Assessment of Ultrasound Features Predicting Axillary Nodal Metastasis in Breast Cancer: The Impact of Cortical Thickness

PURPOSE

To evaluate the accuracy of axillary ultrasound (AUS) in detecting nodal metastasis in patients with early-stage breast cancer and to identify AUS features with high predictive power.

MATERIALS AND METHODS

Prospective single-center preliminary study in 105 patients with a primary diagnosis of breast cancer and clinically negative axilla. AUS was performed using a 12 MHz linear-array transducer before ultrasound-guided needle biopsy. Nodal characteristics (shape, longitudinal-transverse [LT] axis ratio, margins, cortical thickness, hyperechoic hilum) were correlated with histopathological nodal status after SLNB or axillary lymph node dissection (ALND).

RESULTS

Nodal metastases were present in 42/105 patients (40.0%). Univariate analyses showed that absence of hyperechoic hilum, round shape, LT axis ratio<2, sharp margins and cortical thickness>3 mm were associated with lymph node metastasis. Multivariate logistic regression analysis revealed cortical thickness > 3 mm as an independent predictive parameter for nodal involvement. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy were 66.7, 74.6, 63.6, 77.0% and 71.4% respectively when cortical thickness > 3 mm was applied as the criterion for AUS positivity. Axillary tumor volume was low in patients with pT1/2 tumors and negative AUS, since only 3.2% of patients had > 2 metastatic lymph nodes.

CONCLUSION

Cortical thickness>3 mm is a reliable predictor of nodal metastatic involvement. Negative AUS does not exclude lymph node metastases, but extensive axillary tumor volume is rare.

Incidental Suspicious Regional Lymph Nodes on Breast Sonography: Is Sampling Necessary?

Suspicious regional lymph nodes may be incidentally identified on breast ultrasound examinations in patients who present for sonographic evaluation without a known or a suspected breast malignancy, and there is a paucity of data on whether biopsy should be performed. This study aims to characterize incidental sonographically detected suspicious regional lymph nodes and determine whether tissue sampling or follow-up imaging is required. A total of 40,773 consecutive breast ultrasounds were reviewed. Overall, 7 women with nonpalpable, incidental, suspicious axillary or supraclavicular lymph nodes in an otherwise unremarkable breast and without history of malignancy or systemic disease were identified. In all, 5 women with 6 nodes underwent ultrasound-guided fine needle aspiration and 2 women with 3 nodes were recommended follow-up ultrasound. Follow-up imaging, cytology, and all-cause clinical data were reviewed to evaluate outcomes. All 6 biopsied lymph nodes (mean = 1.5cm) were benign on cytology. Follow-up imaging was available for 3 nodes (mean = 2.6 years), with all-cause follow-up for all nodes of 2.2 years. In the follow-up group, 3 lymph nodes (mean = 1.6cm) were monitored (mean = 4.3 years) with all-cause follow-up of 4.7 years. No new cancers, growth, or suspicious features were found in these nodes during follow-up for either group of women. In conclusion, women without history of prior malignancy or systemic disease with incidentally detected, nonpalpable, suspicious regional lymph nodes with an otherwise normal breast ultrasound examination underwent fine needle aspiration or were recommended short-term follow-up ultrasound. No indeterminate features or malignancies were observed at the time of tissue sampling or developed over several years of follow-up. Avoiding sampling of these nodes would reduce patient morbidity and health care costs.

Predictive value of fine needle aspiration biopsy of axillary lymph nodes in preoperative breast cancer staging

OBJECTIVE

Diagnosis of axillary nodal involvement is significant in the management of breast cancer as well as in predicting prognosis. In this prospective study, we evaluated the efficiency of US-guided fine needle aspiration biopsy (FNAB) in preoperative axillary staging of early breast cancer.

MATERIAL AND METHODS

Between January 2011 and July 2013, 46 women were prospectively enrolled in the study. Ultrasound guided-FNABs for axillary assessment were performed preoperatively. Cytology results were compared with histopathology reports to determine its sensitivity, specificity, negative and positive predictive value and accuracy.

RESULTS

Nineteen cases that had malignant cytology on FNAB also had axillary involvement in axillary lymph node dissection (ALND) without any false-positive results. The sensitivity and specificity of US-guided FNAB were 63.3% and 100%, respectively. US-guided FNAB was accurate in predicting the status of the axilla in 76.1% of patients.

CONCLUSION

Although this technique is favorable due to its minimally invasive nature, it is not as effective as sentinel lymph node biopsy (SLNB) in terms of detecting axillary metastasis preoperatively. The low sensitivity and low accuracy rates decrease the usefulness of the technique. Therefore, it seems that US-guided FNAB alone could not replace SLNB. Nevertheless, combining some other molecular studies may be useful in increasing the technique's sensitivity. These issues should be determined by comprehensive clinical trials.

Three-Dimensional Sonography of Axillary Lymph Nodes in Patients With Breast Cancer

Sonography is useful in the evaluation of axillary lymph nodes in patients with breast cancer. In this pictorial essay, we review the range of grayscale and Doppler appearances of abnormal axillary lymph nodes on 2-dimensional and 3-dimensional imaging.

Preoperative axillary lymph node staging by ultrasound-guided cytology using a four-level sonographic score

BACKGROUND

The staging of axillary lymph nodes is critical to the management and prognosis of breast cancer, the most frequent cancer in females. Neoadjuvant therapy and lymph node dissection are recommended when malignant cells invade the lymph nodes. Therefore the pre-operative examination of these lymph nodes is crucial to treatment.

METHODS

In this study, we examined the effectiveness of cytology through ultrasound-guided fine needle aspiration (USG-FNA) and ultrasound (US) imaging using an established classification system in correctly identifying lymph node status compared to the final histological results after surgery.

