Placement of radiopaque clips for tumor localization in patients undergoing neoadjuvant chemotherapy and breast conservation therapy

Abstract

Background: The objective of this study was to determine whether patients with breast cancer who received breast-conservation therapy after neoadjuvant chemotherapy had improved outcomes if radiopaque clips were placed to mark the primary tumor.

Methods: The authors retrospectively reviewed the records of 410 patients with nonmetastatic breast cancer who received doxorubicin-based neoadjuvant chemotherapy and breast-conservation therapy from January 1990 to September 2005. Thirty-seven of those patients were omitted because of the inability to verify radiopaque clip placement in the primary tumor.

Results: Of the 373 patients who were analyzed, 145 patients had radiopaque clips placed to mark the primary tumor before or during neoadjuvant chemotherapy, and 228 patients did not. The distribution of clinical T classification, nuclear grade, estrogen receptor status, final margin status, and extent of residual primary disease was similar between the 2 groups. After a median follow-up of 49 months (range, 20-177 months), 21 patients developed a local recurrence in the treated breast. The 5-year rate of local control was 98.6% in patients who had radiopaque clips placed versus 91.7% in patients who did not have tumor marker clips placed (P=.02; log-rank test). On multivariate analysis, the omission of tumor bed clips was associated with a hazard ratio of 3.69 for increased local recurrence compared with patients who did have radiopaque clip placement (P=.083; 95% confidence interval, 0.84-16.16).

Conclusions: The placement of radiopaque clips in patients who were receiving neoadjuvant chemotherapy and breast-conservation therapy was associated with better local control independent of stage and other clinicopathologic findings. The authors concluded that the placement of tumor-marker clips should be an integral part of the multidisciplinary approach in appropriate patients.

FIGURE 1

Placement and postprocedure mammogram of radiopaque clip in a known invasive ductal carcinoma in a woman aged 48 years. (A) Transverse left breast sonography shows the introducer (short arrow) and the clip marker (long arrow; UltraCLIP II Tissue Marker; INRAD, Inc., Grand Rapids, Mich) in the hypoechoic mass representing the known invasive ductal carcinoma. (B) Left lateromedial mammogram shows the clip marker within the known invasive ductal carcinoma (arrow). The patient was treated with preoperative paclitaxel and combined 5-fluorouracil, doxorubicin and cyclophosphamide chemotherapy. Left breast segmental mastectomy demonstrated residual invasive ductal carcinoma, and left axillary dissection revealed 1 metastatic lymph node of 18 lymph nodes.

FIGURE 2

Local control over the 10-year study period. Cum Proportion indicates cumulative proportion.

FIGURE 3

(A) Local control in patients with residual disease >1 cm after neoadjuvant chemotherapy. (B) Local control in patients with pathologically complete or nearly complete response (median size = 1 mm) after neoadjuvant chemotherapy. Cum Proportion indicates cumulative proportion.