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Recognizing Pitfalls in Early and Late Migration of Clip Markers after Imaging-guided Directional Vacuum-assisted Biopsy¹

¹ From the Department of Radiology, Mount Sinai Medical Center, 4300 Alton Rd, Miami Beach, FL 33140. Recipient of a Certificate of Merit award for an education exhibit at the 2002 RSNA scientific assembly. Received March 6, 2003; revision requested April 4 and received May 23; accepted May 27. All authors have no financial relationships to disclose. Address correspondence to L.E.E. (e-mail: lesserma@salick.com).

View larger version (118K): [in a new window]   Figure 1a.  Accordion effect. (a) Lateral mammogram of the right breast obtained after biopsy shows a clip placed at the site of a nodule. (b) Craniocaudal mammogram obtained immediately after biopsy shows that the clip is medially displaced in the direction of the biopsy track.

View larger version (115K): [in a new window]   Figure 1b.  Accordion effect. (a) Lateral mammogram of the right breast obtained after biopsy shows a clip placed at the site of a nodule. (b) Craniocaudal mammogram obtained immediately after biopsy shows that the clip is medially displaced in the direction of the biopsy track.

View larger version (99K): [in a new window]   Figure 2a.  Migration of a clip wire into the biopsy track. (a) Lateral mammogram obtained 2 months after biopsy at the time of needle localization shows a clip located 5 cm inferior to the biopsy site along a linear density (arrow), which represents the biopsy track. (b) Lateral mammogram shows two wires, which indicate the lesion at the top of the biopsy track (arrow) and the clip at the inferior edge of the biopsy track (arrowhead). One wire was targeted toward the clip with a medial approach but migrated superiorly along the biopsy track to the lesion site (arrow). The other wire was also targeted toward the clip with a medial approach and remains at the site of the clip (arrowhead). The surgeon was able to remove the lesion and the entire biopsy track by taking the tissue around both wires.

View larger version (126K): [in a new window]   Figure 2b.  Migration of a clip wire into the biopsy track. (a) Lateral mammogram obtained 2 months after biopsy at the time of needle localization shows a clip located 5 cm inferior to the biopsy site along a linear density (arrow), which represents the biopsy track. (b) Lateral mammogram shows two wires, which indicate the lesion at the top of the biopsy track (arrow) and the clip at the inferior edge of the biopsy track (arrowhead). One wire was targeted toward the clip with a medial approach but migrated superiorly along the biopsy track to the lesion site (arrow). The other wire was also targeted toward the clip with a medial approach and remains at the site of the clip (arrowhead). The surgeon was able to remove the lesion and the entire biopsy track by taking the tissue around both wires.

View larger version (144K): [in a new window]   Figure 3a.  Clip migration out of the lesion. (a) Craniocaudal mammogram obtained after biopsy shows a clip at the site of biopsy of faint calcifications. The compression applied for bleeding at the biopsy site of the superficial lesion led to extrusion of the clip through the incision. (b) Lateral mammogram obtained for needle localization 2 months after biopsy shows that the clip is no longer present.

View larger version (152K): [in a new window]   Figure 3b.  Clip migration out of the lesion. (a) Craniocaudal mammogram obtained after biopsy shows a clip at the site of biopsy of faint calcifications. The compression applied for bleeding at the biopsy site of the superficial lesion led to extrusion of the clip through the incision. (b) Lateral mammogram obtained for needle localization 2 months after biopsy shows that the clip is no longer present.

View larger version (134K): [in a new window]   Figure 4a.  Clip floating in a hematoma. (a) Lateral mammogram obtained 20 days after biopsy shows inferior migration of a clip. (b, c) Craniocaudal (superior view) (b) and 90° lateral (c) mammograms show attempted placement of a localization needle. The needle is placed at the clip on the craniocaudal view (b); however, after repeated attempts at placement, it is persistently off on the lateral view (c). An attempt to localize the clip stereotactically was also unsuccessful.

View larger version (90K): [in a new window]   Figure 4b.  Clip floating in a hematoma. (a) Lateral mammogram obtained 20 days after biopsy shows inferior migration of a clip. (b, c) Craniocaudal (superior view) (b) and 90° lateral (c) mammograms show attempted placement of a localization needle. The needle is placed at the clip on the craniocaudal view (b); however, after repeated attempts at placement, it is persistently off on the lateral view (c). An attempt to localize the clip stereotactically was also unsuccessful.