RESULTS

Cytology by USG-FNA and US classification were found to be promising methods of axillary lymph node staging.

CONCLUSIONS

US and CB offer minimally invasive techniques to pre-operatively examine these lymph nodes in patients with primary breast cancer.

Axillary ultrasound and fine-needle aspiration in preoperative staging of axillary lymph nodes in patients with invasive breast cancer

OBJECTIVE

To propose an algorithm to determine the necessity for ultrasonography-guided fine-needle aspiration (US-FNA) in preoperative axillary lymph node staging of patients with invasive breast cancer.

MATERIALS AND METHODS

Prospective study developed at National Cancer Institute. The study sample included 100 female patients with breast cancer referred for axillary staging by US-FNA.

RESULTS

The overall US-FNA sensitivity was set at 79.4%. The positive predictive value was calculated to be 100%, and the negative predictive value, 69.5%. The US-FNA sensitivity for lymph nodes with normal sonographic features was 0%, while for indeterminate lymph nodes it was 80% and, for suspicious lymph nodes, 90.5%. In the assessment of invasive breast tumors stages T1, T2 and T3, the sensitivity was respectively 69.6%, 83.7% and 100%. US-FNA could avoid sentinel node biopsy in 54% of cases.

CONCLUSION

Axillary ultrasonography should be included in the preoperative staging of all patients with invasive breast cancer. The addition of US-FNA in cases of lymph nodes suspicious for malignancy may prevent more than 50% of sentinel lymphadenectomies, significantly shortening the time interval to definitive therapy.

A multicentre validation of Metasin: a molecular assay for the intraoperative assessment of sentinel lymph nodes from breast cancer patients

AIMS

Treatment strategies for breast cancer continue to evolve. No uniformity exists in the UK for the management of node-positive breast cancer patients. Most centres continue to use conventional histopathology of sampled sentinel lymph nodes (SLNs), which requires delayed axillary clearance in up to 25% of patients. Some use touch imprint cytology or frozen section for intraoperative testing, although both have inherent sensitivity issues. An intraoperative molecular diagnostic approach helps to overcome some of these limitations. The aim of this study was to assess the clinical effectiveness of Metasin, a molecular method for the intraoperative evaluation of SLNs.

METHODS AND RESULTS

RNA from 3296 lymph nodes from 1836 patients undergoing SLN assessment was analysed with Metasin. Alternate slices of tissue were examined in parallel by histology. Cases deemed to be discordant were analysed by protein gel electrophoresis. There was concordance between Metasin and histology in 94.1% of cases, with a sensitivity of 92% [95% confidence interval (CI) 88-94%] and a specificity of 97% (95% CI 95-97%). Positive and negative predictive values were 88% and 98%, respectively. Over half of the discordant cases (4.4%) were ascribed to tissue allocation bias (TAB).

CONCLUSIONS

Clinical validation of the Metasin assay suggests that it is sufficiently sensitive and specific to make it fit for purpose in the intraoperative setting.

Diagnostic Accuracy and Impact on Management of Ultrasonography-Guided Fine-Needle Aspiration to Detect Axillary Metastasis in Breast Cancer Patients: A Prospective Study

BACKGROUND

The axillary nodal status is essential to determine the stage of disease at diagnosis. Our aim was to prospectively assess the diagnostic accuracy of ultrasonography-guided fine-needle aspiration (US-FNA) for the detection of metastasis in axillary lymph nodes in patients with breast cancer (BC) and its impact on the therapeutic decision.

MATERIALS AND METHODS

Ultrasonography (US) was performed in 407 axillae of 396 patients who subsequently underwent surgery. US-FNA was conducted when lymph nodes were detected by US. Axillary dissection (AD) was performed when US-FNA was positive for metastasis. Patients with negative US-FNA and breast tumors of 30 mm in size were candidates for selective sentinel lymph node biopsy (SLNB). The anatomopathological results of AD or SLNB were used as reference tests.

RESULTS

Lymph nodes were detected by US in 207 (50.8%) axillae. Of these, US-FNA was performed on 180 (86.9%). 94 axillae (52.2%) were positive for carcinoma and 79 women received AD. US-FNA had 77.5% sensitivity, 100% specificity, 100% positive predictive value, 69.3% negative predictive value, and 85.1% diagnostic accuracy. US-FNA avoided SLNB in 18.1% of patients who underwent AD.

CONCLUSIONS

Axillary US-FNA is an accurate technique in the staging of patients with BC. It allows reducing the number of SLNB and, when positive, offers a fast and useful tool.

Fine needle aspiration cytology of lymph nodes in breast cancer follow-up is a feasible alternative to watchful waiting and to histology

Background

Early detection of loco-regional breast cancer recurrence improves patients’ overall survival, as treatment can be initiated or active treatment can be changed. If a suspicious lymph node is diagnosed during a follow-up exam, surgical excision is often performed. The aim of this study was to evaluate the diagnostic performance of the minor invasive ultrasound-guided fine-needle aspiration cytology (FNAC) in sonomorphologically suspicious lymph nodes in breast cancer follow-up.

Methods

Between April 2010 and November 2012, we performed ultrasound-guided FNAC in 38 sonographically suspicious lymph nodes of 37 breast cancer follow-up patients. Cytological specimens were evaluated if the sample material was sufficient for diagnosis and if they contained cancer cells. Patients with negative cytology were followed up clinically and sonographically. To evaluate the diagnostic performance we calculated sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for physical examination, the different sonomorphological malignancy criteria and FNAC.

