Beyond the textbook brought to you by the advanced clinical education and training team at BD, follow and subscribe wherever you get your podcasts to stay up to date with the latest expert conversations in clinical practice. This podcast is on behalf of Becton Dickinson and Company. The opinions and techniques presented herein are for educational purposes only. And the decision of which technique to use in a particular interventional application should be made by the healthcare professional based on the individual facts and circumstances of the patient and previous medical experience. The participating healthcare professionals have been compensated by Becton Dickinson and Company to participate in this podcast. This episode marks the 3rd and final installment of the series Contemporary Perspectives in Breast Biopsy and B3 lesions. Doctor Shakiri serves as the moderator in discussion with Doctor Richardson, who shares her clinical experience and practical approach to vacuum-assisted excision. Together they explore patient selection, procedural considerations, and the role of vacuum-assisted excision in the management of non-malignant breast lesions within contemporary clinical practice. It is our pleasure to introduce Doctor Shakiri and Doctor Richardson for this engaging and informative conversation. Hello and welcome to the BD Advanced Clinical Education and Training podcast, a comprehensive approach to vacuum assisted excision guidance for clinical practice. I'm Shadi Amino Lama Shakeri. I'm professor and division chief of breast imaging, uh, at the University of California Davis, and I'm your moderator today. Uh, I'm delighted to be joined by Doctor Heather Richardson, a breast cancer surgeon at the Bedford Breast Center in Beverly Hills. Dr. Richardson is a recognized top breast cancer surgeon in the Los Angeles area who conducts vacuum assisted excision in her practice. Welcome, Dr. Richardson. I am so happy to be here. Yay. Doctor Richardson, can you walk us through your approach to performing a vacuum assisted excision? Maybe you can, um, elaborate from patient selection and pre-procedure counseling to the actual technique and post procedure care. What is That complete patient pathway look like in your practice? Uh, so, so basically, uh, patients that have lesions that are confirmed or not thought to be malignant, I don't, I haven't recommended this for anything that is, that is concerning for malignancy or biopsy proven to contain malignancy. Uh, and patients, it's, it's usually two pathways either it's patient driven where patients, um, have been told that they have a lesion that doesn't need to come out but yet they want it out, or, um, they, they have been told that they need surgery and maybe they want another option. They don't want a surgical procedure. Um, sometimes it's recommended by other referring practitioners that know about our procedure or ourselves or we say hey this would be a good reason, uh, this would be a reasonable kind of thing for you. Um, we do have coordinators that will kind of. Preemptively talk to the patients about scheduling and expectations and and prepare them in general for it to see if it's something that they really wanna do and if so then I usually have a meeting with them to discuss you know the expectations you know the and look at it myself if I haven't already um to make sure that I can identify the lesion I feel like it would be a good, it would be a good candidate, um, if, if we do think that it's a good candidate, I usually recommend prescribing some, some prescriptions beforehand. I like TX. A, um, to try to reduce, uh, to, to aid in coagulation, reduce bruising, reduce swelling, um, there's, uh, there's no study as far as I know, of being, uh, helpful. However, just having done this for, you know, 18 years, you know, really super actively for 15 years, but for about 18 years I've just learned, you know, the, the number one thing that is the headache is having just to deal with the inevitable inevitability of some bleeding. So, um, managing that, managing expectations for. That and you know just how to mitigate it, how to make it as, as, as low as possible, um, and then, uh, my staff is very familiar with sort of what we're doing and, and, and wow and how and how and why and then, um, the, the procedure itself is, is sort of, uh, it's, it's like a portrait painting you're doing something completely different but yet something exactly the same over and over and over again. So it's like it's, it's pretty rote but yet each individual lesion has its own little finicky things that with experience, you know, become quite easy. And then on the other end, um, you know, deciding ahead of time, I always try to decide ahead of time do we need a clip marker to mark the site for any reason, usually not. Um, do, uh, what are we doing with pathology? Is this a lesion that we do need to, to send pathology off or not? Um, examples where we wouldn't necessarily send off pathologies, um, sometimes we'll treat gynecomastia, gentlemen who have, you know, fairly focal nodularity that's really bothersome to them under their nipple, and we'll, we'll do that for them. That can be very successful. And also, um, women who've undergone cosmetic procedures for fat necrosis, and they might have areas of oil cysts or fat necrosis that. They're multiple and they've been told there's nothing we can do or they've been offered extensive surgery that would really deform their breasts when really it's just a couple little spots so for those patients um you know it's not clinically indicated to necessarily have that analyzed but I always offer it to patients I always make sure that they they have an offer to have any pathologic um evaluations of the tissue and then um afterwards just expectation management you know it the, uh, it's it's just. So helpful