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Singer L, Weiss A, Bellon JR, King TA. Regional Nodal Management After Preoperative Systemic Therapy. Semin Radiat Oncol 2022; 32:228-236. [DOI: 10.1016/j.semradonc.2022.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Astvatsaturyan K, Ramazyan A, Bose S. Is ultrasound-guided fine needle aspiration biopsy of axillary lymph nodes a viable alternative to sentinel lymph node biopsy? Diagn Cytopathol 2021; 49:1099-1109. [PMID: 34264025 DOI: 10.1002/dc.24824] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 03/31/2021] [Accepted: 06/29/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Axillary lymph node (ALN) ultrasound-guided fine needle aspiration biopsy (US-FNAB), a minimally invasive procedure, may be used for the preoperative evaluation of ALN status of breast cancer patients. Despite the relative ease of use and low cost, paucity of comparative studies and variation in the reported sensitivity of FNAB preclude its clinical utility in evaluation of ALNs. This study aims to determine the accuracy of US-FNAB in detecting metastasis in ALN pre-operatively and to assess US-FNAB as a viable alternative to sentinel lymph node (SLN) excision. METHODS The 228 consecutive ALN US-FNABs with subsequent histologic follow up performed from 2005 to 2020 in patients with breast carcinoma were retrospectively evaluated. FNAB results were correlated with histologic diagnosis. Sensitivity, specificity, accuracy, and risk of malignancy of FNAB were calculated. RESULTS 157/228 (69%) FNABs were concordant with histology, 37/228 (16%) discordant. Positive FNAB findings correlated with primary tumor size, grade, number of metastatic lymph nodes and size of metastases. FNAB with negative diagnosis carried a 22% risk of malignancy, atypical 43%, suspicious 80%, and positive a 100% risk of malignancy (100% positive predictive value [PPV]). The sensitivity and specificity were 78% and 95% respectively; accuracy was 77%. SLN biopsy was avoided in all 82 (36%) cases with positive FNAB results. CONCLUSION Negative FNAB result does not exclude metastatic carcinoma. With 100% PPV, full ALN dissection and/or neoadjuvant chemotherapy can be safely planned after a positive FNAB result, avoiding SLN biopsy, reducing management costs and shortening time interval to definitive therapy.
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Affiliation(s)
- Kristine Astvatsaturyan
- Department of Pathology and Laboratory Medicine, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Arsen Ramazyan
- The University of California, Los Angeles, California, USA
| | - Shikha Bose
- Department of Pathology and Laboratory Medicine, Cedars Sinai Medical Center, Los Angeles, California, USA
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To Evaluate the Accuracy of Axillary Staging Using Ultrasound and Ultrasound-Guided Fine-Needle Aspiration Cytology (USG-FNAC) in Early Breast Cancer Patients-a Prospective Study. Indian J Surg Oncol 2020; 11:726-734. [PMID: 33281412 DOI: 10.1007/s13193-020-01222-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 09/15/2020] [Indexed: 10/23/2022] Open
Abstract
In breast cancer, axillary lymph node involvement directly impacts the patient survival and prognosis. Sentinel lymph node biopsy (SLNB) is a procedure of choice for axillary staging in early breast cancer. Currently, management options for axilla management are axillary lymph node dissection and sentinel node biopsy in node positive and in node negative respectively. Accuracy of current clinical methods for evaluating axilla is low. Hence, to select patients for appropriate procedure, ultrasound (USG) combined with fine-needle aspiration cytology (USG-FNAC) using vascular pedicle-based nodal mapping method is emerging as a good tool to address above issues. We evaluated the feasibility of ultrasound and needle aspiration cytology in a tertiary care center. All early breast cancer patients with clinically node-negative axilla and having palpable nodes with less than or equal to 5 cm tumor size in breast were screened by ultrasound of axilla to categorize the nodes as suspicious or non-suspicious based on radiological features and vascular pedicle-based nodal mapping method of axilla. Patients having suspicious nodes underwent ultrasound of axilla and needle aspiration; if found positive, patient underwent axillary node dissection. Sentinel node biopsy (SLNB) performed in all patients found negative on needle aspiration and in all patients having non-suspicious nodes on ultrasound axilla. Final histopathology was taken as gold standard. