Ultrasonography-guided surgical clip placement for tumor localization in patients undergoing neoadjuvant chemotherapy for breast cancer

Low-Cost Radio-Opaque Tumor Marking Techniques for Breast Cancer Patients Undergoing Neoadjuvant Chemotherapy: a Systematic Review

Current standard of care localization techniques used in breast conserving surgery (BCS) after neoadjuvant chemotherapy (NACT) are expensive and may not be available in LMICs (lower-middle income countries). This review evaluated the efficacy of radio-opaque low-cost tumor markers. A systematic search was conducted as per PRISMA guidelines through November 30, 2022, for all studies using non-commercial radio-opaque tumor markers for patients undergoing BCS post NACT. Rate of unsatisfactory margin on final histology was the primary outcome. Oxford Centre for Evidence Based Medicine (OCEBM) levels were used to assess internal validity. After screening, 07 studies were included for data synthesis. For marking, four studies used LIGA clips, two used 5-mm cut pieces of K-wire, and one used cut pieces of 25-G needle. Incidence of unsatisfactory margins (positive/close) ranged from 0 to 11%. All studies found these low-cost markers to be feasible, with 100% pre-surgery visibility and 100% retrieval rate. Low-cost radio-opaque tumor markers (LIGA clips, 5-mm cut pieces of K-wire and 25-G needle) are effective methods of tumor localization especially for LMICs.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13193-023-01845-2.

Assessment of Response to Neoadjuvant Chemotherapy in Locally Advanced Breast Carcinoma Using Image-Guided Clip Placement

Background The present study aims to evaluate the response of locally advanced breast carcinoma (LABC) to neoadjuvant chemotherapy (NACT) using image-guided clip placement based on Response Evaluation Criteria in Solid Tumors (RECIST) 1.1 criteria. Methods Thirty-four patients with LABC were included in the study. Consent for three-dimensional titanium clip placement (400/300/200 mm Liga clips) under local anesthesia with USG guidance was obtained. Serial sonographic/X-ray evaluations of tumor bed size were conducted before every cycle of NACT. All data were recorded in millimeters of concentric tumor regression/non-regression. Tumor regression in a concentric or Swiss cheese pattern and non-responders were evaluated. Assessment of the response to NACT was performed using RECIST criteria, dividing it into four categories. Tumor response was confirmed with computerized tomography (CT) conducted before and after the completion of NACT. Patients underwent surgical management, mostly modified radical mastectomy (MRM), as they had locally advanced breast carcinoma. Following MRM, the clips in the specimen guided the original site of the tumor for histopathological evaluation and response to chemotherapy. Results Tumor response was classified into four types: complete response (CR), partial response (PR), progressive disease (PD), and stable disease. RECIST 1.1 criteria were elaborated and defined. Data for all patients were entered into an Excel sheet (Microsoft Corporation, Redmond, Washington) to prepare a master chart, and the following observations were made and analyzed using SPSS software. The duration of chemotherapy for the study population ranged from 32 to 206 days, with a mean (±SD) of 111.82 (± 52.64) days and a median (IQR) of 81 (63, 158) days. The mean period between clip insertion and completion of NACT was 111.82 days. The baseline sum diameters and post-NACT diameters of the tumors were 70.50 (±13.60) mm before NACT and 17.75 (±17.20) mm after NACT. Hence, the mean size of the lump was statistically significantly lower after NACT, with a mean difference of 52.75 (p<0.05). The mean rate of reduction in tumor diameter was found to be 74.32% (±23.44%) based on RECIST 1.1 criteria. Pathological response was observed in all patients except for 8.8% of the patients. Clinical complete response was seen in 35.29% of patients, and partial response was observed in 52.92% of the patients based on RECIST 1.1 criteria. The study thus demonstrates the effectiveness of NACT in LABC, with a mean reduction in tumor diameter of 74.32%, assessed with the help of RECIST 1.1 criteria. Conclusion NACT for patients with LABC has shown a significant reduction in tumor size. NACT should be the initial mode of management for patients with LABC. RECIST 1.1 criteria are effective and can be used to assess tumor response to NACT. This has aided in the stratification of the response of NACT for further management through systemic therapy (adjuvant chemotherapy) after the surgical excision of the tumor.