to tell patients upfront what's going to happen so that they understand that bruising is to be expected, some swelling may be expected, and that, um, after the procedure there's just that healing inflammation that everybody gets with biopsies, but it tends to be a little bit more pronounced with surgical patients and with this more aggressive sort of because we're, we're, we're we're traumatizing the tissue a little bit more than just a simple core biopsy to kind of come in and out. So, um, just expectation management so that they know, um, if they feel a new hard lump at the site in a month or two, totally expected temporary, and it will go away if it looks a little flattened or a little pulled in a little bit again that's usually completely um expected and temporary it should go away, um, and then, uh, you know, the, the specifics, and I think we've got some more questions about the specifics to cover. Yeah, wonderful. Wow, it's really terrific to learn from your experience. Um, uh, you mentioned, uh, placing or not placing a clip, and as a radiologist, you know, whatever we do, whatever we biopsy, we place a clip. But is that you don't place a clip because it's already a known benign lesion you've already biopsied it, and now you know. So what's the purpose of, what's the purpose of the procedure? What are we there to do if it's something where, um, it's for curative intent, like if I wouldn't place a clip at the time of surgery. To go back and find this again and the expectation is it will be completely removed, well then there's no reason to place a clip. Um, if sometimes the patient will have a clip embedded in the, in the specimen if they've already had a biopsy, not all clips are, are amenable to removal. Some of them are a little wildly and some of them are a little stiff, and some of them, you know, they're newer clips that are sort of made to be, uh, like have a very, they have a very big grip and they just have kind of a footprint in the tissue, so. Then just following up on that, um, do you purposely go after the clip that's there from the biopsy? Perhaps if a patient has a clip present, I try to make a point of removing the clip. And then the question is, well, do you have to document it or not? Do you have to document the clip is that, do I do a specimen radiograph or not? It really depends on, well, what are we doing there? If we're, if we're doing it as an alternative to surgery because of concern for upgrading of the lesion, or if it's one of the European B3 lesions, or, you know, uh. You know, a, a papilloma and we wanna, you know, show that that it's completely removed or whatnot. Sometimes we'll do a specimen radiograph or, you know, if it's a, it's a target with calcifications, maybe we'll do a specimen radiograph to see the calcifications. But if it's something like a proposed probable fibroadenoma or biopsy proven fibroadenoma or pash or something like that and we're symptomatically removing it so that we don't have to keep watching it or the patient doesn't have to feel it, um, then no, I don't necessarily. Put a clip in so that we can say that that's where it was. Yeah. So most of these people without a lot of distortion, it's pretty rare that I see significant distortion where it would be confusing or concerning, um, once it completely heals, once you get over a year or two. Yeah, great. So then I take it no, no follow-up imaging, no follow-up MRI or anything like that, just to follow that area again, it depends on why we're performing the procedure. So if it's something like um for a low grade phyloides tumor, which this is completely reasonable to consider fibroepithelial lesion, that is something, yes, you're gonna want to follow it up to make sure that you don't have any residual um particles that are are regrowing or any recurrence um and if that does, well, the nice thing about it is you can do it again so um it's, it's, it can be repeated if there is so and that's a low probability. wow, fantastic. Um, so, going back to how you choose your, your patients, you talked about lesion criteria. Are there any patient-specific criteria that, that you look for to determine if there are better candidates for vacuum assisted excision versus surgical excision? I think the main thing as far as the patient's concerned is patient. Are they gonna be comfortable? It, it doesn't take very long, surprisingly enough, this is a very quick procedure, sometimes even faster than like a, a spring loaded core biopsy because you're not, you know, you, you, you, once you have good placement and you, and you just press the button and you watch it go away, sometimes it can be 4 or 5 minutes total for a 1 centimeter lesion. It can be very fast. Um, but patient expectations, like, are they gonna be able to tolerate a procedure? You know, it's some, you know, it's a larger device. Some people get a little squirrelly about the larger device, um, as opposed to just if you're doing, if you're used to doing just a small core, and then also the position of the lesion. If it's very close to the skin, it's gonna be very close to the skin edge as you're removing the lesion. Um, you know, if you have that vacuum there is the possibility of it pulling the skin in, um, and, and it's, it's, it's completely workable. You can definitely work with it that way. You just have to orient the probe in a different way, um, and then I've always performed this. I've only used this with ultrasound guidance, um, we don't have MRI at our center. We do have stereotactic and we have breast CT so our radiologist will perform, you know, um, those type of biopsies. With the grid where it's a fixed where the where the device is fixed so therefore you need to have the the you need to tell the device to you know rotate or turn or do a 360 degree device. I don't use that. I've always kept it in a fixed