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Ask an Expert: Targeted Axillary Dissection

Read Time: 3 minutes

Doctor talking with patient and pointing at laptop screen

Targeted axillary dissection (TAD) is a relatively new breast cancer procedure. It allows surgical oncologists to specifically locate a lymph node that contained cancer before chemotherapy, remove it during surgery, and check it to see if there is remaining cancer in the lymph node. With a more accurate picture of the patient’s response to chemotherapy in the lymph nodes, the patient may be able to keep more axillary, or underarm, lymph nodes. We asked Kirstyn E. Brownson, MD, surgical breast oncologist at Huntsman Cancer Institute, to explain TAD, who it may benefit, and what makes TAD unique.

What is TAD?

TAD came about after studying patients’ responses to chemotherapy at the time of surgery. We learned that many women who had chemotherapy before surgery to treat cancer that had spread to their axillary lymph nodes had no remaining cancer found during surgery. Researchers and surgical breast oncologists wanted to reduce long-term side effects by removing fewer lymph nodes while still treating the cancer successfully.

TAD is a surgical technique, but the process of TAD starts when the patient first comes to their doctor with breast cancer. The doctor orders ultrasound imaging of the underarm area, or axilla, to see if there is concern for spread to the lymph nodes. If a suspicious axillary lymph node is found, the doctor will do a core needle lymph node biopsy and leave a clip in the concerning lymph node. This way, doctors pinpoint cancer spread to the lymph nodes before a patient starts chemotherapy.

The “targeted dissection” of TAD means the surgical breast oncologist removes and checks a specific lymph node—the axillary lymph node that was known to contain cancer before the patient started chemotherapy—which may make it possible for the patient to keep more lymph nodes than traditional methods. When the patient can keep more lymph nodes, there is less risk of lymphedema, or painful swelling, in the arm following surgery.

About Core Needle Lymph Node Biopsy

We take small samples of cells from a suspicious-looking lymph node in the armpit and check those cells for cancer using a microscope. Next, we place a tiny metal clip in the lymph node. If the cancer has spread to this lymph node, we will remove it during surgery.

About Chemotherapy

The patient then has chemotherapy. This kills cancer cells in the body and can also help shrink the cancerous tumor in the breast and axilla. Depending on the cancer type, chemotherapy kills all the cancer in the lymph nodes in 21% to 65% of patients.

About Surgery

After chemotherapy, the patient has surgery to remove any remaining tumor in the breast. During surgery, the clipped lymph node is removed and checked again for cancer cells. If there are no cancer cells in the clipped lymph node, and no cancer cells in any of the other lymph nodes identified by sentinel lymph node biopsy, then we can safely avoid removing all of the axillary lymph nodes. It is a successful targeted axillary dissection.

Who is eligible for targeted axillary dissection (TAD)?

TAD is an option for a specific group of breast cancer patients. There are two key questions we consider:

  • When the person is diagnosed, has the cancer already spread to the lymph nodes?
  • Will the person’s first treatment be chemotherapy?

If the answer to both of these questions is “yes,” then the patient may be eligible for TAD.

What makes TAD unique?

The average person has about 20–40 axillary lymph nodes. In traditional breast cancer surgery methods, patients whose breast cancer had spread to the axillary lymph nodes often had all these axillary lymph nodes removed. This leads to a higher rate of lymphedema in the arm, which is a painful buildup of fluid that can lead to lifelong side effects. More recently, patients with a normal examination after chemotherapy were treated with sentinel lymph node biopsy and this allowed fewer lymph nodes to be removed. Unfortunately, sentinel lymph node biopsy alone can miss detecting cancer in the axilla 10% to 15% of the time. With TAD, fewer lymph nodes are removed and it is more likely we will remove all of the cancer.

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