Marking Techniques for Targeted Axillary Dissection Among Patients With Node-Positive Breast Cancer Treated With Neoadjuvant Chemotherapy

Invasive breast cancer with axillary lymph node (LN) invasion is a continuing problem worldwide. The morbidity associated with axillary LN dissection along with the high rate of nodal downstaging after neoadjuvant chemotherapy (NACT) made the standard treatment shift towards less invasive surgery. Sentinel lymph node biopsy (SLNB) after NACT is associated with high false-negative rates (13%-14%). To overcome this problem, it was concluded that the positive nodes should first be indicated with image-detectable markers and then removed together with SLNB: targeted axillary dissection (TAD). This review aims to describe and evaluate the different marking techniques for TAD in patients with node-positive breast cancer treated with NACT, namely: clip placement and guidewire localization; clip placement and 125I-labelled radioactive seed localization; clip placement and skin mark; clip placement and intraoperative ultrasound; tattooing with a sterile black carbon suspension; magnetic seeds; radar and infrared light technology localization. Targeted axillary dissection techniques have shown false-negative rates below 9% and identification rates above 95%. The most studied technique is guidewire localization, as it is also the oldest one. However, according to data gathered from this review, some newer techniques have shown to be very promising due to their statistical results and management factors.

The Evaluation of a Cost-Effective Method for Tumour Marking Prior to Neo-Adjuvant Chemotherapy Using Silver Rods

Objective

The lack of objective documentation of pre-neoadjuvant chemotherapy (NAC) tumour margins is a major constraint in performing safe breast conserving surgery (BCS) in patients with breast cancer. Using a novel method of marking pre-NACT tumour margins with indigenous silver wire markers, this retrospective observational study attempted to assess the feasibility of safe BCS in breast cancer patients by performing excision wide of the marked pre-NACT margins.

Materials and Methods

This retrospective observational study was conducted on breast cancer patients who were attending our oncology centre between May, 2015 and April, 2022. All patients had received NAC followed by surgery as recommended by our multidisciplinary team. All the patients had a primary operable solitary breast cancer. We used radiopaque metallic rods made from silver to localize tumour margins prior to NAC.

Results

Sixty-four breast cancer patients were included; none had marker-related complications. Following NAC, BCS could be easily performed in 60 patients guided by the silver markers, which were used as temporary implants and removed during surgery. Only 2 patients were seen with positive margins and were converted to mastectomy.

Conclusion

Breast cancer localization using sterile silver markers before the initiation of NAC is safe, easy, inexpensive, and effective, causing no morbidity or significant pain to the patients.

Ultrasound-guided percutaneous insertion of small vascular surgical clips versus dedicated breast mammoclips as markers for breast cancer prior to neo-adjuvant therapy: a prospective randomized controlled trial

Aim

To investigate the feasibility of applying small vascular surgical clips as tissue markers for breast cancer in patients scheduled for neoadjuvant chemotherapy (NAC) in comparison with the dedicated breast clips with assessment of their different complications.

Patients and methods

This prospective randomized controlled trial included 160 female patients with breast cancer whose neoadjuvant chemotherapy was required for their management. Patients were randomly allocated into 2 groups; group I for patients who were subjected to the insertion of the small vascular surgical clips, and Group II for patients who were subjected to the insertion of the dedicated breast clips (UltraClips®). Assessment of the feasibility of the application of the vascular surgical clips and detection of the complications of the vascular surgical clips compared to the UltraClip® commercial clips were the endpoints of this study.

