Tomo biopsy with MAMMOMAT B.brilliant - Interview with Dr. med. Romana Goette

My name is. Romana Gote My name is Romana Gote and I'm a radiologist at The Hills London Clinic, St. Anna in Lucerne. I'm a senior physician in our department and one of my main jobs is breast imaging. Today we are performing a biopsy on a patient in her late 50s who had an operation on her left breast in 2016. We can see the metal clips in the area of the. Operation since. 2016 We've noticed progressive calcification throughout the left breast. Quasi Gazampton. Lincoln Grost. We weren't particularly worried by this. At first. The calcifications appeared to be just scattered points and we took them to be benign. Subsequently we started to see very substantial development all on the left side, with some branching calcifications. This caused some uncertainty and so we performed an additional MRI scan which was negative. We decided nevertheless to obtain samples from the most conspicuous areas. We planned a tomosynthesis guided biopsy to make sure we did not have any suspect introductal calcification. When planning a biopsy, I usually start by looking for the shortest path from the skin to the calcification, so as to minimise trauma to the breast. I will make an exception though if the shortest path takes me above the level of a low cut neckline. In that case, I may instead choose a longer path, for example with a lateral approach. The Limited Fiona the. Position of calcifications can limit our biopsy options. We know that we have to consider alternative access paths, especially in the case of smaller breasts and deeper calcifications, because the calcification can only be captured at the edge of the sample window. Changing the access path very simple with the new system, because the alternative lateral approach works very well. Even changing during the biopsy itself is straightforward with the mammal might be brilliant. By the. We originally wanted to use a lateral approach for today's biopsy. Unfortunately, it emerged during planning that there was a heavily calcified blood vessel right in the middle of our biopsy area. We consequently decided to use a cranial approach after all, to prevent more substantial bleeding. The mammography system gives us different access options. We can insert the needle from above the cranial approach, or from either side, lateral or medial. And while that doesn't mean we can approach from anywhere, we do have multiple potential paths to reach the target. We. Aim to have the patient thoroughly involved in the whole procedure to help the biopsy go smoothly. The counseling interview is key for this. We explain what we intend to do and which approach we intend to use so that the process with the patient feels more. Collaborative Every. Woman is going to be anxious at first. When she learns she is to have a vacuum assisted biopsy, she will understand that a large needle will have to be inserted into her breast. She'll be concerned about the diagnosis too, of course, but to start with the big fears of pain during the biopsy procedure. I explain what I am doing step by step and I promise every patient that she will not feel any pain in my care. I also discuss my ideas with my radiographer to find out what she thinks of my plan for the biopsy and whether she agrees with the voice of approach. We use a special biopsy chair at our clinic. It enables us to perform biopsies with the patient seated or lying sideways. We find arranging the patient very easy with a biopsy. Chair, we. Are able to bring patients right up to the system and also immobilize them somewhat so that the breast does not slip out from under the compression plate during the biopsy. Gives us more options than a big biopsy table for positioning the patient at the system and surprisingly gives more biopsy volume. Position for the biopsy, We are able to rest the patient's face against the face shield. The face shield allows us to turn the patient's face away from the site of the biopsy, minimising the patient's fear of seeing the needle in the breast. The. There are two ways to release the needle into the breast. One is to line the needle up with the target lesion and fire it into the breast with an automatic release. The other is to prepare the needle prior to the biopsy and simply insert it smoothly into the breast. Breast biopsies can be performed with needles of two different sizes. The smaller is a 10 gauge needle and the larger at our clinic is A7 gauge. The advantage? Of the larger needle is that we can obtain more tissue in fewer steps. By Kleiner. Small needles give us less material in the biopsy specimen. Today we've decided to use the 10 gauge needle because we have so much calcification in the breast and I am quite confident I can obtain enough of the calcification without having to leave a larger wound in the breast. We have a new feature for biopsies with the new system, the navigator. The Navigator shows us how deep the needle is in the tissue, which makes it easier for us to tell whether or not the lesion is in the center of the needle opening. All the needles we use for vacuum assisted biopsy offer the option to acquire the specimen with a full notch or a half notch needle size. We can reduce the size of the window by which the sample is removed by half. This does of course mean that we obtain less tissue. I choose the half notch method when dealing with lesions close to the surface so that there is no risk of injuring the skin. When we plan a biopsy, we have to specify a target. In a stereotactic biopsy procedure, we work with a summation image. Often I think I have found the calcification or calcification cluster I'm looking for, only to suddenly discover in the second projection that it is somewhere else. More understand does Mammat. The Mammat Be Brilliant allows us to