Ms. Trimby is a 64-year-old female with biopsy proven malignancy in the right breast and node positive disease in a right axillary lymph node. Same day MRI performed earlier today demonstrates an additional suspicious lesion anterior to the index malignancy in the right upper outer breast along with an enhancing lesion in the right inferior breast. She presents today for the following examinations:-Ultrasound-guided research biopsy of the known malignancy in the right upper outer breast-Ultrasound and ultrasound-guided biopsy of MR detected satellite lesion in the right upper outer breast-Ultrasound of right inferior breast for possible correlate to the MR detected enhancing lesion-Ultrasound-guided clip placement of node positive right axillary lymph node -In the right breast 11:00 location, approximately 11 cm from the nipple, the biopsy-proven malignancy was reidentified. This malignancy measures 1.6 x 1.1 x 1.0 cm. A research guided biopsy will be performed of this lesion-In the right breast 10:00 location, approximately 6 cm from the nipple, a sonographic correlate is identified for the MR detected suspected satellite lesion, measuring 0.7 x 0.6 x 0.6 cm. An ultrasound-guided biopsy with clip placement will be performed.-In the right breast 6:00 location, approximately 5 cm from the nipple, no sonographic correlate is identified for the MR detected enhancing lesion.-In the right axilla, an enlarged axillary lymph node is identified measuring 3.6 x 1.8 x 3.1 cm. An ultrasound-guided clip placement will be performed for this node.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.ULTRASOUND-GUIDED RESEARCH BIOPSY FOR THE INDEX MALIGNANCY IN THE RIGHT BREAST: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, six 12-gauge core needle (Celero) specimens were obtained of the lesion. Targeting was judged excellent. Two core specimens were placed in the provided formalin container. Four core specimens were placed in the RNALater container. Specimens were sent with the research assistant with an accompanying history sheet. Using continuous ultrasound-guidance a Hydromark clip was placed into the lesion in the usual manner. Pressure was held over the biopsy site until all bleeding subsided. The skin incision was closed with a Steri-Strip. ULTRASOUND-GUIDED BIOPSY FOR THE SUSPECTED SATELLITE LESION IN THE RIGHT BREAST: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, four 12-gauge core needle (Celero) specimens were obtained of the lesion. Targeting was judged excellent. Two core specimens were placed in the provided formalin container. Four core specimens were placed in the RNALater container. Specimens were sent to Pathology with an accompanying history sheet. Using continuous ultrasound-guidance a Hydromark clip was placed into the lesion in the usual manner. Pressure was held over the biopsy site until all bleeding subsided. The skin incision was closed with a Steri-Strip. MR-DETECTED ULTRASOUND FOR THE ENHANCING LESION IN THE RIGHT BREAST: An MR directed right breast ultrasound was performed of the inferior right breast at the site of focal enhancing lesion. In the right breast 6:00 location, approximately 4 cm from the nipple, no suspicious cystic or solid mass was identified.ULTRASOUND-GUIDED CLIP PLACEMENT FOR THE DISEASE POSITIVE RIGHT AXILLARY LYMPH NODE:Local anesthesia was obtained using 2% lidocaine superficially, with 1% lidocaine with 1:100,000 epinephrine at depth. Using continuous ultrasound-guidance a Hydromark clip was placed into the lymph node in the usual manner. Pressure was held over the biopsy site until all bleeding subsided. The skin incision was closed with a Steri-Strip. Post-procedure digital right CC, MLO and ML views revealed the following:-A Hydromark clip and dumbbell-shaped clip are identified in the index malignancy (the dumbbell shaped clip was placed at the outside hospital)-A Hydromark clip is seen in the right upper outer breast, at site of suspected satellite lesion detected by MRI. The two clips (index + suspected satellite) are separated by approximately 4 cm. -A Hydromark clip was placed in the central aspect of the right axillary lymph node. No evidence of hematoma or other complication.A pressure dressing was positioned over the biopsy sites and ice packs positioned over the pressure dressings. 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. Sheth.
(1) Successful ultrasound-guided research core biopsy of the known right breast malignancy with clip placement.(2) Successful ultrasound guided biopsy of an MR detected suspected satellite lesion in the right breast with clip placement. Pathology is pending at this time.(3) Successful ultrasound-guided clip placement of right axillary lymph node.(4) MR directed ultrasound in the right inferior breast at site of focal enhancing lesion did not demonstrate any sonographic correlate. Given the appearance on MR, a six-month follow-up MRI examination is recommended at this time to confirm stability of this finding. BIRADS: 6 - Known cancer.RECOMMENDATION: X - No Letter.