Breast Calcifications: What’s Good, What’s Bad and What’s What?! (Benign Breast Calcification)

Assessing and demonstrating clearly an area of concern on our images is a long way from diagnosing disease. What is missed or obscured on our clinical images is not analyzed by the Radiologist. Therefore it is essential that we recognize a possible concern and know how to demonstrate it clearly.

Calcifications arise in the breast as a natural process of aging and can be grossly benign. Calcifications can also gather in the ductal paths of the breast parenchyma due to an atypical proliferation of dead or dying cells caused by the presence of some active pathology. To demonstrate breast calcification we first must appreciate their presence and then comprehend their characteristics.

Characteristics of Benign Breast Calcifications:

CHARACTERISTIC	PROPERTIES
Form	Smooth, Round, Oval Curved
Size	Quite Large Usually @ .5mm and Larger
Density	Uniform highly dense Dense with Lucent Areas of Fat
Distribution	Scattered, Surrounding a Smooth Mass, Following a vessel or Embedded in the Skin
Margins	Smooth, Rounded, Easily Seen and Followed
Number of Calcifications	Usually not more than 5 in a Group Always separate and easily Counted
Position in Relation to Mass	Either centered in the Core of a Smooth Mass Gathering Around its Edge

Benign Calcifications:

Benign breast Calcifications Include:

1. Blunt Duct Adenosis

2. Sclerosing Adenosis

3. Fibrosis

4. Arterial Calcification

5. Intra/Peri Ductal Plasma Cell Mastitis

6. Sebaceous, Skin Calcifications

7. Benign Papilloma

8. Eggshell Calcified Galactocele or Oil Cysts

9. Calcified Fibroadenomas

BLUNT DUCT ADENOSIS: Shows a fat for-shortened Terminal Duct Lobular Unit with clusters of calcifications at the base of the ductules

SCLEROSING ADENOSIS: Shows a long spidery elongated TLDU with rows of calcifications strewn along the length of the ductules

FIBROSIS: Shows a fat swollen badly misshapen TLDU with large smooth calcifications filling the distal ends of the ductules

ARTERIAL CALCIFICATIONS:

1. Artery

2. Calcified Internal Arterial Walls

INTERDUCTAL PLASMA CELL MASTITIS:

1. Terminal Duct Lobular Units

2. Branching Ducts

3. Intraductal Calcifications Stretching through the Length of the Ducts

PERIDUCTAL PLASMA CELL MASTITIS:

1. Branching Ducts

2. Periductal Calcifications Coating the walls of the Duct

SEBACEOUS/SKIN CALCIFICATIONS:

1. Skin Pore or Sebaceous Gland

2. Tiny Smooth Calcification

BENIGN PAPILLOMA:

1. Epithial Cell Layer

2. Interductal Papilloma

3. Scattered inter-lesion calcifications

4. Main or Large Branching duct

EGGSHELL TYPE CALCIFICATIONS: Very dense calcifications surrounding a central core mass. If the central core is OPAQUE, the mass very likely is a cyst with a calcified wall, a fibroadenoma or a Phase 1 galactocele. If the central core is RADIOLUCENT, the mass very likely is a calcified lipoma, an oil cyst, fat necrosis or a Phase 3 galactocele.

CALCIFIED FIBROADENOMA: Benign fibroadenoma can calcify in several ways.

Sub capsular calcifications are very dense inside layer of calcification coating the edge of the mass. These can appear linear or eggshell like. Fibroadenomas calcifying with central dense or mixed fat/calcified centers very often appear like pieces of sponge toffee or popcorn.

SUMMARY

All calcifications seen on our breast images should be noted, located and well demonstrated by today’s Mammographer. We should be well versed in the procedures of clarification and follow-up for such abnormalities. Tangential views will easily and efficiently locate calcifications for the Radiologist. Magnification and coned compression are the primary techniques used to further analyze calcifications. These views afford a clearer appreciation of the morphology and distribution of the calcifications thus allowing the Radiologist to make informed diagnostic decisions.

The Mammographer within today’s modern team oriented department must have the advanced positioning and clinical skills to ensure the area of concern is appropriately imaged, clearly seen and able to be characterized by the Radiologist.

What is a ‘Diagnostic Follow-up’? (What, Why, Where & How?)

Diagnostic follow-up is a method of further investigation of a lesion or anomaly revealed by careful routine clinical or radiological examination of the breast.

