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Sonographically Guided Clip Placement Facilitates Localization of Breast Cancer After Neoadjuvant Chemotherapy

¹ Department of Radiology, Medical University of South Carolina, 169 Ashley Ave., P. O. Box 250322, Charleston, SC 29425.
² Hollings Cancer Center, Medical University of South Carolina, Charleston, SC 29425.
³ Department of Surgery, Medical University of South Carolina, Charleston, SC 29425.

Received March 1, 1999; accepted after revision July 20, 1999.

 
Address correspondence to L. F. Baron.

Introduction

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Historically, the gold standard for treating large palpable breast cancer has been mastectomy, chemotherapy, and occasionally radiation therapy. However, data from Europe have shown that patients with palpable tumors can benefit from preoperative neoadjuvant chemotherapy, thus enabling most to undergo lumpectomy rather than mastectomy [1, 2]. Recently, some patients with palpable breast cancer are initially being offered neoadjuvant chemotherapy before surgery to debulk the primary breast tumor. After treatment, the primary tumor bed is surgically excised to verify tumor response and to obtain clean margins before radiation therapy. However, a problem faced by the surgeon in this setting is that the tumor frequently responds so dramatically to preoperative neoadjuvant chemotherapy that it is no longer palpable or visible on a mammogram. If the lesion is not visible on the mammogram, it can be difficult to localize the tumor bed before definitive breast conservation surgery. As a result, the surgeon can benefit from having a needle localization wire placed to identify the prior tumor bed to ensure the tumor's removal.

To address this issue, we devised a simple technique of placing a small clip in the tumor and using sonography to localize and permanently document the tumor site before neoadjuvant chemotherapy. Stability of clip position after core needle biopsy and accuracy as a guide for wire localization have been established with stereotactic vacuum-assisted breast biopsies [3, 4, 5]. When the tumor has a complete response to the systemic treatment, the tumor bed can be easily identified on a mammogram by using the clip to guide needle localization before a standard needle localization-directed excision of the clip site.

Materials and Methods

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Patients presenting with palpable breast cancer are referred for placement of a clip either before receiving neoadjuvant chemotherapy or at the time of the original breast biopsy. Patients are selected for this procedure when the initial diagnosis of breast cancer is made with mammography, sonography, and subsequent histologic confirmation. Tumor grade, hormone receptor status, and other markers are established from the core biopsy. Clinical staging, including palpable tumor size and lymph node status, is recorded. Further evaluation may include diagnostic radiologic imaging and blood studies. Eligible patients are then enrolled in the neoadjuvant chemotherapy protocol approved by the hospital internal review committee.

Before beginning neoadjuvant chemotherapy, the patient is referred to the mammography center for placement of the clip. Informed written consent is obtained from the patient. The surgical tray is assembled in a sterile fashion with the following items: gloves, sterile drape, scalpel, bandage (Steri-Strip; 3M, St. Paul, MN), 11-gauge bone needle with an inner stylet (Ackerman; Cook, Bloomington, IN), surgical clip (MicroMark; Biopsys Medical, Irvine, CA,), and sterile gel (K-Y; Johnson & Johnson, Arlington, TX). Before MicroMark clip deployment, the applicator is placed on the sterile field and held gently against the tray. The plastic introducer housing the clip is manually extended as far forward as possible. The plastic introducer sleeve has an extended portion that does not overlap the clip and wire system. This extended portion is carefully cut away with the scalpel to ensure that the applicator wire and the clip are not cut. The stylet is removed from the cannula. The applicator clip and wire assembly are fed through the inner cannula until the clip extends 2 mm beyond the tip of the cannula. The plastic introducer sleeve is marked where it meets the entrance hub of the cannula. The clip applicator is gently removed from the inner cannula and placed back on the sterile tray. The stylet is reinserted into the inner cannula.

The patient is positioned and the breast is prepared and draped. The sonographic probe is fitted with the sterile probe cover. Sonographic guidance with a 10-MHz transducer (Eccocee SSA-34A; Toshiba America Medical Systems, Tustin, CA) locates the tumor and determines the center. If possible, the dermatotomy is made directly over the center of the tumor because during definitive tumor surgery, the surgeon may include the needle tract in the lumpectomy specimen.

