Caudle Abigail S, Yang Wei T, Mittendorf Elizabeth A, Black Daliah M, Hwang Rosa, Hobbs Brian, Hunt Kelly K, Krishnamurthy Savitri, Kuerer Henry M
Department of Surgical Oncology, MD Anderson Cancer Center, The University of Texas, Houston.
Department of Diagnostic Imaging, MD Anderson Cancer Center, The University of Texas, Houston.
JAMA Surg. 2015 Feb;150(2):137-43. doi: 10.1001/jamasurg.2014.1086.
Nodal ultrasonography with needle biopsy of abnormal lymph nodes helps to define the extent of breast cancer before neoadjuvant chemotherapy. A clip can be placed to designate lymph nodes with documented metastases. Targeted axillary dissection or selective removal of lymph nodes known to contain metastases (clip-containing nodes) as well as sentinel lymph nodes (SLNs) may provide more accurate assessment of the pathologic response after neoadjuvant chemotherapy.
To determine the feasibility of image-guided localization and resection of lymph nodes containing known metastases.
DESIGN, SETTING, AND PARTICIPANTS: This prospective feasibility trial performed at MD Anderson Cancer Center, Houston, Texas, included 12 patients with axillary nodal metastases confirmed by results of fine-needle aspiration biopsy who had a clip placed in the lymph node targeted for biopsy from December 1, 2012, through November 30, 2013.
Preoperative targeting of the clip-containing lymph node under ultrasonographic guidance consisting of wire localization in 2 patients and placement of radioactive iodine I 125 (125I)-labeled seeds in 10 patients. Surgeons removed the localized lymph node before completion axillary lymph node dissection and used radiography of the specimen to confirm removal of the clip-containing lymph node and seed.
Confirmation of the removal of the clip-containing lymph node.
Image-guided localization and selective removal were successful in all 12 patients. Five patients underwent SLN dissection in addition to removal of the clip-containing lymph node. Placement of 125I seeds did not interfere with lymphoscintigraphy or intraoperative identification of SLNs. In 4 of the 5 patients (80%), the clip-containing lymph node was one of the SLNs. Ten patients completed neoadjuvant chemotherapy before surgery. Of the 9 patients who underwent lymph node dissection, 4 (44%) had residual nodal disease after chemotherapy; all had disease identified in the clip-containing lymph node.
Axillary lymph nodes marked with a clip can be localized and selectively removed to accomplish targeted axillary dissection, which is technically possible after chemotherapy and is easily performed with other axillary surgery, such as SLN dissection. The ability to add selective removal of the clip-containing lymph nodes to SLN dissection may identify patients for limited nodal surgery after chemotherapy with increased accuracy for determining residual disease compared with SLN identification alone.
对异常淋巴结进行针吸活检的淋巴结超声检查有助于在新辅助化疗前明确乳腺癌的范围。可放置夹子标记有转移记录的淋巴结。靶向腋窝淋巴结清扫术或选择性切除已知含有转移灶的淋巴结（含夹子的淋巴结）以及前哨淋巴结（SLN），可能会更准确地评估新辅助化疗后的病理反应。
确定影像引导下定位并切除已知含有转移灶的淋巴结的可行性。
设计、地点和参与者：这项前瞻性可行性试验在德克萨斯州休斯顿的MD安德森癌症中心进行，纳入了12例经细针穿刺活检结果证实有腋窝淋巴结转移的患者，这些患者在2012年12月1日至2013年11月30日期间，其靶向活检的淋巴结中放置了夹子。
术前在超声引导下对含夹子的淋巴结进行靶向定位，其中2例患者采用金属丝定位，10例患者放置放射性碘I 125（125I）标记的种子源。外科医生在完成腋窝淋巴结清扫术前切除定位的淋巴结，并通过标本的X线摄影确认含夹子的淋巴结和种子源已被切除。
确认含夹子的淋巴结已被切除。
12例患者影像引导下的定位和选择性切除均成功。5例患者除切除含夹子的淋巴结外还进行了前哨淋巴结清扫。放置125I种子源未干扰淋巴闪烁显像或术中对前哨淋巴结的识别。5例患者中有4例（80%），含夹子的淋巴结是前哨淋巴结之一。10例患者在手术前完成了新辅助化疗。在接受淋巴结清扫的9例患者中，4例（44%）化疗后有残留淋巴结疾病；所有患者在含夹子的淋巴结中均发现有疾病。
用夹子标记的腋窝淋巴结可被定位并选择性切除以完成靶向腋窝淋巴结清扫术，这在化疗后技术上是可行的，并且与其他腋窝手术（如前哨淋巴结清扫）一样易于实施。在前哨淋巴结清扫术中增加选择性切除含夹子的淋巴结的能力，可能会更准确地确定化疗后残留疾病，从而识别适合进行有限淋巴结手术的患者。
