Targeted Axillary Dissection in Node-Positive Breast Cancer: A Retrospective Study and Cost Analysis

Abstract

Introduction Targeted axillary dissection (TAD) is a novel technique in the field of surgical oncology. During TAD, patients with node-positive breast cancer who clinically responded to neoadjuvant chemotherapy undergo resection of a previously proven metastatic node together with sentinel lymph node dissection (SLND). We aimed to assess the success rates of seed insertion and seed retrieval in the Canadian setting, as well as hospital costs of the procedure. Methods Patients converted to clinically node-negative status post-neoadjuvant chemotherapy underwent TAD. Before surgery, an iodine-125 radioactive seed was inserted in the previously proven metastatic node. The seed node was resected together with an SLND. Axillary lymph node dissection (ALND) was performed in all patients with residual metastases. Results Radioactive seeds were successfully inserted in 34/35 patients. In 34 patients, the targeted node was successfully resected with the radioactive probe during TAD. In one patient, the seed was retrieved inferiorly in the axilla during surgery. There was no adverse event. In total, 50% (17/34) of patients had no residual metastases and were able to avoid ALND. Eight out of 17 patients who underwent ALND did not have any residual disease in their specimen. The mean cost of TAD was 25% superior to the mean cost of ALND (p = 0.02). However, the mean total cost of the hospital stay for TAD was 20% superior to the mean cost of ALND (p = 0.11). The mean cost of TAD was 4,322 Can$ (Canadian dollars), similar to the mean cost of both ALND and SLND performed during the same procedure (4,479 Can$). Conclusions TAD was successful in 97% of patients. Despite increased procedural costs, with a lesser impact on total hospital stay costs, TAD was beneficial in 50% of patients. These patients avoided the unnecessary morbidity associated with ALND.

Keywords: axillary lymph node dissection; breast cancer; breast cancer management; iodine seed; neoadjuvant chemotherapy; nodal metastases; radioactive seed; targeted axillary node dissection.

Figure 1. Main steps of the procedure.

Figure 2. Flow diagram and procedural outcomes.

pCR, pathologic complete response

Figure 3. Costs distribution for targeted axillary dissection.

Figure 4. Cost distribution for axillary lymph node dissection.

Figure 5. Mean procedural costs and standard deviations for targeted axillary dissection and other common axillary surgeries.

ALND, axillary lymph node dissection; SLND, sentinel lymph node dissection; TAD, targeted axillary dissection