Case 1 59 y/o 3CM Thigh Mass 59 y/o male 4 x 2 cm distal thigh mass Hard, enlarging Benign Freatures: Wider than Tall Smooth, Pushing Borders 59 y/o 3

Transcription

1 Pathologist US Guided FNA & Core Bx FNA BIOPSY CONSULTATION JOHN S. ABELE, MD OUTPATIENT PATHOLOGY ASSOCIATES 3301 C Street; Suite 103C Sacramento, CA voice fax abele@outpatientpathology.com Moira Kelly, Service Representative ** US = 3D Palpation = GPS for FNA ** Illustrative Cases Equipment Basic Technique Billing & Reimbursement Learning Models & References 1096, 1% 2980, 3% 4255, 4% 22952, 22% FNA SAMPLES * (N = 102,053) 30162, 30% 40608, 40% BREAST THYROID LN/SOFT TISSUE SALIVARY GLAND PROSTATE MISC FINE NEEDLE ASPIRATION CASES SITE 2005 % * % BREAST THYROID SOFT/LN SALIVARY PROSTATE MISC , ,053 Outpatient Pathology Associates Sacramento, CA Outpatient Pathology Associates Sacramento, CA U/S = Palpation in 3 rd Dimension 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

2 Case 1 59 y/o 3CM Thigh Mass 59 y/o male 4 x 2 cm distal thigh mass Hard, enlarging Benign Freatures: Wider than Tall Smooth, Pushing Borders 59 y/o 3CM Thigh Mass Case 2 81 y/o female L Br 2:30, 31 x 26mm Targeting US = WNL Just lateral -> 9mm shadow Breast Nodule: FNA & Core Breast Nodule: FNA & Core John S. Abele,MD Page 2 of 13

3 Breast Nodule: FNA & Core Thyroid Anatomy Grant s Atlas of Anatomy 1962 Left Thyroid Anatomy Left Thyroid Anatomy Surgically Absent Thyroid Case 3 59 y/o female 20 yr hx thyroid nodules 39 x 31mm dom nodule US = Large Rt cyst, vascular solid component on the wall -Image Orientation -Landmarks John S. Abele,MD Page 3 of 13

4 Cyst Drainage Tension Cyst Cyst Aspiration Baxter I.V. Extension 34 Male Luer 4cc Catalogue 2C6227 Adapted from Boccato P. FNA biopsyof small targets. Acta Cytol.1987 Mar-Apr;31(2): Cyst Drainage Cyst Drainage Cyst Aspiration Cyst Drainage John S. Abele,MD Page 4 of 13

5 Cyst Drainage Sonosite Corp th Drive SE Bothell, WA (888) Sonosite: Accessory Monitor Proper Neck Postion before U/S Find Nodule Center Bx Site with Pen Shadow John S. Abele,MD Page 5 of 13

6 Cutaneous Mark Pen Shadow to Center Nodule Anesthesia: 30 Gauge CUTANEOUS ANESTHESIA Needles Plastic Hub 30 GA #100 $9 # Lidocaine Cart 2% Epi l:100,000 #50 $19 # Carbocaine Cart 3% #50 $21 # Aspirating Cartridge Syringe Holder $45 # CUTANEOUS ANESTHESIA AREOLAR ANESTHESIA X X X X John S. Abele,MD Page 6 of 13

7 Dry Skin, Needle in, Probe on, Biopsy 3 2 US Gel Obscuration - Heavy 1 U/S Phantom U/S Side: Centered Dry skin, Needle in, Probe on, Biopsy Instrument View * Monitor View ** U/S End Bx Needle Image High... Hub Higher *Parallel U/S Plane **Perpendicular U/S Plane w/ Patient s Left = Monitor Left John S. Abele,MD Page 7 of 13

8 U/S End: Top U/S End: Top End Side End Side End / Side = 3 / 1 Side: + Faster, Less Tissue Traversed - Not Continuous; Tissue Distortion End: + See Continuously, No Distortion - Slower, Alignment Much Trickier U/S: Markings U/S End: Bore Site U/S Side: Markings U/S End: Markings U/S End : Poor Sighting 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 John S. Abele,MD Page 8 of 13

9 FNA Push, Not Bx FNA Push, Not Bx Breast Mass Breast Mass 11mm Throw Core Biopsy Materials Monopty Instrument, 11 or 22 mm Outer Cannula 7 mm Core Cavity Jennifer M. Smith Product Manager Bard Biopsy Systems 1415 West 3rd Street Tempe, AZ Phone Fax Inner Stylette 11 Throw John S. Abele,MD Page 9 of 13

10 Outer Cannula Inner Stylette Cocked (Yellow) - Ready Fired - 11mm Throw... 11mm Throw Fired - Core Cut Remove Instrument Open 1 Click Extract Core 20g Breast Core Biopsy Close w/2ed Click - Ready John S. Abele,MD Page 10 of 13

11 Core Bx: Relative Sizes 20g Core No 20g Core Situations Excluding Ca Calcifications Vague Asymmetry Breast Core w/o Guidance Breast Core with Guidance 76xxx Diagnostic Ultrasound -Permanently recorded images -Written report for patient s record CPT 2006 AMAPage 303 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 U/S Image Documentation for U/S Image Documentation for Elliott Avenue, Suite 201 Seattle, WA Judith Krebs jkrebs@cortexmed.com or John S. Abele,MD Page 11 of 13

12 Billing/Paid Jan-June 2006 Billing/Paid Jan-June 2006 Item CPT # Billed Paid Range FNA Bx US FNA Bx US Img\Rpt FNA DX Rapid Head/Neck Breast Extremity * * 76645* 76880* * Requires Permanent Image & Written Report Item CPT # Billed Paid Range Core Core\US US Img\Rpt Section Office 30** No FNA Office 15* ** 2 sites, complex, translator * 1 site Radiology 2005; 237: Brant WE. The core curriculum: Ultrasound Thy = 10 of 509. Radiology 2005; 237: Radiology 2005; 237: Academy of Clinical Thyroidologist ( John S. Abele,MD Page 12 of 13

13 Madjar: Practice of Breast Ultrasound Lanfranch Breast Ultrasound John S. Abele,MD Page 13 of 13