X-RAY….
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Albert Einstein
Discovered
Photo Electric Effect
ALBERT EINSTEIN WAS AWARDED THE NOBEL
PRIZE FOR PHYSICS IN 1921 FOR HIS SERVICES TO
THEORETICAL PHYSICS, AND ESPECIALLY FOR
HIS DISCOVERY OF THE LAW OF
PHOTOELECTRIC EFFECT.
• It is the photoelectric absorption that is responsible for most
of the absorption in a mammogram that creates the
contrast in the image.
• Arthur Holly Compton was awarded the Nobel Prize for
physics in 1927 for his discovery of the effect named after
him.
Arthur Holly Compton
“The Compton Effect”
• The Compton effect is considered to be responsible for the
bulk of scattering effects in radiology.
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Certified facilities, as of October 1, 2013
8,691
Certification statistics, as of January 1, 2014
Total certified facilities / Total accredited units
8,705 / 13,129
Certified facilities with FFDM2 units / Accredited FFDM units
8,028 / 12,246
FY 2014 inspection statistics, as of January 1, 2014
Facilities inspected
1,876
Total units at inspected facilities
2,761
Percent of inspections where the highest noncompliance was a:
Level 1 violation
0.3%
Level 2 violation
11.8%
Level 3 violation
Percent of inspections with no violation
Total annual mammography procedures reported, as of January 1, 20141
About 39,620 women in the U.S. are expected to
die in 2014 from breast cancer, though death rates
have been decreasing since 1989 — especially in
women under 50. These decreases are thought to
be the result of treatment advances, earlier
detection through screening, and increased
awareness.
For women in the U.S., breast cancer death
rates are higher than those for any other
cancer, besides lung cancer
In 2013, there were more than 2.8 million breast
cancer survivors in the US.
1.4%
86.5%
38,644,885
In 2014, an estimated 232,340 new
cases of invasive breast cancer are
expected to be diagnosed in women
in the U.S., along with 64,640 new
cases of non-invasive (in situ) breast
cancer.
About 2,240 new cases of invasive
breast cancer are expected to be
diagnosed in men in 2014. A man’s
lifetime risk of breast cancer is
about 1 in 1,000.
• White women are slightly more likely to develop
breast cancer than African-American women.
However, in women under 45, breast cancer is more
common in African-American women than white
women. Overall, African-American women are more
likely to die of breast cancer. Asian, Hispanic, and
Native-American women have a lower risk of
developing and dying from breast cancer.
The most significant risk factors for breast
cancer are gender (being a woman) and
age (growing older).
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HOW DO YOU ACHIEVE
THIS?
ACR WEBSITE
• In order to receive the ACR’s Breast Imaging Center of
Excellence designation, a center must be fully
accredited in:
Mammography by the ACR (or an FDA-approved
state accrediting body)(AIT), Stereotactic Breast
Biopsy by the ACR,
Breast Ultrasound by the ACR
(including the Ultrasound-Guided Breast Biopsy
module).
ACR WEBSITE
• Effective January 1, 2016, Breast MRI by the ACR. (Centers
may also satisfy this requirement if they refer their patients to
another facility for breast MRI and breast MR-guided biopsy
outside their center. This facility must be accredited by the
ACR in Breast MRI and may be within their facility system or
in a referral relationship with the Center of Excellence.)
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BENEFITS OF BREAST IMAGING
CENTER OF EXCELLENCE
• Modality accreditation gets a gold star for your facility.
• Enhanced personnel training(Additional training needed).
• Increased research abilities(National mammography database for
free).
• New breast imaging technologies(3D, Automated breast volume
scanner).
• Higher reputation for your facility worldwide.
• In the late 1980s, stereotactic imaging went
through a short trial period where it was used
for preop needle localizations.
• 1986 the first unit was brought to the United
States and installed.
• 102 patients with SCNB prior to surgical excision 23 cancers
detected with 1 “miss” due to lesion position and unstable
imaging
• 96% agreement rate (more acceptable)
• And as Paul Harvey would put it (Now you know the rest of
the story).
HISTORY OF
STEREOTACTIC CORE BIOPSY
• In the Beginning
• 1976 – First developed at the Karolinska Hospital in
Stockholm
• Stereotactic techniques are rooted in the theory of
triangulation
• Initial utilization was fine needle aspiration
• Testing yielded 90% accuracy and 5% false
negatives (deemed unacceptable).
• In 1990, Dr. Steven Parker and his colleagues
published "Stereotactic Breast Biopsy with a Biopsy
Gun."
• Steve Parker MD in conjunction with Fischer
Imaging adapted the Bard Biopsy Gun, fitted with
an 18 ga Tru-Cut needle fitted for use with the addon units.