Coned Compression Spot Views:

1. Large Focus X-ray Beam

2. Film Receptor

3. Lesion

4. Small Compression Paddle with Small Aperture

Target Area:

• Small superimposed mass

• Mass with partially obscured borders

• Mass with indeterminate characteristics

• Mass with ragged or spiculated edges

• To demonstrate the obscured or indistinct anomaly clearly and free of superimposed tissue

How to Position a Coned Compression Spot View:

• Identify and localize the lesion to be studied

• Use the large focal spot (.3mm) with the grid and bucky in place

• Position the breast in the CC position

• Place a small mark on the skin directly over the location of the abnormality

• Use the smallest compression paddle and aperture possible in view of the size of the anomaly

• Vigilantly identify the projection and laterality

• With the mass centered in the small aperture, compress the breast as vigorously as possible to clear the mass of superimposed tissue

• Expose the image

• Position the breast in the MLO position

• Place a small mark on the skin directly over the site of the lesion in this projection

• Again, use the smallest paddle/aperture combination possible with the large focal spot

• Vigilantly mark the side and projection

• Carefully center the mass and compress vigorously to clear the mass’s borders and expose

• Assess the images to assure that targeted abnormality is centered on the film, it is clear of all super-imposition and is penetrated adequately

Coned Magnification Spot View:

1. Small Focus X-ray Beam

2. Film Receptor

3. Magnification Table with ‘Air-Gap’

4. Magnified Image of Lesion

5. Lesion

6. Small Compression Paddle with Small Aperture

Target Area:

• A new cluster of calcifications

• An increase in existing calcifications

• A change in the configuration, form or size of calcifications

• A irregular or spiculated mass containing fine calcifications

• Surgical or core biopsy specimen

How to Position a Coned Magnified Spot View:

• Using the scout images identify and localize the area to be magnified

• Use the small focal spot (.1mm) and the film holder without the grid and bucky

• Attach the magnification table at the appropriate magnification for the lesion in question (X1.5, X1.8 or X2)

• Use the least magnification possible and still visualize the area properly because the larger the level of magnification the greater the distortion in the image

• Position the breast in the CC position

• Place a small mark on the skin directly over the area of calcification

• Use the smallest compression paddle and aperture that adequately covers the entire area of interest

• Vigilantly identify the projection, laterality and the level of magnification

• With the skin marker centered in the small aperture, compress the breast as vigorously as reasonably possible to separate and discriminate between calcifications

• Expose the image

• Position the breast in the 90º lateral projection (magnification views of calcifications MUST always include a true lateral view to indicate the presence of ‘milk-of-calcium’)

• Again, place a small mark on the skin adjacent to the area of calcifications in this projection

• Using the small paddle and aperture; center the skin marker and compress the breast as vigorously as the patient can tolerate

• Diligently identify projection, side and magnification level

• Expose the image

• Repeat the procedure for the MLO projection and any other views deemed appropriate or useful (the CC & ML or LM projections are the routine magnification views)

• Assess all the images to verify that the calcifications are all well seen, distinct, clear of superimposition and separate

Roll and Turn View:

1. Superior Breast Lesion

2. Inferior Breast Lesion

1. Superior Breast Lesion Moves Medially

2. Inferior Breast Lesion Moves Laterally

3. Superior Aspect of Breast Turned Medially

4. Inferior Aspect of Breast Rolled Laterally

Target Area:

• To separate superimposed tissue

• To confirm the presence of an abnormality

• To better define a lesion

• To determine the validity and location of an anomaly seen in the CC view

How to Position a Rolled/Turned View:

• Position the patient in a true CC projection centering the identified abnormality in the midpoint of the image

• Place one hand on the superior aspect of the breast and one on the inferior aspect.

• Lift the breast up slightly and ‘Roll’ the top hand toward you and ‘Turn’ the bottom hand away from you (or visa/versa).

• Secure the breast on the bucky, holding the ‘rolled’/’turned’ tissue in place.

• Slide your supporting hand out as the final compression takes hold.

• The direction of the roll/turn (medial or lateral) must be clearly indicated on the film so that you can determine whether the lesion resides in the superior or inferior aspect of the breast.

• A superior lesion moves in the same direction of the roll and an inferior lesion moves in the opposite direction to the roll.

