br Kyu HH Bachman VF Alexander LT Mumford
 Kyu HH, Bachman VF, Alexander LT, Mumford JE, Afshin A, Estep K, et al. Physical activity and risk of breast cancer, colon cancer, diabetes, ischemic AMG-176 disease, and ischemic stroke events: systematic review and dose-response meta-analysis for the Global Burden of Disease Study 2013. BMJ 2016;354:i3857.
 Wiklund P. The role of physical activity and exercise in obesity and weight management: time for critical appraisal. J Sport Health Sci 2016;5(2):151e4. Original Study
Axillary Lymph Node Tattooing and Targeted Axillary Dissection in Breast Cancer Patients Who Presented as cNþ Before Neoadjuvant Chemotherapy and Became cN0 After Treatment
Ioannis Natsiopoulos,1 Stavros Intzes,1 Triantafyllos Liappis,1 Konstantinos Zarampoukas,1 Thomas Zarampoukas,2 Vasiliki Zacharopoulou,3 Konstantinos Papazisis4
Axillary lymph node tattooing and targeted axillary dissection, as axillary staging, was evaluated in 75 breast cancer patients who presented as cND before neoadjuvant chemotherapy and became cN0 after treatment. Marking axillary lymph nodes with tattoo is a feasible, accurate, and low-cost method. Tattoo ink migration from one node to another might affect the objectivity of the procedure. Introduction: Targeted axillary dissection (TAD) is an alternative to axillary dissection for breast cancer patients who presented as cNþ before neoadjuvant chemotherapy (NAC) and became cN0 after treatment. TAD is defined as the removal of sentinel lymph nodes (SLNs) along with the pre-NAC marked positive nodes. Tattooing is an option to mark positive nodes. In this study we aimed to investigate the identification rate of tattooed nodes during surgery, corre-spondence between tattooed nodes and SLNs, and difficulties and pitfalls of the method. Patients and Methods: In 75 patients who were cNþ, with axillary lymph nodes known to have or suspected to have disease were tattooed pre-NAC with a sterile carbon suspension (Spot). After NAC completion all patients became cN0 and underwent TAD as an axillary staging procedure. Results: SLNs were identified successfully in 70 of 75 patients (93.3%). All tattooed nodes were identified successfully intraoperatively in 71 of 75 patients (94.6%). Retrieval of all tattooed nodes in surgical specimens was achieved in 74 patients (98.6%). Correspondence between tattooed nodes and SLNs was observed in 53 of 70 patients (75.3%). In 34 patients (45.3%) the number of pigmented nodes in pathological examination was greater than the number of initially tattooed nodes, indicating the possibility of tattoo ink migration. Conclusion: Tattoo of axillary lymph nodes is a feasible, accurate, and low-cost method of positive node marking pre-NAC. Pathological confirmation of black pigment in the lymph nodes excised is not by itself warranty of retrieval of all marked node because of tattoo ink migration from one node to another. Intraoperative identification using visual inspection is essential.
Keywords: Axillary staging, Breast cancer, Neoadjuvant Chemotherapy, Targeted axillary dissection, Tattoo
1Department of Breast Surgery
2Department of Pathology 3Department of Nuclear Medicine 4Department of Clinical Oncology, Interbalkan European Medical Center, Thessalo-niki, Greece
Address for correspondence: Ioannis Natsiopoulos, MD, Interbalkan European Medical Center, Breast Surgery Department, 10 Asclepiou str, Pylaia, Thessaloniki 57001, Greece E-mail contact: [email protected]
Axillary lymph node (ALN) status remains one of the most important prognostic factors in breast cancer, even in the era of tumor biology and gene expression. It is also valuable information for the planning of adjuvant locoregional and systemic treaitment. Sentinel lymph node (SLN) biopsy (SLNB) has become the stan-dard approach to axillary staging for breast cancer cN0 patients; it provides accurate information with low morbidity compared with ALN dissection (ALND).1,2 After results of the ACOSOG (American College of Surgeons Oncology Group) Z0011, IBCSG
(International Breast Cancer Study Group) 23-01, and the Euro-pean Organization for Research and Treatment of Cancer (EORTC) 10981-22023 AMAROS (After Mapping of the Axilla: Radiotherapy or Surgery) trials, which support the omission of complete ALND in selective patients with positive SLNB (small tumors, small tumor burden in the axilla, planned for appropriate adjuvant treatment and radiotherapy), axillary staging seems to be more a prognostic tool in breast cancer care than a local control treatment.3-5
Neoadjuvant chemotherapy (NAC) is increasingly used for oper-able breast cancer. Many questions have been raised about the optimal use of SLNB in axillary staging after NAC. Many studies support the concept of post-NAC SLNB for patients with negative axilla in diagnosis (cN0). They report identification rates (SLN IRs) and false negative rates (FNRs) similar to those observed in the upfront surgery setting. Furthermore, complete ALND rates are lower in post-NAC SLNB compared with those in pre-NAC SLNB. Current National Comprehensive Cancer Network guidelines encourage the perfor-mance of SLNB for cN0 patients after the completion of NAC.6-9 For patients who present with nodal metastases (cNþ), who became cN0 after NAC, SLNB as axillary staging has been debated. Three pro-spective multi-institutional clinical trials, ACOSOG Z1071, SEN-TINA (SENTInel NeoAdjuvant) and SN FNAC (Sentinel Node biopsy Following NeoAdjuvant Chemotherapy), which assessed the accuracy of SLNB after NAC among these patients, reported SLN IRs between 87.6% and 92.9% with the use of a dual tracing technique (radiotracer with blue dye). The overall FNRs were >10% and all of those trials were considered negative trials.10-12 In a subgroup of ACOSOG Z1071, the biopsy-proven positive lymph node was marked with a clip before NAC initiation. When the clipped node was present within retrieved sentinel nodes, the FNR was 6.8%.10 In the MARI [Marking the Axillary lymph node with Radioactive Iodine (125I) seeds] trial, a single-institution prospective trial, the positive lymph node was marked with an I125 radioactive seed. After NAC completion, the removal of the marked node without SLNB had only a 7% FNR.13 In another single-institution prospective trial, the removal of marked lymph nodes, along with sentinel nodes, succeeded FNR by only 2%.14 This procedure is known as targeted axillary dissection (TAD), which seems to be a reliable procedure for axillary staging after NAC, regarding patients who presented with axillary involvement in the diagnosis.