(Radiology. 2000;214:585-590.)
© RSNA, 2000
Lesions Entirely Removed during Stereotactic Biopsy: Preoperative Localization on the Basis of Mammographic Landmarks and Feasibility of Freehand Technique-Initial Experience1
R. James Brenner, MD
1 From the Joyce Eisenberg Keefer Breast Center, John Wayne Cancer Institute, St Johns Health Center, 1328 22nd St, Santa Monica, CA 90404. Received December 9, 1998; revision requested January 26, 1999; final revision received April 28; accepted May 12. Address reprint requests to the author (e-mail: james.brenner@stjohns.org).
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Abstract
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Seven patients with mammographic lesions entirely removed at percutaneous core needle biopsy that required wider excision underwent freehand localization of the site of the prior lesion with orthogonal and reproducible mammographic landmarks to guide needle placement. Successful excision was accomplished in all cases, as evidenced by similar histopathologic findings, fibrin bands or collagen, and core needle biopsy tract at microscopy.
Index terms: Biopsies, technology, 00.1261, 00.1267 • Breast, biopsy, 00.1261, 00.1267 • Breast neoplasms, diagnosis, 00.31, 00.32 • Stereotaxis, 00.1267
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Introduction
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The accuracy and cost-effectiveness of stereotactic core needle biopsy of the breast as compared with excisional biopsy has been validated in several clinical reports (1–10). Management problems arise when a mammographically depicted lesion is removed entirely during the stereotactic biopsy and further surgery is indicated, because the radiographic lesion in question is no longer present for mammography-directed preoperative localization and further excision (11). In anticipation of this problem, visual or more commonly used radiographically visible markers may be introduced into the breast by the radiologist immediately after percutaneous biopsy to help identify the site of biopsy in case subsequent mammographic preoperative localization is required (12,13). Two problems derive from this proposed solution of removal of the entire mammographic lesion during stereotactic biopsy and placement of a marking clip or coil. First, the cost of the 11-gauge needle required to accurately introduce the more commonly used and commercially available clip and the clip itself is more than twice as expensive, for example, as that of the 14-gauge needle used during similar vacuum-assisted biopsy procedures (Mammotome; Biopsys Medical, Irvine, Calif) (14,15). The cost-to-benefit ratio of the procedure becomes less favorable because the large majority of lesions sampled at core biopsy have low suspicion and require no marker (1–6). Second, the placement of the clip does not always correspond to the site of biopsy (Fig 1) and thus does not always provide a reliable marker for preoperative localization.
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Figure 1a. Incorrect placement of localization clip after core needle biopsy. (a) Spiculated lesion (circle and arrow were drawn on original mammogram) was sampled with vacuum-assisted multidirectional core needle biopsy. (b) Mediolateral oblique and (c) craniocaudal mammograms depict a metallic clip (open arrow) 2.3 cm craniad to and 1 cm lateral to biopsy site (long black arrow), which is identified with introduced air in the biopsy cavity. Note also a benign ringlike calcium deposit with a lucent center (short black arrow in b).
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Figure 1b. Incorrect placement of localization clip after core needle biopsy. (a) Spiculated lesion (circle and arrow were drawn on original mammogram) was sampled with vacuum-assisted multidirectional core needle biopsy. (b) Mediolateral oblique and (c) craniocaudal mammograms depict a metallic clip (open arrow) 2.3 cm craniad to and 1 cm lateral to biopsy site (long black arrow), which is identified with introduced air in the biopsy cavity. Note also a benign ringlike calcium deposit with a lucent center (short black arrow in b).
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Figure 1c. Incorrect placement of localization clip after core needle biopsy. (a) Spiculated lesion (circle and arrow were drawn on original mammogram) was sampled with vacuum-assisted multidirectional core needle biopsy. (b) Mediolateral oblique and (c) craniocaudal mammograms depict a metallic clip (open arrow) 2.3 cm craniad to and 1 cm lateral to biopsy site (long black arrow), which is identified with introduced air in the biopsy cavity. Note also a benign ringlike calcium deposit with a lucent center (short black arrow in b).
