Radio-guided localization of clinically occult breast lesions (ROLL): a DGH experience

AIM: Wire-guided localization (WGL) of clinically occult breast lesions is a well established technique. The aim of this study was to evaluate radio-guided localization (ROLL) within the breast screening service of a district general hospital. METHOD: The study group comprised 70 women who underwent ROLL under US and stereotaxis. This required an injection of Technetium-labelled colloidal albumen into the impalpable breast lesion. The women then proceeded to theatre, where localization was achieved with the use of a gamma probe. The lesion was identified by the presence of a high signal, caused by the injected isotope. The results of 70 consecutive cases in which a breast lesion was localized using ROLL were compared with the results of the latest 70 WGLs. RESULTS: All 140 lesions were successfully localized. However, the change in technique from WGL to ROLL offered significant benefits to patients. CONCLUSION: Our study demonstrated that ROLL is a practical and reliable localization technique. It can be implemented in hospital units without using valuable gamma camera time. The cost compares well with WGL. There is an improved cosmetic outcome for patients, and the very small quantity of radioactivity used is safe for both patients and staff.     

Detection and localization of occult lesions using breast magnetic resonance imaging: initial experience in a community hospital

RATIONALE AND OBJECTIVES: To evaluate the outcome of diagnostic breast MR imaging followed by MR guided needle localization for mammographically and sonographically occult breast lesions in a community-based hospital. MATERIALS AND METHODS: Records of the initial 50 consecutive patients who underwent MR guided needle localizations at our institution from November 2001 to January 2003 were reviewed. Sixty-two lesions were localized by MR and were mammographically and sonographically occult. Pathology following excision was reviewed and correlated with the MR findings. RESULTS: Cancer was present in 15 % (9/62) of lesions or 18 % (9/50) of the women localized. Five of the lesions (56%) were invasive carcinoma and four (44%) were ductal carcinoma in situ (DCIS). High-risk lesions, including atypical ductal hyperplasia (ADH) and atypical lobular hyperplasia (ALH), were found in 6.5 % (4/62) of the lesions, while 3 % (2/62) of the lesions contained lobular carcinoma in situ (LCIS). Cancer plus high risk lesions were found in 15/62 (24%) lesions or 14/50 (28%) of women who underwent biopsy. CONCLUSION: The data in this study supports findings from other studies conducted by large research institutions. In this regard, it is important that community-based hospitals, such as the one operating this breast MR program, can achieve the same positive predictive values as those found in data emanating from academic institutions.     

Ultrasound localization of occult breast lesions

High-resolution real-time ultrasound with either a 7.5- or 10-MHz transducer was used to localize 7/9 nonpalpable breast masses previously detected by mammography and to determine where the biopsy needle should be inserted.     

Preoperative localization of breast lesions: Current techniques

Image-guided preoperative localization of breast lesions is a common procedure. This article describes several commercially available localization options—wire localization, radioactive seed localization, localization with a radiofrequency reflector, and magnetic seed localization—and outlines the advantages and disadvantages of each. This information may help radiologists initiate conversations at their facilities with surgeons, pathologists, and hospital administration as they seek to add value and provide patient-centered care.     

Preoperative localization of nonpalpable breast lesions.

Surgeons are increasingly required to resect nonpalpable breast lesions only detected by mammography. Methods for preoperative localization of such lesions were reviewed with emphasis on invasive radiologic techniques using injection, needle, and wire markers. Invasive localization of nonpalpable breast lesions is a relatively simple procedure that should be available wherever breast biopsies and mammography are performed. Its precision and success relate to the radiologist's experience in marker placement and to close cooperation between the radiologist and surgeon.     

Efficacy of specimen radiography of clinically occult noncalcified breast lesions

Breast biopsy specimen radiography is required to ensure the accurate removal of clinically occult lesions discovered by mammography. Although used routinely for calcified lesions, it has not been widely accepted for those abnormalities that do not contain calcium. To determine the efficacy of film-screen specimen radiography for confirming the presence of clinically occult, noncalcified lesions, we undertook a prospective study of 104 specimen radiographs obtained after mammographically guided hookwire localization and planned excision of these lesions. Ninety-seven (93%) of the excised abnormalities were visualized on specimen mammograms. Malignancy was found in 22 (21%) of them. Thirty-five percent of the specimen radiographs showed better anatomic detail of the lesion, 48% showed the same detail, and 16% showed less detail than the original mammograms. Specimen radiographs failed to show the lesion in only seven cases. Five of the seven were true-negative specimen radiographs, making the efficacy rate 98%. Film-screen specimen radiography of clinically occult, noncalcified lesions is a highly effective procedure for correctly identifying the presence of a mammographic abnormality.     

Preoperative MR imaging-guided needle localization of breast lesions

OBJECTIVE: MR imaging of the breast can depict cancer that is occult on mammography and at physical examination. Our study was undertaken to determine the ease of performance and the outcome of MR imaging-guided needle localization and surgical excision of breast lesions. MATERIALS AND METHODS: Retrospective review revealed 101 consecutive breast lesions that had preoperative MR imaging-guided needle localization with commercially available equipment, including a 1.5-T magnet with a breast surface coil, a dedicated biopsy compression device, and MR imaging-compatible hookwires. Imaging studies and medical records were reviewed. RESULTS: Histologic findings in these 101 lesions were carcinoma in 31 (30.7%), high-risk lesions (atypical ductal hyperplasia or lobular carcinoma in situ) in nine (8.9%), and benign lesions in 61 (60.4%). Fifteen (48.4%) of 31 carcinomas were ductal carcinoma in situ, and 16 (51.6%) were infiltrating carcinoma (size range, 0.1-2.0 cm; median, 1.2 cm). Carcinoma was found in 16 (45.7%) of 35 lesions detected in women with synchronous cancer, 10 (32.3%) of 31 lesions detected on MR imaging for problem solving, and five (14.3%) of 35 lesions detected on MR screening. The time range to perform MR imaging-guided localization was 15-59 min (median time, 31 min). Complications encountered in three cases were retained wire fragments in two and breakage of the wire tip in one. CONCLUSION: MR imaging-guided needle localization can be performed quickly and safely with commercially available equipment. The positive predictive value of MR imaging-guided needle localization (30.7%) was comparable to that reported for mammographically guided needle localization and was highest in women with synchronous breast cancer.     

Needle localization of occult breast lesions with a curved-end retractable wire: technique and pitfalls

A series of 100 consecutive occult mammographic abnormalities were localized with a curved-end retractable wire system. A true-positive rate of 24% and a failure rate of 4% for initial excision were found. The pitfalls and advantages of this new needle-wire breast localizer are presented.     

Preoperative localization using a bidimensional mammographic technique of non-palpable lesions of the breast

It is widely known how the early diagnosis and treatment of breast cancer may lead to better prognosis. When a non-palpable breast lesion detected with mammography is correctly localized with fine-needle biopsy under X-ray guidance, the surgeon can easily remove the lesion while preserving normal breast tissue. In such cases, histology is also possible. The authors describe an easy bidimensional technique for the preoperative localization of occult nonpalpable breast lesions with a fine-needle. The procedure is feasible also with out-of-date equipment and does not cause any discomfort to the patients. It should be performed on all women with mammographic suspicion of non-palpable breast lesion. From January through December 1989 the authors performed 64 preoperative fine-needle biopsies of clinically-occult breast lesions. The presence of a lesion associated with microcalcifications was found to be indicative of malignancy more often than in the case of microcalcifications or lesions alone. Of 64 cases, histology demonstrated malignancy in 31 patients.     

Analysis of clinically occult and mammographically occult breast tumors.

Findings by xeromammography and clinical examination were compared in 16,000 self-selected women aged 45-64 who participated in a voluntary breast cancer screening program. A total of 138 malignancies were detected: 108 (78%) by mammography and 78 (57%) by clinical examination. Mammography was more effective for large breasts, fatty breasts, and in older women. Conversely, clinical examination was more effective for small breasts, dense breasts, and retroareolar lesions. Clinical detection decreased strikingly for lesions with negative lymph nodes, in situ and microinvasive lesions, deeply situated lesions, and lesions where microcalcifications were the sole mammographic finding.     

Differential diagnosis of mammographically and clinically occult breast lesions on diffusion‐weighted MRI

Purpose:

To investigate the diagnostic performance of diffusion‐weighted imaging (DWI) for mammographically and clinically occult breast lesions.

Materials and Methods:

The study included 91 women with 118 breast lesions (91 benign, 12 ductal carcinoma in situ [DCIS], 15 invasive carcinoma) initially detected on dynamic contrast‐enhanced magnetic resonance imaging (DCE‐MRI) and assigned BI‐RADS category 3, 4, or 5. DWI was acquired with b = 0 and 600 s/mm². Lesion visibility was assessed on DWI. Apparent diffusion coefficient (ADC) values were compared between malignancies, benign lesions, and normal (no abnormal enhancement on DCE‐MRI) breast tissue, and the diagnostic performance of DWI was assessed based on ADC thresholding.

Results:

Twenty‐four of 27 (89%) malignant and 74/91 (81%) benign lesions were hyperintense on the b = 600 s/mm² diffusion‐weighted images. Both DCIS (1.33 ± 0.19 × 10^?3 mm²/s) and invasive carcinomas (1.30 ± 0.27 × 10^?3mm²/s) were lower in ADC than benign lesions (1.71 ± 0.43 × 10^?3mm²/s; P < 0.001), and each lesion type was lower in ADC than normal tissue (1.90 ± 0.38 × 10^?3mm²/s, P ≤ 0.001). Receiver operating curve (ROC) analysis showed an area under the curve (AUC) of 0.77, and sensitivity = 96%, specificity = 55%, positive predictive value (PPV) = 39%, and negative predictive value (NPV) = 98% for an ADC threshold of 1.60 × 10^?3mm²/s.

Conclusion:

Many mammographically and clinically occult breast carcinomas were visibly hyperintense on diffusion‐weighted images, and ADC enabled differentiation from benign lesions. Further studies evaluating DWI while blinded to DCE‐MRI are necessary to assess the potential of DWI as a noncontrast breast screening technique. J. Magn. Reson. Imaging 2010;1:562–570. © 2010 Wiley‐Liss, Inc.