View larger version (80K): [in a new window]   Figure 4c.  Clip floating in a hematoma. (a) Lateral mammogram obtained 20 days after biopsy shows inferior migration of a clip. (b, c) Craniocaudal (superior view) (b) and 90° lateral (c) mammograms show attempted placement of a localization needle. The needle is placed at the clip on the craniocaudal view (b); however, after repeated attempts at placement, it is persistently off on the lateral view (c). An attempt to localize the clip stereotactically was also unsuccessful.

View larger version (137K): [in a new window]   Figure 5a.  Clip displacement by a hematoma. (a) US scan obtained 2 months after US-guided core biopsy shows a hematoma at the biopsy site. (b, c) Craniocaudal mammograms obtained immediately after biopsy (b) and 2 months after biopsy (c) show anterior migration of the clip.

View larger version (68K): [in a new window]   Figure 5b.  Clip displacement by a hematoma. (a) US scan obtained 2 months after US-guided core biopsy shows a hematoma at the biopsy site. (b, c) Craniocaudal mammograms obtained immediately after biopsy (b) and 2 months after biopsy (c) show anterior migration of the clip.

View larger version (64K): [in a new window]   Figure 5c.  Clip displacement by a hematoma. (a) US scan obtained 2 months after US-guided core biopsy shows a hematoma at the biopsy site. (b, c) Craniocaudal mammograms obtained immediately after biopsy (b) and 2 months after biopsy (c) show anterior migration of the clip.

View larger version (149K): [in a new window]   Figure 6a.  Clip site change due to resorption of air at the biopsy site. (a) Craniocaudal mammogram obtained after biopsy shows a clip anterior to a region of microcalcifications (arrow), where an unusually large air cavity is seen. (b) Lateral mammogram obtained 2 months after biopsy shows scarring at the biopsy site and resorption of air from the large cavity with a consequent change in the position of the clip relative to the microcalcifications (arrow).

View larger version (138K): [in a new window]   Figure 6b.  Clip site change due to resorption of air at the biopsy site. (a) Craniocaudal mammogram obtained after biopsy shows a clip anterior to a region of microcalcifications (arrow), where an unusually large air cavity is seen. (b) Lateral mammogram obtained 2 months after biopsy shows scarring at the biopsy site and resorption of air from the large cavity with a consequent change in the position of the clip relative to the microcalcifications (arrow).

View larger version (129K): [in a new window]   Figure 7a.  Change in clip site after neoadjuvant therapy. (a) US scan obtained after clip deployment shows pellets on either side of the central clip (arrowheads). (b) Lateral mammogram obtained after US-guided core biopsy shows the clip (arrowhead) in the lesion (arrows). (c) Lateral mammogram obtained 3 months later after completion of neoadjuvant chemotherapy shows the clip (arrow). The apparent change in the location of the clip was due to tumor shrinkage.

View larger version (79K): [in a new window]   Figure 7b.  Change in clip site after neoadjuvant therapy. (a) US scan obtained after clip deployment shows pellets on either side of the central clip (arrowheads). (b) Lateral mammogram obtained after US-guided core biopsy shows the clip (arrowhead) in the lesion (arrows). (c) Lateral mammogram obtained 3 months later after completion of neoadjuvant chemotherapy shows the clip (arrow). The apparent change in the location of the clip was due to tumor shrinkage.

View larger version (79K): [in a new window]   Figure 7c.  Change in clip site after neoadjuvant therapy. (a) US scan obtained after clip deployment shows pellets on either side of the central clip (arrowheads). (b) Lateral mammogram obtained after US-guided core biopsy shows the clip (arrowhead) in the lesion (arrows). (c) Lateral mammogram obtained 3 months later after completion of neoadjuvant chemotherapy shows the clip (arrow). The apparent change in the location of the clip was due to tumor shrinkage.

View larger version (98K): [in a new window]   Figure 8a.  Change in clip site after reduction mammaplasty. (a) Craniocaudal mammogram obtained immediately after biopsy shows a clip at the biopsy site. (b) Craniocaudal mammogram obtained 1 year after biopsy shows that the clip is in the lateral aspect of the breast. (c) Lateral mammogram obtained after biopsy shows the clip at the biopsy site. (d) Mediolateral oblique mammogram obtained 1 year after biopsy shows that the clip is in the superior aspect of the breast.

