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. 2024 Jul 25;16(7):e65355.
doi: 10.7759/cureus.65355. eCollection 2024 Jul.

Comparative Evaluation of USG-Guided Single Tissue Marker Versus Multiple Tissue Marker Placements in Breast Malignancy Patients Undergoing Neoadjuvant Chemotherapy for Tumor Localization

Affiliations

Comparative Evaluation of USG-Guided Single Tissue Marker Versus Multiple Tissue Marker Placements in Breast Malignancy Patients Undergoing Neoadjuvant Chemotherapy for Tumor Localization

Yashaswinii P et al. Cureus. .

Abstract

Background Breast cancer remains one of the most common malignancies affecting women globally, contributing significantly to the disease burden. The advent of neoadjuvant chemotherapy (NAC) has revolutionized the treatment for locally advanced breast cancer, allowing tumors to be downstaged and making breast-conserving surgery (BCS) feasible. Accurate localization of the tumor bed post-NAC is crucial for successful surgical removal of residual disease. While traditional single tissue marker placement has been effective, recent advances suggest multiple markers might provide superior localization by comprehensively delineating the entire tumor area. This study aims to compare the effectiveness of single versus multiple tissue marker placements in breast malignancy patients undergoing NAC. Materials and methods A prospective study was conducted in the Department of Radio-diagnosis at Saveetha Medical College over 18 months, including 10 patients diagnosed with breast carcinoma, selected through convenience sampling. Inclusion criteria involved patients diagnosed with breast cancer via mammography, sonography, and histological confirmation, referred for clip placement before NAC. Exclusion criteria were patients unwilling to participate. The procedure involved placing one to two surgical clips within the tumor using a 14/16-gauge coaxial guiding needle under USG guidance, with additional clips for larger or multiple tumors. Data collection included pre-procedural USG, post-procedural mammography (MG1), pre-operative mammography (MG2)/USG, and gross specimen histopathological examination/specimen mammography. Statistical analysis Demographic data, clipping distribution, receptor status, localization methods, surgical outcomes, operation diagnoses, and correlation analysis were statistically analyzed. Mean age, standard deviation, and p-values were calculated to determine the significance of differences between single and multiple clip groups. Results The study included 10 patients with a mean age of 52.5 years. Of these, five (50%) had a single clip, and two (20%) had four clips. The average time from clipping to the second mammogram (MG2) was 106.3 days, and from clipping to operation was 111.0 days, with longer follow-up times for multiple clip patients. Six (60%) of the patients were estrogen receptor (ER) positive, and six (60%) were human epidermal growth factor receptor 2 (HER2) negative. Localization methods were similar between single and multiple clip groups. However, multiple clip patients tended to undergo more extensive surgeries like modified radical mastectomy (MRM). Imaging responses showed no preoperative ultrasound lesions in single clip patients, while multiple clip patients had higher inconsistent diagnoses (10 (100%)) suggesting that multiple clips provide better tumor localization but are linked to increased complexity and longer follow-up times. Conclusion Patients with multiple clips experienced significantly longer follow-up times, reflecting more complex clinical scenarios. Despite no significant differences in receptor status distributions, multiple clip patients required more extensive surgeries, emphasizing the need for tailored surgical planning. The study underscores the importance of considering the number of clips in clinical decision-making. Future research should focus on larger, prospective studies to validate these findings and explore underlying mechanisms.

Keywords: breast carcinoma; clip migration; neoadjuvant chemotherapy; tissue marker; usg-guided procedures.

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Conflict of interest statement

Human subjects: Consent was obtained or waived by all participants in this study. Saveetha Medical College and Hospital Ethics Committee issued approval ECR/724/Inst/TN/2015/RR-19. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