Results

Vascular surgical clips application had significantly longer duration than the duration of application of the UltraClips® (9.10 ± 2.67 min, and 5.44 ± 1.09 min respectively, P < 0.001). The application of vascular surgical clips was feasible in all patients. There were more incidences of non-deployment (6 patients) and mal-deployment (4 patients) in group I, compared to one patient and 2 patients in group II, respectively. All patients of non-deployment and mal-deployment in both groups had reapplication of other clips successfully. There were no significant differences between the two groups regarding incidence of complications.

Conclusions

The spinal needle/surgical vascular clip technique seems to be a cheap and effective alternative to the dedicated commercial mammoclips when required, with convenient results and minimal complications.

Structured Reporting: An Intervention to Improve Procedure Documentation in Breast Imaging

OBJECTIVE

To evaluate intervention of structured reporting after wrong-site surgery that occurred after localization of an incorrect breast biopsy marker.

METHODS

An IRB-exempt retrospective database review identified patients who underwent core-needle biopsy of a breast lesion from July 1, 2014 to July 1, 2020. They were divided into three cohorts: 2014 pre-intervention/pre-sentinel, 2017 pre-intervention/post-sentinel, and 2019 post-intervention of structured reports. One hundred reports per cohort were reviewed for documentation of marker and shape. Statistical analysis was performed with mixed-effects logistic regression model and chi-squared test with P < 0.05 considered significant.

RESULTS

The 2014 cohort consisted of 100 patients with 122 biopsies. Twenty-seven (22.1%) were excluded: 5/122 (4.1%) lesion resolution, 22/122 (18.0%) no documentation whether marker was/was not placed. Of the 95 biopsies remaining, 4/95 (4.2%) had no marker placed, 62/95 (65.3%) reported marker only, and 29/95 (30.5%) reported marker and shape. In the 2017 cohort, 100 patients underwent 108 biopsies. Four/108 (3.7%) were excluded: lesion resolution. Of the 104, 10/104 (9.6%) had no marker placed, 22/104 (21.2%) reported marker only, and 72/104 (69.2%) reported marker and shape. In the 2019 cohort, 100 patients underwent 114 biopsies. Two/114 (1.8%) were excluded: lesion resolution. Of the 112, 3/112 (2.7%) had no marker placed, 3/112 (2.7%) reported marker only, and 106/112 (94.6%) reported marker and shape. The predicted probability of both marker placement and shape described were statistically greater for 2019 compared to the other cohorts (P < 0.05).

CONCLUSION

Using structured reports facilitates and improves documentation of breast biopsy markers and may potentially reduce the risk of medical errors.

Assessment of low-cost surgical metallic clip placement for tumor localization in BIRDAS VI breast cancer patients undergoing neoadjuvant chemotherapy

Background

Neoadjunvant chemotherapy has become a challenging connotation for both surgeons and radiologists due to the high clinical response up to dramatic pathological complete response (pCR) that may hinder proper localization of any residual tumoral tissue. So the radiopaque markers implantation at the tumor bed became a reliable and recommended method for tumor localization before surgical intervention or NAC. Many types of commercial clips and markers are available; however they are relatively of high cost and represent a considerable burden on the governments and the heath institute that made the researchers study cheaper alternatives as standard titanium based cholecystectomy surgical clips for tumor localization.

