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Targeted Axillary Dissection
Ana Paula Refinetti, MD; Dalliah M. Black, MD; Henry M. Kuerer, MD, PhD
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KEY FACTS

  • Terminology

    • Preprocedure

      • Procedure

        • Outcomes

          TERMINOLOGY

          • Abbreviations

            • Targeted axillary dissection (TAD)
          • Definitions

            • TAD: Selective localization and excision of clipped, biopsy-proven metastatic axillary lymph node (LN) in addition to sentinel lymph node (SLN) biopsy with goal of removing at least 3 nodes
            • Clip-node localization: Performed by placement of radioactive I-125 seed, magnetic seed, radiofrequency identification tag, or hookwire under US guidance to target clipped node
            • Completion axillary lymph node dissection (ALND): Level I and II axillary node dissection performed after TAD
            • Nodal pathologic complete response (pCR): Conversion to pathologic negative node after neoadjuvant chemotherapy (NAC)
              • Treatment changes should be evident at pathology
            • Dual tracer technique: Injection of both radioisotope (Tc-99m sulfur colloid) and blue dye
          • Background

            • ACOSOG Z0011: Omission of ALND in patients with T1/T2 tumors, clinically node-negative with 1-2 positive SLNs undergoing segmental mastectomy and whole-breast irradiation without axillary tangents
              • 97% of patients received adjuvant systemic therapy
              • 10-year cumulative incidence of locoregional recurrence similar in ALND and SLN biopsy arms (6.2% and 5.3%, respectively)
            • ACOSOG Z1071: SLN biopsy after NAC in breast cancer patients presenting with biopsy-proven axillary node metastasis; false-negative rate (FNR): 12.6%
              • FNR of SLN biopsy 6.8% when clipped node included in SLN biopsy specimen vs. 19.0% when not
              • Use of dual tracer ↓ FNR to 10.8% vs. 20.3% with single tracer
              • FNR ↓ with number of SLNs evaluated: 31.5% with 1 SLN, 21% with 2 SLNs, and 9.1% with > 3 SLNs
              • Clip-containing node was SLN in 63% of cases on specimen radiograph
              • Clip-containing node was in ALND specimen in 20% of cases
            • MD Anderson prospective study
              • 23% of biopsy-proven metastatic clipped nodes were not SLN
              • FNR of TAD = 2% vs. FNR of 10% for excision of SLN only after NAC

