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 Table of Contents  
SURGEON AT WORK
Year : 2018  |  Volume : 51  |  Issue : 1  |  Page : 38-40

A noninvasive method for preoperative localization of breast microcalcifications


1 Department of Surgery, Division of General Surgery, Chung Shan Medical University Hospital, Taichung City, Taiwan
2 Department of Surgery, Division of General Surgery, Taichung Tzu Chi Hospital, Taichung City, Taiwan

Date of Submission15-Feb-2017
Date of Decision08-Mar-2017
Date of Acceptance01-Jun-2017
Date of Web Publication09-Feb-2018

Correspondence Address:
Dr. Wei-Hsin Chen
No: 110, Sec 1, Jianguo N. Rd., Taichung City 40201
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/fjs.fjs_17_17

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  Abstract 


Wire localization of breast microcalcifications before surgical biopsy has been used for a long time. However, it causes patient's psychical trauma before operation with more cost of money and time as well. We design a noninvasive method using the concept of trigonometric function for preoperative localization. It can yield potential for cost-savings, increased efficacy in operating room and radiology scheduling, and patient comfort and convenience. Our method is simple and its failure rate is low.

Keywords: Breast cancer, breast microcalcifications, excisional biopsy


How to cite this article:
Chen WH, Yeh DC. A noninvasive method for preoperative localization of breast microcalcifications. Formos J Surg 2018;51:38-40

How to cite this URL:
Chen WH, Yeh DC. A noninvasive method for preoperative localization of breast microcalcifications. Formos J Surg [serial online] 2018 [cited 2018 Apr 23];51:38-40. Available from: http://www.e-fjs.org/text.asp?2018/51/1/38/225129




  Introduction Top


The use of screening mammography has increased dramatically, thus leading to the discovery of microcalcifications. For biopsies of breast microcalcifications, surgeons can choose stereotactic biopsy, ultrasound-guided biopsy, or surgical biopsy. For surgical biopsy, wire localization has been used for preoperative localization for a long time. However, it causes patient's physical and psychical trauma before operation with more cost of money and time as well, not to mention that the hookwires will sometimes shift or become dislodged in the biopsy specimen.[1] Some people tried to minimize usage of wire localization with using tissue markers which could be seen by ultrasound, but it still costs money.[2] In view of these shortcomings, we design a noninvasive method using the concept of trigonometric function for excisional biopsy of breast microcalcifications without preoperative wire localization and its failure rate is low. In this way, we can save both money and time for patients and surgeons.


  Operative Techniques Top


  1. We calculated the distance between areas of microcalcifications and nipple both on craniocaudal (CC) and mediolateral oblique (MLO) view of mammography and then performed biopsy directly over corresponding position of the breast under local anesthesia.
  2. The distance between microcalcifications and nipple on CC view [Figure 1]a means the lesion medial or lateral to the nipple.
  3. The distance between microcalcifications and the horizontal line across the nipple on MLO view, divided by 1.414 (√2), means the lesion above or below to the nipple [Figure 1]b.
  4. We make a 2–3 cm incision and carried out an excisional biopsy [Figure 2]. The depth of excisional biopsy should go into the plain of retromammary fat.
  5. After the biopsy, we will take mammography for the specimen and the patient can be discharged.
  6. We send the specimen to mammography room immediately. If the microcalcification was confirmed by x-ray, we put a needle (taken from syringe) into the area of microcalcifications to help the pathologist for exam and take second x-ray for image record.
Figure 1: A 67-year-old female's mammography showed clustered microcalcifications in upper-outer quadrant of left breast categorized breast imaging reporting and data system 4a. (a) Showed distance between microcalcifications and nipple (a) on craniocaudal view which indicates drawing marker lateral to the nipple. (b) Showed distance between microcalcifications and the horizontal line across the nipple (b). The distance (b) measured should be divided by 1.414 (√2) when drawing marker on the skin. It indicates that the lesions are superior to the nipple in this patient

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Figure 2: After two markers are drawn on skin, the excisional biopsy could be carried out

