Recommendations from the European Breast Cancer Guidelines

Should clipmarking vs. no clip-marking after needle core biopsy (NCB)/vacuum assisted needle core biopsy (VANCB) be used for surgical therapy planning in patients with breast cancer lesions?

Recommendation

The ECIBC's Guidelines Development Group suggests using clip-marking after NCB/VANCB for surgical therapy planning in patients with breast cancer lesions (conditional recommendation, very low certainty).

Recommendation strength

  •   Strong recommendation against the intervention
  •   Conditional recommendation against the intervention
  •   Conditional recommendation for either the intervention or the comparison
  • Conditional recommendation for the intervention
  •   Strong recommendation for the intervention

A recommendation can be strong or conditional.

When a recommendation is strong, most women will want to follow it. When a recommendation is conditional, the majority of women want to follow it but may need more discussion with their healthcare professional first.

Subgroup

Palpable lesions possibly candidate for neoadjuvant therapy & Non-palpable lesions: the GDG considered both types of lesion and agreed that the evidence did not support distinguishing these sub-groups under this recommendation or any of the ETD considerations. The GDG noted that lesions that are initially palpable may later become non-palpable following neo-adjuvant chemotherapy.

Justification

Overall justification

The GDG agreed by consensus to support a conditional recommendation for the intervention.

 

Detailed justification

Desirable Effects:
The GDG judged that the desirable effects were large, including fewer cancers with positive margins and fewer local recurrences with the use of clip-marking after NCB / VANCB for surgical therapy planning.

Undesirable Effects:
The GDG noted differences in the performance of clips from the research evidence. The GDG noted that some women may be concerned about having a clip in the breast. The GDG also notes that the materials used in most clips are known to be safe from their use in other devices.

Certainty of evidence:
The GDG noted that only one study with very low certainty of evidence was reviewed. The GDG had significant concern of risk of allocation bias, as it notes that patients in the intervention group receiving clips may have been healthier or had less advanced disease.

Balance of effects:
The GDG judged that the balance of effects probably favours the intervention.

Resources required:
The GDG judged that the intervention would require moderate costs due to the high costs of the clip, however, the GDG noted that the number of women requiring clips would be small.

Cost effectiveness:
No cost-effectiveness studies were included, however, the GDG noted that cost-effectiveness considerations should include the potential for clips to reduce additional interventions such as additional biopsies or surgeries, which would have significant reductions in cost.

Considerations

Implementation

1. The GDG noted that effective communication at the time of clip insertion is essential to ensure that women understand the implications of clip insertion on future management.
2. The GDG noted that the timing of clip insertion is critical and whether it is feasible to insert clips during initial biopsies instead of a follow-up procedure may change the harm benefit ratio because of the additional stress, complications and costs associated with placing the clip in a second time.

Monitoring and Evaluation

The GDG noted that monitoring for whether clips are inserted in the correct position in relation to a lesion is important. The GDG suggests further consideration of assessment mechanisms for the appropriateness of clip position either by radiology follow-up imaging or pathology. The GDG refers this to the QASDG for consideration.

Research Priorities

1. The GDG suggests improved research with higher quality of evidence from observational studies or where clip-marking is not routinely used considering the use of randomized studies for high quality evidence. The GDG notes that improved evidence on the effectiveness is very important. Some members of the GDG suggested that in the context of clinical equipoise randomized trials would provide higher quality evidence.
2. The GDG suggests further research on the local effects of clips and impacts on the psychological wellbeing for women and whether there is an impact of clips on breast cancer progression or recurrence.
3. The GDG suggests improved cost-effectiveness evidence on the use of clip-marking and comparing the economic impact of clip-marking on the need for additional procedures such as biopsies and surgeries. 4. The GDG suggests research on the use of clip-marking for palpable vs non-palpable lesions.

