Training for higher complexity biopsy procedures

[Mordak]

I hope someone has some experience with this. I am looking to see if any pathologist here has had success in obtaining training to perform the following:

A) Ultrasound guided breast biopsies
B) Stereotactic breast biopsies

It looks as if the largest hurdle will be obtaining the initial training (doing 12 initial procedures). Can anyone explain how they received this training (if anyone has done this?) I anticipate you'd have to attend some separate course or have the training as part of, say, a fellowship program. Lastly, you'd also likely have to be paired with someone who has an active breast biopsy clinic so you are able to get numbers. Did anyone go so far as to get additional organizational acknowledgement (from the ACR, etc)? (Can someone please share their experience? Thank you.

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[Mordak]

I know with 100% certainty that physicians (primarily only surgeons) other than radiologists routinely biopsy breast tissue by the above methods. My understanding is that if you are a licensed physician you can perform the procedure. After perusing the ACR website, they offer ACR accreditation for breast ultrasound and stereotactic biopsy. The requirements for accreditation are, predictably, much less strict for radiologists compared to "Other physicians" (most likely breast surgeons). I am just wondering if any pathologist who is currently doing breast biopsies, other than FNA, how they went about obtaining A) initial training (particular course? radiology/surgeon colleague?) B) accreditation (if necessary for granting of privileges or for ?reimbursement?), C) and maintenance of accreditation (if needed).

 

[Taurus]

Lol. This is such a pipe dream on so many levels. In mammography, radiologists control patient flow. They do both the imaging and procedures. Breast work is one of those areas where the imaging and procedures are so interconnected. You can't do good work if you only do the procedure but don't know the imaging. Besides, why would the radiologist not do the procedure if they have the patient right there. This is why the vast majority of breast procedures are done by radiologists.

 

[Mordak]

Thanks for the constructive reply. Anyone have any solid information? Or are we going to get some more 'nay sayers?

 

[Path or bust]

Thanks for the constructive reply. Anyone have any solid information? Or are we going to get some more 'nay sayers?

Taurus is absolutely right. Radiologists are the gatekeepers. Pts referred to them due to a palpable mass might not be biopsied... depending on the imaging findings.

Just because you are not hearing what you want to hear does not mean it is not "solid information".

 

[Mordak]

Original question was if anyone has any personal experience obtaining this training. Of course I realize it is uncommon for pathologists to function in this way- I've already stated that the training/certification requirements are difficult to achieve, but are definitely do-able and it is being done by non-radiologists. In my experience, depending on practice location, radiologists may (most often) or may not be the "gatekeepers" y'all speak of. One must consider how a patient is supposed to get imaged and biopsied if radiologists are not on site or conveniently accessible to them? You also must realize that the ACR allows for the provision for the person doing the biopsy and the person reading the imaging to be different- i.e. that they are working in a so-called "collaborative" setting, whereby the interpretative radiologist has to be either present physically or available through PACS. I know of mobile imaging units that drive out to rural locations where imaging and biopsy procedures are NOT performed by radiologists, but by general surgeons. I want to know if anyone in pathology has incorporated this and cared to share their experiences. Thank you.

 

[icpshootyz]

I don't know of any pathologists doing any procedure such as breast biopsy, or really any biopsy other than rare FNA or bone marrow (and even those are less and less common). I've never heard of a single pathologist doing a breast biopsy. Sorry.

 

[Taurus]

Lol. You have much to learn about breast work, one of the most regulated and litigious areas in all of medicine. I suggest that you read the MQSA federal laws. If surgeons are doing biopsies, it's usually because they threaten the hospital that they will take their surgeries to a competing hospital or none of the radiologists in the local group wants to do it. Surgeons who do breast biopsies have a close relationship to a radiology group because they can't read the imaging. Biopsies and procedures are actually money losers to most groups. You need do a good number of procedures per week to justify the cost of the stereo table, ultrasound machine, supplies, and personnel. No matter who does the biopsy, you the need the right personnel and processes in place to get the path and log it, determine if the path is concordant with the imaging, notify the patient, whether to recommend additional biopsies or imaging, etc. You also have to deal with complications such as bleeding and infections. On top of that, no hospital or facility would credential you if you have only done 12 biopsies or if you do only a handful per year. A busy breast radiologist typically will do 10-20 procedures in a week. You are essentially a clinician. I can't stress enough how interconnected the imaging and doing the procedures are. That's why at the academic centers and most breast practices across the country it's the radiologists who do both. If you don't do things right, the regulators will shut you down in a heartbeat and you will have lawsuits up the wazoo.

 

[Mordak]

I was able to find the necessary literature primarily regarding ultrasound techniques- This has been done in the realm of pathology, but appears in its infancy. I have attached the following pubmed articles for the motivated/interested. I appreciate additional comments in this arena, particularly those who have additional positive insight. http://www.ncbi.nlm.nih.gov/pubmed/22536979 , http://www.ncbi.nlm.nih.gov/pubmed/18418854 . Thank you!

 

[AZpath]

Stereotactic biopsy is totally different than US guided FNA or biopsy.
This is totally viable if you have a referral base since pathologists have been doing FNA's forever.

You want to be bold open a "skin lesion clinic". Shaves are a piece of cake and you could market direct to the public. I our area I get them from indepent NPs. Pathologist could learn this in a day.
The question is it worth the time to develop.