Tangential View:

Lesion located at the 6 o’clock position is demonstrated closest to the skin-line in the 90º lateral projection.

1. Lesion identified at 6 o’clock position

2. Marker placed on patient’s skin directly over lesion

Target Area:

• To project a demonstrated lesion as close to the subcutaneous fat as possible to free it from surrounding parenchyma.

• To establish or exclude micro calcifications as ductal or dermal.

How to Position a Tangential View:

• Place a small visible skin marker on the breast directly over area of concern.

• Marker must be placed on the correct surface. Place the skin marker over the lesion where the abnormality is closest to the skin.

• Correct placement of the skin marker is essential; the fenestrated or multi-hole location paddle can be useful for this purpose.

• Rotate the C-arm and breast tissue until the shadow of the skin marker is projected onto the bucky. This ensures that the lesion or calcifications are tangential to the beam.

Ultrasound:

Ultrasound shows a simple cyst by demonstrating a well circumscribed, thin walled, anechoic structure. There is sharp back wall and enhanced posterior shadowing.

Ultrasound shows a typical fibroadenoma by demonstrating a well circumscribed, hypo echoic nodule with homogeneous echo texture. Its long axis is parallel to the skin and there is enhanced through transmission.

Ultrasound shows an irregular spiculated lesion by demonstrating a poorly circumscribed hypo echoic mass with no through transmission and heightened posterior shadowing. The lesion is greater in height than it is in width.

Target Area:

Ultrasound is not a good screening tool but it is an excellent adjuvant instrument to establish criteria relating to anomalies detected by screening mammography, clinical breast examination or breast self examination. Ultrasound gives us exceptional details of lesions seen or felt in the breast. U/S can determine a whether or not a lesion is a simple cyst with higher than 99% accuracy. It can pinpoint many breast abnormalities for FNA or Core Biopsy. Since U/S’s preferred pallet is parenchyma and not fat as in mammography it can untangle many lesions in the mammographically dense breast.

SUMMARY

Screening mammography makes up a great deal of our daily routine. When we discover some change in the normal parenchymal pattern or find a burgeoning problem in the breast then we have accomplished what we set out to do. Investigating the tiny seemingly innocuous changes in the breast is what our job is all about. Breast imaging is all in relation to ‘do sweat the small stuff’. Find out what the changes mean and save a life!

Until next time friends,

Anne

Why Do We Need EXTRA Views? (What, Why, Where & How?)

The ‘routine’ CC and MLO projections do not always capture all of the breast tissue. Body habitus, the level of patient cooperation, muscular-skeletal deformity, breast size or shape all play a role in the amount of breast tissue acquired on our mammogram. The ‘extra views’ aid the complete visualization of the breast tissue. Sometimes it is difficult to determine which views should be used in what situation. We have excellent tools, many of them designed by technologists just like us, to complete our studies even in the most difficult of situations.

The Laterally Exaggerated Cranial-Caudal View (XCCL)

1. Lateral Edge Demonstrating Lateral Retro Glandular Fat
2. Medial Edge does not Demonstrate medial parenchyma or medial skin line
3. The Tail-of-Spence

Target the area:

• To visualize deep lesions in the outer aspect of the breast
  
• To visualize the Tail-of-Spence entirely

How to Position the XCCL:

• Elevate infra mammary fold to 90º and adjust bucky
  
• Rotate patient’s lateral side toward bucky
  
• Using both hands, gently lift and pull lateral aspect of the breast onto bucky.
  
• Compress the tissue, letting the corner of the paddle begin just under the clavicle and tucked snuggly under the head of the humerus. Angle the bucky 5° laterally if necessary to clear humeral head.

The Cleavage View (CV):

Target Area:

• To visualize lesions in the far postero-medial aspect of the breast.

How to Position the CV View:

• Have patient face the x-ray unit with her head rotated contra-laterally.
  
• Elevate the infra-mammary folds of both breasts.
  
• Adjust the height of the bucky and place both breasts on the receptor.
  
• Gently pull the medial tissue of both breasts anteriorly.
  
• The mammographer can stand either behind the patient or medial to the side of interest.
  
• If the photocell is placed under the open soft tissue cleavage area between the breasts; a manual technique must be set.


• Photo-timing can be used if the cleavage is offset a bit and the cell is positioned under the breast of interest.

