title: Improved Axillary Evaluation Following Neoadjuvant Therapy for Patients With Node-Positive Breast Cancer Using Selective Evaluation of Clipped Nodes: Implementation of Targeted Axillary Dissection.
abstract: OBJECTIVE
  Placing clips in nodes with biopsy-confirmed metastasis before initiating neoadjuvant therapy allows for evaluation of response in breast cancer. Our goal was to determine if pathologic changes in clipped nodes reflect the status of the nodal basin and if targeted axillary dissection (TAD), which includes sentinel lymph node dissection (SLND) and selective localization and removal of clipped nodes, improves the false-negative rate (FNR) compared with SLND alone.
  
  
  METHODS
  A prospective study of patients with biopsy-confirmed nodal metastases with a clip placed in the sampled node was performed. After neoadjuvant therapy, patients underwent axillary surgery and the pathology of the clipped node was compared with other nodes. Patients undergoing TAD had SLND and selective removal of the clipped node using iodine-125 seed localization. The FNR was determined in patients undergoing complete axillary lymphadenectomy (ALND).
  
  
  RESULTS
  Of 208 patients enrolled in this study, 191 underwent ALND, with residual disease identified in 120 (63%). The clipped node revealed metastases in 115 patients, resulting in an FNR of 4.2% (95% CI, 1.4 to 9.5) for the clipped node. In patients undergoing SLND and ALND (n = 118), the FNR was 10.1% (95% CI, 4.2 to 19.8), which included seven false-negative events in 69 patients with residual disease. Adding evaluation of the clipped node reduced the FNR to 1.4% (95% CI, 0.03 to 7.3; P = .03). The clipped node was not retrieved as an SLN in 23% (31 of 134) of patients, including six with negative SLNs but metastasis in the clipped node. TAD followed by ALND was performed in 85 patients, with an FNR of 2.0% (1 of 50; 95% CI, 0.05 to 10.7).
  
  
  CONCLUSIONS
  Marking nodes with biopsy-confirmed metastatic disease allows for selective removal and improves pathologic evaluation for residual nodal disease after chemotherapy.
authors.affiliation: All authors: The University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Abigail S
authors.initials: AS
authors.lastname: Caudle
authors.affiliation: All authors: The University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Wei T
authors.initials: WT
authors.lastname: Yang
authors.affiliation: All authors: The University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Savitri
authors.initials: S
authors.lastname: Krishnamurthy
authors.affiliation: All authors: The University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Elizabeth A
authors.initials: EA
authors.lastname: Mittendorf
authors.affiliation: All authors: The University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Dalliah M
authors.initials: DM
authors.lastname: Black
authors.affiliation: All authors: The University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Michael Z
authors.initials: MZ
authors.lastname: Gilcrease
authors.affiliation: All authors: The University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Isabelle
authors.initials: I
authors.lastname: Bedrosian
authors.affiliation: All authors: The University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Brian P
authors.initials: BP
authors.lastname: Hobbs
authors.affiliation: All authors: The University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Sarah M
authors.initials: SM
authors.lastname: DeSnyder
authors.affiliation: All authors: The University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Rosa F
authors.initials: RF
authors.lastname: Hwang
authors.affiliation: All authors: The University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Beatriz E
authors.initials: BE
authors.lastname: Adrada
authors.affiliation: All authors: The University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Simona F
authors.initials: SF
authors.lastname: Shaitelman
authors.affiliation: All authors: The University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Mariana
authors.initials: M
authors.lastname: Chavez-MacGregor
authors.affiliation: All authors: The University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Benjamin D
authors.initials: BD
authors.lastname: Smith
authors.affiliation: All authors: The University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Rosalind P
authors.initials: RP
authors.lastname: Candelaria
authors.affiliation: All authors: The University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Gildy V
authors.initials: GV
authors.lastname: Babiera
authors.affiliation: All authors: The University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Basak E
authors.initials: BE
authors.lastname: Dogan
authors.affiliation: All authors: The University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Lumarie
authors.initials: L
authors.lastname: Santiago
authors.affiliation: All authors: The University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Kelly K
authors.initials: KK
authors.lastname: Hunt
authors.affiliation: All authors: The University of Texas MD Anderson Cancer Center, Houston, TX. hkuerer@mdanderson.org.
authors.forename: Henry M
authors.initials: HM
authors.lastname: Kuerer
mesh_terms: D000328:Adult; D000368:Aged; D000970:Antineoplastic Agents / Q000627:therapeutic use*; D001365:Axilla; D001943:Breast Neoplasms / Q000473:pathology* / Q000601:surgery; D017024:Chemotherapy, Adjuvant; D005188:False Negative Reactions; D005260:Female; D006801:Humans; D008197:Lymph Node Excision / Q000379:methods*; D008198:Lymph Nodes / Q000473:pathology* / Q000601:surgery; D008207:Lymphatic Metastasis; D008875:Middle Aged; D020360:Neoadjuvant Therapy / Q000379:methods*; D009367:Neoplasm Staging; D018365:Neoplasm, Residual / Q000473:pathology; D011446:Prospective Studies; D021701:Sentinel Lymph Node Biopsy
chemical_list: D000970:Antineoplastic Agents
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