Selective surgical localization of axillary lymph nodes containing metastases in patients with breast cancer: a prospective feasibility trial

Abstract

Importance: Nodal ultrasonography with needle biopsy of abnormal lymph nodes helps to define the extent of breast cancer before neoadjuvant chemotherapy. A clip can be placed to designate lymph nodes with documented metastases. Targeted axillary dissection or selective removal of lymph nodes known to contain metastases (clip-containing nodes) as well as sentinel lymph nodes (SLNs) may provide more accurate assessment of the pathologic response after neoadjuvant chemotherapy.

Objective: To determine the feasibility of image-guided localization and resection of lymph nodes containing known metastases.

Design, setting, and participants: This prospective feasibility trial performed at MD Anderson Cancer Center, Houston, Texas, included 12 patients with axillary nodal metastases confirmed by results of fine-needle aspiration biopsy who had a clip placed in the lymph node targeted for biopsy from December 1, 2012, through November 30, 2013.

Interventions: Preoperative targeting of the clip-containing lymph node under ultrasonographic guidance consisting of wire localization in 2 patients and placement of radioactive iodine I 125 (125I)-labeled seeds in 10 patients. Surgeons removed the localized lymph node before completion axillary lymph node dissection and used radiography of the specimen to confirm removal of the clip-containing lymph node and seed.

Main outcomes and measures: Confirmation of the removal of the clip-containing lymph node.

Results: Image-guided localization and selective removal were successful in all 12 patients. Five patients underwent SLN dissection in addition to removal of the clip-containing lymph node. Placement of 125I seeds did not interfere with lymphoscintigraphy or intraoperative identification of SLNs. In 4 of the 5 patients (80%), the clip-containing lymph node was one of the SLNs. Ten patients completed neoadjuvant chemotherapy before surgery. Of the 9 patients who underwent lymph node dissection, 4 (44%) had residual nodal disease after chemotherapy; all had disease identified in the clip-containing lymph node.

Conclusions and relevance: Axillary lymph nodes marked with a clip can be localized and selectively removed to accomplish targeted axillary dissection, which is technically possible after chemotherapy and is easily performed with other axillary surgery, such as SLN dissection. The ability to add selective removal of the clip-containing lymph nodes to SLN dissection may identify patients for limited nodal surgery after chemotherapy with increased accuracy for determining residual disease compared with SLN identification alone.

Figures

Figure 1

Ultrasound image of clip in lymph node after neoadjuvant chemotherapy

Figure 2

Images of node localization Figure 2A- Images of wire-localization of lymph node as well as intra-operative radiograph confirming that the clip-containing lymph node was removed. Figure 2B: Post-localization mammogram of I125 localization as well as intra-operative radiograph confirming removal

Figure 2

Images of node localization Figure 2A- Images of wire-localization of lymph node as well as intra-operative radiograph confirming that the clip-containing lymph node was removed. Figure 2B: Post-localization mammogram of I125 localization as well as intra-operative radiograph confirming removal

Figure 3

Lymphoscintigraphy performed after I125 seed placed in an axillary node (clipped node). These early images show no axillary radioisotope drainage at that point. However, since the I125 seed had already been placed, this demonstrates no interference in radioisotope imaging with the I125 seed.