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were calculated for ultrasound (USG) and ultrasound-guided needle aspiration (USG-FNAC). A total of 100 patients were included in which 58 had non-suspicious and 42 had suspicious nodes on ultrasound of axilla. Among suspicious group, 24 were positive on ultrasound-guided needle aspiration cytology and 18 were negative. In non-suspicious nodes, sentinel node biopsy was performed. Sensitivity, specificity, positive predictive value, and negative predictive value for ultrasound were 61.5%, 75.6%, 69.5%, and 68.5% respectively. For ultrasound-guided needle aspiration (USG-FNAC), sensitivity, specificity, and positive and negative predictive value are 83%, 100%, 100%, and 72.6% respectively. The accuracy of ultrasound (USG) and ultrasound-guided needle aspiration (USG-FNAC) was 69% and 88.1%. The result of our study indicates the feasibility of USG and USG-FNAC in a high-volume center with good accuracy of around 70-80%. Approximately one-fourth (24%) of the total patients were taken up for axillary lymph node dissection (ALND) without performing SLNB.
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Sattar AK, Ali B, Masroor I, Afzal S, Tariq MU, Idrees R, Uzzaman M, Khalid W. Feasibility of preoperative tattooing of percutaneously biopsied axillary lymph node: an experimental pilot study. Pilot Feasibility Stud 2020; 6:140. [PMID: 32983557 PMCID: PMC7513507 DOI: 10.1186/s40814-020-00682-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Accepted: 09/08/2020] [Indexed: 12/09/2022] Open
Abstract
Background In the last three decades, axillary lymph node dissection (ALND) has been replaced by sentinel lymph node biopsy (SLNB) in all clinically node-negative patients. However, when SLNB alone is performed in clinically node-positive patients who are rendered node-negative by neoadjuvant chemotherapy, the procedure has a high false-negative rate and other complementary procedures have been described to improve its reliability. Preoperative tattooing of the suspicious lymph node with India ink at the time of biopsy, in addition to sentinel lymph node biopsy, is a reasonable alternative. The objective of our study is to determine, in clinically node-positive patients, the feasibility of tattooing suspicious axillary lymph node at the time of percutaneous needle biopsy and its retrieval at the time of surgery. Methods A prospective experimental study will be conducted divided into two phases—phases I and II. In phase I, 10 patients committed to undergo upfront surgery (without neoadjuvant chemotherapy) will have a suspicious lymph node tattooed by injecting India ink at the time of core needle biopsy. All patients will undergo a SLNB, during which the axilla will be inspected to determine if the tattooed lymph node can be visualized. Routine microscopic examination will follow, and concordance between the sentinel and tattooed node will also be established. In phase II, the process will be repeated for 30 patients who undergo surgery after neoadjuvant chemotherapy. The analysis will be performed in Stata version 12. Discussion There is a need to identify and test the techniques for the down-staged axilla in post-neoadjuvant chemotherapy patients, which are not only practical and limit the number of invasive procedures necessary but are representative of the new axillary status and help limit the extent of axillary surgery without negatively impacting outcomes. We propose that, for the patient undergoing neoadjuvant chemotherapy with a biopsy-proven disease in the axilla, this could be achieved by India ink which allows marking, identification, and retrieval of the biopsied lymph node. Retrieval of this previously biopsied lymph node along with sentinel nodes, if found to be representative of the status of the remainder of the axilla, could potentially eliminate the need for routine axillary lymph node dissection and thus limit morbidity. Trial Registration ClinicalTrials.gov, NCT03939598. Retrospectively registered on 7 May 2019.