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Other techniques for localization of biopsy sites where the mammographic lesion has been entirely removed include identification of the postbiopsy hematoma or injected air or reproduction of the stereotactically directed needle path for placement of a localization wire; these techniques have been criticized and not found wide acceptance (13,16–19). Localization of postbiopsy air or hematoma has been advocated by some investigators but considered insufficiently reliable by others (16–19). The possibility of identifying specific anatomic structures at the site of biopsy for preoperative localization has been proposed but not studied (13), to my knowledge. Potential concerns for removal of excess tissue have been raised, but such concerns are probably subordinate to the need for accurate localization techniques that facilitate the removal of possible or frankly malignant disease when markers are inadvertently placed at an unsatisfactory distance from the actual biopsy site or lesions requiring additional surgery are removed without the placement of a clip or coil. If cost savings are to be optimized, then the restriction on the use of clips for low-suspicion lesions will eventually result in situations in which unexpected histologic results may necessitate preoperative localization and wider excision, such as the finding of malignancy incidental to a low-suspicion lesion sampled at biopsy (20).
The purpose of this study was to investigate the feasibility of using mammographic landmarks for preoperative freehand localization of sites previously subjected to stereotactic biopsy in which the entire lesion was removed, where there were no radiographic markers present and additional surgery was required.
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Materials and Methods
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Between November 1993 and July 1998, seven patients (age range, 47–77 years; mean age, 61 years) were referred to this breast center for preoperative localization of sites where solitary mammographically identified lesions had been removed entirely with stereotactic breast biopsy because they required additional surgery. Six of the seven lesions were removed with 14-gauge needles, and five of these with vacuum-assisted biopsy devices. One lesion (case 2) was removed with an 11-gauge needle with a vacuum-assisted biopsy device, and one (case 4) was removed with a 14-gauge needle and a spring-loaded biopsy device.
Mammographic studies performed between the time of stereotactic biopsy and preoperative localization demonstrated complete removal of the mass or calcifications initially subject to core needle biopsy. The mean size of lesions removed, on the basis of greatest diameter measured on standard mammograms, was 9 mm (range, 4–11 mm). The mean time between core needle biopsy and subsequent surgery was 22 days (range, 5–90 days). In one case of a mass and one case of calcifications, a small ill-defined density was seen in the area of the original lesion that measured 8 mm (seen on two images) and 3 mm (seen on only one image), respectively; each was believed to represent hematoma. Informed consent was obtained from each patient prior to the preoperative localization, which included a discussion of the possibility of failure to recover the tissue area subjected to prior core biopsy diagnosis.
Preoperative craniocaudal and mediolateral, lateromedial, or mediolateral oblique (depending on the imaging findings before core needle biopsy) mammograms were obtained and compared with the images obtained before core needle biopsy. The location of the reference lesion was determined by measuring the distance from the nipple to the lesion along the skin in both craniocaudal and mediolateral, lateromedial, or mediolateral oblique projections by using a standard metric ruler; the shortest depth of the lesion location from the skin surface (actual depth) was similarly measured. The same measurements were performed on the preoperative mammograms obtained prior to localization. Review of the two orthogonal images demonstrated sufficient identity and translation of mammographic landmarks from the images obtained before core needle biopsy to the prelocalization images to demarcate closely the approximate location of the removed lesion (Fig 2). Included in evaluation of mammographic landmarks were surrounding parenchymal pattern, calcifications, and vessels. The triangulated point of entry for the needle was marked with indelible ink on the skin overlying the lesion.