Results

The study was conducted on 45 patients where 57 clips were inserted corresponding to number of lesions found in the total number of the patients. The response to Neoadjunvant chemotherapy was recorded and showed that 6 patients (about 13.3%) had complete radiological response after NAC, while 27 patients (60%) had regressive course after the treatment. The low cost surgical clips were evaluated by using sono-mammography and magnetic resonance imaging, and complications that occurred were recorded. Our study showed that in only 2 patients (3.5%) there was difficulty in clip visualization by Ultrasound during post-treatment follow up. In 45 patients, all the inserted clips (100%) were well visualized as small signal void on MRI at both T1WIs and T2WIs sequences, and the primary malignancy was easily visualized on both MRI and sono-mammography not interfering with the image interpretation and judgment. As regards the reported complications, our results revealed that in only 2 patients (3.5%) there was evidence of positive clip migration, while only 2 patients (3.5%) developed hematoma during the procedure as shown by ultrasound, Also 4 patients (7%) complained of pain only shortly after clip insertion. No other significant complications like infection or heat sensation developed either during the procedure or during MRI. The total price of the surgical clips was calculated with average cost of the needle about 10 US$ equivalent to 170 LE Egyptian pounds and the clip about 1.3 US$ or 20 Egyptian pounds, which is considered of lower cost when compared to the commercial breast markers of different companies with an estimated price range for clip = 75–200 US$ (average 90 US$). So insertion of surgical clips saved about 1135 Egyptian pounds equivalent to 73–75 US$ per clip placement.

Conclusion

We concluded from our study that the use of breast markers are mandatory before NAC where Surgical clips can safely substitute the commercial tissue markers as tumor localizers as they are effective, safe, well tolerated, easily visualized on imaging and do not interfere with assessment of the treatment response, with no evidence of complications and are of low cost compared with the commercial breast clips.

Ultrasonic backscatter coefficient estimation in nonlinear regime using an in situ calibration target

Tissue characterization based on the backscatter coefficient (BSC) can be degraded by acoustic nonlinearity. Often, this degradation is due to the method used for obtaining a reference spectrum, i.e., using a planar reference in water compared to a reference phantom approach resulted in more degradation. We hypothesize that an in situ calibration approach can improve BSC estimates in the nonlinear regime compared to using the reference phantom approach. The in situ calibration target provides a reference within the medium being interrogated and, therefore, nonlinear effects would already be contained in the in situ reference signal. Simulations and experiments in phantoms and in vivo were performed. A 2 mm diameter titanium bead was embedded in the interrogated media. An L9-4/38 probe (BK Ultrasound, Peabody, MA) and an analysis bandwidth from 4.5 to 7.4 MHz were used in experiments. Radiofrequency data from the sample, bead, and reference phantoms were acquired at a quasi-linear baseline power level and at further increments of output power. Better agreement between the BSC obtained at low power compared to high power was observed for the in situ calibration compared to the reference phantom approach.

Surgery after Neoadjuvant Chemotherapy: A Clip-Based Technique to Improve Surgical Outcomes, a Single-Center Experience

Background: This study aims to describe the surgical management of breast cancer patients after neoadjuvant chemotherapy, with attention to the impact on surgical outcomes of a clip-based marking technique. Methods: Patients who underwent NACT at the Breast Unit of the A. O Ordine Mauriziano of Turin from January 2018 and had a surgical intervention by January 2022 were included. Data on the feasibility of clip insertion, after-treatment visibility, and successful removal during surgery were collected prospectively. Surgical outcomes in terms of breast-conserving surgery and axillary dissection reduction were described. Results: In 51 patients who had surgery after NACT, 55 clips were placed (34 breast and 21 axillary clips). Ultrasound visibility of the clips was optimal (91%) as well as preoperative localization and retrieval within the surgical specimen. Moreover, the use of the clip positively affected surgical outcomes. In our study, clip insertion allowed to avoid mastectomy and axillary dissection in patients with a complete radiological response. Conclusions: In our findings, the use of breast and/or lymph node clips has proved to be a simple and effective method to improve surgical conservative management of breast cancer patients after NACT.

Breast Radiotherapy after Oncoplastic Surgery—A Multidisciplinary Approach

Simple Summary

This article aims to review and summarize the current evidence for the role of oncoplastic breast surgery and the implications this may have on other therapies, such as radiotherapy and chemotherapy.

Abstract

Oncoplastic breast surgery encompasses a range of techniques used to provide equitable oncological outcomes compared with standard breast surgery while, simultaneously, prioritizing aesthetic outcomes. While the outcomes of oncoplastic breast surgery are promising, it can add an extra complexity to the treatment paradigm of breast cancer and impact on decision-making surrounding adjuvant therapies, like chemotherapy and radiotherapy. As such, early discussions at the multidisciplinary team meeting with surgeons, medical oncologists, and radiation oncologists present, should be encouraged to facilitate best patient care.

