Déplacement de clip post-macrobiopsie sous guidage stéréotaxique et repérage préopératoire : trucs et astuces

Beyond the Needle: Understanding Tissue Marker Migration in Breast MRI-Guided Biopsies

OBJECTIVE

To evaluate the frequency and factors associated with clip migration in MRI-guided breast biopsies.

METHODS

This study was approved by our Institutional Review Board and was compliant with HIPAA. We retrospectively evaluated all MRI-guided biopsies performed between January 2013 and December 2020 in our institution for clip migration. Only patients with follow-up breast MRI showing the clip were included in the study. Migration was defined as movement of the clip of 10 mm or more from the target lesion. Migration frequency and directions were recorded. Factors associated with clip migration were analyzed using statistical tests as appropriate.

RESULTS

A total of 291 biopsies in 268 women were included in the study with 31 migration events recorded (11%; 95% CI, 7%-15%). All migrations occurred along the biopsy tract; 97% (30/31) of them displaced distal to the needle entry site. More than 50% regional fat (around the target lesion) was the strongest factor associated with migration, seen in 21/141 women (15%), compared to 10/150 (7%) with 50% or less local fat (P = .023). Global fatty breast was more loosely associated with migration, showing borderline significance (P = .06). Other factors did not correlate with clip migration, including lesion size, depth, or location; pathology result; breast thickness; or biopsy approach.

CONCLUSION

Although clip migration after breast MRI-guided biopsy is an uncommon event, it occurs more often when the target lesion is surrounded by fat, with the clip usually displaced away from the needle entry site.

The Role of Predeployment Retraction in Biopsy Marker Migration During Stereotactic Breast Biopsies: A Randomized Controlled Trial

OBJECTIVE

Inaccurate breast biopsy marker placement and marker migration during stereotactic biopsy procedures compromise their reliability for lesion localization and precise surgical excision. This trial evaluated the impact of 5-mm predeployment retraction of the marker introducer on marker migration, investigating other potential factors that influence the outcome.

METHODS

This parallel, randomized controlled trial enrolled women aged ≥18 years undergoing stereotactic breast biopsy at a single institution from May 2020 through August 2022. The study was approved by the institutional review board at the University of Alabama at Birmingham (UAB). Patients were randomized to intervention (5-mm introducer retraction before marker deployment) or control (standard marker placement) by drawing a labeled paper. The primary outcome was the distance of marker migration on immediate postprocedure mammogram.

RESULTS

Of 251 patients enrolled, 223 were analyzed; 104 received the intervention, and 119 received control. Mean (SD) marker migration was 12.1 (14.9) mm in the intervention group vs 9.8 (14.9) mm, with differences between groups estimated at 2.3 mm (SE = 1.9, P = .2312) (d = 0.16; 95% CI, 1.5-6.0). Effects of age, breast density, thickness, and biopsy approach showed no statistical significance. In exploratory models, central lesions exhibited 5.7 mm less migration than proximal lesions (95% CI, 0.7-10.6; P = .025), and each body mass index (BMI) unit increase was associated with 0.3 mm greater migration (95% CI, 0-0.6; P = .044).

CONCLUSION

Retracting the marker introducer 5 mm before deployment did not reduce migration. Higher BMI and certain lesion locations were all associated with marker migration, highlighting the need to investigate biomechanical factors and techniques to optimize breast marker placement.Clinical Trials Registration: NCT04398537.

Localisation accuracy with iodine-125 seed versus wire guidance for breast cancer surgery

INTRODUCTION

Impalpable breast lesions generally require image-guided localisation for breast-conserving surgery. A standard technique is to place a hook wire (HW) within the lesion. Radioguided occult lesion localisation using iodine seeds (ROLLIS) involves inserting a 4.5 mm iodine-125 seed (seed) into the lesion. We hypothesised that a seed could be more precisely positioned in relation to the lesion than a HW and that this may be associated with a lower re-excision rate.