The 11-gauge needle and the inner stylet are inserted into the middle of the tumor. The inner stylet is removed and the MicroMark clip applicator unit is inserted through the needle. The clip is deployed when sonography shows that the tip of the clip extends 2 mm past the tip of the outer cannula. The needle and the applicator unit are pulled out and manual pressure is applied to the site. The skin is cleaned with hydrogen peroxide and pressure is maintained until all bleeding ceases. A bandage is placed over the incision.?,?,?,?

View larger version (116K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A. —38-year-old woman with 1.5-cm palpable mass at inferior aspect of right breast found during breast feeding. Diagnostic mammogram shows vague density corresponding to palpable lesion. Note BB marker denoting palpable mass. Sonography (not shown) documented tumor.

View larger version (194K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B. —38-year-old woman with 1.5-cm palpable mass at inferior aspect of right breast found during breast feeding. Sonogram obtained after clip deployment shows hyperechoic focus corresponding to clip.

View larger version (90K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1D. —38-year-old woman with 1.5-cm palpable mass at inferior aspect of right breast found during breast feeding. Mammogram obtained after neoadjuvant chemotherapy shows no evidence of tumor.

View larger version (114K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1E. —38-year-old woman with 1.5-cm palpable mass at inferior aspect of right breast found during breast feeding. Specimen radiograph obtained after lumpectomy shows wire and surgical clip (MicroMark; Biopsys Medical, Irvine, CA). Pathology (not shown) found no residual cancer. SUP = superior, MED = medial.

When the patient is ready, two-view film-screen mammography is performed with craniocaudal and mediolateral projections. A mediolateral oblique mammogram is obtained when the lesion is not visualized on the mediolateral image because the needle localization is performed in the mediolateral projection, rather than the mediolateral oblique projection. Clip placement is now documented for subsequent definitive surgical treatment after neoadjuvant chemotherapy (Fig. 1C).

View larger version (98K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1C. —38-year-old woman with 1.5-cm palpable mass at inferior aspect of right breast found during breast feeding. Craniocaudal mammogram shows location of cancer and clip.

Discussion

Top Introduction Materials and Methods Discussion References

 
Neoadjuvant chemotherapy before surgery is allowing women to undergo breast conservation surgery rather than mastectomy for the treatment of palpable breast cancer [1]. Locating the tumor for subsequent definitive breast cancer treatment can be problematic when a dramatic or complete response to neoadjuvant chemotherapy occurs. We describe an easy method of using sonography to guide a clip into the tumor before chemotherapy and permanently document the tumor site. After chemotherapy, the clip can be used as a marker to guide localization of the tumor site at the time of definitive breast conservation surgery. This technique may prove useful to other clinicians whose patients undergo neoadjuvant chemotherapy before definitive breast conservation therapy.

References

Top Introduction Materials and Methods Discussion References

 

1. Colleoni M, Nole F, Minchella I, et al. Pre-operative chemotherapy and radiotherapy in breast cancer. Eur J Cancer 1998;34:641-645
2. Danforth DN Jr, Zujewski J, O'Shaughnessy J, et al. Selection of local therapy after neoadjuvant chemotherapy in patients with stage IIIA, B breast cancer. Ann Surg Oncol 1998;5:150-158[Abstract]
3. Burbank F, Forcier N. Tissue marking clip for stereotactic breast biopsy: initial placement accuracy, long-term stability and usefulness as a guide for wire localization. Radiology 1997;205:407-415[Abstract/Free Full Text]
4. Liberman L, Dershaw DD, Morris EA, et al. Clip placement after stereotactic vacuum-assisted breast biopsy. Radiology 1997;205:417-422[Abstract/Free Full Text]
5. Fajardo LL, Bird RE, Herman CR, DeAngelis GA. Placement of endovascular embolization microcoils to localize the site of breast lesions removed at stereotactic core biopsy. Radiology 1998;206:275-278[Abstract/Free Full Text]

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