Choice of the optimal metastatic lymph node marking in patients with breast cancer

Often, neoadjuvant treatment in patients with locally advanced breast cancer leads to complete clinical and pathomorphological regression of not only the primary tumor, but metastatic lymph nodes also. Currently, discussions are ongoing regarding the optimal volume of surgical intervention on regional lymph nodes in this category of patients. As a de-escalation of classical lymphadenectomy, a method of targeted axillary dissection (TAD) is used, which presumes a biopsy of sentinel lymph nodes (SLN) with the removal of a previously marked metastatic lymph node. Our study is aimed at choosing the most optimal method for labeling a metastatic lymph node. The study included 63 patients diagnosed with stage T1–3N1M0 breast cancer, all divided into two comparison groups: 29 patients had a radiopaque label placed in the metastatic lymph node before neoadjuvant therapy, and 33 patients had a radioisotope label (with I125).

After the neoadjuvant treatment completion, all patients with complete clinical response in the lymph nodes underwent targeted axillary lymphadenectomy. We evaluated the time of the surgical intervention, the length of the skin incision, the presence of complications when using one or another type of marking. Based on the results of statistical analysis, we propose a variant with a radioisotope label for implementation into the clinical practice. This method, in our opinion, presented the best qualities, reliability and convenience for the surgeon, comfort for the patient.

1. Клинические рекомендации «Рак молочной железы» Ассоциация онкологов России, 2021 г.

2. Lucci A., McCall L.M., Beitsch P.D., Whitworth P.W., Reintgen D.S., Blumencranz P.W., Leitch A.M., Saha S., Hunt K.K., Giuliano A.E. ; American College of Surgeons Oncology Group. Surgical complications associated with sentinel lymph node dissection (SLND) plus axillary lymph node dissection compared with SLND alone in the American College of Surgeons Oncology Group Trial Z0011. J Clin Oncol. 2007 ; 25 (24) : 3657–3663.

3. Boughey J.C., Ballman K.V., Le-Petross H.T., McCall L.M., Mittendorf E.A., Ahrendt G.M., Wilke L.G., Taback B., Feliberti E.C., Hunt K.K., et al. Identification and resection of the clipped node decreases the false negative rate of sentinel lymph node surgery in patients presenting with node-positive breast cancer (T0-T4, N1–2) who receive neoadjuvant chemotherapy — results from ACOSOG Z1071 (Alliance). Ann Surg. 2016 ; 263 (4) : 802–807.

4. Caudle A.S., Yang W.T., Krishnamurthy S., Mittendorf E.A., Black D.M., Gilcrease M.Z., Bedrosian I., Hobbs B.P., DeSnyder S.M., Hwang R.F., et al. Improved axillary evaluation following neoadjuvant therapy for patients with node-positive breast cancer using selective evaluation of clipped nodes: implementation of targeted axillary dissection. J Clin Oncol. 2016 ; 34 (10) : 1072–1078.

5. Donker M., Straver M.E., Wesseling J., Loo C.E., Schot M., Drukker C.A., van Tinteren H., Sonke G.S., Rutgers E.J., Vrancken Peeters M.J. Marking axillary lymph nodes with radioactive iodine seeds for axillary staging after neoadjuvant systemic treatment in breast cancer patients : the MARI procedure. Ann Surg. 2015 ; 261 (2) : 378–372.