Preoperative MR Imaging—Guided Needle Localization of Breast Lesions
Elizabeth A. Morris1,
Laura Liberman1,
D. David Dershaw1,
Jennifer B. Kaplan1,
Linda R. LaTrenta1,
Andrea F. Abramson1 and
Douglas J. Ballon2
1 Breast Imaging Section, Department of Radiology, Memorial Sloan-Kettering
Cancer Center, 1275 York Ave., New York, NY 10021.
2 Physics Section, Department of Radiology, Memorial Sloan-Kettering Cancer
Center, New York, NY 10021.
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Fig. 1A. —Breast MR localization. Bilateral breast coil (Biopsy-System
No. NMR NI 160; MRI Devices, Waukesha, WI) has immobilization and localization
and biopsy capability. Immobilization and localization device is on left in
preparation for needle localization.
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Fig. 1B. —Breast MR localization. Patient is positioned prone in breast
coil with lateral grid plate positioned securely so that right breast is
immobilized. Mobile medial plate was positioned securely against medial aspect
of breast.
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Fig. 1C. —Breast MR localization. Needle localization of two areas in
right breast is shown. Note needle guides and wires. Needles were successfully
placed and removed.
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Fig. 1D. —Breast MR localization. After localization, lateral grid has
been removed. Two MR imaging—compatible wires mark suspicious areas.
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Fig. 2A. —70-year-old woman recently diagnosed with cancer of left
breast in whom MR imaging showed mammographically occult lesion in right
breast. MR localizing image shows compression of breast and indentation of
lateral grid. Vitamin E fiducial marker has been taped over grid hole
estimated by radiologist to correspond to lesion site (not shown).
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Fig. 2B. —70-year-old woman recently diagnosed with cancer of left
breast in whom MR imaging showed mammographically occult lesion in right
breast. Enhanced sagittal fat-suppressed three-dimensional T1-weighted MR
image shows irregular, spiculated mass (arrow) in right upper outer
quadrant.
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Fig. 2C. —70-year-old woman recently diagnosed with cancer of left
breast in whom MR imaging showed mammographically occult lesion in right
breast. Sequential sagittal MR images depict vitamin E capsule position in
relation to grid and lesion. By scrolling through sequential images on
console, we determined that vitamin E capsule is directly over lesion site.
Radiologist then placed needle guide over this grid hole and placed needle in
needle-guide hole estimated to be closest to lesion.
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Fig. 2D. —70-year-old woman recently diagnosed with cancer of left
breast in whom MR imaging showed mammographically occult lesion in right
breast. Sequential sagittal MR images depict vitamin E capsule position in
relation to grid and lesion. By scrolling through sequential images on
console, we determined that vitamin E capsule is directly over lesion site.
Radiologist then placed needle guide over this grid hole and placed needle in
needle-guide hole estimated to be closest to lesion.
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Fig. 2E. —70-year-old woman recently diagnosed with cancer of left
breast in whom MR imaging showed mammographically occult lesion in right
breast. Needle artifact is shown at level of grid (E) and through
lesion (F). Note that needle guide is not visualized on any of the MR
images. Actual grid itself is not visualized; however, cross-hatchings of grid
are seen because of pressure indentation on skin. Histologic analysis revealed
infiltrating ductal carcinoma and ductal carcinoma in situ.
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Fig. 2F. —70-year-old woman recently diagnosed with cancer of left
breast in whom MR imaging showed mammographically occult lesion in right
breast. Needle artifact is shown at level of grid (E) and through
lesion (F). Note that needle guide is not visualized on any of the MR
images. Actual grid itself is not visualized; however, cross-hatchings of grid
are seen because of pressure indentation on skin. Histologic analysis revealed
infiltrating ductal carcinoma and ductal carcinoma in situ.
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Fig. 3A. —39-year-old woman who underwent lumpectomy for 2-cm
spiculated mass in right lower inner quadrant with associated pleomorphic
calcifications on mammography. Pathology yielded infiltrating ductal carcinoma
and ductal carcinoma in situ (DCIS) with positive margins. MR imaging was
performed for assessment of residual disease. Postoperative mammogram shows
surgical site (arrow) with no residual suspicious findings.
