# Targeted Axillary Dissection (TAD) — Caudle et al. (Implementation of TAD)

**Autores:** Caudle AS, Yang WT, Krishnamurthy S, Mittendorf EA, Black DM, Gilcrease MZ, Bedrosian I, Hobbs BP, DeSnyder SM, Hwang RF, Adrada BE, Shaitelman SF, Chavez-MacGregor M, Smith BD, Candelaria RP, Babiera GV, Dogan BE, Santiago L, Hunt KK, Kuerer HM
**Revista:** Journal of Clinical Oncology (2016)
**PMID:** 26811528 | **PMCID:** PMC4933133
**DOI:** [10.1200/JCO.2015.64.0094](https://doi.org/10.1200/JCO.2015.64.0094)
**Fuente:** PubMed Central (abstract; full text vía DOI)

## Relevancia
Artículo seminal del MD Anderson que introduce y valida la **Targeted Axillary Dissection (TAD)**: combinación de SLNB + remoción selectiva del ganglio biopsiado y clipado pre-quimioterapia. Reduce el FNR del 10.1% (SLNB sola) al **2.0% (TAD)** y al 1.4% cuando se añade la evaluación del ganglio clipado al SLNB. Fundamenta toda la práctica actual de marcaje pre-NAC.

## Abstract

**Purpose:** Placing clips in nodes with biopsy-confirmed metastasis before initiating neoadjuvant therapy allows for evaluation of response in breast cancer. Our goal was to determine if pathologic changes in clipped nodes reflect the status of the nodal basin and if **targeted axillary dissection (TAD)**, which includes sentinel lymph node dissection (SLND) and selective localization and removal of clipped nodes, improves the false-negative rate (FNR) compared with SLND alone.

**Methods:** Prospective study of patients with biopsy-confirmed nodal metastases with a clip placed in the sampled node. After neoadjuvant therapy, patients underwent axillary surgery; pathology of the clipped node was compared with other nodes. TAD = SLND + selective removal of the clipped node using iodine-125 seed localization. FNR determined in patients undergoing complete ALND.

**Results:** Of 208 patients enrolled, 191 underwent ALND, with residual disease in 120 (63%).
- **FNR clipped node alone: 4.2%** (95% CI, 1.4-9.5)
- **FNR SLND alone: 10.1%** (95% CI, 4.2-19.8) — 7 false negatives in 69 patients
- **FNR SLND + clipped node evaluation: 1.4%** (95% CI, 0.03-7.3; p=0.03)
- The clipped node was not retrieved as an SLN in **23%** (31/134) of cases
- TAD followed by ALND (n=85): **FNR 2.0%** (1/50; 95% CI 0.05-10.7)

**Conclusion:** Marking nodes with biopsy-confirmed metastatic disease allows for selective removal and improves pathologic evaluation for residual nodal disease after chemotherapy. **TAD is the standard technique to confirm ypN0 with acceptable FNR.**

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## Implicación práctica
- En toda paciente cN+ se debe **clipar el ganglio biopsiado ANTES de iniciar NAC**
- Tras NAC, realizar TAD = SLNB + extracción dirigida del ganglio clipado (con localización por semilla, magseed, clip, etc.)
- Verificar siempre intraoperatoriamente que el clip/marcador está en la pieza
- Si el ganglio clipado no coincide con un SLN, esto ocurre en ~23% — por eso es esencial extraerlo de forma dirigida

*Datos extraídos de PubMed/PMC. Citar siempre: doi 10.1200/JCO.2015.64.0094*
