19 Targeted Axillary Dissection—Does the Biopsy-Proven Node Need to Be Localized? A Retrospective Review of Patients With Node-Positive Breast Cancer Treated With Neoadjuvant Systemic Therapy

Introduction

Optimal axillary management for patients with initially node-positive breast cancer treated with neoadjuvant chemotherapy (NACT) remains controversial. Sentinel lymph node biopsy (SLNB) in this setting is increasingly being used to reduce surgical morbidity, but concerns persist regarding nodal staging accuracy and recurrence risk. Targeted axillary dissection (TAD) has been proposed to improve staging by ensuring the removal of the clipped metastatic node. The aim of this study was to identify the accuracy of removing the clipped node along with SLNB, comparing any differences in localization methods, and determining if retrieving the clipped node is beneficial in improving clinical outcomes.

Methods

Out of 118 patients with biopsy-proven node-positive breast cancer treated with NACT from July 2019 to July 2025, 87 patients underwent TAD and SLNB. The method of targeting the clipped node, the accuracy of identification of the clipped node, the type of axillary surgery, and recurrence rates were analyzed.

Results

All of the preoperatively identified positive nodes were retrieved by identification with a localizing clip (strut-adjusted volume implant [SAVI]; n = 29) or wire localization (n = 58), with no difference in the success of retrieval based on the method of localization. Seventy-two percent of the biopsy-proven clipped nodes were also sentinel nodes (identified with blue dye or radiotracer). In 25 patients, the biopsy-proven clipped node was not a sentinel node and thus was only identified by the localization device. On initial imaging, 54% of patients had 1 suspicious node; the remaining 45% had multiple suspicious nodes. On final pathology, 38% had positive nodes. Twelve patients (14%) had an axillary lymph node dissection (ALND), and 6 were found to have a positive node that was not clipped or sentinel. Ninety-three percent of patients underwent adjuvant radiation. No patients had axillary recurrence (n = 86/87 patients, with 1 patient lost to follow-up). Seven patients (8%) experienced distant metastasis, with a median time to diagnosis from surgery of 16.5 months (IQR, 12-29). Of these, 4 had positive nodes on final pathology but did not undergo an ALND.

Conclusion

Given that 28% of patients with positive nodes after NACT show no uptake of radiotracer or blue dye, localization of the clipped node provides additional benefit to adjuvant treatment planning. The true clinical benefit of removing all nodal disease is unknown, and no patients had axillary recurrence despite only 12% having an ALND. Interestingly, of the 7 patients who had distant metastasis, 4 patients had positive nodes on final pathology but did not undergo an ALND. Although current practice is outpacing clinical trial data and surgeons are more frequently omitting ALND, we are awaiting data from large clinical trials such as Alliance AO11202.