Respectful Insolence

When “minor” cases go bad

“It’s just minor surgery.”

How many times have surgeons said that to patients? How many times have you, as a patient heard that? How many times have I said that to patients? It’s supposed to be reassuring, and most of the time it is.

Unfortunately, there’s no such thing as “minor” surgery if it’s you at the wrong end of the knife. And, in fact, even “minor surgery can on rare occasions have truly bizarre and unexpected complications. I’ve been thinking of writing about perhaps the most memorable and strange complication of a “minor” procedure (in this case, a breast biopsy) that I’ve even seen, but then damned if Dr. Schwab had to go and one-up me (or two-up me–or three-up me; see below). True, his complication has the advantage of not being his, but, as you’ll see, I don’t really think in the end that the complication I’ll tell you about was due to anything I did.

As Dr. Schwab explained, when a suspicious abnormality shows up on mammography that warrants biopsy but is not associated with a palpable mass or lump, then some form of radiology-guided biopsy has to be done, because if a surgeon can’t actually feel the abnormality he can’t cut it out. He needs something to guide him. Since I finished my residency 10 years ago, the old form of biopsy, which is surgical, has mostly been supplanted by core needle biopsy techniques. One is the stereotactic biopsy, in which mammography is used to guide the core needle biopsy device. If the lesion is visible on ultrasound, an ultrasound-guided core biopsy can be done, and, indeed, many surgeons, myself included, are learning to do these in the office, because all you really need is a decent ultrasound machine and the core biopsy instruments. For me the reason is not so much economic (I won’t be making any more money doing these things–I’m strictly on salary) but for the benefit of patients. Because our radiologists are a bit overstretched, if I do the simpler ultrasound-guided biopsies, they tend to get done faster. Oh, it’s not entirely altruistic, as I also get tired of explaining why a patient has to wait sometimes three weeks or more for a simple biopsy, but it is mostly so. And, besides, it’s a skill that all surgeons doing breast surgery these days should probably have.

Sometimes, however, nothing will do except a surgical excision. This can be due to geometry. Lesions close to the chest wall or too close to the skin are simply not easily accessible to the core needle because of the angle. It can be due to faintness (the mammography used to do the biopsy is not as sensitive as standard mammography because it is in essence fluorscopy). Sometimes it can be because the lesion is too diffuse or subtle, in which case a full sampling of tissue is needed to get it. That’s where I’m needed. The procedure is called a wire localization biopsy. It’s one of those “minor” surgical procedures. Basically the patient will go to radiology first, where the mammographer will place a wire through the skin such that it is near the abnormality. The patient then comes to the O.R., where yours truly makes an incision, follows the wire down, excises the tissue around the wire, X-rays the wire to make sure that the abnormality is in the excised specimen, and then closes up. Usually, the case takes less than an hour, and in many cases for me waiting for the X-ray takes at least as long as the procedure itself. Sometimes, however, in the case of a large breast with a deep lesion, the wire localization biopsy can be a frustratingly challenging case, far more difficult than it would appear on its surface.

And it is a pretty safe procedure, going perfectly well without complications between 96-99% of the time. When complications occur, they are almost never life-threatening and consist of a wound infection (which can often be treated with antibiotics but sometimes have to be opened and drained) or bleeding (which usually results in a hematoma that, if small enough, will resolve on its own, although on rare occasions it’s necessary to go back to the O.R. to drain it and find the source of bleeding). Less than 1% of the time, the surgeon will miss the abnormality, sometimes necessitating another attempt in two or three months, after the biopsy has healed. Occasionally, the surgeon will accidentally cut the wire, leaving the end of it in the breast. This can sometimes lead to a truly frustrating surgical tour de force to try to find it with fluoroscopy. This has only ever happened to me once, and fortunately I found the wire. Sometimes the wire ends up being left in, mainly when continuing to dig around for it would cause more harm than just leaving it there.

And then there are the totally bizarre and rare complications, one of which Dr. Schwab describes when he sees a patient in whom another surgeon had lost the wire in the breast and on whom he ordered an additional set of X-rays to find it:

Guessing the wire had migrated itself to the periphery of the breast, outside the mammogram field, I ordered a regular chest Xray, and indeed it showed the wire. But not hardly where I’d expected it. Not hardly at all.

At the far edge of her right lung, is where it was. It had originally been in her left breast! And — for you anatomists out there — subsequent views showed it was definitely within the lung, not overlying it on the outside. Now, here’s the hard part, because I’m not clever enough to be able to draw explanatory pictures and load them into this blog: the only way this could have happened is if the wire had humped itself directly down through the breast, through the chest wall, and into Marlene’s heart: her right ventricle, to be precise, after which it was flushed out into the pulmonary artery and sent into the lung. The only other avenue was for the wire to have entered a vein in Marlene’s breast — or the big vein under her collarbone (the subclavian vein) and then gone to the heart. But the wire was at least two inches long. No way it could have made the twists and turns required of that circuit, starting its journey through a small vein.

“I’ve got some good news, and some bad news,” I told Marlene. “The good news is that the shadow in your breast continues to look harmless, and safe to leave alone. The bad news is that the wire….. DRILLED A HOLE THROUGH YOUR FRIGGIN’ HEART, PASSED RIGHT THROUGH IT AND STABBED ITSELF INTO YOUR LUNG. YOU’RE GONNA DIE!!!!!” OK, I didn’t say that last part. But I figured that’s what she’d hear, no matter what I said.

Yikes!

