E1623. A Breast Radiologist’s Worst Nightmare: The Negative Specimen Radiograph and How Intraoperative Fluoroscopy Can Help
Hundreds of thousands of wire localized excisional breast biopsies and lumpectomies are performed annually in the United States. The specimen radiograph obtained during breast surgery serves to confirm resection of the biopsy-proven malignant or high-risk tissue. The role of the radiologist is to communicate the presence of the biopsy clip in the specimen with the surgeon, while the patient is still in the operating room. However, 3% of specimen radiographs do not show the biopsy clip! This means that the biopsied tissue has not been resected. The radiologist and the surgeon both have limited options. The radiologist can help guide the surgeon to the additional margins that should be resected, often by using the post-localization mammogram. The surgeon can check the suction canister and take additional random surrounding tissue in an attempt to find the clip. Failing these options, the traditional choice is to close the incision and terminate the surgery. Unfortunately, future surgery may be needed (depending on pathology and mammogram).
Educational Goals / Teaching Points
Presence of the biopsy clip on the specimen radiograph is vital for confirming that the biopsied malignant or high-risk tissue has been resected. When the clip is not in the specimen radiograph, the radiologist should recommend the use of intraoperative fluoroscopy which will identify the biopsy clip in the post surgical bed. This will allow for directed resection of the biopsied tissue. Ultimately, resection of the biopsy clip and surrounding tissue prevent the need for return surgery.
Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
Real time fluoroscopy will initially guide the surgeon to the general location of the small foreign body thought to be the biopsy clip. Double magnification should then be used to definitively identify the biopsy clip. A radiopaque object, most conveniently a metallic surgical tool, should be moved into the field to pinpoint the biopsy clip using serial fluoroscopy. An immediate fluoroscopic image of the post surgical bed will show the absence of the clip. Alternatively, a second specimen radiograph can be performed.
When the specimen radiograph from breast surgery does not show the biopsy clip, it is almost certain that the intended tissue has not been resected (unless there has been significant clip migration). Intraoperative fluoroscopy, initially on regular magnification and then on double magnification, will guide the surgeon to the location of the biopsy clip in the post surgical bed. The biopsy clip and surrounding tissue can then be resected. Either an immediate fluoroscopic image of the post surgical bed or a second specimen radiograph can be performed to confirm removal of the clip. This salvage maneuver ultimately prevents the need for return surgery.