Targeted Axillary Dissection Proposed for Breast Cancer Patients

Surgeons use clips to identify metastatic lymph nodes in breast cancer patients in preparation for axillary dissection

medwireNews: Axillary lymph nodes with metastases identified at ultrasound can be clipped and removed at surgery later, alongside sentinel lymph nodes (SLNs) where necessary, preliminary trial findings suggest.

This novel technique, termed targeted axillary dissection (TAD), allows restaging after chemotherapy of lymph nodes identified as metastatic at presentation, explain Abigail Caudle and colleagues, from the University of Texas MD Anderson Cancer Center in Houston, USA.

Between 2012 and 2013, 13 patients had a biopsy-confirmed lymph node clipped under real-time ultrasonography. Ten patients had received neoadjuvant chemotherapy, two had undergone surgery, and the final patient had refused axillary lymph node dissection.

The clipped node was identified before surgery by ultrasound in 10 patients using a radioactive iodine-labelled titanium seed and in two patients using a hook wire. Surgeons were able to dissect the clipped lymph node in all patients and confirm removal using radiography.

Five patients underwent SLN dissection, removing an average of 2.4 SLNs. The clipped lymph node was an SLN in four of these patients and the researchers note that the iodine-labelled seed did not interfere with SLN identification during dissection.

Of the nine patients who underwent axillary lymph node dissection and neoadjuvant chemotherapy, four had residual nodal disease, and all had disease within their clipped lymph node. Five patients were clear of metastases.

Writing in JAMA Surgery, the team describes TAD as “straightforward” for surgeons and feasible alongside other axillary procedures required by breast cancer patients.

“We propose that the selective removal of lymph nodes with confirmed metastases in addition to SLN dissection, that is, TAD, may improve the ability to accurately stage the axilla after chemotherapy”, the authors conclude.

“This study was designed to explore the feasibility of localizing clip-containing lymph nodes and was not designed to assess the [false-negative rate] of TAD, although a prospective study to assess this issue is now ongoing”, they add.


Caudle A, Yan W, Mittendorf E, et al. Selective surgical localization of axillary lymph nodes containing metastases in patients with breast cancer. A prospective feasibility trial. JAMA Surg 2014; Online first 17 December. doi:10.1001/jamasurg.2014.1086

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