•18 ga needles did not provide accurate
sampling
•16 ga and 14 ga needles next advancement
•Currently 11 and 9 ga are the most popular
needle-probes used but 8 & 7g are gaining
popularity.
•Patient movement on upright add-on units
prompted development of prone tables.
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• First prone table in the United States was installed at
the University of Chicago in 1986.
• Establishment of minimum core samples increased
from 3 to 5 for masses and 10 for calcifications, but
when larger core bx’s were introduced, less cores
are required
•Earlier systems included digitizers, dialed in
coordinates, extended processing film/screen
• Biopsy time procedure took 2 to 3 hours
•1992 – advancements into digital imaging
reduced procedure time down to 45 mintues
• ABBI, Site Select, Rubicor, enbloc(intact), are
further advancements in tissue sampling allowing
for larger core samples, in some cases the entire
lesion.
A FEW CPT CODES AND
CHARGES
PRINCIPLES OF STEREOLOGY
• Stereology- deals with the transformation
of 2-D observations to 3-D information
using mathematical, statistical and
geometrical tools
• A familiar comparison is the stereoscopy
the brain accomplishes through our visual
system
• Hold your finger up to nose, close one
eye, then close the other… your finger
appears to shift slightly
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•Now focus in the screen, keeping your finger in
view, close one eye, then the other… the shift
seems greater
•The distance of the apparent shift of your
finger in relation to the reference object (your
finger or the screen), is called Parallax
•Our brain solves the parallax problem (the
difference in relation to the reference) and
accurately perceives the distance to the object
•The result is the accurate, quantitative
computer localization of the abnormality in the
breast in three dimensions, horizontal, vertical
and depth (XYZ)(HVD)
•This is provided by the following:
•Stereo pair: two images acquired with x-ray
tube at two different positions
•The resulting depth of perception allows us to know
how far to reach out to accurately touch the object
•On a mammogram, you can pretty much accurately
determine the vertical and horizontal measurements—
but accurate measurement of depth is elusive
•Stereotactic breast localization involves the same
principles that the brain and eyes use to accurately
see a three dimensional object
• The apparent movement of the lesion
between projections is referred to as parallax
shift and is calculated relative to the
reference point. The terms parallax shift and
apparent movement are used because the
breast and lesion do not actually move
between projections; however, the
projection of the image on the u-v plane
does move in a predictable way
• This phenomenon is analogous to the use of parallax shift
in astronomy. The distance of apparent lesion shift
between images can be used to calculate the depth z of
the lesion. The location of the center of rotation of the
stereotactic biopsy system must be known to understand
the significance of the apparent motion of the lesion.
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Diagram illustrates the projection of an image on a
2D (u-v) plane at +15°, 0°, and −15° angulation.
• If a lesion is located at the center of rotation, the parallax
shift is 0; a lesion located farther away from the center of
rotation along the z axis will demonstrate an increased
apparent motion or parallax shift on the stereo images. It is
essential for an operator to know where the reference point
and center of rotation are located on the imaging unit.
TRIANGULATION
TRIANGULATION
• A way to localize a finding within the
breast on two orthogonal views.
• A three dimensional position of a finding
for subsequent imaging or biopsy.
• Make sure all images involved in
triangulation have the nipples at the
same level and the breast pointing the
same way. Then draw an imaginary line
through the lesions will predict its location
on the third view.
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CC
MLO
ML
Down and Out
CC
MLO
ML
CC
MLO
ML
Up and In
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• A scout image is used to locate and center the
lesion in the biopsy window. Once the lesion is
properly positioned, a pair of images are obtained
after moving the x-ray tube and detector assembly
+15° and −15° relative to the 0° position on the scout
image. This controlled movement about a known
center of rotation creates a pair of images with 30°
of separation between projections.
• Basic geometry is used to determine the location of
the lesion in the 3D coordinate system with the paired
images. Imagine an x ray leaving the tube (a fixed
point with respect to the receptor), extending
through the center of the lesion, and then
intersecting a point on the u-v imaging plane. These
two endpoints—the x-ray tube focal spot and the
lesion center on the u-v plane—define the location of
the x ray in the Cartesian coordinate system.
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• The lesion is known to be located somewhere
along the x ray between these two endpoints. An
additional projection is needed to determine its
exact location and involves rotating the tube and
receptor assembly about the center of rotation
while the position of the breast (and lesion) remains
fixed. The second projection is 30° from the first
projection. In practice, a +15° image and a −15°
image are produced.