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Figure 2a. Needle localization of focus where mammographically visualized microcalcifications were entirely removed. (a) Craniocaudal and (b) mediolateral mammograms of right breast demonstrate small 2-mm focus of suspicious clustered microcalcifications (straight arrow in a and straight arrow drawn on b with indelible ink). Note representative landmarks such as intersecting veins in a (curved arrow) or curving ligaments in b (curved arrows). Open arrow in b points to lymph node. (c) Craniocaudal and (d) mediolateral mammograms obtained 26 days later show placement of needle tip at the site of prior calcifications on the basis of easily identifiable mammographic landmarks. Note again reproducible landmarks of intersecting veins in c (curved arrow) or curving ligaments in d (curved arrows). Observe how even the overlapping appearance of a lymph node (open arrow in c and d) from the more superior portion of the breast in a does not prevent determination of the site of prior calcifications and proper needle placement. (e) Photomicrograph of excisional biopsy specimen shows prior needle tract artifact (solid curved arrows) and associated fibrin band (open curved arrow). Minimal residual atypical ductal hyperplasia (short straight arrow) is seen remaining after initial core needle biopsy. Single residual microcalcification (long straight arrow) adjacent to residual atypical ductal hyperplasia was not depicted at mammography. Needle tract artifact combined with fibrin band and zonal granulation tissue is incompatible with fictitious artifact and represents the site of prior core needle biopsy. (Hematoxylin-eosin stain; original magnification, x100.)
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Figure 2b. Needle localization of focus where mammographically visualized microcalcifications were entirely removed. (a) Craniocaudal and (b) mediolateral mammograms of right breast demonstrate small 2-mm focus of suspicious clustered microcalcifications (straight arrow in a and straight arrow drawn on b with indelible ink). Note representative landmarks such as intersecting veins in a (curved arrow) or curving ligaments in b (curved arrows). Open arrow in b points to lymph node. (c) Craniocaudal and (d) mediolateral mammograms obtained 26 days later show placement of needle tip at the site of prior calcifications on the basis of easily identifiable mammographic landmarks. Note again reproducible landmarks of intersecting veins in c (curved arrow) or curving ligaments in d (curved arrows). Observe how even the overlapping appearance of a lymph node (open arrow in c and d) from the more superior portion of the breast in a does not prevent determination of the site of prior calcifications and proper needle placement. (e) Photomicrograph of excisional biopsy specimen shows prior needle tract artifact (solid curved arrows) and associated fibrin band (open curved arrow). Minimal residual atypical ductal hyperplasia (short straight arrow) is seen remaining after initial core needle biopsy. Single residual microcalcification (long straight arrow) adjacent to residual atypical ductal hyperplasia was not depicted at mammography. Needle tract artifact combined with fibrin band and zonal granulation tissue is incompatible with fictitious artifact and represents the site of prior core needle biopsy. (Hematoxylin-eosin stain; original magnification, x100.)
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Figure 2c. Needle localization of focus where mammographically visualized microcalcifications were entirely removed. (a) Craniocaudal and (b) mediolateral mammograms of right breast demonstrate small 2-mm focus of suspicious clustered microcalcifications (straight arrow in a and straight arrow drawn on b with indelible ink). Note representative landmarks such as intersecting veins in a (curved arrow) or curving ligaments in b (curved arrows). Open arrow in b points to lymph node. (c) Craniocaudal and (d) mediolateral mammograms obtained 26 days later show placement of needle tip at the site of prior calcifications on the basis of easily identifiable mammographic landmarks. Note again reproducible landmarks of intersecting veins in c (curved arrow) or curving ligaments in d (curved arrows). Observe how even the overlapping appearance of a lymph node (open arrow in c and d) from the more superior portion of the breast in a does not prevent determination of the site of prior calcifications and proper needle placement. (e) Photomicrograph of excisional biopsy specimen shows prior needle tract artifact (solid curved arrows) and associated fibrin band (open curved arrow). Minimal residual atypical ductal hyperplasia (short straight arrow) is seen remaining after initial core needle biopsy. Single residual microcalcification (long straight arrow) adjacent to residual atypical ductal hyperplasia was not depicted at mammography. Needle tract artifact combined with fibrin band and zonal granulation tissue is incompatible with fictitious artifact and represents the site of prior core needle biopsy. (Hematoxylin-eosin stain; original magnification, x100.)
