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Invasive Breast Procedures Flashcards

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1
Q

When the mass is palpable what 3 procedures can be done on it?

A
  1. Cyst aspiration or FNA
  2. Core biopsy
  3. Open surgical biopsy
    - excisional or incisional
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2
Q

When the mass is non-palpable what 3 procedures can be done on it?

A
  1. Needle directed biopsy
  2. Stereotactic core biopsy
  3. US directed core biopsy
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3
Q

When are cyst aspirations done?

A

On atypical or complex cysts as well as symptomatic cysts in order to bring relief

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4
Q

Cyst aspiration

A

Using a needle to removed the fluid from a cyst
- typically sent to the lab for testing

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5
Q

What type of approach is commonly used for superficial cysts and large palpable cysts?

A

Vertical or upright approach

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6
Q

What is a horizontal approach used for for cyst aspiration?

A

Used for smaller and deeper cysts

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7
Q

What is an advantage for the horizontal approach for cyst aspiration?

A

Provides superior real time US needle visualization

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8
Q

Can types of fluids can come out of a cyst aspiration? (5)

A
  1. Serious fluid
  2. Yellow fluid
  3. Green fluid
  4. Bloody fluid
  5. Milky fluid
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9
Q

What do yellow and green fluid typically mean?

A

Associated with fibrocystic change

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10
Q

Pneumocystography

A

Injection of air into the evacuated cyst to provide therapeutic benefit of reduced cyst recurrence

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11
Q

What 2 types of mammo are taken after a pneumocystography?

A
  1. Magnified CC
  2. 90 deg lateral projection
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12
Q

What do pneumocystography confirm?

A

Smooth walled, septated cyst without evidence of intracystic mass or wall thickening

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13
Q

When are pneumocystography usually performed?

A

On atypical, complex cysts when further information regarding the cyst walls or intramural lesions is required
- useful for evaluation of the cyst wall

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14
Q

FNA

A

Fine Needle Aspiration

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15
Q

Fine Needle Aspiration

A

Very thin, fine needle is inserted into a suspected tumour and extracts cellular material

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16
Q

What size needles are typically used for an FNA?

A

18-25g

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17
Q

How do benign clusters show up for FNA’s?

A

Evenly monolayer with oval nuclei

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18
Q

How do malignant clusters show up for FNA’s?

A

Have large, irregular, hyper chromatic nuclei with molding, focally showing a vertebrae like pattern

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19
Q

What are 4 breast localization methods?

A
  1. Skin localization
  2. Dye method
  3. Needle or needle/wire combination
    - mammo technique
  4. Needle or needle/wire combination
    - US technique
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20
Q

What are breast localization methods used for?

A

Procedure designed to pinpoint the exact location of an abnormality
- usually performed to identify non palpable lesions

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21
Q

Skin localization

A

Marking the skin surface with an indelible marker

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22
Q

What breast localization method is least precise?

A

Skin localization

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23
Q

What is a negative aspect for skin localization?

A

Results in the surgical removal of more tissue than necessary
- unless the lesion is within 1cm of the skin surface

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24
Q

Dye method

A

Injecting methylene blue dye or inert carbon into the lesion
- US or mammo guided