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  Comments Top


A retrospective analysis of the medical records, mammography, and pathology reports was undertaken to evaluate the success of this procedure. Since January 2006 until December 2010, 186 patients underwent excisional biopsy for microcalcifications of the breast without preoperative wire localization. In our series, a total of 186 patients received excisional biopsy for microcalcifications of the breast. Overall, we had a yield of 22.8% positive biopsies for cancer (45 cancers in 197 biopsies). There were 98 left-side biopsies and 77 right-side biopsies. Eleven patients underwent bilateral biopsies, and one of them was diagnosed with bilateral breast cancer. About 31.7% of patients (59/186) were referred from a local hospital, and a total of 65 biopsies were performed including 1 bilateral biopsies. Fifteen patients including 1 bilateral cancer were diagnosed with cancer (25.4%, 15/59). One hundred and twenty-seven patients underwent examinations at original hospitals, and a total of 132 biopsies were done, including 5 bilateral biopsies. Twenty-nine patients were diagnosed with breast cancer (22.8%, 29/127). Among the cancer cases detected, 53.3% were stage 0. The mean age of patients undergoing biopsy was 49 years old and the mean age diagnosed with breast cancer was 49.4 years old. What is noteworthy is that the mean age of stage 0 cancer patient was 46.6 years old and those with invasive carcinoma was 50.6 years old. The localization procedure without preoperative wire usage was successful in 95.9% of the cases.

We design this method not only to be more efficient in terms of time and money but also to solve the problem of staff shortage of radiologists in some hospitals. This noninvasive method of localization does not intend to take the place of stereotactic or ultrasound-guided biopsies. It is an alternative method for biopsy. In our hospitals, if the microcalcifications are detected on mammography, we will also arrange ultrasound for further inspection. If ultrasound detects microcalcifications at the same area, then ultrasound-guided biopsy will be the first choice. If breast ultrasound detects no lesions in the same area, stereotactic biopsy will be arranged. However, sometimes when the radiologists' schedule is very tight, then we will use this method for biopsies. Moreover, if the results of stereotactic or ultrasound-guided biopsies turned out to be atypical ductal hyperplasia (ADH), we will also perform surgical biopsy using this method under such circumstances. Sometimes when the location of microcalcifications is too deep or shallow in the breast for the radiologist to approach, then surgical biopsy performed in our method can solve the problems.

For beginners who want to try this procedure, we suggest that they start with those ADH diagnosed by ultrasound-guided biopsies which need further biopsies. In this way, they can compare the two locations detected by two methods. In addition to ADH mentioned above, nonpalpable tumors detected both on mammography and ultrasound requiring surgery are also suitable for this method.

Another point worth mentioning is that although the MLO view may be taken from 45° to 60°, the inaccuracy thus caused on MLO view can be recovered during surgery by making larger biopsy (2x2 to 3x3 cm). This noninvasive preoperative localization method could be applied to microcalcifications, nonpalpable tumors, and architectural distortions.

Analysis of our 9 failures shows that the major reasons for failure are mastoptosis, incomplete removal of areas of microcalcifications, breast with multiple microcalcifications, and intolerance of patients [Table 1]. Most Taiwanese women's breast is dense, but if the patient has mastoptosis, we should be cautious when applying this method because there are chances of potential error of calculation on the breast skin. We also found that the length between nipple-areola and pectoralis major muscle is an indicator. If this length is longer than 6 or 7 cm, the failure rate will be higher.
Table 1: Analysis of 9 failures

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Our method yields potential for cost savings, increased efficacy in operating room and radiology scheduling, and patient comfort and convenience. We conclude that the failure rate is low, and the method without wire localization for biopsies of microcalcifications of the breast used is a worthwhile procedure in selected patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgment

The authors would like to thank Miss Jeng-Ya Hsin for English correction.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Yankaskas BC, Knelson MH, Abernethy ML, Cuttino JT Jr., Clark RL. Needle localization biopsy of occult lesions of the breast. Experience in 199 cases. Invest Radiol 1988;23:729-33.  Back to cited text no. 1
    
2.
Blumencranz PW, Ellis D, Barlowe K. Use of hydrogel breast biopsy tissue markers reduces the need for wire localization. Ann Surg Oncol 2014;21:3273-7.  Back to cited text no. 2
    


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