The 90º Lateral Views (LM & ML)

The Lateral Medial View:
The Medial Lateral View:

What We Should See in the 90º Compressed Image:

1. The Nipple in Profile


2. The IMF open and gently curving to the Abdomen


3. The Axillary Tail and the Tip of the Tail-of-Spence are not always imaged on the Lateral Views

Target Area:

• To demonstrate milk-of-calcium, air or fluid levels.


• To demonstrate lesion location for triangulation.


• To remove superimposition.


• To assure shortest object-to-film distance.

How to Position the 90º ML:

• Rotate tube arm 90°.


• Place bucky along the lateral side of the patient with the superior edge of the bucky at axilla level


• Abduct arm and rest it across the bucky.


• Pull breast tissue anteriorly and medially.


• Lift breast up and out.


• Rotate patient toward bucky until breast is in lateral position.


• Nipple centered and in profile.


• Open the IMF.

How to Position the 90º LM:

• Rotate tube arm 90°.


• Place top of bucky at supra-sternal notch.


• Place patient with her sternum against the bucky, neck extended and her chin turned contra-laterally
• Bring her arm up to rest over top of the bucky with her elbow flexed.


• Rotate the patient until the breast is in the lateral position with the nipple centered and in profile.


• Apply compression WITHOUT compressing the latissimus.


• Open the IMF

The Reverse Oblique Views: (LMO & SIO)

The Superior/Inferior Oblique View:

1. Film Receptor
2. Axillary Tail
3. Medial/sternal border
4. X-ray Beam Oriented Superior to Inferior

The Lateral Medial Oblique View:

1. Film Receptor
2. Axillary Tail
3. Medial/Sternal Border
4. X-ray Beam Oriented Inferior to Superior

Target Area:

• To improve visualization of the medial breast tissue.
• To maximize the amount of tissue visualized on the male breast.
• To aid in positioning and adequately visualizing tissue on women with severe osteoarthritis, spinal, sternal, musculoskeletal or other bony abnormalities.
• To aid positioning of patients with recent heart surgeries or prominent pacemakers.

How to Position the LMO & SIO Views:

• LMO: Angle C-arm parallel to pectoral muscle with the central ray pointing in an inferior/superior orientation (from bottom to top).
  
• SIO: Angle C-arm parallel to pectoral muscle with the central ray pointing in a superior/inferior orientation (from top to bottom)
  
• Adjust the height of the bucky to accommodate the entire axillary tail at the top and to show the IMF at the bottom.
  
• Lean your patient forward until her sternum is pressed against the edge of the bucky.
  
• Extend patient’s arm over the top of the bucky with the elbow flexed.
  
• Gently pull the breast tissue up and out from the chest wall.
  
• Rotate the patient slightly toward the bucky and bring all of the lateral tissue forward until the breast is centered with the nipple in profile (if possible).
  
• Remove support on final compression (do not compress the latissimus) with the up and out motion.
  
• Open the infra-mammary fold.

What Should We See on the Compressed Reverse Oblique Image?

The Reverse Oblique Views should demonstrate the same tissue that the Medial/Lateral Oblique illustrates.

1. Complete Axillary Tail & the Entire Tail-of-Spence
2. Pectoralis Major relaxed and visible to below the level of the Nipple Shadow
3. The Nipple in Profile if possible
4. The Infra-Mammary Fold Open and Gently curving to the Abdomen
   

The 30ºAxillary Tail View:

1. Tail-of-Spence
2. Entire Axillary Tail
3. Medial Edge not Imaged in its Entirety
4. Nipple in Profile in the CC Position
5. Position of the Humeral Head

Target Area:

• To visualize the far superior lateral aspect of the breast.
  
• To visualize the entire axillary tail.

How to Position the 30º Axillary Tail View:

• Rotate the C-arm until it is parallel to the axillary tail (approx. 30°).
  
• Stand on the lateral side of the patient.
  
• Rotate patient to bring axillary tail in contact with the bucky.
  
• Keeping the breast in the CC projection; gently lift and pull axillary tail anteriorly.
  
• Place the patient’s arm behind the bucky, elbow flexed and hand resting on the handlebar.
  
• Using your whole hand, anchor the breast in the CC projection.
  
• Bring the compression paddle down slowly so the corner in tucked up under the humeral head.
  
• Pull your hand out anteriorly and towards the medial side as the compression takes hold of the tissue.