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Affiliation(s)
- Abida K Sattar
- Department of Surgery, Aga Khan University, Link Building, Stadium Road, Karachi, 74800 Pakistan
| | - Basim Ali
- Department of Biological and Biomedical Sciences, Aga Khan University, Karachi, Pakistan
| | - Imrana Masroor
- Department of Radiology, Aga Khan University, Karachi, Pakistan
| | - Shaista Afzal
- Department of Radiology, Aga Khan University, Karachi, Pakistan
| | | | - Romana Idrees
- Department of Pathology, Aga Khan University, Karachi, Pakistan
| | - Maseeh Uzzaman
- Department of Radiology, Aga Khan University, Karachi, Pakistan
| | - Wardah Khalid
- Department of Surgery, Aga Khan University, Link Building, Stadium Road, Karachi, 74800 Pakistan
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Afzal S, Masroor I, Munir A, Idress R, Khan P, Khan S. Preoperative Ultrasound-guided Core Biopsy of Axillary Nodes for Staging of Clinically Negative Axilla in Breast Cancer Patients - A Pilot Study. Cureus 2020; 12:e6718. [PMID: 32104639 PMCID: PMC7032606 DOI: 10.7759/cureus.6718] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Objective The aim of the current study is to determine the feasibility and accuracy of ultrasound-guided core biopsy for staging the axilla in clinically node-negative patients with invasive breast cancer. Introduction Historically, in breast cancer patients, axillary lymph node dissection was performed to stage axilla. Because of the high morbidity of axillary lymph node dissection, sentinel lymph node biopsy (SLNB) became the standard of care in patients with clinically node-negative breast cancer. However, SLNB is expensive, time consuming, can cause morbidity and can be complicated by seroma formation, sensory nerve injury, lymphedema, etc. Many centers rely on the availability of frozen section on sentinel lymph nodes to avoid a second procedure with the accuracy of procedure ranging from 73 to 96%, however, the availability of frozen section is limited in our part of the world. Pre-operative identification of axillary node positivity in patients with clinically negative nodes by ultrasound imaging of the axilla would allow one-stage axillary clearance and can decrease the need for SLNB from 21% to 70%. The aim of the present study is to determine the accuracy and feasibility of ultrasound-guided core biopsy to stage the axilla in clinically node-negative breast cancer patients, comparing with final histopathology as gold standard. Material & methods This was a non-randomized, prospective interventional study, done at Radiology Department of Aga Khan University Hospital. All patients diagnosed with breast cancer (histologically proven) with clinically negative axilla and ipsilateral positive axillary ultrasound were included. These patients underwent axillary lymph node core biopsy. If the result was negative they were subjected to SLNB. Histopathology result was taken as gold standard. Results The sensitivity of ultrasound-guided core biopsy was 88%, specificity 100%, positive predictive values (PPV) 100%, negative predictive values (NPV) 89.28%, diagnostic accuracy 94%. Conclusion In conclusion, the present study demonstrated high accuracy of ultrasound-guided axillary lymph node core biopsy in breast cancer patients with clinically node-negative axilla. Positive core biopsy results can thus obviate the need for sentinel lymph node biopsy and allow breast surgeons to directly proceed to axillary lymph node dissection.