Results

In 36/38 (94.7 %) lymph nodes, the pathologist had enough material to establish a final diagnosis; in 2/38 (5.3 %) lymph nodes, the probe material was non-evaluable during cytology, these 2 were excluded from further statistical evaluation. Cytology revealed malignancy in 21 lymph nodes and showed no evidence for malignancy in 15 lymph nodes. There was no evidence for malignant disease in follow-up exams in the 15 cytologically benign lymph nodes with an average follow-up time of 3 years. The diagnostic performances of physical examination and FNAC were: Sensitivity 52/100 %, specificity 88/100 %, PPV 85/100 %, NPV 60/100 %, respectively.

Conclusions

Our preliminary results show that FNAC is a safe and fast diagnostic approach for the evaluation of suspicious lymph nodes in the follow-up of patients with breast cancer and, thus, together with follow-up represents a feasible alternative to surgery.

Incorporating Imaging Into the Locoregional Management of Breast Cancer

Although some breast cancers present as palpable masses or with other clinical findings, many are detected at screening. Most screening is currently done with digital mammography, but high-risk patients or those with dense breast tissue may undergo additional screening examinations with magnetic resonance imaging or ultrasound. Additionally, digital breast tomosynthesis, contrast-enhanced mammography, and molecular breast imaging are newer technologies available at some sites. Optimal usage of breast imaging technologies remains controversial, both in screening and diagnostic settings following a new diagnosis of breast cancer. This article will review well established and newer, alternative breast imaging technologies as well as recent data regarding their role in optimizing patient care.

Pre-operative Ultrasonographic Evaluation of Axillary Lymph Nodes in Breast Cancer Patients: For Which Group Still of Additional Value and in Which Group Cause for Special Attention?

A non-invasive and widely available method for pre-operative evaluation of the axilla is axillary ultrasonography (US). The purpose of this study was to evaluate the diagnostic accuracy of axillary US and fine-needle aspiration cytology in a large cohort of breast cancer patients. The sensitivity and specificity of US and fine-needle aspiration cytology in our cohort of 1124 patients were 42.2% and 97.1%, respectively. As the number of axillary nodes increased, sensitivity increased. The percentage of false-negative US results was 18.9%; patients in this subgroup were significantly younger, had larger tumors, more often had lymph vascular invasion and were more likely to have estrogen receptor-positive tumors. Ultrasonography in combination with fine-needle aspiration cytology is useful in the pre-operative workup of breast cancer patients, especially patients with three or more nodal metastases. Special attention should be paid to younger women with larger tumors in whom a larger percentage of false-negative results are obtained.

The impact of preoperative axillary ultrasonography in T1 breast tumours

OBJECTIVES

To (a) determine the diagnostic validity of axillary ultrasound (AUS) in pT1 tumours and whether fine-needle aspiration (FNA) improves its diagnostic performance, and (b) determine the negative predictive value (NPV) of AUS in a simulation environment (cutoff: two lymph nodes with macrometastases) in patients fulfilling American College of Surgeons Oncology Group (ACOSOG) Z0011 criteria.

MATERIALS AND METHODS

This retrospective multicentre cross-sectional study analysed diagnostic accuracy in 355 pT1 breast cancers. All patients underwent AUS; visible nodes underwent FNA regardless of their AUS appearance. Sentinel node biopsy and axillary lymph node dissection (ALND) were gold standards. Data were analysed considering micrometastases 'positive' and considering micrometastases 'N negative'. The simulation environment included all patients fulfilling ACOSOG Z0011 criteria.

RESULTS

Axillary involvement: 22.8 %; AUS sensitivity: 46.9 % (Nmic positive)/66.7 % (Nmic negative); AUS+FNA sensitivity: 52.6 % (pNmic positive)/72.0 % (pNmic negative). In the simulation environment, AUS had 75.0 % sensitivity, 88.9 % specificity and 99.2 % NPV.

CONCLUSION

AUS has moderate sensitivity in T1 tumours. As ALND is unnecessary in micrometastases, considering micrometastases 'N negative' increases the practical impact of AUS. In patients fulfilling ACOSOG Z0011 criteria, AUS alone can predict cases unlikely to benefit from ALND.

KEY POINTS

• AUS+FNA can predict axillary involvement, thus avoiding SNB. • Not all patients with axillary involvement need ALND. • Axillary tumour load determines axillary management. • AUS could classify patients according to axillary load.

Diagnostic value of preoperative axillary lymph node ultrasound assessment in patients with breast cancer qualified for sentinel lymph node biopsy

Introduction

Sentinel lymph node biopsy (SLNB) is a standard procedure in the therapeutic management of patients with non-advanced breast cancer.

Aim

To analyse the utility of ultrasound scan (USS) examination in the process of patient qualification for SLNB and to estimate the optimal time to perform USS in the clinical preoperational assessment of axillary lymph nodes.

Material and methods

A prospective analysis of 702 patients with invasive breast cancer treated with SLNB between 7.03.2012 and 27.05.2013 was performed. The patients were divided into three groups: I (USS < 8 weeks before SLNB), II (USS > 8 weeks before SLNB and another one on the day before SLNB) and III (USS > 8 weeks before SLNB without perioperative USS). In these patients the percentage of metastases in the sentinel lymph node and the clinical factors influencing the diagnostic value of preoperative ultrasound scan were assessed.

Results

Metastatic lesions in sentinel lymph nodes were found in 154 (21.9%) patients. The highest percentage of metastases was noted in patients operated on in the second and third month from the beginning of preoperative diagnostics. None of the factors tested (size of the original tumour, histological malignancy grading, kind of preoperative diagnostics, Ki-67 value, biological type of the tumour, age) had a statistically significant influence on the diagnostic value of perioperative USS examination in the analysed time span.