Application of ultrasound-guided placement of markers for locating axillary lymph nodes of breast cancer

BACKGROUND

With the continuous improvement of pathological complete response (pCR) rate after neoadjuvant therapy (NAT), it is necessary to locate the tumor bed and axillary lymph nodes (ALNs) for subsequent surgery. Therefore, breast tissue markers emerge. This study aims to evaluate the feasibility and accuracy of ultrasound (US)-guided placement of markers for locating ALNs of breast cancer.

METHODS

A total of 285 patients who received US-guided placement of markers for locating ALNs in our hospital were selected. Among these patients, 87 patients were in the early breast cancer (EBC) group with negative ALNs and 198 ones were in the NAT group with positive ALNs. Data including the basic information of patients, position and size of ALN, process of US-guided marker placement, placement success rate, complications, detection rate of marker by imaging, and shift rate were recorded.

RESULTS

All patients were successfully undergone US-guided marker placement. And the average operation time was 2 minutes with no adverse reactions. All the patients underwent surgery successfully. US, computer tomography (CT) and magnetic resonance imaging (MRI) were used to detect the marker. The detection rate of markers by US and CT/MRI were 100% (87/87) in EBC group, and 98.5% (195/198) and 100% (198/198) by US and CT/MRI, respectively, in NAT group. The postoperative marker shift rate was 2.1% (6/285), including 3.4% (3/87) marker shift rate in EBC group and 1.5% (3/198) in NAT group, with no statistically significant difference between them.

CONCLUSIONS

US-guided marker placement in ALNs of breast cancer is simple and safe, with firm positioning and low shift rate, which is convenient for clinical promotion.

Easy and cost-efficient method for tumour localization in patients with breast cancer undergoing neoadjuvant chemotherapy followed by breast conservation therapy

This article describes placement of a radio-opaque clip for tumour localization to facilitate resection in patients undergoing neoadjuvant chemotherapy followed by breast conservation therapy. Use of a radio-opaque marker made of stainless steel K-wire and use of a Trucut® needle with a blunt stylet for wire placement in the breast tumour bed is a safe, indigenous, and cost-effective method for tumour localization.

Comparison of resection margin status after single or double radiopaque marker insertion for tumor localization in breast cancer patients receiving neoadjuvant chemotherapy

PURPOSE

Insertion of radiopaque markers is helpful for tumor localization in patients receiving neoadjuvant chemotherapy (NAC) followed by breast-conserving surgery (BCS). The aim of this retrospective study was to investigate the pathologic margin status in patients with single or double marker insertion.

METHODS

We reviewed the records of 130 patients with marker insertion prior to NAC followed by BCS from January 2016 to September 2019. Under ultrasonography guidance, single or double markers were inserted to localize a tumor in the breast. The incidence of additional resection after frozen biopsy and re-excision after permanent pathologic diagnosis was analyzed.

RESULTS

In a total of 130 patients, 104 had a single marker in the center of the tumor and 26 had double markers at the periphery of the tumor before NAC. Among 69 patients with residual invasive tumors after NAC, there was no difference in the additional resection rate after frozen biopsy (single vs. double markers; 14.3% vs. 38.5%, P = .059) or the re-excision rate after final pathologic diagnosis (0% vs. 7.7%, P = .188). After propensity score matching for tumor size and subtypes, the two groups showed no differences in the additional resection rate after frozen biopsy (7.7% vs. 19.2%, P = .139) or the re-excision rate (0% vs. 3.8%, P = .308). After a median follow-up of 19 months (range 8-48 months), local recurrence-free survival did not differ between the two groups (log-rank P = .456).

CONCLUSIONS

Number of inserted markers for tumor localization did not affect the pathologic margin status after BCS.