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Fig. 3B. —39-year-old woman who underwent lumpectomy for 2-cm
spiculated mass in right lower inner quadrant with associated pleomorphic
calcifications on mammography. Pathology yielded infiltrating ductal carcinoma
and ductal carcinoma in situ (DCIS) with positive margins. MR imaging was
performed for assessment of residual disease. Sagittal enhanced
three-dimensional T1-weighted fast spoiled gradient-recalled MR image (TR/TE,
17/2.4; flip angle, 35°) depicts postoperative seroma surrounded by
clumped enhancement suggestive of residual carcinoma in right lower inner
quadrant.
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Fig. 3C. —39-year-old woman who underwent lumpectomy for 2-cm
spiculated mass in right lower inner quadrant with associated pleomorphic
calcifications on mammography. Pathology yielded infiltrating ductal carcinoma
and ductal carcinoma in situ (DCIS) with positive margins. MR imaging was
performed for assessment of residual disease. Separate sagittal image from
same MR imaging examination (B) shows spiculated mass (arrow)
in right lower outer quadrant, separate from site of prior surgery. This mass
was not evident on mammography or sonography. MR imaging—guided
localization was recommended.
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Fig. 3D. —39-year-old woman who underwent lumpectomy for 2-cm
spiculated mass in right lower inner quadrant with associated pleomorphic
calcifications on mammography. Pathology yielded infiltrating ductal carcinoma
and ductal carcinoma in situ (DCIS) with positive margins. MR imaging was
performed for assessment of residual disease. Sagittal MR image obtained day
of localization shows needle evident as low-signal artifact in area of
spiculated mass (arrow). Mass represents infiltrating ductal
carcinoma and DCIS. Residual infiltrating ductal carcinoma and DCIS were also
present adjacent to prior biopsy site. Patient underwent mastectomy.
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Fig. 4A. —46-year-old woman with 3-month history of nipple retraction
and vague palpable mass at 12-o'clock position who underwent MR imaging for
assessment of disease extent. Mammogram shows dense glandular tissue and two
vague spiculated masses (arrows) not seen on sonography.
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Fig. 4B. —46-year-old woman with 3-month history of nipple retraction
and vague palpable mass at 12-o'clock position who underwent MR imaging for
assessment of disease extent. Sagittal enhanced three-dimensional T1-weighted
fast spoiled gradient-recalled MR image (TR/TE, 17/2.4; flip angle, 35°)
depicts at least seven separate irregular and spiculated masses
(arrows) with heterogeneous enhancement in regional distribution,
highly suggestive of malignancy. This area was bracketed with MR imaging
guidance using three wires (not shown). Pathology at surgical biopsy revealed
multiple sites of infiltrating mixed ductal and lobular carcinoma as well as
ductal carcinoma in situ, with positive margins. Patient ultimately underwent
mastectomy.
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Fig. 5A. —79-year-old woman with strong family history of ductal
carcinoma in situ (DCIS) who underwent screening evaluation. Findings on
mammogram were interpreted as negative and showed scattered fibroglandular
densities. Screening sagittal fat-suppressed enhanced three-dimensional
T1-weighted fast spoiled gradient-recalled (FSPGR) MR image (TR/TE, 17/2.4;
flip angle, 35°) shows two foci of enhancement in left breast that were
localized under MR imaging guidance. Both areas were interrogated with
targeted sonography before MR localization with no corresponding sonographic
finding.
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Fig. 5B. —79-year-old woman with strong family history of ductal
carcinoma in situ (DCIS) who underwent screening evaluation. Findings on
mammogram were interpreted as negative and showed scattered fibroglandular
densities. FSPGR MR image shows 6-mm spiculated mass (arrow) in upper
inner quadrant that corresponds to 7-mm lesion of DCIS, low grade, cribriform,
and micropapillary.
