67-year-old woman with left retrocrural node or mass with FNA showing cancer cells presents for ultrasound guided core biopsy of the FNA proven malignant mass, abnormal left axillary lymph node and an additional mass seen in the 2:00 position on MRI 7/14/2015. Left ultrasound re-identified the target lesions for biopsy. The first lesion to be targeted is a hypoechoic mass measuring 16 x13 x 12 mm at the 10 o’clock position with increased vascularity, 2 cm from the nipple. The lesion was readily visible.The second lesion to be targeted is an oval hypoechoic mass measuring 6 x 4 x 5 mm at the 2:00 position without internal vascularity, 3 cm from the nipple. The lesion was identified on MRI 7/14/2015, and MR directed ultrasound detected a sonographic correlate. The lesion was somewhat subtle. The third lesion to be targeted is an abnormal lymph node measuring 2.1 x 1.7 cm in the left axilla, readily visible.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 left breast was cleansed with chlorhexidine over the first target area (10 o'clock position). 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, three 12-gauge core needle (Celero) specimens were obtained of the lesion. Targeting was judged excellent. All specimens sank to the bottom of the prefilled container of 10% formalin. Specimen quality was judged excellent. Using continuous ultrasound-guidance a Hydromark clip was placed into the lesion in the usual manner. Subsequently, local anesthesia was obtained for the second lesion (2 o'clock position) 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 inferior to superior approach, two 14-gauge core needle (Achieve) specimens were obtained of the lesion. Targeting was judged very good. All specimens partially sank in the prefilled container of 10% formalin. Specimen quality was judged good. Using continuous ultrasound-guidance a Bard wing clip was placed into the lesion in the usual manner. Finally, local anesthesia was obtained for left axilla 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, two 14-gauge core needle (Achieve) specimens were obtained of the lesion. Targeting was judged excellent. Both specimens sank to the bottom of the prefilled container of 10% formalin. Specimen quality was judged excellent. Using continuous ultrasound-guidance a Hydromark clip was placed into the lesion in the usual manner. Specimens were sent to Pathology with an accompanying history sheet. Pressure was held over the biopsy sites until all bleeding subsided. The skin incisions were closed with a Steri-Strip. Post-procedure digital left CC and ML views revealed the percutaneously placed Hydromark clip to be in the expected location in the central anterior aspect of the first lesion at 10:00, Bard wing clip to be in the expected location at 2:00 position and Hydromark clip to be in the left axillary lymph node. 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. Dr. Udoji, fellow assisted.
Successful ultrasound-guided core biopsy of two left breast lesions and left axillary lymph node with clip placement. Pathology is pending at this time.BIRADS: 5 - Highly suggestive of malignancy.RECOMMENDATION: X - No Letter.