Current status of biopsy markers for the breast in clinical settings

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.

Optimization of Wire-guided Technique With Bracketing Reduces Resection Volumes in Breast-conserving Surgery for Early Breast Cancer

BACKGROUND

Wire-guided localization (WGL) of early breast cancer can be facilitated using multiple wires, which is called bracketing wire-guided localization (BWL). The primary aim of this study is to compare BWL and conventional WGL regarding minimization of resection volumes without compromising margin status. Secondly, BWL is evaluated as an alternative method for intraoperative ultrasound (US) guidance in poorly definable breast tumors on US.

PATIENTS AND METHODS

In this retrospective cohort study, patients with preoperatively diagnosed breast cancer undergoing wide local excision between January 2016 and December 2018 were analyzed. Patients with multifocal disease or neoadjuvant treatment were excluded from this study. Optimal resection with minimal healthy breast tissue removal was assessed using the calculated resection ratio (CRR).

RESULTS

BWL was performed in 17 (9%) patients, WGL in 44 (22%), and US in 139 (70%). The rate of negative margins was comparable in all 3 groups. The CRR was significantly smaller for BWL (0.6) than WGL (1.3) in tumors larger than 1.5 cm. Additionally, BWL (0.8) led to smaller CRRs than US (1.7). This could be explained by the high number of small tumors (≤ 1.5 cm) in the US group for which greater CRRs are obtained than for large tumors (> 1.5 cm) (1.9 vs. 1.4; P = .005).

CONCLUSION

For breast tumors larger than 1.5 cm, BWL achieves more optimal resection volumes without compromising margin status compared with WGL. Moreover, BWL seems a suitable alternative to US in patients with poorly ultrasound-visible breast tumors and patients with a small tumor in a (large) breast.

Intraoperative Ultrasound Guidance With an Ultrasound-Visible Clip: A Practical and Cost-effective Option for Breast Cancer Localization

OBJECTIVES

In partial mastectomy (PM) or lumpectomy, ultrasound (US) localization avoids discomfort and additional procedures associated with wire localization. The purpose of this study was to evaluate the association between ultrasound-visible clip (UVC) use at the time of biopsy and US use during resection, hypothesizing that UVCs facilitate US localization and reduce costs compared with traditional radiopaque clips or no clip placement.

METHODS

The study population consisted of adult female patients with breast cancer undergoing PM or lumpectomy at our institution between 2014 and 2016. The core biopsy clip type and localization method during PM were characterized as wire localization versus US localization, and associations were estimated with multivariable regression models. For the cost evaluation, breast biopsy data were obtained from the Department of Radiology.

RESULTS

Among 674 patients, 490 had data on localization and the clip type. Ultrasound-visible clip placement at biopsy increased US use during resection by 13% (95% confidence interval, 6%-21%). There was no difference in the total specimen weight with US versus wire localization. The cost savings for using UVCs for the 2209 patients who underwent breast biopsy from 2014 to 2016 was $36,000.

CONCLUSIONS

This study demonstrates that US localization for PM is feasible at a single institution and cost-effective when facilitated by UVCs. Placement of a UVC at the time of biopsy is recommended, as it is cost-effective and avoids the discomfort and inconvenience of wire localization.

Initial results of a novel technique of clipped node localization in breast cancer patients postneoadjuvant chemotherapy: Skin Mark clipped Axillary nodes Removal Technique (SMART trial)

Purpose

Removal of clipped nodes can improve sentinel node biopsy accuracy in breast cancer patients post neoadjuvant chemotherapy (NACT). However, the current methods of clipped node localization have limitations. We evaluated the feasibility of a novel clipped node localization and removal technique by preoperative skin marking of clipped nodes and removal by the Skin Mark clipped Axillary nodes Removal Technique (SMART), with the secondary aim of assessing the ultrasound visibility of the various clips in the axillary nodes after NACT.

Methods

Invasive breast cancer patients with histologically metastatic axillary nodes, going for NACT, and ≤3 sonographically abnormal axillary nodes were recruited. All abnormal nodes had clips inserted. Patients with M1 disease were excluded. Post‐NACT, patients underwent SMART and axillary lymph node dissection. Specimen radiography and pathological analyses were performed to confirm the clipped node presence. Success, complication rates of SMART, and ultrasound visibility of the various clips were assessed.

Results

Twenty‐five clipped nodes in 14 patients underwent SMART without complications. The UltraCor Twirl, hydroMARK, UltraClip Dual Trigger, and UltraClip were removed in 13/13 (100%), 7/9 (77.8%), 1/2 (50.0%), and 0/1 (0%), respectively (P = .0103) with UltraCor Twirl having the best ultrasound visibility and removal rate. Removal of three clipped nodes in the same patient (P = .0010) and deeply seated clipped nodes (P = .0167) were associated with SMART failure.

