Prediction of axillary nodal burden in patients with invasive lobular carcinoma using MRI

PURPOSE

To investigate clinical and imaging features associated with a high nodal burden (≥ 3 metastatic lymph nodes [LNs]) and compare diagnostic performance of US and MRI in patients with invasive lobular carcinoma (ILC) and invasive ductal carcinoma (IDC).

METHODS

Retrospective search revealed 239 patients with ILC and 999 with IDC who underwent preoperative US and MRI between January 2016 and June 2019. Patients with ILC were propensity-score-matched with patients with IDC. Univariate and multivariate logistic regression analyses were performed to determine factors associated with ≥ 3 metastatic LNs.

RESULTS

412 patients (206 ILC and 206 IDC) were evaluated. Of all patients with ILC, 27.2% (56/206) were node-positive and 7.8% (16/206) showed a high nodal burden. In multivariate analysis, the clinical N stage was the only independent factor associated with a high nodal burden in patients with IDC (odds ratio [OR] 6.24; 95% confidence interval [CI] 1.57-24.73; P = 0.009), but not in patients with ILC. Increased cortical thickness with loss of fatty hilum on US was associated with a high nodal burden in patients with ILC (OR 58.40; 95% CI 5.09-669.71; P = 0.001) and IDC (OR 24.14; 95% CI 3.52-165.37; P = 0.001), while suspicious LN findings at MRI were independently associated with a high nodal burden in ILC only (OR 13.94; 95% CI 2.61-74.39; P = 0.002).

CONCLUSION

In patients with ILC, MRI findings of suspicious LNs were helpful to predict a high nodal disease burden.

Radiomics Nomogram of DCE-MRI for the Prediction of Axillary Lymph Node Metastasis in Breast Cancer

Purpose

This study aimed to establish and validate a radiomics nomogram based on dynamic contrast-enhanced (DCE)-MRI for predicting axillary lymph node (ALN) metastasis in breast cancer.

Method

This retrospective study included 296 patients with breast cancer who underwent DCE-MRI examinations between July 2017 and June 2018. A total of 396 radiomics features were extracted from primary tumor. In addition, the least absolute shrinkage and selection operator (LASSO) algorithm was used to select the features. Radiomics signature and independent risk factors were incorporated to build a radiomics nomogram model. Calibration and receiver operator characteristic (ROC) curves were used to confirm the performance of the nomogram in the training and validation sets. The clinical usefulness of the nomogram was evaluated by decision curve analysis (DCA).

Results

The radiomics signature consisted of three ALN-status-related features, and the nomogram model included the radiomics signature and the MR-reported lymph node (LN) status. The model showed good calibration and discrimination with areas under the ROC curve (AUC) of 0.92 [95% confidence interval (CI), 0.87-0.97] in the training set and 0.90 (95% CI, 0.85-0.95) in the validation set. In the MR-reported LN-negative (cN0) subgroup, the nomogram model also exhibited favorable discriminatory ability (AUC, 0.79; 95% CI, 0.70-0.87). DCA findings indicated that the nomogram model was clinically useful.

Conclusions

The MRI-based radiomics nomogram model could be used to preoperatively predict the ALN metastasis of breast cancer.

Development and Validation of a Preoperative Scoring System to Distinguish Between Nonadvanced and Advanced Axillary Lymph Node Metastasis in Patients With Early-stage Breast Cancer

BACKGROUND

It has been determined that axillary lymph node dissection after the detection of limited axillary lymph node metastasis does not improve the prognosis of patients with breast cancer. Thus, a need exists for less-invasive axillary surgery. However, it remains unclear whether a predictive model based on preoperative data would be sufficient to accurately predict the probability of pN2-N3 (> 3 lymph node metastases). We sought to develop an easy-to-use scoring system to distinguish between pN0-N1 (0-3 lymph node metastases) and pN2-N3 using only preoperative data and validate its predictive performance.

PATIENTS AND METHODS

We retrospectively identified 2687 patients diagnosed with cT1-3cN0-N1 who had undergone surgery in our hospital from 2013 to 2019. We evaluated the risk factors associated with pN2-N3 by logistic regression analysis and developed a scoring system. Predictive performance was assessed by calculating the receiver operating characteristic area under the curve (AUC) and was validated using K-fold cross-validation.

RESULTS

We identified 1987 patients with stage pN0, 522 with pN1, and 178 with pN2-N3. Multivariate analysis revealed tumor size, number of suspicious lymph nodes on axillary ultrasound examination, histologic type, histologic grade, and receptor status were significant risk factors for pN2-N3. The AUC value was 0.87, and the mean AUC of the 10-fold cross-validation was 0.88. When the cutoff score was set at 6, the negative predictive value for excluding patients with pN2-N3 was 98.4%.

CONCLUSION

Our easy-to-use scoring system could be useful to preoperatively identify patients at lower risk of pN2-N3 and avoid unnecessary axillary lymph node dissection.

Machine learning prediction of axillary lymph node metastasis in breast cancer: 2D versus 3D radiomic features

PURPOSE

The purpose of this study was to distinguish axillary lymph node (ALN) status using preoperative breast DCE-MRI radiomics and compare the effects of two-dimensional (2D) and three-dimensional (3D) analysis.

METHODS

A retrospective study including 154 breast cancer patients all confirmed by pathology; 80 with ALN metastasis and 74 without. All MRI scans were achieved at a 3.0 Tesla scanner with 7 post-contrast MR phases sequentially acquired with a temporal resolution of 60 s. MRI radiomic features were extracted separately from a 2D single slice (i.e., the representative slice) and the 3D tumor volume. Several machine learning classifiers were built and compared using 2D or 3D analysis to distinguish positive vs negative ALN status. We performed independent test and 10-fold cross validation with multiple repetitions, and used bootstrap test, least absolute shrinkage selection operator, and receiver operating characteristic (ROC) curve analysis as statistical tests.

RESULTS

The highest area under the ROC curve (AUC) was 0.81 (95% confidence intervals [CI]: 0.80-0.83) and 0.82 (95% CI: 0.81-0.82) for 2D and 3D analysis, respectively; the corresponding accuracy was 79% and 80%. The linear discriminant analysis (LDA) classifier achieved the highest classification performance. None of the AUC differences between 2D and 3D analysis was statistically significant for the several tested machine learning classifiers (all P> 0.05).

CONCLUSIONS

Radiomic features from segmented tumor region in breast MRI were associated with ALN status. The separate radiomic analysis on 3D tumor volume showed a similar effect to the 2D analysis on the single representative slice in the tested machine learning classifiers.

Prospective evaluation of whole-body MRI and 18F-FDG PET/MRI in N and M staging of primary breast cancer patients

OBJECTIVES

To evaluate and compare the diagnostic potential of whole-body MRI and whole-body 18F-FDG PET/MRI for N and M staging in newly diagnosed, histopathologically proven breast cancer.

MATERIAL AND METHODS

A total of 104 patients (age 53.4 ± 12.5) with newly diagnosed, histopathologically proven breast cancer were enrolled in this study prospectively. All patients underwent a whole-body 18F-FDG PET/MRI. MRI and 18F-FDG PET/MRI datasets were evaluated separately regarding lesion count, lesion localization, and lesion characterization (malignant/benign) as well as the diagnostic confidence (5-point ordinal scale, 1-5). The N and M stages were assessed according to the eighth edition of the American Joint Committee on Cancer staging manual in MRI datasets alone and in 18F-FDG PET/MRI datasets, respectively. In the majority of lesions histopathology served as the reference standard. The remaining lesions were followed-up by imaging and clinical examination. Separately for nodal-positive and nodal-negative women, a McNemar chi2 test was performed to compare sensitivity and specificity of the N and M stages between 18F-FDG PET/MRI and MRI. Differences in diagnostic confidence scores were assessed by Wilcoxon signed rank test.

RESULTS

MRI determined the N stage correctly in 78 of 104 (75%) patients with a sensitivity of 62.3% (95% CI: 0.48-0.75), a specificity of 88.2% (95% CI: 0.76-0.96), a PPV (positive predictive value) of 84.6% % (95% CI: 69.5-0.94), and a NPV (negative predictive value) of 69.2% (95% CI: 0.57-0.8). Corresponding results for 18F-FDG PET/MRI were 87/104 (83.7%), 75.5% (95% CI: 0.62-0.86), 92.2% (0.81-0.98), 90% (0.78-0.97), and 78.3% (0.66-0.88), showing a significantly better sensitivity of 18F-FDG PET/MRI determining malignant lymph nodes (p = 0.008). The M stage was identified correctly in MRI and 18F-FDG PET/MRI in 100 of 104 patients (96.2%). Both modalities correctly staged all 7 patients with distant metastases, leading to false-positive findings in 4 patients in each modality (3.8%). In a lesion-based analysis, 18F-FDG PET/MRI showed a significantly better performance in correctly determining malignant lesions (85.8% vs. 67.1%, difference 18.7% (95% CI: 0.13-0.26), p < 0.0001) and offered a superior diagnostic confidence compared with MRI alone (4.1 ± 0.7 vs. 3.4 ± 0.7, p < 0.0001).

