AJR 2003; 180:352-354
© American Roentgen Ray Society
Sonographically Guided Needle Localization After Stereotactic Breast Biopsy
Dana H. Whaley1,
Darcy L. Adamczyk and
Eric A. Jensen
1 All authors: Department of Radiology, Mayo Clinic, 200 First St. S.W.,
Rochester, MN 59505.
Received May 16, 2002;
accepted after revision July 23, 2002.
Address correspondence to D. H. Whaley.
Introduction
Imaging-guided vacuum-assisted breast biopsy has become a common radiologic
procedure [1]. This procedure
can now be performed with either stereotactic or sonographic guidance. When
malignant or suspicious pathologic findings are detected, surgical resection
is usually indicated. Because all or most of the lesion may be removed during
the initial biopsy, a marking device is frequently needed to assist in
subsequent needle localization procedures. Previously, this has been
accomplished with a metal clip placed through the vacuum device at the time of
biopsy [2,
3]. Any subsequent needle
localization procedure then uses mammographic imaging techniques. We prefer to
use sonographic imaging to guide needle localizations whenever possible
because sonographic guidance causes less patient discomfort and is less
time-consuming. This option is now possible with the use of a new marking
device that can be imaged on either sonography or mammography.
Materials and Methods
The new marking device (Gel Mark Ultra; SenoRx, Aliso Viejo, CA) is
composed of 11 small biodegradable cylinders, with the middle one containing a
stainless steel wire. The wire has a distinctive shape: a circle that has a
short arm and a long arm. The marker is composed of a synthetic compound
(copolomer of polylactic acid and polyglycolic acid) that is similar to Vicryl
suture (Ethicon Endo-Surgery, Cincinnati, OH). Embedded within the wire
cylinders are carbon dioxide bubbles that make the marker highly echogenic and
therefore detectable on sonography (technical report #2; SenoRx). This
Vicryllike compound is easy to see on sonography and is used in place of
collagen, which was used in an earlier version of this product. This compound
has been shown to remain visible for at least 4 weeks (Lechner M et al.,
presented at the 19th Annual Miami Breast Conference, Miami Beach, FL,
February 2002). Over several months, this material degrades so that it is no
longer visible on sonography; however, the metal marker is permanent, as with
other wire marking devices [4,
5].
We recently used this device in a 50-year-old woman with two separate
suspicious clusters of microcalcifications (Breast Imaging Reporting and Data
System [BI-RADS] category 4 lesions
[6]) in the right breast. These
suspicious clusters were biopsied using an 11-gauge vacuum-assisted biopsy
device (Mammotome; Ethicon Endo-Surgery) using standard techniques with the
patient on a prone stereotactic table (Lorad, Danbury, CT). The patient
experienced no complications.
At the completion of each biopsy, the needle was withdrawn approximately 5
mm, and the new marking device applicator was placed into the biopsy needle as
far as possible. The markers were deployed with a gentle injection motion of
the applicator handle. The presence of the clip was verified on digital
imaging, and the needle was removed.
The second cluster of microcalcifications was then biopsied using the same
techniques (Fig. 1A). After
completing the procedure, we obtained craniocaudal, mediolateral oblique, and
mediolateral mammograms to evaluate the position of the markers. By comparing
the mammograms obtained before biopsy with those obtained after biopsy, we
verified that both markers were in the proper location at the biopsy sites.
Both biopsy areas were evaluated with standard- and real-time compound-angle
computed sonographic imaging (HDI 5000 with SonoCT; Advanced Technology
Laboratories, Bothell, WA) (Figs.
1B and
1C). Sonography showed the
cylinders to be highly echogenic and to have prominent posterior shadowing,
which made the markers easy to identify at both locations.
View larger version (139K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1A. —50-year-old woman with suspicious clusters of
microcalcifications in right breast. Digital mammographic images obtained
during stereotactic biopsy show marker clip in first area of calcifications
after biopsy (A) and second area of calcifications before biopsy gun
was fired (B).
|
|
View larger version (135K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1B. —50-year-old woman with suspicious clusters of
microcalcifications in right breast. Digital mammographic images obtained
during stereotactic biopsy show marker clip in first area of calcifications
after biopsy (A) and second area of calcifications before biopsy gun
was fired (B).
|
|
View larger version (87K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1C. —50-year-old woman with suspicious clusters of
microcalcifications in right breast. Longitudinal real-time compound
sonographic image (C) shows most inferior biopsy site, and transverse
conventional sonographic image (D) shows second biopsy site. Both
images were obtained shortly after marker placement.
|
|
Results
Pathologic evaluation showed both biopsy sites to be intermediate-grade
ductal carcinoma in situ, so surgical treatment was arranged. Needle
localization (modified Kopan's Spring Hook; Cook, Bloomington, IN) of both
regions was requested and performed 14 days after biopsy using only
sonographic guidance. During localization, both areas were again easily
visualized using both standard- and real-time compound-angle computed
sonographic techniques (Figs.
