Research Article| Volume 49, ISSUE 4, P709-715, April 2023

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Clinical utility of axillary nodal markers in breast cancer

Published:January 31, 2023DOI:



      De-escalation of axillary surgery for lymph node (LN) positive breast cancer is facilitated by marking involved nodes which, when removed with sentinel nodes constitute risk-adapted targeted axillary dissection (TAD). Whether after chemotherapy or for primary surgery, selected patients with biopsy-proven involvement of nodes may be eligible for axillary conservation. Likewise, impalpable recurrence or stage 4 patients with localised axillary disease may benefit.
      In these contexts, several devices are used to mark biopsied nodes to facilitate their accurate surgical removal. We report our experience using the paramagnetic MAGSEED (Endomag®, Cambridge, UK).


      Local approval (BR2021_149) was obtained to interrogate a prospective database of all axillary markers. The primary endpoint was successful removal of the marked LN.


      Of 241 markers (in 221 patients) inserted between October 2018 and July 2022, all were retrieved.
      Of 74 patients who had Magseeds® inserted after completion of NACT (involved nodes initially marked using an UltraCor™Twirl™ marker), the Magseeds® were found outside the node in neighbouring axillary tissue in 18 (24.3%) patients. When Magseeds® were placed at commencement of NACT in 54 patients, in only 1 (1.8%) was the marker found outside the node – a statistically significantly lower rate (Chi2 10.7581 p = 0.001038). For ‘primary TAD’ patients and those localised for recurrent or stage IV disease, all 93 had the Magseed® found within the biopsied node.


      This series supports our axillary nodal marking technique as safe and reliable. For TAD following NACT, placement at the start of treatment led to a significantly higher localisation rate.