CONCLUSION

18F-FDG PET/MRI has a better diagnostic accuracy for N staging in primary breast cancer patients and provides a significantly higher diagnostic confidence in lesion characterization than MRI alone. But both modalities bear the risk to overestimate the M stage.

Preoperative Prediction of Axillary Lymph Node Metastasis in Breast Carcinoma Using Radiomics Features Based on the Fat-Suppressed T2 Sequence

RATIONALE AND OBJECTIVES

To investigate the value of radiomics method based on the fat-suppressed T2 sequence for preoperative predicting axillary lymph node (ALN) metastasis in breast carcinoma.

MATERIALS AND METHODS

The data of 329 invasive breast cancer patients were divided into the primary cohort (n = 269) and validation cohort (n = 60). Radiomics features were extracted from the fat-suppressed T2-weighted images on breast MRI, and ALN metastasis-related radiomics feature selection was performed using Mann-Whitney U-test and support vector machines with recursive feature elimination; then a radiomics signature was constructed by linear support vector machine. The predictive models were constructed using a linear regression model based on the clinicopathologic factors and radiomics signature, and nomogram was used for a visual prediction of the combined model. The predictive performances are evaluated with the sensitivity, specificity, accuracy, and area under the receiver operating characteristic curve.

RESULTS

A total of 647 radiomics features were extracted from each patient. About 23 ALN metastasis-related radiomics features were selected to construct the radiomics signature, including 17 texture features, 5 first-order statistical features, and one shape feature; patient age, tumor size, HER2 status, and vascular cancer thrombus accompanied or not were selected to construct the cilinicopathologic feature model. The sensitivity, specificity, accuracy, and are under the curve value of radiomics signature, clinicopathologic feature model, and the nomogram were 65.22%, 81.08%, 75.00%, and 0.819 (95% confidence interval [CI]: 0.776-0.861), 30.44%, 81.08%, 61.67%, and 0.605 (95% CI: 0.571-0.624) and 60.87%, 89.19%, 78.33%, and 0.810 (95% CI: 0.761-0.855), respectively.

CONCLUSION

Radiomics methods based on the fat-suppressed T2 sequence and the nomogram are helpful for preoperative accurate predicting ALN metastasis.

Nomogram based on radiomics analysis of primary breast cancer ultrasound images: prediction of axillary lymph node tumor burden in patients

OBJECTIVES

To establish a prediction model for evaluating the axillary lymph node (ALN) status of patients with T1/T2 invasive breast cancer based on radiomics analysis of US images of primary breast lesions.

METHODS

Between August 2016 and November 2018, a total of 343 patients with histologically proven malignant breast tumors were included in this study and randomly assigned to the training and validation groups at a ratio of 7:3. ALN tumor burden was defined as low (< 3 metastatic ALNs) or high (≥ 3 metastatic ALNs). Radiomics features were obtained using the PyRadiomics package, and the radiomics score was established by least absolute shrinkage and selection operator regression. A nomogram combining the breast cancer US radiomics score with patient age and lesion size was generated based on the multivariate logistic regression results.

RESULTS

In the training and validation cohorts, 29.1% (69/237) and 32.08% (34/106) of patients were pathologically diagnosed with more than 2 metastatic ALNs, respectively. The radiomics score consisted of 16 US features, and patient age and lesion diameter identified by US were included to construct the model. The AUC of the model was 0.846 (95% CI, 0.790-0.902) for the training cohort and 0.733 (95% CI, 0.613-0.852) for the validation cohort. The calibration curves showed good agreement between the predictions and observations.

CONCLUSIONS

Our novel nomogram demonstrates high accuracy in predicting ALN tumor burden in breast cancer patients. We also suggest further development of PyRadiomics to improve US radiomics.

KEY POINTS

• A nomogram based on US was developed to predict ALN tumor burden (low, < 3 metastatic ALNs; high, ≥ 3 metastatic ALNs). • The nomogram could assist clinicians in evaluating treatment strategies for T1/T2 invasive breast cancer.

Pre-operative axillary ultrasound with fine-needle aspiration cytology performance and predictive factors of false negatives in axillary lymph node involvement in early breast cancer

PURPOSE

Breast cancer is the most common cancer among females worldwide. Axillary lymph node involvement is an important prognostic factor in pre-operative evaluation. The aim of this study was to evaluate the sensitivity and accuracy of AUS during the initial breast cancer diagnosis and the contribution of ultrasound with guided FNAC (AUS + FNAC) in cases of suspicious node.

METHODS

A retrospective study was conducted at the Lorraine Cancer Institute between 1 January and 31 December 2015. It included patients with early breast cancer, all of whom received AUS. If axillary node involvement was suspected, FNAC was performed. Sentinel lymph node biopsy (SLNB) and/or axillary lymph node dissection (ALND) were performed depending on FNAC results.

RESULTS

In total, 292 patients were included. 88 patients (30.1%) had a suspicious lymph node on ultrasound and had FNAC, of whom 53 tested positive for axillary node involvement (60.2%). Among the 35 patients who tested negative with FNAC, 15 had axillary metastatic involvement. Performance of AUS + FNAC was better than that of AUS alone, with sensitivity, specificity, positive predictive and negative predictive values of approximately 44.5%, 100%, 100% and 72.4%, respectively, and accuracy of approximately 77.4%. Luminal A subgroup, axillary involvement of less than two positive nodes or nodal tumor of less than 7 mm are independent factors of false negative rate.

CONCLUSIONS

AUS performance would seem to be improved by FNAC, with a false negative rate of approximately 26%. It may be possible to reduce the false negative rate of AUS if its contributing factors are taken into consideration, along with the impact of specific echographic signs as revealed by experienced radiologists.

Lymph Node Predictive Model with in Vitro Ultrasound Features for Breast Cancer Lymph Node Metastasis

Ultrasound diagnosis of axillary lymph nodes has the advantages of ease, convenience and low cost; however, most previous studies evaluated lymph node metastasis of the entire axilla rather than the association between the ultrasound features of a single lymph node and its pathology. This prospective study was performed to explore the ultrasound features of lymph nodes observed in bionic medium in vitro and to develop a lymph node-specific model for prediction of metastasis based on analysis of the association between the ultrasound features and pathology of each lymph node. From November 1, 2017 to December 19, 2017, 373 nodes (54 patients) were enrolled into the modeling group; from December 20, 2017 to January 12, 2018, 139 lymph nodes (22 patients) were enrolled into the validation group. Lymph nodes from sentinel lymph node biopsy or axillary lymph node dissection were enrolled. Individual lymph nodes were placed in bionic medium and observed separately using ultrasound. Traditional ultrasound features of metastatic nodes (long axis, short axis, cortical thickness and hilum loss) were recorded, and the longitudinal-to-transverse axis ratio (L/T) and cortical proportion were calculated. Pathologic results specific to each lymph node were recorded. On the basis of two-level binary logistic regression, independent predictors of lymph node metastasis in the modeling group were lymph node long axis (p = 0.004), short axis (p < 0.001), L/T (p = 0.006), cortical thickness (p = 0.001) and hilum loss (p < 0.001). When analysis was done at the node level, the areas under the curve of the modeling and validation groups were 0.97 and 0.75, respectively. When validation was done at the patient level, the areas under the curve of the modeling and validation groups were 0.96 and 0.93, respectively. The model for prediction of metastasis based on the ultrasound features and pathology of each lymph node is of good predictive value for lymph node metastasis.

Mammography-based radiomics nomogram: a potential biomarker to predict axillary lymph node metastasis in breast cancer

OBJECTIVE

To establish a radiomics nomogram by integrating clinical risk factors and radiomics features extracted from digital mammography (MG) images for pre-operative prediction of axillary lymph node (ALN) metastasis in breast cancer.

METHODS

216 patients with breast cancer lesions confirmed by surgical excision pathology were divided into the primary cohort (n = 144) and validation cohort (n = 72). Radiomics features were extracted from craniocaudal (CC) view of mammograms, and radiomics features selection were performed using the methods of ANOVA F-value and least absolute shrinkage and selection operator; then a radiomics signature was constructed with the method of support vector machine. Multivariate logistic regression analysis was used to establish a radiomics nomogram based on the combination of radiomics signature and clinical factors. The C-index and calibration curves were derived based on the regression analysis both in the primary and validation cohorts.