Evidence

Download the evidence profile

Assessment

Background

In order to reduce the number of deaths due to breast cancer, many countries have implemented screening programs for early detection of breast cancer in asymptomatic women. Therefore, the majority of the suspicious lesions detected by screening mammography are small non-palpable lesions, i.e. mass lesions or calcifications. If the lesion remains suspicious after imaging assessment, a biopsy has to be performed for clarification of the diagnosis and treatment planning, particularly to differentiate between benign and malignant lesions and decide if surgical removal is needed.
The detection of non-palpable lesions intraoperatively is difficult and usually directed by wire-marking of the lesion before surgery. However, sometimes the whole aberration is removed through needle biopsy, especially if VANCB is used. In case of breast cancer lesions, this could lead to a wider surgical excision of the quadrant where the lesion was located to assure that the area where the lesion was located is completely removed. This explains why it is helpful to mark these lesions or the lesion bed (when entirely removed) by a marker (clip) which can be applied during the initial biopsy procedure or in a second step.
A clip is a very small device (2-3 mm), usually made of hypoallergenic materials, that is visible in different imaging modalities (e.g. ultrasound, mammography, MRI) and anchored in the tissue either during the initial biopsy or in a second intervention. These clips are MRI compatible, easily seen in mammography and MRI, and some of them also with ultrasound.
Clip-marking is done in order to prove the correct location of the biopsy and to guide the surgeon for the excision. It is useful also for the follow up of imaging suspicious lesions with benign histology, as they can be easily identified. A mammography is performed after the placement of the clip to see its relation to the lesion.
Before surgery these clips are usually located by wire marking. In case of clip displacement the lesion itself could be wire marked instead of the clip. Exact positioning of the clips within or right next to the lesion helps to reduce the size of tissue to be surgically removed. Sometimes even several clips need to be placed at the margins of a lesion to show the total extent or the disease and to help the surgical approach. After removal of the tissue, a specimen radiography should be done to assure that the clip is included, indicating that the removed tissue includes the area of interest.
Modern treatment of breast cancer is adapted to tumor biology, size and stages. In palpable lesions neoadjuvant therapy is sometimes used for downsizing the tumor to increase the operability. In some cases mastectomy and/or axillary clearance could be avoided if the neoadjuvant therapy shows significant tumor response that leads to downstaging of the tumor. In large locally advanced breast cancer, neoadjuvant chemotherapy can enable operability of initially inoperable tumors (Kümmel S, 2014).
Sometimes tumors vanish completely under neoadjuvant chemotherapy in imaging (radiological complete response), but residual tumor cells may have remained and have to be removed by surgery. Clip marking in these cases is important in order to define the area of breast tissue which has to be removed. It can be placed during biopsy or in a second step before the start of chemotherapy or during the first cycles when the tumor is still visible.
The clip is also useful, especially for huge tumour specimens or mastectomies, in directing the pathologist to the tumour site to facilitate thorough sampling of tumour bed where tumour may not be visible macroscopically. If the lesion or pathologic area is widespread, more than one clip is sometimes used to define the extent of the disease, or to show in which areas of an extended lesion biopsies have been taken.
Disadvantages could be an incorrect placement of the clip either through wrong positioning or through movement of the clip in the tissue (13-20%). And, if performed in a second step, the risk of bleeding and infection could occur in very few cases.

Management of Conflicts of Interest (CoI): CoIs for all Guidelines Development Group (GDG) members were assessed and managed by the Joint Research Centre (JRC) following an established procedure in line with European Commission rules. GDG member participation in the development of the recommendations was restricted, according to CoI disclosure. Consequently, for this particular question, the following GDG members were recused from voting: Axel Gräwingholt, Peter Rabe and Kenneth Young; Miranda Langendam, as external expert, was also not allowed to vote, according to the ECIBC rules of procedure.. For more information please visit http://ecibc.jrc.ec.europa.eu/gdg-documents

Is the problem a priority?
Yes *
* Possible answers: ( No , Probably no , Probably yes , Yes , Varies , Don't know )
Research Evidence
The majority of the suspicious lesions detected by screening mammography are small non-palpable lesions, i.e. mass lesions or micro-calcifications .
After a biopsy is performed sometimes the lesion or calcifications are mostly removed, especially if vacuum assisted needle biopsy VANCB is used. Also when under neo adjuvant chemotherapy sometimes tumours vanish completely .
This explains why it is helpful to mark these lesions or the lesion bed (when entirely removed) by a marker (clip) which can be applied during the initial biopsy procedure or in a second step. Main objective of marking is to assure that the area where the lesion was located is completely removed when surgery is indicated.
Other utility could be to follow up of imaging suspicious lesions with benign histology, as they can be easily identified, and helping the pathologist for identification of áreas of interest in a big piece of surgery.
Clip marking can increase the cost and time of the diagnostic-intervention procedure at radiology setting and may have some minor complications (bleeding, pain…).
Additional Considerations

The GDG prioritised this question for the ECIBC.

