Radiography
Findings
Techniques that involve mammography usually require the upright mammographic attachment on a normal mammographic unit, although localizations with stereotactic prone tables also have been described. Before stereotaxy came into use, a grid (see Image 2 ) or holey plate was used to calculate the position of needle placement in the X and Y planes. The depth was calculated from the lateromedial projection. The position was then checked according to the superimposition of target, hub, and shaft of the needle, and the required depth was verified on the orthogonal view (see Image 3).
Stereotaxy enables the exact position to be located. The needle is then placed 1 cm beyond the lesion to ensure that it is adequately transfixed. Because of the accordion effect (the thickness of the breast expands when compression is released), the needle tip may migrate, causing the needle to be placed short of the lesion.18 The final depth of the needle is therefore checked on the orthogonal view to ensure that the lesion is adequately transfixed.
Different needles exist, and most are introduced by using a stiffer, co-axial needle. Some needles are then removed, leaving the wire in situ. The wires commonly have a barb or hook that is deployed in the final position to anchor the wire in place. Some needles require the outer cannula to be retained in situ. The choice of needles and wires used are dictated by the preference of the radiologist and the surgeons.
After surgical removal of the lesion, specimen radiography must be performed to ensure that the lesion was adequately excised (see Image 4).
Magnetic Resonance Imaging
Findings
The use of MRI localization reflects the increasing use of magnetic resonance mammography. Although a portion of MRI-depicted lesions can subsequently be localized with ultrasonography, some of them are mammographically and ultrasonographically occult, which means that they require MRI-guided needle biopsy or localization.5,19
All of the major manufacturers of MRI units have made biopsy attachments available; these require the patient to be kept in a semiprone position.
MRI is then performed with the intravenous administration of a gadolinium-based contrast agent, and the lesion is localized by using MRI-compatible localization needles. The correct placement of the needle can be confirmed by obtaining a T2-weighted MRI to verify the signal void to transfix the lesion.
Gadolinium-based contrast agents (gadopentetate dimeglumine [Magnevist], gadobenate dimeglumine [MultiHance], gadodiamide [Omniscan], gadoversetamide [OptiMARK], gadoteridol [ProHance]) have recently been linked to the development of nephrogenic systemic fibrosis (NSF) or nephrogenic fibrosing dermopathy (NFD). For more information, see the eMedicine topic Nephrogenic Fibrosing Dermopathy. The disease has occurred in patients with moderate to end-stage renal disease after being given a gadolinium-based contrast agent to enhance MRI or magnetic resonance angiography (MRA) scans.
As of late December 2006, the Food and Drug Administration (FDA) had received reports of 90 such cases. Worldwide, over 200 cases have been reported, according to the FDA. NSF/NFD is a debilitating and sometimes fatal disease. Characteristics include red or dark patches on the skin; burning, itching, swelling, hardening, and tightening of the skin; yellow spots on the whites of the eyes; joint stiffness with trouble moving or straightening the arms, hands, legs, or feet; pain deep in the hip bones or ribs; and muscle weakness. For more information, see the FDA Public Health Advisory or Medscape.
Technical difficulties and challenges include the tendency of the MRI-visible lesion to fade over time (because enhancement with contrast material is transient).5 In addition, because of the amount of time required to perform the procedure (30-60 min), the patient may begin to move, which could cause an error in needle placement. Nevertheless, MRI localizations have generally been as accurate as mammographic localizations, with miss rates of 2-9%. Some have suggested that postoperative MRI should be performed to verify complete excision of the lesion.
Ultrasonography
Findings
When the lesion is visible, ultrasonography is the modality of choice for needle placement. It provides the advantage of real-time imaging, allowing accurate placement of the needle. Being able to directly visualize the lesion and needle position results in a quicker procedure, reducing the risk of patient morbidity. As in mammographic techniques, the lesion must be transfixed, and orthogonal mammography can be used to confirm that the correct lesion has been localized.
The use of intraoperative ultrasonography by the surgeon in the operating theatre, as well as the employment of skin marking, is described in Preferred Examination.
Nuclear Imaging
Findings
Nuclear medicine study was originally used for sentinel lymph node biopsy. Colloidal albumin labeled with technetium-99m (99m Tc) is injected directly into the lesion under stereotactic or ultrasonographic guidance.13 The accuracy of isotope placement is checked with scintigraphy. Excision biopsy is then performed by using a gamma probe. After excision, the excised lesion and the cavity are checked for radioactivity, and the specimen is radiographed to ensure the radiographic adequacy of the excision.
