65-year-old female with suspicious left breast mass at 2:00 position, and left abnormal axillary lymph node detected on the recent mammographic and ultrasound workup. The patient underwent breast MRI earlier today, which demonstrated additional mass in the left breast at 5:00 position. Ultrasound-guided biopsy of these lesions has been scheduled. MR directed ultrasound study is performed for the mass seen on the today's MRI at 5:00 position in the left breast. Detected is an irregularly-shaped hypoechoic mass with increased blood flow measuring 8 x 5 mm at 5:00 position, 2 cm from nipple in the left breast. Left ultrasound re-identified the mass at 2:00 position, 2 cm from the nipple measuring 6 x 6 mm, and the abnormal lymph node in the left axilla measuring 10 x 6 mm. 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 and post-procedure unilateral 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.The left breast was cleansed with chlorhexidine over the target area. Transducer was sterilely sheathed. 1. Left breast mass at 5:00 position: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 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 manner. 2. Left breast mass at 2:00 position:Local anesthesia was obtained using 1% lidocaine with 1:100,000 epinephrine at depth. Using the same skin entry as the prior biopsy, continuous ultrasound guidance and a inferolateral to superomedial approach, three 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 Bard ribbon clip was placed into the lesion in the usual manner. 3. Left axillary lymph node: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 inferolateral to superomedial approach, three 14-gauge core needle (Inrad) specimens were obtained of the lesion. Targeting was judged very good. All specimens partially sank in 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 manner. Specimens 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 left CC and ML views revealed the percutaneously placed Hydromark clip to be in the expected location at 5:00 position in the left breast, and at left axilla, and ribbon clip within the mass at upper outer quadrant in the left breast. Distance between two clips in the left breast is 45 mm on MLO view and 43 mm on CC view. 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. Abe.
Successful ultrasound-guided core biopsy of the left breast two masses and left axillary lymph node with clip placement. Pathology is pending at this time.BIRADS: 4 - Suspicious Abnormality.RECOMMENDATION: X - No Letter.