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Lee CU, Urban MW, Hesley GK, Wood BG, Meier TR, Chen B, Kassmeyer BA, Larson NB, Lee Miller A, Herrick JL, Jakub JW, Piltin MA. Long-Term Ultrasound Twinkling Detectability and Safety of a Polymethyl Methacrylate Soft Tissue Marker Compared to Conventional Breast Biopsy Markers-A Preclinical Study in a Porcine Model. ULTRASOUND IN MEDICINE & BIOLOGY 2024; 50:1001-1009. [PMID: 38575416 DOI: 10.1016/j.ultrasmedbio.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 02/21/2024] [Accepted: 03/18/2024] [Indexed: 04/06/2024]
Abstract
OBJECTIVE We have studied the use of polymethyl methacrylate (PMMA) as an alternative biopsy marker that is readily detectable with ultrasound Doppler twinkling in cases of in vitro, ex vivo, or limited duration in vivo settings. This study investigates the long-term safety and ultrasound Doppler twinkling detectability of a PMMA breast biopsy marker following local perturbations and different dwell times in a 6-mo animal experiment. METHODS This study, which was approved by our Institutional Animal Care and Use Committee, involved three pigs and utilized various markers, including PMMA (Zimmer Biomet), 3D-printed, and Tumark Q markers. Markers were implanted at different times for each pig. Mesh material or ethanol was used to induce a local inflammatory reaction near certain markers. A semiquantitative twinkling score assessed twinkling for actionable localization during monthly ultrasounds. At the primary endpoint, ultrasound-guided localization of lymph nodes with detectable markers was performed. Following surgical resection of the localized nodes, histomorphometric analysis was conducted to evaluate for tissue ingrowth and the formation of a tissue rind around the markers. RESULTS No adverse events occurred. Twinkling scores of all markers for all three pigs decreased gradually over time. The Q marker exhibited the highest mean twinkling score followed by the PMMA marker, PMMA with mesh, and Q with ethanol. The 3D-printed marker with mesh and PMMA with ethanol had the lowest scores. All wire-localized lymph nodes were successfully resected. Despite varying percentages of tissue rind around the markers and a significant reduction in overall twinkling (p < 0.001) over time, mean PMMA twinkling scores remained clinically actionable at 6 and 5 mo using a General Electric C1-6 probe and 9L-probe, respectively. CONCLUSIONS In this porcine model, the PMMA marker demonstrates an acceptable safety profile. Clinically actionable twinkling aids PMMA marker detection even after 6 mo of dwell time in porcine lymph nodes. The Q marker maintained the greatest twinkling over time compared to all the other markers studied.
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Affiliation(s)
- Christine U Lee
- Department of Radiology, Division of Breast Imaging and Intervention, Mayo Clinic, Rochester, MD, USA.
| | - Matthew W Urban
- Department of Radiology, Division of Radiology Research, Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MD, USA
| | - Gina K Hesley
- Department of Radiology, Division of Breast Imaging and Intervention, Mayo Clinic, Rochester, MD, USA
| | | | - Thomas R Meier
- Department of Comparative Medicine, Mayo Clinic, Rochester, MD, USA
| | - Beiyun Chen
- Department of Laboratory Medicine and Pathology, Division of Anatomic Pathology, Mayo Clinic, Rochester, MD, USA
| | - Blake A Kassmeyer
- Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MD, USA
| | - Nicholas B Larson
- Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MD, USA
| | - A Lee Miller
- Biomaterials and Histomorphometry Core, Department of Orthopedic Surgery, Mayo Clinic, Rochester, MD, USA
| | - James L Herrick
- Biomaterials and Histomorphometry Core, Department of Orthopedic Surgery, Mayo Clinic, Rochester, MD, USA
| | - James W Jakub
- Department of Surgery, Division of Surgical Oncology, Mayo Clinic, Jacksonville, FL USA
| | - Mara A Piltin
- Department of Surgery, Breast and Melanoma Surgical Oncology, Mayo Clinic, Rochester, MD, USA