          PREPROCEDURE

          • Indications

            • Contraindications

              • Preprocedure Imaging

                • Getting Started

                  PROCEDURE

                  • Patient Position/Location

                    • Equipment Preparation

                      • Procedure Steps

                        • Findings and Reporting

                          • Alternative Procedures/Therapies

                            POST PROCEDURE

                            • Expected Outcome

                              • Things To Do

                                OUTCOMES

                                • Problems

                                  • Complications

                                    Selected References

                                    1. Hartmann S et al: Wire localization of clip-marked axillary lymph nodes in breast cancer patients treated with primary systemic therapy. Eur J Surg Oncol. 44(9):1307-11, 2018
                                    2. Le-Petross HT et al: Axillary ultrasound identifies residual nodal disease after chemotherapy: results from the American College of Surgeons Oncology Group Z1071 Trial (Alliance). AJR Am J Roentgenol. 210(3):669-76, 2018
                                    3. Giuliano AE et al: Effect of axillary dissection vs no axillary dissection on 10-year overall survival among women with invasive breast cancer and sentinel node metastasis: The ACOSOG Z0011 (Alliance) Randomized Clinical Trial. JAMA. 318(10):918-26, 2017
                                    4. Nguyen TT et al: Localizing the clipped node in patients with node-positive breast cancer treated with neoadjuvant chemotherapy: early learning experience and challenges. Ann Surg Oncol. 24(10):3011-16, 2017
                                    5. Caudle AS et al: Improved axillary evaluation following neoadjuvant therapy for patients with node-positive breast cancer using selective evaluation of clipped nodes: implementation of targeted axillary dissection. J Clin Oncol. 34(10):1072-8, 2016
                                    6. Giuliano AE et al: Locoregional recurrence after sentinel lymph node dissection with or without axillary dissection in patients with sentinel lymph node metastases: long-term follow-up from the American College of Surgeons Oncology Group (Alliance) ACOSOG Z0011 Randomized Trial. Ann Surg. 264(3):413-20, 2016
                                    7. Shin K et al: Radiologic mapping for targeted axillary dissection: needle biopsy to excision. AJR Am J Roentgenol. 207(6):1372-79, 2016
                                    8. Boughey JC et al: Factors affecting sentinel lymph node identification rate after neoadjuvant chemotherapy for breast cancer patients enrolled in ACOSOG Z1071 (Alliance). Ann Surg. 261(3):547-52, 2015
                                    9. Caudle AS et al: Selective surgical localization of axillary lymph nodes containing metastases in patients with breast cancer: a prospective feasibility trial. JAMA Surg. 150(2):137-43, 2015
                                    10. Boughey JC et al: Tumor biology correlates with rates of breast-conserving surgery and pathologic complete response after neoadjuvant chemotherapy for breast cancer: findings from the ACOSOG Z1071 (Alliance) Prospective Multicenter Clinical Trial. Ann Surg. 260(4):608-14; discussion 614-6, 2014
                                    11. Boughey JC et al: Sentinel lymph node surgery after neoadjuvant chemotherapy in patients with node-positive breast cancer: the ACOSOG Z1071 (Alliance) clinical trial. JAMA. 310(14):1455-61, 2013
                                    12. Kuerer HM, Sahin AA, Hunt KK, Newman LA, Breslin TM, Ames FC, Ross MI, Buzdar AU, Hortobagyi GN, Singletary SE. Incidence and impact of documented eradication of breast cancer axillary lymph node metastases before surgery in patients treated with neoadjuvant chemotherapy. Ann Surg. 230(1):72-8, 1999.
                                    Related Anatomy
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                                    Related Differential Diagnoses
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                                    References
                                    Tables

                                    Tables

                                    KEY FACTS

                                    • Terminology

                                      • Preprocedure

                                        • Procedure

                                          • Outcomes

                                            TERMINOLOGY

                                            • Abbreviations

                                              • Targeted axillary dissection (TAD)
                                            • Definitions

                                              • TAD: Selective localization and excision of clipped, biopsy-proven metastatic axillary lymph node (LN) in addition to sentinel lymph node (SLN) biopsy with goal of removing at least 3 nodes
                                              • Clip-node localization: Performed by placement of radioactive I-125 seed, magnetic seed, radiofrequency identification tag, or hookwire under US guidance to target clipped node
                                              • Completion axillary lymph node dissection (ALND): Level I and II axillary node dissection performed after TAD
                                              • Nodal pathologic complete response (pCR): Conversion to pathologic negative node after neoadjuvant chemotherapy (NAC)
                                                • Treatment changes should be evident at pathology
                                              • Dual tracer technique: Injection of both radioisotope (Tc-99m sulfur colloid) and blue dye
                                            • Background

                                              • ACOSOG Z0011: Omission of ALND in patients with T1/T2 tumors, clinically node-negative with 1-2 positive SLNs undergoing segmental mastectomy and whole-breast irradiation without axillary tangents
                                                • 97% of patients received adjuvant systemic therapy
                                                • 10-year cumulative incidence of locoregional recurrence similar in ALND and SLN biopsy arms (6.2% and 5.3%, respectively)
                                              • ACOSOG Z1071: SLN biopsy after NAC in breast cancer patients presenting with biopsy-proven axillary node metastasis; false-negative rate (FNR): 12.6%
                                                • FNR of SLN biopsy 6.8% when clipped node included in SLN biopsy specimen vs. 19.0% when not
                                                • Use of dual tracer ↓ FNR to 10.8% vs. 20.3% with single tracer
                                                • FNR ↓ with number of SLNs evaluated: 31.5% with 1 SLN, 21% with 2 SLNs, and 9.1% with > 3 SLNs
                                                • Clip-containing node was SLN in 63% of cases on specimen radiograph
                                                • Clip-containing node was in ALND specimen in 20% of cases
                                              • MD Anderson prospective study
                                                • 23% of biopsy-proven metastatic clipped nodes were not SLN
                                                • FNR of TAD = 2% vs. FNR of 10% for excision of SLN only after NAC

