AJR 2001; 176:417-419
© American Roentgen Ray Society
Percutaneous Removal of Postbiopsy Marking Clip in the Breast Using Stereotactic Technique
R. James Brenner1
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.
Introduction
The placement of a radiographic marker after percutaneous stereotactic core
needle biopsy of the breast has been described for cases in which lesions are
likely to be entirely removed and in which there is reasonable likelihood that
additional surgery will be required
[1]. The marker serves as a
target for preoperative needle localization, although such markers have been
reported to have been misplaced
[2]. When surgery is performed,
the inclusion of a properly placed marker clip in the excisional specimen
ensures that the area previously biopsied (malignant or proliferative disease,
whichever is prompting surgery) has been removed. I report the case of a
patient whose wide excision for malignancy diagnosed at core biopsy showed no
evidence of tumor at the margins but whose marker clip had not been recovered
at surgery, and I describe a method for percutaneous removal of the clip to
assess the likelihood of residual disease associated with the clip.
Case Report
During a routine mammographic examination of a 54-year-old postmenopausal
woman, a suspicious cluster of microcalcifications 4 mm in diameter associated
with an ill-defined 1-cm focus of asymmetric tissue was identified.
Percutaneous stereotactic core biopsy was performed using an 11-gauge needle
with a directional vacuum-assisted biopsy device (Mammotome; Ethicon
Endo-Surgery, Cincinnati, OH). All the mammographically visible calcifications
were removed, followed by placement of a stainless steel clip (Micro Mark;
Ethicon Endo-Surgery) at the site of biopsy. On a postoperative mammogram, the
clip was located 1 cm inferior to the mammographic site of the calcifications.
Pathology revealed poorly differentiated infiltrating ductal carcinoma.
Preoperative localization was performed with the hookwire placed 1 cm superior
to the clip to compensate for the clip's position relative to the biopsy site
(Figs. 1A and
1B). Wide surgical excision
with clip placement for radiotherapy planning was performed, followed by six
specimen radiographs. None of the radiographs showed the marking clip, and the
operation was terminated. The surgical pathologic finding was a 1.6-cm
high-grade infiltrating ductal carcinoma with no residual tumor within 5 mm of
six separate margins.
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Fig. 1A. —Mammograms of 54-year-old postmenopausal woman showing pre-
and postsurgical persistent marking clip. Close-up mediolateral (A) and
craniocaudal (B) mammographic views of preoperative hookwire
localization show wire tip 1 cm superior to postbiopsy marking clip (encircled
with indelible ink on radiograph).
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Fig. 1B. —Mammograms of 54-year-old postmenopausal woman showing pre-
and postsurgical persistent marking clip. Close-up mediolateral (A) and
craniocaudal (B) mammographic views of preoperative hookwire
localization show wire tip 1 cm superior to postbiopsy marking clip (encircled
with indelible ink on radiograph).
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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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Fig. 1C. —Mammograms of 54-year-old postmenopausal woman showing pre-
and postsurgical persistent marking clip. Postsurgical craniocaudal spot
compression magnification (x1.5) mammographic view shows persistent
marking clip (short arrow) among surgical clips (long
arrows).
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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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Fig. 1D. —Mammograms of 54-year-old postmenopausal woman showing pre-
and postsurgical persistent marking clip. Pre-fire stereotactic radiographic
images show biopsy needle tip in front of marking clip.
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Fig. 1E. —Mammograms of 54-year-old postmenopausal woman showing pre-
and postsurgical persistent marking clip. Pre-fire replacement stereotactic
images show needle reposition so that open chamber is directly adjacent to
marking clip.
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Discussion
In cases in which the removal of the entire mammographic lesion is
anticipated and the patient is likely to require additional surgery, the
placement of a marking clip after core needle biopsy facilitates preoperative
localization for surgical excision
[1]. Although some reports
indicate that clip placement is stable, other researchers suggests that either
the clip can, in fact, move after placement or the clip may be placed
incorrectly [2].
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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Introduction
Case Report