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Fig. 5C. —79-year-old woman with strong family history of ductal
carcinoma in situ (DCIS) who underwent screening evaluation. Findings on
mammogram were interpreted as negative and showed scattered fibroglandular
densities. FSPGR MR image shows 9-mm smooth linear enhancement
(arrow) in lower outer quadrant that corresponds to fibrocystic
change, which includes ductal hyperplasia and fibrosis.
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Fig. 6A. —49-year-old woman 3 years after lumpectomy and radiation for
papillary carcinoma, which was predominantly intraductal with small focus of
invasion. She now presents with new bloody discharge from left nipple.
Mammogram shows clips at site of prior lumpectomy, but findings are otherwise
unremarkable.
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Fig. 6B. —49-year-old woman 3 years after lumpectomy and radiation for
papillary carcinoma, which was predominantly intraductal with small focus of
invasion. She now presents with new bloody discharge from left nipple.
Sagittal enhanced three-dimensional (3D) T1-weighted fast spoiled
gradient-recalled (FSPGR) MR image (TR/TE, 17/2.4; flip angle, 35°)
depicts two suspicious areas of enhancement. Clumped enhancement is seen in
retroareolar region (arrow).
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Fig. 6C. —49-year-old woman 3 years after lumpectomy and radiation for
papillary carcinoma, which was predominantly intraductal with small focus of
invasion. She now presents with new bloody discharge from left nipple.
Sagittal enhanced 3D T1-weighted FSPGR MR image shows linear irregular
branching enhancement (arrow) in left upper inner quadrant. MR
imaging—guided needle localization (not shown) and surgical excision
revealed ductal carcinoma in situ (DCIS), papillary and cribriform type, from
both sites, with tumor extending close to margin.
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Fig. 6D. —49-year-old woman 3 years after lumpectomy and radiation for
papillary carcinoma, which was predominantly intraductal with small focus of
invasion. She now presents with new bloody discharge from left nipple.
Postoperative MR image obtained 2 months after surgery shows seroma with thin
rim enhancement that is nonspecific in retroareolar region. Residual disease
cannot be excluded on basis of image. Note artifact (arrow) from
lumpectomy clips in posterior breast.
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Fig. 6E. —49-year-old woman 3 years after lumpectomy and radiation for
papillary carcinoma, which was predominantly intraductal with small focus of
invasion. She now presents with new bloody discharge from left nipple.
Sagittal slice from same postoperative MR image (D) shows residual
highly suspicious enhancement (arrows). Because patient refused
mastectomy, this area was subsequently localized using MR imaging guidance and
yielded DCIS, papillary and cribriform type.
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Fig. 7A. —60-year-old woman with vaguely palpable density at 12-o'clock
position that was biopsied and revealed infiltrating lobular carcinoma. MR
imaging was performed to assess disease extent. Subtracted sagittal enhanced
three-dimensional T1-weighted fast spoiled gradient-recalled (FSPGR) MR image
(TR/TE, 17/2.4; flip angle, 35°) shows irregular mass at 12-o'clock
position (arrow), corresponding to biopsy-proven carcinoma.
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Fig. 7B. —60-year-old woman with vaguely palpable density at 12-o'clock
position that was biopsied and revealed infiltrating lobular carcinoma. MR
imaging was performed to assess disease extent. Subtracted sagittal enhanced
three-dimensional T1-weighted FSPGR MR image (TR/TE, 17/2.4; flip angle,
35°) shows additional suspicious mammographically occult irregular mass in
upper outer quadrant (arrow). Directed sonography (not shown) showed
lesion at 12-o'clock position but not upper outer quadrant lesion. MR
imaging—guided needle localization (not shown) revealed infiltrating
lobular carcinoma at both sites, with tumor extending to margins.
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Fig. 7C. —60-year-old woman with vaguley palpable density at 12-o'clock
position that was biopsied and revealed infiltrating lobular carcinoma. MR
imaging was performed to assess disease extent. Sagittal image of
postoperative MR image (B) shows persistence of mass in upper outer
quadrant (arrow). Subsequent MR imaging—guided needle
localization (not shown) of residual mass shows infiltrating lobular carcinoma
in intramammary lymph node.
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Copyright © 2002 by the American Roentgen Ray Society.