How substantial are the desirable anticipated effects?
Large *
* Possible answers: ( Trivial , Small , Moderate , Large , Varies , Don't know )
Research Evidence

Outcomes№ of participants
(studies)
Follow up
Certainty of the evidence
(GRADE)
Relative effect
(95% CI)
Anticipated absolute effects* (95% CI)
Risk with no clip-marking after NCB/VANCBRisk difference with clipmarking
Number of patients with Close/Positive marginsa373
(1 observational study)
1

VERY LOW
b,c,d
RR 0.72
(0.41 to 1.25)
Study population
154 per 1.00043 fewer per 1.000
(91 fewer to 38 more)
Local breast recurrence (overall)
follow up: median 49 months
373
(1 observational study)
1

VERY LOW
b,d,e
RR 0.17
(0.04 to 0.70)
f
Study population
83 per 1.00069 fewer per 1.000
(80 fewer to 25 fewer)
Risk of recurrence
assessed with: Cox hazard multivariate model
follow up: median 49 months
f
373
(1 observational study)
1

VERY LOW
b,c
HR 0.27
(0.06 to 1.16)
Study population
83 per 1.00060 fewer per 1.000
(78 fewer to 13 more)
Mortalityg373
(1 observational study)
1

VERY LOW
b,d,e
RR 0.22
(0.09 to 0.56)
Study population
154 per 1.000120 fewer per 1.000
(140 fewer to 68 fewer)
Adverse events0
(0 studies)
--The study did not report this outcome.
  1. Oh JL, Nguyen G,Whitman GJ,Hunt KK,Yu TK,Woodward WA,et al.. Placement of radiopaque clips for tumor localization in patients undergoing neoadjuvant chemotherapy and breast conservation therapy.. Cancer; 2007.
  1. This is an operational definition of "final margin status". The status "close" means that the post-surgical specimen had less than 2 mm. of free cancer cells margin. Twelve (8.3%) and four (2.7%) women had close or positive margins respectively in the clip group whereas 23 (10.1%) and 12 (5.3%) of women had close and positive margins respectively in the group without clip.
  2. Since Oh 2007 included women with palpable lesions, for women with non-palpable lesions the confidence should be downrated due to indirectness.
  3. The margins of confidence intervals are wide, so there is not enough certainty about the real impact of the intervention.
  4. There is a serious risk of bias due to confounding factors; women without clip had a more advanced nodal disease (24.5%) than women with clip (13%). The neoadjuvant chemotherapy was not the same for everyone, only 53% received an additional taxane cycle. The reasons for not deployment of a clip in the control group were not clear. There were missing data regarding lymphovascular invasion status, it was unknown in 13% of the total population, it represented 18% of women with clip and 9% in women without a clip.
  5. The number of events was small. This fact may affect the robustness of estimations.
  6. This outcome is a supplementary measure for local breast recurrence. None of the 57 women with residual disease (RD) with a clip inserted presented local recurrence; compared with 11 of the 113 (9.7%) women with RD but without clip placement RR 0.09 (95%CI, 0.01-1.42). In women with pathological complete response (pCR) o near pCR there were no differences in local recurrences between clip and no-clip groups (, 2.47% and 6.48% respectively, RR 0.38 (95% CI 0.08- 1.8). Other three factors were independently associated with an increased hazard for local recurrence: T3-T4 clinical tumor size versus clinical stage 1-2 HR 2.66 (95% CI 1.03-6.86), Close or positive margins versus negative margins HR 3.37 (95% CI 1.13-10.07) and Modified Black Nuclear grade (MBNG) 3 versus MBNG 1 or 2 HR 3.86 (95% CI 1.13-13.22).
  7. Mortality rate was selected instead of overall survival,due incomplete data reporting.


Additional Considerations

The ESMO Clinical Practice Guideline for diagnosis, treatment and follow up considers that marking the tumour bed with clips in a standardised way facilitates accurate planning of the radiation boost field, if it is indicated (Senkus E et al., 2015).

In the absence of biopsy clips, clear margins were reported in only 31–62% of women after mammographically guided wire localization (Rahusen FD, 1999), (Kaufman CS, 1998), (Cangiarella J, 2000), but this number increased to 90% in the presence of biopsy clips (Nurko J, 2005).

The GDG judged that the desirable effects include 43 fewer cancers with positive margins and 69 fewer local recurrences. The GDG had less confidence in the mortality reduction estimate that was 120 fewer per 1,000 women, due to incongruence with the magnitude of effects for positive margins and local recurrences.
The GDG notes that it is important to have safe surgical margins to prevent recurrence. The GDG notes that the use of clip may allow smaller surgical resection of a tumour after neo-adjuvant chemotherapy.
The GDG noted that it could possibly result in the need for additional boundary biopsies or mastectomy in the absence of a clip.
The GDG also notes that the presence of a clip may facilitate identification of the original tumour bed by the pathologist.