Conclusion

Skin Mark clipped Axillary nodes Removal Technique is feasible for removing clipped nodes post‐NACT, with 100% observed success rate, using the UltraCor Twirl marker in patients with <3 not deeply seated clipped nodes. Larger studies are needed for validation.

Rapid Implementation of Intraoperative Ultrasonography to Reduce Wire Localization in The Permanente Medical Group

CONTEXT

Preoperative wire localization (WL), the most common localization technique for nonpalpable breast lesions, has drawbacks including scheduling constraints, cost, and patient discomfort.

OBJECTIVE

To reduce WL use in our health care system, we investigated using hydrogel clips to facilitate intraoperative ultrasonography-guided lumpectomies.

DESIGN

We retrospectively reviewed electronic medical records of patients with nonpalpable, ultrasound-visible breast lesions who underwent lumpectomy by 7 surgeons at 4 pilot sites in Kaiser Permanente Northern California between January 2015 and October 2015. Hydrogel clips, used for several years before the study period, were placed routinely during core-needle biopsy in all patients with nonpalpable, ultrasound-visible breast lesions.

MAIN OUTCOME MEASURES

Localization method, lesion size, margin positivity, and receipt of neoadjuvant therapy.

RESULTS

One hundred forty-three patients underwent hydrogel clip placement and lumpectomy by pilot-site surgeons. Localization consisted of intraoperative ultrasonography alone, preoperative skin marking, or WL. Of the 143 patients, 71.3% did not need WL (60.8% ultrasonography alone and 10.5% skin marking). The non-WL and WL groups had similarly sized lesions, and the positive margin rate was 7.2% overall, with no significant difference between the non-WL and WL groups (5.9% vs 11.5%, p = 0.33). Of the 12 patients who underwent neoadjuvant chemotherapy, 8 (67%) did not require WL.

CONCLUSION

A multifacility protocol using intraoperative ultrasonography to visualize hydrogel clips was implemented, which decreased WL procedures and produced no significant difference in margin positivity between the WL and non-WL groups. This technique can be a cost-effective alternative to WL in patients who are candidates for hydrogel clip placement.

Radio-guided and clip-guided preoperative localization for malignant microcalcifications offer similar performances in breast-conserving surgery

Obtaining a tailored breast resection is challenging in microcalcifications detected on screening mammography, and an accurate localization is required. The aim of this study was to compare the efficacy of radio-guided localization (ROLL) versus ultrasound localization of a titanium clip with collagen (TCC) in terms of clear margins, re-intervention rates, excess of resected breast tissue, and operative times in pure malignant microcalcifications detected on screening mammography. Two hundred and twenty-one consecutive patients with malignant microcalcifications detected on screening mammography from a tertiary breast unit were reviewed: 177 patients were localized by TCC and 44 patients by stereotactic ROLL. A propensity score-matched analysis was performed, followed by a logistic regression model, to avoid selection bias. Adequacy of resection was expressed as the calculated resection ratio considering lesion size. No differences were found in clear margins with ROLL versus TCC (77.3% vs 81.8%, adjusted OR 2, P = 0.27). Re-operation rates were similar, being 11.3% with ROLL and 7.4% with TCC (P = 0.627). Mean resection volume was 46.2 cm³ with ROLL versus 54.2 cm³ with TCC (P = 0.222). Adjusted mean calculated resection ratio was 1.8 with ROLL and 2.1 with TCC (P = 0.38). Surgery time was longer with TCC compared to ROLL (69.6 vs 52.7 minutes, P < 0.0001). ROLL and TCC are equally effective to excise malignant microcalcifications with clear margins, providing similar re-intervention rates and resection volumes.

Comparison of the value of superficial mark guided localization and hook-wire guided localization techniques for non-palpable breast microcalcifications: A retrospective clinical research

AIM

The present study compares the effect and accuracy of the superficial mark guided localization (SGL) and hook-wire guided localization (WGL) techniques for non-palpable breast microcalcifications.

METHODS

This retrospective study was conducted to compare SGL and WGL techniques. These techniques were performed on 51 patients with non-palpable breast microcalcifications from January 2015 to May 2016.

RESULTS

Among these 51 patients, 25 (49.01%) patients were subjected to WGL and 26 patients (50.99%) were subjected to SGL. The SGL technique had a higher rate of malignant cancer detection (WGL = 12.0% and SGL = 23.0%). Furthermore, no significant differences were found with regard to average age, the rate of a second excision and the diameter of the excised tissue. Moreover, no complications were observed in the SGL group, while four (16.0%) patients in the WGL group experienced problems.

