Pre-surgical Hook-wire Localization

DEFINITION

Hook-wire needle localization is a procedure performed on occult lesions identified in the breast by mammography. It is a process which results in inserting a flexible wire beside and beyond the breast lesion pre-operatively to indicate the area of concern to be removed during surgery.

INDICATIONS

• A suspicious lesion observed in flat field or diagnostic mammogram
• A non-palpable or occult lesion visible on mammography
• Multiple occult, lesions seen unilaterally
• Carried out in conjunction with Ductography on a Intraductal lesion

CONTRAINDICATIONS

• Lesion is palpable and will be easily identified during surgery
• Lesion is probably benign and is better tested under core biopsy
• Patient unable to endure or cooperate with examination

EQUIPMENT

1. Hexachloridine or similar antibacterial skin wash
2. Antibacterial cream antiseptic
3. 10X10 sterile gauze wipes
4. 1” transpore surgical tape
5. 
   
6. An indelible skin marke
7. Sterile gloves
8. 3cm, 5cm, 7.5cm or 10cm 20g needle hook-wire combinationAn immobilization clip
9. A dedicated mammography unit
10. A variety of paddle and bucky sizes
11. Fenestrated location paddle
12. Multi-holed location paddle
13. A cross-hair wire localization aperture
14. An armless adjustable wheeled procedure chair
15. An adjustable height stretcher
16. An alpha/numeric specimen container

PROCEDURE

1. Alpha/numeric fenestrated localization paddle
2. Cross-hair localization wires set on lesion at 2@E.5
3. Lesion

1. Alpha/numeric fenestrated localization paddle
2. 20g needle and hook-wire localization device
3. Lesion
   
4. Hook-wire deployed at 2@E.5 coordinates

1. Immobilization clip
2. Hook-wire with needle removed anchored beside and beyond lesion
3. Lesion imaged in orthogonal projection

1. Take patient history

2. Perform physical breast exam

3. Patient is placed into the procedure chair and rolled to the mammography unit

4. Acquire orthogonal (CC and 90º) projections of breast lesion

5. Technologist marks the target with an indelible marker and cleanses skin with disinfectant

6. The proper approach is chosen: APPROACH CHART

LESION LOCATION	APPROACH PROJECTION
Superior Aspect	CC Projection
Lateral Aspect	90º Lateral/medial projection
Medial Aspect	90º Medial/lateral projection
Inferior Aspect	“From Below” projection (difficult to achieve)

7. The lesion is imaged in the proper approach projection using the appropriate localization paddle (fenestrated/multi-holed)

8. Using the indelible marker on the skin and an outline of the paddle marked on the skin the lesion is positioned as close to the center of the paddle opening as possible

9. The patient remains in compression and the projection must remain identical

10. The cross-hair localization wires are placed at the proper coordinates

11. The suitable length needle hook-wire device is selected

12. Equipment is opened for the radiologist

13. Radiologist inserts the 20g needle and hook-wire device perpendicularly into the proper cross-hair wire coordinates

14. The cross-hairs are removed and the technologist acquires an image of the position of the tip of the needle in relation to the lesion

15. The radiologist remains with the immobilized patient while the images are being processed

16. The radiologist adjusts the needle and guide wire as needed according to the images

17. The technologist releases the compression and rolls the patient back from the unit

18. The projection is changed to an exact orthogonal view of the scout projection

19. The localization paddle is removed and the regular mammogram paddle is attached and the orthogonal view is acquired

20. The patient again remains in compression while the images are processed

21. The images are assessed as to the relationship between the needle tip and the lesion in the opposite direct

22. The radiologist adjusts the position of the needle/hook-wire device as required

23. The radiologist advances the hook-wire through the needle and deploys it into the breast, leaving the wire in the breast tissue, the needle is carefully removed from the breast

24. The technologist acquires a final image of the hook-wire imbedded in the tissue beside and beyond the lesion

25. The wire is trimmed to 2” above the skin and an immobilization clip is inserted across the wire at the skin

26. An antibacterial ointment is applied to the wire/skin junction

27. The technologist applies a drain sponge around the wire and a 10X10 sterile gauze dressing secured with 1” surgical tape

28. The patient is cautioned to keep the involved arm as still as possible and she is transferred to a stretcher to be relocated to the operating room

29. An alpha/numeric specimen container is sent with the patient

30. The radiologist reports the images of the procedure and they are sent to the operating room with the patient for the surgeon to use in locating the lesion to be removed

31. All patient contact surfaces must be cleaned with antibacterial/antifungal cleaner

32. All sharps must be disposed of in proper sharps containers

33. All biohazardous material must be disposed of in the proper biohazard containers

34. The surgeon will use the wire as a guide to removing the suspicious lesion and the piece of tissue including the wire will be sent for imaging

35. The technologist images the breast specimen using the magnification table

36. The specimen is imaged compressed within the alpha/numeric specimen box

37. If the offending lesion is not seen within the specimen, the technologist must inform the surgeon who will then remove further tissue and place it in the specimen box

38. If the lesion is contained within the specimen image a ‘pin’ is placed at the correct alpha/numeric coordinates and the box is sent to pathology

39. The technologist informs the surgeon that the lesion lies within the specimen and the patient’s procedure is finished

WHAT ARE THE ADVANTAGES OF HOOK-WIRE PRE-OPERATIVE NEEDLE LOCALIZATION?

• Safe
• Simple
• Fast
• Inexpensive
• Minimal discomfort
• Patient surgery is more accurate
• Patient surgery is less extensive
• Patient surgery is less disfiguring
• The surgeon knows that the lesion has been completely removed before ending procedure
• The pathologist gets a more specific tissue sample with the lesion area marked with a ‘pin’

CAN THERE BE COMPLICATIONS WITH HOOK-WIRE PRE-OPERATIVE NEEDLE LOCALIZATION?

Complications are very rare but can include:

• Bruising (therefore care is taken to insert the needle quickly, minimally and proficiently and to apply some pressure when dressing the area)
• Infection (therefore care is taken to cleanse skin at every juncture and sterile technique is used during procedure)
• Pneumothorax (therefore the insertion of the needle is monitored very carefully with appropriate imaging to assure integrity of the needle tip)

SUMMARY

Routine mammographic projections, diagnostic follow-up such as magnification, coned compression, U/S, or even MRI or PET scanning do not always show everything we need to see. Often we have to resort to interventional procedures to identify the existence of breast disease.

Our specialty is unique combination of technology, nursing care, chemistry, physics and art. We must be ready, willing and eager to rise to the challenge. If we can’t image it, often, no one knows its there.

Until next time friends,

Anne