state um pointed superiorly so that with ultrasound the, um, the device is directed at the base of the lesion and then I kind of make a skiing motion back and forth this way. So therefore if we're underneath the skin. And the lesion is here, then I simply have the aperture this way and I'm going this way. Or sometimes I'll have the aperture sort of focused a little bit more, maybe not completely straight down, but maybe kind of at an angle like this, whereas I'm taking, I'm kind of um taking the lesion this way so that I'm not going this way and sucking in the skin and going to create a hole in the skin. And that's just experience. That's just, you know, with experience. So, so the trough is not facing the skin, you're saying you turn it. 90 degrees maybe if you're going to be directly under the skin and and the lesion is against the dermis, you absolutely can remove it, but you have to address it in this direction or kind of this direction, you know what I'm, so I'm saying it's either you're kind of at 90 degrees this way or kind of sort of this direction so that you're not going to, um, the vacuum is not going to capture the skin section device and break the skin. Yeah, wow, OK, fascinating. I'm learning a ton here. So you're, you're taking the As you go from one side of the lesion to the other, then you're, you're taking a sample and moving in one direction and then turning and moving back the other direction. OK, right. So if this is my lesion here, I'm going to put my device here with the aperture of this in this direction, and I'm going to kind of ski back and forth like this. That's the, that's the best way. It's, it's, I've found with a lot of experience, especially if you have like a fibroadenoma that's sort of like popcorn with multiple lobules, kind of to start on one end outside of it and come this. This way the hardest thing to do is if you kind of start in the middle and go all the way up and then you break it into two pieces and it's now it's they're kind of bobbing and weaving in space so to have one cohesive lesion and just try to go at it this way is very easy and if you have a little piece to kind of if, if this is my piece here to kind of come out at at this edge and then come from underneath this way and then and then sweep back and forth underneath it, that's, that's been really helpful. And then also. You can look, you know, you can put your, put your probe, go 90 degrees to kind of see where you are in terms of, are you all the way to one end or all the way to the other. And sometimes you want to start in the dead center and go back and forth. Sometimes you want to start at one end and kind of sweep back and forth, just kind of depending on the position, size and shape and experience gets you there. Wow, I have so many questions. One of the things that, that occurred to me is, do you ever take a case maybe that your radiology colleague has um biopsied. Say under stereo, and now it's something that would be amenable maybe to VAE. Um, and so since we've got these clips that are very visible under ultrasound, do, do you ever, or, or, you know, do you think you would take it to ultrasound then and, and offer VAE? Mhm. I, um, we've had a couple of interesting cases. I had one patient that had, uh, I have had a couple of patients that just don't want the clips, you know, a clip was placed at the time of biopsy in another center and they didn't feel like they were adequately. Uh, you know, counseled, and they, and they, they don't want those clips in. So I have performed this only for clip removal. I've done that a couple of times. Sometimes it's successful, sometimes it's not. It just depends on how ultrasound visible the clip itself is. And then, um, and, and I know other, there are plenty of radiologists who've done stereos where they pulled some clips out, which is happy and you're very familiar with that. So, um, but the to place and if you have a really good ultrasound visible clip and you have a really good idea. Idea of how big your lesion is in relationship and the position of that clip, yes, you could absolutely target it and take a generous biopsy to kind of remove it or, or sample that area. Like, for instance, if somebody has something that's not really amenable to MR or um, or, uh, stereo, and they can cover a clip above it, or maybe they have an implant or maybe it's too close to the chest wall, that's a great thing to do for this where you can see your clip and you can direct it underneath your clip and kind of skate underneath it to do it. Generous biopsy for that and interesting. So um the terms VAB VAE, I personally, I don't use those. I use the term Miller, M I L R, which um we've kind of, kind of defined as minimally invasive lesion removal. Miller, um, I, I switched over and VAE VAB. I understand that's the, that's the terminology and that's certainly fine. The reason that I felt like I needed to say something different was because. Of the public's understanding of vacuum assisted biopsy, vacuum assisted excision. I don't think they understand that it's a different thing. It's we're trying to do something different. It takes a different instrumentation, a different skill set, different expectation management. It's not as simple as a biopsy, and many payers are going to be like, Oh, you're doing a biopsy. Well then, here, here's your $1 for your biopsy. It's like, well, no, this is more planning, more skills, more effort on everybody's behalf, and we should be paid accordingly in the same sense that, you know, in the back in the day before we had laparoscopic surgery, if someone were to say, Well, I'm going to take out a gallbla. Ladder. I'm gonna perform a cholecystectomy, but I'm gonna use it with these cameras, and I'm gonna, it's all this extra equipment, and I'm gonna have to do specialty training in order to do this, but the