title: Selective surgical localization of axillary lymph nodes containing metastases in patients with breast cancer: a prospective feasibility trial.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  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.
  
  
  METHODS
  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.
  
  
  METHODS
  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
  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.
authors.affiliation: Department of Surgical Oncology, MD Anderson Cancer Center, The University of Texas, Houston.
authors.forename: Abigail S
authors.initials: AS
authors.lastname: Caudle
authors.affiliation: Department of Diagnostic Imaging, MD Anderson Cancer Center, The University of Texas, Houston.
authors.forename: Wei T
authors.initials: WT
authors.lastname: Yang
authors.affiliation: Department of Surgical Oncology, MD Anderson Cancer Center, The University of Texas, Houston.
authors.forename: Elizabeth A
authors.initials: EA
authors.lastname: Mittendorf
authors.affiliation: Department of Surgical Oncology, MD Anderson Cancer Center, The University of Texas, Houston.
authors.forename: Daliah M
authors.initials: DM
authors.lastname: Black
authors.affiliation: Department of Surgical Oncology, MD Anderson Cancer Center, The University of Texas, Houston.
authors.forename: Rosa
authors.initials: R
authors.lastname: Hwang
authors.affiliation: Department of Biostatistics, MD Anderson Cancer Center, The University of Texas, Houston.
authors.forename: Brian
authors.initials: B
authors.lastname: Hobbs
authors.affiliation: Department of Surgical Oncology, MD Anderson Cancer Center, The University of Texas, Houston.
authors.forename: Kelly K
authors.initials: KK
authors.lastname: Hunt
authors.affiliation: Department of Pathology, MD Anderson Cancer Center, The University of Texas, Houston.
authors.forename: Savitri
authors.initials: S
authors.lastname: Krishnamurthy
authors.affiliation: Department of Surgical Oncology, MD Anderson Cancer Center, The University of Texas, Houston.
authors.forename: Henry M
authors.initials: HM
authors.lastname: Kuerer
mesh_terms: D000328:Adult; D000368:Aged; D001365:Axilla; D001943:Breast Neoplasms / Q000000981:diagnostic imaging* / Q000473:pathology / Q000601:surgery*; D018270:Carcinoma, Ductal, Breast / Q000000981:diagnostic imaging* / Q000556:secondary* / Q000601:surgery; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D008197:Lymph Node Excision / Q000379:methods*; D008297:Male; D008408:Mastectomy; D008875:Middle Aged; D020360:Neoadjuvant Therapy; D009367:Neoplasm Staging; D011446:Prospective Studies; D025321:Surgery, Computer-Assisted; D014463:Ultrasonography