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Lee CU, Piltin MA, Moldoveanu D, Urban MW, Hesley GK. Using US Twinkling Artifact to Identify Breast Biopsy Markers: Brief Report. Radiol Imaging Cancer 2023; 5:e220168. [PMID: 37326508 PMCID: PMC10413298 DOI: 10.1148/rycan.220168] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 03/08/2023] [Accepted: 05/15/2023] [Indexed: 06/17/2023]
Abstract
Breast biopsy markers play an essential role in the surgical management of patients with clinically node-positive breast cancer. Marking a pathology-proven lymph node ensures accurate imaging assessment of response to neoadjuvant systemic therapy and decreased false-negative rates in sentinel lymph node biopsy. There is a clinically unmet need to make breast biopsy markers, particularly in the axilla, more sonographically visible or identifiable for preoperative localization purposes. Previously described color Doppler US twinkling artifact of some breast biopsy markers in in vitro gel phantoms and in ex vivo cadaveric breasts suggests that twinkling of such markers can be leveraged for improved in vivo detection. In this retrospective case series of eight female patients (mean age, 58.6 years ± 12.3 [SD]), conventional B-mode US imaging failed to identify the biopsy marker associated with a surgical target in the breast or in an axillary lymph node. However, in each patient, the marker was successfully identified with the help of color Doppler US twinkling. Keywords: Breast, Ultrasound, Color Doppler US, Lymphatic, Artifacts, Biopsy Marker Published under a CC BY 4.0 license.
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Affiliation(s)
- Christine U. Lee
- From the Department of Radiology, Division of Breast Imaging and
Intervention (C.U.L., G.K.H.), Department of Surgery, Division of Breast and
Melanoma Surgical Oncology (M.A.P., D.M.), Department of Radiology, Division of
Radiology Research (M.W.U.), and Department of Physiology and Biomedical
Engineering (M.W.U.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - Mara A. Piltin
- From the Department of Radiology, Division of Breast Imaging and
Intervention (C.U.L., G.K.H.), Department of Surgery, Division of Breast and
Melanoma Surgical Oncology (M.A.P., D.M.), Department of Radiology, Division of
Radiology Research (M.W.U.), and Department of Physiology and Biomedical
Engineering (M.W.U.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - Dan Moldoveanu
- From the Department of Radiology, Division of Breast Imaging and
Intervention (C.U.L., G.K.H.), Department of Surgery, Division of Breast and
Melanoma Surgical Oncology (M.A.P., D.M.), Department of Radiology, Division of
Radiology Research (M.W.U.), and Department of Physiology and Biomedical
Engineering (M.W.U.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - Matthew W. Urban
- From the Department of Radiology, Division of Breast Imaging and
Intervention (C.U.L., G.K.H.), Department of Surgery, Division of Breast and
Melanoma Surgical Oncology (M.A.P., D.M.), Department of Radiology, Division of
Radiology Research (M.W.U.), and Department of Physiology and Biomedical
Engineering (M.W.U.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - Gina K. Hesley
- From the Department of Radiology, Division of Breast Imaging and
Intervention (C.U.L., G.K.H.), Department of Surgery, Division of Breast and
Melanoma Surgical Oncology (M.A.P., D.M.), Department of Radiology, Division of
Radiology Research (M.W.U.), and Department of Physiology and Biomedical
Engineering (M.W.U.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
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Editorial Comment: Improving Visibility of Breast Biopsy Markers on MRI. AJR Am J Roentgenol 2023; 220:357. [PMID: 36129227 DOI: 10.2214/ajr.22.28503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Factors Associated With Ultrasound Color Doppler Twinkling by Breast Biopsy Markers: In Vitro and Ex Vivo Evaluation of 35 Commercially Available Markers. AJR Am J Roentgenol 2023; 220:358-370. [PMID: 36043610 DOI: 10.2214/ajr.22.28107] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND. Targeted axillary lymph node dissection after neoadjuvant systemic therapy (NST) for breast cancer depends on identifying marked