Figures

Figure 1
Figure 1. Pathway and procedure of clip insertion
Figure 2
Figure 2. Initial ultrasound of left breast findings
Ill-defined hypoechoic lesion (yellow arrow) with radiating borders and adjacent ductal dilatation reaching upto the nipple of size ~2.8x2 cm in 3 o’clock position within zone 2b-BIRADS 4.
Figure 3
Figure 3. MG1: A) MLO, B) CC, and C) post-procedural USG image
A) Opacity with partly defined borders retro-mammary tenting and architectural distortion in the upper quadrant of the left breast (yellow arrow), B) radio-opaque ribbon-shaped marker (yellow circle) seen within the above-mentioned lesion, and C) a linear hyperechoic structure - clip (yellow arrow) within the center of the lesion. In this case, only a single marker was placed. MLO, mediolateral oblique view; CC, craniocaudal view; MG1, post-procedural mammography
Figure 4
Figure 4. MG2: A) MLO, B) CC view, and C) post-chemotherapy/pre-operational USG
A) MLO view - there is a significant reduction of the tumor (yellow arrow) in comparison to the initial mammography MLO, B) CC view - radio-opaque ribbon-shaped marker (yellow circle) seen at the site of the assumed lesion and there is no evidence of clip migration, and C) USG - a linear hyperechoic structure - clip (green arrow) within the center of the significantly reduced lesion. MLO, mediolateral oblique view; CC, craniocaudal view; MG2, post-chemotherapy/pre-operational mammography
Figure 5
Figure 5. Pre-procedural mammography: A) CC, B) MLO, and C) post-procedural USG
A) Cranio-caudal view opacity with partly defined borders and mild architectural distortion in the upper inner quadrant of the right breast - BIRADS 4 (yellow arrow). B) MLO view shows the same lesion (yellow arrow). C) Two linear hyperechoic structures - clip (yellow arrows) within the center of the lesion. In this case, four markers were placed. MLO, mediolateral oblique view; CC, craniocaudal view
Figure 6
Figure 6. MG2: A) MLO, B) CC, C) post-chemotherapy/pre-operational USG, and D) specimen mammography
A) MLO view shows there is significant reduction of the tumor (yellow arrow) in comparison to the initial mammography. B) CC view shows four radio-opaque ribbon-shaped markers seen at the site of assumed lesion (yellow arrow) and there is no evidence of clip migration. Post-chemotherapy/pre-operational USG findings: C) USG image shows two linear hyperechoic structures - clips (white arrows) at the assumed site of the lesion. There is significant reduction in the size of the lesion. D) Specimen mammography findings show a linear wire structure (white arrow) within the excised lesion, and all four clip markers (yellow arrow) were removed and were seen within the lesion with no evidence of clip migration. MLO, mediolateral oblique view; CC, craniocaudal view; MG2, post-chemotherapy/pre-operational mammography
Figure 7
Figure 7. A) Age distribution, B) ER distribution, C) PR distribution, and D) HER2 receptor distribution
HER2, human epidermal growth factor receptor 2; ER, estrogen receptor; PR, progesterone receptor
Figure 8
Figure 8. Comparison of frequency of localization methods for multiple and single clips
Figure 9
Figure 9. Types of surgeries by age group
BCS, breast conservation surgery; MRM, modified radical mastectomy
Figure 10
Figure 10. Receptor status by age group
ER, estrogen receptor; PR, progesteron receptor
Figure 11
Figure 11. Consistency between biopsy and operation diagnosis

References

    1. NCCN guidelines insights: Breast cancer, version 1.2017. Gradishar WJ, Anderson BO, Balassanian R, et al. J Natl Compr Canc Netw. 2017;15:433–451. - PubMed
    1. Ultrasonography-guided surgical clip placement for tumor localization in patients undergoing neoadjuvant chemotherapy for breast cancer. Youn I, Choi SH, Kook SH, Choi YJ, Park CH, Park YL, Kim DH. J Breast Cancer. 2015;18:44–49. - PMC - PubMed
    1. The role of magnetic resonance imaging in assessing residual disease and pathologic complete response in breast cancer patients receiving neoadjuvant chemotherapy: a systematic review. Lobbes MB, Prevos R, Smidt M, et al. Insights Imaging. 2013;4:163–175. - PMC - PubMed
    1. Role of MRI to assess response to neoadjuvant therapy for breast cancer. Reig B, Heacock L, Lewin A, Cho N, Moy L. J Magn Reson Imaging. 2020;52:249–258. - PubMed
    1. Breast tissue markers: Why? What's out there? How do I choose? Shah AD, Mehta AK, Talati N, Brem R, Margolies LR. Clin Imaging. 2018;52:123–136. - PubMed

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