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25
What happens when the needle leaves the skin in the dye method?
It leaves a dye track behind, which can be followed by the surgeon, leading them directly to the tissue to be excised
26
What are the steps for needle or needle/wire combination (mammo technique)? (6)
1. When the breast is compressed, a needle is put in place using either an anteroposterior approach or a parallel to chest approach 2. Another mammo is take to prove proper position 3. After confirmation, the needle is then withdrawn, leaving a guide wire in place 4. The wire is fixed to the breast using tape 5. Patient is sent to the operating room 6. Sample is sent to x-ray to make sure borders are good
27
What are 3 types of wires?
1. Hook wire 2. J-wire 3. Retractable barb wire
28
What range are the wires used for breast localization?
3-15cm
29
When is spot compression used?
The device is typically used for small breasts, or for lesions located near the axilla or subareolar area where the full compression paddle would be suboptimal
30
What needs to be considered with the needle or needle/wire combination (ultrasound technique)? (3)
1. Location of nodule 2. Position of the transducer 3. Location of the needle - approach type
31
What kind of angle do superficial needles need?
More acute angle
32
What kind of angle do deep needles need?
Approached at the angle as close to parallel with the rib cage as possible - avoid pleural space
33
Tissue penetration with what kind of needle orientation is easier to follow?
Horizontal needle is easier to follow
34
When is the needle shaft best visualized?
If the needle is advanced parallel to the long axis of the transducer
35
When you biopsy a lesion, what do you have to make sure happens?
Make sure you can see the needle in two planes
36
What are the 2 most common breast biopsy techniques?
1. Open surgical biopsy - excisional or incisional 2. Core needle biopsy
37
What is considered the gold standard for breast biopsy?
Open surgical biopsy
38
What is excisional biopsy?
Will attempt to remove the entire lesion
39
What happens when the lesion is extracted after surgery?
It gets an X-ray to make sure the borders were good
40
What is the biggest advantage for open surgery biopsy?
Complete removal of the lesion
41
What is the biggest disadvantage for open surgery biopsy? (2)
1. Size of the incision 2. Discomfort
42
What kind of biopsy happens when the lesion is very large and/or poorly defined?
An incisional biopsy is done
43
Incisional biopsy
Surgeon removes only a portion of the suspicious tissue
44
Core Biopsy
Larger size needle with a hollow or recesses core is inserted into the suspected tumour in order to get small tissue samples
45
What is the most common size needle for a core biopsy on a palp lesion?
11 gauge
46
How many samples are usually taken for a core biposy?
3-6 - usually 4
47
What are the tissue samples placed in for core biopsy?
Formalin
48
When is the core biopsy needle best visualised?
When imaged parallel to the long axis of the transducer
49
What is another term for Vacuum Assisted Biopsy?
Minimally invasive breast biopsy
50
MIBB
Minimally invasive breast biopsy
51
Vacuum Assisted Biopsy
Provides a larger core tissue sample following a single insertion of a larger core
52
What 2 modalities can be used to guid the instrument for a vacuum assisted biopsy?
1. Ultrasound 2. Stereotactic mammo
53
What is the vacuum assisted biopsy especially utilized?
When calcifications are identified on mammo
54
what are the steps to MIBB? (6)
1. With a vacuum activated, a rotating cutting device removes a tissue sample 2. Sucked through the probe into a tissue collection area 3. Rad then rotates the thumbwheel - which positions the cutting edge in the new position 30deg from the original axis 4. Procedure is repeated 8-10 times - until a full 360deg of samples have been acquired 5. When done and removed a sterile marker is placed 6. Samples sent to pathologist
55
What option is better, core biopsy of MIBB? Why (3)?
1. Core biopsy 2. Less invasive, more simple and gets a similar effect
56
What is the preferred method of biopsy when suspicious calcifications are identified on a mammo?
Stereotactic guided, vacuum assisted biopsy
57
What is another term for large core biopsy?
Advanced breast biopsy instrumentation
58
ABBI
Advanced breast biopsy instrumentation
59
What are 6 advantages to ABBI?
1. Reduce breast scarring 2. Reduced breast disfiguration 3. Local anesthesia - no operating room required) 4. Smaller incision - smaller scar 5. Potential removal of the entire lesion 6. Provides large sample without heavy sedation
60
What position is the patient in ABBI?
Prone
61
What are the steps to ABBI? (5)
1. A computer used to run a stereotactic x-ray mammo unit and a small surgical device 2. Table contains an opening where the patients can place the patients breasts - prone 3. Once the breasts are in the table, mammo pictures are obtained in several planes, using the stereotactic mammo unit 4. Computer then locates the suspected lesion in 3D so the system can biopsy or removed the suspicious tissue 5. Post mammos are taken to confirm removal and a second pic is of the mass itself
62
What are 4 disadvantages for ABBI?
1. Too much normal tissue was being removed 2. Did not ensure an adequate margin 3. Requires stitches 4. Scar
63
What are 4 advantages for an FNA?
1. Fastest and easiest method 2. Results rapidly available 3. No stitches or scar 4. Excellent for cysts
64
What are 3 disadvantages for an FNA?
1. Small sample size - may cause incomplete assessment or misdiagnosis 2. Multiple needle insertion 3. Operator dependant
65
What are 3 advantages for a core biopsy?
1. Larger sample than FNA 2. Can lead to a more accurate diagnosis 3. No stitches or internal scar
66
What are 2 disadvantages for a core biopsy?
1. Multiple needle insertions 2. Limited sample size may underestimate more serious diagnosis
67
What are 4 advantages for a MIBB?
1. Excellent for calcium deposits 2. Removes several large samples with one needle insertion 3. No stitches 4. Minimal scar
68
What are 3 disadvantages for a MIBB?
1. May be less accurate than surgical biopsy which removes entire lesion 2. Not ideal for hard to reach lesions (eg. Near chest wall) 3. Operator dependent
69
What are 2 advantages for an open surgical biopsy?
1. Yields largest tissue sample 2. Most accurate method of diagnosis - near 100%
70
What are 4 disadvantages for an open surgical biopsy?
1. Causes permanent scar 2. Can make future mammos difficult to read 3. Possible breast disfiguration 4. Requires stitches and longer recovery
71
What is important for local recurrence control?
Adequacy of margins
72
IOUS
Intraoperative specimen
73
What is intraoperative specimen used to determine?
Adequate histologically tumour free margins during surgery
74
What needs to be done in order to complete the surgery for IOUS?
Surgeon must confirm complete removal before surgery can be completed - Pt remains on table until this is done
75
How are unresponsive abscesses to antibiotics treated?
Surgically - but are now done under US guidance
76
How do abscesses typically present? (3)
1. Firm 2. Painful 3. Palpable mass
77
Where are breast abscesses usually located?
Retroareolar
78
What are breast abscesses usually associated with? (4)
1. Erythema 2. Nipple discharge - often malodorous 3. Retraction of nipple 4. Skin thickening
79
How do breast abscesses show in US? (6)
1. Complex 2. Thick walled 3. Irregular shaped 4. Hypoechoic 5. Can have low level internal echoes / debris / septations 6. Through transmission of sound
80
What types of breast abscesses take several drainages over several weeks to clear up?
Mulit-loculated
81
What size abscesses tend to be more successfully treated by ultrasound?
Those smaller than 2.5cm - compared to those greater than 3cm
82

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