patient's gonna benefit from this. It's like you don't get reimbursed for a lap coli the same way you do for an open coli, you know, it's like they're two different procedures, even if your endpoint is the same. So I felt like the terminology of vacuum assisted biopsy shoves it into a category of this is just a biopsy. There's nothing special about this, like, no, this. Intention. This is training. This is special equipment. This is something where the patient benefits and the system benefits as well, and it should be understood as a separate entity. So I kind of needed a new name to do so. Yeah, no, that's, that's fantastic. I'm so glad that, you know, you're, you're working on bringing something to your patients and, and also managing expectations and making it clear for everybody else involved. So, in, in that sense, how do you explain the procedure? To to your patients and then address their concerns about the procedure. Most people have a con, you know, an understanding of like a biopsy is something that is taking small bites of things or or or whittling away at something. So most people kind of understand that concept. And when you, um, you know, we do have some videos that we share with people and also kind of the understanding of how the device works, you know, it's a door that opens up that has a vacuum that pulls the tissue into it and then, you know, takes, you know, a tic tac bite of, of tissue and if. You know, if somebody has a small chickpea sized area, you know, they can kind of understand if you put the device underneath and, and take 4 to 6 bites of it, you should probably remove most of the chickpea, and people sort of sort of understand that. So, um, sometimes people wonder or worry about, are you gonna get it all? And I have to explain to people that there's, there's no way to guarantee that every cell will be removed. But, you know, studies have shown if you have safe things that, that, um, don't need curative intent removal where we don't have to get a margin around it. That um in removing it, um, in that piecemeal fashion that if there are some little cells that are left behind they usually don't have enough uh presence to be able to stick and grow back um and also what is the process? Is it something we were just gonna leave there forever anyway and the whole point of this is just so the patient doesn't feel it, or is the point there to get more tissue to investigate this to make sure that there aren't concerning cells, you know, whether it needs upgrading, we're just avoiding a. Surgery. So it's, you know, what are we doing this and what are we trying to get out of it and understanding that, you know, if we don't get all of it out or if a tiny bit is left behind, that's OK. And then, you know, 5 to 10% of people who have fibroadenomas larger than about, you know, 1 to 1.5 centimeters, you might leave a little bit behind. But if you make something 80% smaller, well, it's OK. You're, you're, so you were gonna be the option to just leave it there and never do anything was an option anyway. Yeah, yeah, of course. And just to clarify for our, um, for our audience, you do this with local anesthesia. You don't use conscious sedation or anything like that. It doesn't require it whatsoever, none whatsoever. I do, I have in the past year added, um, so we prescribe ahead of time or offer ahead of time Gernavix, um, which is. A new sodium channel blocker that was uh available around January 2025 so we've been using that for, you know, since it came out in January 2025 we offer it to patients we uh we uh recommend that they take uh two pills two hours before the procedure to help in analgesia. I can't say that we've had a huge, huge difference with it, but we have been using it for our surgical. Patients and our anesthesiologists have noted that they've actually been using a little less anesthesia during our surgical cases so there has to be something. So I mean it's one of those things it doesn't seem to be doing any harm and as long as it's not too expensive and patients are interested in taking it, um, there don't seem to be any major contraindications for any major health conditions. So I feel like that's a safe option, um. And then of course Tylenol, ibuprofen are perfectly fine. Tylenol, ibuprofen, ice pack are perfectly fine afterwards. Yeah, perfect. Wonderful. Uh, is there anything special that in the way that you communicate with your pathologist to make sure that, you know, you've had adequate schooling and accurate diagnosis? I think if, um, if you haven't ever done this and you plan on doing it for the first time, I think it's a really good idea to reach, reach out to your pathologist who's going to be reading this and say, hey, are you OK with this? Um, I did this in a Atlanta for many years and it was very organic, you know, we, we, I started out doing just regular core biopsies and then honestly what made it happen was, um, we were doing cryoablations and of course with cryoablation you really had to have had a biopsy before you could cryoablate the lesions. Some of these lesions were so small it was just sort of like and I and I really wasn't super happy with the cryoablation process and the outcomes. And it was like, why am I doing a little, you know, a core biopsy on this 7 millimeter lesion when I could just take 2 more bites with a larger gauge device and just get it gone, be done, yeah. So that's literally what happened. Like that's literally the conversation I had with myself and with patients that were, and it really started out with like cryoablation not being, you know, my favorite thing. At the time, so, um, so it happened very organically where, you know, I would, I would only do very small lesions, just the tiniest little lesions. I never would do this for anything larger than about 1 centimeter. And so, you know, and then when I