AJR AJR-based Continuing Ed for Technologists
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Abstract Freely available
Right arrow Figures Only
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Erguvan-Dogan, B.
Right arrow Articles by Middleton, L. P.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Erguvan-Dogan, B.
Right arrow Articles by Middleton, L. P.
Social Bookmarking
Add to CiteULike   Add to Complore   Add to Connotea   Add to Del.icio.us   Add to Digg   Add to Reddit   Add to Technorati  
What's this?
Hotlight (NEW!)
Right arrow
What's Hotlight?
DOI:10.2214/AJR.05.0422
AJR 2006; 187:339-344
© American Roentgen Ray Society

Clinical Observations

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.

Received March 18, 2005; accepted after revision June 7, 2005.

 
Address correspondence to B. Erguvan-Dogan (basakerguvan{at}yahoo.com).


Abstract
Top
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
OBJECTIVE. Confirmation of lesion retrieval after MRI-guided needle localization and surgical excision of breast lesions are difficult because the targeted lesion is not enhanced ex vivo. The aim of this study was to determine the feasibility of using specimen radiography to verify lesion removal after MRI-guided needle localization and surgical excision.

CONCLUSION. To our knowledge, our study was the first to examine the use of specimen radiography in the localization and excision of breast lesions. Specimen radiography is a reliable, cost-effective alternative to repeated dynamic contrast-enhanced MRI for confirming lesion removal after surgery. Specimen radiography has the additional advantage of facilitating immediate assessment of surgical margins.

Keywords: breast cancer • mammography • MRI • specimen radiography


Introduction
Top
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
Dynamic contrast-enhanced MRI of the breast is becoming increasingly useful in the detection, diagnosis, and management of breast cancer. For lesions that cannot be detected with other techniques, MRI-guided interventional procedures, such as needle localization and core biopsy, facilitate histopathologic analysis. MRI-guided needle localization and excisional biopsy is a well-recognized technique used in a growing number of practices [1-8]. However, it is difficult to confirm removal of the targeted lesion, because enhancement of the lesion diminishes over time and does not occur ex vivo.

Specimen radiography may be performed with different methods at various institutions [9, 10]. An especially successful method previously described entails imaging the entire biopsy specimen, slicing the specimen into thin sections, and acquiring a second radiograph of the sections [9]. This technique allows 3D assessment of surgical margins and confirmation of removal of the targeted lesion. Specimen radiography has been deemed especially effective for patients undergoing limited surgery who need immediate intraoperative assessment [9]. We hypothesized that specimen radiography may be useful in verifying that the targeted lesion has been excised after MRI-guided needle localization and excisional biopsy. To test our hypothesis, we studied the feasibility of using two-view specimen radiography to confirm removal of targeted lesions after MRI-guided needle localization and excision.


Materials and Methods
Top
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
We retrospectively reviewed charts, dynamic contrast-enhanced MR images of the breast, MRI-guided needle localization procedures, and specimen radiographs of patients who had undergone MRI-guided needle localization and excisional biopsy at a large academic institution. Owing to the nonexperimental and retrospective nature of the study, informed consent was not obtained from the patients. The institutional review board approved a waiver of informed consent.

Review of medical records provided patient demographics, initial indications for dynamic contrast-enhanced MRI studies of the breast and MRI-guided needle localization procedures, types of surgery, and the outcome of patient follow-up. Two breast radiologists experienced in interpreting breast MR images and breast specimen radiographs reviewed the MRI-guided needle localization procedures and specimen radiographs. An experienced breast pathologist reviewed the pathology specimens.

Patient Characteristics and Indications for Dynamic Contrast-Enhanced Breast MRI
Ten patients had undergone MRI-guided needle localization and excisional biopsy for 12 breast lesions. Eleven lesions were mammographically and sonographically occult; one lesion was seen only on the craniocaudal view. Indications for MRI-guided needle localization and excision were a history of ipsilateral or contralateral breast cancer and suspicious enhancement on MRI (n = 4), high genetic risk of breast cancer and a suspicious enhancing lesion (n = 3), newly diagnosed stage I breast cancer and ipsilateral enhancement suspicious for multicentric disease (n = 2), and occult primary tumor presenting as axillary metastasis (n = 1). The American College of Radiology BI-RADS—MRI Lexicon was used to classify the morphologic and dynamic characteristics of the lesions [11].