• Because in theory the lesion has not moved
between projections, the two x rays that are
responsible for creating the image of the lesion
center on the +15° and −15° u-v planes must
intersect at the center of the lesion in real space. By
equating these two x rays, the x, y, and z
coordinates of the lesion can be determined with
basic trigonometry
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Reference point: the coordinates are
determined from a reference point
which is located on either the,
A) Compression Paddle (Lorad)
Determines the depth from the
proximal aspect of the breast
B) Breast Support
(Fischer)(Siemens)(Echoserve)
Determines the depth from the
distal aspect of the breast
• The primary purpose of the coordinate
system is to identify a specific threedimensional point in the breast,
• which will be used as the target for the
needle biopsy.
• • X or H expresses the horizontal plane.
• • Y or V expresses the vertical plane.
• • Z or D expresses the depth.
• There are two coordinate systems: polar and
Cartesian
Computer: determines the location based on
the abnormalities shift from the reference
point and will give location in three
dimensions
Two Different Coordinate systems and the
manufacturer.
*Polar (Fischer)(Siemens)(Echoserve) (H, V, D)
Autoguide
*Cartesian (Lorad) (uprights) (X, Y, Z) Stage
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Diagram illustrates the relationship between a 3D object (x, y, and z
coordinates) and a 2D image (u, v coordinates).
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NEW CALCULATIONS FOR
STROKE MARGIN
• Lorad Table- Suros is Z + 6
Mammotome is Z + 5
• Every prone table on the market
has a built in safety stroke margin
about 4-6 mm of safety zone not
factored into the stroke margin
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FISCHER/SIEMENS WILL GIVE YOU
A WARNING
STROKE
• The stroke is different on each brand of needle sets.
• For an example for Mammotome the stroke is 19
• For Suros the stroke is 20, Eviva is 23
• For SenoRx the stroke is 19
• Make sure your stroke isn’t changed by accident.
The stroke goes by your needle length/aperture.
20 mm sample notch
8mm dead space
10 mm Center of sample notch
10+8=18 in order to get desired target in center of sample notch
Throw(Stroke) of needle is 23mm
18-23= -5 so you set your z to -5 when advancing biopsy device into
the breast
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ANNOTATIONS
• You want your needle underneath
the calcifications when using
prone tables.
• Why do you think this is?
• Most all consultants will teach you
this.
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• Answers……
• Works with gravity
• Can see cals/masses without the needle covering them
up
• If you have to retarget you can see the calcs/masses to
do so
• Only need to move half the clock 9-3
• Can see the post clip better
• The Rumor is if you can’t see the calcs then
that means the needle is perfectly on them.
This is not true……
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KVP (QUALITY)
SOME MORE TROUBLE SHOOTING
CHANGING YOUR TECHNIQUES AND
TECHNIQUE CHARTS.
• kVp is the energy beam controlled by voltage. It is
the difference controlled b/t the cathode and the
anode. The higher the kVp the more energetic the
beam of the x-ray. Remember high contrast (low
kVp) has lots of blacks and whites. Low contrast
(high kVp) gives you lots of grays because high
penetration of beam.
• kVp controls your contrast
• That is subject contrast and radiograph contrast.
MAS (QUANTITY)
• The ma control determines how much current is
allowed to flow through the filament which is
the cathode side of the tube. More current,
more electrons. The effect of the mA is linear. If
you want to double the number of photons,
you double the mAs.
LETS LOOK AT UPRIGHT ADD-ON
UNITS
This affects the blackness of the image.
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ADD-ON UNITS: PROS
*Cost Effective
*Allows for multi-use of machine
*Doesn’t require separate room
*Breast size and body habitus not
a factor
* No weight limit
ADD-ON UNITS: CONS
*Ties up mammography machine
*Limited working space
*Patient is subjected to viewing
procedure
*Increased risk for vasovagal
reaction. 2-7% vasovagal
reaction
DIGITIZERS FOR UPRIGHT
STEREO’S
EARLY 90’S
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Add-on
Add-on
units
units
MAMMOMAT 3000 NOVA
WITH STEREOTACTICS
Recumbent
SIEMENS INSPIRATION FFDM
Upright
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Digital StereoLoc® II for Selenia
• Proven Upright Stereotactic Technology
Hologic's StereoLoc II was built on the
technology platform developed for
prone stereotactic applications. This
common platform allows the StereoLoc
II to provide the same image quality,
targeting accuracy, flexibility in
procedural options, image processing
functions, and operational efficiencies.
The StereoLoc II with DSM considerably
reduces procedure time and allows
maximum utilization of mammography
suites. With a quick and easy transition
from mammography to stereotactic
mode, the StereoLoc II provides an
effective solution to room size limitations
and gives practices a cost-effective
method to expand its range of service
offerings.
• Digital Stereotaxy -with Senographe DS Interventional• The stereotactic device and the lateral decubitus table,
transform in a few minutes your Senographe DS into a Full Field
Digital Stereotaxy system.
This Senographe DS Interventional literally revolutionizes the
stereotaxy approach thanks to:
• Similar image geometry for diagnosis and stereotaxy.
