AJR 2000; 175:1053-1055
© American Roentgen Ray Society
Clip Placement During Sonographically Guided Large-Core Breast Biopsy for Mammographic-Sonographic Correlation
Mark A. Guenin1
1
Diagnostic Services for Women, Tristán
Associates, 4518 Union Deposit Rd., Harrisburg, PA 17111.
Received November 18, 1999;
accepted after revision March 6, 2000.
Address correspondence to M. A. Guenin.
Introduction
There are occasions when it is unclear whether a worrisome lesion visible
on a mammogram and a lesion visible in the corresponding region on a sonogram
represent the same structure within the breast. Accordingly, it may be useful
to perform sonographically guided aspiration or biopsy, then verify that the
mammographically visible lesion has disappeared or has been thoroughly
sampled. If the lesion is a cyst, aspiration under sonographic guidance
followed immediately by mammography can establish that the mammographic lesion
has disappeared, thereby proving mammographic-sonographic correlation.
However, this proof can be more difficult to obtain when the lesion proves to
be solid and a core needle biopsy must be performed. Although air, local
anesthesia, or blood may be visible on a postbiopsy mammogram, these findings
are often too widely dispersed to permit sufficiently precise
mammographic-sonographic correlation. Other proposed methods have included
performing sonography with the breast compressed in a modified compression
plate for mammography [1];
performing sonography of the compressed breast through the fenestrated
compression plate during the scout image phase of a stereotactic biopsy
[2]; or placing a radiopaque BB
on the skin at the site of the sonographic abnormality, followed immediately
by mammography [3]. However,
there can be substantial change in the configuration of the sonographic lesion
under such circumstances, and mammographic-sonographic correlation may still
be ambiguous. Because of the limitations of each of these techniques, a less
problematic and more permanent method of marking the site of a sonographically
guided biopsy was sought.
A tissue-marking clip (MicroMark; Ethicon Endo-Surgery, Cincinnati, OH) was
developed for use during vacuum-assisted directional breast biopsy (Mammotome;
Ethicon Endo-Surgery). However, the MicroMark clip was designed to be
delivered through an 11-gauge Mammotome probe, not a conventional 14-gauge
automated core needle of the type used for most sonographically guided core
needle biopsies. A method to permit delivery of the marking clip during such a
procedure was devised.
Recent reports have addressed sonographically guided marking of a known
carcinoma before neoadjuvant (preoperative) chemotherapy so that the site of
the primary tumor could be located even after tumor shrinkage or disappearance
resulting from chemotherapy. These reports describe the use of vascular
embolization coils [4],
MicroMark clips [5], or
segments of wire [6]. In these
patients, the diagnosis of carcinoma was known and had been made during a
separate percutaneous procedure, not coincident with marker placement. Burbank
and Forcier [7] described
coaxial placement of a MicroMark clip through a 13-gauge needle, but this
technique was used after a stereotactic biopsy had been performed with a
14-gauge Mammotome probe and required the use of a purpose-built needle
holder.
Subject and Methods
Mammography of a 43-year-old woman (Figs.
1A and
1B) showed a new focal zone of
increased density containing a mostly obscured, partially circumscribed oval
1-cm nodule in the upper inner quadrant of the left breast. A sonogram was
obtained (Fig. 1C), showing a
somewhat indistinct 0.9-cm hypoechoic nodule deep within the left upper inner
quadrant, immediately superficial to the pectoral muscle. It was unclear to
the radiologist performing these studies whether the mammographic and
sonographic findings represented the same object. Each study was believed
sufficiently worrisome to warrant a biopsy.
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Fig. 1A. —57-year-old woman with vague zone of palpable thickening in left
upper inner quadrant. Mediolateral oblique (A) and craniocaudal
(B) mammograms of left breast show focal zone of increased density
containing mostly obscured, partially circumscribed oval 1-cm nodule
(arrows). Radiopaque markers show borders of zone of palpable
thickening, unrelated to imaging findings, that represented lipomatous
pseudomass or fat lobule.
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Fig. 1B. —57-year-old woman with vague zone of palpable thickening in left
upper inner quadrant. Mediolateral oblique (A) and craniocaudal
(B) mammograms of left breast show focal zone of increased density
containing mostly obscured, partially circumscribed oval 1-cm nodule
(arrows). Radiopaque markers show borders of zone of palpable
thickening, unrelated to imaging findings, that represented lipomatous
pseudomass or fat lobule.
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Fig. 1C. —57-year-old woman with vague zone of palpable thickening in left
upper inner quadrant. Longitudinal sonogram shows somewhat indistinct 0.9-cm
hypoechoic nodule (calipers) deep within left upper inner quadrant,
immediately superficial to pectoral muscle (arrows).
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I performed sonographically guided core needle biopsy in a standard coaxial
manner with a slight modification of the technique described by Kaplan et al.
[8], using a 13-gauge cannula
(Tru-Guide; Bard, Covington, GA). The approach was inferior-to-superior, and
six passes were made through the lesion with a 14-gauge automated core biopsy
needle (MaxCore; Bard).
