AT Harris

Dimitrios Dardamanis

F Zagouri

Flora Zagouri

GC Zografos

George C. Zografos

George M. Filippakis

George Papadimitriou

Georgia Giannakopoulou

L Liberman

L Witek-Janusek

LE Hoorntje

Marios Panou

MS Dhillon

RL Birdwell

Sophia Stamouli

Theodoros N. Sergentanis

Journal of Medical Case Reports

English

PubMed

Springer - Publisher Connector

Psychiatric disorder associated with vacuum-assisted breast biopsy clip placement: a case report

BioMed CentralJournal of Medical Case Reports
ssOpen AcceCase report
Psychiatric disorder associated with vacuum-assisted breast biopsy 
clip placement: a case report
George C Zografos*1, Flora Zagouri1, Theodoros N Sergentanis1, 
Marios Panou1, Dimitrios Dardamanis1, Georgia Giannakopoulou1, 
George M Filippakis1, George Papadimitriou2 and Sophia Stamouli2
Address: 1Breast Unit, 1st Department of Propaedeutic Surgery, Hippokratio Hospital, School of Medicine, University of Athens, Vas Sofias Avenue, 
Athens 116 27, Greece and 2Department of Psychiatry, Eginition Hospital, University of Athens, Greece
Email: George C Zografos* - gzografo@med.uoa.gr; Flora Zagouri - florazagouri@yahoo.co.uk; 
Theodoros N Sergentanis - tsergentanis@yahoo.gr; Marios Panou - marios_panou@yahoo.gr; Dimitrios Dardamanis - dardaman@hol.gr; 
Georgia Giannakopoulou - ggiannakopoulou@gmail.com; George M Filippakis - gfilipp@hotmail.com; 
George Papadimitriou - breastunit_ipp@yahoo.gr; Sophia Stamouli - sstamouli@med.uoa.gr
* Corresponding author    
Abstract
Introduction: Vacuum-assisted breast biopsy is a minimally invasive technique that has been used increasingly in the
treatment of mammographically detected, non-palpable breast lesions. Clip placement at the biopsy site is standard
practice after vacuum-assisted breast biopsy.
Case presentation: We present the case of a 62-year-old woman with suspicious microcalcifications in her left breast.
The patient was informed about vacuum-assisted breast biopsy, including clip placement. During the course of taking the
patient's history, she communicated excellently, her demeanor was normal, she disclosed no intake of psychiatric
medication and had not been diagnosed with any psychiatric disorders. Subsequently, the patient underwent vacuum-
assisted breast biopsy (11 G) under local anesthesia. A clip was placed at the biopsy site. The pathological diagnosis was
of sclerosing adenosis. At the 6-month mammographic follow-up, the radiologist mentioned the existence of the metallic
clip in her breast. Subsequently, the woman presented complaining about "being spied [upon] by an implanted clip in [her]
breast" and repeatedly requested the removal of the clip. The patient was referred to the specialized psychiatrist of our
breast unit for evaluation. The Mental State Examination found that systematized paranoid ideas of persecutory type
dominated her daily routines. At the time, she believed that the implanted clip was one of several pieces of equipment
being used to keep her under surveillance, the other equipment being her telephone, cameras and television. Quite
surprisingly, she had never had a consultation with a mental health professional. The patient appeared depressed and her
insight into her condition was impaired. The prevalent diagnosis was schizotypal disorder, whereas the differential
diagnosis comprised delusional disorder of persecutory type, affective disorder with psychotic features or comorbid
delusional disorder with major depression.
Conclusion: This is the first report of a psychiatric disorder being brought to the fore using a vacuum-assisted breast
biopsy clip. Vacuum-assisted breast biopsy, and breast biopsy in general, represent a significant experience, encompassing
anxiety and pain; it may thus aggravate psychiatric conditions. Apart from these well-established factors, other aspects,
such as the clip, may occasionally become significant. In a modern breast unit, the evaluation of patients should be
multidisciplinary. A psychiatrist may be needed for optimal management of anxiety-related issues, as well as for the
detection of psychiatric disorders.
Published: 17 October 2008
Journal of Medical Case Reports 2008, 2:332 doi:10.1186/1752-1947-2-332
Received: 25 October 2007
Accepted: 17 October 2008
This article is available from: http://www.jmedicalcasereports.com/content/2/1/332
© 2008 Zografos et al; licensee BioMed Central Ltd. 
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 3
(page number not for citation purposes)
Journal of Medical Case Reports 2008, 2:332 http://www.jmedicalcasereports.com/content/2/1/332Introduction
Vacuum-assisted breast biopsy (VABB) is a minimally
invasive technique increasingly use in the diagnosis of
mammographically detected, non-palpable breast lesions
[1,2]. VABB is effective on lesions both with and without
microcalcifications [3,4].
It is standard practice to place a clip at the biopsy site at