• Freedom in the choice of biopsy angle (lateral, vertical
approach).
• Superior insight into lesions.
• Complete comfort and ergonomics for patients and medical
staff.
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GE SENOGRAPHE ESSENTIAL
UPRIGHT STEREO
PLANMED NUANCE DIGIGUIDE
STEROTACTICS
PLANMED NUANCE DIGIGUIDE
STEROTACTICS
• Superior image quality using the integrated a-Se
detector of the Planmed FFDM unit
• The most light-weight biopsy unit on the market
• Motorized movements in all three coordinate directions
(x, y and z)
• Intuitive workflow assistant including features such as
automatic needle length selection and reference point
recognition
• Compatible with both vertical and lateral biopsy
approach and devices.
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FFDM
GIOTTO IMAGE 3D/3DL
GIOTTO
• Giotto Tomo is biopsy ready.
Using the same Detector is possible perform stereotactic
biopsy when approved in the United States
ADD ON UNITS
• If you want to reduce vasovagal reaction with patients
sitting up, another option is doing the patient in a decubitus
position.
• DBI table is an option for the patient lying down for the
upright stereotactic procedure.
• Most of these tables have 1000 pound limit.
TABLE SOLVES THE COMMON PROBLEMS
ENCOUNTERED WITH THE PRONE TABLE
AND UPRIGHT CORE BIOPSY TECHNIQUES
General Information
• Patient Positioning
• The patient comfortably lies on their right or left side.
• An adjustable head support or pillow may be used to increase
patient comfort.
• DBI alleviates the numbness some patients experience in
dependent arm.
• Back support built into the DBI table reduces patient motion.
• There are no vasovagal reactions.
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LORAD HOLOGIC DIMENSIONS
SELENIA- DBT
THE AFFIRM
• Hologic latest addition to its breast health portfolio,
the Affirm™ breast biopsy guidance system,
represents the next step in the evolution of upright
breast biopsy procedures. Designed to work
seamlessly with any Selenia® Dimensions® digital
mammography system, the Affirm system delivers
exceptional images, accurate targeting, and
streamlined workflow.
• This revolutionary system is designed to provide
biopsy solutions for today and the future. Innovations
including a novel, 10° angled biopsy approach
provides an unobstructed view of lesions, and opens
the pathway for tomorrow's advances in breast
biopsy.
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STEREOTACTIC BREAST BIOPSY IN
TOMO MODE
STEREOTACTIC UPRIGHT TOMO
PRONE TABLES
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PRONE UNITS: PROS
AUTO GUIDE
STAGE
 Greater working space for Radiologist
and technologist
Less vasovagal reactions
 Positioning ease- medial and inferior
lesions are more easily accessible
 Frees up mammography unit
PRONE UNITS: CONS
 Cost
 Requires dedicated room
 Limited use
 Weight limit
 Limitations due to breast size and
body habitus
LORAD PRONE TABLE
• DSM-Digital Spot Mammography
• Cartesian coordinates mm-mm adjustments
• Adjustable breast tray to compensate for variable breast
thicknesses and reduce lesion shift in stereo views
• Air gap between breast and image receptor to minimize
scatter
• 512 matrix for masses or for course calcifications (high
contrast resolution)
• 1024 matrix for powdered looking calcifications ( high
spatial resolution)
• ScoutMarc
OLDER VERSION
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NEW MULTI-CARE PLATINUM
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APERTURE IS 10 INCHES
SLIDER
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• Positioning on Lorad Prone Table is
different than positioning on Fischer, Siemens or on
Echoserve Table
Here is the positioning chart for Lorad
Prone Table
EXTRA PADDLES FOR LORAD TABLE
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MultiCare Comfort package
Hologic's MultiCare® Platinum prone breast biopsy table offers efficient and
precise breast biopsy technology. We understand that patient care and
comfort is also a major concern. You've asked us, "how can we make this
procedure better for our patients?"