Conclusions

The lowest percentage of metastases in the sentinel lymph node was noted in the patients qualified for SLNB who had the ultrasound performed directly before the surgical procedure (not more than 4 weeks before the surgery).

Clinical audit of ultrasound guided fine needle aspiration in a general cytopathology service

Background:

Studies on ultrasonography (USG) guided fine needle aspiration cytology (FNAC) have been conducted in specialized settings such as thyroid, breast, and intra-abdominal aspirates. There is a paucity of literature on the practices of guided FNAC in a general cytopathology service.

Aim:

The aim was to determine prevailing practices of USG guided FNAC in a general cytopathology service of a teaching hospital.

Settings and Design:

Metropolitan hospital, clinical audit.

Materials and Methods:

Audit of 112 USG guided percutaneous FNAC done over 12 months.

Statistical Analysis:

Data were coded, entered in an excel spreadsheet and analyzed by translating into percentages and proportions.

Results:

The 112 guided FNACs included constituted 36 thyroid (32.14%), 45 intra-abdominal (40.17%), 11 breast (9.82%), 10 superficial lymph node (8.92%) and 10 soft tissue and miscellaneous (8.92%) lesions. Previous freehand FNAC was documented on the requisition forms in 14 cases. The reports were: Inadequate 33 (29.46%), nondiagnostic descriptive 35 (31.25%) or diagnostic 44 (39.28%). Inadequacy rates of aspirates from thyroid were 11 (30.56%) breast were 2 (18.18%), and intra-abdominal lesions were 13 (28.88%). Majority of the reports were nonstructured: 108 (96.42%) and nonrecommendatory: 101 (90.17%).

Conclusions:

Reporting practices varied and did not conform to a uniform structure. The inadequacy rates of breast and thyroid aspirates were comparable to the rates in the literature. Comparable studies were not available for intra-abdominal aspirates.

Axillary lymph nodes in breast cancer patients: sonographic evaluation

Axillary staging of patients with early-stage breast cancer is essential in the treatment planning. Currently such staging is intraoperatively performed, but there is a tendency to seek a preoperative and less invasive technique to detect lymph node metastasis. Ultrasonography is widely utilized for this purpose, many times in association with fine-needle aspiration biopsy or core needle biopsy. However, the sonographic criteria for determining malignancy in axillary lymph nodes do not present significant predictive values, producing discrepant results in studies evaluating the sensitivity and specificity of this method. The present study was aimed at reviewing the literature approaching the utilization of ultrasonography in the axillary staging as well as the main morphological features of metastatic lymph nodes.

A practical approach to imaging the axilla

Imaging of the axilla typically occurs when patients present with axillary symptoms or newly diagnosed breast cancer. An awareness of the axillary anatomy is essential in order to generate an accurate differential diagnosis and guide patient management. The purpose of this article is to review the indications for axillary imaging, discuss the logistics of the scanning technique and percutaneous interventions, and present the imaging findings and management of a variety of breast diseases involving the axilla.

Teaching points

• Knowledge of normal axillary anatomy aids in determining the aetiology of an axillary mass.

• The differential diagnosis of an axillary mass is broad and can be subdivided by the location of the lesion.

• Imaging evaluation of the axilla usually entails diagnostic mammography and targeted ultrasound.

• FNA or core needle biopsies are safe and accurate methods for diagnosis and guiding management.

Role of [18F]fluorodeoxyglucose positron emission tomography-computed tomography, sonography, and sonographically guided fine-needle aspiration biopsy in the diagnosis of axillary lymph nodes in patients with breast cancer: comparison of diagnostic performance

OBJECTIVES

The aim of this study was to compare the diagnostic performance of [(18)F]fluorodeoxyglucose (FDG) positron emission tomography-computed tomography (PET-CT) with that of sonography and sonographically guided fine-needle aspiration (FNA) for determining the preoperative axillary lymph node (ALN) status and to evaluate the factors related to false-negative PET-CT, sonographic, and FNA results in ALN staging of invasive ductal carcinoma.

METHODS

From March 2009 to July 2012, 226 patients had a diagnosis of primary breast cancer. Among these patients, 107 constituted the study population after exclusion of transferred patients and patients with breast cancer other than invasive ductal carcinoma. The diagnostic performance of the modalities was compared with pathologic reports. Univariate and multivariate analyses were used to evaluate the relationship between clinicopathologic factors (symptoms, T stage, hormone receptors, and histologic grade), false-negative results, and true-negative results on PET-CT, sonography, and FNA.

RESULTS

Of the 107 patients, 45 (42.1%) had positive results on final pathologic analysis of ALNs. Sonographically guided FNA had a significantly higher specificity, positive predictive value, accuracy, and area under the receiver operating characteristic curve than sonography and PET-CT (P < .01). When sonography and PET-CT were combined, the sensitivity was significantly improved (P = .019) compared with sonography alone. When FNA and PET-CT were combined, the sensitivity and negative predictive value were significantly increased compared with each modality (P < .01).

CONCLUSIONS

Sonographically guided FNA was found to be an excellent diagnostic tool for preoperative evaluation of the ALN status. To obviate the step of sentinel lymph node biopsy for determining the ALN status, combined evaluation of ALNs by these modalities may be more complementary than the use of a single modality.