metastatic lymph nodes. However, ultrasound visualization of biopsy markers is challenging. OBJECTIVE. The purpose of our study was to identify biopsy markers that show actionable twinkling in cadaveric breast and to assess the association of actionable twinkling with markers' surface roughness. METHODS. Commercial breast biopsy markers were evaluated for twinkling artifact in various experimental conditions relating to scanning medium (solid gel phantom, ultrasound coupling gel, cadaveric breast), transducer (ML6-15, 9L, C1-6), and embedding material (present vs absent). Markers were assigned twinkling scores from 0 (confident in no twinkling) to 4 (confident in exuberant twinkling); a score of 3 or greater represented actionable twinkling (sufficient confidence to rely solely on twinkling for target localization). Markers were hierarchically advanced to evaluation with increasingly complex media if showing at least minimal twinkling for a given medium. A 3D coherence optical profiler measured marker surface roughness. Mixed-effects proportional odds regression models assessed associations between twinkling scores and transducer and embedding material; Wilcoxon rank sum test evaluated associations between actionable twinkling and surface roughness. RESULTS. Thirty-five markers (21 with embedding material) were evaluated. Ten markers without embedding material advanced to evaluation in cadaveric breast. Higher twinkling scores were associated with presence of embedding material (odds ratio [OR] = 5.05 in solid gel phantom, 9.84 in coupling gel) and transducer (using the C1-6 transducer as reference; 9L transducer: OR = 0.36, 0.83, and 0.04 in solid gel phantom, ultrasound coupling gel, and cadaveric breast; ML6-15 transducer: OR = 0.07, 0.18, and 0.00 respectively; post hoc p between 9L and ML6-15: p < .001, p = .02, and p = .04). In cadaveric breast, three markers (Cork, Professional Q, MRI [Flex]) exhibited actionable twinkling for two or more transducers; surface roughness was significantly higher for markers with than without actionable twinkling for C1-6 (median values: 0.97 vs 0.35, p = .02) and 9L (1.75 vs 0.36; p = .002) transducers. CONCLUSION. Certain breast biopsy markers exhibited actionable twinkling in cadaveric breast. Twinkling was observed with greater confidence for the C1-6 and 9L transducers than the ML6-15 transducer. Actionable twinkling was associated with higher marker surface roughness. CLINICAL IMPACT. Use of twinkling for marker detection could impact preoperative or intraoperative localization after NST.
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Martin EA, Chauhan N, Dhevan V, George E, Laskar P, Jaggi M, Chauhan SC, Yallapu MM. Current status of biopsy markers for the breast in clinical settings. Expert Rev Med Devices 2022; 19:965-975. [PMID: 36524747 DOI: 10.1080/17434440.2022.2159807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION A breast biopsy marker is a very small object that is introduced into the breast to serve as a tissue marker. The placement of a breast marker following a biopsy or to mark an abnormality in the breast has become standard practice in the clinical setting. Breast biopsy markers offer a wide range of benefits which includes the prevention of re-biopsy of a benign tumor, differentiating multiple lesions within the breast, evaluation of the extent of a tumor, and increased precision during surgery. AREAS COVERED This review article presents a range of breast biopsy markers used in clinical practice. First, an overview of the necessity of breast markers in healthy breast management. Second, it summarizes the diversity in composition, shape, unique properties and features, and bio-absorbable carriers of breast biopsy markers. Finally, it also discusses the possible use of clinically approved breast biopsy markers in various scenarios and their implications. EXPERT OPINION This review serves as a guide in the selection of an appropriate breast marker. We believe that some of the common drawbacks associated with current breast biopsy markers can be overcome by developing novel polymer-metal and composite-based breast biopsy markers.