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ergonomically engineered
Memory foam cushioned table
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FISCHER PRONE TABLE
• 1024 x 1024 matrix
• Lateral arm- for superficial lesions and
thinly compressed breasts to come from
below
• Target on Scout
• Large aperture in table
• 48 micron pixel size
• Fiber optic CCD camera (.1/.3 focal spots)
FISCHER IMAGING
Mammotest Stereotactic Biopsy System
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SIEMENS PRONE TABLE
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SIEMENS MAMMOTEST
• Changed color of table to blue
• Changed name/no more Plus S
• Changed detail imaging detector resolution with 10
lp/mm using Syngo Opdima software programming
• 360 degree access to breast
• Polar coordinate system is best for unobstructed view
for needle/calcs or mass position
• Aperture 11 inches (Largest)
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ECHOSERVE
• MamoTest Flx
• Show clip
YouTube- MammoTest FLX
System.mp4
• MammoTest Flx offers all the benefits of standard MammoTest®, plus:
• • Mobile platforms for the table and generator allow the unit to be
easily moved within a room
or across locations
• • Cable connections moved for more accessibility and quick
disconnect added for convenience
• • Table-control handles under the tabletop, decreasing table width
and eliminating interference for the patient
• Largest breast aperture in the industry at 11
inches/28 cm, ideal for arm-through procedures,
• Rotating gantry and lateral arm to provide 360°
patient and lesion access, especially suited
for thin, compressed breasts and superficial lesions
• Flat detector, CCD camera (1024 x 1024 matrix),
and CsI scintillator to allow for visualization of even
the smallest calcs
PROCEDURE WITH
LORAD PRONE TABLE
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PROCEDURE WITH A
FISCHER PRONE TABLE
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OPTIONS FOR WHEN
YOUR PRONE TABLE
WON’T LIFT UP
ASK ME WHY?
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LATERAL ARM POSITION
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SCOUT
WHAT THE IMAGES LOOK LIKE
COMING FROM BELOW WITH
FISCHER, SIEMENS, AND ECHOSERVE.
Stereo Pair
POST FIRE (WITH OFFSET)
Pre fire (lateral arm)
SCOUT
Post Clip
DCIS Grade 2-3
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POSITIONING TIPS
Periareolar biopsy
PERIAREOLAR BIOPSY
• If the breast is thin and you need to build up
thickness. You can turn a paddle around and
tape to image receptor for added thickness.
Remember to take paddle into consideration
when calculating depth
• If lesion near chest wall you can bring patient’s
arm thru hole in table to drop breast down
farther. Remember to give patient something
to rest hand on.
BREAST TOO THIN, NO PROBLEM
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LETS TALK ABOUT BI-RADS
• What does it stand for?
• BI-RADS is an acronym for
Breast Imaging-Reporting and Data System, a
quality assurance tool originally designed for
use with mammography. The system is a
collaborative effort of many health groups but
is published and trademarked by the
American College of Radiology (ACR).
• The assessment categories were developed for mammography and
later adapted for the MRI and Ultrasound Atlases. The summary of
each category, given below, is identical for all 3 modalities.
• Category 6 was added in the 4th edition of the Mammography Atlas.
•
•
•
•
•
•
•
•
BI-RADS Assessment Categories are:
0: Incomplete
1: Negative
2: Benign finding(s)
3: Probably benign
4: Suspicious abnormality
5: Highly suggestive of malignancy
6: Known biopsy – proven malignancy
BI-RADS 4
• A BI-RADS classification of 4 or 5 warrants biopsy to
further evaluate the offending lesion. Some experts
believe that the single BI-RADS 4 classification does
not adequately communicate the risk of cancer to
doctors and recommend a subclassification
scheme:
• 4A: low suspicion for malignancy
• 4B: intermediate suspicion of malignancy
• 4C: moderate concern, but not classic for
malignancy
• The Breast Imaging Reporting and Data System
(BI-RADS) initiative, instituted by the ACR, was
begun in the late 1980s to address a lack of
standardization and uniformity in mammography
practice reporting. An important component of
the BI-RADS initiative is the lexicon, a dictionary of
descriptors of specific imaging features.
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• The BI-RADS lexicon has always been data driven,
using descriptors that previously had been shown in
the literature to be predictive of benign and
malignant disease. Once established, the BI-RADS
lexicon provided new opportunities for quality
assurance, communication, research, and improved
patient care. The history of this lexicon illustrates a
series of challenges and instructive successes that
provide a valuable guide for other groups that
aspire to develop similar lexicons in the future.
BREAST PATHOLOGY
TDLU
(TERMINAL DUCTAL LOBULAR UNIT)
• Primary anatomical and functional unit of the
breast
• Terminal acini (Ductules)
• Extralobular terminal duct
• All major lesions of the breast are believed to
arise from the mammary epithelium of the TDLU
• Fibroadenomas, Cysts, Apocrine cysts, radial
scars, invasive ductal and lobular carcinoma
• Exceptions are intraductal papilloma and
papillary carcinoma
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Results were TDLU
NON-INVASIVE COMEDO DCIS
TYPICALLY A HIGH-GRADE CANCER
FOUR MAIN TYPES OF DCIS
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NON- INVASIVE CRIBIFORM DCIS
MID/LOW GRADE CANCER
NON-INVASIVE SOLID DCIS
MID/LOW-GRADE CANCER
NON-INVASIVE PAPILLARY DCIS
MID/LOW-GRADE CANCER
PATIENT’S PATHOLOGY
• RIGHT BREAST 8-9 O’CLOCK
CALCIFICATIONS, STEREOTACTIC-GUIDED
CORE BIOPSY:
• DUCTAL CARCINOMA IN SITU (DCIS)
INTERMEDIATE GRADE, SOLID,
CRIBRIFORM AND PAPILLARY
• PATTERNS WITH NECROSIS AND
ASSOCIATED MICROCALCIFICATIONS.