METHODS

Retrospective review of consecutive participant data from three ROLLIS RCT (ACTRN12613000655741) sites. Participants underwent preoperative lesion localisation (PLL) with seed or HW between September 2013 and December 2017. Lesion and procedural characteristics were recorded. Distances between (1) any part of the seed or thickened segment of the HW ('TSHW') and the lesion/clip ('distance to device' DTD) and (2) centre of the TSHW/seed and centre of the lesion/clip (device centre to target centre 'DCTC') were measured on immediate postinsertion mammograms. Pathological margin involvement and re-excision rates were compared.

RESULTS

A total of 390 lesions (190 ROLLIS and 200 HWL) were analysed. Lesion characteristics and guidance modality used were similar between groups. Ultrasound-guided DTD and DCTC for seed were smaller than for HW (77.1% and 60.6%, respectively, P-value < 0.001). Stereotactic-guided DCTC for seeds was 41.6% smaller than for HW (P-value = 0.001). No statistically significant difference in the re-excision rates was found.

CONCLUSION

Iodine-125 seeds can be more precisely positioned for preoperative lesion localisation than HW, however, no statistically significant difference in re-excision rates was detected.

Does lateral arm technique decrease the rate of clip migration in stereotactic and tomosynthesis-guided biopsies?

Background

Mammography-guided vacuum-assisted biopsies (MGVAB) can be done with stereotaxis or digital breast tomosynthesis guidance. Both methods can be performed with a conventional (CBA) or a lateral arm biopsy approach (LABA). Marker clip migration is relatively frequent in MGVAB (up to 44%), which in cases requiring surgery carries a risk of positive margins and re-excision. We aimed to compare the rates of clip migration and hematoma formation between the CBA and LABA techniques of prone MGVAB. Our HIPAA compliant retrospective study included all consecutive prone MGVAB performed in a single institution over a 20-month period. The LABA approach was used with DBT guidance; CBA utilized DBT or stereotactic guidance. The tissue sampling techniques were otherwise identical.

Results

After exclusion, 389 biopsies on 356 patients were analyzed. LABA was done in 97 (25%), and CBA in 292 (75%) cases. There was no statistical difference in clip migration rate with either 1 cm or 2 cm distance cut-off [15% for CBA and 10% for LABA for 1 cm threshold (p = 0.31); 5.8% or CBA and 3.1% or LABA for 2 cm threshold (p = 0.43)]. There was no difference in the rate of hematoma formation (57.5% in CDB and 50.5% in LABA, p = 0.24). The rates of technical failure were similar for both techniques (1.7% for CBA and 3% for LABA) with a combined failure rate of 1%.

Conclusions

LABA and CBA had no statistical difference in clip migration or hematoma formation rates. Both techniques had similar success rates and may be helpful in different clinical situations.

Clip migration after stereotactic vacuum-assisted breast biopsy with the patient in the decubitus position

OBJECTIVE

To investigate the factors contributing to clip migration in stereotactic vacuum-assisted biopsy (VAB) of the breast using an upright unit with the patient in the decubitus position.

METHODS

This retrospective study included 176 women with microcalcifications on mammograms undergoing stereotactic VAB with clip marking for analysis. The prebiopsy mammograms, stereotactic VAB images, immediate postbiopsy mammograms, and follow-up mammograms were reviewed. All VAB procedures were performed using an add-on upright unit with the patient in the decubitus position. The clip-to-lesion distance on the orthogonal view (craniocaudal view) on immediate postbiopsy mammography was estimated for each biopsy. Two cutoff points of clip-to-lesion distance of > 1 cm or > 2 cm were set for clip migration. The possible factors for clip migration based on clinical and imaging findings were then analyzed by Fisher's exact test.

RESULTS

When the cutoff for clip migration was set at > 1 cm, thin breast (p = 0.013) and more superficial lesion (lesion closer to the skin along the line perpendicular to the posterior nipple line, p = 0.004) were associated with clip migration. When the cutoff was set at > 2 cm, thin breast (p = 0.019), high specimen number (p = 0.030), and posterior depth (p = 0.021) were associated with clip migration.

CONCLUSIONS

Thin breasts, superficial lesion location, posterior lesion depth, and high specimen number were the factors associated with clip migration.