specify the target guided by the tomosynthesis images, which makes it easier to line the calcification cluster up right in the middle of the biopsy window. If. We cannot find the target lesion on the scout image. We start searching for it. We go back to our PAX workstation, think about where we might have gone wrong with our settings, and reposition the breast for biopsies. I like to have the target lesion right in the middle of the sample window. I can accept small variations, but really I prefer to start again and stay with the middle because we have differences in compression within the sample window and the depth at the edge does not always match the depth at the center. By garbage the local anesthesia. My main objective when administering local anesthesia is pain relief. I take it in two steps. First, I anaesthetize the skin with a really thin needle. Then I go under the skin via this accumulation of local anaesthetic and work along the chosen access pathway to inject the anaesthetic into the deeper part of the breast. The target lesion very often moves when the local anaesthetic is administered, so our standard procedure is to acquire another after every round of anesthesia and check whether the lesion is. Vacuum assisted biopsy uses a thicker needle. There are two ways to insert the. Needle 1. Is to make a small incision in the skin with a scalpel so the needle can penetrate easily, and the other is simply to insert the needle directly into the breast. The new. Needles have a cutting edge integrated into the tip and are extremely sharp. I prefer to insert the needle without a scalpel incision. The tip of the needle does tear the skin slightly like this. It looks a little like a Mercedes star, but in my experience this method allows the skin to recover and heal better afterwards. Some of my colleagues, though, prefer to make an incision with a scalpel first. The vacuum. There are different ways to perform a vacuum assisted biopsy. Some like to see the needle in the pre fire and post fire position to be sure of reaching the targeted calcification. And it means the patient has to spend more time in the uncomfortable compressed position. Additional radiation exposure. We consequently experimented with skipping this step and encountered no disadvantages. As a result, we reached the targeted micro calcification cluster every time. So we've carried on doing it this way. The the biggest?

14:05:28 00 10 Tomo biopsy with MAMMOMAT B.brilliant Interview with Dr. med. Romana Goette Hirslanden Klinik St. Anna, Lucerne , Switzerland Dr. med. Romana Goette MD, Senior Physician Hirslanden Klinik St. Anna Lucerne, Switzerland My name is Romana Goette and I am a radiologist at the Hirslanden Klinik St. Anna in Lucerne. I am a senior physician in our department and one of my main jobs is breast imaging. HIRSLANDEN KLINIK ST. ANNA Trakt G Mammographie Today we are performing a biopsy on a patient in her late fifties who had an operation on her left breast in 2016. We can see the metal clips in the area of the operation. Since 2016 we have noticed progressive calcification throughout the left breast. We weren't particularly worried by this at first. The calcifications appeared to be just scattered points and we took them to be benign. Subsequently we started to see very substantial development, all on the left side, with some branching calcifications. This caused some uncertainty and so we performed an additional MRI scan, SIEMENS MAGNETOM Lumina, MRI, Brea ... This image is not for diagnostic use MAGNETOM Lumina, MRI, Breast PID6234, WH Current 3 IMA 95 Rows/Columns: 448/574 which was negative. We decided nevertheless to obtain samples from the most conspicuous areas. We planned a tomosynthesis-guided biopsy to make sure we did not have any suspect intraductal calcification. Planning Phase Access to lesion When planning a biopsy, I usually start by looking for the shortest path from the skin to the calcification so as to minimize trauma to the breast. I will make an exception though if the shortest path takes me above the level of a low-cut neckline. In that case I may instead choose a longer path, for example with a lateral approach. The position of calcifications can limit our biopsy options. We know that we have to consider alternative access paths, especially in the case of smaller breasts and deeper calcifications, because the calcification can only be captured at the edge of the sample window. Change of access I find changing the access path very simple with the new system because the alternative lateral approach works very well. Even changing during the biopsy itself is straightforward with the MAMMOMAT B.brilliant. Anatomical and clinical challenges We originally wanted to use a lateral approach for today's biopsy. Unfortunately it emerged during planning that there was a heavily calcified blood vessel right in the middle of our biopsy area. We consequently decided to use a cranial approach after all to prevent more substantial bleeding. The mammography system gives us different access options: We can insert the needle from above - the cranial approach or from either side - lateral or medial. And while that doesn't mean we can approach from anywhere, we do have multiple potential paths to reach the target. Informational conversation We aim to have the patient thoroughly involved in the whole procedure to help the biopsy go smoothly. The counseling interview is key for this. We explain what we intend to do and which approach we intend to use so that the process with the patient feels more collaborative. Every woman is going to be anxious at first when she learns she is to have a vacuum-assisted biopsy. She will understand that a large needle ANDEN will have to be inserted into her breast. She will be concerned about the diagnosis too, of course, but to start with