• COLUMNAR CELL CHANGES.
POSSIBLE CASE’S THAT MIGHT
NEED A STEREO BIOPSY
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PATIENT’S THAT DON’T NEED
STEREO, THEY NEED ???
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STEREO BX OF BREAST
WITH IMPLANTS
INTERESTING STEREO CASE
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What do you see?
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NEEDLE LOCALIZATIONS
USING STEREOTACTIC GUIDANCE
NEEDLE LOCALIZATION
• Performing needle localization on a dedicated prone
stereotactic biopsy table, rather than on a conventional
mammography unit, has four advantages. First, the prone
table makes fainting virtually impossible, and the entire
procedure is conducted out of sight of the patient. Second,
the digital acquisition and display of images speed the
procedure considerably. These two advantages are shared
by all procedures performed on a stereotactic table,
whether with the technique described by Sanders et al.
• Most of the other major advantages
claimed by the authors relate not to their
technique in particular but rather to all
needle procedures performed on
dedicated prone stereotactic tables. The
authors would do well to scale back the
overreaching claims for their technique.
Better yet, they should take full advantage
of the high-tech capabilities of their
stereotactic table when performing needle
localizations.
• Third, the combination of the stereotactic calculations
and the computer-controlled stage permits precise
needle placement. Once the appropriate coordinates
have been locked in, the front and back needle guides
provide a foolproof guidance system for placing the
needle, permitting skewering of even tiny targets. Fourth,
stereotactic imaging provides nearly instant feedback,
permitting verification of placement of the needle tip in
three dimensions relative to the target before compression
is released. By skipping the stereotactic portion of the
needle localization procedure, Sanders et al. forego these
last two advantages, in essence dumbing down a reliable
and accurate procedure.
NEEDLE’S FOR STEREOTACTIC NEEDLE
LOCALIZATIONS AND OTHER OPTIONS
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DESIGNED FOR EASE OF USE, SPEED, AND SAFETY IN
ULTRASOUND-GUIDED LOCALIZATION PROCEDURES
The Bard® UltraWire® One-Handed Breast
Localization Device facilitates the precise marking of
breast lesions under ultrasound guidance.
•Preloaded wire design allows you to deploy the wire
with one hand while your other hand holds the
transducer, enabling continuous imaging and
accurate wire placement
•Eliminates need to set down transducer during
deployment
•Needle retracts into handle to minimize risk of
needle sticks
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TYPES OF BREAST BIOPSY’S
FNA
(FINE NEEDLE ASPIRATION)
Advantages
• Quick procedure
• Painless
• Inexpensive
• No incision required
• Minimal chance for infection or
bruising
FNA
Disadvantages
• Less accurate than core needle or
surgical biopsy
• Not recommended for abnormal areas
only seen on mammogram and that
cannot be felt
• Cannot tell in-situ cancers from invasive
cancers
• Requires that an experienced
cytopathologist analyze the cells
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FNA
U/S ROOM
• 21-23 gauge needle
• Guidance
-Freehand
-Ultrasound
-Stereotactic
• Cytology vs. Histology
• Unable to differentiate invasive or in-situ
• Unable to mark biopsy site
FNA SET-UP
FNA SPECIMEN
FNA BIOPSY
CORE NEEDLE BIOPSY
Advantages
• Quick procedure
• Painless
• Inexpensive
• Very small incision, if any
• Minimal chance for infection or bruising
• Can be used for lumps and for abnormal
areas seen on mammograms
• Can often tell in-situ from invasive cancers
• If findings are benign, avoids more
extensive surgical biopsy
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CORE BIOPSY
CORE NEEDLE BIOPSY
Disadvantages
• Slightly less accurate than
surgical biopsy
• May not provide a complete
description of the tumor
US BARD BIOPSY DEVICE
14-16 gauge needle
Guidance
-Freehand
-Ultrasound
-Stereotactic
4-6 needle insertions to
collect sufficient
amount of breast
tissue for accurate
diagnosis
Unable to mark site
US BIOPSY: BARD
• 14 G, 16 G, 18 G
8 mm invasive
ductal
carcinoma
EXCISION BIOPSY
(SURGICAL PROCEDURE TO REMOVE
ENTIRE TUMOR FROM THE BREAST)
Advantages
• Most accurate biopsy method
• Can provide complete information about
