Titanium clip for lymph node marking in node-positive breast cancer: a reliable, cost-effective approach to targeted...

Targeted axillary dissection (TAD) is increasingly utilised in node-positive breast cancer patients who convert to node-negative status following neoadjuvant chemotherapy (NACT). TAD combines sentinel lymph node biopsy (SLNB) with removal of the previously marked metastatic node. Localisation of the marked node, however, remains one of the most technically challenging aspects of TAD and is a major barrier to its wider implementation. This study aimed to evaluate the clinical feasibility of using a low-cost titanium clip for lymph node (LN) marking and to determine the clipped node (CN) identification rate (IR) as well as its concordance with sentinel lymph nodes (SLNs).

This prospective feasibility study was conducted at Sri Shankara Cancer Hospital and Research Centre, Bangalore, between January 2024 and January 2025 after IEC approval. Patients with cN1, fine needle aspiration cytology/biopsy-proven nodal metastasis undergoing axillary LN clipping before NACT were included. The most suspicious LN was clipped using a coaxial system to deploy a titanium clip (Ligaclip, Ethicon Endo-Surgery, USA). Pre-operatively, the CN was localised using intra-operative ultrasound and direct skin marking. SLNB was performed using dual tracers: indocyanine green (ICG) combined with either methylene blue (MB) or radioisotope (RI). All patients subsequently underwent axillary lymph node dissection.

A total of 28 patients were included, with a mean age of 50.8 years. The CN IR was 100%, with an average CN size of 20 mm. In 92.5% of cases, the CN corresponded to the SLN. SLNB mapping success was 91.6% (11/12) with ICG + RI and 86.6% (13/15) with ICG + MB. A median of four LNs were retrieved during TAD. Nodal pathological complete response was achieved in 77.7% (21/27) of patients, more frequently among triple-negative (9/21) and Human epidermal growth factor receptor 2-positive (8/21) subtypes.

The titanium clip demonstrated no migration and achieved 100% identification and retrieval of the CN, with high concordance to the sentinel node. These results establish clip-assisted TAD as a clinically feasible, reproducible and cost-effective approach that may facilitate wider adoption of TAD in node-positive breast cancer patients following NACT, particularly in resource-constrained settings.