Local treatment of the axilla in early breast cancer: concepts from the national surgical adjuvant breast and bowel project B-04 to the planned intergroup sentinel mamma trial

Local treatment of the axilla in clinically node-negative, early-stage breast cancer patients has been hotly debated after the release of the American College of Surgeons Oncology Group (ACOSOG) Z0011 findings. However, this review does not focus on the 'Z0011-eligible' patients alone, because this subgroup represents a minority of our patients undergoing breast-conserving surgery (BCS) and sentinel lymph node biopsy (SLNB). The following topics are discussed: axillary diagnostics, timing of axillary procedures in the neoadjuvant setting, long-term follow-up of SLNB trials, omission of axillary surgery in randomized trials, management of the involved axilla with low tumor volume, positive sentinel lymph nodes and BCS, involved sentinel lymph nodes and mastectomy, and axillary radiotherapy. Finally, the current innovative study concepts (i.e. Sentinel Node versus Observation after Axillary Ultrasound (SOUND) and Intergroup Sentinel Mamma (INSEMA)) including patients with axillary observation alone in clinically node-negative women are presented.

Sentinel lymph node biopsy and neoadjuvant chemotherapy in breast cancer patients

ABSTRACT: 

Patient selection and timing of sentinel lymph node (SLN) in the context of primary chemotherapy continues to evolve; there is some evidence that primary chemotherapy may modify lymphatic drainage patterns and cause differential downstaging between SLNs and non-SLNs. SLN biopsy undertaken prior to chemotherapy will minimize the risk of a false-negative result, may allow more accurate initial staging and provides important information on prognostication which can guide decisions about adjuvant radiotherapy. However, quantification of regional metastatic load is incomplete and some advocate SLN biopsy after primary chemotherapy to take advantage of nodal downstaging and avoidance of axillary dissection in up to 40% of patients. Initial reports on false-negative rates for SLN biopsy after primary chemotherapy in patients who had proven axillary node metastases at presentation based on needle core biopsy were relatively high and a cause for clinical concern. However, more recent data suggest that SLN biopsy is as accurate when performed post- as pre-neochemotherapy and current practice incorporates both approaches.

Performance characteristics of ultrasound-guided fine-needle aspiration of axillary lymph nodes for metastatic breast cancer employing rapid on-site evaluation of adequacy: analysis of 136 cases and review of the literature

BACKGROUND

It has been demonstrated that axillary ultrasound-guided fine-needle aspiration (US-FNA) has excellent positive predictive value for the axillary lymph node status of patients with breast cancer before surgery or neoadjuvant therapy and, thus, can obviate the need for sentinel lymph node biopsy in FNA-positive patients. However, US-FNA has only moderate sensitivity, in part because of the collection of nondiagnostic or equivocal specimens. Rapid on-site evaluation for adequacy (ROSE) can improve definitive diagnosis rates but has not been well characterized in this setting.

METHODS

One hundred thirty-three patients with breast carcinoma were identified who underwent 136 US-FNAs of axillary lymph nodes, all with ROSE, and the results were correlated with the diagnosis on a subsequent surgical procedure.

RESULTS

The adequacy rate was 95.6% (130 of 136 FNAs), and a definitive diagnosis was made in 91.2% (124 of 136 FNAs). Among definite diagnoses, sensitivity was 75%, specificity was 100%, the positive predictive value was 100%, and the negative predictive value was 79%. Sources of false-negative and potential false-positive diagnoses were evaluated among these cases and in the literature.

CONCLUSIONS

Small metastasis size is the most common cause of false-negative results, whereas interpretation errors by pathologists are quite rare. ROSE appears to improve adequacy and definitive diagnosis rates and, thus, can more accurately triage patients to appropriate care.

Breast ultrasonography: state of the art

Ultrasonography (US) is an indispensable tool in breast imaging and is complementary to both mammography and magnetic resonance (MR) imaging of the breast. Advances in US technology allow confident characterization of not only benign cysts but also benign and malignant solid masses. Knowledge and understanding of current and emerging US technology, along with the application of meticulous scanning technique, is imperative for image optimization and diagnosis. The ability to synthesize breast US findings with multiple imaging modalities and clinical information is also necessary to ensure the best patient care. US is routinely used to guide breast biopsies and is also emerging as a supplemental screening tool in women with dense breasts and a negative mammogram. This review provides a summary of current state-of-the-art US technology, including elastography, and applications of US in clinical practice as an adjuvant technique to mammography, MR imaging, and the clinical breast examination. The use of breast US for screening, preoperative staging for breast cancer, and breast intervention will also be discussed.

Value of preoperative ultrasound-guided axillary lymph node biopsy for preventing completion axillary lymph node dissection in breast cancer: a systematic review and meta-analysis

PURPOSE

This meta-analysis was designed to evaluate the utility of preoperative axillary ultrasound combined with US-guided lymph node biopsy if indicated (AUS ± biopsy), in terms of staging the axilla and preventing two-step axillary surgery in the form of sentinel node biopsy (SNB) followed by completion axillary lymph node (ALN) dissection.

METHODS

We systematically searched electronic databases for studies that addressed preoperative assessment of ALN status by AUS ± biopsy. A pooled estimate was calculated for the false-negative rate (FNR) of AUS ± biopsy (defined as the proportion of women with a negative AUS ± biopsy result subsequently proven to have a positive axilla) and sensitivity (defined as the proportion of women with a positive AUS ± biopsy result among all women with a tumor positive axilla).

RESULTS

The pooled FNR was 25 % (95 % confidence interval [CI] = 24-27) and the pooled sensitivity was 50 % (95 % CI = 43-57). There was substantial heterogeneity across studies for both FNR (I (2) = 69.42) and sensitivity (I (2) = 93.25), which was not explained by between-study differences in biopsy technique, mean/median tumor size, biopsy indication, or study design. Sensitivity was increased in studies with a high prevalence of ALN metastases.

CONCLUSIONS

Preoperative axillary ultrasound-guided biopsy is a useful step in the process of axillary staging. Approximately 50 % of women with axillary involvement can be identified preoperatively. Still, one in four women with an ultrasound-guided biopsy-"proven" negative axilla has a positive SNB.

