This study aimed to investigate the feasibility and accuracy of tattooing suspicious axillary lymph nodes with carbon suspension at the time of breast cancer (BC) diagnosis and the intraoperative correspondence between tattooed lymph node (TLN) and sentinel lymph node (SLN) in patients who underwent neoadjuvant chemotherapy (NACT).
Methods:
In this retrospective study, we analyzed consecutive BC patients who underwent NACT, between April 2019 and May 2021, at the Breast Unit of Sant‘Anna Hospital in Turin, Italy. Before NACT, all suspicious biopsied lymph nodes were marked with carbon suspension. All SLNs, TLNs, and axillary nodal dissection specimens were sent for histopathological examination.
Results:
The study group included a total of 49 patients with BC. The overall identification rate of TLNs was 83.7% (41/49; 95%, confidence interval - CI 0.70-0.92). In patients who underwent target axillary dissection (TAD) the carbon tattooing had an intraoperative identification rate of 84.4% (27/32; 95% CI 0.67-0.95) while, in the case of axillary lymph node dissection, TLNs were detected in 82.3% (14/17; 95% CI 0.56-0.96) of patients. The correlation between TLN and SLN was 71.8% (23/32).
Conclusions:
These results confirmed that tattooing axillary lymph nodes has an acceptable identification rate. We also confirmed that this procedure, in addition to SLN biopsy, improves the accuracy of surgical axillary staging.
VeronesiUPaganelliGGalimbertiV, et al. Sentinel-node biopsy to avoid axillary dissection in breast cancer with clinically negative lymph-nodes. Lancet1997; 349: 1864–1867.
2.
XingYFoyMCoxDD, et al. Meta-analysis of sentinel lymph node biopsy after preoperative chemotherapy in patients with breast cancer. Br J Surg2006; 93: 539–546.
3.
KuehnTBauerfeindIFehmT, et al. Sentinel-lymph-node biopsy in patients with breast cancer before and after neoadjuvant chemotherapy (SENTINA): a prospective, multicentre cohort study. Lancet Oncol2013; 14: 609–618.
4.
BougheyJCSumanVJMittendorfEA, et al. Sentinel lymph node surgery after neoadjuvant chemotherapy in patients with node-positive breast cancer: The ACOSOG Z1071 (Alliance) Clinical Trial. JAMA2013; 310: 1455.
5.
SimonsJMvan NijnattenTJAvan der PolCC, et al. Diagnostic accuracy of different surgical procedures for axillary staging after neoadjuvant systemic therapy in node-positive breast cancer: a systematic review and meta-analysis. Ann Surg2019; 269: 432–442.
KimWHKimHJJungJH, et al. Ultrasound-guided restaging and localization of axillary lymph nodes after neoadjuvant chemotherapy for guidance of axillary surgery in breast cancer patients: experience with activated charcoal. Ann Surg Oncol2018; 25: 494–500.
9.
GoyalAPuriSMarshallA, et al. A multicentre prospective feasibility study of carbon dye tattooing of biopsied axillary node and surgical localisation in breast cancer patients. Breast Cancer Res Treat2021; 185: 433–440.
10.
HartmannSKühnTde BonifaceJ, et al. Carbon tattooing for targeted lymph node biopsy after primary systemic therapy in breast cancer: prospective multicentre TATTOO trial. Br J Surg2021; 108: 302–7.
11.
PatelRMacKerricherWTsaiJ, et al. Pretreatment tattoo marking of suspicious axillary lymph nodes: reliability and correlation with sentinel lymph node. Ann Surg Oncol2019; 26: 2452–2458.
12.
ParkSKooJSKimGM, et al. Feasibility of charcoal tattooing of cytology-proven metastatic axillary lymph node at diagnosis and sentinel lymph node biopsy after neoadjuvant chemotherapy in breast cancer patients. Cancer Res Treat2018; 50: 801–812.
13.
ChoyNLipsonJPorterC, et al. Initial results with preoperative tattooing of biopsied axillary lymph nodes and correlation to sentinel lymph nodes in breast cancer patients. Ann Surg Oncol2015; 22: 377–382.
14.
NatsiopoulosIIntzesSLiappisT, et al. Axillary lymph node tattooing and targeted axillary dissection in breast cancer patients who presented as cN+ before neoadjuvant chemotherapy and became cN0 after treatment. Clin Breast Cancer2019; 19: 208–215.
15.
AllweisTMMenesTRotbartN, et al. Ultrasound guided tattooing of axillary lymph nodes in breast cancer patients prior to neoadjuvant therapy, and identification of tattooed nodes at the time of surgery. Eur J Surg Oncol2020; 46: 1041–1045.
16.
KhallafEWessamRAbdoonM.Targeted axillary dissection of carbon-tattooed metastatic lymph nodes in combination with post–neo-adjuvant sentinel lymph node biopsy using 1% methylene blue in breast cancer patients. Breast J2020; 26: 1061–1063.
17.
GreenwoodHIWongJMMukhtarRA, et al. Feasibility of magnetic seeds for preoperative localization of axillary lymph nodes in breast cancer treatment. AJR Am J Roentgenol2019; 213: 953–957.
18.
FalconSWeinfurtnerRJMooneyBNiellB, et al. SAVI SCOUT® localization of breast lesions as a practical alternative to wires: Outcomes and suggestions for trouble-shooting. Clin Imaging2018; 52: 280–286.
19.
TayehSGeraRPerryN, et al. The use of magnetic seeds and radiofrequency identifier tags in breast surgery for non-palpable lesions. Anticancer Res2020; 40: 315–321.
20.
DonkerMStraverMEWesselingJ, et al. Marking axillary lymph nodes with radioactive iodine seeds for axillary staging after neoadjuvant systemic treatment in breast cancer patients: the MARI procedure. Ann Surg2015; 261: 378–382.
21.
NguyenTTHiekenTJGlazebrookKN, et al. Localizing the clipped node in patients with node-positive breast cancer treated with neoadjuvant chemotherapy: early learning experience and challenges. Ann Surg Oncol2017; 24: 3011–3016.
22.
KimEYByonWSLeeKH, et al. Feasibility of preoperative axillary lymph node marking with a clip in breast cancer patients before neoadjuvant chemotherapy: a preliminary study. World J Surg2018; 42: 582–589.
23.
HartmannSReimerTGerberB, et al. Wire localization of clip-marked axillary lymph nodes in breast cancer patients treated with primary systemic therapy. Eur J Surg Oncol2018; 44: 1307–1311.
24.
KuemmelSHeilJRuelandA, et al. A prospective, multicenter registry study to evaluate the clinical feasibility of targeted axillary dissection (TAD) in node-positive breast cancer patients. Annals of Surgery2020; DOI: 10.1097/SLA.0000000000004572
25.
PintoDBatistaEGouveiaP, et al. Targeted axillary dissection after chemotherapy: feasibility study with clip and carbon dye tattoo – Neotarget Trial. Breast Care2021; 1–6.
26.
Banys-PaluchowskiMGasparriMLde BonifaceJ, et al. Surgical management of the axilla in clinically node-positive breast cancer patients converting to clinical node negativity through neoadjuvant chemotherapy: current status, knowledge gaps, and rationale for the EUBREAST-03 AXSANA Study. Cancers2021; 13: 1565.