RESULTS

95 of 216 patients were confirmed with ALN metastasis by pathology, and 52 cases were diagnosed as ALN metastasis based on MG-reported criteria. The sensitivity, specificity, accuracy and AUC (area under the receiver operating characteristic curve of MG-reported criteria were 42.7%, 90.8%, 24.1% and 0.666 (95% confidence interval: 0.591-0.741]. The radiomics nomogram, comprising progesterone receptor status, molecular subtype and radiomics signature, showed good calibration and better favorite performance for the metastatic ALN detection (AUC 0.883 and 0.863 in the primary and validation cohorts) than each independent clinical features (AUC 0.707 and 0.657 in the primary and validation cohorts) and radiomics signature (AUC 0.876 and 0.862 in the primary and validation cohorts).

CONCLUSION

The MG-based radiomics nomogram could be used as a non-invasive and reliable tool in predicting ALN metastasis and may facilitate to assist clinicians for pre-operative decision-making.

ADVANCES IN KNOWLEDGE

ALN status remains among the most important breast cancer prognostic factors and is essential for making treatment decisions. However, the value of detecting metastatic ALN by MG is very limited. The studies on pre-operative ALN metastasis prediction using the method of MG-based radiomics in breast cancer are very few. Therefore, we studied whether MG-based radiomics nomogram could be used as a predictive biomarker for the detection of metastatic ALN.

Axillary lymph node dissection is not obligatory in breast cancer patients with biopsy-proven axillary lymph node metastasis

PURPOSE

The ACOSOG Z0011 trial demonstrated that axillary lymph node dissection (ALND) is unnecessary in select patients with cT1-2N0 tumors undergoing breast-conserving therapy with 1-2 positive sentinel lymph nodes (SLNs). However, patients with preoperatively confirmed ALN metastasis were not included and may be subjected to unnecessary ALND. The aim of this study is to identify patients who can be considered for ALND omission when the preoperative ALN biopsy results are positive.

METHODS

Breast cancer patients who underwent preoperative ALN biopsy and primary surgery were retrospectively reviewed. Among patients with positive ALN biopsy results, clinicopathological and imaging characteristics were compared according to LN disease burden (1-2 positive LNs vs. ≥ 3 positive LNs).

RESULTS

A total of 542 patients were included in the analysis. Among them, 225 (41.5%) patients had a preoperative positive ALN biopsy. More than 40% of the patients (n = 99, 44.0%) with a positive biopsy had only 1-2 positive ALNs. The association between nodal burden and imaging factors was strongest when ≥ 2 suspicious LNs were identified on PET/CT images (HR 8.795, 95% CI 4.756 to 13.262). More than one imaging modality showing ≥ 2 suspicious LNs was also strongly correlated with ≥ 3 positive ALNs (HR 5.148, 95% CI 2.881 to 9.200).

CONCLUSIONS

Nearly half of patients with a preoperative biopsy-proven ALN metastasis had only 1-2 positive LNs on ALND. Patients meeting ACOSOG Z0011 criteria with only one suspicious LN on PET/CT or those presenting with few abnormal ALNs on only one imaging modality appear appropriate for SLNB and consideration of ALND omission.

Analysis of the radio-pathological factors of triple negative breast cancer and determination of risk profiles

OBJECTIVE

Triple-negative tumors are the most aggressive type of breast cancer. We aimed to analyze the main radiologic and histopathologic factors of these tumors to create a risk profile.

MATERIALS AND METHODS

We analyzed data from 140 patients diagnosed with triple-negative breast cancer between January 2007 and December 2016, with follow-up through April 2018. We analyzed the following variables in the breast MRI done for staging: size, necrosis, associated findings, adenopathies, and perfusion and diffusion parameters. We analyzed the following variables in histopathologic studies of biopsy specimens: histological type, Scarf-Bloom, Ki67, and p53 in the infiltrating component as well as in the in situ component. We analyzed the following variables in histopathologic studies of positive lymph nodes and surgical specimens: size, lymphovascular/perineural invasion, and microglandular adenosis. We analyzed the relation between the radiologic and histopathologic factors and recurrence and disease-free survival.

RESULTS

MRI tumor size>25mm, non-nodular enhancement, breast edema, areola-nipple complex retraction, and lymph-node involvement were associated with recurrence and lower disease-free survival. Invasive lobular carcinoma, postsurgical size>20mm, and p53<15% were also associated with recurrence and lower disease-free survival. Histologically positive lymph nodes were associated with a greater percentage of recurrence and lymphovascular invasion and with lower disease-free survival. The multivariate analysis found that the variables MRI size>25mm, non-nodular enhancement, adenopathies on MRI, and p53 expression <15% were independent predictors of lower disease-free survival.

CONCLUSIONS

In triple-negative breast tumors, factors associated with lower disease-free survival are non-nodular enhancement, size>25mm, and adenopathies on MRI, and p53 expression <15% on histopathologic study.

Utility of Ultrasound and Mammography in Detection of Negative Axillary Nodal Metastasis in Breast Cancer

Objective The status of axillary lymph nodes is one of the most important prognostic factors in patients with breast cancer. A precise noninvasive evaluation of axillary lymph node status preoperatively, although challenging, is vital for optimization of the treatment plan for patients. The objective of our study was to assess the utility of ultrasound and mammography in detecting the absence of axillary lymph nodal metastasis in patients of breast cancer, taking histopathology as gold standard. Methods A cross-sectional study was conducted in the Department of Radiology, Aga Khan University Hospital, Karachi. All female patients between 20 and 95 years of age with a known diagnosis of breast cancer with mammographic and ultrasound imaging done at our institute were included. Patients with abnormal lymph nodes on mammography or on ultrasound, patients already operated for breast cancer, patients who already underwent axillary lymph node dissection and those whose histopathology reports were not available or who did not undergo surgery were excluded. Results A total of 262 women with breast carcinoma who had both ultrasound and mammography done and also had surgery performed at our institution were included. At final surgical pathology, a total of 45 of the 262 patients (17.2%) with breast carcinoma had one or more positive lymph nodes. Out of the total 262 patients, 217 patients were found to be true negatives as they had absent axillary nodal metastasis on imaging as well as on histopathology. In all, 45 out of 262 patients were found to be false negatives as they had absent axillary nodal metastasis on imaging; however, they were found to be positive for metastasis on histopathology. The negative predictive value was 82.8%. Patient age was considered as a factor that may influence the outcome of results; the patients were stratified into age ranges seven groups with the age range of 10 years, ranging from 26 to 95 years. Chi-square test showed a p-value of 0.148, which showed no significant difference in the effect of age on diagnosing the absence of metastasis by ultrasound and mammography. Conclusion Our study shows that ultrasound and mammography even when used in combination cannot safely exclude axillary metastasis and thus cannot eliminate the need for sentinel node biopsy.

Evaluation of Diagnostic Accuracy and Impact of Preoperative Positron Emission Tomography/Computed Tomography in the Management of Early Operable Breast Cancers

AIM

Our aim of this study was to evaluate the diagnostic accuracy of staging positron emission tomography/computed tomography (PET/CT) in early breast cancers (EBCs) and to assess its impact on disease management.

PATIENTS AND METHODS

We retrospectively reviewed preoperative PET/CT scans of patients from January 2015 to December 2018 with Stage I/II, clinically T1-T2 N0-N1 breast cancers. The diagnostic performance of PET/CT for nodal (N) and distant metastases (M), its correlation with patient/tumor-specific factors, and its impact on disease management were analyzed using histopathology/clinical follow-up as standards of reference.

RESULTS

Of 158 patients evaluated, 14% of patients were Stage I (T1N0), 60% were Stage IIA (T1N1, T2N0), and 26% were Stage IIB (T2N1). Sensitivity, specificity, and the diagnostic accuracy of PET/CT for axillary staging were 76%, 97%, and 84% and for distant metastasis evaluation were 100%, 98%, and 99%, respectively. The diagnostic accuracy of PET/CT for axillary staging was lower for low-grade, T1 tumors, postmenopausal group, and luminal A pathological subtype (77%, 84%, 81%, and 73%, respectively) compared to high-grade, T2 tumors, premenopausal group, and nonluminal A subtype (88%, 88%, 94%, and 87%, respectively). Distant metastases were detected on PET/CT in overall 16% (n = 25) of the patients (9% in Stage IIA and 27% in Stage IIB). PET/CT also incidentally identified clinically occult internal mammary nodes in 5% (n = 8) and organ-confined synchronous second malignancies in 5% (n = 8) of the patients.