The ‘From Below’ View (FB):

1. Tail-of-Spence
2. Axillary Tail
3. Medial/Sternal Border
4. X-ray Beam Perpendicular to the Receptor and in the Caudal/Cranial Orientation
5. The Film Receptor

What Should We See in the Compressed Image of the FB View?

In theory, we should produce an identical image on the FB view as we produce on the CC view. However, because we use the FB projection mostly to image patients with severe skeletal/muscular deformations, mobility problems and/or surgical deformity, we rarely get a perfect view using this projection.

1. Tail-of-Spence & Axillary Tail
2. Medial Curve to Contra-Lateral Side
3. Nipple in Profile if Possible
4. Crescent of Pectoral Muscle

Target Area:

• To improve visualization of lesions in the superior aspect of the breast.
• To maximize the amount of tissue demonstrated in patients with severe skeletal/muscular deformations, mobility problems and/or surgical deformity
  To aid in the demonstration of the male breast.
• To produce the shortest distance to a lesion for interventional procedures
  

How to Position the ‘From Below’ View:

• Rotate the C-arm 180°.
• Face your patient towards the x-ray unit with her legs on either side of the tube head.
• Elevate the IMF to its full extent.
• Adjust the height of the transom to place the bucky in contact with the superior border of the breast.
• Have your patient lean over the bottom of the bucky and rest her head on her folded arms
• Gently pull the breast tissue away from the chest wall.
• Anchor the breast from the inferior aspect and release on final compression with a forward motion.
  

SUMMARY

It is our responsibility to image all of the breast tissue on a routine mammogram. If we cannot demonstrate it all with the regular CC and MLO projections we must keep going until all is revealed. We never know when a dangerous lesion is hiding just out of sight. Use the ‘extra views’ without restraint be creative and see all there is to see.

Until next time friends,
Anne

Viewing Your Views: Assessing & Correcting the Standard Mammogram Projections

With the implementation of standard pectoral mobilization mammography techniques, it is now possible to produce consistent images and correct our errors dependably instead of merely ‘repeating’ our mistakes ad infinitum. To properly assess the routine projections of the breast we must identify the delineating landmarks of the breast borders and then take any corrective measures necessary to include them in our film field.

The CC Projection: The cranial\caudal view of the breast should demonstrate all of the breast tissue except for the axillary tail. The essential landmarks delineating the CC view include:

1. Medial curve of the breast: Should be smooth open with a ‘ski-slope’ of tissue toward the contra-lateral side
2. Nipple should be in clear profile (tissue should not be sacrificed to accomplish this)
3. Tail-of-Spence
4. Pectoral muscle
5. Parenchyma spread smoothly across image
6. Posterior Nipple Line must be within 1cm of the MLO’s PNL

1. It is essential for the medial curve or nub to be visible on the CC view. To ensure that this is always the case, be sure to position from the medial\anterior aspect of your patient. Lift, abduct and drape the opposite breast tissue over the edge of the bucky. Never sacrifice medial tissue to obtain the Tail of Spence.
2. The nipple on the CC view should be in direct profile on the image. To help accomplish this be careful to raise the IMF until it is directly parallel with the bucky, use two hands to pull and anchor the breast onto the bucky. NEVER sacrifice tissue to accomplish a profile outline of the nipple. Take adjuvant ‘nipple shot’ to achieve this if necessary.
3. The tail of Spence is the axillary tail visible in the CC projection. To assure we have both the essential medial and the axillary tail in the CC view position from the medial side of the patient and is careful to pull the lateral breast tissue forward and towards you as the compression takes hold of the view. If it is impossible to image the entire tail-of-Spence, take an adjuvant XCCL view.
4. A small ‘half-moon’ of pectoral shadow should show on about 40-65% of your CC images. It is advantageous to image the pectoral ‘moon’ at every opportunity. To do so, lift the IMF and breast mound cephalically until you see the bulge of pectoral muscle emerge just under the clavicle and the IMF is parallel to the bucky. Compress directly along the posterior edge and pull the breast forward and laterally as the compression takes hold.
5. To achieve a well compressed CC projections use the thumb and index fingers to anchor the breast tissue firmly. Pull your hand anteriorly and laterally as the compression takes hold but do NOT let go of the breast until the view is definitely immobilized. The skin of the breast should be taut and slightly whitened. Compression should never cross the line from discomfort to actual pain.
6. The posterior nipple line is measured from the nipple\skin junction directly to the back of the image. The PNL on the CC image MUST be within 1cc of the PNL on the MLO view. Obviously, these measurements loose validity if your MLO was positioned poorly. However, the PNL still provides a simple mechanism for comparative assessment of the adequate depth of the CC projection.
   

