Abstract
BackgroundSelective removal of initially tumor-positive axillary lymph nodes in breast cancer patients who underwent neoadjuvant systemic treatment (NST) improves the accuracy of nodal staging and provides the opportunity for more tailored axillary treatment. This study evaluated whether radioguided occult lesion localization (ROLL) of clip-marked lymph nodes is feasible in clinical practice.MethodsPrior to NST, a clip marker was placed inside a proven tumor-positive lymph node in all breast cancer patients (cTis-4N1-3 M0). After NST, technetium-99m-labeled macroaggregated albumin was injected in the clip-marked lymph nodes. The next day, these ROLL-marked nodes were selectively removed at surgery to evaluate the pathological response of the axilla.ResultsThirty-seven patients (38 axillae) underwent clip insertion. After NST, the clip was visible by ultrasound in 36 procedures (95%). In the other two patients, the ROLL-node injection was performed in a sonographically suspicious unclipped node (1), and near the clip under computed tomography guidance (1). Initial surgery successfully identified the ROLL-marked node with clip in 33 procedures (87%). Removed specimens in the other five procedures contained only the sonographically suspicious tumor-positive unclipped node (1), a node with signs of complete response but no clip (2), a clip without node (1), and tissue without node nor clip, and a second successful ROLL-node procedure was performed (1). Overall, 10 ROLL-marked nodes had no residual disease.ConclusionsThis study demonstrates that the ROLL procedure to identify clip-marked lymph nodes is feasible. This facilitates selective removal at surgery and may tailor axillary treatment in patients treated with NST.
Highlights
Selective removal of initially tumor-positive axillary lymph nodes in breast cancer patients who underwent neoadjuvant systemic treatment (NST) improves the accuracy of nodal staging and provides the opportunity for more tailored axillary treatment
Pathological complete response of axillary lymph nodes in patients who were node-positive prior to NST is associated with improved disease-free survival [2] and potentially minimizes the need for axillary lymph node dissection (ALND) [3]
Sentinel lymph node (SLN) biopsy has become the standard of care for nodal staging of clinically nodenegative breast cancer patients [7], sentinel lymph node (SLN) biopsy after NST is less reliable in patients who had tumor-positive axillary nodes prior to NST
Summary
Selective removal of initially tumor-positive axillary lymph nodes in breast cancer patients who underwent neoadjuvant systemic treatment (NST) improves the accuracy of nodal staging and provides the opportunity for more tailored axillary treatment. Neoadjuvant systemic treatment (NST) is applied for tumor downstaging to facilitate breast-conserving therapy in patients with node-negative or node-positive disease [1]. Pathological complete response (pCR) of axillary lymph nodes in patients who were node-positive prior to NST is associated with improved disease-free survival [2] and potentially minimizes the need for axillary lymph node dissection (ALND) [3]. Sentinel lymph node (SLN) biopsy has become the standard of care for nodal staging of clinically nodenegative breast cancer patients [7], SLN biopsy after NST is less reliable in patients who had tumor-positive axillary nodes prior to NST. A more accurate nodal staging method is preferred to tailor further axillary treatment
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