CONCLUSION

Preoperative PET/CT should be considered in all EBCs> 2 cm as it upstages the disease and alters management in about 24% of these patients. Given its high specificity for axillary staging PET/CT, patients with PET-positive axilla can be subjected to axillary dissection and those with PET-negative axilla to sentinel lymph node biopsy. The yield and diagnostic accuracy of PET/CT is less for low-grade tumors <2 cm and with luminal A subtype.

Ultrasound as a replacement for physical examination in clinical staging of axillary lymph nodes in breast cancer patients

BACKGROUND

The status of axillary lymph nodes (ALNs) is one of the important factors in decision-making for breast cancer treatment. Physical examination (PE) has long been the main, or even the only, means of clinical staging for ALNs in breast cancer. However, the sensitivity and accuracy of PE remains unsatisfactory. The results from this study suggest that axillary ultrasonography (US) should replace PE as a standard method for the clinical staging of ALNs in breast cancer.

METHODS

Consecutive and nonselective breast cancer patients treated between September 2018 and November 2018 in our center were enrolled in the study. Comparisons of ALN results between PE/US and pathological results were conducted and the difference in sensitivity, specificity and accuracy between PE and US were tested by McNemar chi-square test.

RESULTS

A total of 123 patients were enrolled into the study. Their ages ranged from 28 to 76 years with a median age of 53 ± 10. There were 83 ALN positive cases and 40 ALN negative cases confirmed pathologically. The sensitivity, specificity, accuracy, positive predictive value and negative predictive value of PE and US were 54.2%, 90.0%, 65.9%, 91.8%, 48.7% versus 86.8%, 72.5%, 82.1%, 86.8%, 72.5%, respectively. The sensitivity and accuracy of US was significantly higher than that of PE (P = 0.004 and P = 0.002).

CONCLUSION

The results of this study demonstrated that US is superior in evaluating ALNs when compared with PE and that US should replace PE as the standard method for the clinical staging of ALNs in breast cancer.

Ultrasound Imaging for Detecting Metastasis to Level II and III Axillary Lymph Nodes after Axillary Lymph Node Dissection for Invasive Breast Cancer

OBJECTIVES

The diagnostic value of axillary ultrasound (US) for level II and III axillary lymph node metastasis after axillary lymph node dissection for invasive breast cancer is currently not clear. The objectives of this study were to retrospectively analyze the diagnostic value of axillar US for level II and III axillary lymph node metastasis and compare it with palpation and to analyze the US features of level II and III axillary lymph nodes that are predictive of metastatic recurrence during follow-up.

METHODS

Cases with level II or III axillary lymph nodes detected by US between January 2005 and December 2017 at a cancer center were divided into 2 groups according to a retrospective analysis of US findings: potential malignancy group and follow-up group. Biopsy was performed in all patients in the potential malignancy group. In the follow-up group, the patients were followed for at least 2 years, and biopsy was performed if suspicious US features were detected.

RESULTS

The 401 enrolled cases were followed by axillary US and physical examination (PE) for comparison. Finally, 55 axillary metastases were pathologically confirmed (14%). The sensitivity, specificity, and area under the receiver operating characteristic curve for axillary US were 92.7%, 93.9%, and 0.933, respectively, and the corresponding values for PE were 49.1%, 91.3%, and 0.702 (P < .001). An increase in the major or minor axis diameter of the lymph nodes of greater than 2 mm, a Solbiati index value of less than 1.5, and the presence of new suspicious lesions in other regions were significant predictors of lymph node metastasis based on the US findings (P = .013, .006, .015, and .036).

CONCLUSIONS

Axillary is helpful in the follow-up of level II and III axillary lymph nodes after axillary lymph node dissection for invasive breast cancer and can detect cancer recurrence earlier than PE.

Lymph Node Imaging in Patients with Primary Breast Cancer: Concurrent Diagnostic Tools

The detection of lymph node metastasis affects the management of patients with primary breast cancer significantly in terms of staging, treatment, and prognosis. The main goal for the radiologist is to determine and detect the presence of metastatic disease in nonpalpable axillary lymph nodes with a positive predictive value that is high enough to initially select patients for upfront axillary lymph node dissection. Features that are suggestive of axillary adenopathy may be seen with different imaging modalities, but ultrasound is the method of choice for evaluating axillary lymph nodes and for performing image-guided lymph node interventions. This review aims to provide a comprehensive overview of the available imaging modalities for lymph node assessment in patients diagnosed with primary breast cancer. IMPLICATIONS FOR PRACTICE: The detection of lymph node metastasis affects the management of patients with primary breast cancer. The main goal for the radiologist is to detect lymph node metastasis in patients to allow for the selection of patients who should undergo upfront axillary lymph node dissection. Features that are suggestive of axillary adenopathy may be seen with mammography, computed tomography, and magnetic resonance imaging, but ultrasonography is the imaging modality of choice for evaluating axillary lymph nodes. A normal axillary lymph node is characterized by a reniform shape, a maximal cortical thickness of 3 mm without focal bulging, smooth margins, and, depending on size, a discernable central fatty hilum.

Does use of axillary ultrasound in clinically node-negative patients receiving neo-adjuvant systemic therapy for breast cancer lead to surgical overtreatment?

Increased use of neo-adjuvant chemotherapy (NAC) for breast cancer has raised uncertainty regarding staging of the axilla, particularly for patients with a clinically negative axillary physical examination (PE). We sought to determine whether axillary ultrasound (AUS) prior to NAC to identify occult nodal disease is beneficial in patients with a clinically negative examination by evaluating the difference in nodal burden on final pathology in those with abnormal vs normal AUS. A retrospective review of an institutional cancer registry identified patients who underwent NAC for breast cancer and had a pretreatment AUS. Differences in the number of positive lymph nodes (PLN) in patients with a normal axillary PE and abnormal vs normal AUS prior to NAC were determined. A total of 120 patients who received NAC had a negative axillary PE prior to treatment. Fifty-three had an abnormal AUS and biopsy-proven lymph node (LN) involvement. In patients with an abnormal AUS, median number of PLNs at surgery was 1 vs 0 for those with a normal AUS (mean difference of 2.12, P < .0001). Of those patients with an abnormal AUS and biopsy-proven LN involvement, 87% underwent axillary lymph node dissection (ALND) and nearly half had no PLN on final pathology (N = 23, 43%). Patients with a clinically negative axilla and an abnormal AUS were more likely to have PLN at the time of surgery. However, almost half of those patients had no residual LN involvement. Routine AUS prior to NAC may lead to more extensive surgical management of the axilla.

Radiomic nomogram for prediction of axillary lymph node metastasis in breast cancer

OBJECTIVE

To develop a radiomic nomogram for preoperative prediction of axillary lymph node (LN) metastasis in breast cancer patients.

METHODS

Preoperative magnetic resonance imaging data from 411 breast cancer patients was studied. Patients were assigned to either a training cohort (n = 279) or a validation cohort (n = 132). Eight hundred eight radiomic features were extracted from the first phase of T1-DCE images. A support vector machine was used to develop a radiomic signature, and logistic regression was used to develop a nomogram.

RESULTS

The radiomic signature based on 12 LN status-related features was constructed to predict LN metastasis, its prediction ability was moderate, with an area under the curve (AUC) of 0.76 and 0.78 in training and validation cohorts, respectively. Based on a radiomic signature and clinical features, a nomogram was developed and showed excellent predictive ability for LN metastasis (AUC 0.84 and 0.87 in training and validation sets, respectively). Another radiomic signature was constructed to distinguish the number of metastatic LNs (less than 2 positive nodes/more than 2 positive nodes), which also showed moderate performance (AUC 0.79).

CONCLUSIONS

We developed a nomogram and a radiomic signature that can be used to identify LN metastasis and distinguish the number of metastatic LNs (less than 2 positive nodes/more than 2 positive nodes). Both nomogram and radiomic signature can be used as tools to assist clinicians in assessing LN metastasis in breast cancer patients.

KEY POINTS

• ALNM is an important factor affecting breast cancer patients' treatment and prognosis. • Traditional imaging examinations have limited value for evaluating axillary LNs status. • We developed a radiomic nomogram based on MR imagings to predict LN metastasis.