The GDG agreed by consensus that the desirable effects were large.

How substantial are the undesirable anticipated effects?
Trivial *
* Possible answers: ( Large , Moderate , Small , Trivial , Varies , Don't know )
Research Evidence

Outcomes№ of participants
(studies)
Follow up
Certainty of the evidence
(GRADE)
Relative effect
(95% CI)
Anticipated absolute effects* (95% CI)
Risk with no clip-marking after NCB/VANCBRisk difference with clipmarking
Number of patients with Close/Positive marginsa373
(1 observational study)
1

VERY LOW
b,c,d
RR 0.72
(0.41 to 1.25)
Study population
154 per 1.00043 fewer per 1.000
(91 fewer to 38 more)
Local breast recurrence (overall)
follow up: median 49 months
373
(1 observational study)
1

VERY LOW
b,d,e
RR 0.17
(0.04 to 0.70)
f
Study population
83 per 1.00069 fewer per 1.000
(80 fewer to 25 fewer)
Risk of recurrence
assessed with: Cox hazard multivariate model
follow up: median 49 months
f
373
(1 observational study)
1

VERY LOW
b,c
HR 0.27
(0.06 to 1.16)
Study population
83 per 1.00060 fewer per 1.000
(78 fewer to 13 more)
Mortalityg373
(1 observational study)
1

VERY LOW
b,d,e
RR 0.22
(0.09 to 0.56)
Study population
154 per 1.000120 fewer per 1.000
(140 fewer to 68 fewer)
Adverse events0
(0 studies)
--The study did not report this outcome.
  1. Oh JL, Nguyen G,Whitman GJ,Hunt KK,Yu TK,Woodward WA,et al.. Placement of radiopaque clips for tumor localization in patients undergoing neoadjuvant chemotherapy and breast conservation therapy.. Cancer; 2007.
  1. This is an operational definition of "final margin status". The status "close" means that the post-surgical specimen had less than 2 mm. of free cancer cells margin. Twelve (8.3%) and four (2.7%) women had close or positive margins respectively in the clip group whereas 23 (10.1%) and 12 (5.3%) of women had close and positive margins respectively in the group without clip.
  2. Since Oh 2007 included women with palpable lesions, for women with non-palpable lesions the confidence should be downrated due to indirectness.
  3. The margins of confidence intervals are wide, so there is not enough certainty about the real impact of the intervention.
  4. There is a serious risk of bias due to confounding factors; women without clip had a more advanced nodal disease (24.5%) than women with clip (13%). The neoadjuvant chemotherapy was not the same for everyone, only 53% received an additional taxane cycle. The reasons for not deployment of a clip in the control group were not clear. There were missing data regarding lymphovascular invasion status, it was unknown in 13% of the total population, it represented 18% of women with clip and 9% in women without a clip.
  5. The number of events was small. This fact may affect the robustness of estimations.
  6. This outcome is a supplementary measure for local breast recurrence. None of the 57 women with residual disease (RD) with a clip inserted presented local recurrence; compared with 11 of the 113 (9.7%) women with RD but without clip placement RR 0.09 (95%CI, 0.01-1.42). In women with pathological complete response (pCR) o near pCR there were no differences in local recurrences between clip and no-clip groups (, 2.47% and 6.48% respectively, RR 0.38 (95% CI 0.08- 1.8). Other three factors were independently associated with an increased hazard for local recurrence: T3-T4 clinical tumor size versus clinical stage 1-2 HR 2.66 (95% CI 1.03-6.86), Close or positive margins versus negative margins HR 3.37 (95% CI 1.13-10.07) and Modified Black Nuclear grade (MBNG) 3 versus MBNG 1 or 2 HR 3.86 (95% CI 1.13-13.22).
  7. Mortality rate was selected instead of overall survival,due incomplete data reporting.


Additional Considerations

The GDG identified concern that certain clips may perform better than others with less migration from the original insertion site. Some studies assessing different types of clips found variation in the pathological success of surgery with clear margins from 60% to 89% (Fusco R, 2014).
The GDG judged that evidence on the different outcomes of different types of clips was outside of the context of this PICO question.

The GDG noted that some women may be concerned about having a clip in the breast and this may have impact on psychological wellbeing.
The GDG also notes that the materials (titanium and teflon coating) used in most clips are known to be safe from their use in other devices such as prostheses.

