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Feasibility of Preoperative Axillary Lymph
Node Marking with a Clip in Breast Cancer
Patients before Neoadjuvant Chemotherapy:
A Preliminary Study
[ABS-0078] GBCC 2018
Eun Young Kim1, Kwan Ho Lee1, Yong Lai Park1, Chan Heun Park1,
In Young Youn2, Seon Hyeong Choi2, Yoon Jung Choi2, Shin Ho Kook2
Department of Surgery1 and Radiology2
Kangbuk Samsung Hospital
Sungkyunkwan University School of Medicine
Axilla restaging after neoadjuvant chemotherapy
• The extent of persistent axillary nodal disease after neoadjuvant chemotherapy
(NAC)
- established prognostic marker for locoregional recurrence and survival
• However, no clear consensus for reliable method (SLNB vs ALND) of restaging the
axilla after NAC to confirm conversion to negative lymph node status
Kuerer HM et al. Ann Surg Oncol. 2012
Von Minckwitz G. et al. J Clin Oncol. 2012
Introduction
Introduction
Introduction
Targeted axillary dissection after neoadjuvant
chemotherapy
• To decrease false negative rate (FNR), targeted axillary dissection has been
proposed
• NCCN Guidelines Version 4.2017
Marking of sampled axillary nodes with a tattoo or clip should be considered to
permit verification that the biopsy-positive lymph node has been removed at the time of
definitive surgery
Introduction
1. Mayo Clinic
Clip placement in the positive node at
initial diagnosis
Introduction
2. Netherlands
Radioactive iodine (125I) seeds placement to
axillary lymph node
3. MD Anderson Cancer Center
Clip placement in the positive node at
initial diagnosis
Accuracy of targeted axillary dissection after
neoadjuvant chemotherapy
ACOSOG
Z1071
MARI TAD
No of patients 141 100 208
Identification rate of clip in SLN 82.9%
(141/170)
97.0%
(97/100)
60.2%
(115/191)
FNR of clipped node 6.8% 7.0% 4.2%
Introduction
Boughey JC et al. Ann Surg. 2016Donker M. et al. Ann Surg. 2015
Kuehn T et al. Lancet Oncol. 2013
• To determine the feasibility of image-guided marker- clip placement in
axillary lymph nodes (ALNs) for breast cancer on upon initial presentation
• To assess the reliability of this method with SLNB for axillary restaging
after NAC
Purpose
Introduction
Patients and Methods
• Prospective study from June 2015 to August 2016
- Women aged from 20-75 years who were diagnosed as breast cancer
- Suspicious axillary LNs (thickened cortex or absent hilum) on US or PET-CT
- US-guided FNA or core needle biopsy on LNs before initiation of NAC
- Underwent NAC followed by surgery
• Exclusion criteria
- Disease progression during NAC
- Pregnant or plan for pregnancy
- Patients’ refusal
Materials and Methods
US-guided clip insertion
• Surgical clips (LigaClip) was inserted into the suspicious lymph node before NAC
• One day after the procedure and one day before surgery
- unilateral digital mammography (MLO) to confirm the location of clip
Materials and Methods
Wire localization of marker-clipped nodes
• 1 hour before surgery, a 21-G 7.5-cm hooked wire was inserted to retrieve
the clips
Materials and Methods
Wire localization of marker-clipped nodes
• Cone-beam CT (CBCT) was performed for the selected region of interest
• After hook- wire localization
- repeatedly acquired CT images to confirm the location of the marker clip
Materials and Methods
SLN and marker-clipped lymph node surgery
• After excision of the marker- clipped LNs
- intraoperative palpation, inspection of the specimen by a surgeon, specimen
radiography confirmed that the excised LNs contained the clip
• Conventional SLNB proceeded using dual tracers
Materials and Methods
Pathologic assessment
• The nodal specimens evaluated intraoperatively
- to identify marker-clipped LNs and SLNs
• Axillary LN dissection (ALND) proceeded
- if more than two LNs (including marker-clip LNs and SLNs) were found to
be metastatic during intraoperative frozen biopsy
Materials and Methods
Results
Patient characteristics
N = 20
Age, mean, y 44.6±7.3 (29-58)