 

[Mordak]

Agreed that it appears stereotactic is a whole different ballgame- I haven't seen any literature with path sniffing the subject, but the whole incorporation of radiation safety, equipment costs, and additional technologists/personnel, I'm inclined to believe this would be probably not worth the hassle. Now about US guided FNA/biopsy in other areas: Is it worth the time to develop? That is perhaps the best question to ask. In some situations I believe it might, it just depends on so many factors, none the least of which is the potential for a referral base. The equipment cost does not appear to be exorbitant. There does seem to be a significant requirement for initial training, especially if one desires some accreditation. Whole clinics are devoted to FNA cytology, so there are definitely viable practices. I have some more technical issues if anyone has any answers: How often are FNA biopsies switched to core specimens? For a non cytopath fellowshipped pathologist, I think most interpretive preferences would be for core tissue. Assuming additional IHC and/or molecular/flow/cytogenetics, I also think core tissue would be preferable, especially in the breast for prognostic information. Does anyone know if current pathology organizations offer ultrasound guided FNA training of superficial lesions pertaining to body sites? Most that I have heard using US guided FNA focus on Thyroid FNA and perhaps other superficial US guided lesions- but I haven't heard of anyone specifically training for breast tissue, other than the articles mentioned. It seems as if there is a distinction between a "superficial" FNA/core biopsy and a deeper area or high-risk (potentially legally) area? It was rightfully brought up that interpretation for what and what-not to biopsy in a breast ultrasound is imperative, but, with rigorous experience (see links below), these parameters are learned. Moreover, documents from the American College of Radiology give guidelines on who can perform an US guided biopsy of breast tissue, indications for biopsy, and provides accreditation.

SEE:

http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/US_Guided_Breast.pdf

http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/US_Breast.pdf

Obviously this could be desirable from multiple stand points but, does anyone know if this type of accreditation is seemingly "voluntary" or required specifically if you are doing FNA's of the breast? To my knowledge, there is no current additional accreditation required for cytopathologists to do US guided FNAs of the thyroid or head and neck lesions. If I'm wrong about this, please someone enlighten me. As for skin shaves- maybe this could be a possibility be incorporated as well, I'm not sure how often this is being done by pathologists. I see this as less of a option though for a few reasons: Firstly, competition would probably be high-I believe mid-levels as well as physicians can take these skin biopsies with relative ease and have the primary access to patients; whereas US guided techniques, from everything that I have read, is only performed by a licensed physician who has done radiology, surgery, or additional CME training. And although some pathologist may beg to differ, sample quality is likely less of an issue with skin than with lesions that are subcutaneous. Moreover, one of the benefits and possibly reasons for referral to a pathologist is the increased probability for a satisfactorily FNA/Core sampled specimen with faster (and in some cases immediate) feedback than could be given by a radiologist or surgeon alone. I think that is highly relevant and marketable, but there are only rare precedents for this type of pathology practice.

 

[WEBB PINKERTON]

I have a horror/humorous story about breast FNA. It involved a breast implant getting perforated.

 

[LADoc00]

I have been involved in some very heavy procedural related pathology practices including one where I ran a FNA clinic that including performing breast exams, FNA if appropriate, review of mammography and scheduling of follow up. I also ran a bone marrow biopsy clinic and even did rare CT guided biopsy procedures after getting ghetto training by the radiologists.

All of it is an epic waste of time for a real pathologist. You are better off focusing on high volume glass and if that fails you then do something like botox/cosmetics rather than try to dabble in interven. rads.

 

[WEBB PINKERTON]

Does anyone actually do breast FNA anymore? All of ours disappeared over a decade ago. I remember someone wrote a eulogy for it in a journal long time ago as well.

Why not do tattoo removal for extra cash? Lot of people making a killing off it in my area.

 

[AZpath]

FNA clinics have mostly focused on other sites than breast particularly thyroid and lymph nodes. I am sure a few groups still have a lot of bone marrows too. Outside of this pathologist biopsies are fairly rare IMO

 

[Taurus]

I hope that the OP big plans work out and he is able to do US guided biopsies. I want him to prove me wrong. I want to see how long he lasts before he gets sued to oblivion.

Btw, here is a recent case where a radiologist lost a $7 million lawsuit in a mammo case. Like I said, mammo is one of the most regulated and litigious areas in all of medicine. I wouldn't touch it with a 40 foot pole if you don't have to.

http://www.thestate.com/news/local/article56055575.html

 

[WEBB PINKERTON]

Last year there was a 10 MILLION dollar lawsuit for 3 supposedly misread pap tests.....We have enough litigation to worry about in women's health

http://bangordailynews.com/2015/05/...ple-nearly-10-million-for-misread-pap-smears/

 

[Taurus]

The difference between mammography and other areas of radiology or pathology is that everyone who does a significant amount of mammography expects to get into one lawsuit during their career. It's so common that it's an inescapable fact. If I do get sued, I wouldn't want to be a pathologist who dabbles in mammo as the OP suggests. The expert witness probably will be a mammo expert from radiology. You will get killed. Remember that you are also responsible for the imaging if you look at it. They will ask you why didn't you biopsy this other area when it was apparent on the imaging, etc. That's why I keep saying that the imaging and procedures are so interconnected.

 

[icpshootyz]

Just open a skin shave biopsy clinic. The public hates their moles and will love having them removed, you don't need any radiology equipment or other medical devices other than cheap shave biopsy tools (or just a scalpel), and you can do far more volume than any breast bx clinic ever could.