PMC9875611_01
Relative size and shape of a SmartClip
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The SmartClip  is a fiducial composed of a non-radioactive ferrite core with parylene C coating, measuring 8 mm in length and 1.4 mm in diameter (Figure 1).
Images of single-view bracketed SmartClip  localization of the malignant mass and calcifications using a superior approach in the craniocaudal view. (A). Tomosynthesis facilitates targeting and insertion of the applicator to the posterior margin of the calcifications, (B), and deployment of the Pink SmartClip  (pink arrow), (C), immediately followed by placement of the Green SmartClip  applicator (green arrow) along the anterior margin, D
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First, the bracketed localization of the malignant mass and calcifications in the left breast was performed using tomosynthesis guidance utilizing a single-view superior approach (Figure 2). Repeat tomosynthesis breast images confirmed the bevel of the SmartClip  applicator in the targeted position (Figure 2B) and the SmartClip  was deployed (Figure 2C). Repeat tomosynthesis images confirmed the position of the applicator tip (Figure 2D) and the Green SmartClip  was deployed.
Ultrasound images during SmartClip  localization of the tagged left axillary lymph node containing a Tumark Vision  marker (solid arrow). (A). The applicator is placed into the lymph node with the bevel adjacent to the marker, (B), and the Purple SmartClip  is deployed (dashed arrow), C
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Tumark  Vision tissue marker placed at the time of prior biopsy (Figure 3A) (Hologic, Inc.; Marlborough, MA). The patient was positioned supine in the ultrasound biopsy suite with her left arm overhead. The SmartClip  was deployed once the applicator tip was visualized within the node (Figure 3B, C).
Bracketed residual left breast cancer with Pink (square) SmartClip  posterior to the lesion, Green (circle) SmartClip  anterior to the lesion, and Purple (triangle) SmartClip  targeting the node. The patient's larger breast size overlapped the axilla at rest
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Display" (HUD) screen was mounted pre-operatively on the drape pole to the patient's right, across from the operating surgeons. Detection of the SmartClips  was confirmed on the EnVision View (Figure 4) of the HUD. HUD demonstrated that the Pink and Green SmartClips  were close from an anterior perspective as they appeared superimposed in position over the detection cassette under the pad beneath the patient's back (Figure 4). However, they were separated in depth, marking the anterior and posterior extent.
The orientation of the patient is depicted by the small gray circle "head" relative to the gray boxed "torso" central within the concentric rings. Using the foot pedal, the Purple (triangle) SmartClip  was chosen for localized resection. The left margin indicates the relative depth (anterior to posterior) of the electrocautery tip to the targeted SmartClip . The target circles indicate planar distance from the target in centimeters. The numeral in the lower right indicates the direct distance in millimeters to the chosen SmartClip  target:here 3 mm. The pictured electrocautery tip is pointing to the Purple SmartClip  within the tagged node
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After the incision was made and extended through the dermis, the location of the SmartClip  tagged node was easily checked for depth and relative location on a regular basis since the electrocautery and Navigator are attached (Figure 5).
Resection of a SmartClip -bracketed lesion allows the surgeon to toggle between the two SmartClip  images on the HUD; the SmartClips  are actually physically placed along the posterior and anterior aspects of the lesion in this case. Relative distance to the other SmartClip  can be visualized as denoted by the small geometric figure that is not concentrically located. A denotes the posterior Pink SmartClip  and B denotes the anterior Green SmartClip
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After making the incision for the lumpectomy, the surgeon toggled the foot pedal to alternate the focus on the HUD screen between the Pink (square) SmartClip  and the Green (circle) SmartClip  (Figure 6 A, B), specifically to reflect which SmartClip  was closest in the dissection of this bracketed specimen.