the big fear is of pain during the biopsy procedure. I explain what I am doing step-by-step. And I promise every patient Dr. med. Romana Goette that she will not feel any pain in my care. Romana Go I also discuss my ideas with my radiographer to find out what she thinks of my plan for the biopsy and whether she agrees with the choice of approach. Patient Positioning We use a special biopsy chair at our clinic. It enables us to perform biopsies with the patient seated or lying sideways. We find arranging the patient very easy with the biopsy chair. We are able to bring patients right up to the system and also immobilize them somewhat so that the breast does not slip out from under the compression plate during the biopsy. The biopsy chair gives us more options than a big biopsy table for positioning the patient at the system and, surprisingly, gives more biopsy volume. Faceshield When using the seated position for the biopsy, we are able to rest the patient's face against the face shield. The face shield allows us to turn the patient's face away from the site of the biopsy, minimizing the patient's fear of seeing the needle in the breast. Lesion Localization There are two ways to release the needle in the breast. One is to line the needle up with the target lesion and fire it into the breast with an automatic release. The other is to prepare the needle prior to the biopsy and simply insert it smoothly into the breast. leedle size Breast biopsies can be performed with needles of two different sizes. The smaller is a 10-Gauge needle and the larger, at our clinic, is a 7-gauge. The advantage of the larger needle is that we can obtain more tissue in fewer steps. Small needles give us less material in the biopsy specimen. Stereotactic 10G Cutter is Sampling. Please wait. VAC Today we have decided to use the 10-gauge needle because we have so much calcification in the breast and I am quite confident I can obtain enough of the calcification without having to leave a larger wound in the breast. Navigator We have a new feature for biopsies with the new system: The Navigator. Slice Heigh Entra Biopsie links 53 mm Bestatige The Navigator shows us how deep the needle is in the tissue, Slice which makes it easier for us to tell whether or not the lesion is in the center of the needle opening. Full notch vs. half notch needle size All the needles we use for vacuum-assisted biopsy offer the option to acquire the specimen kV: 27 mAs: 137.0 mAs Angle: -0.4 Focus: large Comp. Force: 50 N Slice Height: 22 mm of 5 Entrance Dose: 9.2 mGy Operators: So, In Verfahren: Nadel with a full-notch or half-notch needle size. 10G_vert_FN_Encor We can reduce the size of the window Nade 16.4 22.0 by which the sample is removed by half. This does of course mean that we obtain less tissue. I choose the half-notch method when dealing with lesions close to the surface so that there is no risk of injuring the skin. Targeting When we plan a biopsy, we have to specify a target. In a stereotactic biopsy procedure, we work with a summation image. Often I think I have found the calcification or calcification cluster I am looking for only to suddenly discover in the second projection that it is somewhere else. The MAMMOMAT B.brilliant allows us to specify the target guided by the tomosynthesis images, which makes it easier to line the calcification cluster up right in the middle of the biopsy window. If we cannot find the target lesion on the scout image, we start searching for it. We go back to our PACS workstation, think about where we might have gone wrong with our settings and reposition the breast. For biopsies, I like to have the target lesion right in the middle of the sample window. I can accept small variations, but really I prefer to start again and stay with the middle because we have differences in compression within the sample window and the depth at the edge does not always match the depth at the center. Biopsy procedure Local anesthesia My main objective when administering local anesthesia is pain relief. I take it in two steps. First, I anesthetize the skin with a really thin needle, then I go under the skin, via this accumulation of local anesthetic, and work along the chosen access pathway to inject the anesthetic into the deeper part of the breast. The target lesion very often moves when the local anesthetic is administered, so our standard procedure is to acquire another image after every round of anesthesia and check whether the lesion is still in the center. Insert needle Vacuum-assisted biopsy uses a thicker needle. AT B.brill AT B.brilliant There are two ways to insert the needle: One is to make a small incision in the skin with a scalpel so that the needle can penetrate easily, and the other is simply to insert the needle directly into the breast. The new needles have a cutting edge integrated into the tip and are extremely sharp. I prefer to insert the needle without a scalpel incision. The tip of the needle does tear the skin slightly like this - it looks a little like a Mercedes star - but in my experience, this method allows the skin to recover and heal better afterwards. Some of my colleagues though prefer to make an incision with a scalpel first. Pre- and post-fire images There are different ways to perform a vacuum-assisted biopsy. Some like to see the needle in the pre-fire and post-fire position to be sure of reaching the targeted calcifications. This makes the procedure longer though and it means the patient has to spend more time in the uncomfortable compressed position. It also means additional radiation exposure. We consequently experimented with skipping this step and encountered no disadvantages as a result. We reached the targeted microcalcification cluster every time, so we have carried on doing it this way. specimen X-ray InSpect: The biggest improvement