Technical Innovation
Vascular and Interventional Radiology
September 2011

Imaging-Guided Preoperative Hookwire Localization of Nonpalpable Extramammary Lesions

Abstract

OBJECTIVE. Imaging-guided hookwire localization of nonpalpable lesions in the breast is frequently performed preoperatively. Outside the breast, this procedure is useful for planning resection of lesions in anatomic regions without intrinsic landmarks. The purpose of this study was to review an experience with hookwire localization of nonpalpable extramammary lesions.
CONCLUSION. Preoperative imaging-guided hookwire localization is a useful technique that allows precise exploration and resection of nonpalpable lesions and increases confidence that the lesions have been entirely resected.
Preoperative hookwire localization is an essential tool in the surgical management of nonpalpable breast lesions [1]. Soon after the initial descriptions of hookwire localization in the breast, hookwires were successfully used for preoperative localization of lesions outside the breast. Some of the reports described use of the technique in the musculoskeletal and pulmonary systems and within the abdomen [27]. Rodrigues et al. [8] described preoperative needle localization for metastatic lesions of melanoma that were nonpalpable and metabolically active at PET.
The evolution and increased use of PET/CT and MDCT have resulted in increased vis ualization of small and metabolically active metastatic lesions that might not have been detected with older-generation imaging techniques. For types of cancer best treated surgically, early detection of isolated metastatic disease is of paramount importance, and targeted resection can render patients free of detectable disease. Most commonly, these lesions are confirmed to represent metastasis by use of imaging-guided percutaneous fine-needle aspiration or core biopsy followed by definitive resection. In the case of small nonpalpable lesions, wide excision can be time-consuming and unnecessarily traumatic, requiring extensive exploration to ensure complete removal of diseased tissue.
Because of the desire for precise, less invasive, and shorter-duration surgery, surgical oncologists increasingly request hookwire localization of small, nonpalpable lesions identified at PET/CT or MDCT. We describe our experience with this procedure as a consecutive case series and describe the techniques used. To our knowledge, previous reports of extramammary hookwire localization have been limited to case reports and case series with few subjects.

Materials and Methods

The institutional review board approved this retrospective HIPAA-compliant study. From October 2008 through October 2010, 16 nonpalpable extramammary hookwire needle localizations were performed on 12 patients (five men, seven women; average age, 52 years; range, 37–67 years) at our tertiary referral center. All 12 patients had known primary disease previously treated with curative intent. Two patients had multiple lesions. The 16 lesions were detected at follow-up imaging as part of standard oncologic imaging algorithms. PET/CT was available before localization of all but one lesion, all lesions exhibiting mild to moderate 18F-FDG activity. In all cases, imaging-guided biopsy for metastasis had been performed, results were positive, and a decision had been made to pursue definitive resection on clinical and imaging grounds. In addition, no other lesions suspicious for metastasis were seen at imaging, and hookwire localization was requested before definitive surgical resection.
All patients provided written informed consent before the procedure. After appropriate positioning, the patients were prepared and draped in the standard sterile manner. Once the lesion was identified with ultrasound (CT for one lesion), the overlying skin was anesthetized with 2% lidocaine buffered with sodium bicarbonate. A 20-gauge 5- to 11-cm-outer-diameter cannula needle (Modified Kopans Breast Lesion Localization needle, Cook) containing a preloaded hookwire was advanced through the lesion. To facilitate needle placement with ultrasound guidance, an attachable needle guide was fitted to the transducer, and the anticipated path of the needle was displayed with onscreen markers (Fig. 1). After confirmation of the needle-tip position within the lesion, the hookwire was held in position, the outer cannula was withdrawn, and deployment of the hook was confirmed by sonographic visualization (Figs. 2A, 2B, 2C, 2D, and 2E).
Fig. 1 Photograph shows 20-gauge 11-cm modified Kopans breast lesion localization needle set. Dark band (arrowhead) on hookwire indicates depth at which needle tip and wire tip are flush with one another.

