Targeted axillary dissection of carbon‐tattooed metastatic lymph nodes in combination with post–neo‐adjuvant sentinel lymph node biopsy using 1% methylene blue in breast cancer patients

Abstract

Staging the axilla post-NACT (neo-adjuvant chemotherapy) by sentinel lymph node biopsy (SLNB) may allow patients to avoid undergoing axillary lymph node dissection (ALND) 1 ; however, its optimum usage is still questionable. Three prospective clinical trials (ACOSOG Z1071, SENTINA, and SN FNAC) evaluated the accuracy of SLNB post-NACT described identification rates (IR) ranging from 87.6%-92.9%. Overall, false-negative rates (FNRs) were higher than 10%, and all those trials did not achieve their primary end point.Reduction of the FNR (12.6%-9.8%) could be achieved in those patients with a normal axillary ultrasound (US) after NACT and three or more removed SLNs. [2][3][4] Methylene blue (MB) 1% is used for SLNB in node-negative (-ve) early breast cancer with IR and FNR comparable to other blue dyes or radioactive isotopes at a very low cost 5The natural concept that the best LN to evaluate response to NACT is the pathologic proven LN before starting NACT has been previously emphasized. Marking +ve LNs pre-NACT and then removing them together with SLNB post-NACT was described as targeted axillary dissection (TAD). Applying a marker clip for +ve LNs under US guidance and then marking these LNs post-NACT with radioactive I 125 seeds achieved IR of 96.7%, concordance among clipped LNs and SLNs reached 91%. 6 Caudle et al, 2016, used similar technique with IR of clipped nodes of 97.6%. The marked LN was recognized as SLN in 77% of cases. 7 Donker et al, 2015, used only radioactive I 125 seed for marking +ve ALNs pre-NACT with IR of 97%. 8 Tattooing of biopsied ALNs using sterile black carbon suspension (Spot TM ) was tried as a technique for TAD. Spot TM is FDA-approved carbon-based marker for presurgical colonic tattooing and remains in the site for months. An equivalent to Spot TM is also available, BlackEye ink. Choy et al, 2015, used suspended carbon particles (Spot TM ) to mark +ve ALNs in 28 cases. Overall, IR was 96.4%. 9 Park et al, in 2018, used Charcotrace TM for 20 cases pre-NACT, IR was 100% during surgery. Concordance among tattooed LNs and SLNs was described to be 75%. 10

Surgical Management of the Axilla in Clinically Node-Positive Breast Cancer Patients Converting to Clinical Node Negativity through Neoadjuvant Chemotherapy: Current Status, Knowledge Gaps, and Rationale for the EUBREAST-03 AXSANA Study

“…In this subgroup, three out of 33 patients with residual axillary disease had not been correctly identified by TAD, resulting in a FNR of 9.1%. A similar FNR of 8.3% was reported from the only other study on FNR in carbon solution-based TAD [50].…”

Diagnostic accuracy of de‐escalated surgical procedure in axilla for node‐positive breast cancer patients treated with neoadjuvant systemic therapy: A systematic review and meta‐analysis

“…On the contrary, patients with high axillary metastatic burden (more than 4 abnormal nodes on ultrasound before NST, ≥cN2) were less likely to have TLNs corresponding to SLNs 37,59 . In our study, the coincidence rate of TLNs and SLNs ranged from 35.7% to 87.5%, among whom groups with high overlap rates and high initial cN1 rates tended to achieve superior IFRs and FNRs 24,44 . We considered this could be explained from the aspect of anatomy.…”

“…The third method, suspended carbon particles, was a liquid black dye for labeling nodes at no risk of dislodgement and with a low potential for causing foreign body reactions 43 . It showed unexpectedly excellent detection rates without any positioning support, with most studies reporting success rates as high as 100% 43‐47 . One study in the carbon group presented an extremely low IFR of 63.3%, probably due to the difference in physician operating techniques between participating institutions, suggesting learning curves should be considered when planning future researches 48 .…”

Magnetic Seed (Magseed) Localisation in Breast Cancer Surgery: A Multicentre Clinical Trial

“…Several studies investigated lymph node localisation with a radioactive iodine-125 seed with promising results of 97–100% successful lymph node retrieval [13]. Khallaf et al [14] used carbon for lymph node localisation in 20 patients after NAC with 95% identification rate. According to the results mentioned above, the Magseed lymph node localisation seems to be comparable to other localisation methods, even if up-to-date evidence is scarce and further studies are needed.…”