eMedicine Specialties > Radiology > Breast

Breast, Needle Localization

Author: William Teh, MB, ChB, FRCR, Clinical Director, Department of Radiology, Northwick Park Hospital, UK
Coauthor(s): Hemant Singhal, MD, MBBS, FRCSE, FRCS(C), Senior Lecturer, Department of Surgery, Imperial College School of Medicine, UK; Consultant Surgeon, Northwick Park and St Marks Hospitals, UK
Contributor Information and Disclosures

Updated: Feb 29, 2008

Introduction

Background

This article discusses the techniques applicable to the localization of breast lesions. As breast cancer screening with mammography increases, many impalpable breast lesions are being detected. These lesions should first and foremost be definitively diagnosed by using image-guided needle biopsy. After needle biopsy, some of these lesions may require diagnostic or therapeutic surgical biopsy. If a malignant or indefinite diagnosis is obtained, surgical excision is indicated. This, in turn, requires accurate localization of the lesion.

Good accuracy of such localizations is required to ensure correct and adequate removal of the lesions and to minimize the degree of cosmetic disfigurement.1

For excellent patient education resources, visit eMedicine's Cancer and Tumors Center. Also, see eMedicine's patient education articles Mammogram and Breast Cancer.

See also the following related Medscape topics:
Resource Center Breast Cancer
CME/CE NCCN Clinical Practice Guidelines in Oncology Symposium: Breast Cancer
CME/CE Refining First-line Treatment for Metastatic Breast Cancer
CME/CE Treatment Options for Early-Stage Breast Cancer: Information for Primary Care Providers

Preferred Examination

The modality of choice depends on operator expertise and the type of lesion. Most palpable lesions do not require image-guided localization. Breast lesions that are visible with ultrasonography can be adequately localized by using a skin marker if the lesion lies fairly superficially within the breast.2 In addition, a surgeon can easily perform ultrasonographic localization in the operating room to identify the lesion and to confirm its adequate removal.3,4

Other localization techniques include magnetic resonance imaging (MRI) and mammography (by using a grid, a holey plate, or a stereotactic method).5,6 Although a number of techniques are used to localize nonpalpable breast lesions, needle localization is the most common.7,8,9

After successful placement, the patient is then taken to the operating room, where the surgeon commonly makes an incision at the site of the wire insertion and excises the wire and the lesion. Some surgeons place a stiff outer cannula along the wire down to the wire tip and excise the tip along with the lesion.

Impalpable lesions may also be marked by using an injection of methylene blue,10,11 charcoal suspension,12 or radioisotopes.13

It is essential to obtain a diagnosis with a core biopsy under ultrasonographic or stereotactic guidance before surgery so that a definitive, 1-step surgical procedure can be planned. Once malignancy is diagnosed, any of the following procedures can be used to localize the lesion:

  • Skin-marker localization
  • Needle localization under ultrasonographic guidance
  • Needle localization under stereotactic guidance6
  • Radionuclide localization combined with sentinel-node biopsy11

See also the following related eMedicine topics:
Breast Cancer [Oncology]
Breast Cancer [Plastic Surgery]
Breast Cancer Evaluation
Breast Cancer, Mammography
Breast Cancer, Ultrasonography
Breast, Stereotactic Core Biopsy/Fine Needle Aspiration

Limitations of Techniques

All methods are subject to potential inaccuracies.14 It is important to confirm the correct placement of the guidewire. Ultrasonographic and mammographic wire localizations can be followed by mammography performed in 2 planes (eg, lateromedial and craniocaudal projections) to confirm that the correct lesion has been accurately targeted.

Ideally, the guidewire should transfix the lesion on both projections (see Image 1). The tip of the guidewire should ideally be placed within 1 cm of the target lesion.

Guidewires may be dislodged or may migrate prior to surgery. Complications, including pneumothoraces, have been described. Wire fragments may also be retained following surgery. Published literature show that the rate of needle-localization failure is in the range of 0-20%. Factors associated with failure include the following15,16,17 :

  • Lesion type
  • Lesion size
  • Increased distance of the needle from the lesion
  • Decreased breast size
  • Decreased specimen volume

More on Breast, Needle Localization

Overview: Breast, Needle Localization
Imaging: Breast, Needle Localization
Follow-up: Breast, Needle Localization
Multimedia: Breast, Needle Localization
References
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References

  1. 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].

  2. 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].

  3. 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].

  4. 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].

  5. 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].

  6. 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].

  7. 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].

  8. 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].

  9. 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].

  10. 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].

  11. 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].

  12. 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].

  13. 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].

  14. 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].

  15. Jackman RJ, Marzoni FA Jr. Needle-localized breast biopsy: why do we fail?. Radiology. Sep 1997;204(3):677-84. [Medline]. [Full Text].

  16. Abrahamson PE, Dunlap LA, Amamoo MA, et al. Factors predicting successful needle-localized breast biopsy. Acad Radiol. Jun 2003;10(6):601-6. [Medline].

  17. 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].

  18. Guenin MA. Stereotactic needle localization. AJR Am J Roentgenol. Jan 2001;176(1):254-5. [Medline]. [Full Text].

  19. 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].

  20. 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].

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Further Reading

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Keywords

wire localization, guidewire localization, localization biopsy, hookwire breast localization, hook-wire breast localization

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Contributor Information and Disclosures

Author

William Teh, MB, ChB, FRCR, Clinical Director, Department of Radiology, Northwick Park Hospital, UK
William Teh, MB, ChB, FRCR is a member of the following medical societies: British Institute of Radiology, British Medical Association, and Royal College of Radiologists
Disclosure: Ethicon Johnson & Johnson Honoraria Speaking and teaching

Coauthor(s)

Hemant Singhal, MD, MBBS, FRCSE, FRCS(C), Senior Lecturer, Department of Surgery, Imperial College School of Medicine, UK; Consultant Surgeon, Northwick Park and St Marks Hospitals, UK
Hemant Singhal, MD, MBBS, FRCSE, FRCS(C) is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada and Royal College of Surgeons of Edinburgh
Disclosure: Nothing to disclose.

Medical Editor

John M Lewin, MD, Section Chief, Breast Imaging, Diversified Radiology of Colorado, PC; Associate Clinical Professor, Department of Preventative Medicine and Biometrics, University of Colorado Denver
John M Lewin, MD is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, Radiological Society of North America, and Society of Breast Imaging
Disclosure: Nothing to disclose.

Pharmacy Editor

Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.

Managing Editor

Edward Azavedo, MD, PhD, Director of Clinical Breast Imaging Services, Associate Professor, Department of Radiology, Karolinska University Hospital, Sweden
Edward Azavedo, MD, PhD is a member of the following medical societies: Swedish Medical Association and Swedish Society of Medicine
Disclosure: Nothing to disclose.

CME Editor

Robert M Krasny, MD, Consulting Staff, Department of Radiology, The Angeles Clinic and Research Institute
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Chief Editor

Lawrence M Davis, MD, Assistant Professor of Diagnostic Imaging (Clinical), Department of Diagnostic Imaging, Warren Alpert Medical School at Brown University
Lawrence M Davis, MD is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, American Society of Neuroradiology, Radiological Society of North America, and Rhode Island Medical Society
Disclosure: Nothing to disclose.

 
 
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