Radiographic identification of a positive clipped axillary lymph node in a mastectomy specimen following neoadjuvant chemotherapy

Sentinel lymph node biopsies are recommended for staging in node-positive breast cancer patients who become clinically node-negative after neoadjuvant therapy. Current guidelines support the omission of an axillary lymph node dissection if 3 negative sentinel nodes are retrieved during surgery. Consequently, the utility of routine clip placement in biopsied nodes prior to neoadjuvant chemotherapy and the necessity of targeted removal of these clipped nodes is in question. There are various methods for retrieving clipped nodes. We describe a case in which an intraoperative radiograph of a mastectomy specimen identified a clipped node that had not been localized with targeted axillary dissection in a patient with breast cancer. Pathology revealed persistent nodal positivity after neoadjuvant therapy, resulting in an escalation in care and a complete axillary dissection. We review the current literature on nodal clipping, and discuss the importance of localizing clipped nodes and the impact it can have on management.