What is the role of imaging in breast biopsy with needle localization?

Updated: Dec 28, 2015
  • Author: William Teh, MBChB, FRCR; more...
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Answer

Answer

The modality of choice depends on operator expertise and the type of lesion. Most palpable lesions do not require image-guided localization. Breast lesions that are visible with ultrasonography can be adequately localized by using a skin marker if the lesion lies fairly superficially within the breast. [2] In addition, a surgeon can easily perform ultrasonographic localization in the operating room to identify the lesion and to confirm its adequate removal. [3, 4]

Other localization techniques include magnetic resonance imaging (MRI) and mammography (by using a grid, a holey plate, or a stereotactic method) (see the images below). [5, 6] Although a number of techniques are used to localize nonpalpable breast lesions, needle localization is the most common. [7, 8, 9]

Mammogram shows a spiculated mass to be transfixed Mammogram shows a spiculated mass to be transfixed by the guidewire.
Grid technique of localization. Grid technique of localization.

After successful placement of a guidewire, the patient is then taken to the operating room, where the surgeon commonly makes an incision at the site of the wire insertion and excises the wire and the lesion (see the following images). Some surgeons place a stiff outer cannula along the wire down to the wire tip and excise the tip along with the lesion.

Orthogonal (mediolateral) projection confirms the Orthogonal (mediolateral) projection confirms the position of the needle to be placed beyond the cluster of microcalcification.
Specimen radiograph shows the wire and the localiz Specimen radiograph shows the wire and the localized speculated mass in situ, with a good excision margin.

Impalpable lesions may also be marked by using an injection of methylene blue, [10, 11] charcoal suspension, [12] or radioisotopes. [13]

It is essential to obtain a diagnosis with a core biopsy under ultrasonographic or stereotactic guidance before surgery so that a definitive, 1-step surgical procedure can be planned. Once malignancy is diagnosed, any of the following procedures can be used to localize the lesion:

  • Skin-marker localization

  • Needle localization under ultrasonographic guidance

  • Needle localization under stereotactic guidance [6]

  • Radionuclide localization combined with sentinel-node biopsy [11]


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