started giving them more tissue and the lesions started getting bigger as my comfort level got better, got, got more, I got more comfortable with the procedure, the, uh, the pathologists, I never got any pushback. It was just, it just, you know, it just happened very organically and slowly over time, where suddenly I'm doing two. 2 centimeter 3 centimeters. I'm doing gentlemen with gynecomastia. I'm giving them like, you know, a lot of tissue, and they never said anything about like what are you doing? We don't, we're not comfortable with this now. I then left Atlanta and came to LA and worked with some major, you know, major hospital centers, and I started doing this and I got pushback. The pathologists were like, what are you doing? We're not comfortable with this. Like, like you shouldn't be doing this and I don't want anybody to do anything that they're not comfortable with, but at the same time. That was their opinion on a worldwide scale. I didn't invent this, you know, I, I'm not the one who came up with it. It's been performed in Europe safely for many, many years in Asia safely for many, many years, so. I felt like, well, if you're not comfortable with this, even though it's a thing many people are, if you're not comfortable with this, I'm not gonna, I don't want you to do anything that you're not comfortable with. So I called other area pathologists that I work with anyway, and said, are you comfortable with this? And they talked amongst themselves and they came back to me and said, absolutely, no problem. They said, but we just, we're gonna put a caveat that you are clinically responsible and that we're, we're not gonna be able to look at everything. And they put, they put a little comment at the bottom that kind of covers everything. And I again say, of course I, I'm clinically responsible for this procedure and the outcome and the follow up, and they, we had very clear communication on that. I don't expect them to look at every single piece. I don't expect them to, to, uh, uh, guarantee me anything, you know, if there's some future outcome, you know, they, they appreciate they can't look at everything as they would if they had a whole lesion. And, um, and so we came to that conclusion. So I have pathologists that are perfectly fine with it, and that's where I send the tissue. Wonderful. Can I ask you, in your experience, what's the largest lesion that you've, uh, 5 centimeters, 5 centimeters, 5 centimeters, and I didn't, um, the patient kind of insisted on it, um. That was the first time I did a lesion that big. 3.5 is kind of the upwards of, of the, the, the size that I'm really comfortable with in one setting. But it really depends on the patient's body, the, the position, you know, the, the, the placement of the lesion, and it, it, the only limiting factor is time. It's not if you think about it, it's not because it's more or less safe to remove a larger or smaller lesion. I mean, we do them in surgery all the time in just one piece, so it's, it's not a safety issue. It's really just, um, appreciating that if you're taking small bites of something that's quite large, you know, a 3 by 3 by 3, you know, centimeter lesion is 9 times bigger than a 1 by 1 by 1. Centimeter lesion. So it's just, it's exponential in the amount of volume that you have to take. So it's the time. It's like I don't have two hours to sit there. And then of course studies have shown that the larger the lesion, the less likely you are to get it all and the less likely you, the, the more likely you are to maybe leave a small bit behind. So again, judging what are you, what are you, what's the purpose of this? What's the purpose of going through this this way, so. Wonderful. And, um, what about for follow up? Do you have a particular, um, protocol for follow up for patients? I love that you said you manage their expectations before you even do the procedure so they know what's coming. I want people to know again that it's going to be completely normal for them to feel a hard lump in 6 to 8 weeks, that that is totally normal, and I, I still get calls. I feel a new lump. Uh, remember we talked? Give it another 6. Months to 12 months and then we'll talk. So, um, and most of the time I don't get a call back after that. So, um, managing that is very important as far as follow up is concerned. Again it depends on the lesion. If it's, if it's a fibroadenomatous lesion that has never been biopsied that has been there for 6 years and it's slowly gotten a little bit larger and it's bothersome to the patient and we remove it and the pathology is a fibroadenoma, well then. I just, as, as if I would have taken it out in surgery, I wouldn't bring them back to check their fibroadenomacyte. So you're done, you're by just regular screening, regular routine screening, and then if you have any future issues, if you feel a new problem or have a new concern, well then come on back, we'll check it out. Something like um a fibroepithelial growth or a phyloides tumor, then yes I do check those every 6 months for a period of about 2 or 3 years um and then um I'm seeing a lot of these patients for their routine screening and management of their breast health anyway so um it might be that I don't really need to check up on the thing that we did that procedure for but I'm gonna see them anyway and do an ultrasound screen and make sure that they're. Mammograms have done and do their breast exam. So I'm doing that to go over their risk score. I'm doing that anyway. So, um, I don't make a point of checking the sites necessarily over and over again as long as they're healed, and I can't really tell if it's there anymore, and that's the most, most case. Some of these patients do come from out of town or out of state, um, to have us perform this procedure, and I don't think it's necessary for patients to fly back to see