Measured doses to the breast and to the surgeon's hand appear to be negligible (0.03 ± 0.02 mGy/MBq and 7.5 ± 5.0 µSv/h, respectively).
Degree of Confidence
Results from a study of 67 consecutive patients showed complete removal of the lesion in 99.5% of them. Thus, this technique is accurate and at least comparable to conventional wire localization.20
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References
Guidelines for surgeons in the management of symptomatic breast disease in the United Kingdom. Eur J Surg Oncol. Oct 1995;21 Suppl A:1-13. [Medline].
Wilson M, Boggis CR, Mansel RE, et al. Non-invasive ultrasound localization of impalpable breast lesions. Clin Radiol. May 1993;47(5):337-8. [Medline].
Fornage BD, Ross MI, Singletary SE. Localization of impalpable breast masses: value of sonography in the operating room and scanning of excised specimens. AJR Am J Roentgenol. Sep 1994;163(3):569-73. [Medline]. [Full Text].
Fortunato L, Penteriani R, Farina M, et al. Intraoperative ultrasound is an effective and preferable technique to localize non-palpable breast tumors. Eur J Surg Oncol. Jan 11 2008;[Medline].
Morris EA, Liberman L, Dershaw DD, et al. Preoperative MR imaging-guided needle localization of breast lesions. AJR Am J Roentgenol. May 2002;178(5):1211-20. [Medline]. [Full Text].
Welch BL, Brem R, Black R, et al. Quality assurance procedure for a gamma guided stereotactic breast biopsy system. Phys Med. 2006;21 Suppl 1:102-5. [Medline].
Silverstein MJ, Gamagami P, Rosser RJ, et al. Hooked-wire-directed breast biopsy and overpenetrated mammography. Cancer. Feb 15 1987;59(4):715-22. [Medline].
Lannin DR, Grube B, Black DS, et al. Breast tattoos for planning surgery following neoadjuvant chemotherapy. Am J Surg. Oct 2007;194(4):518-20. [Medline].
Haid A, Knauer M, Dunzinger S, et al. Intra-operative sonography: a valuable aid during breast-conserving surgery for occult breast cancer. Ann Surg Oncol. Nov 2007;14(11):3090-101. [Medline].
Zografos GC, Doumitriou C, Lappas D, et al. Localization of nonpalpable breast lesions using hook-wire combined with isosulfan blue dye. J Surg Oncol. Jan 2003;82(1):73-4. [Medline].
Varghese P, Abdel-Rahman AT, Akberali S, et al. Methylene blue dye--a safe and effective alternative for sentinel lymph node localization. Breast J. Jan-Feb 2008;14(1):61-7. [Medline].
Canavese G, Catturich A, Vecchio C, et al. Pre-operative localization of non-palpable lesions in breast cancer by charcoal suspension. Eur J Surg Oncol. Feb 1995;21(1):47-9. [Medline].
Luini A, Zurrida S, Paganelli G, et al. Comparison of radioguided excision with wire localization of occult breast lesions. Br J Surg. Apr 1999;86(4):522-5. [Medline].
Hasselgren PO, Hummel RP, Georgian-Smith D, et al. Breast biopsy with needle localization: accuracy of specimen x-ray and management of missed lesions. Surgery. Oct 1993;114(4):836-40; discussion 840-2. [Medline].
Jackman RJ, Marzoni FA Jr. Needle-localized breast biopsy: why do we fail?. Radiology. Sep 1997;204(3):677-84. [Medline]. [Full Text].
Abrahamson PE, Dunlap LA, Amamoo MA, et al. Factors predicting successful needle-localized breast biopsy. Acad Radiol. Jun 2003;10(6):601-6. [Medline].
Kouskos E, Gui GP, Mantas D, et al. Wire localisation biopsy of non-palpable breast lesions: reasons for unsuccessful excision. Eur J Gynaecol Oncol. 2006;27(3):262-6. [Medline].
Guenin MA. Stereotactic needle localization. AJR Am J Roentgenol. Jan 2001;176(1):254-5. [Medline]. [Full Text].
van den Bosch MA, Daniel BL, Pal S, et al. MRI-guided needle localization of suspicious breast lesions: results of a freehand technique. Eur Radiol. Aug 2006;16(8):1811-7. [Medline].
Gennari R, Galimberti V, De Cicco C. Use of technetium-99m-labeled colloid albumin for preoperative and intraoperative localization of nonpalpable breast lesions. J Am Coll Surg. Jun 2000;190(6):692-8; discussion 698-9. [Medline].
Further Reading
Keywords
wire localization, guidewire localization, localization biopsy, hookwire breast localization, hook-wire breast localization