MRI-Guided Needle Localization Technique
All MRI-guided needle localization procedures were performed with a 1.5-T MRI scanner (Signa, GE Healthcare). For MRI-guided needle localization procedures, patients were positioned prone in a breast array coil with a fenestrated grid localizing system applying moderate to slight compression, and a fiducial marker was placed at the approximate entry site. After a localizing sequence was obtained, a limited sagittal dynamic 3D fast spoiled gradient-recalled echo study of the region of the lesion was performed immediately after rapid IV bolus infusion of 0.1 mmol/kg gadopentetate dimeglumine (Magnevist, Schering) at 3 mL/s with a power injector (Spectris MR injector, Medrad).

On review of the images on a workstation, a cursor was placed over the enhancing lesion on the monitor, and its distance from the lateral skin surface and the fiducial marker was determined by manual scrolling through sequential sagittal slices. An MR-compatible 20-gauge needle (MReye modified disposable Kopans spring hook localization needle, Cook) was used for lesion localization. An axial 3D fast imaging employing steady-state aquisition (FIESTA) sequence was obtained to verify the location of the needle, and depth adjustments were made if necessary. The hookwire was then deployed, and FIESTA scanning in the axial and sagittal planes was repeated to verify wire placement. A diagram outlining the procedure was drawn, and the approach was discussed with the surgeon in each case. The diagrams and representative films were reviewed with the surgeon before surgery. The surgeon excised a small amount of breast tissue that contained the hookwire and the lesion.

Specimen Radiography
After the targeted lesion was excised, the specimen margins were inked with six colors, each color indicating separate margins for histopathologic evaluation. Slices 0.3-0.5 cm thick were radiographed with a dedicated specimen radiography unit (Specimen Radiography System Model MX-20 Digital, Faxitron) at 25 kVp and 1.5-minute exposure time. The radiologist viewed the specimen radiographs and consulted with the pathologist and the surgeon while the patient was in the operating room. The integrity of the hookwire was assessed with whole-specimen radiography. Attention was also directed at identifying a discrete lesion and evaluating margin status. The findings on specimen radiography were used to guide the pathologist. When necessary, additional margins were obtained during surgery. In four cases, MRI was repeated 2 weeks after surgery to confirm successful excision of the targeted lesion.

For the purposes of this study, two experienced breast imagers retrospectively reviewed the specimen radiographs of all patients. On sliced-specimen radiography, the morphologic features of the lesion were compared with those seen on MRI. The morphologic criteria were those described for mammography and MRI in the BI-RADS lexicon [11]. The findings on specimen radiography were correlated with the histopathologic findings.


Results
Top
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
Final pathologic analysis revealed five (42%) of the lesions were malignant and seven (58%) were benign. Mean lesion size on MR images was 1 cm, ranging from 0.5 to 2.5 cm. Mean lesion size on specimen radiographs was 0.9 cm, ranging from 0.4 to 2.2 cm. Mean lesion size at final histopathologic analysis was 1.1 cm, ranging from 0.1 to 2.6 cm. Two benign lesions that did not show abnormalities on specimen radiographs were fibrocystic disease associated with benign epithelial hyperplasia. In one case in which specimen radiography revealed fibroadenoma associated with a 0.1-cm focus of ductal carcinoma in situ, findings on MRI 3 weeks after surgery showed no additional or residual suspicious enhancement. Histopathologic results are summarized in Table 1.


View this table:
[in this window]
[in a new window]

  		TABLE 1: Final Histopathologic Analysis of Excised Lesions

 

Whole-specimen assessment with specimen radiography showed an abnormality in five (42%) of 12 lesions. Three of these lesions were malignant and two were benign. In the three cases of malignancy, findings at margin assessment on whole-specimen radiography were concordant with those of the final histopathologic analysis. Integrity of the localizing wire was assessed on whole-specimen radiography, and all of the localization wires were intact. In all cases, the hookwire was seen inside or within 2 mm of the abnormality detected on whole-specimen radiography and therefore was a marker for identifying the targeted lesion.

