Radio-isotope occult lesion localization (ROLL) techniques to identify the clipped node for targeted axillary dissection (TAD) in breast cancer.

Background: Breast cancer patients having neoadjuvant systemic therapy (NAST) who have a positive (clipped) lymph node (CN) at presentation must have that CN removed to assess pathologic response at later surgery. Multiple techniques for localizing the CN have been described. We describe a novel ROLL-based approach.
Methods: Consecutive patients between 2018 and 2021, having NAST with biopsy proven positive lymph node(s), had a clip placed into the most abnormal node(s). At later surgery sentinel node and occult lesion localization (SNOLL) was performed with peritumoral radio-isotope ( ^99m Tc-Nanoscan) injected under ultrasound guidance. Planar and single photon emission computed tomography (SPECT-CT) images were used to identify sentinel nodes (SN) and the CN. If the CN was not a SN, then additional ^99m Tc-Nanoscan was injected directly into the CN using ultrasound (ROLL). TAD was performed using a gamma probe and intra-operative specimen radiographs to confirm excision of the CN.
Results: Thirty-eight patients underwent TAD. 20/38 CNs were SNs on SPECT-CT. 17/38 CN were localized separately. 1/38 CN was not a SN and could not be identified on ultrasound. The remaining 37/38 (97.4%) of the CNs were removed intra-operatively. Pathological complete response in the axilla was identified in 18/38 cases. The CN was the only positive node in 10/20 cases. In 18/20 cases the CN contained the largest tumour deposit.
Conclusion: Combining SNOLL and ROLL techniques to identify the SNs and, if separate, the CN for TAD is very reliable and logistically robust, especially for units already performing peritumoral lymphoscintigraphy.
(© 2022 Royal Australasian College of Surgeons.)