br Our study is retrospective and
Our study is retrospective and had a relatively small number of patients, which indicates that the results must be interpreted care-fully. In concordance with 2 previously published studies by Choy et al15 and Park et al,31 our results indicate that the intraoperative
Lymph Node Tattooing and TAD for Axillary Staging After NAC
IR of tattooed nodes is high. Moreover, the influence of tattoo ink migration in accurate pathological confirmation of marked nodes’ retrieval is emphasized for the first time.
Axillary Y-27632 node tattooing is a feasible, accurate, and low cost method to mark positive lymph nodes in patients cNþ before NAC. Tattooed lymph nodes are easily identified by surgeons during the surgery, so further invasive methods or expensive equipment is not required. Correspondence between tattooed nodes and SLNs is not so high, establishing that TAD is a more appropriate method than SLNB for axillary assessment of these patients. Intraoperative recog-nition of all tattooed nodes using visual inspection is necessary, as pathological confirmation by itself is not always a warranty of all marked node retrieval, because of black pigment migration from one node to another. Macroscopically non-black nodes with microscop-ically detected small foci of carbon particles should not be considered as retrieved marked nodes. More prospective trials with long-term follow-up are needed to determine the optimum technique of ALN mapping as well as to study the morbidity of TAD.
Clinical Practice Points
Targeted axillary dissection seems to be the most appropriate method for axillary staging after NAC for breast cancer patients who presented as axillary positive at diagnosis and became negative after treatment.
It is less invasive and probably carries less morbidity than axillary lymph node dissection that used to be the standard approach for axillary staging for those patients.
Targeted axillary dissection is defined as the removal of SLNs along with the pre-NAC marked positive nodes.
Various methods have been proposed for marking positive nodes pre-NAC and for localizing them post-NAC.
Only 2 studies, with a small number of patients, have reported on axillary lymph node tattooing as a pre-NAC lymph node marking method.
In our study, in concordance with the results of those studies, we found high rates of intraoperative identification of tattooed nodes (94.6%). Furthermore, we ascertained a high rate of tattoo ink migration from one node to another (45.3%), which means that histological confirmation of black pigment presence in the lymph nodes excised is not by itself warranty of all marked nodes’ retrieval.
The intraoperative identification of tattooed nodes using visual inspection is essential.
The authors have stated that they have no conflicts of interest.
1. Lyman GH, Somerfield MR, Giuliano AE. Sentinel lymph node biopsy for pa-tients with early-stage breast cancer: 2016 American Society of Clinical Oncology clinical practice guideline update summary. J Oncol Pract 2017; 13:196-8. 2. Lyman GH, Temin S, Edge SB, et al. Sentinel lymph node biopsy for patients with early-stage breast cancer: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol 2014; 32:1365-83.
3. Giuliano AE, Hunt KK, Ballman KV, et al. Axillary dissection vs no axillary dissection in women with invasive breast cancer and sentinel node metastasis: a randomized clinical trial. JAMA 2011; 305:569-75.
4. Galimberti V, Cole BF, Zurrida S, et al. Axillary dissection versus no axillary dissection in patients with sentinel-node micrometastases (IBCSG 23-01): a phase 3 randomised controlled trial. Lancet Oncol 2013; 14:297-305.
6. Xing Y, Foy M, Cox DD, Kuerer HM, Hunt KK, Cormier JN. Meta-analysis of sentinel lymph node biopsy after preoperative chemotherapy in patients with breast cancer. Br J Surg 2006; 93:539-46.
7. Tan VK, Goh BK, Fook-Chong S, Khin LW, Wong WK, Yong WS. The feasi-bility and accuracy of sentinel lymph node biopsy in clinically node-negative pa-tients after neoadjuvant chemotherapy for breast cancerea systematic review and meta-analysis. J Surg Oncol 2011; 104:97-103.
8. van Deurzen CH, Vriens BE, Tjan-Heijnen VC, et al. Accuracy of sentinel node biopsy after neoadjuvant chemotherapy in breast cancer patients: a systematic re-view. Eur J Cancer 2009; 45:3124-30.
9. NCCN Clinical Practice Guidelines in Oncology. Breast Cancer. Version 3.2018, Available at: https://www.nccn.org/professionals/physician_gls/pdf/breast.pdf. Accessed December 9, 2018.