Wire localization of clip-marked axillary lymph nodes in breast cancer patients treated with primary systemic therapy

Hartmann, Steffi; Reimer, Toralf; Gerber, Bernd; Stubert, Johannes; Stengel, Bernd; Stachs, Angrit

doi:10.1016/j.ejso.2018.05.035

Cited by 94 publications

(72 citation statements)

References 25 publications

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“…We faced a challenge in US-guided dual-localization technique suggested in this study. Although clips were easily placed in all cases, without significant complications, 21% of clips were not clearly visible on US performed after NAC, as demonstrated previously in several studies [21, 35]. Although the hyperechoic (metallic) clip is easily visible against the background hypoechoic cortex of the axillary node before NAC, the cortex becomes thinner as NAC proceeds, which hinders differentiating the clip from echogenic fat strands.…”

Section: Discussionmentioning

confidence: 70%

“…The National Cancer Comprehensive Network guidelines recommend clip placement before NAC, because CN biopsy along with SN biopsy reduces the FNR [20]. However, invisibility of CNs during surgery needs further localization technique with materials of iodine seed or wire [21]. Iodine seeds have been suggested by studies in the US and Netherlands, but they are not available in many other countries.…”

Section: Discussionmentioning

confidence: 99%

“…Use of such seeds also requires a special device, with the accompanying regulations of handling and disposal of radioactive materials. The wire has also been used for localizing axillary nodes in some prospective studies [14, 21, 22]. It induces pain and discomfort in patients prior to their surgical removal.…”

Section: Discussionmentioning

confidence: 99%

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Ultrasound-guided dual-localization for axillary nodes before and after neoadjuvant chemotherapy with clip and activated charcoal in breast cancer patients: a feasibility study

Kim

et al. 2019

BMC Cancer

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Background We report on our experience of ultrasound (US)-guided dual-localization for axillary nodes before and after neoadjuvant chemotherapy (NAC) with clip and activated charcoal to guide axillary surgery in breast cancer patients. Methods Between November 2017 and May 2018, a dual-localization procedure was performed under US guidance for the most suspicious axillary nodes noted at initial staging (before NAC, with clip) and restaging (after NAC, with activated charcoal) in 28 cytologically proven node-positive breast cancer patients. Patients underwent axillary sampling or dissection, which involved removing not only the sentinel nodes (SNs), but also clipped nodes (CNs) and tattooed nodes (TNs). Success (or failure) rates of biopsies of SNs, CNs, and TNs and inter-nodal concordance rates were determined. Sensitivities for the individual and combined biopsies were calculated. Results SN biopsy failed in four patients (14%), whereas the CN biopsy failed in one patient (4%). All TNs were identified in the surgical field. Concordance rates were 79% for CNs–TNs, 63% for CNs–SNs, and 58% for TNs–SNs. Sensitivity for SN, CN, and TN biopsy was 73%, 67%, and 67%, respectively. Sensitivity was 80% for any combination of biopsies (SN plus CN, SN plus TN, SN plus CN plus TN). Conclusions US-guided dual-localization of axillary nodes before and after NAC with clip and activated charcoal was a feasible approach that might facilitate more reliable nodal staging with less-invasive strategies in node-positive breast cancer patients.

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Section: Discussionmentioning

confidence: 70%

Section: Discussionmentioning

confidence: 99%

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Ultrasound-guided dual-localization for axillary nodes before and after neoadjuvant chemotherapy with clip and activated charcoal in breast cancer patients: a feasibility study

Kim

et al. 2019

BMC Cancer

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“…Accurate identification of the clip remained a crucial factor in determining the precise placement of the localizing agent or skin mark and hence the success of clipped node removal. However, ultrasound visibilities of clips in the axillary lymph nodes post‐NACT have been suboptimal with reported rates of 72%‐83.3% . This is because chemotherapy can cause shrinkage and fibrosis of the lymph nodes resulting in loss of hypoechogenicity of the lymph nodes upon ultrasound, which makes it challenging to identify the tiny clips against a background of echogenic fat.…”

Section: Discussionmentioning

confidence: 99%

“…The removal rate of SMART in our study was comparable to the rates reported for other localization agents. The radioactive seed, wire and tattooing techniques had a removal rate of nodes of 97%-100%, 6,20 71%-100%, 11,13,21,22 and 83%-100%, 16,17 respectively.…”