Can Preoperative Ultrasonography and MRI Replace Sentinel Lymph Node Biopsy in Management of Axilla in Early Breast Cancer-a Prospective Study from a Tertiary Cancer Center

Although SLNB is a less invasive procedure in detecting axillary lymph node metastases(ALNM) in early breast cancer; still, it carries some complications like lymphedema and in addition, performing SLNB requires surgical skills, technical knowledge, presence of facility like preoperative sentinel lymphoscintigraphy, and availability of hand-held gamma probe for intraoperative assessment. We calculated the relative diagnostic strength of preoperative axillary USG and MRI and compared with of SLNB for detection of ALNM in early breast cancer and assessed whether MRI and USG could accurately predict axillary LN status, potentially replacing SLNB. We evaluated 40 cases of clinically node-negative early breast cancer with preoperative axillary USG and MRI and subsequently subjected to SLNB. The sensitivity, specificity, PPV, NPV, and accuracy of axillary USG were 62.5%, 96.88%, 88.33%, 91.18%, and 90% respectively (p value < 0.001). The sensitivity, specificity, PPV, NPV, and accuracy of MRI in detection of ALNM were 75%, 93.75%, 75%, 93.75%, and 90% (p value < 0.001). The sensitivity, specificity, PPV, NPV, and accuracy of combined USG and MRI in detection of ALNM were 87.5%,90.63%, 70%, 96.67%, and 90% respectively (p value < 0.001), which are comparable to previous study series. The diagnostic performance of combined approach of axillary USG and MRI is promising, as the NPV of combined USG and MRI is approaching the NPV of the SLNB in detecting ALNM. Based on above findings, if axillary LNs are found nonsuspicious in preoperative axillary USG and MRI, further axillary dissection may be avoided, and if found suspicious, then ALND may be directly proceeded avoiding SLNB in between.

[Systematic second opinion review of outside imaging in breast cancer diagnosis: An added value]

INTRODUCTION

The systematic second opinion review in cancer centers after breast cancer detection is currently under development. The purposes were the evaluation of review's consequences, in particularly of the axillary staging and the evolution of the delays.

METHODS

A retrospective study was conducted on patients who consulted a clinician at Cancer Center of Lorraine in Nancy from January 1st, 2016 to December 31th, 2016. We analyzed from their medical charts: the outside exams, the initial therapeutic plan, the second opinion review, the additional exams, the multidisciplinary consultation conclusions, the first treatment, the multidisciplinary consultation after surgery.

RESULTS

In all, 251 patients were analyzed. Second opinion review discrepancies were seen in 72.5%. As a result, 43.4% of all patients had new breast-axillary biopsies. New malignancies lesions were identified in 19.9% of patients. Modifications in therapeutic plan were recommended in 19.9% of patients (including patients with and without new malignancies lesions diagnosed). Before a second opinion review, 9.8% of axillary ultrasound lead to a positive fine-needle biopsy. The additional exams identified 9.6% additional lesions. After a positive sentinel lymph node excision biopsy, the multidisciplinary consultation recommended a revision surgery of axillary lymph node dissection for 27% of patients with axillary ultrasound performed in our cancer center, and for 70% of patients without ultrasound (P=0.023).

DISCUSSION

The systematic second opinion at cancer center allows the detection of new malignancies lesions and significant modifications in the therapeutic plan. A systematic evaluation of axillary ultrasound in cancer center could be considered.

Preoperative Prediction of Axillary Lymph Node Metastasis in Breast Cancer Using Mammography-Based Radiomics Method

It is difficult to accurately assess axillary lymph nodes metastasis and the diagnosis of axillary lymph nodes in patients with breast cancer is invasive and has low-sensitivity preoperatively. This study aims to develop a mammography-based radiomics nomogram for the preoperative prediction of ALN metastasis in patients with breast cancer. This study enrolled 147 patients with clinicopathologically confirmed breast cancer and preoperative mammography. Features were extracted from each patient's mammography images. The least absolute shrinkage and selection operator regression method was used to select features and build a signature in the primary cohort. The performance of the signature was assessed using support vector machines. We developed a nomogram by incorporating the signature with the clinicopathologic risk factors. The nomogram performance was estimated by its calibration ability in the primary and validation cohorts. The signature was consisted of 10 selected ALN-status-related features. The AUC of the signature from the primary cohort was 0.895 (95% CI, 0.887-0.909) and 0.875 (95% CI, 0.698-0.891) for the validation cohort. The C-Index of the nomogram from the primary cohort was 0.779 (95% CI, 0.752-0.793) and 0.809 (95% CI, 0.794-0.833) for the validation cohort. Our nomogram is a reliable and non-invasive tool for preoperative prediction of ALN status and can be used to optimize current treatment strategy for breast cancer patients.

Value of Axillary Ultrasound after Negative Axillary MRI for Evaluating Nodal Status in High-Risk Breast Cancer

BACKGROUND

It is assumed that axillary ultrasound (AxUS) is the best method for axillary nodal evaluation in newly diagnosed breast cancer patients. However, few have evaluated the efficacy of preoperative axillary MRI. We compared the statistical accuracy of AxUS and MRI in detecting nodal metastases among breast cancer patients who were selected for neoadjuvant chemotherapy.

STUDY DESIGN

We retrospectively analyzed 219 breast cancer patients undergoing neoadjuvant chemotherapy from 2007 to 2015, all of whom had AxUS and breast MRI before chemotherapy. Two breast radiologists, blinded to clinical, pathologic, and AxUS findings, re-reviewed all breast MRIs, specifically focusing on axillary nodal characteristics. We correlated clinico-pathologic characteristics, AxUS, and MRI findings, and quantified predictive values of both imaging modalities.

RESULTS

Overall, 101 of 219 (47%) patients had T2 tumors. The most common abnormal nodal finding was size >10 mm. Axillary ultrasound and MRI agreed on nodal status in 192 of 219 patients (87.6%). When correlated with pre-chemotherapy needle biopsy in 129 patients, AxUS and axillary MRI performed similarly (sensitivity of 99.1% vs 97.4% and specificity 15.4% vs 15.4%, respectively). Only 4 of 129 (3.1%) patients had a negative MRI and positive AxUS; 3 of 4 of these patients (75%) had a positive biopsy and 2 of 3 had positive lymph nodes on final pathology, therefore suggesting MRI missed clinically significant disease in only 2 of 129 (1.5%) patients.

CONCLUSIONS

In a high-risk patient population, AxUS and MRI have similar statistical profiles in evaluating axillary nodal status. Routine use of AxUS after a normal axillary MRI is not warranted.

Preoperative prediction of lymphovascular invasion in invasive breast cancer with dynamic contrast-enhanced-MRI-based radiomics

BACKGROUND

Lymphovascular invasion (LVI) status facilitates the selection of optimal therapeutic strategy for breast cancer patients, but in clinical practice LVI status is determined in pathological specimens after resection.

PURPOSE

To explore the use of dynamic contrast-enhanced (DCE)-magnetic resonance imaging (MRI)-based radiomics for preoperative prediction of LVI in invasive breast cancer.

STUDY TYPE

Prospective.

POPULATION

Ninety training cohort patients (22 LVI-positive and 68 LVI-negative) and 59 validation cohort patients (22 LVI-positive and 37 LVI-negative) were enrolled.

FIELD STRENGTH/SEQUENCE

1.5 T and 3.0 T, T₁ -weighted DCE-MRI.

ASSESSMENT

Axillary lymph node (ALN) status for each patient was evaluated based on MR images (defined as MRI ALN status), and DCE semiquantitative parameters of lesions were calculated. Radiomic features were extracted from the first postcontrast DCE-MRI. A radiomics signature was constructed in the training cohort with 10-fold cross-validation. The independent risk factors for LVI were identified and prediction models for LVI were developed. Their prediction performances and clinical usefulness were evaluated in the validation cohort.

STATISTICAL TESTS

Mann-Whitney U-test, chi-square test, kappa statistics, least absolute shrinkage and selection operator (LASSO) regression, logistic regression, receiver operating characteristic (ROC) analysis, DeLong test, and decision curve analysis (DCA).

RESULTS

Two radiomic features were selected to construct the radiomics signature. MRI ALN status (odds ratio, 10.452; P < 0.001) and the radiomics signature (odds ratio, 2.895; P = 0.031) were identified as independent risk factors for LVI. The value of the area under the curve (AUC) for a model combining both (0.763) was higher than that for MRI ALN status alone (0.665; P = 0.029) and similar to that for the radiomics signature (0.752; P = 0.857). DCA showed that the combined model added more net benefit than either feature alone.

DATA CONCLUSION

The DCE-MRI-based radiomics signature in combination with MRI ALN status was effective in predicting the LVI status of patients with invasive breast cancer before surgery.

LEVEL OF EVIDENCE

1 Technical Efficacy Stage: 2 J. Magn. Reson. Imaging 2019;50:847-857.

The use of single-photon emission computed tomography-computed tomography in detecting multiple metastatic lymph nodes in patients with breast cancer

AIM

The aim of the present study was to determine the accuracy of single-photon emission computed tomography-computed tomography (SPECT-CT) with technetium-99m-sestamibi (Tc-MIBI) for detecting multiple (>2 nodes) axillary lymph node involvement in patients with breast cancer (BC).

