Pathologist Directed US Biopsy...Sacramento, CA 95816 916-444-0889 voice 916-444-6016 fax...
Transcript of Pathologist Directed US Biopsy...Sacramento, CA 95816 916-444-0889 voice 916-444-6016 fax...
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
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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
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Case 2
• 81 y/o female• L Br 2:30, 31 x 26mm• Targeting US = WNL• Just lateral -> 9mm shadow
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Breast Nodule: FNA & Core
OPA /UCSF
Breast Nodule: FNA & Core
John S. Abele,MD Page 2 of 13
Pathologist Directed US Biopsy
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Breast Nodule: FNA & Core
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Grant’s Atlas of Anatomy 1962
Thyroid Anatomy
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Left Thyroid Anatomy
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Left Thyroid Anatomy
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Surgically Absent Thyroid
-Image Orientation-Landmarks
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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”
John S. Abele,MD Page 3 of 13
Pathologist Directed US Biopsy
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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
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Cyst Aspiration
OPA /UCSF
Cyst Drainage
John S. Abele,MD Page 4 of 13
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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
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Find Nodule
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Center Bx Site with Pen Shadow
John S. Abele,MD Page 5 of 13
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Pen Shadow to Center Nodule
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Cutaneous Mark
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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
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X X
X X
AREOLAR ANESTHESIAAREOLAR ANESTHESIA
John S. Abele,MD Page 6 of 13
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Dry Skin,Needle in,Probe on,Biopsy
1
23
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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
John S. Abele,MD Page 7 of 13
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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”
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U/S End : Poor Sighting
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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
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FNA Push, Not Bx
OPA /UCSF
FNA Push, Not Bx
OPA /UCSF
Breast Mass
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Breast Mass
11mm Throw
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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
John S. Abele,MD Page 9 of 13
Pathologist Directed US Biopsy
OPA /UCSF
Cocked (Yellow) - Ready
Outer Cannula Inner Stylette
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Fired - 11mm Throw ...
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Fired - Core Cut – Remove Instrument
11mm Throw
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Open 1 Click – Extract Core
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Close w/2ed Click - Ready
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20g Breast Core Biopsy
John S. Abele,MD Page 10 of 13
Pathologist Directed US Biopsy
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20g Core
Core Bx: Relative Sizes
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www.bardbiopsy.com
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No 20g Core Situations
• Excluding Ca• Calcifications• Vague Asymmetry
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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
John S. Abele,MD Page 11 of 13
Pathologist Directed US Biopsy
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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)
John S. Abele,MD Page 12 of 13
Pathologist Directed US Biopsy
OPA /UCSF OPA /UCSF
Madjar: Practice of Breast Ultrasound
OPA /UCSF OPA /UCSF
LanfranchBreast Ultrasound
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Pathologist Directed US Biopsy