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Figure 2d. Needle localization of focus where mammographically visualized microcalcifications were entirely removed. (a) Craniocaudal and (b) mediolateral mammograms of right breast demonstrate small 2-mm focus of suspicious clustered microcalcifications (straight arrow in a and straight arrow drawn on b with indelible ink). Note representative landmarks such as intersecting veins in a (curved arrow) or curving ligaments in b (curved arrows). Open arrow in b points to lymph node. (c) Craniocaudal and (d) mediolateral mammograms obtained 26 days later show placement of needle tip at the site of prior calcifications on the basis of easily identifiable mammographic landmarks. Note again reproducible landmarks of intersecting veins in c (curved arrow) or curving ligaments in d (curved arrows). Observe how even the overlapping appearance of a lymph node (open arrow in c and d) from the more superior portion of the breast in a does not prevent determination of the site of prior calcifications and proper needle placement. (e) Photomicrograph of excisional biopsy specimen shows prior needle tract artifact (solid curved arrows) and associated fibrin band (open curved arrow). Minimal residual atypical ductal hyperplasia (short straight arrow) is seen remaining after initial core needle biopsy. Single residual microcalcification (long straight arrow) adjacent to residual atypical ductal hyperplasia was not depicted at mammography. Needle tract artifact combined with fibrin band and zonal granulation tissue is incompatible with fictitious artifact and represents the site of prior core needle biopsy. (Hematoxylin-eosin stain; original magnification, x100.)
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Figure 2e. Needle localization of focus where mammographically visualized microcalcifications were entirely removed. (a) Craniocaudal and (b) mediolateral mammograms of right breast demonstrate small 2-mm focus of suspicious clustered microcalcifications (straight arrow in a and straight arrow drawn on b with indelible ink). Note representative landmarks such as intersecting veins in a (curved arrow) or curving ligaments in b (curved arrows). Open arrow in b points to lymph node. (c) Craniocaudal and (d) mediolateral mammograms obtained 26 days later show placement of needle tip at the site of prior calcifications on the basis of easily identifiable mammographic landmarks. Note again reproducible landmarks of intersecting veins in c (curved arrow) or curving ligaments in d (curved arrows). Observe how even the overlapping appearance of a lymph node (open arrow in c and d) from the more superior portion of the breast in a does not prevent determination of the site of prior calcifications and proper needle placement. (e) Photomicrograph of excisional biopsy specimen shows prior needle tract artifact (solid curved arrows) and associated fibrin band (open curved arrow). Minimal residual atypical ductal hyperplasia (short straight arrow) is seen remaining after initial core needle biopsy. Single residual microcalcification (long straight arrow) adjacent to residual atypical ductal hyperplasia was not depicted at mammography. Needle tract artifact combined with fibrin band and zonal granulation tissue is incompatible with fictitious artifact and represents the site of prior core needle biopsy. (Hematoxylin-eosin stain; original magnification, x100.)
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After local application of a sterilizing solution, preoperative localization was performed with a freehand technique with placement of the localization device (either hypodermic needle or needle with hook wire) forward from the skin marker site, perpendicular to the chest wall in an anteroposterior manner, parallel to the ground so that the introduced needle hub was not moved during subsequent mammography performed to determine the needle tip location, in a manner that has been previously described (21) (Fig 2). With the needle in place, manual compression of the breast was performed to approximate the diversion of the needle direction during mammography; the needle direction was readjusted until the needle maintained a straight and direct approach to the lesion site as corroborated with manual compression and confirmed with orthogonal mammography. For example, if the needle tip was 1 cm superior to the intended site, the needle was replaced and diverted inferiorly until the tip corresponded to the target site.