The GDG noted that if this is performed as a second intervention it requires recall and additional appointment for the patient and may cause side effects like bleeding, infection and hematoma.

The GDG judged the undesirable anticipated effects to be trivial.

What is the overall certainty of the evidence of effects?
Very low *
* Possible answers: ( Very low , Low , Moderate , High , No included studies )
Additional Considerations

The GDG notes that downgrading was performed for imprecision and risk of bias. Risk of bias was identified as serious because patients who are healthier or with less advanced disease may have received clip-marking.
The GDG notes that there is serious prescription bias that may introduce confounding in the results due to the lack of random allocation of treatment: patients who received the indication for clip marking may have smaller lesion and therefore have a better prognosis than those who did not receive clip marking, independently of the intervention.
The GDG notes that the results identifying benefits in this evidence for palpable lesion was assumed to be of greater magnitude in non-palpable lesions.

The GDG agreed by consensus that the overall certainty of the evidence of effects was very low.

Is there important uncertainty about or variability in how much people value the main outcomes?
Possibly important uncertainty or variability *
* Possible answers: ( Important uncertainty or variability , Possibly important uncertainty or variability , Probably no important uncertainty or variability , No important uncertainty or variability , No known undesirable outcomes )
Research Evidence
No systematic review was conducted.
Additional Considerations

The GDG agreed by consensus that there is possibly important uncertainty or variability in how people value the main outcomes.

Does the balance between desirable and undesirable effects favor the intervention or the comparison?
Probably favors the intervention *
* Possible answers: ( Favors the comparison , Probably favors the comparison , Does not favor either the intervention or the comparison , Probably favors the intervention , Favors the intervention , Varies , Don't know )
Additional Considerations

The GDG noted significant concern with potential confounding in the results that are presented (healthier women may be more likely to receive the clips). This decreased the confidence by the GDG that the balance of effects favours the intervention.

The GDG did not reach consensus and therefore voting was conducted.
Among 20 GDG members eligible to vote, results were: 1 member voted ‘favours the comparison’, 2 members voted ‘does not favour ‘either the intervention or comparison’, 13 members voted ‘probably favours the intervention’, 3 members voted ‘favours the intervention’, 1 member voted ‘don’t know’, and 1 member abstained.

How large are the resource requirements (costs)?
Moderate costs *
* Possible answers: ( Large costs , Moderate costs , Negligible costs and savings , Moderate savings , Large savings , Varies , Don't know )
Research Evidence
No systematic review was conducted.
Additional Considerations

Cost (estimated from information provided by members of the GDG):
Bard ultraclip (5 clips) 450 Euros (Hospital setting in Germany, 2017).
No research evidence was identified for the total resources required for clip-marking. However, one study reporting costs for MicroMark; Biopsy Ethicon Endo-Surgery clip was found. In this study the unitary clip cost was 64 US Dollar estimated from the Medicare perspective in 1997 in the USA (Liberman L, 2000).

The GDG judged that the cost of the clip on the basis of the data identified was expensive; however, the GDG considered that few women compared to the number of women examined would require a clip.

What is the certainty of the evidence of resource requirements (costs)?
Very low *
* Possible answers: ( Very low , Low , Moderate , High , No included studies )
Does the cost-effectiveness of the intervention favor the intervention or the comparison?
No included studies *
* Possible answers: ( Favors the comparison , Probably favors the comparison , Does not favor either the intervention or the comparison , Probably favors the intervention , Favors the intervention , Varies , No included studies )
Research Evidence
No systematic review was conducted.
Additional Considerations

The GDG noted that no evidence was identified, however, they noted that consideration of re-biopsy and re-surgery must be considered in the context of cost-effectiveness. The GDG considered that there may be benefits in reducing other interventions such as additional biopsies and surgeries, which would have significant reductions in costs.
The GDG noted that due to the costs of clips, clips may not be inserted if there are concerns over costs in certain settings or reimbursement of the costs of the clip.

What would be the impact on health equity?
Varies *
* Possible answers: ( Reduced , Probably reduced , Probably no impact , Probably increased , Increased , Varies , Don't know )
Research Evidence
No systematic review was conducted.
Additional Considerations

The GDG noted that equity would be impacted by whether the cost of the clip and insertion would be borne by the woman. If the woman is responsible for paying for the cost of the clip in certain settings equity may be reduced.
The GDG noted that if clips are available for everyone equity would probably increase.
The GDG agreed by consensus that the impact on health equity would therefore vary.

