No imaging test can reliably detect residual nodal disease after NAC; therefore, surgical intervention (either sentinel node biopsy or axillary dissection) is necessary after completion of neoadjuvant treatment, provided the patient demonstrated a PR or CR warranting surgery and did not undergo axillary surgery before treatment [112,137]. Some centers place a clip in the biopsied positive axillary node before treatment so that it can be surgically excised along with the sentinel node(s) after completion of the NAC; this procedure is sometimes referred to as targeted axillary dissection [138]. US-guided localization of the clipped lymph node can be performed preoperatively [139]. Excising the clipped lymph node and SLN(s) decreases the false-negative rate of SLNB [140]. In a study of 31 patients, 11 patients had residual axillary disease, and, in all cases, the clipped lymph node was positive [141]. In a prospective study of 23 patients with clipped axillary metastases before NAC, the surgeon retrieved the clipped node in 22 cases, and the SLN was retrieved in only 19. The clipped node was the SLN in only 14 cases (61%). The NPV was 100% for removal of clipped and sentinel node but only 85% for SLN removal alone [119]. Variant 8: Adult female or male or transfeminine (male-to-female) or transmasculine (female-to-male). Known breast cancer. Axillary imaging suspicious for metastatic disease on mammography, US, or MRI during initial evaluation. Next imaging study. Digital Breast Tomosynthesis Diagnostic There is no relevant literature to support the use of DBT in further evaluation of axillary imaging suspicious for metastatic disease. Mammography or DBT is performed for initial diagnosis of the primary breast cancer. This procedure incompletely images the axilla, although pathologically enlarged stage I and II nodes may be included on the lateral and mediolateral oblique projections.
Monitoring Response to Neoadjuvant Systemic Therapy for Breast Cancer. No imaging test can reliably detect residual nodal disease after NAC; therefore, surgical intervention (either sentinel node biopsy or axillary dissection) is necessary after completion of neoadjuvant treatment, provided the patient demonstrated a PR or CR warranting surgery and did not undergo axillary surgery before treatment [112,137]. Some centers place a clip in the biopsied positive axillary node before treatment so that it can be surgically excised along with the sentinel node(s) after completion of the NAC; this procedure is sometimes referred to as targeted axillary dissection [138]. US-guided localization of the clipped lymph node can be performed preoperatively [139]. Excising the clipped lymph node and SLN(s) decreases the false-negative rate of SLNB [140]. In a study of 31 patients, 11 patients had residual axillary disease, and, in all cases, the clipped lymph node was positive [141]. In a prospective study of 23 patients with clipped axillary metastases before NAC, the surgeon retrieved the clipped node in 22 cases, and the SLN was retrieved in only 19. The clipped node was the SLN in only 14 cases (61%). The NPV was 100% for removal of clipped and sentinel node but only 85% for SLN removal alone [119]. Variant 8: Adult female or male or transfeminine (male-to-female) or transmasculine (female-to-male). Known breast cancer. Axillary imaging suspicious for metastatic disease on mammography, US, or MRI during initial evaluation. Next imaging study. Digital Breast Tomosynthesis Diagnostic There is no relevant literature to support the use of DBT in further evaluation of axillary imaging suspicious for metastatic disease. Mammography or DBT is performed for initial diagnosis of the primary breast cancer. This procedure incompletely images the axilla, although pathologically enlarged stage I and II nodes may be included on the lateral and mediolateral oblique projections.