The MLO Projection: When properly obtained the mediolateral oblique view should demonstrate virtually all of the breast tissue. The essential landmarks for the MLO view include:

1. Pectoral muscle gently curving convexly from the axilla to below the nipple shadow
   
2. Axillary Tail clearly seen through the pectoralis in its entirety
   
3. Nipple in profile if possible
   
4. Infra-mammary Fold open gently curving to the abdomen
   
5. Posterior Nipple Line
   
6. Parenchyma Spread evenly across the image with the parenchyma ‘up & out’ imaging a line of retro mammary fat at the chest wall

1. The Pectoral Muscle should be seen to below the level of the nipple shadow. If this is not the case, then, the determination of the pectoral angle has been incorrectly estimated. Reassess and change to bucky’s angle if necessary. Mobilize the full length of the lateral border of the pectoral grid. Bring it medially and anteriorly until the pectoral bulge appears along the sternal border from the shoulder to the lower 1\3 of the sternum. Set the bucky angle absolutely parallel to the edge of this pectoral angle. Compress parallel to and directly behind this pectoral bulge until your positioning is immobilized. It is important to remember when performing the MLO view that you are positioning parallel to the pectoral muscle NOT the chest wall. The anterior margin of the pectoral muscle should exhibit a soft convex configuration. Triangular, concave or vastly bulging muscle shadows indicate a significant loss of posterior\inferior breast tissue and/or poor breast compression. To accomplish this we must have our patient’s shoulder softly open and relaxed over the bucky corner. Place the corner of the bucky high up and posteriorly into the axilla. Her elbow should be bent and relaxed with her arm hanging loosely behind the bucky. She should loosely grasp the handle bar with her elbow making an 80 – 95 degree angle.
2. The Axillary Tail The upper glandular tissue that projects over the pectoral muscle MUST project into the field of view. The Tail of Spence is an essential landmark and must not be ‘cut off’. This tissue lies beside and behind the lateral edge of the pectoral margin. The technologist must mobilize the upper lateral edge of the pectoral grid and move it adequately anteriorly and medially to adequately visualize the entire axillary tail in the MLO view.
   
3. The Nipple in profile has been over emphasized in many positioning manuals. This should never be accomplished at the expense of posterior breast tissue. An extra subareolar view can always be obtained with the nipple in profile. The radiologist usually insists upon seeing a profile of the nipple in either the CC or the MLO projection.


4. The Infra-mammary Fold (IMF) should appear as a smooth open concave curve toward the belly at the inferior border of your image. Visualizing the IMF assures the radiologist that a marked amount of inferior posterior tissue has not been excluded form the image. To produce a clear open IMF gently curving toward the abdomen, the mammographer must hold the MLO position immobile until the compression has taken over the task of holding the breast mound perpendicular to the pectoral angle. After removing your hand with the upward\outward movement, as your very last positioning procedure, run your thumb and forefinger down along the IMF towards the abdomen. Carefully tilt your patient’s hips backwards removing any belly folds that are in the field of vision.
5. The Posterior Nipple Line (PNL) on the MLO should be measured from just behind the nipple base directly parallel to the cooper’s ligaments to the front of the pectoral shadow (not to the chest wall). The PNL of the MLO must measure within 1cm of the PNL on the CC.
6. The Parenchyma must spread evenly across the image with cooper’s ligament straight and perpendicular to the pectoralis. To demonstrate all the breast tissue on the MLO view a line of fat should always separate the glandular parenchyma from the pectoral fascia.




To accomplish clearly visualized, well compressed, complete parenchyma in the MLO we must mobilize the pectoral grid medially and pull it forward. We must hold the breast mound perpendicular to the pectoral angle and then, allow the compression to take hold parallel to and just behind the pectoral bulge. If these positioning criteria are adhered to the entire parenchyma will be clearly visualized



SUMMARY

We would never dream of handing in a chest x-ray with a missing apex or base. Please, don’t forget to ‘view your views’ look for the delineating landmarks for your breast x-rays and take the appropriate corrective action.

Until next time friends,
Anne

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