Pathologist Directed US Biopsy...Sacramento, CA 95816 916-444-0889 voice 916-444-6016 fax [email protected] Moira Kelly, Service Representative OPA /UCSF Pathologist US

OPA /UCSF

FNA BIOPSY CONSULTATION

JOHN S. ABELE, MDOUTPATIENT PATHOLOGY ASSOCIATES

3301 C Street; Suite 103CSacramento, CA 95816

916-444-0889 voice916-444-6016 [email protected] Kelly, Service Representative

OPA /UCSF

Pathologist US Guided FNA & Core Bx

• Illustrative Cases• Equipment• Basic Technique• Billing

& Reimbursement• Learning Models

& References

** US = 3D Palpation = GPS for FNA **

OPA /UCSF

FNA SAMPLES1984 – 2005* (N = 102,053)

30162, 30%

40608, 40%

22952, 22%

4255, 4%

2980, 3%

1096, 1%

BREAST

THYROID

LN/SOFT TISSUE

SALIVARY GLAND

PROSTATE

MISC

Outpatient Pathology AssociatesSacramento, CA 95816

OPA /UCSF

FINE NEEDLE ASPIRATION CASES

SITE 2005 1984-2005* %

BREAST 725 14 30162 30

THYROID 3272 63 40608 40

SOFT/LN 901 17 22952 22

SALIVARY 141 3 4255 4

PROSTATE 0 0 2980 3

MISC 130 3 1096 1

5,169 102,053

%

Outpatient Pathology AssociatesSacramento, CA 95816

OPA /UCSF

U/S = Palpation in 3rd Dimension

OPA /UCSF

Pathologist US Guided Benefits

• Deep Palpation & Bx– Posterior Thyroid

• Edges– Carotid / Trachea

• False Physical Image• Patient Communication• Better Sample Than Radiologist• Market Forces - TTHALTS

John S. Abele,MD Page 1 of 13

Pathologist Directed US Biopsy

OPA /UCSF

Case 1

• 59 y/o male• 4 x 2 cm distal thigh mass• Hard, enlarging

OPA /UCSF

59 y/o 3CM Thigh Mass

Benign Freatures:Wider than TallSmooth, Pushing Borders

OPA /UCSF

59 y/o 3CM Thigh Mass

OPA /UCSF

Case 2

• 81 y/o female• L Br 2:30, 31 x 26mm• Targeting US = WNL• Just lateral -> 9mm shadow

OPA /UCSF

Breast Nodule: FNA & Core

OPA /UCSF




OPA /UCSF


OPA /UCSF

Grant’s Atlas of Anatomy 1962

Thyroid Anatomy

OPA /UCSF

Left Thyroid Anatomy

OPA /UCSF

Left Thyroid Anatomy

OPA /UCSF

Surgically Absent Thyroid

-Image Orientation-Landmarks

OPA /UCSF

Case 3

• 59 y/o female• 20 yr hx thyroid nodules• 39 x 31mm dom nodule• US = Large Rt cyst,

“vascular solidcomponent on the wall”



OPA /UCSF

Cyst Drainage – Tension Cyst

OPA /UCSF

Cyst Aspiration

Baxter I.V. Extension 34” Male Luer4cc Catalogue 2C6227

Adapted from Boccato P. FNA biopsy of small targets. Acta Cytol.1987 Mar-Apr;31(2):200-1.

OPA /UCSF

Cyst Drainage

OPA /UCSF

Cyst Drainage

OPA /UCSF

Cyst Aspiration

OPA /UCSF

Cyst Drainage



OPA /UCSF

Cyst Drainage

OPA /UCSF

Sonosite Corp21919 30th Drive SEBothell, WA 98021-3904

(888) 482-9449

www.sonosite.com

OPA /UCSF

Sonosite: Accessory Monitor

OPA /UCSF

Proper Neck Postion before U/S

OPA /UCSF

Find Nodule

OPA /UCSF

Center Bx Site with Pen Shadow



OPA /UCSF

Pen Shadow to Center Nodule

OPA /UCSF

Cutaneous Mark

OPA /UCSF

Anesthesia: 30 Gauge

http://www.pattersondental.com 800-873-7683Needles Plastic Hub 30 GA #100 $9 #085-5569Lidocaine Cart 2% Epi l:100,000 #50 $19 #085-3978Carbocaine Cart 3% #50 $21 #085-4075Aspirating Cartridge Syringe Holder $45 #222-4228

