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Sonography of Postexcision Specimens of Nonpalpable Breast Lesions: Value, Limitations, and Description of a Method

Benoît Mesurolle1, Mona El-Khoury1, David Hori2, Jean-Pierre Phancao1, Salah Kary1, Ellen Kao1 and David Fleiszer3

1 Department of Radiology, Cedar Breast Clinic, McGill University Health Center, Royal Victoria Hospital, 687 Pine Ave. West, Montreal, QC H3G 1A4, Canada.
2 Department of Pathology, Cedar Breast Clinic, McGill University Health Center, Royal Victoria Hospital, Montreal, QC H3G 1A4, Canada.
3 Department of Surgery, Cedar Breast Clinic, McGill University Health Center, Royal Victoria Hospital, Montreal, QC H3G 1A4, Canada.


Figure 1
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  		Fig. 1A —Technique of postexcision specimen sonography. Two malignant masses at 2-o'clock position in left breast in 50-year-old woman. Photograph obtained during specimen sonography shows transducer head (with gel) covered with plastic sheath. When scanning specimen previously oriented by surgeon, hookwire (arrow) is followed (longitudinal scan). Specimen shows type B background (nonfatty tissue).

 

Figure 2
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  		Fig. 1B —Technique of postexcision specimen sonography. Two malignant masses at 2-o'clock position in left breast in 50-year-old woman. Sentinel node biopsy was performed. Sonogram obtained during needle localization shows hookwire (black arrowheads) traversing two masses (arrows). Hyperechoic linear structure (white arrowheads) seen posteriorly is generated by surface of table.

 

Figure 3
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  		Fig. 1C —Technique of postexcision specimen sonography. Two malignant masses at 2-o'clock position in left breast in 50-year-old woman. After lesions have been detected, transverse scans of both lesions are obtained. Hookwire (black arrowheads) appears as hyperechoic dot within masses. Note presence of two adjacent calcifications within smallest mass in C. Hyperechoic linear structure (white arrowheads) seen posteriorly is generated by surface of table. Margins have been deemed grossly free, with sonography finding characterized as negative.

 

Figure 4
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  		Fig. 1D —Technique of postexcision specimen sonography. Two malignant masses at 2-o'clock position in left breast in 50-year-old woman. After lesions have been detected, transverse scans of both lesions are obtained. Hookwire (black arrowheads) appears as hyperechoic dot within masses. Note presence of two adjacent calcifications within smallest mass in C. Hyperechoic linear structure (white arrowheads) seen posteriorly is generated by surface of table. Margins have been deemed grossly free, with sonography finding characterized as negative.

 

Figure 5
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  		Fig. 1E —Technique of postexcision specimen sonography. Two malignant masses at 2-o'clock position in left breast in 50-year-old woman. Only smaller mass containing microcalcifications (arrow) can be clearly identified on specimen radiograph. Pathologic examination revealed two foci of invasive ductal carcinoma measuring 0.4 and 0.9 cm. Closest margin was measured at 0.5 cm, which is considered negative. Sonography margin assessment: true-negative result.

 

Figure 6
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  		Fig. 2A —78-year-old asymptomatic woman with history of left breast carcinoma 6 years earlier. Right mediolateral oblique mammogram shows new small mass at 9-o'clock position adjacent to vascular calcification (arrow) (BI-RADS category 4).

 

Figure 7
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  		Fig. 2B —78-year-old asymptomatic woman with history of left breast carcinoma 6 years earlier. Breast sonogram shows 0.4-cm round solid mass. Doppler image shows contiguous vessel. Sonographically guided biopsy yielded invasive ductal carcinoma (IDC).

 

Figure 8
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  		Fig. 2C —78-year-old asymptomatic woman with history of left breast carcinoma 6 years earlier. Sonogram obtained during needle localization shows satisfactory position of needle (arrowheads) within lesion (arrows).

 

Figure 9
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  		Fig. 2D —78-year-old asymptomatic woman with history of left breast carcinoma 6 years earlier. On right craniocaudal view obtained after needle localization, only vascular calcification (arrow) is identified.