PATIENTS AND METHODS

A total of 184 women with BC were examined. Clinically, axillary lymph nodes were classified as N0 in all cases. Patients underwent SPECT-CT breast and axillary region imaging 10-15 min after a 740 mBq intravenous injection of Tc-MIBI. SPECT-CT data were then verified by definitive histopathological examination (sentinel-node biopsy and/or axillary lymph node dissection were used as reference standard). Diagnostic values of different CT and SPECT signs of multiple (>2) lymph node involvement were evaluated.

RESULTS

Histological examination of excised lymph nodes showed metastatic involvement in 62 (33.7%) out of 184 patients. In fact, 25 (13.6%) patients had more than two lymph node involvements. In another 37 (20.1%) cases the metastasis was revealed in one or two sentinel lymph nodes only. The main SPECT-CT criteria of multiple (>2) lymph node involvement were as follows: the maximum size of the primary tumor (>20 mm), lymph node dimensions (>12 mm along the long axis and >10 mm along the short axis), nodal cortical thickness (>4 mm), round shape, solid structure, quantity of identified abnormal lymph nodes (>1), and intensity of tracer uptake. The developed integrated model offers the possibility to exclude multiple lymph node metastasis (>2) in BC patients with a probability of 99%.

CONCLUSION

This single-center study showed that in patients with BC, a combination of functional and anatomical data that were obtained by using SPECT-CT with Tc-MIBI can significantly improve detectability of multiple (>2) axillary metastases.

L’exploration axillaire en pratique quotidienne dans le parcours diagnostique d’un cancer du sein

Lors de la découverte d’un cancer du sein, la qualité du bilan préthérapeutique est essentielle afin d’orienter la décision thérapeutique. L’exploration axillaire est primordiale, car elle évalue l’extension régionale de la maladie, ce qui en fait un des facteurs pronostiques majeurs. Différents examens d’imagerie préopératoires peuvent révéler une atteinte de ces ganglions axillaires. Cependant, l’imagerie de référence reste l’échographie axillaire, qui permet également de guider des prélèvements. Depuis l’étude ACOSOGZ0011, nous sommes face à une désescalade thérapeutique de la chirurgie axillaire. Selon des résultats récents, on constate que la place de l’imagerie axillaire est encore plus importante. Le but de l’échographie est d’éviter un curage en deux temps après un ganglion sentinelle positif lorsque les critères de l’ACOSOG-Z0011 ne sont pas remplis.

Introduction of a New Staging System of Breast Cancer for Radiologists: An Emphasis on the Prognostic Stage

In 2017, the American Joint Committee on Cancer announced the 8th edition of its cancer staging system. For breast cancer, the most significant change in the staging system is the incorporation of biomarkers into the anatomic staging to create prognostic stages. Different prognostic stages are assigned to tumors with the same anatomic stages according to the tumor grade, hormone receptor (estrogen receptor; progesterone receptor) status, and HER2 status. A Clinical Prognostic Stage is assigned to all patients regardless of the type of therapy used; in contrast, a Pathologic Prognosis Stage is assigned to patients in whom surgery is the initial treatment. In a few situations, low Oncotype DX recurrence scores can change the prognostic stage. The radiologists need to understand the importance of the biologic factors that can influence cancer staging.

Breast sentinel lymph node biopsy with imaging towards minimally invasive surgery

Breast sentinel lymph nodes are still commonly assessed through complete lymph node dissections, which is a time-consuming and radical approach because the nodes are difficult to identify. To prevent false diagnosis and achieve accurate results, minimally invasive, image-guided procedures are applied and constantly improved. The purpose of this paper is to present the currently used imaging modalities ultrasound, fluorescence, single-photon emission computed tomography (SPECT), magnetic resonance imaging (MRI) and hybrid imaging methods and comparing their effectiveness for breast sentinel lymph node biopsy. A definition for an ideal imaging system combining efficient minimally invasive techniques with workflow considerations is also discussed. As a conclusion, upcoming imaging methods and their future outlook with areas of advancement are presented.

Predictive value of primary tumor parameters using 18F-FDG PET/CT for occult lymph node metastasis in breast cancer with clinically negative axillary lymph node

OBJECTIVE

This study aimed to demonstrate the clinical significance of total lesion glycolysis (TLG) of primary breast cancer using ¹⁸F-FDG PET/CT to predict axillary lymph node (ALN) metastasis in invasive ductal breast cancer (IDC) with a clinically negative axillary lymph node (cN-ALN).

METHODS

135 patients, newly diagnosed with IDC with _CN-ALN between July 2016 and October 2017, were retrospectively enrolled. We estimated primary tumor PET/CT parameters including the maximum standard uptake value (SUV_max), metabolic tumor volume (MTV), and TLG, as well as clinicopathologic findings. All patients received breast surgery followed by pathologic axillary lymph node examination.

RESULTS

Of the 135 patients, 31 (23.0%) were diagnosed with pathologically proven metastatic ALN. In univariate analysis, SUV_max, MTV, and TLG of the primary breast tumor were correlated with metastatic ALN along with tumor size, lymphovascular invasion, CD34, and D2-40. On multivariate analysis, TLG (> 5.74, p = 0.009) had independent significance for predicting ALN metastasis in IDC with cN-ALN.

CONCLUSION

We demonstrated that TLG of primary tumors can be useful in predicting pathologic ALN metastasis in IDC patients with cN-ALN.

Preoperative assessment of axillary lymph node status in breast cancer patients by ultrasonography combined with mammography: A STROBE compliant article

Preoperative assessment of nodal stage is of importance in breast cancer treatment decision-making. This study was done to determine the power of combined mammography and ultrasonography in differentiating N0-N1 from N2-N3 breast cancer.We retrospectively reviewed clinical data of 3944 female patients with invasive breast cancer by preoperative mammography and ultrasonography between January 2006 and December 2013 at our hospital. Pathological diagnosis was available for each patient. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of mammography alone, ultrasonography alone, and combination of them for assessment of axillary lymph node (ALN) status were calculated, using definitive histological results as the baseline.The sensitivity, specificity, PPV, NPV, and accuracy was 90.4%, 68.2%, 36.5%, 97.2%, and 71.9% for ultrasonography; was 66.9%, 80.8%, 41.3%, 92.3%, and 78.4% for mammography; and was 94.9%, 62.4%, 33.8%, and 98.4% for combined mammography and ultrasonography. For combination, accuracy and the area under the receiver operating characteristic curve was 67.9% and 0.85, respectively.In conclusion, combining ultrasonography and mammography improves the sensitivity in differentiating N0-N1 breast cancer from N2-N3 breast cancer, but leading to a reduced specificity. Addition of mammography to ultrasonography seems not to provide significant benefits in predicting ALN status in breast cancer patients.

Use of Quantitative Morphological and Functional Features for Assessment of Axillary Lymph Node in Breast Dynamic Contrast-Enhanced Magnetic Resonance Imaging

Background

Axillary lymph-node assessment is considered one of the most important prognostic factors concerning breast cancer survival.

Objective

We investigated the discriminative power of morphological and functional features in assessing the axillary lymph node.

Methods

We retrospectively analysed data from 52 consecutive patients who undergone DCE-MRI and were diagnosed with primary breast carcinoma: 94 lymph nodes were identified. Per each lymph node, we extracted morphological features: circularity, compactness, convexity, curvature, elongation, diameter, eccentricity, irregularity, radial length, entropy, rectangularity, roughness, smoothness, sphericity, spiculation, surface, and volume. Moreover, we extracted functional features: time to peak (TTP), maximum signal difference (MSD), wash-in intercept (WII), wash-out intercept (WOI), wash-in slope (WIS), wash-out slope (WOS), area under gadolinium curve (AUGC), area under wash-in (AUWI), and area under wash-out (AUWO). Selection of important features in predicting metastasis has been done by means of receiver operating characteristic (ROC) analysis. Performance of linear discriminant analysis was analysed.

Results

All morphological features but circularity showed a significant difference between median values of metastatic lymph nodes group and nonmetastatic lymph nodes group. All dynamic parameters except for MSD and WOS showed a statistically significant difference between median values of metastatic lymph nodes group and nonmetastatic lymph nodes group. Best results for discrimination of metastatic and nonmetastatic lymph nodes were obtained by AUGC (accuracy 75.8%), WIS (accuracy 71.0%), WOS (accuracy 71.0%), and AUCWO (accuracy 72.6%) for dynamic features and by compactness (accuracy 82.3%), curvature (accuracy 71.0%), radial length (accuracy 71.0%), roughness (accuracy 74.2%), smoothness (accuracy 77.2%), and speculation (accuracy 72.6%) for morphological features. Linear combination of all morphological and/or of all dynamic features did not increase accuracy in metastatic lymph nodes discrimination.