Accuracy of axillary ultrasound in preoperative nodal staging of breast cancer - size of metastases as limiting factor

Since the performance of surgical procedures of the axilla in the treatment of early breast cancer is decreasing, the role of axillary ultrasound (AUS) as staging procedere has newly to be addressed. The aim of this study was to determine which patient or histopathological characteristics are related to false-negative AUS. In a retrospective study design data of 470 women with primary breast cancer were collected from patient charts and imaging and pathology records were reviewed. True positive and false negative axillary ultrasound groups were compared in terms of tumor size, histological subtype, grade, estrogen receptor (ER) and HER2 status, proliferation index, number and size of nodal metastases, extracapsular extension (ECE) and lymphovascular invasion (LVI). Of 470 patients, 166 (35%) were node positive, 79 of them with suspicious AUS. Factors associated with false negative AUS by univariate analysis were included in a multivariate model. By multivariate analysis, only size of nodal metastases was an independent factor for false negative AUS. In the sentinel lymph node biopsy (SLNB) subgroup, 45% of patients had nodal metastasis size less than or equal to 5 mm. In conclusion, AUS in preoperative staging of early stage breast cancer is limited by small size of metastases in a substantial number of patients. Prospective studies have to show whether small metastatic deposits leaving in patients in case of no axillary surgery have no negative effect on disease free and overall survival.

Axillary lymph node biopsy in newly diagnosed invasive breast cancer: comparative accuracy of fine-needle aspiration biopsy versus core-needle biopsy

PURPOSE

To compare the diagnostic accuracy of ultrasonographically (US)-guided fine-needle aspiration biopsy (FNAB) and core-needle biopsy (CNB) of the axillary lymph nodes (LNs) of patients with newly diagnosed invasive breast cancer.

MATERIALS AND METHODS

This prospective single-center study had institutional review board approval, and written informed consent was obtained. Between April 2011 and March 2012, 178 consecutive patients (182 axillae) were evaluated by using axillary US. Sixty-six axillae fulfilled the inclusion criteria (cortical thickness greater than 2 mm or abnormal morphologic characteristics), and patients with these axillae underwent US-guided axillary LN biopsy. Both FNAB and CNB were obtained from the same suspicious LN. Patients with biopsy-proved metastasis underwent axillary clearance, and those with a negative biopsy underwent sentinel LN biopsy with completion axillary clearance if needed. Diagnostic performance was calculated separately for US, FNAB, and CNB. Statistical differences in sensitivities were evaluated by using the McNemar test.

RESULTS

From the total study population, 45.6% (83 of 182 axillae) had metastases. A total of 66 axillae underwent both FNAB and CNB. The sensitivity for US was 61.4% (51 of 83 axillae), and specificity was 84.8% (84 of 88 axillae). The sensitivities for FNAB and CNB were 72.5% (37 of 51 axillae) and 88.2% (45 of 51 axillae), respectively (P = .008). Specificity for both was 100% (15 of 15 axillae). The negative predictive value for FNAB was 81.7%, and that for CNB was 91.2%. The positive predictive value was 100% for both methods.

CONCLUSION

When accurate preoperative staging of the axilla is needed in patients with newly diagnosed invasive breast cancer, CNB is more sensitive than FNAB.

The efficacy of axillary ultrasound in the detection of nodal metastasis in breast cancer

OBJECTIVE

Recent reports indicate a lack of survival benefit for axillary lymph node dissection (ALND) versus sentinel lymph node biopsy in early breast cancer. To study this issue further, we assessed the accuracy and effectiveness of ultrasound examination in detecting axillary nodal involvement in breast cancer patients with the aim of refining our current clinical pathways.

MATERIALS AND METHODS

Ultrasound data were collected from breast cancer cases over 3 years. Images were reviewed by experienced radiologists and the following characteristics were assessed: size, morphology, hyperechoic hilum, and cortical thickness of the ipsilateral axillary nodes. The findings were correlated with histologic outcomes after ALND.

RESULTS

Two hundred twenty-four cases were included in the analysis, 113 (50.4%) of which had evidence of metastatic nodal involvement at final histology. Of these 113 cases, ultrasound findings for 59 (52.2%) were positive. The overall positive predictive value of ultrasound for detecting metastatic nodal involvement measured 0.81. The negative predictive value was 0.60. The sensitivity was 53.7%; specificity, 85.1%; and accuracy, 67.9%. The ultrasound morphologic lymph node features with the greatest correlation with malignancy were the absence of a hyperechoic hilum (p = 0.003) and increased cortical thickness (p = 0.03). Patients with a metastatic nodal burden density of at least 20% were more likely to have abnormal findings on axillary ultrasound examination (p = 0.009).

CONCLUSION

Axillary ultrasound has a low negative predictive value and negative ultrasound results do not exclude axillary node metastases with sufficient sensitivity to justify its routine clinical use. Clinical pathways need to consider an evidence-based approach, focusing on the criteria by which we select breast cancer patients for ALND.

Surgical sentinel lymph node biopsy in early breast cancer. Could it be avoided by performing a preoperative staging procedure? A pilot study

Background

The aim of this pilot trial was to study the feasibility of sentinel node percutaneous preoperative gamma probe-guided biopsy as a valid preoperative method of assessment of nodal status compared to surgical sentinel lymph node biopsy.

Material/Methods

This prospective study enrolled 10 consecutive patients without evidence of axillary lymph node metastases at preoperative imaging. All patients underwent sentinel node occult lesion localization (SNOLL) using radiotracer intradermic injection that detected a “hot spot” corresponding to the sentinel node in all cases. Gamma probe over the skin detection with subsequent ultrasonographically guided needle biopsy of the sentinel node were performed. The percutaneous needle core histopathological diagnosis was compared to the results of the surgical biopsy.

