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
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
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
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
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
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
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
Shin K et al: Radiologic mapping for targeted axillary dissection: needle biopsy to excision. AJR Am J Roentgenol. 207(6):1372-79, 2016
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
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
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
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
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
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
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
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
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
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
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
Shin K et al: Radiologic mapping for targeted axillary dissection: needle biopsy to excision. AJR Am J Roentgenol. 207(6):1372-79, 2016
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
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
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
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
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.
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