40 year old female who underwent breast MRI earlier today for evaluating multiple masses in the left breast, one mass in the right breast and a suspicious left axillary lymph node, which had been detected at recent diagnostic mammogram and ultrasound (2/16/16). MRI demonstrated a highly suspicious mass with a possible satellite in the left breast, an enlarged intramammary lymph node in the left breast, a highly suspicious left axillary lymph node, and a small enhancing mass in the right breast. Following MRI findings correlated with the findings of recent mammogram and ultrasound performed on 2/16/16;A highly suspicious mass in the left breast, an enlarged intramammary lymph node in the left breast, a highly suspicious left axillary lymph node, and a small mass in the right breast. Because MR demonstrated a new finding, a possible satellite focus at lower outer quadrant in the left breast, MR-directed ultrasound was performed. A 4 mm mass was detected at 8:00 position, 3 cm from the nipple in the left breast, and it corresponded with the enhancing focus on MRI.Subsequently, ultrasound guided biopsy of following lesions were performed. 1. Right breast, 4 x 5 x 6 mm, 3:00 position, 2 cm from the nipple 2. Left breast, 11 x 10 x 13 mm, 7:00 position, 2 cm from the nipple (a highly suspicious mass)3. Left breast, 4 x 3 x 4 mm, 8:00 position, 3 cm from the nipple (a possible satellite focus)4. Left axilla, 21 x 17 x 21 mm necrotic lymph node.All the lesions demonstrate increased vascularity and readily visible.PROCEDURE: The procedure and its risks, including bleeding, infection, and failure to diagnose, and expected benefits of ultrasound-guided core biopsy with percutaneous placement of a marking clip to each biopsy site and post-procedural mammogram were discussed with the patient. Questions were answered. Consent was obtained both verbally and in writing. The time-out form was completed to confirm patient identity and side/type of procedure.First, the right breast lesion was biopsied.The right breast was cleansed with chlorhexidine over the target area. Transducer was sterilely sheathed. Local anesthesia was obtained using 2% lidocaine superficially, with 1% lidocaine with 1:100,000 epinephrine at depth. A 3 mm incision was made in the skin with a #11 scalpel blade. Using aseptic technique, continuous ultrasound guidance and a inferior to superior approach, three 14-gauge core needle (Inrad) specimens were obtained of the lesion. Targeting was judged very good. All specimens floated in the prefilled container of 10% formalin. Specimen quality was judged good. Using continuous ultrasound-guidance a Bard ribbon clip was placed into the lesion in the usual manner. Second, the mass in the left breast at 7:00 position (highly suspicious mass) was biopsied.The left breast was cleansed with chlorhexidine over the target area. Transducer was sterilely sheathed. Local anesthesia was obtained using 2% lidocaine superficially, with 1% lidocaine with 1:100,000 epinephrine at depth. A 3 mm incision was made in the skin with a #11 scalpel blade. Using aseptic technique, continuous ultrasound guidance and a lateromedial approach, three 12-gauge core needle (Celero) specimens were obtained of the lesion at the 7:00 position. Targeting was judged very good. All specimens floated in the prefilled container of 10% formalin but contained solid white tissue. Specimen quality was judged very good. Using continuous ultrasound-guidance a Hydromark clip was placed into the lesion in the usual manner. Third, the mass in the left breast at 8:00 position (possible satellite) was biopsied.Using the same sterile technique and local anesthesia, the 8:00 position lesion was biopsied by inferolateral to superomedial approach, and three 14-gauge core needle (Inrad) specimens were obtained of the lesion. All specimens floated. One specimen were fragmented. Specimen quality was judged good. Using continuous ultrasound-guidance a Bard wing clip was placed into the lesion in the usual manner. Finally, the largest suspicious left axillary lymph node was biopsied.Using same aseptic technique and local anesthesia, continuous ultrasound guidance and a inferolateral to superomedial approach, two 14-gauge core needle (Inrad) specimens were obtained of the lesion. Targeting was judged very good. All specimens sank to the bottom of the prefilled container of 10% formalin. Specimen quality was judged very good. Using continuous ultrasound-guidance a Hydromark clip was placed into the lesion in the usual mannerSpecimens were sent to Pathology with an accompanying history sheet. Pressure was held over the biopsy site until all bleeding subsided. The skin incision was closed with a Steri-Strip. Post-procedure digital right and left CC and ML views and the left axillary view revealed the percutaneously placed clips to be in the expected location, within the targets. No evidence of hematoma or other complication.A pressure dressing was positioned over the biopsy site and an ice pack positioned over the pressure dressing. Post-procedure instructions were reviewed with the patient both verbally and in writing. She tolerated the procedure well with no evident complications and left the Breast Imaging Department in stable condition.The procedure was performed by Dr. Wang and Al-Saraf. Dr. Abe was present during the procedure at all times.
Successful ultrasound-guided core biopsy of following lesions and clip placement;1. Right breast mass at 3:00 position: a Bard ribbon clip2. Left breast mass at 7:00 position (a highly suspicious mass): a Hydromark clip3. Left breast mass at 8:00 position (a possible satellite focus): a Bard wing clip4. Left suspicious axillary lymph node: a Hydromark clipPathology is pending at this time.BIRADS: 5 - Highly suggestive of malignancy.RECOMMENDATION: X - No Letter.