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        • Boughey J.C.
        • Ballman K.V.
        • Le-Petross H.T.
        • McCall L.M.
        • Mittendorf E.A.
        • Ahrendt G.M.
        • et al.
        Identification and resection of clipped node decreases the false-negative rate of sentinel lymph node surgery in patients presenting with node-positive breast cancer (T0–T4, N1–N2) who receive neoadjuvant chemotherapy: results from ACOSOG Z1071 (alliance).
        Ann Surg. 2016 Apr; 263: 802-807
        • Racz J.M.
        • Caudle A.S.
        Sentinel node lymph node surgery after neoadjuvant therapy: principles and techniques.
        Ann Surg Oncol. 2019 Oct; 26: 3040-3045
        • Goyal A.
        • Dodwell D.
        POSNOC: a randomised trial looking at axillary treatment in women with one or two sentinel nodes with macrometastases.
        Clin Oncol. 2015 Dec; 27: 692-695
        • Straver M.E.
        • Loo C.E.
        • Alderliesten T.
        • Rutgers E.J.T.
        • Vrancken Peeters M.T.F.D.
        Marking the axilla with radioactive iodine seeds (MARI procedure) may reduce the need for axillary dissection after neoadjuvant chemotherapy for breast cancer.
        Br J Surg. 2010 Jul 5; 97: 1226-1231
        • Donker M.
        • Straver M.E.
        • Wesseling J.
        • Loo C.E.
        • Schot M.
        • Drukker C.A.
        • et al.
        Marking axillary lymph nodes with radioactive iodine seeds for axillary staging after neoadjuvant systemic treatment in breast cancer patients: the MARI procedure.
        Ann Surg. 2015 Feb; 261: 378-382
        • Balasubramanian R.
        • Morgan C.
        • Shaari E.
        • Kovacs T.
        • Pinder S.E.
        • Hamed H.
        • et al.
        Wire guided localisation for targeted axillary node dissection is accurate in axillary staging in node positive breast cancer following neoadjuvant chemotherapy.
        Eur J Surg Oncol. 2020 Jun; 46: 1028-1033
        • García-Novoa A.
        • Acea-Nebril B.
        • Díaz Carballada C.
        • Bouzón Alejandro A.
        • Conde C.
        • Cereijo Garea C.
        • et al.
        Combining wire localization of clipped nodes with sentinel lymph node biopsy after neoadjuvant chemotherapy in node-positive breast cancer: preliminary results from a prospective study.
        Ann Surg Oncol. 2021 Feb; 28: 958-967
        • Allweis T.M.
        • Menes T.
        • Rotbart N.
        • Rapson Y.
        • Cernik H.
        • Bokov I.
        • et al.
        Ultrasound guided tattooing of axillary lymph nodes in breast cancer patients prior to neoadjuvant therapy, and identification of tattooed nodes at the time of surgery.
        Eur J Surg Oncol. 2020 Jun; 46: 1041-1045
        • Gatek J.
        • Petru V.
        • Kosac P.
        • Ratajsky M.
        • Duben J.
        • Dudesek B.
        • et al.
        Targeted axillary dissection with preoperative tattooing of biopsied positive axillary lymph nodes in breast cancer.
        Neoplasma. 2020 Nov; 67: 1329-1334
        • Khallaf E.
        • Wessam R.
        • Abdoon M.
        Targeted axillary dissection of carbon-tattooed metastatic lymph nodes in combination with post–neo-adjuvant sentinel lymph node biopsy using 1% methylene blue in breast cancer patients.
        Breast J. 2020 May; 26: 1061-1063
        • Natsiopoulos I.
        • Intzes S.
        • Liappis T.
        • Zarampoukas K.
        • Zarampoukas T.
        • Zacharopoulou V.
        • et al.
        Axillary lymph node tattooing and targeted axillary dissection in breast cancer patients who presented as cN+ before neoadjuvant chemotherapy and became cN0 after treatment.
        Clin Breast Cancer. 2019 Jun; 19: 208-215
        • Patel R.
        • MacKerricher W.
        • Tsai J.
        • Choy N.
        • Lipson J.
        • Ikeda D.
        • et al.
        Pretreatment tattoo marking of suspicious axillary lymph nodes: reliability and correlation with sentinel lymph node.
        Ann Surg Oncol. 2019 Aug; 26: 2452-2458
        • Goyal A.
        • Puri S.
        • Marshall A.
        • Valassiadou K.
        • Hoosein M.M.
        • Carmichael A.R.
        • et al.
        A multicentre prospective feasibility study of carbon dye tattooing of biopsied axillary node and surgical localisation in breast cancer patients.
        Breast Cancer Res Treat. 2021 Jan; 185: 433-440
        • Lim G.H.
        • Teo S.Y.
        • Gudi M.
        • Ng R.P.
        • Pang J.
        • Tan Y.S.
        • et al.
        Initial results of a novel technique of clipped node localization in breast cancer patients postneoadjuvant chemotherapy: skin Mark clipped Axillary nodes Removal Technique (SMART trial).
        Cancer Med. 2020 Mar; 9: 1978-1985
        • Kuemmel S.
        • Heil J.
        • Rueland A.
        • Seiberling C.
        • Harrach H.
        • Schindowski D.
        • et al.
        A prospective, multicenter registry study to evaluate the clinical feasibility of targeted axillary dissection (TAD) in node-positive breast cancer patients.
        Ann. Surg. Internet. 2022 Nov 1; 276: e553-e562
        • Miller M.E.
        • Patil N.
        • Li P.
        • Freyvogel M.
        • Greenwalt I.
        • Rock L.
        • et al.
        Hospital system adoption of magnetic seeds for wireless breast and lymph node localization.
        Ann Surg Oncol [Internet]. 2020 Nov; (10 [cited 2021 Jan 30]; Available from:
        • Falcon S.
        • Weinfurtner R.J.
        • Mooney B.
        • Niell B.L.
        SAVI SCOUT® localization of breast lesions as a practical alternative to wires: outcomes and suggestions for trouble-shooting.
        Clin Imag. 2018 Nov; 52: 280-286
        • Laws A.
        • Dillon K.
        • Kelly B.N.
        • Kantor O.
        • Hughes K.S.
        • Gadd M.A.
        • et al.
        Node-positive patients treated with neoadjuvant chemotherapy can Be spared axillary lymph node dissection with wireless non-radioactive localizers.
        Ann Surg Oncol. 2020 Nov; 27: 4819-4827
        • Taback B.
        • Jadeja P.
        • Ha R.
        Enhanced axillary evaluation using reflector-guided sentinel lymph node biopsy: a prospective feasibility study and comparison with conventional lymphatic mapping techniques.
        Clin Breast Cancer. 2018 Oct; 18: e869-e874
        • Micha A.E.
        • Sinnett V.
        • Downey K.
        • Allen S.
        • Bishop B.
        • Hector L.R.
        • et al.
        Patient and clinician satisfaction and clinical outcomes of Magseed compared with wire-guided localisation for impalpable breast lesions.
        Breast Cancer. 2021 Jan; 28: 196-205
        • Giuliano A.E.
        Axillary dissection vs No axillary dissection in women with invasive breast cancer and sentinel node metastasis: a randomized clinical trial.
        JAMA. 2011 Feb 9; 305: 569
      1. NCCN guidelines breast cancer [Internet]. [cited 2022 Dec 18]. Available from:

        • Simons J.M.
        • Scoggins M.E.
        • Kuerer H.M.
        • Krishnamurthy S.
        • Yang W.T.
        • Sahin A.A.
        • et al.
        Prospective registry trial assessing the use of magnetic seeds to locate clipped nodes after neoadjuvant chemotherapy for breast cancer patients.
        Ann Surg Oncol. 2021 Aug; 28: 4277-4283
        • Martínez M.
        • Jiménez S.
        • Guzmán F.
        • Fernández M.
        • Arizaga E.
        • Sanz C.
        Evaluation of axillary lymph node marking with Magseed® before and after neoadjuvant systemic therapy in breast cancer patients: MAGNET study.
        in: Cabioglu N. The breast journal. 2022 Jul 9: 1-8 (2022)
        • Reitsamer R.
        • Peintinger F.
        • Forsthuber E.
        • Sir A.
        The applicability of Magseed® for targeted axillary dissection in breast cancer patients treated with neoadjuvant chemotherapy.
        Breast. 2021 Jun; 57: 113-117
        • Boughey J.C.
        Sentinel lymph node surgery after neoadjuvant chemotherapy in patients with node-positive breast cancer: the ACOSOG Z1071 (alliance) clinical trial.
        JAMA. 2013 Oct 9; 310: 1455
        • Kuehn T.
        • Bauerfeind I.
        • Fehm T.
        • Fleige B.
        • Hausschild M.
        • Helms G.
        • et al.
        Sentinel-lymph-node biopsy in patients with breast cancer before and after neoadjuvant chemotherapy (SENTINA): a prospective, multicentre cohort study.
        Lancet Oncol. 2013 Jun; 14: 609-618
        • Boileau J.F.
        • Poirier B.
        • Basik M.
        • Holloway C.M.B.
        • Gaboury L.
        • Sideris L.
        • et al.
        Sentinel node biopsy after neoadjuvant chemotherapy in biopsy-proven node-positive breast cancer: the SN FNAC study.
        J Clin Orthod. 2015 Jan 20; 33: 258-264
        • Caudle A.S.
        • Yang W.T.
        • Mittendorf E.A.
        • Black D.M.
        • Hwang R.
        • Hobbs B.
        • et al.
        Selective surgical localization of axillary lymph nodes containing metastases in patients with breast cancer: a prospective feasibility trial.
        JAMA Surg. 2015 Feb 1; 150: 137
        • Morrow M.
        • Van Zee K.J.
        • Patil S.
        • Petruolo O.
        • Mamtani A.
        • Barrio A.V.
        • et al.
        Axillary dissection and nodal irradiation can Be avoided for most node-positive z0011-eligible breast cancers: a prospective validation study of 793 patients.
        Ann Surg. 2017 Sep; 266: 457-462
        • Weber W.P.
        • Matrai Z.
        • Hayoz S.
        • Tausch C.
        • Henke G.
        • Zwahlen D.R.
        • et al.
        Tailored axillary surgery in patients with clinically node-positive breast cancer: pre-planned feasibility substudy of TAXIS (OPBC-03, SAKK 23/16, IBCSG 57-18, ABCSG-53, GBG 101).
        Breast. 2021 Dec; 60: 98-110
        • Rodriguez Gallo E.
        • Vives I.
        • Alonso I.
        • Caparros F.X.
        • Ganau S.
        • Bargallo X.
        • et al.
        A novel dual technique combining radiotracer and magnetism for restaging axilla after neoadjuvant therapy in axillary node-positive breast cancer patients.
        J Nucl Med Radiat Ther. 2018; 9: 6
        • Greenwood H.I.
        • Wong J.M.
        • Mukhtar R.A.
        • Alvarado M.D.
        • Price E.R.
        Feasibility of magnetic seeds for preoperative localization of axillary lymph nodes in breast cancer treatment.
        Am J Roentgenol. 2019 Oct; 213: 953-957
        • Mariscal Martínez A.
        • Vives Roselló I.
        • Salazar Gómez A.
        • Catanese A.
        • Pérez Molina M.
        • Solà Suarez M.
        • et al.
        Advantages of preoperative localization and surgical resection of metastatic axillary lymph nodes using magnetic seeds after neoadjuvant chemotherapy in breast cancer.
        Surg Oncol. 2021 Mar; 36: 28-33
        • McCamley C.
        • Ruyssers N.
        • To H.
        • Tsao S.
        • Keane H.
        • Poliness C.
        • et al.
        Multicentre evaluation of magnetic technology for localisation of non-palpable breast lesions and targeted axillary nodes.
        ANZ J Surg. 2021 Aug 17; (ans)17108
        • Donker M.
        • van Tienhoven G.
        • Straver M.E.
        • Meijnen P.
        • van de Velde C.J.
        • Mansel R.E.
        • et al.
        Radiotherapy or surgery of the axilla after a positive sentinel node in breast cancer (EORTC 10981-22023 AMAROS): a randomised, multicentre, open-label, phase 3 non-inferiority trial.
        Lancet Oncol. 2014 Nov; 15: 1303-1310