Clip and wire localization of locally advanced malignant breast masses in patients undergoing neoadjuvant chemotherapy and breast conservation therapy

Background

In locally advanced breast cancers, the use of preoperative systemic therapy has been shown to induce tumor response and to improve the local control rate after subsequent surgery and radiation therapy. The purpose of the study is to evaluate the accuracy of localization of breast malignant masses in patients who received neoadjuvant chemotherapy and will undergo conservative breast surgery by using clip and wire marker.

Results

Clip placement was done in 20/20 cases (100%). There was no mammographic evidence of clip migration or complication related to the clip insertion. Wire localization of tumor bed marked by radiopaque clip 1-day preoperative was done in 18/20 patient (90%), the other 2 patients, the masses were clinically palpable (10%). Accurate localization by wire was positive in 18/18 cases. Clip and wire retrieval were positive in all cases.

Conclusion

Clip markers can be used for tumor localization in breast cancer patients undergoing neoadjuvant chemotherapy without migration. Clips are tolerated and safe for the patient, easily visualized on imaging, do not interfere with treatment response, and are cost-effective. Also, serves as a guide for post-neoadjuvant chemotherapy localization when the tumor is not palpable.

Comparison of breast tissue markers for tumor localization in breast cancer patients undergoing neoadjuvant chemotherapy

PURPOSE

The purpose of this study was to compare the visibility of breast tissue markers in cases of breast cancer on ultrasonography (US) after neoadjuvant chemotherapy (NAC) and to analyze whether the type of marker affected the choice of localization method after NAC.

METHODS

We included 153 tissue markers inserted within breast cancers that showed pathologically complete response (pCR) after NAC from January 2012 to April 2017. One of three types of markers (a surgical clip, Cormark, or UltraClip) was inserted. Medical records and imaging findings were retrospectively reviewed. We compared the visibility of the different types of tissue markers on US after NAC, and also compared the imaging modalities used in the preoperative localization. The chi-square test, Fisher exact test, and multiple logistic regression were used for analysis.

RESULTS

Of the 153 tissue markers, 56 were surgical clips, 61 Cormark, and 36 UltraClip. After NAC, residual lesions were not seen on US in 42 cases (27.5%). In multivariate analysis, the visibility of the surgical clips and Cormark markers was better than that of the UltraClip markers (odds ratio [OR], 5.467; 95% confidence interal [CI], 1.717 to 17.410; P=0.004 and OR, 3.045; 95% CI, 1.074 to 8.628; P=0.036, respectively). Among the 131 cases where localization targeting the marker was required, the proportion of US-guided localizations was significantly higher when a surgical clip was used than when an UltraClip marker was used (OR, 5.566; 95% CI, 1.610 to 19.246; P=0.007) in the multivariate analysis.

CONCLUSION

The type of breast tissue marker affected its visibility on US in cases with pCR after NAC, which in turn affected the localization methodology.

Feasibility of Preoperative Axillary Lymph Node Marking with a Clip in Breast Cancer Patients Before Neoadjuvant Chemotherapy: A Preliminary Study

BACKGROUND

The aim of this study was to determine the feasibility of image-guided marker-clip placement in axillary lymph nodes (ALNs) for breast cancer upon initial presentation and to assess the reliability of this method with sentinel lymph node biopsy (SLNB) for axillary restaging after neoadjuvant chemotherapy (NAC).

METHODS

Between June 2015 and August 2016, a marker clip was placed at a clinically positive ALN under ultrasonography (US) guidance before initiation of NAC in 20 patients. Preoperative localization of marker-clipped LNs was performed, and the localized LNs were removed by SLNB. We compared the postoperative results of the marker-clipped LNs, SLNs and ALNs.

