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Breast Procedures:

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Ultrasound Guided Breast Biopsy

 

  • typical indication is to obtain histologic diagnosis of a solid or complex breast lesion diagnosed on ultrasound.

  • Oftentimes the lesion is a likely fibroadenoma

  • Sometimes for diagnosis of a likely cancer, if seen as a hypoechoic spiculated taller than wide breast lesion


1.  Localize lesion with ultrasound probe.  Use radial and anti radial orientations.  Localize the lesion and orient the probe so that you can access with needle oriented in long axis of probe.  Make sure to place patient's arm up over head.  Mark spot where probe should go with marker such that you can replace the probe in same position after sterilizing skin
2.  sterilize skin with chlorhexidine or iodine swabs
3.  Numb skin with buffered lidocaine.  Make skin wheel at needle insertion site.  
4.  Do deep tissue numbing using ultrasound probe and infiltrate as you pull needle back.  Make sure to visualize the needle tip at all times.
5.  Make skin nick with scalpel, use ultrasound to watch tip of scalpel.
6.  Start with 14 g hollow needle-stylet system.  Under ultrasound guidance, place needle at the near/proximal margin of the lesion.  This can be tricky and skill is needed to "see" the needle under ultrasound.
7.  Once the lesion is access, remove inner stylet, leaving the hollow needle for access. 
8.  Use 14 gauge biopsy needle through access needle eo access the lesion.
9.  Ensure the biopsy needle is oriented paralllel to the chest wall to avoid hitting the chest wall and causing injury or worse pneumothorax.  The throw of the biopsy needle is approx. 2 cm.
10.  Obtain 4-7 cores, goal being to adeuately sample lesion to obtain durable specimen for diagnosis.
11.  Remove biopsy needle, place marker into the biopsy site.  Visualize the marker dropping into the lesion site using ultrasound
12.  Clean gel and blood, place DSD with steristrip on breast.
13.  Consider post biopsy mammo to ensure placement of clip
14.  With specimen:  cut  approx 1 x 1 inch square of telfa, place multipole specimen on the telfa, cover with tissue, then place into plastic jacket and then into the formalin, ensure labeling is correct
15.  Procedure complete
16.  Follow up biopsy result and call patient to discuss.
31.  Procedure complete.

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Mammo-Guided Needle / Wire localization (aka Wire Loc)

 

  1. First look at pre localization films to get a sense of which quadrant the lesion is

  2. usually the pt. has a biopsy clip in place and the target for the localization is the biopsy clip.  Other times, the target will be suspicious calcifications for surgical excision

  3. Decide whether coming from medial or lateral part of the breast

  4. typically pt. will be imaged in the M-L tomographic view

  5. localize the clip on the ML image, locate image using the ABC 123 system.  

  6. Give localization to technologist

 

 

  1. Start procedure

  2. clean skin with alcohol swab

  3. numb skin with lidocaine needle.  numb in the following fashion, make skin wheal, then advance needle in, inject lido on the way out, keep doing till all the way through the breast to the other side.  Make sure entire thickness of the breast from medial to lateral is numb.

  4. Then grab the needle, usually 5 cm Homer or Kopans needle

  5. insert needle straight down the crosshairs of the target.  Ensure the hub shadow directly overlies the cross between the cross hairs.  This ensures the needle is going exactly flush and perpendicular to the skin surface, going straight to the target.  Go all the way to hub of the needle

  6. Then release pt's breast and go to CC mammo view

  7. Now can adjust the other plane of localization. 

  8. If lesion is more proximal, pull needle back slightly.  Avoid pulling too far back because cannot advance in a straight line any longer and will have to restart procedure

  9. If using Kopans needle, make sure to engage needle.  Check the lines on the needle to see where the wire exits the needle

  10. Print localization films and mark them so surgeon is aware of distance from needle to target, if not obvious.

  11. Procedure complete

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