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Affiliation(s)
- Elian A Martin
- Department of Immunology and Microbiology, School of Medicine, The University of Texas Rio Grande Valley, McAllen, Texas, USA
| | - Neeraj Chauhan
- Department of Immunology and Microbiology, School of Medicine, The University of Texas Rio Grande Valley, McAllen, Texas, USA.,South Texas Center of Excellence in Cancer Research, School of Medicine, The University of Texas Rio Grande Valley, McAllen, Texas, USA
| | - Vijian Dhevan
- Department of Surgery, the University of Texas Rio Grande Valley, Edinburg, Texas, USA.,Department of Surgery, Valley Baptist Medical Center, Harlingen, Texas, USA
| | - Elias George
- Department of Immunology and Microbiology, School of Medicine, The University of Texas Rio Grande Valley, McAllen, Texas, USA.,South Texas Center of Excellence in Cancer Research, School of Medicine, The University of Texas Rio Grande Valley, McAllen, Texas, USA
| | - Partha Laskar
- Department of Immunology and Microbiology, School of Medicine, The University of Texas Rio Grande Valley, McAllen, Texas, USA.,South Texas Center of Excellence in Cancer Research, School of Medicine, The University of Texas Rio Grande Valley, McAllen, Texas, USA
| | - Meena Jaggi
- Department of Immunology and Microbiology, School of Medicine, The University of Texas Rio Grande Valley, McAllen, Texas, USA.,South Texas Center of Excellence in Cancer Research, School of Medicine, The University of Texas Rio Grande Valley, McAllen, Texas, USA
| | - Subhash C Chauhan
- Department of Immunology and Microbiology, School of Medicine, The University of Texas Rio Grande Valley, McAllen, Texas, USA.,South Texas Center of Excellence in Cancer Research, School of Medicine, The University of Texas Rio Grande Valley, McAllen, Texas, USA
| | - Murali M Yallapu
- Department of Immunology and Microbiology, School of Medicine, The University of Texas Rio Grande Valley, McAllen, Texas, USA.,South Texas Center of Excellence in Cancer Research, School of Medicine, The University of Texas Rio Grande Valley, McAllen, Texas, USA
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Kutay E, Milch H, Sayre J, Joines M, Hoyt A, Li B, Chan TL. Fear of the Unknown: The Benefits of a Patient Educational Handout on Breast Biopsy Markers. JOURNAL OF BREAST IMAGING 2022; 4:285-290. [PMID: 38416970 DOI: 10.1093/jbi/wbac016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Indexed: 03/01/2024]
Abstract
OBJECTIVE To determine whether providing a biopsy marker informational handout to patients improves patient knowledge and comfort with receiving a marker. METHODS In this IRB-exempt prospective study, a patient educational handout on breast biopsy markers was developed. A questionnaire was created with four questions asking patients to self-evaluate their knowledge of biopsy markers and their comfort level with marker placement before and after reading the handout. Technologists distributed the educational handouts to patients presenting for a percutaneous breast biopsy under any modality from December 11, 2020, to April 23, 2021. Data from the completed questionnaires were entered into a database. Statistical analyses included paired t-test and Wilcoxon analyses. RESULTS In total, 141 completed surveys were included in the analysis. The mean scores prior to reading the handout for knowledge and comfort were 2.59 and 3.40, respectively. After reading the handout, there was a significant increase in mean scores for knowledge and comfort (4.26 and 4.20, respectively) (P < 0.001). There was a 64% increase vs 23% increase for knowledge and comfort, respectively. CONCLUSION Patient-assessed knowledge of biopsy markers increased significantly after reading our educational handout. Patient-assessed comfort with biopsy marker placement also increased significantly after reading the educational handout, though to a lesser degree than knowledge. Although not included in our study, use of an educational handout may impact patient acceptance of marker placement. Future directions may include quantitatively assessing the effect of the handout on time to consent for a biopsy or influence on acceptance of marker placement.
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Affiliation(s)
- Erin Kutay
- University of California Los Angeles, Department of Radiology, Los Angeles, CA, USA
| | - Hannah Milch
- University of California Los Angeles, Department of Radiology, Los Angeles, CA, USA
| | - James Sayre
- University of California Los Angeles, Department of Radiological Sciences and Biostatistics, Los Angeles, CA, USA
| | - Melissa Joines
- University of California Los Angeles, Department of Radiology, Los Angeles, CA, USA
| | - Anne Hoyt
- University of California Los Angeles, Department of Radiology, Los Angeles, CA, USA
| | - Bo Li
- University of California Los Angeles, Department of Radiology, Los Angeles, CA, USA
| | - Tiffany L Chan
- University of California Los Angeles, Department of Radiology, Los Angeles, CA, USA
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Harvey JA. So Many Ways to Screen. JOURNAL OF BREAST IMAGING 2022; 4:1-2. [PMID: 38422418 DOI: 10.1093/jbi/wbab093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Indexed: 03/02/2024]
Affiliation(s)
- Jennifer A Harvey
- University of Rochester Medical Center, Department of Imaging Sciences, Rochester, NY, USA
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