What are the uses and management guidelines for axilla clips in medical conditions such as axillary hyperhidrosis (excessive sweating) or post-surgical care?

Axillary Clips in Breast Cancer Management

Axillary clips are surgical markers placed in biopsied lymph nodes to enable accurate identification and removal of previously positive nodes after neoadjuvant chemotherapy, ensuring complete surgical excision and proper staging. 1

Primary Indication: Marking Positive Axillary Nodes Before Neoadjuvant Therapy

Clinically positive axillary lymph nodes (cN+) that are sampled by fine-needle aspiration or core biopsy must be clipped with an image-detectable marker at the time of biopsy. 1 This is critical because:

• The clipped positive lymph nodes must be removed at definitive surgery if the biopsy was positive before neoadjuvant therapy 1
• Clip placement into the biopsied node may improve the accuracy of post-neoadjuvant sentinel lymph node biopsy 2
• Without clips, identifying which node was originally positive becomes impossible after chemotherapy-induced response 2

When to Place Axillary Clips

Place clips at the time of initial diagnostic biopsy in any patient with:

• Clinically positive nodes (cN+) confirmed by ultrasound-guided FNA or core biopsy 1
• Clinically negative nodes that appear suspicious on ultrasound and are subsequently proven positive on biopsy 1
• Any patient planned for neoadjuvant therapy with documented nodal involvement 2

Surgical Management After Neoadjuvant Therapy

The clipped node must be surgically excised at definitive surgery. 1 The approach depends on response:

• If the axilla is initially clinically positive but has clinical complete response after treatment, sentinel lymph node biopsy may be performed only if the clipped node is removed, dual tracer is used, and more than 2 sentinel nodes are removed 2
• Otherwise, axillary lymph node dissection should be performed 2
• The false-negative rate of sentinel lymph node biopsy after neoadjuvant chemotherapy ranges from 7.3% to 12.6%, which improves with dual tracer method and removal of ≥3 sentinel nodes 2

Accuracy of Post-Neoadjuvant Axillary Assessment

Imaging cannot reliably detect residual nodal disease after neoadjuvant chemotherapy. 2 Specifically:

• Ultrasound, MRI, and PET/CT have reported sensitivities of only 69.8%, 61.0%, and 63.2% respectively for detecting residual disease 2
• Axillary ultrasound has variable sensitivity (52-90%) and should not be the sole determinant for axillary management 3
• Therefore, surgical intervention (either sentinel node biopsy or axillary dissection) is necessary after completion of neoadjuvant treatment 2

Critical Pitfalls to Avoid

Pitfall #1: Performing pre-neoadjuvant sentinel lymph node biopsy - This is not recommended because assessment of nodal response in the axilla becomes unreliable after excision of a positive node, and it invalidates the residual cancer burden score and ypN stage 2

Pitfall #2: Delaying clip placement - If clips are not placed at initial biopsy and the tumor shows significant response, it becomes impossible to identify the correct surgical area after treatment completion 1

Pitfall #3: Assuming imaging can replace surgical staging - Even with complete clinical response on imaging, the false-negative rate of imaging modalities is too high to omit surgical assessment 2

Pitfall #4: Failure to document clip placement - Communication between radiology, surgery, and pathology is essential to ensure clips are identified and the marked areas are appropriately excised 1

Distinction from Primary Tumor Clips

While axillary clips mark positive lymph nodes, primary tumor clips serve a different purpose - they mark the original breast tumor location before neoadjuvant therapy-induced shrinkage or complete response 1. Both types of clips are essential but address different anatomic sites and surgical planning needs.