To Mark or Not to Mark; that is the Question?

OBJECIVES

Skin markers: should we use them all of the time? Should we use them some of the time? Should we never use them? Is there a rule?

Unfortunately, like in much of breast imaging, there is no hard and fast rule. We are the thin ‘pink’ line between radiologist and patient. The clinical information is our responsibility. What we choose to chart, what visual information we impart, how we convey that data is the only link the reading radiologist has to the patients physical characteristics. If we are remiss or misleading in our descriptions of our patient’s breast health, attributes or abnormalities the radiologist can make an error in judgment or under or over call a situation. In some cases this can lead to a tragic mistake.

A controlled skin marking system can help us be clear, concise and accurate about certain clinical breast features. Used with a little common sense, knowledge and proficiency markers on the skin can be invaluable; sometimes even a life saver.

NIPPLE MARKERS:

The practice of placing a tiny spot marker on the nipple when imaging the breast has become a very common practice. The topography of the inside of the breast is very complex: made up of several lobes of tortuous parenchyma.

The radiologist usually uses the nipple marker as a stable guide as to distance and depth. We mammographers use the nipple markers to locate lesions that are not seen well in two projections, to measure the posterior nipple line or to estimate lesion location for diagnostic follow-up, core or open biopsy.

Most facilities place nipple markers on every patient. It is a sensible, easy, efficient method of making the exam a little more explicit.

These markers come in various sizes 1.5, 1.8, 2.0 etc. I use the smallest markers I can get so they are as unobtrusive as possible. So, unless the reading radiologist objects, I recommend nipple markers on all exams.

Example:

MARKING RAISED SKIN LESIONS:

Moles, skin-tags, hemangiomas, warts and any variety of skin lesions sometimes show up on the mammogram and mimic pathology. How can we make it clear to the reading radiologist where the lesions are on the skin, what they are and are they visible on the x-ray or digital image?

If we indicate every mark on the skin of the breast and chest wall we risk our images looking like a Christmas tree. Too many markers can be confusing and even distracting to the radiologist. So, which lesion to mark and which to leave untouched?

All aspects of mammography require a good working knowledge of what is acute and what is innocent. The first place to start is the previous exam if it is available. Peruse the images, indicate which skin lesion showed before and find them on the patient. Next use your diagram to draw all the raised skin lesions and signify what they are (mole, wart, sebaceous cyst, skin tag etc.). Finally only mark lesions that are likely to appear on the image and chart carefully which markers designate which lesions.

As in all instances, the radiologist has the last word on what goes on the image and does not. What ever the decision of the reader on skin markers, the diagram and description of skin lesions is essential.

Example:

1. Large Mole (crusty): Marked
2. Small Sebaceous Cyst: Marked
3. Accessory Nipple: Marked
4. Small patch of raised acne: Not Marked

SCAR MARKERS:

Widespread breast screening detects early small changes in breast tissue and leads to much increased incidence of breast surgery. Every invasive open breast biopsy produces a scar on the skin with an adjacent scar bed within the breast parenchyma. The distortion and asymmetry caused by this type of breast trauma can lead to serious misdiagnosis if the radiologist is unaware of the surgery. Once again we stand between the patient and the reader as a go between; a translator of our patient’s physical condition. And, once yet again we are faced with the dilemma of which scars to mark and which ones to leave alone.

As a well trained mammographer we should have a working understanding of what surgery does to the breast; what kind of image is produced by which kind of operation? We must ask ourselves: Is this recent or old surgery? Is the surgical bed broad and deep or narrow and superficial? Was the lesion benign or malignant? Was the surgery accompanied by radiation treatment? Is there skin distortion involved with the scarring?

Once again marking every small scar on the patient’s skin can lead to a confusing, misleading over decorated mammogram. So is there a rule? Of course not! There is NEVER a rule!

Start by perusing the pre and post operative images that you have on hand. Note any distortion, skin thickening, asymmetry or opacity related to a relatively new resolving scar bed. This type of scar should be marked with a translucent wire until the “post-operative” distortion has stabilized or resolved completely. Once the scar has been measured and read as “post-op scarring = no change”, subsequent mammograms should not need the scar markers. Old healed scarring should not be marked with a skin marker. These old surgeries have been stable for years and have already been assessed.

Having said all that, there is a significant exception to this policy of imaging old healed surgeries without translucent wires. If the patient is experiencing any symptoms in or around the old surgical site, if a recent mammogram shows any change in the symmetry of the parenchyma or if the patient’s health care provider questions any change in the patient’s current breast health then it again becomes imperative to carefully mark the old scar bed.

Whether your radiologist wants the scar beds marked or not it is vital that we chart the scars, new and old, describe the surgery, type and diagnosis.

Charted Diagram of Surgical History:

1. Partial Mastectomy: 2004/ DCIS
2. Lymph Node Dissection: 2004/ Positive
3. Cyst Removal: 1992/ Benign

Mammography Image with Scar Markers in Place:

LESION MARKERS:

The patient’s clinical history both current and past is essential for a proper assessment of the diagnostic image. The reading radiologist gets all his/her clinical information from the mammographer. We are the ones who collect the clinical data, we are ones who examine the patient’s breast, we are the ones who see the ravages of disease and/or treatment, and therefore, we are also the ones who must carefully impart that information.

Signs and symptoms of early breast cancer are subtle. Anyone who chooses to work as a diagnostic mammographer must be willing to accept the responsibility of assessing the clinical condition of the patient and of accurately communicating that data to her medial partner, the radiologist. This skill is essential; the patient’s prognosis can depend on it.

Our first responsibility is to correctly describe any current clinical abnormality you, the patient or the health care provider has observed. We describe clinical lesions as to size, shape, margins, location and attenuation. We chart them as to these certain criteria by using a standard set of symbols on the torso diagram.

All palpable masses should be marked on the skin to indicate to the reader the location of the lesion inside the breast in relation to the palpable mass, the nipple base, any scar bed in the vicinity and the skin line. This is where your skin marking system really proves its value. Using all different markers to ensure that each piece of the locating puzzle is identified uniquely the actual location, size and origin of lesion is much easier of ascertain.

Lesion markers can also designate calcifications for tangential projection to determine the presence of internal breast calcification or skin calcification.

Clinical Image Diagram of Palpable Lesion:

BREAST SYMPTOM SYMBOLS =



1. Firm, mobile, 3 cm mass
2. Fibroadenoma removal: 1999/Benign
3. Large Mole (Crusty)

Mammography Image with Coordinating Skin Marking System:

1. Nipple Marker
2. Scar Marker
3. Lesion Marker
4. Mole Marker

CONCLUSION:

As mammographers our responsibilities are daunting. We can be overwhelmed by the task at hand. As always, knowledge, experience, team consultation and training are our allies. Don’t be afraid to look something up, don’t be afraid to ask the radiologist, surgeon or nurse for advice. Our patients count on us to represent their circumstances to the proper clinicians accurately, dispassionately and plainly. Use all the tools at your disposal to do that. A comprehensive skin marking system used properly is one of those valuable tools. Use them in consultation with your radiologists to assist is clear, concise accurate diagnosis.