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Clip Migration after 11-gauge Vacuum-assisted Stereotactic Biopsy: Case Report¹

¹ From the Department of Radiology, Yale University School of Medicine, 333 Cedar St, PO Box 208042, New Haven, CT 06520. Received July 23, 2001; revision requested August 23; revision received September 14; accepted September 20. Address correspondence to L.E.P. (e-mail: philpotts@biomed.med.yale.edu).

	ABSTRACT

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A 68-year-old woman underwent stereotactic biopsy of a small cluster of calcifications. The postbiopsy mammograms showed the biopsy-marking clip to be located correctly at the biopsy site. Follow-up mammograms 1 year later showed that the clip migrated to another quadrant of the breast. Findings in this case demonstrate that at long-term follow-up a biopsy-marking clip may not be accurately marking the biopsy site.

© RSNA, 2002

Index terms: Breast, biopsy, 00.1267 • Breast radiography, 00.11 • Foreign bodies, 00.93

	INTRODUCTION

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Biopsy-marking clips ideally should mark biopsy sites accurately. However, incorrect location of the clip immediately after biopsy can occur owing to the "accordion effect." In the case we report here, findings showed that the clip migrated after the immediate postbiopsy period. Since clip migration can affect interpretation of mammographic findings and localization for future surgery, the radiologist should not assume that the clip is correctly located at the biopsy site. The radiologist should compare prebiopsy, postbiopsy, and follow-up mammograms to determine whether the biopsy-marking clip has moved.

	Case Report

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We received approval from our Human Investigation Committee for Medical Record Review; informed consent was not required.

At mammography, a 68-year-old woman had a small cluster of calcifications at the 10- to 11-o’clock position in the posterior third of the right breast. Stereotactic core biopsy was performed from a superior approach in the craniocaudal projection with an 11-gauge vacuum-assisted suction device (Mammotome; Biopsys/Ethicon-Endosurgery, Cincinnati, Ohio). Since most of the calcifications were removed, a biopsy-marking clip (MicroMark; Biopsys/Ethicon-Endosurgery) was deployed. Our method of clip deployment is to withdraw the probe 3–5 mm, to insert the introducer, and to deploy the clip while the vacuum is simultaneously applied. The postprocedural digital stereotactic images demonstrated the presence of the clip in the air-filled biopsy cavity. The postbiopsy craniocaudal and mediolateral mammograms showed the clip accurately located at the site where samples of calcifications were removed (Fig 1). There were no complications. In particular, no excessive bleeding occurred during the biopsy. The histologic results were benign.

View larger version (67K): [in this window] [in a new window] [Download PPT slide]   Figure 1a. (a) Craniocaudal and (b) mediolateral postprocedural mammograms show the clip (arrow) accurately located at the biopsy site. Almost all of the calcifications were removed. Results of histologic analysis showed that the calcifications were benign.

View larger version (73K): [in this window] [in a new window] [Download PPT slide]   Figure 1b. (a) Craniocaudal and (b) mediolateral postprocedural mammograms show the clip (arrow) accurately located at the biopsy site. Almost all of the calcifications were removed. Results of histologic analysis showed that the calcifications were benign.

View larger version (67K): [in this window] [in a new window] [Download PPT slide]   Figure 2a. (a) Craniocaudal and (b) mediolateral oblique images obtained 1 year after the biopsy show the clip (solid arrow) in the inferior aspect of the breast. A small scar and a few residual calcifications are at the previous biopsy site (open arrow).

View larger version (70K): [in this window] [in a new window] [Download PPT slide]   Figure 2b. (a) Craniocaudal and (b) mediolateral oblique images obtained 1 year after the biopsy show the clip (solid arrow) in the inferior aspect of the breast. A small scar and a few residual calcifications are at the previous biopsy site (open arrow).

	Discussion

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In this case, although the postbiopsy mammograms showed the clip to be located correctly at the site where samples of calcifications were removed, subsequent mammograms 1 year later revealed the clip to be markedly displaced. The exact mechanism and timing of the displacement are not known. On review of the digital image obtained after clip deployment, the clip was in a dependent portion of the cavity, possibly indicating poor adherence to tissue. Applying the vacuum suction while the clip is deployed should, theoretically, allow the clip to adhere to tissue rather than to be free floating in the biopsy cavity. Despite good technique, however, the clip may not always be firmly attached. Although there was no hematoma formation or history of postprocedural bleeding in this case, it is possible that the clip migrated within the patent needle track soon after the procedure.

An alternative explanation is that the clip freely migrated within the predominantly fatty tissue of the breast. Wires used for needle localization prior to surgery have been reported (7,8) to migrate within the breast and to remote areas of the body. If the case presented here represents similar migration, then biopsy-marking clips may have the potential to migrate some distances within or away from the breast.

Burbank and Forcier (3) have shown long-term stability (mean follow-up time, 8.6 months) of the localizing clip in 31 cases. No measurable movement over time was noted. Longer follow-up times have not been reported. Findings in our case demonstrate that clip migration after postbiopsy imaging is possible, and the position of the clip on subsequent mammograms, therefore, may not be accurate and reliable for future documentation of the biopsy site. This has important implications for subsequent localization for surgery and for interpretation of follow-up mammograms. Radiologists who perform needle localizations or who interpret mammograms after stereotactic core biopsies in which a clip was placed should not assume that the clip is in the correct location and should always review prebiopsy mammograms.

	FOOTNOTES

 
Author contributions: Guarantors of integrity of entire study, L.E.P., C.H.L.; study concepts and design, L.E.P.; literature research, L.E.P.; clinical studies, L.E.P.; data acquisition and analysis/interpretation, L.E.P.; manuscript preparation, L.E.P., C.H.L.; manuscript definition of intellectual content, L.E.P.; manuscript editing, revision/review, and final version approval, L.E.P., C.H.L.

	REFERENCES

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1. 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.
2. Reynolds HE. Marker clip placement following directional, vacuum-assisted breast biopsy. Am Surg 1999; 65:59-60.
3. 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.
4. Rosen EL, Vo TT. Metallic clip deployment during stereotactic breast biopsy: retrospective analysis. Radiology 2001; 218:510-516.
5. Brenner RJ. Lesions entirely removed during stereotactic biopsy: preoperative localization on the basis of mammographic landmarks and feasibility of freehand technique—initial experience. Radiology 2000; 214:585-590.
6. DiPiro PJ. Disappearance of a localizing clip placed after stereotactic core biopsy of the breast (letter). AJR Am J Roentgenol 1999; 173:1134.
7. Davis PS, Wechsler RJ, Feig SA, March DE. Migration of breast biopsy localization wire. AJR Am J Roentgenol 1988; 150:787-788.
8. Owen AW, Kumar EN. Migration of localizing wires used in guided biopsy of the breast. Clin Radiol 1991; 43:251.

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This Article Abstract Figures Only Full Text (PDF) All Versions of this Article: 2223011263v1 222/3/794    most recent Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Philpotts, L. E. Articles by Lee, C. H. Search for Related Content PubMed PubMed Citation Articles by Philpotts, L. E. Articles by Lee, C. H.