me or necessarily have special imaging. Um, at their center, as long as, um, it's concordant, as long as we got everything that we expected to get, and it's something that could have been observed anyway, so yeah, yeah, thank you for that. So, you talked about some of the challenges already that you face coming to a new practice, new pathologists, um, and, and I love your unique way of branding the procedure, um, as something different than just a regular biopsy. What are some challenges, other challenges that you've faced regarding maybe reimbursement, the workflow integration, um, Acceptance of patients, that sort of thing? Um, sometimes we'll do these on the fly, meaning sometimes we'll see something and the patient will want to do it, we'll do it right there. So, Appreciating you have to have time in the schedule to do that and I have to sort of put a little asterisk up there um we are a very small center we are not a high volume center we're not seeing 30 patients a day um it's a we're, you know, we work with, with insurance and, and, and self pay and things like that. We're not, we're not a center where, um. We're, we're RVU centric, or that's not the kind of center that we are, so we have a lot of time and people sometimes have tried other places and they can't get anywhere or we're offering something that's totally different and they see value in that and they will pay for it. So we have payment, payment structures and you know we, we tell people up front, you know what the costs are and they are, they are aware, um. When I first tried to do this, I really, really tried to work with, uh, payers and insurance companies to say, but we would try to appeal, say, but this is not a, this is, this is an excision, and I try, we try to build like a surgical excision. It's like, but this is an excision, we're performing an excision. Um, occasionally we would get some payments from it, and again it's the insurance companies will pay you what they want to pay you unless there's more demand and more pushback and things like that. So if we just accept, you know, that they're going to pay us like any other biopsy, well then. It's hard to make that work because it costs time, it costs personnel, and again it's, it's not as simple as a simple little core biopsy that's, you know, you're in and out in 6 minutes. It's it, there's more planning and, and more that has to be done with that and. We should be compensated for as such. And so centers that maybe want to take this on but are seeing that kind of like contrast enhanced mammogram. It's like you're gonna do a lot more work. There's gonna be a lot more. There's gonna be some complications as a result that you're gonna have to deal with and actually not even complications, just, you know, the, the side effects complexity, complexity, you know, you're gonna place an IV in someone if you're doing a contrast enhanced mammogram, and what's the reimbursement for that. So, um. Appreciating that there's value in it and the value might be offering something to your community that no one else is offering, appreciating that a lot of these patients would have zero procedures at all because they could just be observed and no one will operate on them. So things like simple papillomas that everyone's willing to follow. Well, you could do this procedure instead and that will be revenue generating for your for your center and it's just how do you want to work that into your workflow. Do you want to be more procedure centric? Do you have maybe, are you or another staff member really just wants to do procedures and you're looking to find more procedures? This is a great way to do it, um, but I do think it's really important to try to, um, convey to insurance companies and demand. If we don't ask for it, yes, they can say no, but if we just bill it like an ordinary biopsy, then nothing is ever going to change. So I think something does have to happen to try to get this to be its own category. Um, because it's really not a category right now. This is not, this is really not a listed code that really stands. So unless something happens with that, and they can say, oh, but it qualifies as this code, well, because you, well, that's like saying a laparoscopic cholecystectomy is the same as an open cholecystectomy when it's entirely different procedure with different skill set, different instruments, different patient expectations for outcomes. So I really think that we need to do something about that. I don't know how that's going to be done though. Well, you've been doing this for a long time. Um, what do you think if you were to make a guess of what the future brings? Do you think this is going to have broader adoption, um, or really new innovations? Yeah. I see so many people inundated with cancers and ORs, people backed up where they can't do surgeries for ordinary things. And so now. We've just turned around and these people that we used to say for years this is oh this is a pathoma or this has some atypia in it or this has some this is some LCIS or this is pash we should take this out. Well now we don't have room in the ORs anymore surge ordinary surgeons and the time it takes for a radiologist and a surgeon to get together and for it to be pointed out for the surgeon. It's a waste of time and it's a waste of resources for a lot of centers, so they're just not doing them at all. And I feel like that that is a disservice to patients and it, it really doesn't marry well for the years we've said, oh, this is really significant, we should operate on you to now, never mind, you need nothing. Um, and I'm all for, I'm all for de-escalation, and I think that's great, but I think that some of these lesions still need to be dealt with, and patients with symptomatic benign findings, you know, patients with symptomatic ductal discharge where they clearly have