KEY POINTS

• We reported clip migration after ST VAB using an upright unit with the patient in the decubitus position. • The occurrence of clinically significant clip migration (> 2 cm) in our study was 8.5%, which was within the range of the other reports with the patient undergoing ST VAB in the prone position. • Thin breasts, high specimen number, and more posterior depth were the factors associated with significant clip migration.

Subsequent Marking under Ultrasound Guidance of Vacuum-Assisted Breast Biopsy Areas after Receipt of Histology: A Feasibility Study of a New Technique

Purpose

The aim of this study was to evaluate the feasibility and the accuracy of a secondary, metachronous ultrasound (US)-guided marking of the stereotactic vacuum-assisted breast biopsy (ST-VABB) area.

Materials and Methods

The institutional ethics committee approved the study. The retrospective study included 98 patients. In ST-VABB of 45 women, no tissue markers were deployed at the biopsy site, even if no residual calcifications remained. After histology proved the necessity for a subsequent operation, the biopsy site was marked under US guidance using a coil marker. All interventions were technically successful. No complications occurred. Mammography was done to visualize the coil deployment. The distances from the center of the lesion and the biopsy cavity to the coil location were measured in both planes to evaluate the accuracy of the marking procedure.

Results

In 24 of the 46 cases, the whole lesion was biopsied without residual elements. The mean time between ST-VABB and sonographic marking of the lesion was 9.7 days (median 6.5). The biopsy cavity could be detected in 40 (87%) cases and thus marked exactly. The mean time of US-guided marking was 12.5 min. The mean distance between the coil and the target lesion was 0.6 ± 1.5 cm in the craniocaudal (cc) view and 0.5 ± 1.5 cm in the mediolateral (ml) view for all markings. The mean delta value from the distance nipple-original lesion and from the distance nipple-coil was 0.85 ± 1.2 cm (median 0.5) in the cc view and 0.88 ± 1.2 cm (median 0.6) in the ml view for all cases. Clip migration was not observed.

Conclusion

Our study demonstrates the feasibility and the technical success of secondary metachronous coil marking of the biopsy site under US guidance after receipt of histology. This approach seems to be a cost-effective alternative to the standard procedure of the primary coil marking especially in all completely removed lesions. It may offer advantages for allergic patients.

A prospective comparative study to evaluate the displacement of four commercially available breast biopsy markers

OBJECTIVE

Radiopaque markers are commonly deployed following breast biopsies to indicate the location of the targeted lesion. A frequently encountered complication is the displacement of these markers. This study compared the degree of displacement among four newer generation markers after stereotactic core needle biopsy.

METHODS

80 consecutive biopsies were performed at three breast centre sites. The markers included: HydroMARK(®) (Mammotome, Cincinnati, OH), MammoMARK™ (Mammotome, Cincinnati, OH), MammoStar™ (Mammotome, Cincinnati, OH) and SecurMark(®) (Hologic, Bedford, MA). Each marker was composed of a radiopaque core with a unique polymeric encasing component. Post-procedure mammograms were obtained and the degree of marker displacement was measured.

RESULTS

MammoMARK™ exhibited the greatest mean net displacement, followed by HydroMARK(®), SecurMark(®) and MammoStar™ (13.9, 7.7, 5.8 and 4.7 mm, respectively), although these differences did not reach statistical significance (p = 0.398). 73% of the markers did not displace at all. However, in the 19 of 22 markers in which displacement occurred, the distance from the biopsy cavity was >10 mm. No statistically significant contributing factors to predict displacement were found.

CONCLUSION

Newer generation biopsy markers perform comparably with one another. However, clinically significant and unpredictable marker displacement persists. Compared with multiple similar studies of older generation bare metallic markers, the overall displacement rate of newer generation markers seems to be lower, possibly owing to the use of polymeric embedding agents that self-expand within the biopsy cavity.

ADVANCES IN KNOWLEDGE

This article compares the post-procedure displacement of breast biopsy markers, which have not been evaluated or discussed in detail since markers with polymeric embedding agents gained widespread use.