 

Figure 10
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  		Fig. 2E —78-year-old asymptomatic woman with history of left breast carcinoma 6 years earlier. Specimen shows type A background (fatty). Two orthogonal views obtained during specimen sonography show mass (arrowheads) located close to posterior margin, which is considered positive. Post = posterior, Ant = anterior.

 

Figure 11
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  		Fig. 2F —78-year-old asymptomatic woman with history of left breast carcinoma 6 years earlier. Specimen shows type A background (fatty). Two orthogonal views obtained during specimen sonography show mass (arrowheads) located close to posterior margin, which is considered positive. Post = posterior, Ant = anterior.

 

Figure 12
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  		Fig. 2G —78-year-old asymptomatic woman with history of left breast carcinoma 6 years earlier. Specimen radiograph shows mostly vascular calcification (arrow). Localized mass is barely visible. Final pathology result revealed 0.5-cm IDC. Closest margin was measured at 0.2 cm, which is considered a positive finding. Sonography margin assessment: true-positive result.

 

Figure 13
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  		Fig. 3A —38-year-old asymptomatic woman with abnormal findings on mammography. Left mediolateral oblique view shows spiculated mass associated with calcifications (arrow) (BI-RADS category 5). Left breast sonogram (not shown) revealed two contiguous suspicious masses at 3-o'clock position. Sonographically guided core biopsy of larger one yielded invasive ductal cancer (IDC).

 

Figure 14
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  		Fig. 3B —38-year-old asymptomatic woman with abnormal findings on mammography. Sonogram obtained during needle localization shows both masses traversed with same hookwire.

 

Figure 15
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  		Fig. 3C —38-year-old asymptomatic woman with abnormal findings on mammography. Specimen radiograph reveals only larger nodule (arrows) containing calcifications (needles have been inserted for specimen orientation).

 

Figure 16
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  		Fig. 3D —38-year-old asymptomatic woman with abnormal findings on mammography. Specimen sonography—guided by hookwire (arrowheads)—shows both solid masses, with larger exhibiting close posterior margin (arrows). Specimen shows type B background (nonfatty tissue). Post = posterior.

 

Figure 17
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  		Fig. 3E —38-year-old asymptomatic woman with abnormal findings on mammography. Specimen has been turned over and rescanned. Posterior margin (arrows) appears close and was deemed positive. Smaller mass (asterisk) is well identified also. Final pathology result showed bifocal IDC. Closest margin (posterior) was measured at 0.4 cm, which is considered negative. Sonography margin assessment: false-positive result. Ant = anterior, Post = posterior.

 

Figure 18
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  		Fig. 4A —Asymptomatic 62-year-old woman with history of right ductal carcinoma in situ (DCIS) 4 years earlier. Left craniocaudal view shows questionable retroareolar distortion. No microcalcification is identified. Breast sonogram (not shown) revealed vague, but real, ill-defined hypoechoic and attenuating area measuring approximately 1 cm at 12-o'clock position.

 

Figure 19
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  		Fig. 4B —Asymptomatic 62-year-old woman with history of right ductal carcinoma in situ (DCIS) 4 years earlier. Sonogram obtained during biopsy shows needle (arrowheads) and mass (arrows). Sonographically guided biopsy yielded DCIS.

 

Figure 20
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  		Fig. 4C —Asymptomatic 62-year-old woman with history of right ductal carcinoma in situ (DCIS) 4 years earlier. Needle localization is performed under sonography guidance.

 

Figure 21
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  		Fig. 4D —Asymptomatic 62-year-old woman with history of right ductal carcinoma in situ (DCIS) 4 years earlier. Specimen sonography shows subtle hypoechoic mass (arrows). Specimen shows type B background (nonfatty tissue). Margins have been deemed grossly free: negative. Ant = anterior, Post = posterior.

 

Figure 22
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  		Fig. 4E —Asymptomatic 62-year-old woman with history of right ductal carcinoma in situ (DCIS) 4 years earlier. Specimen radiography shows ill-defined density without definite mass. Final pathologic results showed wide (> 5 cm) DCIS with massive involvement of posterior and medial margins: positive. Sonography margin assessment: false-negative result.

 

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