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Affiliation(s)
- Shaista Afzal
- Radiology, Aga Khan University Hospital, Karachi, PAK
| | | | - Asma Munir
- Breast Surgery, Aga Khan University Hospital, Karachi, PAK
| | - Romana Idress
- Histopathology, Aga Khan University Hospital, Karachi, PAK
| | - Poonum Khan
- Radiology, Aga Khan University Hospital, Karachi, PAK
| | - Shaista Khan
- Breast Surgery, Aga Khan University Hospital, Karachi, PAK
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Diagnostic Accuracy of Axillary Ultrasound in Early–Stage Breast Cancer. Indian J Surg 2019. [DOI: 10.1007/s12262-018-1828-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Kane G, Fleming C, Heneghan H, McCartan D, James P, Trueick R, Harrington L, Nally F, Quinn C, O'Doherty A, McNally S, Rothwell J, Evoy D, Geraghty J, McDermott E, Prichard R. False‐negative rate of ultrasound‐guided fine‐needle aspiration cytology for identifying axillary lymph node metastasis in breast cancer patients. Breast J 2019; 25:848-852. [DOI: 10.1111/tbj.13402] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 06/29/2018] [Accepted: 06/29/2018] [Indexed: 02/05/2023]
Affiliation(s)
- Gavin Kane
- Department of Breast Surgery St. Vincent's University Hospital Dublin 4 Ireland
| | - Christina Fleming
- Department of Breast Surgery St. Vincent's University Hospital Dublin 4 Ireland
| | - Helen Heneghan
- Department of Breast Surgery St. Vincent's University Hospital Dublin 4 Ireland
| | - Damian McCartan
- Department of Breast Surgery St. Vincent's University Hospital Dublin 4 Ireland
| | - Philip James
- Department of Breast Surgery St. Vincent's University Hospital Dublin 4 Ireland
| | - Robert Trueick
- Department of Breast Surgery St. Vincent's University Hospital Dublin 4 Ireland
| | - Luke Harrington
- Department of Breast Surgery St. Vincent's University Hospital Dublin 4 Ireland
| | - Fionn Nally
- Department of Breast Surgery St. Vincent's University Hospital Dublin 4 Ireland
| | - Cecily Quinn
- Department of Histopathology St. Vincent's University Hospital Dublin 4 Ireland
| | - Ann O'Doherty
- Department of Radiology St. Vincent's University Hospital Dublin 4 Ireland
| | - Sorcha McNally
- Department of Radiology St. Vincent's University Hospital Dublin 4 Ireland
| | - Jane Rothwell
- Department of Breast Surgery St. Vincent's University Hospital Dublin 4 Ireland
| | - Denis Evoy
- Department of Breast Surgery St. Vincent's University Hospital Dublin 4 Ireland
| | - James Geraghty
- Department of Breast Surgery St. Vincent's University Hospital Dublin 4 Ireland
| | - Enda McDermott
- Department of Breast Surgery St. Vincent's University Hospital Dublin 4 Ireland
| | - Ruth Prichard
- Department of Breast Surgery St. Vincent's University Hospital Dublin 4 Ireland
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Patel R, MacKerricher W, Tsai J, Choy N, Lipson J, Ikeda D, Pal S, De Martini W, Allison KH, Wapnir IL. Pretreatment Tattoo Marking of Suspicious Axillary Lymph Nodes: Reliability and Correlation with Sentinel Lymph Node. Ann Surg Oncol 2019; 26:2452-2458. [PMID: 31087176 DOI: 10.1245/s10434-019-07419-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND Tattooing is an alternative method for marking biopsied axillary lymph nodes (ALNs) before initiation of treatments for newly diagnosed breast cancer. Detection of black ink-stained nodes is performed under direct visualization at surgery and is combined with sentinel node (SLN) mapping procedures. METHODS Women with newly diagnosed breast cancer who underwent fine or core-needle biopsy of suspicious ALNs were recruited. The nodal cortex and perinodal soft tissue was injected with 0.1-1.0 ml of Spot™ (GI Supply) black ink under ultrasound guidance. Intraoperatively, black stained nodes were removed along with SLNs, noting concordance between the two. RESULTS Sixty-six evaluable patients were enrolled (2013-2017). Nineteen received surgery first (Group 1) and 47 neoadjuvant therapy (NAT, Group 2). The average number of nodes tattooed was 1.16 for Group 1 and 1.04 for Group 2. The average interval from tattoo to surgery was 21 days (range 1-62) for Group 1 and 148 days (range 71-257) for Group 2. The tattooed node(s) were visually identified at surgery and corresponded to the sentinel lymph node(s) in 98.5% of cases (18/19 in Group 1 and 47/47 in Group 2). Of the 14 patients in Group 2 whose nodes remained positive following NAT, the tattooed node was the SLN associated with carcinoma. CONCLUSIONS Tattooing is an alternative method for marking biopsied ALNs. Tattooed nodes coincided with SLNs in 98.5% of cases. This technique is advantageous, because it allows for fewer procedures and lower costs compared with other methods.