View larger version (112K): [in a new window]   Figure 8b.  Change in clip site after reduction mammaplasty. (a) Craniocaudal mammogram obtained immediately after biopsy shows a clip at the biopsy site. (b) Craniocaudal mammogram obtained 1 year after biopsy shows that the clip is in the lateral aspect of the breast. (c) Lateral mammogram obtained after biopsy shows the clip at the biopsy site. (d) Mediolateral oblique mammogram obtained 1 year after biopsy shows that the clip is in the superior aspect of the breast.

View larger version (112K): [in a new window]   Figure 8c.  Change in clip site after reduction mammaplasty. (a) Craniocaudal mammogram obtained immediately after biopsy shows a clip at the biopsy site. (b) Craniocaudal mammogram obtained 1 year after biopsy shows that the clip is in the lateral aspect of the breast. (c) Lateral mammogram obtained after biopsy shows the clip at the biopsy site. (d) Mediolateral oblique mammogram obtained 1 year after biopsy shows that the clip is in the superior aspect of the breast.

View larger version (102K): [in a new window]   Figure 8d.  Change in clip site after reduction mammaplasty. (a) Craniocaudal mammogram obtained immediately after biopsy shows a clip at the biopsy site. (b) Craniocaudal mammogram obtained 1 year after biopsy shows that the clip is in the lateral aspect of the breast. (c) Lateral mammogram obtained after biopsy shows the clip at the biopsy site. (d) Mediolateral oblique mammogram obtained 1 year after biopsy shows that the clip is in the superior aspect of the breast.

View larger version (108K): [in a new window]   Figure 9a.  Clip displacement by another clip. (a) Craniocaudal mammogram of the right breast shows cluster microcalcifications at two sites. (b) Lateral mammogram shows the two clusters of microcalcifications in the superior right breast. (c) Craniocaudal mammogram obtained after biopsy shows two clips at site 1, in the medial aspect of the breast. A second clip was placed at this site because the stereoradiograph pair did not show the first clip. Both clips were placed with a superior approach. A different type of marker was placed at site 2 (arrowhead), in the lateral aspect of the breast, to differentiate the two lesions. (d) Magnified lateral mammogram obtained after biopsy shows that the first clip placed at site 1 has been displaced inferiorly by the second clip placed at that site.

View larger version (102K): [in a new window]   Figure 9b.  Clip displacement by another clip. (a) Craniocaudal mammogram of the right breast shows cluster microcalcifications at two sites. (b) Lateral mammogram shows the two clusters of microcalcifications in the superior right breast. (c) Craniocaudal mammogram obtained after biopsy shows two clips at site 1, in the medial aspect of the breast. A second clip was placed at this site because the stereoradiograph pair did not show the first clip. Both clips were placed with a superior approach. A different type of marker was placed at site 2 (arrowhead), in the lateral aspect of the breast, to differentiate the two lesions. (d) Magnified lateral mammogram obtained after biopsy shows that the first clip placed at site 1 has been displaced inferiorly by the second clip placed at that site.

View larger version (93K): [in a new window]   Figure 9c.  Clip displacement by another clip. (a) Craniocaudal mammogram of the right breast shows cluster microcalcifications at two sites. (b) Lateral mammogram shows the two clusters of microcalcifications in the superior right breast. (c) Craniocaudal mammogram obtained after biopsy shows two clips at site 1, in the medial aspect of the breast. A second clip was placed at this site because the stereoradiograph pair did not show the first clip. Both clips were placed with a superior approach. A different type of marker was placed at site 2 (arrowhead), in the lateral aspect of the breast, to differentiate the two lesions. (d) Magnified lateral mammogram obtained after biopsy shows that the first clip placed at site 1 has been displaced inferiorly by the second clip placed at that site.

View larger version (101K): [in a new window]   Figure 9d.  Clip displacement by another clip. (a) Craniocaudal mammogram of the right breast shows cluster microcalcifications at two sites. (b) Lateral mammogram shows the two clusters of microcalcifications in the superior right breast. (c) Craniocaudal mammogram obtained after biopsy shows two clips at site 1, in the medial aspect of the breast. A second clip was placed at this site because the stereoradiograph pair did not show the first clip. Both clips were placed with a superior approach. A different type of marker was placed at site 2 (arrowhead), in the lateral aspect of the breast, to differentiate the two lesions. (d) Magnified lateral mammogram obtained after biopsy shows that the first clip placed at site 1 has been displaced inferiorly by the second clip placed at that site.