                                            PREPROCEDURE

                                            • Indications

                                              • Contraindications

                                                • Preprocedure Imaging

                                                  • Getting Started

                                                    PROCEDURE

                                                    • Patient Position/Location

                                                      • Equipment Preparation

                                                        • Procedure Steps

                                                          • Findings and Reporting

                                                            • Alternative Procedures/Therapies

                                                              POST PROCEDURE

                                                              • Expected Outcome

                                                                • Things To Do

                                                                  OUTCOMES

                                                                  • Problems

                                                                    • Complications

                                                                      Selected References

                                                                      1. Hartmann S et al: Wire localization of clip-marked axillary lymph nodes in breast cancer patients treated with primary systemic therapy. Eur J Surg Oncol. 44(9):1307-11, 2018
                                                                      2. Le-Petross HT et al: Axillary ultrasound identifies residual nodal disease after chemotherapy: results from the American College of Surgeons Oncology Group Z1071 Trial (Alliance). AJR Am J Roentgenol. 210(3):669-76, 2018
                                                                      3. Giuliano AE et al: Effect of axillary dissection vs no axillary dissection on 10-year overall survival among women with invasive breast cancer and sentinel node metastasis: The ACOSOG Z0011 (Alliance) Randomized Clinical Trial. JAMA. 318(10):918-26, 2017
                                                                      4. Nguyen TT et al: Localizing the clipped node in patients with node-positive breast cancer treated with neoadjuvant chemotherapy: early learning experience and challenges. Ann Surg Oncol. 24(10):3011-16, 2017
                                                                      5. Caudle AS et al: Improved axillary evaluation following neoadjuvant therapy for patients with node-positive breast cancer using selective evaluation of clipped nodes: implementation of targeted axillary dissection. J Clin Oncol. 34(10):1072-8, 2016
                                                                      6. Giuliano AE et al: Locoregional recurrence after sentinel lymph node dissection with or without axillary dissection in patients with sentinel lymph node metastases: long-term follow-up from the American College of Surgeons Oncology Group (Alliance) ACOSOG Z0011 Randomized Trial. Ann Surg. 264(3):413-20, 2016
                                                                      7. Shin K et al: Radiologic mapping for targeted axillary dissection: needle biopsy to excision. AJR Am J Roentgenol. 207(6):1372-79, 2016
                                                                      8. Boughey JC et al: Factors affecting sentinel lymph node identification rate after neoadjuvant chemotherapy for breast cancer patients enrolled in ACOSOG Z1071 (Alliance). Ann Surg. 261(3):547-52, 2015
                                                                      9. Caudle AS et al: Selective surgical localization of axillary lymph nodes containing metastases in patients with breast cancer: a prospective feasibility trial. JAMA Surg. 150(2):137-43, 2015
                                                                      10. Boughey JC et al: Tumor biology correlates with rates of breast-conserving surgery and pathologic complete response after neoadjuvant chemotherapy for breast cancer: findings from the ACOSOG Z1071 (Alliance) Prospective Multicenter Clinical Trial. Ann Surg. 260(4):608-14; discussion 614-6, 2014
                                                                      11. Boughey JC et al: Sentinel lymph node surgery after neoadjuvant chemotherapy in patients with node-positive breast cancer: the ACOSOG Z1071 (Alliance) clinical trial. JAMA. 310(14):1455-61, 2013
                                                                      12. Kuerer HM, Sahin AA, Hunt KK, Newman LA, Breslin TM, Ames FC, Ross MI, Buzdar AU, Hortobagyi GN, Singletary SE. Incidence and impact of documented eradication of breast cancer axillary lymph node metastases before surgery in patients treated with neoadjuvant chemotherapy. Ann Surg. 230(1):72-8, 1999.