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Ultrasound of the axilla preoperative. Clipped biopsy proven positive node. I125 radioactive seed before surgery. Sentinel node biopsy using Tc99 +/- blue dye. Targeted Axillary Node Dissection performed at surgery

Sentinel Node Biopsy (SNB; using Tc99 +/- Blue dye) + Radioactive Seed Localisation (RSL) of clipped node using I125 seed = Targeted Axillary Dissection (TAD)

Targeted Axillary Dissection

Prospectively recorded preoperative ultrasound of the axilla. Number of suspicious nodes recorded. Biopsy and clipping of the positive node.

Ultrasound of the axilla

Jean-François Boileau, MD,MSc,FRCSC

Léamarie Meloche-Dumas, MD

Lucas Sidéris, MD

Erica Patocskai, MD

Isabelle Trop, MPH,FRCPC

Danh Tran-Thanh, MD,MSc,FRCPC

Mona El Khoury, MD

Stephanie Wong, MD,MPH,FRCSC

Francesca Marie Grazia Proulx, MD

Livia Florianova, MD,MSc,FRCPC

RATIONALE: It is now standard for most breast cancer patients with 1-2 positive sentinel nodes to avoid completion node dissection when eligibility criteria from the American College of Surgeons Oncology Group (ACOSOG) Z0011 trial are met. The National Comprehensive Cancer Network (NCCN) recently proposed to extend this indication to patients that present with biopsy proven node positive disease if only 1 or 2 suspicious nodes are found on imaging, these positive nodes are not palpable clinically, and the other eligibility criteria from the Z0011 study are otherwise met. However, this recommendation is based on an expert consensus and no study has yet confirmed the optimal method to stage the axilla in this patient population.

PURPOSE: Evaluate the technical success rate and accuracy of sentinel node biopsy (SNB) and the potential benefits of clipping and removing the biopsy proven node using radioactive seed localisation (RSL) (SNB+RSL = Targeted Axillary Dissection (TAD)) in patients with biopsy proven positive nodes, limited nodal disease in imaging and clinically negative axillary examination.

This is a prospective multicenter study. Patients with T1-2 Breast cancer and clinically negative axilla on palpation, 1-2 suspicious nodes on ultrasound, and a biopsy proven positive node (by core biopsy of fine needle aspiration) will have a radioactive seed (I125) placed in their clipped node before surgery. At the time of surgery, patients that are scheduled for breast conserving surgery or mastectomy will have sentinel node biopsy (SNB) using radioactive dye (Tc99) +/- blue dye as well as retrieval of the clipped node using radioactive seed localisation (RSL). Removal of the I125 radioactive seed in the clipped node will be performed before the Tc99 counts are performed to prevent "shine through" and biased measurements. Imaging of the surgical specimen will confirm retrieval of the clipped node. Prospectively recorded information on pre-operative axillary imaging, characteristics of the retrieved nodes in the operating room and detailed pathological analysis of each corresponding node will be performed. Completion node dissection (CND) is not mandatory in this study but recommended if the clipped positive node is not retrieved, if 4 nodes or more are positive or if 3 nodes are positive in the absence of axillary radiation. The benefits of adding RSL to SNB and the benefits of adding SNB to RSL staging of the axilla will be evaluated in this study and will help to better define the value of using TAD in this patient population.

Targeted Axillary Dissection (TAD) in Early-stage Node Positive Breast Cancer

Sentinel Node Biopsy and Targeted Axillary Dissection in Node-Positive Breast Cancer Patients With Clinically Negative Axilla

Recommended completion node dissection rate (CND) = false negative rate (FNR) + technical failure rate (TFR).

TAD CND (TAD FNR + TAD TFR) vs. SNB CND (SNB FNR + SNB TFR)

Evaluate if the addition of SNB to RSL improves the ability to identify patients with 3+ positive nodes that do not otherwise meet the ACOSOG Z0011 criteria and require further regional axillary therapy

Percentage of patients with successful removal of at least one node (using this method) where at least one positive node was not retrieved (using this method)

Percentage of patients with unsuccessful removal of at least one node using this method, including the clipped node

Percentage of patients with unsuccessful removal of at least one node using this method (clipped node or not)

Study title	NCT ID	Conditions	Interventions	Eligibility	Organization	Link
Targeted Axillary Dissection (TAD) in Early-stage Node Positive Breast Cancer	NCT04671511	Breast Cancer F... Early-stage Bre... Lymph Node Meta... Axillary Metast... Sentinel Lymph ...	Targeted Axilla... Ultrasound of t...	18 Years -	Jewish General Hospital
Targeted Axillary Dissection (TAD) in Early-stage Node Positive Breast Cancer	NCT04671511	Breast Cancer F... Early-stage Bre... Lymph Node Meta... Axillary Metast... Sentinel Lymph ...	Targeted Axilla... Ultrasound of t...	18 Years -	Jewish General Hospital

Spots Global Cancer Trial Database for metastatic axillary lymph nodes