Clinical tumor size,
mean, cm
3.9±1.6 (1.7-7.0)
Suspicious LNs on US
1
2
≥3
2
8
10
Tumor histology
IDC
ILC
DCIS
18
1
1
Histologic grade
1
2
3
unspecified
6
8
4
2
N = 20
Tumor subtype
ER/PR-positive, HER2-negative
ER-positive, HER2-positive
HER2-enriched
Triple-negative
6
8
3
3
NAC regimen
AC-T
AC-TH
TCHP
9
8
3
Type of breast surgery
Partial mastectomy
Total mastectomy
8
12
• Total of 24 clips inserted in 20 patients
-1 marker clip insertion :16 patients , 2 marker clips insertion : 4 patients
• Wire localization of marker clipped LNs was successfully performed in all 24 clips
• 23 clips were successfully retrieved intraoperatively
(identification rate of marker clipped LNs , 23/24 =95.8%)
• However, 1 clip could not be found and retrieved intraoperatively
- possibly due to loosening of the anchored hook
• The location of the clip that we failed to retrieve was confirmed on the 6-month
follow-up chest CT at the placement site, without migration
Results
Clip insertion and wire localization
Results
Surgical Procedure and Pathologic Outcomes
N = 20
Pathological tumor size,
mean, cm
1.7±2.0 (0-9.5)
Pathological tumor response
Complete (no residual tumor)
Residual DCIS only
Residual infiltrating ca ≤ 1 cm
Residual infiltrating ca > 1 cm
3
2
1
14
Pathological response of LN
No residual tumor
Metastatic residue
13
7
pCR of both primary tumor, LN 3
N = 20
Size of marker-clipped LN,
mean, cm
1.4±0.7 (0.3-3.0)
Clips identified in SLN 17
Clips identified in ALN 6
SLNB performed 12
SLNB and ALND performed 8
No. of marker-clipped LNs
removed, mean
1.1±0.3 (1-2)
No. of SLNs removed, mean 2.2±1.8 (1-7)
No. of ALNs removed, mean 6.7±5.2 (1-13)
Results
Clinicopathologic staging and pathologic status of
ALNs before and after NAC
Case Prechemo
Clinical stage
Postchemo
Clinical stage
Pathologic
stage
Prechemo
Marker-clipped LN
Postchemo
Marker-clipped LN
SLN ALN
1 T2N1 T1N1 ypT1N0 Negative Negative Negative Negative
2 T3N1 T2N0 ypT2N0 Negative Negative Negative
5 T1N1 T0N0 ypT0N0 Negative Negative Negative
6 T3N1 T3N0 ypT3N0 Negative Negative Negative
7 T2N1 T1N0 ypT0N0 Negative Negative Negative
10 T2N1 T2N1 ypT2N0 Negative Negative Negative
13 T2N1 T1N1 ypT1N0 Negative Negative Negative
17 T4N1 T2N0 ypT0N0 Negative Negative Negative Negative
19 T3N1 T2N1 ypT1N0 Negative Negative Negative
Results
Clinicopathologic staging and pathologic status of
ALNs before and after NAC
Case Prechemo
Clinical stage
Postchemo
Clinical stage
Pathologic
stage
Prechemo
Marker-clipped LN
Postchemo
Marker-clipped LN
SLN ALN
3 T3N1 T2N1 ypT1N0 Positive Negative Negative Negative
4 T2N1 T1N0 ypT1N0 Positive Negative Negative
8 T2N1 T1N0 ypT1N1 Positive Positive Positive Negative
9 T2N2 T1N1 ypT1N1 Positive Positive Negative Positive
11 T2N2 T1N0 ypTisN2 Positive Positive Positive Positive
12 T3N1 T2N1 ypT1N0 Positive Negative Negative
14 T2N1 T1N1 ypT2N1 Positive Positive Negative Negative
15 T2N1 T1N1 ypT1N1 Positive Positive Negative
16 T2N2 T1N1 ypT2N2 Positive Positive Negative Positive
18 T2N1 T2N1 ypT1N0 Positive Negative Negative
20 T2N1 T0N0 ypTisN1 Positive Positive Negative
• All patients were underwent follow-up exams for axillary recurrence until March, 2018
(mean : 24.3 months)
• Disease-free status of the axilla was confirmed in all 20 patients
• No complications (bleeding, hematoma formation, nerve injury) were reported during
clip insertion or wire localization
• No intraoperative or postoperative complications were reported
Results
• Image-guided marker-clip placement on positive ALNs before NAC and removal
with SLNB is technically feasible and safe
• This procedure can improve the accuracy of the residual disease evaluation of axilla,
especially in patients who have negative SLNB results
• It can also identify candidates for limited axillary surgery after neoadjuvant
chemotherapy
Conclusion
Conclusion
Kim EY et al. World J Surg. 2017
Conclusion
Thank you for your attention
