46 year old female presenting with recent biopsy-proven intraductal papillary proliferation and focal ADH in the right breast inner quadrant presents for preoperative wire localization. On review of the prior studies, there are multiple oval masses in the lower inner right breast in a ductal distribution confirmed on ultrasound. One of the masses subsequently biopsied showed intraductal papillary proliferation and focal ADH. On MRI similar findings are seen within a large area of abnormal segmentally distributed clumped non-mass enhancement, spanning approximately 13 cm. Upon discussion with Dr. Jaskowiak, plan is to perform a bracket localization targeting the biopsy clip and additional asymmetry anteriorly.Target biopsy clip with adjacent masses are in the right breast in the lower inner quadrant region located posteriorly at 3 o’clock (site 1). Target asymmetric density is located in the right breast in the lower inner quadrant region located in mid-breast (site 2), anterior to site 1.The procedure, risks including bleeding, mis targeting and infection, and benefits of needle-wire localization 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 site of procedure. Right breast wire localization site 1:The right breast was placed in an alphanumeric grid using medial to lateral approach. When the target was positioned in the aperture of the grid, the skin was cleansed with chlorhexidine. Local anesthesia was obtained using 2% Lidocaine. Using coordinates from the grid, a 5 cm Kopans needle was placed adjacent to the lesion. On orthogonal mammography, adequate positioning of the needle was confirmed after adjusting depth so the needle tip was approximately 2cm deep to the center of the target. A spring wire was then deployed. Repeat two view orthogonal mammograms reveal the spring wire to be in excellent position.Right breast wire localization site 2:The right breast was placed in an alphanumeric grid using medial to lateral approach. When the target was positioned in the aperture of the grid, the skin was cleansed with chlorhexidine. Local anesthesia was obtained using 2% Lidocaine. Using coordinates from the grid, a 5 cm Kopans needle was placed through the lesion. On orthogonal mammography, adequate positioning of the needle was confirmed after adjusting depth so the needle tip was approximately 2cm deep to the center of the target. A spring wire was then deployed. Repeat two view orthogonal mammograms reveal the spring wire to be in excellent position. The mammogram was annotated and reviewed with Dr. Jaskowiak prior to the patient's procedure. Patient tolerated the procedure well and was sent to the holding area in stable condition. Dr. Udoji performed the procedure under direct supervision of Dr. Abe, who was present during the procedure at all times.Orthogonal digital specimen radiographs revealed the clip, multiple small masses, and both wires to be within the specimen.
Successful needle localization of the right breast, two sites.BIRADS: 4 - Suspicious Abnormality.RECOMMENDATION: X - No Letter.