Results

Preoperative sentinel node identification was successful in all patients.

Conclusions

The combination of preoperative gamma probe sentinel node detection and ultrasound-guided biopsy could represent a valid alternative to intraoperative sentinel node biopsy in clinically and ultrasonographically negative axillary nodes, resulting in shorter duration of surgery and lower intraoperative risks.

False negative results of preoperative axillary ultrasound in patients with invasive breast cancer: correlations with clinicopathologic findings

The purpose of this study was to investigate false-negative results of preoperative axillary ultrasound (US) and to evaluate clinicopathologic factors related to false-negative results in patients with invasive breast cancer. Four-hundred eighty-two patients with 483 invasive breast cancers who had no suspicious findings on preoperative axillary US were included in this study. All patients underwent sentinel lymph node biopsy (SLNB) or axillary lymph node dissection. False-negative and true-negative results were compared in terms of age, body mass index (BMI), T-stage, pathologic N-stage and final diagnosis of breast cancer. Statistical analyses were performed using the chi-square or Fisher's exact tests. Of the 483 axillae with negative results on axillary US, 93 axillae of 93 patients showed false-negative results and the negative predictive value of axillary US was 80.8% (390/483). Seventy-five axillae (15.5%, 75/483) had N1 and 18 axillae (3.7%, 18/483) had N2 or N3 disease. Eighteen false-negative results with N2/N3 disease showed a significantly higher T stage (T2/T3) than those with N1 disease. As the T-stage increased, false-negative results were found more often on preoperative axillary US (p < 0.05). Age, BMI and final diagnosis of primary breast cancer were not associated with false-negative results on preoperative axillary US. Preoperative axillary US alone is insufficiently specific to obviate the need for SLNB because of the substantial number of false-negative results in patients with invasive breast cancer, although preoperative axillary US alone may exclude most cases of N2 and N3 disease.

Preoperative needle biopsy of sentinel lymph nodes using intradermal microbubbles and contrast-enhanced ultrasound in patients with breast cancer

OBJECTIVE

The purpose of this study was to assess whether sentinel lymph nodes (SLNs) that undergo targeted needle biopsy after identification by contrast-enhanced ultrasound (CEUS) using intradermally injected microbubbles results in more node-positive breast cancer patients being diagnosed preoperatively. Furthermore, we sought to determine whether the addition of CEUS to gray-scale sonography of the axilla reduces the number of patients having axillary lymph node (ALN) dissection as a second procedure.

SUBJECTS AND METHODS

Intradermal microbubble injection was performed in 136 breast cancer patients who had no abnormal ALNs on routine gray-scale axillary sonography. When an enhancing ALN was visualized, percutaneous sonography-guided fine-needle aspiration cytology or core needle biopsy was performed. Depending on the biopsy results, patients underwent SLN biopsy or ALN dissection. If the putative SLN biopsy was positive or a biopsy tract was seen in the excised SLN, the procedure was defined as successful.

RESULTS

SLNs were identified and biopsied in 126 of the 136 cases (93%). Seventeen patients had positive sonography-guided biopsy results (13%) and were treated with immediate ALN dissection. In seven patients, the biopsied node was the only positive node. The remaining 109 patients underwent SLN biopsy. In nine cases (8%), a positive lymph node was identified. Four of these false-negative cases had only micrometastases.

CONCLUSION

SLNs can be identified and biopsied using CEUS to increase the accuracy of preoperative axillary staging. If the needle biopsy result is negative, conventional SLN biopsy is indicated.

The role for sentinel lymph node dissection after neoadjuvant chemotherapy in patients who present with node-positive breast cancer

BACKGROUND

Sentinel lymph node (SLN) dissection has been investigated after neoadjuvant chemotherapy and has shown mixed results. Our objective was to evaluate SLN dissection in node-positive patients and to determine whether postchemotherapy ultrasound could select patients for this technique.

METHODS

Between 1994 and 2010, 150 patients with biopsy proven axillary metastasis underwent SLN dissection after chemotherapy and 121 underwent axillary lymph node dissection (ALND). Clinicopathologic characteristics were analyzed before and after chemotherapy. Statistical analyses included Fisher's exact test for nodal response and multivariate logistic regression for factors associated with false-negative events.

RESULTS

Median age was 52 years. Median tumor size at presentation was 2 cm. The SLN was identified in 93 % (139/150). In 111 patients in whom a SLN was identified and ALND performed, 15 patients had a false-negative SLN (20.8 %). In the 52 patients with normalized nodes on ultrasound, the false-negative rate decreased to 16.1 %. Multivariate analysis revealed smaller initial tumor size and fewer SLNs removed (<2) were associated with a false-negative SLN. There were 63 (42 %) patients with a pathologic complete response (pCR) in the nodes. Of those with normalized nodes on ultrasound, 38 (51 %) of 75 had a pCR. Only 25 (33 %) of 75 with persistent suspicious/malignant-appearing nodes had a pCR (p = 0.047).

CONCLUSIONS

Approximately 42 % of patients have a pCR in the nodes after chemotherapy. Normalized morphology on ultrasound correlates with a higher pCR rate. SLN dissection in these patients is associated with a false-negative rate of 20.8 %. Removing fewer than two SLNs is associated with a higher false-negative rate.

Should axillary ultrasound be used in patients with a preoperative diagnosis of ductal carcinoma in situ?

BACKGROUND

We evaluated the usefulness of axillary ultrasound (US) in patients with core biopsy-proven ductal carcinoma in situ (DCIS).

METHODS

Preoperative axillary US, fine-needle aspiration (FNA), and sentinel lymph node (SLN) data from women with DCIS were reviewed.