CONCLUSION

The SGL technique is as accurate as the WGL technique. Furthermore, the procedure has advantages of being less expensive and causing less complications.

Doppler Ultrasound-Visible SignalMark Microspheres are Better Identified than HydroMARK® Clips in a Simulated Intraoperative Setting in Breast and Lung Tissue

BACKGROUND

Preoperative breast and lung markers have significant drawbacks, including migration, patient discomfort, and scheduling difficulties. SignalMark is a novel localizer device with a unique signal on Doppler ultrasound.

OBJECTIVE

We aimed to evaluate intraoperative identification of SignalMark microspheres compared with HydroMARK^® clips. We also assessed the safety and efficacy of SignalMark in the lung.

METHODS

Twelve breasts of lactating pigs were injected with SignalMark or HydroMARK^® by a breast radiologist, and subsequently identified using a standard ultrasound machine by three surgeons blinded to marker location. Time to identification of each marker was recorded, with a maximum allotted time of 300 s. To further demonstrate efficacy in lung parenchyma, a second cohort of pigs underwent lung injections.

RESULTS

A total of eight SignalMark markers and four HydroMARK^® clips were placed in pig breasts. Overall, the surgeons correctly identified SignalMark 95.8% of the time (n = 23/24) and HydroMARK^® clips 41.7% of the time (n = 5/12) within 300 s (p < 0.001). The mean time to identification was significantly faster for SignalMark, at 80.8 ± 20.1 s, than for HydroMARK^®, at 209.4 ± 35.2 s (p < 0.002). For the lung injections, all 10 SignalMark markers were visible on Doppler ultrasound at the time of placement, and at the 7- and 21-day time points.

CONCLUSIONS

Surgeons identified SignalMark in significantly less time than HydroMARK^® clips in a simulated intraoperative setting, and SignalMark was easily viewed in the lung. These results suggest that SignalMark is a feasible option for efficient intraoperative localization of non-palpable breast and lung tumors using ultrasound guidance.

Histological changes secondary to wire coil placement in breast tissue and lymph nodes

We describe the histological and immunohistochemical features of the changes produced by spiral coil localization wires in the breast parenchyma and lymph nodes of a total of 100 patients undergoing surgery for different breast lesions. Coil wires produced cystic lesions containing a hyaline, mucous-like, PAS-negative fluid. Cavities were lined by cells of variable morphology ranging from synovial-like cells (with a conspicuous epithelial appearance) to mononuclear or multinucleate histiocytic cells that expressed CD68, but were negative for keratins. CD3-positive/CD8-positive T lymphocytes predominated in the inflammatory reaction. Pathologists should be aware of these changes in order to differentiate coil-related lesions from other granulomatous or epithelial lesions, including mucocele-like and ductal carcinoma in situ lesions.

Evaluation of the dislocation and long-term sonographic detectability of a hydrogel-based breast biopsy site marker

PURPOSE

To evaluate the usefulness of the HydroMARK, a hydrogel-based breast biopsy site marker for ultrasound localization of breast lesions, we investigated the tendency for dislocation and sonographic detectability of the marker placed in patients.

MATERIALS AND METHODS

The marker was placed in lesions that were expected to become obscured after biopsy for a suspicious breast lesion or after neoadjuvant chemotherapy for breast cancer. The patients consented to return for a repeat ultrasound ± mammography examination, and the degree of displacement of the marker was measured as the marker-to-residual lesion distance.

RESULTS

The marker was placed after stereotactic biopsy, ultrasound-guided biopsy, and before/during neoadjuvant chemotherapy, in 11, 22, and 7 lesions, respectively. Surgical resection was performed for 22 of the 40 lesions, while remaining 18 benign lesions were followed. The marker was sonographically detectable in 89.7% (35/39), 100% (35/35), and 100% (18/18) of the cases, respectively, at a median of 8 days, 13 weeks, and 11 months after the deployment. The degree of displacement was lower in the ultrasound-guided placement group than in the stereotactic placement group (median displacement: 0 vs. 4.3 mm; p = 0.001), it was also lower in the core-needle biopsy and neoadjuvent therapy cases than in the vacuum-assisted biopsy cases (p = 0.003). At a median interval of 2.5 months after deployment, the marker remained unchanged in location in all cases (n = 18, p = NS).

CONCLUSIONS

The HydroMARK appears to be a safe and effective marker with the advantageous characteristics of a low tendency for dislocation with time and long-term sonographic detectability.