(Radiology. 2001;219:495-497.)
© RSNA, 2001
Displacement of Microcalcifications during Stereotactic 11-gauge Directional Vacuum-assisted Biopsy with Marking Clip Placement: Case Report1
Steven G. Lee, MD,
Catherine W. Piccoli, MD and
Jane S. Hughes, MD
1 From the Breast Imaging Center, Thomas Jefferson University Hospital, 1100 Walnut St, M.O.B./Ground Level, Philadelphia, PA 19107. Received May 22, 2000; revision requested July 17; revision received August 30; accepted September 6. Address correspondence to S.G.L. (e-mail: seraph99@flash.net).
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ABSTRACT
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A 53-year-old woman with right breast microcalcifications of intermediate concern underwent stereotactic directional vacuum-assisted biopsy with marking clip placement. Postbiopsy mammograms showed displacement of a few of the targeted microcalcifications adjacent to misplaced marker clips. Mammography following stereotactic breast biopsy is important to document the location and number of residual calcifications and to determine the adequacy and location of clip placement.
Index terms: Breast, biopsy, 00.1261, 00.1267 • Breast, calcification, 00.81 • Breast radiography, 00.11 • Interventional procedures, complications, 00.1261, 00.1267
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INTRODUCTION
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Epithelial displacement has been shown to occur during stereotactic directional vacuum-assisted biopsy in 7%–23% of cases (1,2). This finding has been noted during histologic review of surgical specimens from patients who subsequently underwent excisional biopsy or mastectomy (1–4). Stereotactic biopsy performed by using an 11-gauge directional vacuum-assisted device is commonly used for biopsy of microcalcifications. When using this technique, it is customary to place a metallic clip to mark the biopsy site. However, misplacement of the clip with deployment at greater than 24 mm from the target lesion may occur in 7%–11% of cases (5). We report a case of mammographically evident displacement of calcifications with associated clip misplacement during stereotactic directional vacuum-assisted biopsy.
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Case Report
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A 53-year-old woman was found to have a cluster of microcalcifications of intermediate concern in the upper outer quadrant of the right breast at mammography (Figure, part a). Imaging-guided biopsy of the microcalcifications was recommended.
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Figure 1a. (a) Right craniocaudal mammogram depicts a cluster of microcalcifications (arrow) in the outer part of the breast targeted for biopsy. (b) Postbiopsy right craniocaudal mammogram shows no residual microcalcifications at the biopsy site, which is demarcated by air bubbles (solid arrow). The two marking clips are 3 cm posteromedial to the biopsy site. There are two faint punctate microcalcifications (open arrow) adjacent and posterior to the marking clips. (c) Postbiopsy magnified right craniocaudal mammogram better demonstrates the two punctate microcalcifications (arrow) adjacent to the marking clips. Magnified 6-month follow-up mammograms in the (d) craniocaudal and (e) mediolateral oblique projections demonstrate at least two microcalcifications (arrow) close to the two marker clips.
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Figure 1b. (a) Right craniocaudal mammogram depicts a cluster of microcalcifications (arrow) in the outer part of the breast targeted for biopsy. (b) Postbiopsy right craniocaudal mammogram shows no residual microcalcifications at the biopsy site, which is demarcated by air bubbles (solid arrow). The two marking clips are 3 cm posteromedial to the biopsy site. There are two faint punctate microcalcifications (open arrow) adjacent and posterior to the marking clips. (c) Postbiopsy magnified right craniocaudal mammogram better demonstrates the two punctate microcalcifications (arrow) adjacent to the marking clips. Magnified 6-month follow-up mammograms in the (d) craniocaudal and (e) mediolateral oblique projections demonstrate at least two microcalcifications (arrow) close to the two marker clips.
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Figure 1c. (a) Right craniocaudal mammogram depicts a cluster of microcalcifications (arrow) in the outer part of the breast targeted for biopsy. (b) Postbiopsy right craniocaudal mammogram shows no residual microcalcifications at the biopsy site, which is demarcated by air bubbles (solid arrow). The two marking clips are 3 cm posteromedial to the biopsy site. There are two faint punctate microcalcifications (open arrow) adjacent and posterior to the marking clips. (c) Postbiopsy magnified right craniocaudal mammogram better demonstrates the two punctate microcalcifications (arrow) adjacent to the marking clips. Magnified 6-month follow-up mammograms in the (d) craniocaudal and (e) mediolateral oblique projections demonstrate at least two microcalcifications (arrow) close to the two marker clips.
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Figure 1d. (a) Right craniocaudal mammogram depicts a cluster of microcalcifications (arrow) in the outer part of the breast targeted for biopsy. (b) Postbiopsy right craniocaudal mammogram shows no residual microcalcifications at the biopsy site, which is demarcated by air bubbles (solid arrow). The two marking clips are 3 cm posteromedial to the biopsy site. There are two faint punctate microcalcifications (open arrow) adjacent and posterior to the marking clips. (c) Postbiopsy magnified right craniocaudal mammogram better demonstrates the two punctate microcalcifications (arrow) adjacent to the marking clips. Magnified 6-month follow-up mammograms in the (d) craniocaudal and (e) mediolateral oblique projections demonstrate at least two microcalcifications (arrow) close to the two marker clips.
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Figure 1e. (a) Right craniocaudal mammogram depicts a cluster of microcalcifications (arrow) in the outer part of the breast targeted for biopsy. (b) Postbiopsy right craniocaudal mammogram shows no residual microcalcifications at the biopsy site, which is demarcated by air bubbles (solid arrow). The two marking clips are 3 cm posteromedial to the biopsy site. There are two faint punctate microcalcifications (open arrow) adjacent and posterior to the marking clips. (c) Postbiopsy magnified right craniocaudal mammogram better demonstrates the two punctate microcalcifications (arrow) adjacent to the marking clips. Magnified 6-month follow-up mammograms in the (d) craniocaudal and (e) mediolateral oblique projections demonstrate at least two microcalcifications (arrow) close to the two marker clips.