I can honestly say that I’ve never seen such a complication, nor have I ever even heard of this as a potential complication of a wire localization breast biopsy. I suppose it does make me feel a little better at my complication, which happened around three years ago and which I will not be likely to live down until the crop of interns from that year graduate the program. Basically, the complication that occurred after a wire localization biopsy that I did did involve the wire penetrating the chest, but nothing nearly as strange and unusual as above. In my case, I was called about an hour after the procedure because my patient, a delightful elderly woman, was complaining of shortness of breath. A chest X-ray in the recover room showed that the wire had caused a small but clearly significant pneumothorax (collapse of the lung), and we had to place a chest tube to reexpand the lung (after picking my jaw up off of the floor, that is), and fortunately the patient did very well, going home afer about a day and a half. I distinctly remember that the wire tip was right next to the chest wall, with the tip abutting the muscle. However, this is not unusual for deep lesions. The best that I can guess is that the radiologist must have inadvertently entered the chest cavity with the needle used to insert the wire, as I saw the wire throughout its entire course during the procedure. I can’t really cast aspersions, given that the lesion was deep and next to the chest wall. Any time you insert needles or wires into anywhere near the chest wall, a pneumothorax is a possibility, particularly in the thin and the elderly (both of which my patient was). Certainly, it has been observed on occasion after needle biopsy techniques at a rate of less than 1/1000. It’s also all too easy just to blame the radiologist, rather than to look long and hard at myself and what I did to determine if there is any chance that the complication was due to something I did. I don’t think that it was, but I can’t completely rule it out, either. To this day, I still wonder if there was anything I could have done differently.

What Sid Schwab’s story and my complication should tell you is that even “minor” surgery can, on rare occasions, have not-so-minor complications, even if no obvious mistake can be identified. I’m not telling you this to scare you (quite frankly, the complications described above are quite rare compared to the more run-of-the-mill complications of bleeding, infection, or missing the lesion), but rather to inform you. No surgical procedure is without risk, an observation that is always part of my answer when I’m asked why I don’t recommend biopsying every mammographic abnormality.

It’s also one reason why I try never to tell a patient that it’s just “minor” surgery. There’s no such thing as truly “minor” surgery, although there is what I like to call small surgery that can be done under local anaesthesia with sedation. It’s a subtle but to me important distinction.

Comments

  1. #1 Emily DeVoto
    September 27, 2006

    Indeed… often, a lot of the risk is in the workup, which a lot of docs discount and which is why mass screening in the absence of clear benefit (e.g., for prostate cancer) is such a dicey concept. (If you think I might have more to say on this topic, you’re right, but I don’t want to take over your blog!)

  2. #2 Ahistoricality
    September 27, 2006

    My father’s definition of minor surgery is “surgery happening to someone else”…..

  3. #3 JohnnieCanuck
    September 27, 2006

    My mother was a nurse between the Wars and one of her oft told stories was of needles and how very far they could move in the body. Sometimes they would reappear under the skin where they could be removed.

    I can’t remember any explanations for the needles being there in the first place or even if they were sewing or hypodermic needles.

    I’m a little skeptical that the wire penetrated the heart in a way that it could leave through a valve. Note the barb in the image.

    Just a layman’s opinion, but then what training would allow anyone to make predictions of that thing’s path.

  4. #4 epador
    September 27, 2006

    I’d voter for the venous route – I’ve seen a few errant catheters of larger diameter and similar length wend their way to distal lung sites. But the direct route sure is more dramatic, and feasible, especially in a frail elderly patient.

    We need to get someone like Mayo CSI to work this one up.

  5. #5 Diora
    September 28, 2006

    Indeed… often, a lot of the risk is in the workup, which a lot of docs discount and which is why mass screening in the absence of clear benefit (e.g., for prostate cancer) is such a dicey concept. (If you think I might have more to say on this topic, you’re right, but I don’t want to take over your blog!)
    Emily, I am with you here. I think that even if the benefit is present, screening should be a personal choice. Because while the risks are small, so is the probability of an individual benefitting. The people shouldn’t be cajoled or “convinced” or scared into screening but given correct and honest information about both the chance of a potential life-saving benefit (expressed in absolute rather than relative numbers) as well as risks (biopsies,overdiagnosis) and are allowed to make their own decision. And whatever the decision is it should be respected. (I also have more to say on the subject, but it is off-topic here).

  6. #6 Sid Schwab
    September 28, 2006

    JohnnieCanuck: things much larger than that pass thru heart valves. Check out “pulmonary embolus.” And we pass all sorts of catheters through the heart chambers as well.

    epador: of course the path is only supposition on my part. But it would have had to start in a small vein and then pass into larger and larger ones if the venous route were the way. It was a couple of inches long and pretty stiff. I find the logistics less likely than a straight shot. Educated (based on no experience) guess.

    Orac: I had a patient who’d had a core biopsy done with a tru-cut needle, by her internist (!!!!!) who gave her a pneumo while diagnosing her cancer. It was otherwise pretty favorable (small, node-negative.) Being a tough Alaskan, she chose mastectomy and headed home, refused adjuvant therapy. Couple of years later she recurred in her pleura, right at the location of the penetration.

  7. #7 CardioNP
    September 28, 2006

    Recently had a cardiology consult for “chest pain” in a woman who had a retained wire from a needle loc bx. The patient described the pain as being in the breast near the retained wire. Guess her PCP didn’t believe her…. so she got radiation from a myocardial perfusion scan that was not indicated, then referred for a consultation that was not needed, all causing unneccessary iatrogenic anxiety.

    So those “minor” surgeries could have quite far reaching consequences.