Clip Placement Indication in Breast Cancer
Clip placement in the breast tumor is indicated for all patients anticipated to receive neoadjuvant/preoperative systemic therapy, regardless of tumor stage, to demarcate the tumor bed for post-chemotherapy surgical management. 1
Primary Tumor Clip Placement
When to Place Clips in the Breast Tumor
Core biopsy with placement of image-detectable marker(s) must be performed at diagnosis in any patient planned for neoadjuvant therapy to mark the original tumor location before treatment-induced shrinkage or complete response. 1
Clip placement should occur at the time of diagnostic or research biopsy, ideally before starting any systemic therapy. 1
If a clip was not placed initially and the tumor shows significant response after the first cycle(s) of chemotherapy suggesting possible complete response, it is imperative to place a clip immediately—even if mastectomy is planned—as it may become impossible to identify the correct surgical area after treatment completion. 1
Rationale for Tumor Clip Placement
Complete or near-complete clinical responses are common with neoadjuvant therapy, making the original tumor location difficult or impossible to identify at surgery without marking. 1
The clips aid in post-chemotherapy resection of the original tumor area, ensuring adequate surgical margins and appropriate radiation field planning. 1
Neoadjuvant therapy increases breast conservation rates, but accurate localization of the pre-treatment tumor bed is essential for oncologic safety. 1
Axillary Lymph Node Clip Placement
When to Place Clips in Lymph Nodes
Clinically positive axillary lymph nodes (cN+) that are sampled by FNA or core biopsy must be clipped with an image-detectable marker at the time of biopsy. 1
Clinically negative axillary lymph nodes that appear suspicious on ultrasound should be sampled by FNA or core biopsy and clipped if positive. 1
The clipped positive lymph nodes must be removed at definitive surgery if the biopsy was positive before neoadjuvant therapy. 1
Evidence Supporting Nodal Clip Placement
The practice of clipping positive nodes significantly improves surgical staging accuracy after neoadjuvant therapy:
Removal of the clipped node reduces the false-negative rate of sentinel lymph node biopsy from 10.1% to 1.4% after neoadjuvant chemotherapy. 2
The clipped node itself has a false-negative rate of only 4.2% for detecting residual disease. 2
In 23% of cases, the clipped node is not retrieved as a sentinel lymph node, and in some of these cases the clipped node contains metastasis while sentinel nodes are negative—meaning disease would be missed without targeted removal of the clipped node. 2, 3
Studies show that when the clipped node is confirmed to be within the sentinel node specimen, the false-negative rate is 6.8%, compared to 19.0% when the clipped node is found only in the completion axillary dissection specimen. 3
Stage-Specific Considerations
Early Stage Disease (Stage I-IIB)
Clip placement is indicated for patients with clinical stage I, IIA, or IIB disease (T1-T3, N0-N1) who desire breast preservation and will receive neoadjuvant therapy. 1
Even for small tumors (T1), if neoadjuvant therapy is planned, clips should be placed as complete responses can occur regardless of initial tumor size. 1
Locally Advanced Disease (Stage IIIA-IIIC)
For inoperable, non-inflammatory locally advanced disease (clinical stages IIIA [except T3N1M0], IIIB, or IIIC), clip placement is essential as neoadjuvant therapy is standard and may produce dramatic responses. 1
These patients have higher likelihood of complete or near-complete responses, making clip placement critical for surgical planning. 1
Common Pitfalls and How to Avoid Them
Pitfall: Delaying clip placement until after starting chemotherapy. The tumor may shrink significantly or disappear radiologically after even one cycle, making accurate placement impossible. Place clips at initial diagnostic biopsy. 1
Pitfall: Assuming mastectomy patients don't need clips. Even with planned mastectomy, clips are imperative for identifying the tumor bed for pathologic assessment and potential radiation planning. 1
Pitfall: Not clipping positive lymph nodes. Without nodal clips, targeted axillary dissection cannot be performed, resulting in higher false-negative rates (10.1% vs 1.4%) and potentially missed residual disease. 2
Pitfall: Removing too much tumor tissue during biopsy. Oversampling with wide-gauge needles interferes with response assessment. Obtain adequate but not excessive tissue, and place the clip in the remaining tumor. 1
Pitfall: Failure to document clip placement. Communication between radiology, surgery, and pathology is essential to ensure clips are identified and the marked areas are appropriately excised. 1