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The patient underwent stereotactic biopsy with an 11-gauge directional vacuum-assisted device (Mammotome; Biopsys/Ethicon Endo-Surgery, Cincinnati, Ohio). The procedure was performed with the patient in the prone position on a dedicated digital imaging table (StereoGuide with Digital Spot Mammography; Lorad, Danbury, Conn). The calcifications were approached from the lateral aspect of the breast. Biopsy was performed by using the standard technique. The probe was fired within the breast. Nine specimens were taken. Specimen radiographs showed that most of the microcalcifications had been removed. An initial attempt at marking clip (MicroMark; Biopsys/Ethicon Endo-Surgery) deployment was made, but the clip was not visible on the stereotactic images. A second clip was then deployed.
Postbiopsy craniocaudal and mediolateral mammograms were compared with prebiopsy mammograms. No microcalcifications remained at the target site (Figure, parts b, c). The two marking clips were observed to be adjacent to each other but approximately 3 cm medial to the target site. In addition, at least two microcalcifications were observed to be adjacent to the clips. There had been no microcalcifications in this region on the prebiopsy mammograms. Histologic review of the biopsy specimens revealed fibrocystic change, ductal hyperplasia, and calcium oxalate microcalcifications. At follow-up mammography 6 months after biopsy, the location and appearance of the clips and microcalcifications were unchanged (Figure, parts d, e).
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Discussion
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This case represents our first experience with mammographic evidence of tissue displacement during stereotactic directional vacuum-assisted biopsy with marking clip placement. The clip is introduced into the tissue through the sampling notch of the 11-gauge probe. Because this is a blind procedure, the precise location of the clip at deployment is not known. The greatest misplacement errors occur in the depth or z axis (6). Although the clip may appear to be close to the target lesion on stereotactic images when the breast is compressed, the clip may be farther from the target lesion at mammography with compression in the orthogonal plane. Burbank and Forcier (5) were aware of marker clip misplacements only after obtaining postbiopsy two-view mammograms. Breast tissue is analogous to an accordion: Structures that are close together when the breast is compressed move further apart when compression is released (6). Liberman et al (1) hypothesized that the firing of the probe through the lesion is the step most likely to result in cellular displacement.
In the present case, a few of the targeted microcalcifications may have traveled with the probe as it coursed through the breast. Alternatively, the mechanical act of pushing and closing the clip may have caused the tissue containing the microcalcifications—or the microcalcifications themselves—to be caught and dragged. A third possible mechanism for tissue displacement is that a small fragment of harvested tissue may have remained within the bowl of the probe. With clip deployment, this loose tissue fragment containing the microcalcifications may have been caught by one of the two deployed clips. Cleaning the probe thoroughly before clip deployment may have prevented this occurrence.
Diaz et al (2) observed a decreasing incidence of tumor displacement at increasing intervals between core biopsy and excision, and they strongly suggested that displaced tumor cells do not survive displacement. Displaced benign tissue is not clinically important. However, when there is mammographic evidence of epithelial displacement in the case of core biopsy findings positive for malignancy or atypical ductal hyperplasia, it may be prudent to consider surgical excision of the displaced microcalcifications.
Postbiopsy mammography typically is recommended to document clip location. In addition, despite the low incidence of microcalcification displacement, immediate postbiopsy mammography enables documentation of the location and number of residual calcifications. This is important to ensure proper management of malignant cases and to exclude the presence of developing microcalcifications dis-tant from the target site at subsequent mammography.
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FOOTNOTES
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Author contributions: Guarantors of integrity of entire study, S.G.L., C.W.P.; study concepts and design, S.G.L., C.W.P., J.S.H.; literature research, S.G.L., C.W.P.; clinical studies, S.G.L., C.W.P.; data acquisition and analysis/interpretation, S.G.L., C.W.P., J.S.H.; manuscript preparation and definition of intellectual content, S.G.L., C.W.P.; manuscript editing and revision/review, S.G.L., C.W.P., J.S.H.; manuscript final version approval, S.G.L., C.W.P.
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REFERENCES
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Liberman L, Vuolo M, Dershaw DD, et al. Epithelial displacement after stereotactic 11-gauge directional vacuum-assisted breast biopsy. AJR Am J Roentgenol 1999; 172:677-681.[Abstract/Free Full Text]
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Diaz LK, Wiley EL, Venta LA. Are malignant cells displaced by large-gauge needle core biopsy of the breast?. AJR Am J Roentgenol 1999; 173:1303-1313.[Abstract/Free Full Text]
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Youngson BJ, Liberman L, Rosen PP. Displacement of carcinomatous epithelium in surgical breast specimens following stereo-taxic core biopsy. Am J Clin Pathol 1995; 103:598-602.[Medline]
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Youngson BJ, Cranor M, Rosen PP. Epithelial displacement in surgical breast specimens following needling procedures. Am J Surg Pathol 1994; 18:896-903.[Medline]
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Burbank F, Forcier N. Tissue marking clip for stereotactic breast biopsy: initial placement accuracy, long-term stability, and usefulness as a guide for wire localization. Radiology 1997; 205:407-415.[Abstract/Free Full Text]
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Liberman L, Dershaw DD, Morris EA, Abramson AF, Thornton CM, Rosen PP. Clip placement after stereotactic vacuum-assisted breast biopsy. Radiology 1997; 205:417-422.[Abstract/Free Full Text]
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ABSTRACT
INTRODUCTION