For the two cases in which only prior mediolateral oblique images were available, manual compression was used in only the lateral and craniocaudal directions, but an additional mediolateral oblique image was obtained in addition to the mediolateral and craniocaudal images. The position of the needle with respect to the landmarks did not change in one case from the mediolateral oblique to the mediolateral images (presumably because the prior mediolateral oblique and thus preoperative mediolateral oblique images were acquired at a steep angle). In the other case, with the lesion in the upper outer quadrant, the needle was repositioned slightly more cranially to approximate the site identified on the original mediolateral oblique images, and both mediolateral oblique and mediolateral images were obtained.
This procedure was followed up with consultation with the surgeon to facilitate extension of the biopsy sampling slightly more cranially and caudally to account for a potential discrepancy. In this manner, all surrounding mammographic landmarks could be identified with respect to the needle tip to ensure proper placement. In one additional case, a single readjustment of the needle position was required, and five needles were placed satisfactorily on the first attempt. In the right breast, two biopsy sites were located in the upper outer quadrant and one at the 6 o'clock position; in the left breast, one biopsy site was located in the 12 o'clock position and three in the upper outer quadrant. Methylene blue dye (0.1 mL) was injected after all needle insertions. After localization, all cases were discussed preoperatively with the surgeon, and routine surgery was performed in the same manner as used in any excisional biopsy or wide resection after a malignant diagnosis. One surgeon was involved with five cases and another with two cases. The weight of the specimen is not recorded at this institution, but the two largest diameters of the removed specimen were measured at radiography of the specimen.
Histopathologic findings were reviewed in all cases to confirm the concordance of the initial biopsy site, the preoperative localization site, and the final histopathologic findings. Evidence of similar disease or upgrading of initial core needle biopsy diagnosis together with evidence of core needle biopsy tract with fibrin bands and granulation tissue (eg, macrophages, fibroblasts) were considered conclusive that the proper location of the prior biopsy site was identified and surgically removed (Fig 2). For invasive cancers, lymph node dissections were performed of sentinel nodes by using conventional hematoxylin-eosin and immunohistochemical staining. All patients underwent clinical and mammographic follow-up at 6-month intervals for the first year (where applicable) and annually thereafter.
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Results
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No complications occurred during the preoperative localization or surgical procedures. All seven sites of prior biopsy were successfully localized on the basis of measurements and anatomic landmarks on preoperative mammograms that recapitulated the parenchymal pattern seen on initial mammographic studies that showed the suspicious lesions (Table). All sites were confirmed on the basis of the histologic identification of prior core needle biopsy diagnoses or upgraded disease (eg, core needle biopsy diagnosis of atypical ductal carcinoma with ductal carcinoma in situ or invasive cancer shown at surgery) associated with core needle tracts, fibrin bands, and granulation tissue; in the case delayed by 90 days, collagen and fibrous scar were identified. The average diameter of tissue removed at excisional biopsy, as measured at noncompressed single-view radiography of the specimen, was 4.2 cm (range, 2.5–6.0 cm). The dimensions of the excised material were comparable to those obtained during routine needle-localized excisional biopsy of mammographic lesions less than 1.5 cm.
Three cases of atypical ductal hyperplasia diagnosed with core needle biopsy showed additional microscopic foci of atypical ductal hyperplasia at surgery. One case of atypical ductal hyperplasia demonstrated evidence of low-grade ductal carcinoma in situ with cribriform morphology and a 0.4-cm focus of low-grade infiltrating ductal carcinoma. One case of ductal carcinoma in situ, intermediate grade with both solid and cribriform morphology, found at core needle biopsy showed evidence of a microfocus of residual ductal carcinoma in situ at surgery.