the tumor
• May be the only surgery needed to
remove the tumor
EXCISION BIOPSY
Disadvantages
• Expensive
• More invasive and painful than core
biopsy
• Requires time to heal from surgery
• Greater chance for infection and bruising
than with needle biopsy
• Can change the look and feel of the
breast
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INCISION BIOSPY
(SURGICAL PROCEDURE TO REMOVE A
SECTION OF THE TUMOR)
Advantages
• Another accurate biopsy method
• Can provide a lot of information
about the tumor
INCISION BIOPSY
Disadvantages
More invasive and painful than needle biopsy
Expensive
Requires time to heal from surgery
Greater chance for infection and bruising than
with needle biopsy
• Can change the look and feel of the breast
• Additional surgery will be needed for treatment
•
•
•
•
BIOPSY DEVICES
• FNA• CoreTru-cut, Manan, Maxcore,
Biopince (spring loaded) 14,16, 18
gauge
• VACNB- Mammotome, Suros, SenoRx,
Bard, range from 7-14 gauge
• RF-Intact, Encapsule
• Large core biopsy- ABBI, Site Select
VACNB
Mammotome: 8, 11, 14 gauge
MRI compatible
Suros: 9, 12 gauge with 12g petite
MRI compatible
SenoRx Encor: 7, 10, 14 gauge
MRI compatible
Bard Vacora: 10, 14 guage
MRI compatible
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MAMMOTOME
8G Probe Tip
Bladed tip facilitates insertion through dense tissue: 1
gram of tissue in 4 cores; tissue architecture is
preserved; take a sample/see a sample.
11G Probe Tip
Facilitates stroke margin management
Variable Aperture Sleeve
Enables the biopsy of thin breasts and superficial
lesions.
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Mutiple Probe Tips
Ensure maximum entry and oprimal access to chest
wall lesions. The 8-gauge yields 1g of tisseus with 4
cores (porcine tissue samples using 8- and 11-gauge
probe tips.
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BREAKING NEWS FOR MAMMOTOME
MARCH 2013
MAMMOTOME® REVOLVE™
Mammotome® revolve™, a new dual-vacuum assisted biopsy platform, is the
only device to offer advanced tissue management technology. Designed to
empower clinical decision-making, increase procedural efficiency, and provide
optimized sample reliability; Mammotome® revolve™ puts information, ease,
and clinical reassurance at your fingertips.
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• Specimen Management System
• Provides touch-free tissue collection in numbered, pathology-ready
chambers to preserve tissue integrity. Cartridge trays can be flattened and
imaged with tissue to identify and easily locate calcifications. Organized
presentation and visualization of the tissue specimens allows real time
sampling adjustment.
MAMMOSTAR TISSUE MARKER IS AN
ORGANIC ALTERNATIVE
Original Mammotome® MI for Molecular Imaging (MI)
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SUROS (ATEC)(HOLOGIC)
SHOW CLIP FROM WINDOWS MEDIA OF
MAMMOTOME
ATEC(AUTOMATED TISSUE EXCISION AND COLLECTION)
ATEC (Automatic Tissue Excision and Collection) Breast Biopsy System
The first ever all-in-one
console gives radiologists
and surgeons the ability to
perform breast biopsy in any
of the three primary imaging
modalities using a single
biopsy system. Find your
complete solution with one
system: a faster, safer, easier
biopsy designed with
patient care and advanced
technology in mind.
The ATEC Emerald was designed specifically for
clinicians performing MRI-guided breast biopsy and
for facilities with dedicated breast MRI programs.
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NEWEST SUROS NEEDLE 11/2008
eviva (LIFE)
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DIFFERENCE IS STROKE IS 23 AND CAN BX THIN BREAST TO
1.5CM BREAST THICKNESS WITH PETITE NEEDLE
suros complete.wmv
SENORX NEEDLE SYSTEMS
IS NOW BARD ENSPIRE
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Show SenoRx(Bard) Video
http://www.bardbiopsy.com/products/enspire_video
.php
VACORA
OTHER VACNB DEVICES
• Vacora (Bard) can be used under
stereo, MRI and ultrasound 10ga, 14g
adjustable, self contained, all inclusive
( vacuum, power source and tubing)
adjustable chamber length for
superficial lesions and small breasted
women, weighs 1 lb,
VACORA™ Breast Biopsy System
• self-contained,
vacuum-assisted
biopsy system
• tubing, fluid
canister, battery
power source, and
needle
• one pound
• MRI, ultrasound,
and stereotactic
biopsies
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SHOW VACORA U.S.
