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Specimen Radiography in Confirmation of MRI-Guided Needle Localization and Surgical Excision of Breast Lesions

Basak Erguvan-Dogan1, Gary J. Whitman1, Victoria A. Nguyen1, Mark J. Dryden1, R. Jason Stafford2, John Hazle2, Krista R. McAlee2, Michael J. Phelps1, Mary F. Ice1, Henry M. Kuerer3 and Lavinia P. Middleton4

1 Department of Diagnostic Radiology, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1350, Houston, TX 77230.
2 Department of Imaging Physics, The University of Texas M. D. Anderson Cancer Center, Houston, TX 77230.
3 Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX 77230.
4 Department of Pathology, The University of Texas M. D. Anderson Cancer Center, Houston, TX 77230.


Figure 1
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  		Fig. 1A —50-year-old woman who underwent evaluation of questionable density in outer aspect of left breast visible only on craniocaudal mammographic views and not identified sonographically. Sagittal contrast-enhanced dynamic MR image of breast in maximum slope in first minute after contrast injection (TR/TE, 9/4; slice thickness, 4.0 mm; interslice gap, 4.0 mm; field of view, 22 cm) shows 9-mm lobulated mass (arrow) in upper outer aspect of left breast. Results of dynamic time-intensity analysis were consistent with findings at fast initial enhancement and delayed plateau (not shown).

 

Figure 2
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  		Fig. 1B —50-year-old woman who underwent evaluation of questionable density in outer aspect of left breast visible only on craniocaudal mammographic views and not identified sonographically. Axial 3D fast imaging employing steady-state acquisition (FIESTA) image of breast (TR/TE, 4/1; slice thickness, 5.0 mm; interslice gap, 5.0 mm, matrix size, 256 x 256; field of view,16 cm) after insertion of needle shows needle (white arrows) localizing region of targeted lesion according to x, y, and z coordinates and anatomic landmarks (not shown). Changes associated with injection of local anesthesia (black arrows) at skin entry are evident.

 

Figure 3
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  		Fig. 1C —50-year-old woman who underwent evaluation of questionable density in outer aspect of left breast visible only on craniocaudal mammographic views and not identified sonographically. Whole-specimen radiograph shows targeted lesion at thickened segment (arrows) of intact hookwire. S = superior, L = lateral.

 

Figure 4
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  		Fig. 1D —50-year-old woman who underwent evaluation of questionable density in outer aspect of left breast visible only on craniocaudal mammographic views and not identified sonographically. Sliced-specimen radiograph shows irregular, spiculated mass (arrows) excised with acceptable surgical margins. Image shows only sections of sliced-specimen radiograph that contain excised lesion and surrounding margins. All specimen margins are clear of tumor. A = anterior, P = posterior, M = medial.

 

Figure 5
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  		Fig. 1E —50-year-old woman who underwent evaluation of questionable density in outer aspect of left breast visible only on craniocaudal mammographic views and not identified sonographically. Histopathologic image shows moderately differentiated invasive ductal carcinoma (arrow) and intermediate-grade ductal carcinoma in situ (arrowhead) infiltrating around adenosis. Tumor measured 0.9 cm; minimum 1-cm negativity of all margins was verified. (H and E, x100)

 

Figure 6
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  		Fig. 2A —45-year-old woman with history of cancer of left breast and segmental mastectomy who underwent evaluation of palpable area in 6-o'clock position of left breast. Mammographic and sonographic findings were normal. Sagittal contrast-enhanced dynamic MR image obtained in maximum slope in first minute after contrast injection (TR/TE, 9/4; slice thickness, 4.0 mm; interslice gap, 4.0 mm; field of view, 22 cm) shows spiculated mass (arrow) with heterogeneous enhancement in left breast suspicious for malignancy according to morphologic findings. Results of dynamic time-intensity curve analysis (not shown), which is also suspicious for malignancy, were consistent with rapid wash-in and subsequent early washout.

 

Figure 7
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  		Fig. 2B —45-year-old woman with history of cancer of left breast and segmental mastectomy who underwent evaluation of palpable area in 6-o'clock position of left breast. Mammographic and sonographic findings were normal. Axial 3D fast imaging employing steady-state acquisition (FIESTA) image (TR/TE, 4/1; slice thickness, 5.0 mm, interslice gap, 5.0 mm; matrix size, 256 x 256; field of view, 16 cm) shows needle (arrows) localizing region of targeted lesion.

 

Figure 8
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  		Fig. 2C —45-year-old woman with history of cancer of left breast and segmental mastectomy who underwent evaluation of palpable area in 6-o'clock position of left breast. Mammographic and sonographic findings were normal. Whole-specimen radiograph shows mass (arrows) with adjacent intact hookwire at periphery of specimen. L = lateral, S = superior, I = inferior, m = medial.

 

Figure 9
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  		Fig. 2D —45-year-old woman with history of cancer of left breast and segmental mastectomy who underwent evaluation of palpable area in 6-o'clock position of left breast. Mammographic and sonographic findings were normal. Sliced-specimen radiograph shows dense oval mass (arrows) with inconspicuous margins at superior lateral margin of excised tissue sample. Markers show 3D orientation to specimen. Markers indicating medial and lateral margins are not shown. P = posterior, S = superior, A = anterior.

 

Figure 10
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  		Fig. 2E —45-year-old woman with history of cancer of left breast and segmental mastectomy who underwent evaluation of palpable area in 6-o'clock position of left breast. Mammographic and sonographic findings were normal. Photomicrograph shows cauterized invasive and in situ carcinoma involving inked lateral margin (arrows) of resection. Additional excised tissue had evidence of malignancy. At mastectomy 6 weeks after this image was obtained, no residual tumor was identified in mastectomy specimen. (H and E, x100)

 

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