a

b c

Facility: Radiologist: Angela Sie, MD Pathologist: Lowell Rogers, MD Long Beach Memorial Breast Center Long Beach Memorial Hospital Long Beach, CA Long Beach, CA

Indication: 58-year old woman referred for screening mammography.

Findings: The screening mammogram was interpreted along with computer aided detection. A new 4 mm. irregular nodule was identifi ed in the right upper inner breast, 3 o’clock position, middle third. No other abnormalities were appreciated. On additional imaging, the irregular nodule persisted. No signifi cant associated calcifi cations or architectural distortion were appreciated. The ultrasound examination failed to visualize a mass in the region, and therefore, a breast MRI was performed.The breast MRI showed an enhancing nodule in the right 3 o’clock position. A second-look ultrasound exam revealed a very subtle, 5 mm, hypoechoic, solid, irregular nodule in the right 3 o’clock position, in the deep third of the breast, adjacent to the chest wall. The imaging fi ndings were deemed to be suspicious for malignancy, and therefore, biopsy was performed.

Equipment:

Model 3000 en-bloc® Biopsy System RF Controller with integrated vacuum-assist system

10 mm en-bloc® Biopsy System Probe Siemens Allegra Ultrasound

Method: The patient was placed on the examination table in the supine position and the lesion was imaged in the standard manner. A 10mm en-bloc® biopsy probe was placed in the en-bloc® handle.The patient’s right breast was cleaned and prepared. Anesthetic was administered according to standard protocol (a small skin weal followed by small boli (a) behind the lesion, (b) circumferential to the le-sion in both the deep and near quadrants, and (c) along the proposed needle track as the syringe was withdrawn). Because the lesion was adjacent to the chest wall, a fi nal bolus of lidocaine was adminis-tered between the lesion and the chest wall just prior to probe insertion (to elevate the lesion approxi-mately 0.5cm.)A small incision was made with a #11 scalpel. The incision was dilated with a tissue-spreader and the en-bloc® biopsy probe was inserted. The probe was

CASE PRESENTATION: Manipulating a chest wall lesion with a Lidocaine bolus to facilitate use of Ultrasound Guided en-bloc® to Biopsy a Lesion in the breast

Figure 1: RCC pre-procedure mammogram wih inner nodule (a) and RCC post-procedure mammogram wih clip and biopsy cavity(b).

Figure 2: Pre-Procedure ultra-sound image, be-fore (a) and after (b) application of lidocaine. Lido-caine lifts lesion approximately 0.5cm off chest

wall (highlighted).

a b

CASE PRESENTATION: Use of Ultrasound Guided en-bloc® to Biopsy a Lesion Initially Detected by MR

manually advanced in 5mm to 10mm increments by activating the precursor electrode. A more-than-usual horizontal approach was used due to the relatively deep location of the lesion. Care was taken not to hold power on the precursor electrode during periods when the ultrasound image was studied closely to determine the relative location of the probe and the lesion. The probe was advanced so that the probe tip was immedi-ately adjacent to the nodule.

The en-bloc® biopsy capture mechanism was activated. The specimen was removed by manually removing the probe from the breast. The skin adjacent to the probe dilated easily to allow specimen removal. A marker, consisting of a metal clip and a collagen plug, was placed in the biopsy cavity to aid in possible future localization

As can be seen in Figure 3 (the specimen ultrasound) and Figure 4 (the histopa-thology), capture succeeded in retrieving a representa-tive specimen.

Diagnosis: Invasive ductal carcinoma, Bloom Richardson grade 2. There is excellent tissue perservation with minimal thermal artifact focally and good correlation with the imaging fi ndings.

Follow-up: The patient underwent lumpectomy and sentinel lymph node biopsy after preoperative wire localiza-tion. The surgical pathology report indicated no residual malignancy. The en-bloc biopsy cavity and the clip were identifi ed. Lymph node dissection revealed 2 benign lymph nodes.

Discussion: This case explored two potential challenges of a breast biopsy: (1) a lesion which was diffi cult to image dur-ing the biopsy procedure and (2) a lesion which was close to the chest wall, increasing the need for greater precision in the targeting phase.

Regarding the fi rst challenge, MR imaging has greatly improved patient care, as it can detect many lesions not easily identifi able by X-ray mammography and/or Ultrasound. It can be a very useful tool in providing additional information when there is a discrepancy between the mammographic and sonographic fi ndings, as in this case. At times, a second-look ultrasound, after the breast MRI, succeeds in locating an abnormality which was not appreciated prior to the MRI. In this case, the MRI confi rmed the suspicious mammographic fi ndings, and prompted the second-look ultrasound exam and subsequent biopsy. Furthermore, we use MRI frequently in preoperative planning for breast cancer patients to help defi ne the extent of disease and for screening of the remainder of the breast tissue.

The other challenge of this case, performing biopsy on a lesion close to the chest wall, was facilitated by using the anesthetic to lift the lesion away from the chest wall. By elevating the lesion about 0.5cm , and targeting slightly off center (as can be seen in the histopathology slide), we were still able to procure a speci-men which gave us an adequate diagnosis, and in fact, removed the entire lesion in one piece.

CASE PRESENTATION: Manipulating a chest wall lesion with a Lidocaine bolus to facilitate use of Ultrasound Guided en-bloc® to Biopsy a Lesion in the breast

Figure 3: Ultrasound of en-bloc® specimen.

Figure 4: Histopathology of en-bloc® specimen.

Published by Neothermia Corporation ML076 Rev00