Sliced-specimen radiography was performed in 11 of 12 cases. In 9 (82%) of 11 cases in which sliced-specimen radiographs were obtained, an abnormality similar to that seen on dynamic contrast-enhanced breast MRI was identified. In all five malignant cases, sliced-specimen radiographs showed the lesion in question and helped the pathologist to correctly identify the lesion (Figs. 1A, 1B, 1C, 1D, and 1E). In the one case in which only whole-specimen radiography was performed, benign epithelial proliferation and fibrocystic changes were found at histopathologic analysis. On sliced-specimen radiography in the cases of malignant lesions, four malignant lesions were associated with negative margins, and one invasive ductal cancer had positive margins (Figs. 2A, 2B, 2C, 2D, and 2E). In all malignant lesions, sliced-specimen radiographic findings were concordant with the final pathologic assessment of the margins.


Figure 1
View larger version (4K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		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
View larger version (5K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		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
View larger version (2K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		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
View larger version (2K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		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
View larger version (173K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		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
View larger version (5K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		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
View larger version (5K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		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
View larger version (2K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		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
View larger version (1K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		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
View larger version (164K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		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)

 
Of the five patients with malignant lesions, two were treated by mastectomy; one of these patients underwent axillary lymph node dissection and the other, sentinel lymph node biopsy. Two patients were treated with segmental mastectomy and sentinel lymph node dissection. One patient, who had a single 0.7-cm focus of ductal carcinoma in situ, underwent no additional surgery. All five patients with malignant disease underwent adjuvant chemotherapy, and four patients underwent postoperative radiation therapy. The patient with atypical ductal hyperplasia bordering on ductal carcinoma in situ was treated by wide excision with negative findings at the surgical margins. All patients were free of disease 7-27 months after MRI-guided needle localization and surgical excision.


Discussion
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
Specimen radiography is routinely used after mammographically guided needle localization and excision. Specimen radiography is also commonly used after sonographically guided needle localization and surgical excision, even though the targeted lesion may be mammographically occult. Another method of verification of lesion removal after sonographically guided needle localization and excision is specimen sonography. Specimen sonography, however, requires an expert sonographer, and margin assessment is difficult [12, 13]. Although none of the lesions evaluated in our study was seen on two-view mammography or sonography, specimen radiography revealed an abnormality in most (82%) of the cases. Radiographic margin assessment based on the two-view specimen radiographic findings also was correct.

All malignant lesions were correctly identified with two-view specimen radiography. A possible explanation for this condition may be that overlapping breast parenchyma is removed during ex vivo radiographic evaluation of the lesion. This theory is further supported by the fact that a higher percentage (82%) of the lesions was visualized on sliced-specimen radiography than on whole-specimen radiography (42%).

Identification of diffuse processes such as fibrocystic changes within the parenchyma with specimen radiography was less successful than identification of 3D masses. In our study, all of the detected cancers were ductal in origin. On the basis of our results with diffuse benign processes, evaluation of ill-defined malignant lesions, such as invasive lobular cancer, may be difficult with specimen radiography.

An important advantage of specimen radiography is identification of fractured localization wires after excisional biopsy. Specimen radiography allows removal of wire fragments before patients leave the operating room. Morris et al. [2] described two fractured localization wires, which were detected on follow-up mammograms in a series of 101 patients undergoing MRI-guided needle localization. In our study, specimen radiography helped verify removal of all hookwires after MRI-guided needle localization and excision.

Our results suggest that specimen radiography is helpful after MRI-guided needle localization and excisional biopsy. To our knowledge, this study was the first to examine the use of specimen radiography in this setting. A limitation of our study is the small number of cases. Larger studies are necessary for assessment of the use of specimen radiography after MRI-guided needle localization and excision of otherwise occult lesions. Another limitation is the lack of diffusely infiltrating cancers, which are difficult to identify on radiography. Specimen radiography is a reliable, cost-effective alternative to repeated dynamic contrast-enhanced MRI in the confirmation of lesion removal after surgery. Specimen radiography has the additional advantage of enabling immediate assessment of surgical margins. Further work in this area might include placement of a radiographically visible marker clip within the lesion to aid in identifying the lesion in question on sliced-specimen radiography and on in vitro specimen MR spectroscopy.