RESULTS

Image-guided marker-clip placements and localization of marker-clipped LNs were performed successfully in 20 patients. A total of 24 marker clips were inserted, and 23 marker-clipped LNs were successfully retrieved during surgery (identification rate, 23/24, 95.8%). In the 11 patients with pathologically confirmed metastatic marker-clipped LNs, four became negative after NAC, and seven maintained metastatic residues on the marker-clipped LNs. Three of the seven patients had metastatic residues on the ALNs, and two of the three patients also had negative SLNs. Marker-clipped nodes accurately predicted the axillary nodal status in these two patients compared with SLNs alone.

CONCLUSION

Image-guided marker-clip placement on positive ALNs before NAC and removal with SLNB is technically feasible. This technique can improve the accuracy of the residual disease evaluation on the axilla, especially in patients with negative SLNB results, and can identify candidates for limited axillary surgery after NAC.

Using a New Marker Clip System in Breast Cancer: Tumark Vision® Clip - Feasibility Testing in Everyday Clinical Practice

Background

This study presents first feasibility experiences with a new 3-dimensional (3D) marker clip system in clinical practice. The rate of clinical complete responses in the treatment of breast cancer patients is increasing; additionally, a change to targeted axillary dissection is being considered after neoadjuvant chemotherapy (NACT). Consequently, marker clips are needed which are reliable and easy to handle even in the axillary lymph node system.

Methods

A total of 50 patients from the Breast Care Unit of the Kliniken Essen Mitte were included. Clip marking of all 50 primary breast cancer lesions as well as 23 lymph nodes was performed using the Tumark Vision® clip. Following application, the position and visibility of the marker clip were monitored and documented in 2 axes.

Results

The feasibility of the Tumark Vision clip was excellent in everyday clinical practice as none of the markers dislocated. After clip marking of the tumor region and/or suspicious lymph nodes, all Tumark Vision clips could be detected in both axes. The 3D shape could be observed in all cases after application.

Conclusion

The new 3D-shaped marker clip seems to be a promising tool for marking breast cancer lesions and even lymph nodes before NACT. As there are many studies ongoing to prove the feasibility of a shift from standard axillary dissection after NACT towards targeted axillary dissection, the Tumark Vision clip seems to provide good visibility even in lymph nodes after NACT. Further studies are warranted.

Hygroscopic sonographically detectable clips form characteristic breast and lymph node pseudocysts

The use of hygroscopic sonographically detectable clips (HSDCs) has dramatically increased during the last years, especially in breast cancer patients who undergo neoadjuvant chemotherapy. The aims of this study are to define the appearance of HSDC sites in histopathological specimens, and to enable pathologists to recognize these sites and differentiate them from other lesions. We examined 124 breast cancer specimens in which the application of HSDCs was documented, 88 breast tissues and 36 lymph nodes, and analyzed the appearance of the clip site in these tissues. The clip site was clearly detected histologically in 79/88 (90%) of the breast specimens and in 29/36 (81%) of lymph node specimens. In most of the specimens, the HSDC site had a specific characteristic appearance of a pseudocyst, lined by layers of epithelioid histiocytes, sometimes with pseudopapillary formation, and with minimal or no fibrosis. This was the appearance in 69 of the breast specimens and in 23 of the lymph node specimens. In other specimens, scarring, scattered foamy macrophages and abundant siderophages were the predominant findings, as usually found in sites of other clips. As non-palpable breast lesions become more frequent, clips play a major role in the treatment of breast cancer, making them an important component of the communication among radiologists, surgeons, pathologists, and oncologists. HSDCs in tissues have a characteristic appearance with an epithelioid component. Pathologists should be able to recognize this finding, differentiate it from other breast lesions and include it in the pathology report.

