Ms. Jackson is a 50-year-old female with biopsy-proven breast cancer on the left 3:00 location and metastatic left axillary lymph node. She presents today for MR-directed ultrasound and possible ultrasound-guided biopsy of the lesion found on the recent MRI dated 9/18/2015, and a marker clip placement into the proven metastatic left axillary lymph node. Left breast ultrasound was performed over the lower inner quadrant. At the 6:00 location, 4 cm from the nipple, there is a 9 x 10 x 9 mm hypoechoic mass with irregular margin and increased blood flow. In addition, at the 6:30 location, 3 cm from the nipple, there is another 4 x 5 x 7 mm hypoechoic mass with irregular margin and increased blood flow. These 2 lesions correspond to the two abnormal enhancement found on the MRI dated 9/18/2015. It was decided to sample the mass at 6:00 position in the left breast.On discussion with Dr. Jaskowiak, we decided to place an additional marker clip (Hydromark) in the proven metastatic lymph node in the left axilla, to make sure the marker clip would be seen on ultrasound after completion of chemotherapy. Left axillary ultrasound identified the target lymph node for clip placement. It was in the medial part of the axilla. Bipolar maximum dimension was 25 mm, complete fatty hilar replacement and mild non-hilar cortical blood flow was seen on color flow imaging. 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 EVALUATION AND ULTRASOUND-GUIDED BIOPSY OF THE INFERIOR LEFT BREAST MASSES:The left breast and left axilla were 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 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.Specimens were sent to Pathology with an accompanying history sheet. Using continuous ultrasound-guidance a Bard wing 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 CLIP PLACEMENT IN THE LEFT AXILLARY LYMPH NODE:Subsequently, ultrasound guided clip placement in the metastatic left axillary lymph node was performed.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 inferior to superior approach, a Hydro mark clip was directed into the target node in the usual manner.No evidence of hematoma or other complication on post procedure ultrasound. The skin incision was closed with a Steri-Strip. 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.Post-procedure digital left CC and ML views revealed the percutaneously placed clip to be in the expected location in the central aspect of the lesion at 6:00 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 Drs. Abe and Wang Dr. Abe was present during the procedure at all times.
1. Successful ultrasound-guided core biopsy of the left breast 6:00 lesion, and clip placement. Pathology is pending at this time.2. Ultrasound-guided clip placement to the known metastatic left axillary lymph node.BIRADS: 4 - Suspicious Abnormality.RECOMMENDATION: X - No Letter.