Conclusions

Compactness as morphological feature and area under time-intensity curve as dynamic feature were the best parameters in identifying metastatic lymph nodes on breast MRI.

Ultrasound Imaging Technologies for Breast Cancer Detection and Management: A Review

Ultrasound imaging is a commonly used modality for breast cancer detection and diagnosis. In this review, we summarize ultrasound imaging technologies and their clinical applications for the management of breast cancer patients. The technologies include ultrasound elastography, contrast-enhanced ultrasound, 3-D ultrasound, automatic breast ultrasound and computer-aided detection of breast ultrasound. We summarize the study results seen in the literature and discuss their future directions. We also provide a review of ultrasound-guided, breast biopsy and the fusion of ultrasound with other imaging modalities, especially magnetic resonance imaging (MRI). For comparison, we also discuss the diagnostic performance of mammography, MRI, positron emission tomography and computed tomography for breast cancer diagnosis at the end of this review. New ultrasound imaging techniques, ultrasound-guided biopsy and the fusion of ultrasound with other modalities provide important tools for the management of breast patients.

Developments in optical imaging for gastrointestinal surgery

To improve outcomes for patients with cancer, in terms of both survival and a reduction in the morbidity and mortality that results from surgical resection and treatment, there are two main areas that require improvement. Accurate early diagnosis of the cancer, at a stage where curative and, ideally, minimally invasive treatment is achievable, is desired as well as identification of tumor margins, lymphatic and distant disease, enabling complete, but not unnecessarily extensive, resection. Optical imaging is making progress in achieving these aims. This review discusses the principles of optical imaging, focusing on fluorescence and spectroscopy, and the current research that is underway in GI tract carcinomas.

Preoperative Axillary Lymph Node Evaluation in Breast Cancer: Current Issues and Literature Review

Axillary lymph node (ALN) status is an important prognostic factor for overall breast cancer survival. In current clinical practice, ALN status is evaluated before surgery via multimodal imaging and physical examination. Mammography is typically suboptimal for complete ALN evaluation. Currently, ultrasonography is widely used to evaluate ALN status; nonetheless, results may vary according to operator. Ultrasonography is the primary imaging modality for evaluating ALN status. Other imaging modalities including contrast-enhanced magnetic resonance imaging, computed tomography, and positron emission tomography/computed tomography can play additional roles in axillary nodal staging.The purpose of this article is (1) to review the strengths and weaknesses of current imaging modalities for nodal staging in breast cancer patients and (2) to discuss updated guidelines for ALN management with regard to preoperative ALN imaging.

Use of Breast Magnetic Resonance Imaging and Ultrasonography for Identifying Nonpalpable Axillae Metastases in Newly Diagnosed Breast Cancer Patients

BACKGROUND

The metastasis of axillary lymph node (ALNs) is a critical step in the initial cancer staging of newly diagnosed breast cancer (BC) patients. Various imaging modalities can enhance the sensitivity of clinical examination in assessing the ALN status.

PATIENTS AND METHODS

We enrolled 135 patients with BC, confirmed via histopathology, including 4 bilateral BC cases. A total of 139 ipsilateral ALNs adjacent to the breast lesion were examined via physical examination, ultrasonography (US), and magnetic resonance imaging (MRI); of these, 100 were nonpalpable ALNs, as determined by experienced breast surgeons and physicians. The relative size parameters on MRI and US images were recorded. Receiver operating characteristic (ROC) analyses were conducted, and the area under the ROC curve (AUC) was compared.

RESULTS

Of 139 ALNs, 67 (48%) were malignant and 72 (52%) were benign on pathological examination. In all of the ALNs, the US short diameter appeared to be the most discriminative quantitative measurement for detecting positive findings (AUC, 0.854). In nonpalpable ALNs as well, the US short diameter exhibited the greatest discriminability (AUC, 0.746). However, the 2-dimensional and 3-dimensional parameters on MRI did not exhibit any significant differences between the enrolled and nonpalpable ALNs (P > .05).

CONCLUSION

The shortest diameter on US exhibited better discriminative ability than MRI for predicting positive ALNs in nonpalpable axillae. Moreover, the 2-dimensional and 3-dimensional parameters on MRI did not differ in terms of discriminability.

Outcome following sentinel lymph node biopsy-guided decisions in breast cancer patients with conversion from positive to negative axillary lymph nodes after neoadjuvant chemotherapy

PURPOSE

Many breast cancer patients with positive axillary lymph nodes achieve complete node remission after neoadjuvant chemotherapy. The usefulness of sentinel lymph node biopsy in this situation is uncertain. This study evaluated the outcomes of sentinel biopsy-guided decisions in patients who had conversion of axillary nodes from clinically positive to negative following neoadjuvant chemotherapy.

METHODS

We reviewed the records of 1247 patients from five hospitals in Korea who had breast cancer with clinically axillary lymph node-positive status and negative conversion after neoadjuvant chemotherapy, between 2005 and 2012. Patients who underwent axillary operations with sentinel biopsy-guided decisions (Group A) were compared with patients who underwent complete axillary lymph node dissection without sentinel lymph node biopsy (Group B). Axillary node recurrence and distant recurrence-free survival were compared.

RESULTS

There were 428 cases in Group A and 819 in Group B. Kaplan-Meier analysis showed that recurrence-free survivals were not significantly different between Groups A and B (4-year axillary recurrence-free survival: 97.8 vs. 99.0%; p = 0.148). Multivariate analysis also indicated the two groups had no significant difference in axillary and distant recurrence-free survival.

CONCLUSIONS

For breast cancer patients who had clinical conversion of axillary lymph nodes from positive to negative following neoadjuvant chemotherapy, sentinel biopsy-guided axillary surgery, and axillary lymph node dissection without sentinel lymph node biopsy had similar rates of recurrence. Thus, sentinel biopsy-guided axillary operation in breast cancer patients who have clinically axillary lymph node positive to negative conversion following neoadjuvant chemotherapy is a useful strategy.

Risk Factors for a False-Negative Result of Sentinel Node Biopsy in Patients with Clinically Node-Negative Breast Cancer

Purpose

Although sentinel lymph node biopsy (SLNB) can accurately represent the axillary lymph node (ALN) status, the false-negative rate (FNR) of SLNB is the main concern in the patients who receive SLNB alone instead of ALN dissection (ALND).

Materials and Methods

We analyzed 1,886 patientswho underwent ALND after negative results of SLNB,retrospectively. A logistic regression analysis was used to identify risk factors associated with a falsenegative (FN) result. Cox regression model was used to estimate the hazard ratio of factors affecting disease-free survival (DFS).

Results

Tumor located in the upper outer portion of the breast, lymphovascular invasion, suspicious node in imaging assessment and less than three sentinel lymph nodes (SLNs) were significant independent risk factors for FN in SLNB conferring an adjusted odds ratio of 2.10 (95% confidence interval [CI], 1.30 to 3.39), 2.69 (95% CI, 1.47 to 4.91), 2.59 (95% CI, 1.62 to 4.14), and 2.39 (95% CI, 1.45 to 3.95), respectively. The prognostic factors affecting DFS were tumor size larger than 2 cm (hazard ratio [HR], 1.86; 95% CI, 1.17 to 2.96) and FN of SLNB (HR, 2.51; 95% CI, 1.42 to 4.42) in SLN-negative group (FN and true-negative), but in ALN-positive group (FN and true-positive), FN of SLNB (HR, 0.64; 95% CI, 0.33 to 1.25) did not affect DFS.

Conclusion

In patients with risk factors for a FN such as suspicious node in imaging assessment, upper outer breast cancer, less than three harvested nodes, we need attention to find another metastatic focus in non-SLNs during the operation. It may contribute to provide an exact prognosis and optimizing adjuvant treatments.

Clinically node negative breast cancer patients undergoing breast conserving therapy, sentinel lymph node procedure versus follow-up: a Dutch randomized controlled multicentre trial (BOOG 2013-08)

BACKGROUND

Studies showed that axillary lymph node dissection can be safely omitted in presence of positive sentinel lymph node(s) in breast cancer patients treated with breast conserving therapy. Since the outcome of the sentinel lymph node biopsy has no clinical consequence, the value of the procedure itself is being questioned. The aim of the BOOG 2013-08 trial is to investigate whether the sentinel lymph node biopsy can be safely omitted in clinically node negative breast cancer patients treated with breast conserving therapy.

