Migration of a breast guidewire into the pleural cavity

Abstract

A 72-year-old woman with a body mass index of 38 but otherwise healthy was scheduled for a partial mastectomy for a non-palpable 12 × 16 × 10 mm invasive ductal carcinoma in the outer quadrant of the left breast. A guidewire was inserted prior to surgery under ultrasound guidance. The technique was uneventful, apart from some difficulty in securing the wire to the skin because the breast was very large. A dressing was applied to the left breast to prevent any movement of the guidewire. The patient was admitted to the operating room 2 h later. When the dressing was removed, the guidewire was not found. The radiologist who inserted the guidewire was called and an ultrasound was performed. The tumour was easily found but the guidewire was not visible. A partial mastectomy was performed, successfully removing the lesion. However, the guidewire was still not found, despite thorough probing of the wound. The patient then underwent intraoperative C-arm fluoroscopy, which showed the image of the guidewire projected over the surgical field, and the possibility of intrathoracic migration was suggested. Meanwhile, the patient remained completely stable. At this point, the procedure was terminated and a computed tomography scan was performed, showing that the guidewire had migrated into the left pleural cavity (Fig. 1). There was no evidence of pneumothorax or bleeding, and the patient remained completely asymptomatic. The guidewire was retrieved thoracoscopically without incident, and the patient was discharged on post-operative day 1 (Fig. 2,3, Video S1). The patient subsequently developed a large seroma (approximately 1000 cc) at the site of the lumpectomy, requiring readmission and percutaneous drainage. The seroma resolved and there were no further complications. Wire localization is the most widespread technique to guide the resection of clinically occult breast lesions. The most frequent complications associated with breast guidewires are vasovagal reactions (up to 7–10% of patients), wire rupture and wire migration. Most wire migrations are minor and involve only displacement of the tip away from the target lesion. This usually occurs during patient transfer from the radiology suite to the operating room. Evolving localization techniques include radioactive and magnetic seeds, radar reflectors and radiofrequency tags, which may limit complications while improving accuracy and scheduling flexibility, but cost and logistical constraints limit widespread availability. In contrast, carbon-dye tracking has been reported as a possible alternative, which is straightforward and avoids foreign bodies altogether. Migration of a guidewire into the thoracic cavity has been reported only anecdotally. If this occurs, there is a risk of trauma to intrathoracic organs, including lung (pneumothorax and bleeding) and cardiac injury. In one report, a patient suffered from intermittent chest pains for several months after an unrecognized fragment of the guidewire had perforated the pericardium. It was eventually found that the wire had also penetrated the left ventricle and projected through the aortic valve into the ascending aorta. Invasive cardiothoracic surgery was required for successful removal. In another case, a guidewire became entrapped in the phrenic nerve, causing permanent paralysis despite surgical removal. There are several factors that may increase the risk of breast guidewire migration. If the open hook of the guidewire reaches into the pectoralis muscle, repeated contractions may ‘drive’ the wire through the intercostal space and into the pleural cavity. For lesions located deep within the breast where this may be a concern, the pectoralis muscle