Results

Table 1 outlines primary malignant tumors, lesion locations, localization modalities, and pathologic results of surgical resection. Fifteen of 16 lesions localized were in the subcutaneous tissues, superficial musculature, or extraabdominal and extrathoracic lymph node chains. One of the lesions was within the abdominal cavity along the anterior peritoneal lining, thus CT guidance was used in that case. The remaining lesions were localized with ultrasound guidance.
Most localizations (10/16) were performed for metastatic melanoma; other indications were chondrosarcoma (four lesions in one patient) and colonic adenocarcinoma (two lesions in two patients). Nearly all lesions (15/16) were confirmed to be metastatic, and one patient (patient 10) was found to have no malignancy. That patient had previously undergone partial vulvectomy for vulvar melanoma, and one of two sentinel lymph nodes was positive for metastasis. PET/CT showed mild abnormal activity in one inguinal lymph node, and because inguinal and femoral lymph node dissection was planned because of the positive sentinel node, hookwire localization was performed to ensure resection of the most suspicious node. The final pathologic result was no metastatic disease in any of the 24 resected lymph nodes, including the node localized with a hookwire.

Discussion

In hookwire localization of breast lesions, the cannula is typically advanced through the lesion and the hookwire deployed so that the thickened portion of the wire is located across the lesion. Our technique differs slightly in that we prefer to place the tip and barb of the wire in the center of the lesion. Ultimately, the exact technique used can vary as long as the radiologist and surgeon share their understanding of the location of the lesion with respect to the hookwire components.
Fig. 2A 58-year-old man with previously resected melanoma of right upper extremity metastatic to chest wall.
A, Contrast-enhanced CT scan shows enhancing mass (arrow) in right chest wall musculature.
Fig. 2B 58-year-old man with previously resected melanoma of right upper extremity metastatic to chest wall.
B, PET scan shows avid FDG uptake (arrow).
Fig. 2C 58-year-old man with previously resected melanoma of right upper extremity metastatic to chest wall.
C, Ultrasound images show nonpalpable lesion before needle placement (C), after placement of hollow cannula needle (arrows) into lesion (D), and after deployment of hookwire (arrows) and removal of cannula (E). Dotted line shows expected trajectory of needle placed with needle guide fixed to ultrasound transducer.
Fig. 2D 58-year-old man with previously resected melanoma of right upper extremity metastatic to chest wall.
D, Ultrasound images show nonpalpable lesion before needle placement (C), after placement of hollow cannula needle (arrows) into lesion (D), and after deployment of hookwire (arrows) and removal of cannula (E). Dotted line shows expected trajectory of needle placed with needle guide fixed to ultrasound transducer.
Fig. 2E 58-year-old man with previously resected melanoma of right upper extremity metastatic to chest wall.
E, Ultrasound images show nonpalpable lesion before needle placement (C), after placement of hollow cannula needle (arrows) into lesion (D), and after deployment of hookwire (arrows) and removal of cannula (E). Dotted line shows expected trajectory of needle placed with needle guide fixed to ultrasound transducer.
Although preoperative placement of a hookwire into nonpalpable lesions under imaging guidance is commonly performed for patients with breast cancer, we found only a few case reports of the use of this technique outside the breast [38]. Nonetheless, this technique is extremely useful when resection is needed for nonpalpable lesions in regions of the body where the absence of adequate landmarks prevents detailed correlation between imaging and the surgical site. Other techniques, including methylene blue and charcoal injection and gold marker placement, can be used for percutaneous localization of nonpalpable lesions. We did not consider these techniques because most of our experience has been with wire localization. An advantage of wire localization is that the surgeon can dissect along the length of the wire until the lesion is encountered. Such specific guidance is not possible when the lesions are marked with methylene blue or charcoal.
TABLE 1: Primary Tumor, Lesion Location, Imaging Modality, and Pathologic Results
Imaging-guided hookwire localization is a technically straightforward procedure that can be accomplished in the peripheral tissue and lymph nodes with a standard breast localization kit. As with all ultrasound-guided procedures, experienced eye-hand coordination is required to complete the wire localization. A successful procedure primarily results from accurate interpretation of the imaging examinations and careful selection of the target. Although rarely an issue in wire localizations in the breast, avoiding injury to normal anatomic structures, including blood vessels and nerves, is particularly important for extramammary procedures. In withdrawal of the needle over the wire, it is particularly important to hold the wire still for accurate placement. This step can be accomplished by resting the hand holding the wire on a part of the patient's body to avoid accidental advancement or withdrawal of the wire. Even with careful technique, wire misplacement and slippage can occur, and careful postprocedural imaging should be performed to assure proper placement.
Although we have found that the attachable needle guide facilitates prompt and accurate wire placement, a limitation of its use is that the angled approach requires transgressing a longer distance. This limitation can be overcome by use of a freehand technique or a perpendicular needle guide device.
At our center, hookwire localization is typically performed on the morning of surgery. After placement, the external end of the hookwire is wrapped in gauze and the patient transferred to the perioperative area. The patient and operative team are counseled to avoid dislodging the wire during transport and positioning for surgery. The surgeon can choose to make an incision in the skin through or adjacent to the site of entry of the wire and follow it to the lesion or can incise elsewhere and dissect down to meet the wire. The surgeon also can palpate the thickened portion of the wire. If the wire is properly positioned so the thickened portion is adjacent to the lesion, the surgeon can extend the surgical incision around the wire tip and barb to confidently excise the entire lesion. In addition, the oblique angle of the wire can define a longer path from skin to lesion than can a direct approach perpendicular to the skin surface. However, the surgeon can choose to follow the wire through the skin puncture or to approach the wire tip at a different angle on the basis of multiple considerations, including local anatomic compartments, the appearance of the postsurgical scar, and the presence of preexisting scars related to previous resections. It is important that the radiologist performing the procedure communicate with the surgeon to discuss the most useful approach to hookwire placement.
In our experience, preoperative hookwire localization allows accurate removal of nonpalpable abnormalities visualized on surveillance images. The technique can be used not only for removal of the abnormality for diagnostic purposes but also for therapeutic intervention for malignant tumors in which metastasectomy is a primary form of treatment, such as melanoma, sarcoma, and colon cancer. On the basis of anecdotal evidence, the surgeons at our institution believe that this procedure facilitates less extensive, less traumatic surgical exploration of these sites and increases the surgeon's confidence that the lesions in question have been resected in their entirety. Although the procedure can be mildly uncomfortable for patients and adds time to presurgical preparation, wire localization can minimize the time needed for the operation and reduce the likelihood of a repeat operation.