METHODS

The BOOG 2013-08 is a Dutch prospective non-inferiority randomized multicentre trial. Women with pathologically confirmed clinically node negative T1-2 invasive breast cancer undergoing breast conserving therapy will be randomized for sentinel lymph node biopsy versus no sentinel lymph node biopsy. Endpoints include regional recurrence after 5 (primary endpoint) and 10 years of follow-up, distant-disease free and overall survival, quality of life, morbidity and cost-effectiveness. Previous data indicate a 5-year regional recurrence free survival rate of 99% for the control arm and 96% for the study arm. In combination with a non-inferiority limit of 5% and probability of 0.8, this result in a sample size of 1.644 patients including a lost to follow-up rate of 10%. Primary and secondary endpoints will be reported after 5 and 10 years of follow-up.

DISCUSSION

If the sentinel lymph node biopsy can be safely omitted in clinically node negative breast cancer patients undergoing breast conserving therapy, this study will cost-effectively lead to a decreased axillary morbidity rate and thereby improved quality of life with non-inferior regional control, distant-disease free survival and overall survival.

TRIAL REGISTRATION

The BOOG 2013-08 study is registered in ClinicalTrials.gov since October 20, 2014, Identifier: NCT02271828. https://clinicaltrials.gov/ct2/show/NCT02271828.

An objective nodal staging system for breast cancer patients undergoing neoadjuvant systemic treatment

BACKGROUND

In this study, we aimed to develop an objective staging system to determine the degree of nodal metastasis in breast cancer patients undergoing neoadjuvant systemic treatment (NST).

METHODS

We reviewed the pretreatment computed tomography (CT) images of 392 breast cancer patients who received NST. The association between the patterns of the enlarged regional lymph nodes and treatment outcome was analyzed.

RESULTS

In the development cohort of 260 patients, 88 (33.8%) patients experienced tumor recurrence and had a significantly higher number of enlarged lymph nodes on the pretreatment CT compared to patients with no recurrence. When patients were classified according to the numbers and locations of enlarged lymph nodes on pretreatment CT, the number of lymph nodes larger than 1 cm was most significantly associated with tumor recurrence. The accuracy of the CT-based nodal staging system was validated in an independent cohort of 132 patients. The presence of the enlarged supraclavicular nodes was associated with worse outcome, but the effect seemed to originate from the accompanied extensive axillary nodal burden. The prognostic effect of the objectively measured axillary nodal metastasis was more pronounced in hormone receptor-negative tumors.

CONCLUSIONS

We have developed and validated an objective method of nodal staging in breast cancer patients who undergo NST based on the number of enlarged axillary lymph nodes. Our system can improve the current subjective approach, which uses physical examination alone.

A nomogram to predict the probability of axillary lymph node metastasis in female patients with breast cancer in China: A nationwide, multicenter, 10-year epidemiological study

Axillary lymph node dissection (ALND) or sentinel lymph node biopsy (SLNB) alone may lead to postoperative complications. Among patients with positive ALN in the preoperative examination, approximately 40% patients do not have SLN metastasis. Herein, we aimed to develop a model to predict the probability of ALN metastasis as a preoperative tool to support clinical decision-making. We retrospectively analyzed the clinicopathological features of 4211 female patients with breast cancer who were diagnosed in seven breast cancer centers representing entire China, over 10 years (1999-2008). The patients were randomly categorized into a training cohort or validation cohort (3:1 ratio). Multivariate logistic regression analysis was performed for 1869 patients with complete information on the study variables. Age at diagnosis, tumor size, tumor quadrant, clinical nodal status, local invasion status, pathological type, and molecular subtypes were the independent predictors of ALN metastasis. The nomogram was then developed using the seven variables. Further, it was subsequently validated in 642 patients with complete data on variables in the validation cohort. Coefficient of determination (R²) and the area under the receiver-operating characteristic (ROC) curve (AUC) were calculated to be 0.979 and 0.7007, showing good calibration and discrimination of the model, respectively. The false-negative rates of the nomogram were 0 and 6.9% for the predicted risk cut-off values of 14.03% and 20%, respectively. Therefore, when the predicted risk is less than 20%, SLNB may be avoided. After further validation in various patient populations, this model may support increasingly limited axillary surgery in breast cancer.

Can We Skip Intraoperative Evaluation of Sentinel Lymph Nodes? Nomogram Predicting Involvement of Three or More Axillary Lymph Nodes before Breast Cancer Surgery

Purpose

The American College of Surgeons Oncology Group Z0011 trial reported that complete dissection of axillary lymph nodes (ALNs) may not be warranted in women with clinical T1-T2 tumors and one or two involved ALNs who were undergoing lumpectomy plus radiation followed by systemic therapy. The present study was conducted to identify preoperative imaging predictors of ≥ 3 ALNs.

Materials and Methods

The training set consisted of 1,917 patients with clinical T1-T2 and node negative invasive breast cancer. Factors associated with ≥ 3 involved ALNs were evaluated by logistic regression analysis. The validation set consisted of 378 independent patients. The nomogram was applied prospectively to 512 patients who met the Z0011 criteria.

Results

Of the 1,917 patients, 204 (10.6%) had ≥ 3 positive nodes. Multivariate analysis showed that involvement of ≥ 3 nodes was significantly associated with ultrasonographic and chest computed tomography findings of suspicious ALNs (p < 0.001 each). These two imaging criteria, plus patient age, were used to develop a nomogram calculating the probability of involvement of ≥ 3 ALNs. The areas under the receiver operating characteristic curve of the nomogram were 0.852 (95% confidence interval [CI], 0.820 to 0.883) for the training set and 0.896 (95% CI, 0.836 to 0.957) for the validation set. Prospective application of the nomogram showed that 60 of 512 patients (11.7%) had scores above the cut-off. Application of the nomogram reduced operation time and cost, with a very low re-operation rate (1.6%).

Conclusion

Patients likely to have ≥ 3 positive ALNs could be identified by preoperative imaging. The nomogram was helpful in selective intraoperative examination of sentinel lymph nodes.

Role of Axillary Ultrasound, Fine Needle Aspiration Cytology and Sentinel Lymph Node Biopsy in clinically N0 Breast Cancer

This study evaluates the combined role of axillary ultrasound, fine needle aspiration cytology and sentinel lymph node biopsy in clinically N0 axilla. Between January 2014 and June 2015, 150 women with early breast cancer underwent axillary ultrasound as a first investigation for nodal status. Suspicious nodes were subjected to image guided fine needle aspiration cytology. Non-suspicious and fine needle aspiration cytology negative axillary nodes proceeded to sentinel lymph node biopsy at time of primary breast surgery. All confirmed positive (cytology and frozen) cases proceeded to axillary lymph node dissection. 52 women had positive axillary nodes at final histology. Axillary ultrasound with fine needle aspiration cytology identified 27 patients with positive axillary nodal status and had a sensitivity of 84.36 % (27/32) and specificity of 87.5 % (14/16). Intraoperative frozen analysis identified a further 13 cases with sensitivity of 56.52 % (13/23) and specificity of 97.56 % (80/82). Overall 76.92 % (40/52) patients with positive axillary metastasis were identified peri-operatively using combination of axillary ultrasound, cytology and sentinel lymph node biopsy.

Investigation of optical coherence micro-elastography as a method to visualize micro-architecture in human axillary lymph nodes

Background

Evaluation of lymph node involvement is an important factor in detecting metastasis and deciding whether to perform axillary lymph node dissection (ALND) in breast cancer surgery. As ALND is associated with potentially severe long term morbidity, the accuracy of lymph node assessment is imperative in avoiding unnecessary ALND. The mechanical properties of malignant lymph nodes are often distinct from those of normal nodes. A method to image the micro-scale mechanical properties of lymph nodes could, thus, provide diagnostic information to aid in the assessment of lymph node involvement in metastatic cancer. In this study, we scan axillary lymph nodes, freshly excised from breast cancer patients, with optical coherence micro-elastography (OCME), a method of imaging micro-scale mechanical strain, to assess its potential for the intraoperative assessment of lymph node involvement.

Methods

Twenty-six fresh, unstained lymph nodes were imaged from 15 patients undergoing mastectomy or breast-conserving surgery with axillary clearance. Lymph node specimens were bisected to allow imaging of the internal face of each node. Co-located OCME and optical coherence tomography (OCT) scans were taken of each sample, and the results compared to standard post-operative hematoxylin-and-eosin-stained histology.

Results

The optical backscattering signal provided by OCT alone may not provide reliable differentiation by inspection between benign and malignant lymphoid tissue. Alternatively, OCME highlights local changes in tissue strain that correspond to malignancy and are distinct from strain patterns in benign lymphoid tissue. The mechanical contrast provided by OCME complements the optical contrast provided by OCT and aids in the differentiation of malignant tumor from uninvolved lymphoid tissue.

Conclusion

The combination of OCME and OCT images represents a promising method for the identification of malignant lymphoid tissue. This method shows potential to provide intraoperative assessment of lymph node involvement, thus, preventing unnecessary removal of uninvolved tissues and improving patient outcomes.