Radio‐isotope occult lesion localization (ROLL) techniques to identify the clipped node for targeted axillary dissection (TAD) in breast cancer

Abstract

Background Breast cancer patients having neoadjuvant systemic therapy (NAST) who have a positive (clipped) lymph node (CN) at presentation must have that CN removed to assess pathologic response at later surgery. Multiple techniques for localizing the CN have been described. We describe a novel ROLL‐based approach. Methods Consecutive patients between 2018 and 2021, having NAST with biopsy proven positive lymph node(s), had a clip placed into the most abnormal node(s). At later surgery sentinel node and occult lesion localization (SNOLL) was performed with peritumoral radio‐isotope (99mTc‐Nanoscan) injected under ultrasound guidance. Planar and single photon emission computed tomography (SPECT–CT) images were used to identify sentinel nodes (SN) and the CN. If the CN was not a SN, then additional 99mTc‐Nanoscan was injected directly into the CN using ultrasound (ROLL). TAD was performed using a gamma probe and intra‐operative specimen radiographs to confirm excision of the CN. Results Thirty‐eight patients underwent TAD. 20/38 CNs were SNs on SPECT‐CT. 17/38 CN were localized separately. 1/38 CN was not a SN and could not be identified on ultrasound. The remaining 37/38 (97.4%) of the CNs were removed intra‐operatively. Pathological complete response in the axilla was identified in 18/38 cases. The CN was the only positive node in 10/20 cases. In 18/20 cases the CN contained the largest tumour deposit. Conclusion Combining SNOLL and ROLL techniques to identify the SNs and, if separate, the CN for TAD is very reliable and logistically robust, especially for units already performing peritumoral lymphoscintigraphy.

Systematic review of targeted axillary dissection in node-positive breast cancer treated with neoadjuvant systemic therapy: variation in type of marker and timing of placement

“…In three of five studies 52–54 , the clipped TLN was injected with 99m Tc-labelled macroaggregated albumin under ultrasound guidance 1 day before surgery. In the other two 55 , 56 , either 99m Tc-labelled Nanoscan tracer or 99m Tc-labelled nanocolloid was injected (peritumorally or periareolarly) to localize the SLN by single-photon emission CT (SPECT)/CT on the day of surgery or 1 day before, and to determine whether the clipped TLN was an SLN. If not, either 99m Tc-labelled Nanoscan tracer was injected into the clipped TLN, or a wire was placed under ultrasound guidance to enable excision of the clipped TLN.…”

Current bi‐national attitudes towards targeted axillary dissection

“…11 The Australian and New Zealand (ANZ) acceptance of TAD has been evident with institutional experiences published, recent integration into the Breast Quality Audit (BQA) recordable fields, and it being incorporated into the University of Sydney Graduate Certificate of Advanced Breast Surgery course. 12,13 It is hypothesised that TAD is predominantly performed at specialist Breast Oncology institutionsincluding those with BreastSurgANZ Post Fellowship Trainees (PFTs). However, the extent of TAD acceptance across ANZ is unknown.…”