Breast cancer is the most frequently diagnosed malignancy and the second most common cause of cancer-related death in women worldwide [8].
Despite recent advances in screening mammography, locally advanced breast cancer remains a challenging clinical problem [9] accounting for 50–70% of patients with breast cancer presenting for treatment [10].
LABC includes large tumors (>5 cm or T3), tumors of any size that involve skin and/or chest wall (cT4a-c or Stage IIIB), tumors with fixed or matted axillary lymph nodes or tumors clinically detected in the ipsilateral internal mammary nodes without involvement of axillary lymph nodes (N2), and tumors that involve ipsilateral infraclavicular, supraclavicular, or internal mammary lymph nodes with axillary lymph nodes involvement (cN3 or Stage IIIC) [11].
Nineteen out of the 20 patients (95%) in this study were diagnosed invasive duct carcinoma close to the results of Masroor et al. [12] who stated that 88% of the cases were invasive duct carcinoma.
Untch et al. [13] stated that although one of the major benefits of neoadjuvant chemotherapy is the possibility to assess the clinical response of the primary tumor and reduction in its size which can range from a minimal response to clinical complete response (cCR), the later effects often make it difficult for surgeons and pathologists to clearly identify the former tumor area and ensure clear resection margins. The insertion of a clip at the time of diagnosis can ensure the identification of the tumor area after multiple cycles of chemotherapy and improve the accuracy of the surgical excision and subsequent pathological assessment after neoadjuvant therapy. Similar to McLaughlin [14], whose study stated that surgeons considering neoadjuvant chemotherapy and the possibility of BCT must ensure the tumor is properly marked with a clip before the start of therapy to allow localization and removal of the tumor bed in the event of a cCR.
The use of a marker clip placed in the tumor bed has been reported as a safe and inexpensive technique that allows for subsequent localization of the tumor bed before surgical resection in patients who are receiving neoadjuvant chemotherapy [4].
The current research is a prospective study to evaluate the localization of breast malignant masses in patients who received neoadjuvant chemotherapy and will undergo conservative breast surgery by using clip and wire marker.
In the present study, 40% of patients (8/20) with breast cancer were in the age group from 46 to 55 years in agreement with Siegel et al. [15] study where breast cancer was most common in the age group 40–59 years. However, Mir and Singh [16] reported in their epidemiological study that the highest frequency of breast cancer occurred between 45 and 49 years.
In this study, all patients received neoadjuvant chemotherapy. Tumor response was assessed by comparing the imaging findings after two cycles of chemotherapy. In concordance with OH et al. [17], clip placement was done if lesion decreased to 50% of its size or reached 2 cm in diameter as the possibility of complete disappearance is anticipated.
In our study, wire localization was done on radiopaque clip in 18 cases with non-palpable lesions at the end of neoadjuvant chemotherapy for accurate and easy approach by the surgeon to the tumor bed and in the other 2 patients. The mass was clinically palpable and there was no need for wire localization.
In concordance with our study, Chan et al. [18] and Sharek et al. [19] stated that the most widely adopted approach radiographic wire localization immediately before surgical resection is currently the accepted standard of care for preoperative localization of nonpalpable breast lesions.
While Ramos et al. [20], reported that wire-guided localization is the standard procedure but is a time-consuming procedure because it requires the expertise of an experienced radiologist and it is uncomfortable and usually stressful for the patient. Moreover, it may be associated with a high number of positive margins, increases in local recurrences, inadvertent wire displacement during patient transfer, surgical positioning, or during postprocedure mammography and a poor cosmetic result while intraoperative ultrasound (IOUS) excision, an attractive and recommendable practice as an alternative to other excision techniques in patients with complete clinical responses after NACT as wire localization.
In our study, as in studies conducted by Youn et al. [4] and Masroor et al. [12], there was no evidence of clip migration during postprocedural follow-up, preoperative final follow-up, and in surgical specimens. Moreover, no complication related to the clip insertion was noted during the study period, and no patient complained of heat sensation or pain.
Achieving negative surgical margins is a hallmark of successful BCT because this is associated with a lower rate of local recurrence [14].
In the current study, the specimens were examined radiologically by mammography to ensure clip and wire presence and to assess the margin. The clip and wire retrieval was positive in all cases similar to Masroor et al. [12] study. The margin was free radiologically in 17 out of the 18 patients underwent wire localization with accuracy of 95%. These results were close to Ihrai et al. [21], results that stated specimen mammography allowed the achievement of negative margins in 93.5% of the cases.
