Evaluation of targeted axillary dissection following neoadjuvant therapy for a patient with node-positive breast cancer as initial experience in Ain Shams University Hospitals

Introduction
Surgical treatment of the axilla in breast cancer shows a lot of advances over the past decade. Patients with clinically positive lymph node (LN) have a great chance to turn by neoadjuvant chemotherapy (NACT) to be negative clinically and radiologically, and so surgical management in those patients is still a field of research. Sentinel lymph node biopsy (SLNB) in such patients showed a high false-negative rate (FNR), which was decreased by the use of immunohistochemistry and if a clip was placed in the node with biopsy-confirmed metastases, with removal of that node with the SLNB which is called targeted axillary dissection (TAD).
Objectives
To determine the accuracy of TAD, ensuring that surgical removal of clipped nodes would improve accuracy of nodal staging in patients with initial positive LN.
Patients and methods
A prospective study including 30 patients with cT cN M breast cancer post-NACT, who had shown downstaging of their nodal status (N0) as proven by clinical examination and ultrasound assessment, who were recommended for TAD removing the clipped LN added to the SLNB at Ain Shams University Hospital, between March 2020 and March 2021.
Results
Out of the 29 patients, two patients showed residual disease in the clipped LN in a frozen section; one of them revealed positive SLN as well. Completion of axillary lymph node (ALN) dissection was done regardless of the frozen section results to detect any residual nodal disease, which revealed negative results in all cases and that indicate the success of TAD in removing the diseased LN and decreasing the FNR of SLN alone. Twenty-four patients with clipped ALNs were stained with patent blue dye while five patients with clipped ALNs were not stained by patent blue dye. Therefore, SLN was unable to detect clipped ALNs, which were previously positive in five patients, so there is a FNR of 17.2% if SLNB was done alone. So, with targeted procedure we can decrease the FNR of sentinel study and accurately assess the neoadjuvant effect on diseased LNs.
Conclusion
TAD is a feasible technique for axillary management in patients with clinically N1 breast cancer, who receive NACT and turned to N0. Preoperative clipped node guide wire localization significantly improves the identification rate of the clipped node and decreases the FNR of SLNB alone.