Evaluation of a Marker Clip System in Sonographically Guided Core Needle Biopsy for Breast Cancer Localization Before and After Neoadjuvant Chemotherapy

Introduction The placement of intramammary marker clips has proven to be helpful for tumor localization in patients undergoing neoadjuvant chemotherapy and breast-conserving surgery. The purpose of our study was to investigate the feasibility of using a clip marker system for breast cancer localization and its influence on the imaging assessment of treatment responses after neoadjuvant chemotherapy. Patients and Methods Between March and June 2015, a total of 25 patients (n = 25), with a suspicion of invasive breast cancer with diameters of at least 2 cm (cT2), underwent preoperative sonographically guided core needle biopsy using a single-use breast biopsy system (HistoCore™) and intramammary clip marking using a directly adapted clip system based on the established O-Twist Marker™, before their scheduled preoperative neoadjuvant chemotherapy. Localization of the intramammary marker clip was controlled by sonography and digital breast tomosynthesis. Results Sonography detected no dislocation of intrammammary marker clips in 20 of 25 patients (80 %), while digital breast tomosynthesis showed accurate placement without dislocation in 24 patients (96 %) (p < 0.05). There was no evidence of significant clip migration during preoperative follow-up imaging after neoadjuvant chemotherapy. No complication related to the clip marking was noted and there was no difficulty in evaluating the treatment response to neoadjuvant chemotherapy. Among the breast-conserving surgeries performed, no cases were identified in which intraoperative loss of the marker clip had occurred. Conclusion Our study underscores the importance of intramammary marking clip systems before neoadjuvant chemotherapy. Placement of marker clips is advised to facilitate accurate tumor bed localization. With regard to digital breast tomosynthesis, its development continues to improve the quality of diagnostics and the therapy of breast cancer particularly for small breast cancer tumors or in neoadjuvant chemotherapy setting.

Pathologic Evaluation of Breast Cancer after Neoadjuvant Therapy

Breast cancer, one of the most common cancers in women, has various treatment modalities. Neoadjuvant therapy (NAT) has been used in many clinical trials because it is easy to evaluate the treatment response to therapeutic agents in a short time period; consequently, NAT is currently a standard treatment modality for large-sized and locally advanced breast cancers, and its use in early-stage breast cancer is becoming more common. Thus, chances to encounter breast tissue from patients treated with NAT is increasing. However, systems for handling and evaluating such specimens have not been established. Several evaluation systems emphasize a multidisciplinary approach to increase the accuracy of breast cancer assessment. Thus, detailed and systematic evaluation of clinical, radiologic, and pathologic findings is important. In this review, we compare the major problems of each evaluation system and discuss important points for handling and evaluating NAT-treated breast specimens.

Outcome and Cost Effectiveness of Ultrasonographically Guided Surgical Clip Placement for Tumor Localization in Patients undergoing Neo-adjuvant Chemotherapy for Breast Cancer

BACKGROUND

To determine the outcome and cost saving by placing ultrasound guided surgical clips for tumor localization in patients undergoing neo-adjuvant chemotherapy for breast cancer.

MATERIALS AND METHODS

This retrospective cross sectional analytical study was conducted at the Department of Diagnostic Radiology, Aga Khan University Hospital, Karachi, Pakistan from January to December 2014. A sample of 25 women fulfilling our selection criteria was taken. All patients came to our department for ultrasound guided core biopsy of suspicious breast lesions and clip placement in the index lesion prior to neo-adjuvant chemotherapy. All the selected patients had biopsy proven breast cancer.

RESULTS

The mean age was 45 ± 11.6 years. There were no complications seen after clip placement in terms of clip migration or hemorrhage. The cost of commercially available markers was approximately PKR 9,000 (US$ 90) and that of the surgical clip was PKR 900 (US$ 9). The cost of surgical clips in 25 patients was PKR 22,500 (US$ 225), when compared to the commercially available markers which may have incurred a cost of PKR 225,000 (US$ 2,250). The total cost saving for 25 patients was PKR 202,500 (US$ 2, 025), making it PKR 8100 (US$ 81) per patient.

CONCLUSIONS

The results of our study show that ultrasound guided surgical clip placement in index lesions prior to neo-adjuvant therapy is a safe and cost effective method to identify tumor bed and response to treatment for further management.