the end of the procedure [5] in order to locate the biopsy
site in the case of subsequent malignancy. To date, the
only clip-related complications in the literature concern
clip migration [6,7].
This is the first report of an unusual sequela after clip
placement: the unexpected occurrence of a psychiatric
incident.
Case presentation
We present the case of a 62-year-old Caucasian woman
who is divorced and lives alone. Suspicious microcalcifi-
cations (BI-RADS 4A) were detected in her left breast. Sub-
sequently, VABB was scheduled; the patient was informed
about the procedure, including the clip placement, by the
surgeon performing the intervention. During the course
of taking the patient's history, she communicated excel-
lently, her demeanor was normal, she disclosed no intake
of psychiatric medication and had not been diagnosed
with any psychiatric disorders. According to the standard
practice of the unit, the patient gave her written informed
consent without any problem.
Subsequently, the patient underwent VABB (Mammo-
tome; Ethicon Endo-Surgery Inc, Johnson & Johnson,
Cincinnati, OH, USA). VABB was performed on a digital
prone table (Mammotest, Fischer Imaging, Denver, CO,
USA) using 11-gauge vacuum probes, under local anesthe-
sia. The examination proceeded according to a standard
protocol to ensure quality control. A radiologist was
present to assist in the targeting. A mammogram of the
specimens taken after VABB confirmed the excision of
microcalcifications. A clip was placed at the biopsy site.
The pathological diagnosis was sclerosing adenosis.
At the 6-month mammographic follow-up, the radiolo-
gist mentioned the existence of the metallic clip in her
breast. Subsequently, the woman presented to our breast
unit complaining about "being spied [upon] by an
implanted clip in [her] breast" and repeatedly requested
the removal of the clip.
From the interaction with the nursing and medical staff, it
was apparent that she was irritable, dysphoric, very suspi-
cious and verbally aggressive. The patient was referred to
the specialized psychiatrist of our breast unit for evalua-
tion.
The Mental State Examination found the existence of sys-
tematized paranoid ideation of persecutory type dominat-
ing the daily routines of the patient. At the time, she
believed that the implanted clip was one of several pieces
of equipment being used to keep her under surveillance.
During the psychiatric interview, the patient revealed
symptoms originating 11 years previously, at the time of
her divorce, when she felt that her ex-husband was paying
some religious organizations to spy on her, especially
when she was at home. She stated that this was being
done through the telephone, cameras, television and
other technologically advanced equipment using electro-
magnetic waves. The patient had never consulted a mental
health professional.
The thought content of the patient was also positive for
ideas of reference and her speech was of normal rhythm,
rate and quantity.
The patient appeared depressed, but occasionally she
expressed anger about what was happening to her and she
reported anhedonia, helplessness, hopelessness and
decreased concentration. She had no suicidal thoughts.
As far as her social life was concerned, she reported having
gradually decreased her social contacts over the past 10
years, as she believed that all of her friends were under sur-
veillance as well and that this seriously disrupted their
lives. The patient did not have any disturbances in percep-
tion, or in her thought processes. She did not have any
insight into her psychiatric condition.
It should also be kept in mind that the patient has never
met criterion A of schizophrenia. In conclusion, with
respect to chronicity, the paranoid ideation first appeared
approximately 10 years ago and since then has been
chronic.
The prevalent diagnosis was schizotypal disorder encom-
passing paranoid or bizarre ideas not amounting to true
delusions, anhedonia, disaffection and a tendency toward
social withdrawal; the differential diagnosis comprised
delusional disorder of persecutory type, affective disorder
with psychotic features or delusional disorder and comor-
bid major depression.
Discussion
This is the first report of a psychiatric disorder being
brought to the fore from the use of a VABB clip. Indeed,
this is a rather rare case: more than 800 VABB procedures
have been performed in our breast unit and no compara-
ble cases have been noted.Page 2 of 3
(page number not for citation purposes)
Journal of Medical Case Reports 2008, 2:332 http://www.jmedicalcasereports.com/content/2/1/332VABB represents a significant experience. Its psychological
impact on the patient is noteworthy, as documented at a
psychoendocrinological level [8]. In addition, pain in
VABB is a major parameter, which merits study and eval-
uation [9]. Fear and anxiety before the biopsy, the biopsy