Both cancers diagnosed with core needle biopsy were tubular carcinomas and were associated with small residual infiltrating tubular carcinoma at surgery after preoperative localization. The first measured 6 mm at initial mammography prior to surgery, and a 1-mm focus was found at surgery. The second measured 7 mm at initial mammography, and a 3-mm focus was found at surgery. Clear margins greater than 4 mm circumferentially were found on both surgical specimens obtained at wide excision, and they measured 5 x 4 cm and 5 x 3 cm, respectively, at radiography of the specimen. Sentinel lymph node dissections with both hematoxylin-eosin and immunohistochemical (cytokeritan) staining demonstrated no evidence of metastatic disease. In the case in which excisional biopsy demonstrated ductal carcinoma in situ and a 0.4-mm focus of low-grade infiltrating ductal carcinoma, findings at sentinel node biopsy were negative for malignant disease.
Except for the most recent case, all patients were followed up for 6 months to 4 years (mean, 1 year; median, 1 year) with no evidence of interval or residual disease at clinical or mammographic examination. In particular, the patients with infiltrating cancer were followed up for 3 months (surgery recently completed), 8 months, and 4
years, respectively.
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Discussion
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The removal of mammographically visualized portions of a breast lesion does not ensure complete removal of the lesion itself (13,22,23). In cases of anticipated tissue sampling error, additional surgical excision is recommended. For example, the diagnosis of atypical ductal hyperplasia has been associated with intraductal or invasive malignancy in up to 54% of cases in which surgery has been performed (24,25). In addition, the finding of malignancy at initial biopsy will prompt further surgery in most cases as part of definitive management (7).
Removal of all mammographic features of a lesion during percutaneous core needle biopsy creates a difficult situation when further surgery is required. Burbank (11) reported 48% of 345 breast lesions did not appear at mammography after core needle biopsy with use of a vacuum-assisted core biopsy cutting device. Fajardo et al (13) reported placement of microcoils at the core needle biopsy site after observation of inadvertent removal of the entire lesion at postbiopsy stereotactic imaging in 13 cases. The placement of coils or clips is usually successful but unfortunately does not ensure precise identification of the biopsy sites in all cases. Liberman et al (22) reported placement of a metallic clip within 1 cm of 40 (95%) of 42 lesions in which a clip was placed after stereotactic 11-gauge directional vacuum-assisted breast biopsy. In an additional two lesions, the clip failed to deploy.
Even with deployment, the insertion of the clip too deep into the biopsy cavity may result in considerable displacement of the clip from the intended site during release of the compression plate. This has been described as a problem for introducing clips through 14-gauge needles (the accordion effect [22]), but the problem may also occur with 11-gauge needles. (Fig 1). The placement of clips or coils is accomplished during the percutaneous biopsy with the anticipation that further surgery and therefore mammographically guided preoperative localization may be necessary. Unless clips or coils are placed during every core needle biopsy procedure in which the entire lesion might be removed, a finite percentage of cases will occur in which radiographic localization must be performed without an easily identifiable metallic marker. Sometimes the clip will appear properly placed because of the obliquity of the mammographic projection when in fact it is not immediately adjacent to the lesion removed.
Alphanumeric grids and fenestrated paddles are commonly used for preoperative mammographic localization, which usually permits the needle to enter from a craniocaudal or lateral approach, but freehand techniques are commonly used by many radiologists, with some radiologists using both techniques depending on the location of the lesion. Preference for one approach or another has been the subject of incidental commentary but has undergone no direct comparative study (26–29), to my knowledge.
Notwithstanding the preference for a given approach, the use of a grid is predicated on approaching the lesion as seen in one image during the procedure so that visualization of all surrounding identifiable breast parenchymal landmarks is restricted. Transgression through the lesion is necessary during grid-assisted localization to ensure that when the breast is released from compression, the proximity of the lesion to the needle tip can be determined along its path. In cases in which the lesion has been removed, this determination may be more difficult. Freehand localization with an anteroposterior approach permits landmarks to be reproduced in two orthogonal projections both during and after needle placement. The position of the localization needle tip with respect to the desired location can be more easily determined during the procedure. In this study, the needle tip was determined to approximate the location of the original lesions with orthogonal geometry as opposed to the method of stereotaxis available to Liberman et al (22). However, it is likely that sufficiently identifiable landmarks may be identified with grid-assisted techniques, perhaps with more difficulty, and the feasibility of this more commonly used approach to preoperative localization is also worth studying.