Acknowledgments
 
We thank Dawn Chalaire for editing the manuscript; Joe Zhou and Michelle Garcia for technical assistance; and Barbara Almarez Mahinda for secretarial assistance.


References
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

  1. Prat X, Sittek H, Grosse A, et al. European quadricentric evaluation of a breast MR biopsy and localization device: technical improvements based on phase-I evaluation. Eur Radiol2002; 12:1720 -1727[CrossRef][Medline]
  2. Morris EA, Liberman L, Dershaw DD, et al. Preoperative MR imaging-guided needle localization of breast lesions. AJR 2002; 178:1211 -1220[Abstract/Free Full Text]
  3. Schneider E, Rohling KW, Schnall MD, et al. An apparatus for MR-guided breast lesion localization and core biopsy: design and preliminary results. J Magn Reson Imaging 2001;14 : 243-253[CrossRef][Medline]
  4. Lo LD, Orel SG, Schnall MD. MR imaging-guided interventions in the breast. Magn Reson Imaging Clin N Am2001; 9:373 -380[Medline]
  5. Helbich TH. Localization and biopsy of breast lesions by magnetic resonance imaging guidance. J Magn Reson Imaging2001; 13:903 -911[CrossRef][Medline]
  6. Daniel BL, Birdwell RL, Ikeda DM, et al. Breast lesion localization: a freehand, interactive MR imaging-guided technique. Radiology 1998;207 : 455-463[Abstract/Free Full Text]
  7. Kuhl CK, Elevelt A, Leutner CC, et al. Interventional breast MR imaging: clinical use of a stereotactic localization and biopsy device. Radiology 1997;204 : 667-675[Abstract/Free Full Text]
  8. Orel SG, Schnall MD, Newman RW, et al. MR imaging-guided localization and biopsy of breast lesions: initial experience. Radiology 1994;193 : 97-102[Abstract/Free Full Text]
  9. Chagpar A, Yen T, Sahin A, et al. Intraoperative margin assessment reduces re-excision rates in patients with ductal carcinoma in situ treated with breast-conserving surgery. Am J Surg2003; 186:371 -377[CrossRef][Medline]
  10. McCormick JT, Keleher AJ, Tikhomirov VB, Budway RJ, Caushaj PF. Analysis of the use of specimen mammography in breast conservation therapy. Am J Surg 2004;188 : 433-436[CrossRef][Medline]
  11. American College of Radiology. Breast imaging reporting and data system atlas (BI-RADS atlas). Reston, VA: American College of Radiology, 2003
  12. Fornage BD, Ross MI, Singletary SE, Paulus DD. Localization of impalpable breast masses: value of sonography in the operating room and scanning of excised specimens. AJR 1994;163 : 569-573[Abstract/Free Full Text]
  13. Frenna TH, Meyer JE, Sonnenfeld MR. US of breast biopsy specimens. Radiology 1994;190 : 573[Abstract/Free Full Text]

Add to CiteULike CiteULike   Add to Complore Complore   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us   Add to Digg Digg   Add to Reddit Reddit   Add to Technorati Technorati    What's this?


This article has been cited by other articles:


Home page
 Am. J. Roentgenol.Home page
J. Li, D. D. Dershaw, C. H. Lee, J. Kaplan, and E. A. Morris
MRI Follow-Up After Concordant, Histologically Benign Diagnosis of Breast Lesions Sampled by MRI-Guided Biopsy
Am. J. Roentgenol., September 1, 2009; 193(3): 850 - 855.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Figures Only
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Erguvan-Dogan, B.
Right arrow Articles by Middleton, L. P.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Erguvan-Dogan, B.
Right arrow Articles by Middleton, L. P.
Social Bookmarking
Add to CiteULike   Add to Complore   Add to Connotea   Add to Del.icio.us   Add to Digg   Add to Reddit   Add to Technorati  
What's this?
Hotlight (NEW!)
Right arrow
What's Hotlight?

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS