Hookwire localisation of breast lesion

Clinical:

  • A 47 years old lady
  • Came for screening mammogram
  • Asymptomatic
  • No family history of cancer 
    Bilateral mammogram in MLO and CC views

    Mammogram findings:

    • Bilateral fatty breasts (Birads a) with symmetrical parenchymal pattern.
    • There is a speculated mass seen at left upper outer quadrant.
    • This lesion measured about 10 mm in largest diameter.
    • Associated stromal distortion seen.
    • No suspicious clustered microcalcification. No¬† skin changes or nipple retraction. No abnormal axillary nodes.
Ultrasound breast

Ultrasound findings:

  • There is a hypoechoic lesion at Lt2-3H measuring about 10×10 mm in size.
  • It showed speculated margin with ‘finger-like’ projection.
  • Posterior shadowing and presence of penetrating vessels are also seen.
  • No other lesion is seen in both breasts. No dilated duct.
  • No abnormal axillary node.

US-guided hookwire localisation done prior to wide local excision:

  • Mass lesion is identified using ultrasound noted to be at about 3H location.
  • Procedure performed under aseptic technique.
  • Puncture using Kopan hookwire needle done under ultrasound guidance.
  • J-tip secured about 2.0 cm from the mass lesion.
  • Mammogram done post hookwire localisation showed the tip is about 2 cm from the edge of the lesion.
  • No complication noted immediately after the procedure.
  • Post procedural specimen shows mass lesion removed with surrounding tissue.

HPE result:

  • Invasive carcinoma of no special type, Grade 2
  • TNM stage T1N1aMx
  • Tumour cells are seen at medial margin, other margins (superficial, deep, superior, inferior and lateral margins are free
  • Left axillary clearance: 1 out of 13 lymph nodes with evidence of metastasis.

Progress of patient:

  • Referred to other hospital for further treatment.
  • Planned for re-excision for non-clear margin

Discussion (Hookwire localisation):

  • Pre-operative hookwire localization is part of surgical management of non-palpable breast lesions
  • It can be done using mammography, ultrasound or MRI guidance.
  • There is no specific preparation for this procedure, however since operation usually planned few hours after the procedure, patient is prepared for the operation.
  • Recent mammograms, ultrasounds or MRI scans and the reports, should be available to be reviewed by the radiologist before the procedure.
  • Procedure is performed under aseptic technique with local analgesia.
  • Once the needle is in the correct position, a fine wire is passed down the centre of the needle and the needle is removed, leaving the wire in place.
  • A final mammogram/ultrasound is carried out to show the surgeon where the tip of the wire lies in relation to the abnormality that is to be removed (a mammogram provides a better visual image for the surgeon of where the tip of the wire lies than ultrasound).
  • Some surgeons prefer marking on the skin of the patient of where the tip of wire.
  • After the procedure, part of the wire that is sticking out from breast tissue is taped down to the skin, and the hookwire remains in the abnormality in the breast.
  • Patient is pushed to OT with previous imaging and the images from the breast hookwire localisation will be sent together¬† to the operating theatre, so that the surgeon can refer to them.
  • The surgeon will remove the wire together with the abnormality at the time of the operation.
  • Specimen is sent back to radiology department to confirm removal of lesion.

 

Author: radhianahassan