Axillary Evaluation with Targeted Axillary Dissection using Ultrasound-visible Clips after Neoadjuvant Chemotherapy for Patients with Node-Positive Breast Cancer

Abstract

Background: Targeted Axillary Dissection (TAD) can decrease the False-Negative Rate (FNR) of sentinel lymph node biopsy after Neoadjuvant Chemotherapy (NAC). This study aimed to investigate the accuracy of TAD using ultrasound-visible clips for axillary staging, with the secondary aims of assessing the ultrasound identification rate and localization technique of the clipped node.Methods: This prospective study was conducted using patients with clinically T1-3, N1, 2, M0 breast cancer undergoing NAC followed by surgery. For targeted lymph node biopsy, a Hydromark or a UltraCore Twirl clip was placed in a biopsyproven node. During the surgery, the clipped node was removed with sentinel lymph nodes and palpable nodes.Results: A total of 26 patients were enrolled. The median number of lymph nodes removed with TAD was four (range, 2-10). The FNR of TAD was 0% (0/16). Ultrasound identified the clipped node marked with the UltraCore Twirl in 100% (12/12) and with the Hydromark in 92.9% (13/14, p = ns) of the respective cases. Wire localization combined with dye injection successfully removed the node marked with the UltraCore Twirl in 100% (12/12), whereas the node marked with the Hydromark was removed by localization with fluorescence technique, wire-and-fluorescence technique, and wire-and-dye injection in 50% (1/2), 100% (2/2), and 80% (8/10) of the cases, respectively (p = ns).Conclusions: TAD predicted post-NAC axillary nodal status with an FNR of 0%. Labelling the positive node with a USvisible clip and localizing it with a wire and dye allowed successful TAD.