58 year old female with a suspicious lesion seen on mammogram and ultrasound at right 12:30 position. Additional suspicious lesion was seen on the breast MRI performed earlier today at right 12 o'clock position. Right ultrasound re-identified the target lesion (lesion #1) for biopsy. This is a hypoechoic mass measuring 10 x 8 mm at the 12:30 position with slightly vascularity, 5 cm from the nipple. The lesion was somewhat subtle.MR directed ultrasound was performed for the additional suspicious lesion seen on the MRI. Detected is an elongated intraductal lesion with increased vascularity measuring 14 x 3 mm at 12 o'clock position, 1 cm from the nipple (lesion #2). This lesion corresponds to the additional enhancing lesion on MRI.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 right breast was cleansed with chlorhexidine. Transducer was sterilely sheathed. Biopsy for lesion #1 (12:30 position, 5-cm from nipple):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 mediolateral approach, three 14-gauge core needle (Inrad) specimens were obtained of the lesion. Targeting was judged very good. One specimen sank to the bottom of the prefilled container of 10% formalin. Two specimens partially sank. Specimen quality was judged very good. 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. Biopsy for lesion #2 (12:00 position, 1-cm from nipple):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 mediolateral 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. Pressure was held over the biopsy site until all bleeding subsided. The skin incision was closed with a Steri-Strip. Specimens were sent to Pathology with an accompanying history sheet. Post-procedure digital right CC and ML views revealed the percutaneously placed Hydromark clip to be at the peripheral superior aspect of the lesion and the ribbon clip to be at expected location at anterior 12 o'clock position. 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 right breast lesion (2 sites) and clip placement. Pathology is pending at this time.BIRADS: 4 - Suspicious Abnormality.RECOMMENDATION: X - No Letter.