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1 Eisenberg Keefer Breast Center, John Wayne Cancer Institute, Saint Johns Hospital, 1328 22nd St., Santa Monica, CA 90404.
Received March 9, 2000;
accepted after revision August 10, 2000.
Address correspondence to R. J. Brenner.
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In accordance with protocol and because the clip could not be defined radiographically during surgery, a postoperative mammographic study was performed before radiotherapy. This study showed the core needle biopsy marking clip at the edge of the surgical bed (Fig. 1C). Although it was unlikely that any malignancy remained at this site, the presence of the clip required further investigation. This decision was predicated on three considerations: the stereotactic biopsy had shown malignancy and the clip was either at or immediately proximal to the tumor; the pathologic assessment of margins is fallible [3]; and therefore there were persistent mammographic findings (the clip) suggesting the presence of residual disease. Given the low likelihood of residual disease because of surgical margins that were negative for tumor, percutaneous removal of the marking clip and surrounding tissue was deemed preferable to additional surgery.
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The patient underwent stereotactic biopsy in a manner previously described [4, 5]. However, because of the intent of this biopsy and the need to remove a 2-mm clip within a 19-mm biopsy needle aperture chamber, an 11-gauge needle was placed so that the middle of its open chamber was directly adjacent to the clip and surrounding tissue (Figs. 1D and 1E). A core biopsy sample was obtained by advancing the rotating cutting blade and was immediately radiographed, showing the clip within the biopsy specimen (Fig. 1F). Fifteen additional biopsy samples were obtained, with pathology showing no significant finding. There were no complications from the procedure, and the patient underwent adjuvant therapy.
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Definitive surgery for breast cancer is intended to remove all identifiable tumor in the breast, including the marking clip, which, when properly placed, is assumed to be associated with malignant tissue. Although missed marker clip recovery rates vary, Jackman and Marzoni [6] reported a rate of 2.5% (7/280) in a recent series; all the cases involved microcalcifications that were not identifiable on specimen radiographs. The authors noted that removal of additional tissue decreases but does not eliminate failure to completely recover the intended lesion. At subsequent surgery, all missed lesions except one that did not undergo reexcision were associated with benign disease, a finding already suggested by removed tissue near but not at the site of the remaining calcifications.
When surgery is being performed for malignancy, wide excision is used to remove all tumor and provide disease-free margins [7]. However, evaluation of surgical margins is fallible and not always consistent [3]. Although in this case residual disease was identified at reexcision and margins were reported as clear, three circumstances prompted the removal of the clip.
First, as mentioned, analysis of surgical margins is not infallibly accurate. However, this issue may always be a concern, and clinical experience provides a basis for assuming that in most cases histologic assessment of clear margins is correct [7]. The assessment of clear margins was suspect in this case because of the two other circumstances that prompted intervention: the clip was sufficiently proximal to the biopsy site showing malignancy, and failed surgery is often indicated by persistent mammographic findings prompting biopsy [6], (i.e., in this case, the postbiopsy marking clip). These circumstances provided an important rationale for retrieving the clip and surrounding tissue and verifying the absence of residual disease. In other situations, such as when the postbiopsy clip is at a greater distance from the biopsy site as a result of misplacement, retrieval may not be necessary. For example, Rosen [2] reviewed 55 cases, noting clip deployment at a mean distance of 13.3 mm from the biopsy site after lateral compression and 10.4 mm from the biopsy site after craniocaudal compression. Moreover, in 20% (11/55) of cases, the clip was more than 2 cm from the biopsy site. Under these circumstances, retrieval of the clip would not be indicated after surgical excision of the tumor and confirmation of clear margins.
Thus, the decision to remove a marking clip after surgery needs to be assessed in light of the clinical circumstances. Additional cost and patient anxiety should also be considered when making such a determination. In cases in which residual malignancy is found at surgical margins, further excision is indicated. Under circumstances such as those described in this case, in which the likelihood of residual disease is low but not negligible, more limited intervention may be a preferable approach. The technique of stereotactic removal of the clip and surrounding tissue described here permits this objective to be accomplished successfully.
Parker et al. [8] reported removing a retained localization wire using a sonographically guided core needle biopsy with an 11-gauge rotational vacuum-assisted device, although such retained wires do not compromise the patient's health and are removed electively [8]. Similarly, postbiopsy clips placed after removal of benign disease may be removed percutaneously by the method described here, although the clinical indications would be similarly limited. Based in part on the prior report for removal of localizing wires, I believe that it is unlikely that the rotating blade will be damaged or the clip transected [8]. More important, this method is available for cases of excised malignancy with clear margins in which the clip has not been surgically removed and was initially placed within close proximity to the biopsy site as described in this report.
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