procedure per se, and the pain experienced all represent
multiple contributory factors exerting significant psycho-
logical pressure upon the patient, irrespective of the out-
come. Unexpected aggravating factors, such as the clip,
might also be present. Thus, exacerbation of underlying
psychiatric disorders, after either a malignant or a benign
finding, may be expected; this possibility should not be
underestimated. Unfortunately, the literature has not
shed light upon this subject.
Nevertheless, for the optimal interpretation of the above,
some limitations have to be addressed. Given the presence
of ideation in the past, the emergence of paranoid ideas
may not be completely unexpected. In addition, in this
patient, the clip seemed to play the major triggering role;
in a broader context, however, other parts of the breast
biopsy-related experience may similarly be proven impor-
tant. At any rate, the nature of this case report is one of
observation and suggestion; in the absence of systematic
studies assessing the incidence of triggered psychiatric
conditions, caution is warranted in drawing conclusions
about the possibility of breast biopsies exacerbating psy-
chiatric conditions or bringing them to the fore.
All in all, it seems quite surprising that a breast-related
procedure was the stimulus for the diagnosis of the psy-
chiatric disorder. The evaluation of patients in a modern
breast unit should be multidisciplinary. A psychiatrist
may be required for the optimal management of anxiety-
related issues as well as for the detection of psychiatric dis-
orders.
Conclusion
This is the first report of a psychiatric disorder being
brought to the fore as a result of the use of a VABB clip.
VABB, and breast biopsy in general, represents a signifi-
cant experience, encompassing anxiety and pain; it may
thus aggravate psychiatric conditions. Apart from these
well-established factors, other aspects, such as the clip,
may occasionally become significant. In a modern breast
unit, the evaluation of patients should be multidiscipli-
nary. A psychiatrist may be required for the optimal man-
agement of anxiety-related issues, as well as for the
detection of psychiatric disorders.
Abbreviations
VABB: vacuum-assisted breast biopsy
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
GCZ supervised and performed the VABB, critically
revised the manuscript for important intellectual content
and gave final approval of the version to be published. FZ
wrote the manuscript and reviewed the international liter-
ature. TNS wrote the manuscript and interpreted the case
findings with respect to the international literature. MP
participated in the interpretation of the psychiatric find-
ings and contributed to the review of the literature. DD
performed the VABB. GG made the radiological evalua-
tion and assisted in the VABB; both DD and GG helped in
editing the manuscript. GMF performed the VABB and
participated in the evaluation of the case findings. GP
revised the manuscript for important intellectual content
and contributed to the psychiatric evaluation. SS per-
formed the Mental State Examination and revised the
manuscript for important intellectual content.
Consent
Written informed consent was obtained from the patient
and her next-of-kin for publication of this case report and
any accompanying images. A copy of the written consent
is available for review by the Editor-in-Chief of this jour-
nal.
Acknowledgements
Efstratios Patsouris is thanked for revising the manuscript for important 
intellectual content. We would like to thank the President of the Hellenic 
Anticancer Institute, E Frangoulis, for his contribution to the technical 
organization of the breast unit.
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Crossref

Clip migration within 8 days of 11-gauge vacuumassisted stereotactic breast biopsy: case report. Radiology

DW: Mammotome biopsy: impact on preoperative diagnosis rate. Clin Radiol

HL: Psychologic stress, reduced NK cell activity, and cytokine dysregulation in women experiencing diagnostic breast biopsy. Psychoneuroendocrinology

Is zero underestimation feasible? Extended vacuum-assisted breast biopsy in solid lesions – a blind study. World J Surg Oncol

Minimizing underestimation rate of microcalcifications excised via vacuum-assisted breast biopsy: a blind study. Breast Cancer Res Treat

Rinkes IH: Vacuumassisted breast biopsy: a critical review.

RJ: Clip or marker migration 5–10 weeks after stereotactic 11-gauge vacuum-assisted breast biopsy: report of two cases. Radiology

Stereotactic core biopsy.

Zografos GC: Pain in different methods of breast biopsy: Emphasis on vacuum-assisted breast biopsy. Breast

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Psychiatric disorder associated with vacuum-assisted breast biopsy clip placement: a case report

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