HAEMATOMADIRECTED GUIDEWIRE LOCALISATION OF BREAST LESIONS CM Lee, A Redman Breast Screening Unit, Q

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HAEMATOMA-DIRECTED GUIDEWIRE LOCALISATION OF
BREAST LESIONSCM Lee, A Redman Breast
Screening Unit, Queen Elizabeth Hospital,
Gateshead, UK

• Introduction
• The standard technique for surgical excision of
  mammographically detected, ultrasound invisible
  non-palpable breast lesions is by pre-operative
  stereotactic guidewire localization (SGL).
• Disadvantages of SGL include patient discomfort,
  ionizing radiation, requires more staff and
  longer procedure time.
• Ultrasound visible clips are used for
  localisation after vacuum-assisted core biopsies
  (VACB) but clip migration and visibility are
  problems. Post-VACB, the biopsy cavity fills with
  haematoma which is ultrasonically visible and can
  be used as a marker for guidewire localisation.
  
• Centres in America have successfully used
  ultrasound intraoperatively to identify the
  post-biopsy haematoma and guide surgical
  excision but no centres have attempted to use
  ultrasound pre-operatively to locate the
  post-biopsy haematoma and direct guidewire
  placement.
• We aim to describe this new technique of
  haematoma-directed ultrasound guidewire
  localisation (HUGL) and compare its accuracy with
  SGL.

• Methods
• Between September 2007 to June 2009, 15 patients
  with mammographically detected, non-palpable,
  ultrasound invisible microcalcification had VACB
  followed by HUGL (Image 1).
• We compared these cases with 15 consecutive
  patients who had mammographically detected,
  non-palpable, ultrasound invisible
  microcalcification subjected to VACB followed by
  SGL.
• Comparison was made by reviewing the skin to
  hook distance, guidewire overthrow (Image 2) and
  histology reports.

Skin to Hook Distance Guidewire Overthrow
Haematoma-directed Ultrasound Guidewire
Localisation
Overthrow
Skin to Hook Distance
Clip
Image 1Guidewire transfixing the post-VACB
haematoma
Image 2Post guidewire placement check film
showing position of the guidewire
Results
Table 1 Radiology, Surgery Pathology Results

• Only a single guidewire was needed in all cases.
• Both techniques located all lesions successfully.
  
• The mean skin to hook distance and guidewire
  overthrow for HUGL was 47.5mm and 10.4mm
  respectively.
• The mean skin to hook distance and guidewire
  overthrow for SGL was 67.5mm and 15.3mm
  respectively.
• Histology of the final surgical specimen
  confirmed the presence of targeted lesions in all
  cases.
• Of the 13 patients who had wide local excision in
  the HUGL group, 1 patient had inadequate margins.
• Of the 12 patients who had wide local excision in
  the SGL group, 2 patients had inadequate margins
  and 1 patient proved to have multifocal cancer.

Image 1 Post VACB haematoma visible on
ultrasound with a guidewire transfixing it

• Conclusion
• This study demonstrates the effectiveness of HUGL
  of breast lesions.
• There are several advantages of ultrasound over
  stereotactic localisation - potentially more
  comfortable for patients, lacks ionising
  radiation, technically easier, faster and cheaper
  than SGL.
• Results support the employment of HUGL as a new
  first line technique.

• Discussion
• All cases using HUGL were successfully localised.
• Results for skin to hook difference and overthrow
  were actually slightly better in the study group
  than the control group.
• No suggestion that HUGL leads to higher rates of
  incomplete margins.