In this series of patients, the amount of tissue removed with excision, as determined by measuring the diameter of specimens, was relatively larger than the diameter that might be obtained by experienced surgeons for mammographic lesions of negligible diameter. The larger excision was not considered excessive, given the importance of removing the area of concern with only mammographic landmarks for guidance, especially as it was similar to that removed for lesions less than 1.5 cm in diameter. In like manner, the size of the wide excision specimens obtained for malignancy was no greater than that of specimens customarily received and imaged, although specific recommendations for the size of wide excision specimens have not been established, to my knowledge, and depend in part on the size of the original malignancy. In cases in which the landmarks appear substantially different on mediolateral oblique and lateral images and no lateral images were obtained before core needle biopsy—a situation that we did not encounter but that may arise—consultation between the radiologist and surgeon should include analysis of such discrepancies and a surgical plan that may include more tissue obtained in the superoinferior (craniocaudal) direction.
When the clip or coil is at a distance from the lesion that was sampled at core needle biopsy, this preoperative method of localization may actually be more accurate than would simple localization of the site of the clip or coil and require removal of less tissue. Of paramount importance is the identification of concordant pathologic conditions and prior core needle biopsy tracts, fibrin bands, and granulation tissue. No case was encountered where evidence of prior biopsy site could not be validated.
Complete removal of lesions during core needle biopsy with no residual tumor at subsequent surgery has been reported (7,22,30,31). Therefore, experience with the freehand technique should be gained during routine preoperative localizations before use of this method for lesions removed entirely at core needle biopsy so sufficient confidence in accurate localization can be gained in case no residual disease is encountered at surgery. Even under such circumstances, careful search of the specimen for needle tract, fibrin strands, and hemosiderin deposits from the core needle biopsy will validate that the correct site has been removed. Our limited follow-up data serve to corroborate the more important proof of successful localization provided with microscopy.
In summary, the radiologist performing percutaneous stereotactic breast biopsy is likely to encounter situations in which the mammographic signs of the lesion are entirely removed. In this case, unless the radiologist has anticipated this situation by accurately placing a radiographic localization device in the biopsy cavity during the procedure, the problem of localization of the site of the previously demonstrated lesion can be remedied by using the freehand technique described herein on the basis of reproducible mammographic anatomic landmarks that surround the initial lesion as determined on two orthogonal images obtained during needle placement. This technique may also be useful if a metal clip or coil is placed inadvertently in a position at an unfavorable distance from the biopsy site. For very small mammographic lesions, and those likely to be removed during core biopsy procedures, placement of a metallic marker is still a very helpful procedure for subsequent preoperative localization procedures and should lead to successful excision in the majority of cases. The ability to perform preoperative freehand localization of lesions entirely removed during stereotactic biopsy by using mammographic landmarks, even among those who use grid or fenestrated paddle technology for routine mammographic localizations, may enable radiologists to salvage otherwise unresolvable situations. When a small but finite percentage of such cases nonetheless require additional surgery, this technique will facilitate successful preoperative localization and excision. Future controlled prospective studies involving both freehand and grid-assisted localization with mammographic landmarks or metallic markers may provide a basis for assessment of a cost-to-benefit analysis with regard to selection of technique and amount of tissue for adequate resection.
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Acknowledgments
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I thank Allan Morris, MD, for his assistance in review of the histopathologic findings.
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Footnotes
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Author contributions: Guarantor of integrity of entire study, R.J.B.
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Abstract
Introduction