After the last pass of the biopsy needle but before withdrawing the needle
to retrieve the specimen, the cannula was advanced farther and positioned in
the center of the nodule. The biopsy needle was withdrawn, the last specimen
was retrieved from the needle, and the tissue marker delivery system was
prepared. Because the MicroMark flexible introducer
(Fig. 2) does not fit inside a
standard 13-gauge 7-cm-long cannula, deploying the clip was not possible
without cutting off most of the flexible introducer with a sterile surgical
blade (no. 11), taking care to fully retract the clip into the flexible
introducer so that the clip was not disturbed during the cutting process.
Under observation with real-time sonography, the applier shaft and clip were
advanced out the far end of the cannula until the clip was seen and tissue
resistance was encountered; the clip was then deployed
(Fig. 1D). In this patient, the
first tissue resistance encountered was at the far (superior) border of the
nodule, rather than in the center of the nodule. Finally, the clip delivery
system and metal cannula were withdrawn, and the skin nick was dressed.
Standard mammographic craniocaudal and oblique views were obtained immediately
afterward (Figs. 1E and
1F).
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Fig. 2. —Drawing of tissue marker delivery system (MicroMark; Ethicon
Endo-Surgery, Cincinnati, OH). Marker is deployed through flexible introducer
that is typically inserted into 11-gauge probe (Mammotome; Ethicon
Endo-Surgery) at conclusion of stereotactic biopsy. Flexible introducer does
not fit inside 13-gauge cannula used in coaxial sonographically guided core
needle biopsy. Instead, flexible introducer must be cut at site indicated to
permit clip with its inner applier shaft to pass into cannula.
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Fig. 1D. —57-year-old woman with vague zone of palpable thickening in left
upper inner quadrant. Longitudinal sonogram obtained after large-core needle
biopsy shows clip (MicroMark; Ethicon Endo-Surgery, Cincinnati, OH)
(arrowhead) deployed at superior edge of lesion. Histology (not
shown) revealed papillary carcinoma.
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Fig. 1E. —57-year-old woman with vague zone of palpable thickening in left
upper inner quadrant. Mediolateral oblique (E) and craniocaudal
(F) mammograms of left breast immediately after biopsy show clip
(arrow) at superior edge of nodule as predicted during
sonographically guided biopsy, proving mammographic-sonographic
correlation.
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Fig. 1F. —57-year-old woman with vague zone of palpable thickening in left
upper inner quadrant. Mediolateral oblique (E) and craniocaudal
(F) mammograms of left breast immediately after biopsy show clip
(arrow) at superior edge of nodule as predicted during
sonographically guided biopsy, proving mammographic-sonographic
correlation.
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Results
The postbiopsy mammogram showed that the MicroMark clip was embedded in the
superior end of the mammographically visible nodule, objectively proving that
the sonographic abnormality that had been biopsied and the mammographic lesion
were indeed the same structure. A stereotactic biopsy, which had been planned
in the event of persistent mammographic-sonographic discordance, was canceled
as a result. Histologically, the lesion proved to be a small papillary
carcinoma. The patient elected breast conservation therapy. Needle
localization before excision was performed, targeting the easily visible clip,
and the papillary carcinoma with its adjacent clip was excised with clean
margins. Therefore, not only did the clip prove correlation between the
mammographic and sonographic findings, it also served its original design
purpose as a tissue marker for needle localization before wide local
excision.
Discussion
I have used this technique in five patients. In three (including the
patient presented here), mammographic-sonographic correlation was proven. In
the other two patients, it was evident that mammography and sonography were
depicting separate lesions, because the clip was remote from the mammographic
nodule on the postbiopsy mammogram. Stereotactic biopsy was necessary to
obtain a diagnosis of the mammographically evident second lesion in these two
patients.
The techniques involved in deploying the clip are relatively
straightforward for radiologists familiar with and experienced in coaxial
sonographically guided core needle biopsy of the breast. Only a minute or two
are added to the procedure time (not including the postprocedure
mammogram).
Several technical points are worth noting. First, after shearing the
flexible introducer, one should be certain that the clip and applier shaft can
slide smoothly out through the newly cut end of the flexible introducer.
Second, one may want to fill the cannula with saline or local anesthesia
between every biopsy pass and before deploying the marker. This practice
avoids pushing the 2-3 ml of air contained in an empty (air-filled) 13-gauge
7-cm-long cannula into the biopsy site, which can cause the target to be
obscured under sonographic visualization. Third, it is important to remember
that, unlike with the vacuum-assisted Mammotome, when deploying the clip under
sonographic guidance, no vacuum is available to help collapse the surrounding
tissue and provide purchase for the clip. This is not a problem: the position
of deployment relative to the nodule should simply be noted for correlation
with the postbiopsy mammogram. In the case presented here, the clip was
deployed at the superior end of the nodule, precisely where it appeared on the
postbiopsy mammogram.
In conclusion, although the correlation of a mammographic and sonographic
abnormality is usually straightforward for an experienced radiologist, there
are occasions when it is unclear whether the different modalities are
depicting one abnormality or two. I describe a technique for depositing a
tissue marker during a sonographically guided biopsy, followed immediately by
mammography, thereby proving mammographic-sonographic correlation in an
objective fashion.
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Introduction
Subject and Methods