RESULTS

Eighty-two women with DCIS underwent axillary US. In 16 women (19.5%) US was abnormal; however, FNA was negative in all cases. Sixty-one women (74%) underwent SLN surgery; 2 were positive for macrometastasis (3%) and 1 had isolated tumor cells. None of them had an abnormal US. Axillary US did not change the management in any of the cases.

CONCLUSIONS

Axillary US and FNA did not change the management in any of the 82 cases. In women with a core biopsy diagnosis of DCIS, positive nodes are uncommon and unlikely to be detected by axillary US. Routine preoperative axillary US is not recommended for pure DCIS on core biopsy.

Efficiency of ultrasound and ultrasound-guided fine needle aspiration cytology in preoperative assessment of axillary lymph node metastases in breast cancer

PURPOSE

We performed this study to detect preoperative axillary metastases with ultrasound (US)-guided fine needle aspiration biopsy (FNAB), to eliminate the need for time-consuming and costly sentinel lymph node (SLN) scintigraphy and biopsy steps in the treatment of breast cancer patients, and in that of with suspicious US findings, and to evaluate the accuracy of preoperative US-guided FNAB for patients with suspicious lymph node metastases on US.

METHODS

Patients with a suspicious breast lump or histopathologically proven breast cancer underwent breast-axillary US. Increase in lymph node size, cortical thickening, non-hilar cortical flow, and hilar changes were evaluated with gray scale-color Doppler US. FNAB was performed if US results were suspicious for malignancy.

RESULTS

Thirty-eight axillary lymph nodes (ALN) underwent FNAB. ALN dissection, SLN scintigraphy, and biopsy steps were bypassed in 23 axillas with positive ALN FNAB (60.5%). The sensitivity of ALN FNAB was 88.46%; specificity and positive predictive value were 100%; and negative predictive value was 66.6% (inadequate cytology included; 76.7%, 100%, 100%, 53.3%, respectively). Asymmetrical cortical thickening, non-hilar cortical flow, and increase in hypoechogenity were only detected in metastatic nodes. Cortical thickening, and lymph node and breast mass size was higher in the metastatic group.

CONCLUSION

By performing FNAB on suspicious lymph nodes, the routine, high-cost SLN scintigraphy and intraoperative gamma probe steps may be skipped, and axilla dissection can be performed directly. This leads to the elimination of the need for SLN investigation in more than half of the patients. The assessment of ALN metastases with preoperative US-guided FNAB is a cost-effective method with high specificity, that eliminates the need for costly and time-consuming SLN scintigraphy and biopsy steps, and helps in preoperative staging.

Rapid on-site evaluation of axillary fine-needle aspiration cytology in breast cancer

BACKGROUND

Axillary ultrasonography (AUS) and fine-needle aspiration cytology (FNAC) can establish axillary lymph node status before surgery, although this technique is hampered by poor adequacy rates. To achieve consistently high rates of FNAC adequacy, rapid on-site evaluation (ROSE) of FNAC samples was introduced.

METHODS

This single-centre, retrospective observational study of patients with newly diagnosed breast cancer undergoing preoperative AUS and FNAC between February 2008 and November 2010 examined the effect of the introduction of ROSE.

RESULTS

A total of 381 patients were included. AUS revealed 152 axillae with suspicious radiological features. FNAC was positive for malignant cells in 75 (49·3 per cent) of 152 samples. Sentinel lymph node mapping was avoided in 75 patients, representing 19·7 per cent of the entire study population. Adequacy rates increased from 78 per cent to 96 per cent following the introduction of ROSE (P = 0·001). The overall sensitivity and specificity of AUS and FNAC was 80·6 and 100 per cent respectively. A lymph node diameter equal to or larger than 10 mm and extranodal extension were significantly associated with positive FNAC (P < 0·001 and P = 0·012 respectively). Maximum lymph node diameter of at least 10 mm was an independent predictor of positive FNAC (odds ratio 11·2, 95 per cent confidence interval 3·32 to 37·76; P < 0·001).

CONCLUSION

AUS with FNAC provided accurate preoperative staging of the axilla for metastatic breast disease and avoided unnecessary sentinel lymph node mapping. The introduction of ROSE ensured the efficiency of AUS and FNAC.

Axillary lymph node dissection in early-stage invasive breast cancer: is it still standard today?

Evaluation of axillary lymph node status by sentinel lymph node biopsy (SLNB) and complete axillary lymph node dissection (ALND) are an inherent part of breast cancer treatment. Increased understanding of tumor biology has changed the prognostic and therapeutic impact of lymph node status. Non-invasive imaging techniques like axillary ultrasound, FDG-PET, or MRI revealed moderate sensitivity and high specificity in evaluation of lymph node status. Therefore, they are not sufficient for lymph node staging. Otherwise, the impact of remaining micrometastases and even macrometastases for prognosis and treatment decisions is overestimated. Considering tumor biology, the distinction of axillary metastases in isolated tumor cells (ITC, pN0(i+)); micrometastases (pN1mi), and macrometastases (pN1a) is not comprehensible. Increasing data support the thesis that remaining axillary metastases neither increase the axillary recurrence rate nor decrease overall survival. It is doubtful that axillary tumor cells are capable to complete the complex multistep metastatic process. If applied, axillary metastases are sensitive to systemic treatment and are targeted by postoperative tangential breast irradiation. Therefore, the controversy about the clinical relevance of tumor cell clusters or micrometastases in SLN is a sophisticated but not contemporary discussion. Currently, there is no indication for axillary surgery in elderly patients with favorable tumors and clinically tumor-free lymph nodes. Nonetheless, a rational and evidence-based approach to the management of clinically and sonographically N0 patients with planned breast-conserving surgery and limited tumor size is needed now.