British Journal of Radiology (2003) 76, 425-426
© 2003 British Institute of Radiology
doi: 10.1259/bjr/27639166
Intraductal injection of the breast: a potential pitfall of radioisotope occult lesion localization
R S Rampaul, MB, BS1,
R D Macmillan, MD, FRCS1 and
A J Evans, FRCR2
Department of 1 Surgery and 2 Radiology, City Hospital, Nottingham NG1 5PB, UK
Correspondence: Dr A J Evans
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Abstract
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The use of radioisotope for the localization of occult breast lesions (ROLL) has been advocated in preference to wire guided excision as it allows reduced excision volume and better lesion centering. However, as this technique is new, potential complications are unknown. In 2 out of 38 ROLL procedures performed at our institution, intraductal injection of isotope has occurred. This was diagnosed on check mammography as non-ionic iodinated contrast was mixed with the isotope. In one of these cases conversion to wire localization was required.
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Introduction
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Diagnostic and therapeutic procedures on non-palpable breast lesions require some form of an image-guided localization. Such procedures often involve a wire but carbon granules have also have also been employed. Problems associated with wire localization include kinking of the wire, wire fracture and wire migration between placement and surgery. To help address these problems, the use of radioisotope has been advocated as an alternative for occult breast lesion localization – radio-occult lesion localization (ROLL) [1]. Zurrida et al [1] first described the technique and they utilized scintigraphy for checking correct placement of the isotope. We are at present conducting a prospective randomized trial comparing ROLL with wire guided lesion localization. As we envisaged routine check scintigraphy to be cumbersome and time consuming in our practice, we have modified Luini's approach to ROLL in that 0.2 ml of water soluble, non-ionic iodinated contrast medium is mixed with the isotope (2 MBq of 99Tcm labelled macro-aggregated albumin (MAA)) to allow identification on check mammography [2]. Surgical excision of the lesion is facilitated with the use of a gamma probe (NeoProbe, Etticon Endosurgery, Bracknell, UK) the same as in sentinel node biopsy. The probe is placed over the breast to detect the area of radioactivity. Also the threshold is adjusted to drop off sharply at the margins of injection. This is useful for planning the skin incision and obtaining adequate excision margins. We wish to describe a complication encountered in two cases with the use of ROLL, which can be recognized quickly if water-soluble contrast and mammography are used to check correct localization.
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Case report
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Two patients with microcalcifications on screening mammography were to undergo therapeutic marker localization. Following entry into the ROLL Trial [3], they were randomized to isotope localization (ROLL). In both cases contrast was seen tracking into the duct system following sterotactically guided injection of isotope (Figure 1
) on check mammography giving an appearance similar to a galactogram. Transport of isotope with contrast was confirmed with a hand held gamma probe demonstrating similar migration rates. One case was still suitable to proceed with surgery despite this complication as only a small amount of contrast was in the duct, the other had to wait approximately 45 min for the contrast to drain out as it obscured visibility of the calcifications. Re-localization was then performed using a guide-wire.
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Discussion
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Pre-operative localization under radiographic guidance is mandatory in clinically occult breast cancers, yet none of the methods in current use are without shortcomings [4, 5]. For example, the introducing needle can become displaced, particularly in a fatty breast and in very dense breast wires can be difficult to place. ROLL offers the opportunity to avoid many of these disadvantages [1].
A theoretical drawback would be that the isotope migrates from its point of injection (as it does in sentinel node biopsy). By employing a large particle size, the isotope does not rapidly enter the lymphatic system and should remain concentrated at the site of injection. Previous groups using the ROLL technique have carried out surgery the day after injection demonstrating that isotope does not diffuse away [6]. The two cases presented illustrate a potential source of isotope migration injection into a duct. The transport of the isotope within the duct system was confirmed with the hand held gamma probe. Such complications would be difficult to recognize with scintigraphy, which may explain why there are no previous reports in other published studies. The use of contrast with isotope and check mammography in ROLL as we advocate, will help allow early recognition and timely intervention.
Received for publication January 24, 2002.
Revision received October 1, 2002.
Accepted for publication October 21, 2002.
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References
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- Zurrida S, Galimberti V, Monti S, Luini A. Radioguided localization of occult breast lesions. Breast 1998;7:11–3.
- Bagnall MJC, Rampaul RS, Evans AJ, Wilson ARM, Burrell HC, Geraghty JG. Radioguided occult lesion localization (ROLL)—a new method for locating impalpable breast lesions at surgery. Br J Radiol 2000;73(Suppl.):49.
- Rampaul RS, Burrell H, Macmillan RD, Evans AJ. A prospective randomized study of ROLL versus wire-guidance for impalpable lesion localization of the breast. [Abs] Eur J Cancer 2001 (In Press).
- Silverstein MJ, Gamagami P, Rosser RJ, et al. Hooked-wire-directed breast biopsy and overpenetrated mammography. Cancer 1987;59:715–22.[CrossRef][Medline]
- Hermann G, Janus G, Lesnick GJ. Percutaneous localization of nonpalpable breast lesions. Breast 1983;9:4–6.
- Luini A, Zurrida S, Paganelli G, et al. Comparison of radioguided excision with localization of occult breast lesions. Br J Surg 1999;86:522–5.[CrossRef][Medline]
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Abstract
Introduction