OPA /UCSF

CUTANEOUS ANESTHESIACUTANEOUS ANESTHESIA

OPA /UCSF

CUTANEOUS ANESTHESIACUTANEOUS ANESTHESIA

OPA /UCSF

X X

X X

AREOLAR ANESTHESIAAREOLAR ANESTHESIA



OPA /UCSF

Dry Skin,Needle in,Probe on,Biopsy

1

23

OPA /UCSF

US Gel Obscuration - Heavy

OPA /UCSF

U/S Phantom

http://www.pharminnovations.comhttp://www.bluephantom.com

OPA /UCSF

Dry skin,Needle in,Probe on,Biopsy

U/S Side: Centered

OPA /UCSF

Monitor View **Instrument View *

Needle Image High ...Hub Higher

*Parallel U/S Plane **Perpendicular U/S Plane w/ Patient’s Left = Monitor Left

OPA /UCSF

U/S End Bx



OPA /UCSF

U/S End: Top

End / Side = 3 / 1

End

Side

OPA /UCSF

U/S End: Top

End

Side

Side: + Faster, Less Tissue Traversed- Not Continuous; Tissue Distortion

End: + See Continuously, No Distortion- Slower, Alignment Much Trickier

OPA /UCSF

U/S: Markings

U/S End: Markings

U/S Side: Markings

OPA /UCSF

U/S End: “Bore Site”

OPA /UCSF

U/S End : Poor Sighting

OPA /UCSF

How Core Benefits Br FNA

• Prove Invasion• Material for Special Studies• Mobile / Soft Target

– FAD / Low Tension Cyst

• FAD vs. Circumscribed CA– Colloid / Medullary / Met CA

• Backup to FNA



OPA /UCSF

FNA Push, Not Bx

OPA /UCSF

FNA Push, Not Bx

OPA /UCSF

Breast Mass

OPA /UCSF

Breast Mass

11mm Throw

OPA /UCSF

Core Biopsy Materials

OPA /UCSF

Monopty Instrument, 11 or 22 mm

Jennifer M. Smith

Product ManagerBard Biopsy Systems1415 West 3rd StreetTempe, AZ 85281

480-303-2781 Phone480-449-2570 Fax

www.bardbiopsy.com

7 mm Core Cavity

11 Throw

Outer Cannula

Inner Stylette



OPA /UCSF

Cocked (Yellow) - Ready

Outer Cannula Inner Stylette

OPA /UCSF

Fired - 11mm Throw ...

OPA /UCSF

Fired - Core Cut – Remove Instrument

11mm Throw

OPA /UCSF

Open 1 Click – Extract Core

OPA /UCSF

Close w/2ed Click - Ready

OPA /UCSF

20g Breast Core Biopsy



OPA /UCSF

20g Core

Core Bx: Relative Sizes

OPA /UCSF

www.bardbiopsy.com

OPA /UCSF

No 20g Core Situations

• Excluding Ca• Calcifications• Vague Asymmetry

OPA /UCSF

76xxx Diagnostic Ultrasound-Permanently recorded images-Written report for patient’s record

CPT 2006 AMA Page 303

19100 Breast Core w/o Guidance19102 Breast Core with Guidance

DIAGNOSIS

diaginosko (dee-ag-in-o'-sko)

dia = “by means of”ginosko (ghin-oce'-ko) =

“to know”

DIAGNOSIS =“to know by means of”“to know thoroughly”

OPA /UCSF

U/S Image Documentation for 76942

OPA /UCSF

http://www.cortexmed.com2107 Elliott Avenue, Suite 201Seattle, WA 98121

Judith Krebs [email protected]

206-826-5032 or 800.278.4645

U/S Image Documentation for 76942



OPA /UCSF

Item CPT # Billed Paid Range

Billing/Paid Jan-June 2006

* Requires Permanent Image & Written Report

135 - 7095.99150.0012376536*Head/Neck

86 - 4972.27150.002976645*Breast

15 125 - 89110.76150.0076880*Extremity

150 - 72116.74150.0032776942*US Img\Rpt

160 - 57121.99175.0027810022US FNA Bx

29

1988

434

56 - 4553.72175.0088172Rapid

155 - 56118.33169.0088173FNA DX

144 - 63108.69151.0010021FNA Bx

OPA /UCSF

420

336

336

64 - 4151.7864.0099241Office 15*

94 - 7580.0094.0099242No FNA

94 - 7580.0094.0099242Office 30**

Item CPT # Billed Paid Range

** 2 sites, complex, translator* 1 site

Billing/Paid Jan-June 2006

150 - 72116.74150.0032776942US Img\Rpt

5567

9

1

132.26188.0088305Section

241.19275.0019102Core\US

136.00200.0019100Core

OPA /UCSF

Radiology 2005; 237:794-800

Brant WE. The core curriculum: Ultrasound. 2001 Thy = 10 of 509.

OPA /UCSF

Radiology 2005; 237:794-800

OPA /UCSF

Radiology 2005; 237:794-800

OPA /UCSF

Academy of Clinical Thyroidologist(www.thyroidologists.com)



OPA /UCSF OPA /UCSF

Madjar: Practice of Breast Ultrasound

OPA /UCSF OPA /UCSF

LanfranchBreast Ultrasound



Documents

Pathologist Directed US Biopsy...Sacramento, CA 95816 916-444-0889 voice 916-444-6016 fax [email protected] Moira Kelly, Service Representative OPA /UCSF Pathologist US