CD
ULTRASOUND CORE BX CASSI
u.s. bx bard.wmv
Cassi (Sanarus) used under US,
rotational core biopsy device,
disposable, self contained,
“Stick Freeze Technology”
warm tissue adheres to frozen
needle
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cassi visica.avi
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LARGE CORE(BORE) BIOPSY
• ABBI(advanced
breast biopsy
instrumentation)
• 5-10-15-20mm
cylinders of tissue just
below skin level
capturing fat normal
breast tissue and the
abnormality and 1.01.5cm of the tissue
beyond
• Requires suturing
and electro cautery
• Site Select
• 10-15-22 mm cylinder
after it goes thru normal
fat and breast tissue,
thus less normal tissue
removed, minimizing
the cosmetic deformity
• Requires suturing, may
require electro cautery
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MAMMOGRAM POST ABBI
USSC(UNITED STATES SURGICAL COMPANY)
ABBI WENT OUT
OF BUSINESS,
WHY???
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Site Select (Imagyn)
Site Select.mpg
RF BIOPSY DEVICES
• Encapsule
<Rubicor>
• 14 gauge device
extracting 2.5
cm diameter of
tissue
• Enbloc
(Intact)
<Neothermia>
• 10-12-15-20
mm probes
RUBICOR MEDICAL
14 G NEEDLE, 2.5 CM SPECIMEN
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Houston Cow
• One Pass Procedure
The Intact™ Breast Lesion Excision System (BLES) captures
breast tissue for histological review, using RF energy. The
Intact™ BLES is uniquely able to deliver a sample with
intact architecture and clear margins around the area of
interest, in a swift in-office procedure.
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ENBLOC (INTACT)
SHOW MOVIE CLIP
intact rf.wmv
ROLES AND RESPONSIBILITIES…
FIRST IS THE TECHNOLOGIST
• Responsible for daily QC
• Make sure patient has been worked
up (i.e.: orthogonal viewssupplemental –us if indicated
• Verify procedure with report
recommendations
Review films with radiologist prior to procedure,
allows tech to have room set prior to patient
coming in room ( ie-approach of biopsy, if more
than one area)
Greet patient- introduce yourself
Explain procedure and answer questions
Review consent, if you do not have a nurse
who does this
Discuss allergies and medications
Complete worksheets
Perform “time out” just before biopsy begins,
verify name, mrn, side, and films
Position patient for exam
THE PATIENT’S ROLE
THE RADIOLOGIST, SURGEON,
PHYSICIAN ROLE
• Physician should review films prior day to
ensure proper work up and procedure are
being done
• Physician should review films and
procedure with technologist
• Physician should review films and
procedure with patient
• Review consent and have patient sign
• Patient prep is crucial to a successful biopsy
• Patient should wear a two piece comfortable
outfit
• Make sure patient is aware they have to lie on
their stomach, if they have back or neck
problems
• Patient needs to be off anti-coagulant
medications 3-5 days prior to biopsy (Patient
should discuss this with primary care doctor
before stopping)
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•Patient should know they may have to
remain still for up to one hour
•Important for patient to relax
•We use a patient check list to be filled
out by the clinic scheduling exam
STERILE TRAY
• 2-10 cc syringes
• 1-3 cc syringe
• Needles varies sizes
(18ga, 22ga, 25ga)
• Scalpel
• Sterile 4 x 4’s
• Hemostats
• Mosquitoes
• Forceps
• Sterile q-tips
• Sterile pen
Container for specimens
Steri-strips
Alcohol swabs
Betadine swabs
Sodium Bicarbonate
1% lidocaine with
epinephrine
• 1% lidocaine with out
epinephrine
• Sterile drape
• Sterile gloves
•
•
•
•
•
•
EACH SYSTEM COMES WITH A
PRE-PACKED STERILE TRAY
YOU CAN ORDER
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THE PROCEDURE
• Perform “time out”, verify name, MRN or DOB, side to be biopsied,
and films
• Position patient using closest approach to lesion (IE: CC, LM, ML, FB if
possible)
• Take stereo scout – reposition if necessary
• Mark corners of biopsy window
• Take stereo pair
• Target area to be biopsied
• Verify coordinates to make sure you are able to reach lesion (watch
stroke margin)
• Transmit coordinates to auto guide
Prep patients skin
Move probe into target position
Inject local anesthesia
Make cut with scalpel
Insert probe into target position
Take pre-fire stereo pair-verify probe position
“Fire” probe into final position for biopsy
Take post-fire stereo pair-verify probe position
Proceed with biopsy
Take specimen image to verify removal of lesion
If area of interest has been removed ready for
tissue marker placement
Depending on type of tissue marker used you
may need to pull back probe 5-10mm
Deploy tissue marker into biopsy cavity
Take post procedure image to verify tissue
marker placement
Remove probe and hold compression on biopsy
site
Steri strip opening
Take post procedure mammogram starting with
the view biopsy was preformed (IE: CC-ML, etc.)_
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END OF PART I
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