Is the intervention acceptable to key stakeholders?
Probably yes *
* Possible answers: ( No , Probably no , Probably yes , Yes , Varies , Don't know )
Research Evidence
No systematic review was conducted.
Additional Considerations

For women and providers the GDG judged that the intervention would probably be acceptable to implement.
For policy-makers and healthcare payers: there may be less acceptability due to the costs of the clip and insertion.

Is the intervention feasible to implement?
Probably yes *
* Possible answers: ( No , Probably no , Probably yes , Yes , Varies , Don't know )
Research Evidence
No systematic review was conducted.
Additional Considerations

The GDG judged that the intervention is relatively easy to train healthcare providers to perform and widely used in practice at the present time.
The GDG agreed by consensus that the intervention is probably feasible to implement.


References summary

  • Kaufman CS, Delbecq R Jacobson L., [Excising the reexcision: steriotactic core biopsy decreases need for reexcision of breast cancer.] World J Surg; 1998
  • Kümmel S, Holtschmidt J Loibl S., [Surgical treatment of primary breast cancer in the neoadjuvant setting] Br J Surg; 2014
  • Rahusen FD, Taets Van Amerongen AH Van Diese PJ et al, [Ultrasound- guided lumpectomy of nonpalpable breast cancers: a feasibility study looking at the accuracy of obtained margins] J Surg Oncol; 1999
  • Liberman L, Sama MP., [Cost-effectiveness of stereotactic 11-gauge directional vacuum-assisted breast biopsy] AJR Am J Roentgenol.; 2000
  • Nurko J, Mancino AT Whitacre E Edwards MJ., [Surgical benefits conveyed by biopsy site marking system using ultrasound localization] Am J Surg; 2005
  • Senkus E, Kyriakides S Ohno S Penault-Llorca F Poortmans P Rutgers E Zackrisson S Cardoso F, , , [ESMO Guidelines Committee. Primary breast cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up] Ann Oncol; 2015
  • Fusco R, Petrillo A Catalano O Sansone M Granata V Filice S et al, [Procedures for location of non-palpable breast lesions: a systematic review for the radiologist.] Breast Cancer; 2014
  • Cangiarella J, Gross J Symmans WF et al, [The incidence of positive margins with breast conserving therapy following mammotome biopsy for microcalcification.] J Surg Oncol; 2000

Bibliography

Background

  • Kümmel S, Holtschmidt J, Loibl S. Surgical treatment of primary breast cancer in the neoadjuvant setting. Br J Surg. 2014;101(8):912–24.
Evidence of effects
  • Senkus E, Kyriakides S, Ohno S, Penault-Llorca F, Poortmans P, Rutgers E, et al. Primary breast cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2015 Sep;26 Suppl 5:v8–30.
  • Rahusen FD, van Amerongen AHMT, van Diest PJ, Borgstein PJ, Bleichrodt RP, Meijer S. Ultrasound-guided lumpectomy of nonpalpable breast cancers: A feasibility study looking at the accuracy of obtained margins. J Surg Oncol. 1999;72(2):72–6.
  • Kaufman CS, Delbecq R, Jacobson L. Excising the reexcision: stereotactic core-needle biopsy decreases need for reexcision of breast cancer. World J Surg. 1998 Oct;22(10):1023–7; discussion 1028.
  • Cangiarella J, Gross J, Symmans WF, Waisman J, Petersen B, D’Angelo D, et al. The incidence of positive margins with breast conserving therapy following mammotome biopsy for microcalcification. J Surg Oncol. 2000 Aug;74(4):263–6.
  • Nurko J, Mancino AT, Whitacre E, Edwards MJ. Surgical benefits conveyed by biopsy site marking system using ultrasound localization. Am J Surg. 2005 Oct;190(4):618–22.
  • Oh JL, Nguyen G, Whitman GJ, Hunt KK, Yu T-K, Woodward WA, et al. Placement of radiopaque clips for tumor localization in patients undergoing neoadjuvant chemotherapy and breast conservation therapy. Cancer. 2007 Dec 1;110(11):2420–7.
  • Fusco R, Petrillo A, Catalano O, Sansone M, Granata V, Filice S, et al. Procedures for location of non-palpable breast lesions: a systematic review for the radiologist. Breast Cancer. 2014 Sep;21(5):522–31.
Values and preferences

No references

Economic Evidence
  • Liberman L, Sama MP. Cost-effectiveness of stereotactic 11-gauge directional vacuum-assisted breast biopsy. AJR Am J Roentgenol. 2000 Jul;175(1):53–8.
Acceptability

No references