Using Ultrasound Color Doppler Twinkling to Identify Biopsy Markers in the Breast and Axilla

Christine U. Lee, Gina K. Hesley, Susheil Uthamaraj, Nicholas B. Larson, James F. Greenleaf, Matthew W. Urban

Research output: Contribution to journalArticlepeer-review


In breast radiology, ultrasound detection of biopsy markers or clips for localization purposes is often challenging, especially in the axilla. The purpose of this research was to test the hypothesis that the surface roughness of biopsy clips would elicit a twinkling signature on color Doppler, making them more readily identifiable by ultrasound. Ultrasound color Doppler imaging of 12 biopsy markers was performed and consensus scoring of the degree of twinkling (0 [no twinkling] to 4 [exuberant twinkling]) was obtained for each of the markers. The surface roughness characteristics of the markers were measured using 3-D coherence scanning interferometry. The 3 markers scoring at least 3 for twinkling in vitro were cork, Q and Vision. Of these 3 markers, only the cork marker scored a 4 ex vivo and in cadaveric tissue. Surface roughness metrics demonstrated a positive estimated correlation with the twinkling scores (rho = 0.33, 95% CI = [–0.48 to 0.84]). Of the 12 markers tested, the markers that twinkled corresponded to surface roughness measured with non-contact 3-D optical imaging. Qualitatively, lower color scales and color frequencies optimized twinkling, but the most specific qualitative predictor of confidence in twinkling was insensitivity to changes in color scale and color frequency values.

Original languageEnglish (US)
Pages (from-to)3122-3134
Number of pages13
JournalUltrasound in Medicine and Biology
Issue number11
StatePublished - Nov 2021


  • Biopsy clips
  • Biopsy marker
  • Breast cancer
  • Breast imaging
  • Breast ultrasound
  • I-125 seed localization
  • Lymph node biopsy
  • Ultrasound-guided localization

ASJC Scopus subject areas

  • Radiological and Ultrasound Technology
  • Biophysics
  • Acoustics and Ultrasonics


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