Retained Biopsy Clips Do Not Compromise Surgical Margins
A retained biopsy clip left in the breast after cancer excision does not compromise surgical margins—in fact, clips are intentionally designed to remain in the excision cavity to guide radiation therapy planning and ensure adequate field coverage. 1
The Intended Purpose of Biopsy Clips
Biopsy clips are meant to be left behind after breast cancer excision as a standard practice:
Localization titanium clips may be left in the excision cavity to aid in placement of irradiation boost volume and to ensure adequate coverage with tangential fields, especially for lateral and medial lesions. 1
The Society of Surgical Oncology recommends marking the tumor bed with clips to facilitate accurate planning of the radiation boost field and demarcate the tumor bed for future imaging studies. 2
After neoadjuvant chemotherapy, in cases of complete radiologic response, the center of the tumor bed should be removed, including any radiologic clips—demonstrating that clips serve as intentional markers rather than contaminants. 1
Clips Guide Surgical Excision, Not Compromise It
The evidence demonstrates that clips improve rather than compromise margin adequacy:
Strong recommendation exists for clip placement at the time of diagnostic or research biopsy, as it may be difficult to identify the correct area in the breast or ensure appropriate excision without a clip. 1
Clip placement into biopsied lymph nodes may improve the accuracy of post-neoadjuvant sentinel lymph node biopsy. 1
Proper specimen orientation by the surgeon using sutures, clips, or other markers is essential for accurate margin assessment. 2
The Real Concern: Clip Migration or Loss
The actual clinical problem is not retained clips compromising margins, but rather clip migration or loss affecting surgical accuracy:
Clip migration after vacuum-assisted core biopsy can be clinically significant, with mean migration distance of 13.5 mm (range 0-78.3 mm), and 21.5% of clips migrating more than 20 mm from the targeted site. 3
Intraoperative loss of metallic clips occurs in approximately 3.8% of cases, likely due to inadvertent removal with suction devices during surgery. 4
When clips migrate significantly or are lost, surgeons cannot rely on needle localization of the clip alone and must use alternative techniques such as hematoma-directed ultrasound-guided localization. 3
Clinical Algorithm for Managing Biopsy Clips
When the clip is properly positioned:
- Leave the clip in the excision cavity after tumor removal 1
- Use the clip to guide radiation boost field planning 1
- Confirm clip presence on specimen radiograph to verify complete excision of the target area 1
When clip migration is suspected:
- Obtain post-biopsy mammogram to document clip position relative to the original biopsy site 3
- If clip has migrated >20 mm, consider hematoma-directed ultrasound guidance rather than relying solely on clip localization 3
- Compare pre- and post-biopsy imaging to identify the true biopsy cavity location 4
When clip is absent on specimen radiograph:
- Repeated inability to locate the clip after accurate preoperative localization suggests the clip was lost intraoperatively (removed with suction), not missed during surgery 4
- Confirm absence on postoperative mammogram 4
- The biopsy cavity itself (not the clip) should guide margin assessment 3
Margin Assessment Remains Independent of Clip Presence
Surgical margins are determined by histologic examination of tumor-to-ink distance, not by clip location:
Margins are reported as positive when ink touches invasive cancer or DCIS, regardless of clip position. 2
The specimen radiograph and margin status are complementary means of assessing completeness of excision, but the radiograph alone is not adequate to determine complete excision. 1
Histologically negative margins do not guarantee complete removal because DCIS may grow discontinuously, independent of clip location. 1