Section: Discussionmentioning

confidence: 99%

Initial results of a novel technique of clipped node localization in breast cancer patients postneoadjuvant chemotherapy: Skin Mark clipped Axillary nodes Removal Technique (SMART trial)

et al. 2020

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Purpose Removal of clipped nodes can improve sentinel node biopsy accuracy in breast cancer patients post neoadjuvant chemotherapy (NACT). However, the current methods of clipped node localization have limitations. We evaluated the feasibility of a novel clipped node localization and removal technique by preoperative skin marking of clipped nodes and removal by the Skin Mark clipped Axillary nodes Removal Technique (SMART), with the secondary aim of assessing the ultrasound visibility of the various clips in the axillary nodes after NACT. Methods Invasive breast cancer patients with histologically metastatic axillary nodes, going for NACT, and ≤3 sonographically abnormal axillary nodes were recruited. All abnormal nodes had clips inserted. Patients with M1 disease were excluded. Post‐NACT, patients underwent SMART and axillary lymph node dissection. Specimen radiography and pathological analyses were performed to confirm the clipped node presence. Success, complication rates of SMART, and ultrasound visibility of the various clips were assessed. Results Twenty‐five clipped nodes in 14 patients underwent SMART without complications. The UltraCor Twirl, hydroMARK, UltraClip Dual Trigger, and UltraClip were removed in 13/13 (100%), 7/9 (77.8%), 1/2 (50.0%), and 0/1 (0%), respectively (P = .0103) with UltraCor Twirl having the best ultrasound visibility and removal rate. Removal of three clipped nodes in the same patient (P = .0010) and deeply seated clipped nodes (P = .0167) were associated with SMART failure. Conclusion Skin Mark clipped Axillary nodes Removal Technique is feasible for removing clipped nodes post‐NACT, with 100% observed success rate, using the UltraCor Twirl marker in patients with <3 not deeply seated clipped nodes. Larger studies are needed for validation.

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Nodal Recurrence in Patients With Node-Positive Breast Cancer Treated With Sentinel Node Biopsy Alone After Neoadjuvant Chemotherapy—A Rare Event

et al. 2021

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IMPORTANCEProspective trials have demonstrated sentinel lymph node (SLN) false-negative rates of less than 10% when 3 or more SLNs are retrieved in patients with clinically node-positive breast cancer rendered clinically node-negative with neoadjuvant chemotherapy (NAC). However, rates of nodal recurrence in such patients treated with SLN biopsy (SLNB) alone are unknown because axillary lymph node dissection (ALND) was performed in all patients, limiting adoption of this approach. OBJECTIVE To evaluate nodal recurrence rates in a consecutive cohort of patients with clinically node-positive (cN1) breast cancer receiving NAC, followed by a negative SLNB using a standardized technique, and no further axillary surgery. DESIGN, SETTING, AND PARTICIPANTSFrom November 2013 to February 2019, a cohort of consecutively identified patients with cT1 to cT3 biopsy-proven N1 breast cancer rendered cN0 by NAC underwent SLNB with dual tracer mapping and omission of ALND if 3 or more SLNs were identified and all were pathologically negative. Metastatic nodes were not routinely clipped, and localization of clipped nodes was not performed. The study was performed in a single tertiary cancer center.INTERVENTION Omission of ALND in patients with cN1 breast cancer after NAC if 3 or more SLNs were pathologically negative. MAIN OUTCOME AND MEASURESThe primary outcome was the rate of nodal recurrence among patients with cN1 breast cancer treated with SLNB alone after NAC. RESULTSOf 610 patients with cN1 breast cancer treated with NAC, 555 (91%) converted to cN0 and underwent SLNB; 234 (42%) had 3 or more negative SLNs and had SLNB alone. The median (IQR) age of these 234 patients was 49 (40-58) years; median tumor size was 3 cm; 144 (62%) were ERBB2 (formerly HER2)-positive, and 43 (18%) were triple negative. Most (212 [91%]) received doxorubicin-based NAC; 205 (88%) received adjuvant radiotherapy (RT), and 164 (70%) also received nodal RT. At a median follow-up of 40 months, there was 1 axillary nodal recurrence synchronous with local recurrence in a patient who refused RT. Among patients who received RT (n = 205), there were no nodal recurrences.CONCLUSIONS AND RELEVANCE This cohort study found that in patients with cN1 disease rendered cN0 with NAC, with 3 or more negative SLNs with SLNB alone, nodal recurrence rates were low, without routine nodal clipping. These findings potentially support omitting ALND in such patients.

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Wire localization of clip-marked axillary lymph nodes in breast cancer patients treated with primary systemic therapy

Abstract: Ultrasound-guided wire localization of the target lymph node is not suitable for clinical practice because of limitations regarding clip visibility and selective surgical preparation of the target lymph node. Further prospective evaluation of alternative techniques is needed.

Cited by 94 publications

References 25 publications

Ultrasound-guided dual-localization for axillary nodes before and after neoadjuvant chemotherapy with clip and activated charcoal in breast cancer patients: a feasibility study

Ultrasound-guided dual-localization for axillary nodes before and after neoadjuvant chemotherapy with clip and activated charcoal in breast cancer patients: a feasibility study

Initial results of a novel technique of clipped node localization in breast cancer patients postneoadjuvant chemotherapy: Skin Mark clipped Axillary nodes Removal Technique (SMART trial)

Nodal Recurrence in Patients With Node-Positive Breast Cancer Treated With Sentinel Node Biopsy Alone After Neoadjuvant Chemotherapy—A Rare Event

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