Breast Biopsy Marker: Is Bigger Better?

Mammographically-detected cancers and cancers that underwent neoadjuvant therapy are small and may be challenging to localize pre-operatively unless a marker is left during the biopsy that helps in their detection and subsequent localization prior to surgery especially if complete response is achieved after neoadjuvant chemotherapy. Since their initial introduction in 1990s, more and more, larger markers with a 3D shape are used such as Ultracor Twirl (Nitinol ring shaped) or Hologic Professional Tumark (known to expand into different shapes upon deployment) and hygroscopic sonographically detectable markers such as HydroMark with an expansile hydrogel component that absorbs the surrounding fluid allowing long-term visibility. The main disadvantage reported in breast tissue markers is their possible dislodgment especially if deployed under stereotactic guidance. To our best knowledge, no study has highlighted any difficulties related to these markers, more specifically their size, during pathologic analysis. In fact, when the excised specimen is submitted to the pathology suite, a specimen radiograph is obtained to identify the biopsy marker used as a landmark for the targeted lesion before painting all the surfaces of the specimen with India ink to help define the margins. Subsequently, the marker and radioactive seed, if used for localization, are withdrawn to allow serial sectioning across the specimen and hence, margin assessment. If not carefully done, manipulating the lumpectomy specimen to extrude the marker, can lead to fragmentation of the specimen hence difficulty assessing the margins. This risk is likely higher in case of small ill-defined lesions especially, those altered by neoadjuvant chemotherapy and when a large marker is embedded. One of our patients, recently underwent breast conservative surgery for a 0.5 cm invasive lobular carcinoma after which, re-operation to achieve negative margins was mandatory since initial assessment of the margins was extremely difficult due to fragmentation while retrieving the Ultracor Twirl marker deployed after the biopsy. Good sonographic visibility of a large biopsy marker eases pre-operative localization at the risk of shattering the tumor into pieces at retrieval, hence suboptimal margin assessment. Since these markers are more and more used, meticulous handling of the specimen in pathology, is mandatory.