74-year-old female with architectural distortion in the right breast identified on screening mammogram, subsequent ultrasound identified 2 suspicious areas in the right breast. Subsequent MRI identified additional lesions in the right breast, 12 o'clock position, 6:00 position, and left breast 9-10 o'clock position and 5:00 position. Right ultrasound re-identified the target lesion for biopsy. Lesion to be targeted for biopsy in the right breast at the 7:00 position 4 cm from the nipple (labeled #1) is hypoechoic and ill-defined and measures 1.9 x 1.0 cm. 2 masses identified at the at the 7:00 position 2 cm from the nipple in the right breast, with the largest lesion measuring 6 x 4 mm (labeled #2 and 3) which will be targeted to biopsy. No correlate was identified with MR finding in the right breast 6:00 position. Oval hypoechoic lesion in the right breast at the 12:00 position 4 cm from the nipple measures 4 x 3 mm, thought to correspond to the MRI finding, was chosen for biopsy.Targeted left breast second look ultrasound in the 9:00 position in the area of the enhancing mass identified at MR was not identified on ultrasound. Enhancing focus in the left breast at the 4-5 o'clock position identified on MRI had no ultrasound correlate.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 lesion 7:00 position #1 biopsy was cleansed with chlorhexidine over the target area. Transducer was sterilely sheathed. Local anesthesia was obtained using 2% lidocaine superficially and 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 excellent. No specimens sank to the bottom of the prefilled container of 10% formalin. All specimens partially sank. Specimen quality was judged very good.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. The right breast lesion 7:00 position #2 biopsy was cleansed with chlorhexidine over the target area. Transducer was sterilely sheathed. Local anesthesia was obtained using 2% lidocaine superficially and 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 excellent. No specimens sank to the bottom of the prefilled container of 10% formalin. All specimens partially sank. Specimen quality was judged very good.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. The right breast 12:00 position biopsy was cleansed with chlorhexidine over the target area. Transducer was sterilely sheathed. Local anesthesia was obtained using 2% lidocaine superficially and 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 excellent. No specimens sank to the bottom of the prefilled container of 10% formalin. All specimens partially sank. Specimen quality was judged very good.Specimens were sent to Pathology with an accompanying history sheet. 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. Post-procedure digital right CC and ML views revealed the percutaneously placed clips to be in the expected location in the central anterior aspect of the lesion. No evidence of hematoma or other complication. Distance between the 2 Hydro mark clips is 2.2 cm.A pressure dressing was positioned over the biopsy sites 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. Kulkarni and Dr. Jahangir. Dr. Kulkarni was present during the procedure at all times.
Successful ultrasound-guided core biopsy of the right breast lesions ( 7:00 (#1 and satellite) and 12:00 position) and clip placement. This is most likely a malignancy. Pathology is pending at this time.No sonographic correlate identified to the lesions seen on MRI in the left breast.No sonographic correlate identified to the lesion seen on MRI in the right breast 6:00 position.BIRADS: 5 - Highly suggestive of malignancy.RECOMMENDATION: X - No Letter.