some papillomas, and it was biopsied and. Wasn't atypical. Well, that patient should be able to have, you know, a procedure to, to, to improve that. But maybe if the surgeon doesn't want to operate on it, it makes perfect sense for, uh, you know, a surgeon with ultrasound experience or a radiologist to take care of that for them. It's, it's a win-win. It's a win-win. So it's a wonderful procedure that can be really elegant and when done for the right situation and when everything else kind of falls together easily, it, it's, it's really satisfying for everybody involved. Yeah, patient, patient, yeah, I was gonna say this is a great patient-centered approach. Yes, they love that like they came in with a big grape and they could feel it and they left and they couldn't feel it anymore and they don't have a scar. There's no stitches. One thing that I like to do is whenever I perform any procedure, I try as best I can to place it in an existing. Scar. So if they've had a previous wise pattern of breast reduction, go ahead and use that to, to, to take my angle or put it on the edge of the areolar margin. So there's literally no scar, especially like people of color, you know, a lot of times people will put the probe down and go, Well, I'm right handed, so I'm gonna put it to the right of the probe, and there, that's my scar. And there's nothing wrong with that. That's completely safe and reasonable, but it's just as easy instead of go to go like this, it's just as easy to go like this and put the, put the insertion site down by the areolar margin and then take that angle and address the same lesion, you know, instead of from this trajectory, just from this trajectory. It's, it's, it's quite simple, um, and I think that's, that's a huge advantage to this procedure as you are going to make a little bit more of a poke, you know, it's about a 3 to 5 millimeter maybe little poke that we make, and then we just do a steri strip on top of it. Sometimes the device will create a little bit more of a rent, and it might be if it's a little bit uneven or a little gaping, I'll put up maybe a little absorbable suture in it, but usually never, usually just a just it's really easy. Yeah, wow, that was an amazing tremendous tip for how we should approach the, the patient and think about cosmesis as, uh, as the Golden surgeon's touch or we would, we would consider that. I'm sure, I'm sure that's what everybody does anyway, but it's just, it's, it's funny when I'll see people from other centers who have had had. Uh, biopsies done, and especially if it's a person of color, sometimes we'll, you know, we'll treat their cancer and we'll do a beautiful mastectomy and they have a big old scar, you know, in some sort of visible area like medially where, uh, that was their biopsy. It's like, uh, but I understand, especially with stereotactic and MRIs, nobody has a choice for that. But ultrasound, we have a little bit of a choice. Like I think it's a good idea. I think it's a good idea to think of these things, but. Doesn't have to be. Most heal, most heal fine. Yeah. Well, uh, if you were to summarize some salient points for someone, like a breast radiologist like me, starting to do VAE or, or a surgeon colleague, are there any points that you would want us to walk away with? Um, start small, you know, don't, don't, don't try the biggest, hardest things. Um, I do these on patients with implants. I do these for fat necrosis. I do these for, you know, all sorts of lesions, but there's no reason for you to do something you're not comfortable with right off the bat, you know, the, the simplest things, the recommendations for the American Society of Breast Surgery, and I think even the, um, the, the European groups. They say, you know, stay small, stay about, you know, less than 1 to 1.5 centimeters. That is completely reasonable. Starting with something that is like, uh, you know, 5 millimeters to 1 centimeter, that's the perfect, perfect place to start. And once you build confidence in your skill set and um getting angles and just kind of working with the device, um, like I said, I don't utilize the. Reset device kind of whirling around and taking tissue. I'm personally controlling the aperture all the time, but it might be as you know, as things get better and things get advanced and I have access to some newer equipment, it may be that I, um, maybe try that out a little bit more, but I found that the fixed keeping the fixed aperture, um, superiorly is kind of the best thing. Um, it's really good to have, uh, some tips and tricks. I really like to have the spinal needles around. Sometimes my lesion is gonna be a little further away because I'm using that areolar margin access. So sometimes it might be a little further out. So I wanna make sure that my. Um, I want to make sure that my, uh, anesthesia is going to be past the lesion under beyond the lesion because your tip is gonna go beyond the lesion as opposed to if you're just simply biopsying it, you may not go all the way past it because you need to, to have it sit in the aperture, um, so just making sure that your anesthesia is really good. People do very well with this. It's very, usually people have very little pain with this. It's sometimes a funny pressure feeling and kind of and keeping the patient distracted while you're performing the procedure. Absolutely having a nice conversation and having some music on it does worlds, worlds of world of good, um, starting small, um, and then the patient management and understanding that there will be bleeding, um, I think as a, as a surgeon we're not as afraid of bleeding and of course when we're looking at the, the ultrasound screen, you know, you're seeing a lesion and it's this big and the, and you, you turn on the Doppler and there's huge amounts of bleeding and you're like, oh my God. Appreciating that