1D and
1E). Mammograms were obtained
after localization to assist with surgery
(Fig. 1F). Complete surgical
removal was subsequently accomplished without
difficulty.
View larger version (93K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1D. —50-year-old woman with suspicious clusters of
microcalcifications in right breast. Longitudinal real-time compound
sonographic image (C) shows most inferior biopsy site, and transverse
conventional sonographic image (D) shows second biopsy site. Both
images were obtained shortly after marker placement.
|
|
View larger version (83K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1F. —50-year-old woman with suspicious clusters of
microcalcifications in right breast. Transverse conventional sonographic image
of second site shows needle placement for surgery 14 days after stereotactic
biopsy.
|
|
View larger version (100K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1G. —50-year-old woman with suspicious clusters of
microcalcifications in right breast. Craniocaudal mammogram shows both biopsy
clips and needle localization wires before surgical removal.
|
|
Discussion
Improvements in percutaneous biopsy techniques have made it increasingly
necessary to accurately mark the site of a breast lesion at biopsy. The option
to perform needle localization procedures with sonography and mammography
equipment adds needed flexibility and increases patient flow in a radiology
department. The combination of high echogenicity and prominent shadowing
offered by this device allowed it to be used for needle localization under
sonographic guidance 14 days after stereotactic biopsy. Using both standard-
and real-time compound-angle computed sonographic imaging, we could easily and
definitively identify the cylinder-shaped markers. The distinctive appearance
of the metallic marker in this device can also be used to distinguish it from
other currently available markers and allow multiple lesions to be accurately
marked by different devices.
Since this initial case, we have placed more than 40 of these devices in
patients who subsequently required surgery. In six patients, the marker was
used to complete the needle localization procedure using sonographic guidance.
Three of these markers were placed at stereotactic biopsy, and three were
placed with a hand-held vacuum device (Mammotome; Ethicon Endo-Surgery) using
sonographic guidance. We look forward to future comprehensive evaluation and
comparison of the strengths and weaknesses of this and other new biopsy
markers.
References
- Burbank F, Parker S, Fogarty T. Stereotactic breast biopsy:
improved tissue harvesting with the mammotome. Am Surg
1996;62:128
-150[Medline]
- Burbank F, Forcier N. Tissue marking clip for stereotactic breast
biopsy: initial placement accuracy, long-term stability, and usefulness as a
guide for wire localization. Radiology
1997;205:407
-415[Abstract/Free Full Text]
- Liberman L, Dershaw DD, Morris EA, Abramson AF, Thornton CM, Rosen
PP. Clip placement after stereotactic vacuum-assisted breast biopsy.
Radiology
1997;205:417
-422[Abstract/Free Full Text]
- Penco M, Marcioni S, Ferruti P, D'Antone S, Deghenghi R.
Degradation behaviour of block copolymers containing poly (lactic-glycolic
acid) and poly (ethylene glycol) segments.
Biomaterials
1996;17:1583
-1590[Medline]
- Vert M, Li S, Garreau H. New insights on the degradation of
bioresorbable polymeric devices based on lactic and glycolic acids.
Clin Mater
1992;10:3
-8[Medline]
- American College of Radiology. Breast imaging reporting
and data system (BI-RADS), 3rd ed. Reston, VA: American College
of Radiology, 1998
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
This article has been cited by other articles:
|
|
|
|
 
C. C. Genson, C. E. Blane, M. A. Helvie, S. A. Waits, and T. L. Chenevert
Effects on Breast MRI of Artifacts Caused by Metallic Tissue Marker Clips
Am. J. Roentgenol.,
February 1, 2007;
188(2):
372 - 376.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. R. Parikh
Delayed Migration of Gel Mark Ultra Clip Within 15 Days of 11-Gauge Vacuum-Assisted Stereotactic Breast Biopsy
Am. J. Roentgenol.,
July 1, 2005;
185(1):
203 - 206.
[Full Text]
[PDF]
|
|
|
Top
Introduction
Materials and Methods