Clip placement after an 11-gauge vacuum-assisted stereotactic breast biopsy: correlation between breast thickness and clip movement

PURPOSE

To retrospectively evaluate the accuracy of clip placement on the basis of measurements obtained on pre- and post-vacuum-assisted 11-gauge stereotactic biopsy mammograms and to analyze the factors that can predict which patients will experience a significant movement of the clip.

MATERIALS AND METHODS

The pre- and post-vacuum-assisted 11-guage stereotactic biopsy mammographic findings in 204 cases undergoing clip placement were reviewed. The clip-to-lesion distance was measured. The correlations between the clinical-mammographic findings and the likelihood of clip movement were evaluated.

RESULTS

Target mammographic lesion types of the 204 cases were characterized as calcification in all but one case, which was a distortion lesion. The clip-to-lesion distance was within 5 mm on both the craniocaudal and mediolateral oblique projections in 119 (58%) cases, within 6-10 mm in 28 (14%), within 11-19 mm in 25 (12%), and was > 20 mm in 32 (16%). The variability of the clip-to-lesion distance was greatest in the plane orthogonal to the compression plane used for stereotactic biopsy. Breast thickness was the only factor that was predictive of a significant movement of the clip, and thin breasts tended to exhibit greater clip movement.

CONCLUSION

Breast thickness may be a useful factor for predicting the degree of clip movement after 11-gauge vacuum-assisted stereotactic biopsy.

Ten-year experience with hematoma-directed ultrasound-guided (HUG) breast lumpectomy

BACKGROUND

Pain, patient inconvenience, vasovagal symptoms, scheduling problems, wire malposition, and a positive margin rate of 40-75% are problems commonly associated with needle localized biopsy (NLBB). Despite these issues, NLBB is still the primary means of identifying nonpalpable lesions in the breast. We hypothesized that the hematoma-directed ultrasound-guided (HUG) procedure for intraoperative localization of nonpalpable lesions would allow for lumpectomy without the downfalls of needle localization and decrease the high positive-margin rate with NLBB.

METHODS

This is a retrospective study from January 2000 to October 2009. Electronic chart review identified lumpectomy procedures performed in the clinic and operating room. These patients underwent preoperative core-biopsy diagnosis by ultrasound (US) or stereotactic means. When excision was necessary needle localization or HUG was planned. A multifrequency linear array transducer was used intraoperatively for the HUG procedures, and a block of tissue surrounding the hematoma was removed.

RESULTS

Localization procedures were performed in 455 patients: 126 (28%) via needle localization and 329 (72%) via HUG. The previous core-biopsy site in 100% of patients was successfully excised using HUG: 152 of 329 (46%) were benign and 177 of 329 (54%) were malignant. Margins were positive in 42 of these 177 cases (24%). was successful in 100% of patients: 88 of 126 (70%) were benign and NLBB 38 of 126 (30%) were malignant; margins were positive in 18 of these 38 (47%). Margin positivity was significantly higher for NLBB than HUG (P = 0.045, Fisher exact).

CONCLUSIONS

This 10-year experience, representing the largest to date, suggests that HUG is more accurate in localizing nonpalpable lesions than NLBB. Compared with the additional painful procedure of NLBB, HUG is more time and cost-efficient. Preoperative needle core biopsy is not only the minimally invasive diagnostic procedure of choice, but also becomes the localization procedure when excisional biopsy is necessary.

Image-guided breast biopsy: state-of-the-art

Percutaneous image-guided breast biopsy is widely practised to evaluate predominantly non-palpable breast lesions. There has been steady development in percutaneous biopsy techniques. Fine-needle aspiration cytology was the original method of sampling, followed in the early 1990s by large core needle biopsy. The accuracy of both has been improved by ultrasound and stereotactic guidance. Larger bore vacuum-assisted biopsy devices became available in the late 1990s and are now commonplace in most breast units. We review the different types of breast biopsy devices currently available together with various localization techniques used, focusing on their advantages, limitations and current controversial clinical management issues.