like when we're in the operating room and we're actually taking out that 2 centimeter, you know, that 2 centimeter gum ball of a, a fibroadenoma, when we take it out, those little blood vessels are like little hairs, they're tiny little things, they're not, they're not, there's nothing, it's not the portal vein, it's not, it's not gonna, no one's gonna bleed to death from a, from a large gauge device in the breast. They're just the blood vessels aren't that big. But when you're doing an ultrasound, it can be very, you can seem like, oh, this is a lot of bleeding. Right. And so I mean, as, as, as radiologists have more experience with stereo and MRI, they're used to sort of like, oh, there's, there's a lot of blood there. It will stop. It always stops. And just I think one of the key points is having staff having time and being prepared afterwards to hold pressure for enough time. It takes about 11 to 15 minutes for the coagul coagulation cascade. It takes about 11 to 15 minutes for the coagulation cascade to kick in. So you just have to be very patient. And I will frequently, um, you know, myself personally just, you know, stay around for another 1520 minutes if, if, you know, if I have the time, um, and just hold pressure and just be very still. You can't keep checking it. If you keep checking it, then everything is just gonna bleed and wash away all that coagulation that you just built up. So you just have to be very patient. Just have somebody hold pressure for that amount of time. Um, previously I did use like a sandbag, you know, sometimes that that'll help. You just don't have time and staff just to hold it right there and then come back and check on them. And then that's another thing I do recommend that um. I keep the equipment sterile and I'm only doing one of these at a time. I'm not doing multiple patients at one time, so I'll keep their equipment. Just I'll leave it in the room for them and or or set it to the side for them and keep it sterile, and then I encourage them to go for a walk for 30 to 45 minutes, come back and let us check them again to make sure that they don't have a hematoma. If they have a hematoma, and not very often, but occasionally I'll bring them back and then reintroduce the sterile device and. And evacuate the with the vacuum and then just kind of recheck them and and then just again kind of repeat the process. We also wrap the patients in an Ace wrap, you know, to, to put a little pressure down to try to reduce the probability of a little hematoma. But I warn people that, you know, if I am gonna take this device and do this on your arm right here, what's gonna happen? It's gonna bleed and that's gonna happen inside your breast and people understand that it's like it's going to be very bruised. It's you're gonna have a little lump. It's gonna be a little blood blister, blood clot, but it's not one that can travel or hurt you, and that, um, your body will break it down in time and it will go away. And Arnica sometimes will recommend things like that. So just expectation management is key. Um, sometimes people are very, are not bruised at all. I mean, we've kind of got this down to the point where we really don't have a lot of problems with like hematoma, little, little retained little blood clots. It, it's, they're going to happen in every single person. It's just a question of how noticeable is it, um, but we've really kind of got it down where people don't, aren't having as much bruising. I think the steady pressure, the AceCE wrap, the TXA, all of those things have been really, really helpful in avoiding it. But even if you do everything right, you can still have. A huge black and blue breast and so just kind of telling people this might happen and it's not because we did anything bad or wrong it's just I don't get to control where the blood vessels are and if they get pinched then you're gonna have some bleeding and it will stop. I can't, you can't get hurt by that. Wow. Amazing tips and tricks and lessons, um, learned here. Well, I really appreciate this conversation. I've learned a ton. I'll tell you really cool. Yes, so wonderful. We, we could keep going about this probably for a while, and I'll probably have to call you when we start doing it and say, I know, I have a few more questions, but I'd really like to thank you, Doctor Richardson, for sharing your expertise and your perspectives and your insights. This has been incredible. Uh, incredibly valuable, and I do truly appreciate the time that you took, um, to talk with us. I'd also like to thank our audience for listening. We hope that today's conversation has provided some useful takeaways that you can apply to your own practice, and it sparked some new ideas. I know that I'm walking away with a lot of new learned lessons, so I really want to thank you for participating. Yeah, that was fun. I enjoyed it. It was a great conversation. Me too. Thank you to Doctor Shakeri and Doctor Richardson for sharing your time, expertise, and real world experience. Discussions like this underscore the importance of multidisciplinary collaboration, appropriate patient selection, and procedural considerations on the role of vacuum-assisted excision in the management of non-malignant breast lesions. Your insights into the role of vacuum assisted excision provide valuable guidance for clinicians seeking to optimize patient care and outcomes. Thanks for being part of the BD Advanced community. This podcast is intended for educational purposes only. Follow and subscribe so you never miss an episode. For more clinical education, visit advancedEDU.bd.com. We look forward to continuing the conversation in our next episode. BD and the BD logo are trademarks of Becton Dickinson and Company or its affiliates. Copyright 2026 BD all rights reserved.
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