Footnote

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References

1.
Kopans DB, DeLuca S. A modified needle-hookwire technique to simplify preoperative localization of occult breast lesions. Radiology 1980; 134:781
2.
Hall FM, Frank HA. Preoperative localization of nonpalpable breast lesions. AJR 1979; 132:101–105
3.
Morrison WB, Sanders TG, Parsons TW, Penrod BJ. Preoperative CT-guided hookwire needle localization of musculoskeletal lesions. AJR 2001; 176:1531–1533
4.
Shah RM, Spirn PW, Salazar AM, et al. Localization of peripheral pulmonary nodules for thoracoscopic excision: value of CT-guided wire placement. AJR 1993; 161:279–283
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Finch IJ. Preoperative CT-guided percutaneous localization of small masses with a Kopans needle. AJR 1991; 157:179–180
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Lossef SV. CT-guided Kopans hookwire placement for preoperative localization of an appendicolith. AJR 2005; 185:81–83
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Kagalwala DZ, Shankar S, Zota V, Sandor A, Litwin DE. Preoperative computed tomography-guided hookwire needle localization of a peritoneal multilocular inclusion cyst. J Comput Assist Tomogr 2005; 29:602–603
8.
Rodrigues LK, Habib FA, Wilson M, Turek L, Kerlan RK, Leong SP. Resection of metastatic melanoma following wire localization guided by computed tomography or ultrasound. Melanoma Res 1999; 9:595–598

Information & Authors

Information

Published In

American Journal of Roentgenology
Pages: W525 - W527
PubMed: 21862783

History

Submitted: November 17, 2010
Accepted: January 25, 2011

Keywords

  1. extramammary
  2. hookwire
  3. lesion localization
  4. nonpalpable

Authors

Affiliations

Kelan J. Brown
Department of Radiology, Division of Abdominal Imaging, Duke University Medical Center, 200 Trent Dr, DUMC 3808, Durham, NC 27710.
Mustafa R. Bashir
Department of Radiology, Division of Abdominal Imaging, Duke University Medical Center, 200 Trent Dr, DUMC 3808, Durham, NC 27710.
Jay A. Baker
Department of Radiology, Division of Breast Imaging, Duke University Medical Center, Durham, NC.
Douglas S. Tyler
Department of Surgery, Division of Surgical Oncology, Duke University Medical Center, Durham, NC.
Erik K. Paulson
Department of Radiology, Division of Abdominal Imaging, Duke University Medical Center, 200 Trent Dr, DUMC 3808, Durham, NC 27710.

Notes

Address correspondence to M. R. Bashir ([email protected]).

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