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Affiliation(s)
- Rupa Patel
- Department of Surgery, Stanford University School of Medicine, Stanford Cancer Institute, Stanford, CA, USA
| | - Wendy MacKerricher
- Department of Pathology, Stanford University School of Medicine, Stanford Cancer Institute, Stanford, CA, USA
| | - Jacqueline Tsai
- Department of Surgery, Stanford University School of Medicine, Stanford Cancer Institute, Stanford, CA, USA
| | - Nicole Choy
- Department of Surgery, Stanford University School of Medicine, Stanford Cancer Institute, Stanford, CA, USA
| | - Jafi Lipson
- Department of Radiology, Stanford University School of Medicine, Stanford Cancer Institute, Stanford, CA, USA
| | - Debra Ikeda
- Department of Radiology, Stanford University School of Medicine, Stanford Cancer Institute, Stanford, CA, USA
| | - Sunita Pal
- Department of Radiology, Stanford University School of Medicine, Stanford Cancer Institute, Stanford, CA, USA
| | - Wendy De Martini
- Department of Radiology, Stanford University School of Medicine, Stanford Cancer Institute, Stanford, CA, USA
| | - Kimberly H Allison
- Department of Pathology, Stanford University School of Medicine, Stanford Cancer Institute, Stanford, CA, USA
| | - Irene L Wapnir
- Department of Surgery, Stanford University School of Medicine, Stanford Cancer Institute, Stanford, CA, USA.
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Slanetz PJ, Moy L, Baron P, diFlorio RM, Green ED, Heller SL, Holbrook AI, Lee SJ, Lewin AA, Lourenco AP, Niell B, Stuckey AR, Trikha S, Vincoff NS, Weinstein SP, Yepes MM, Newell MS. ACR Appropriateness Criteria ® Monitoring Response to Neoadjuvant Systemic Therapy for Breast Cancer. J Am Coll Radiol 2018; 14:S462-S475. [PMID: 29101985 DOI: 10.1016/j.jacr.2017.08.037] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 08/14/2017] [Indexed: 12/28/2022]
Abstract
Patients with locally advanced invasive breast cancers are often treated with neoadjuvant chemotherapy prior to definitive surgical intervention. The primary aims of this approach are to: 1) reduce tumor burden thereby permitting breast conservation rather than mastectomy; 2) promptly treat possible metastatic disease, whether or not it is detectable on preoperative staging; and 3) potentially tailor future chemotherapeutic decisions by monitoring in-vivo tumor response. Accurate radiological assessment permits optimal management and planning in this population. However, assessment of tumor size and response to treatment can vary depending on the modality used, the measurement technique (such as single longest diameter, 3-D measurements, or calculated tumor volume), and varied response of different tumor subtypes to neoadjuvant chemotherapy (such as concentric shrinkage or tumor fragmentation). As discussed in further detail, digital mammography, digital breast tomosynthesis, US and MRI represent the key modalities with potential to help guide patient management. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - Priscilla J Slanetz
- Principal Author, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
| | - Linda Moy
- Panel Vice Chair, NYU Clinical Cancer Center, New York, New York
| | - Paul Baron
- Roper St. Francis Physician Partners Breast Surgery, Charleston, South Carolina; American College of Surgeons
| | | | - Edward D Green
- The University of Mississippi Medical Center, Jackson, Mississippi
| | | | | | - Su-Ju Lee
- University of Cincinnati, Cincinnati, Ohio
| | - Alana A Lewin
- New York University School of Medicine, New York, New York
| | - Ana P Lourenco
- Alpert Medical School of Brown University and Rhode Island Hospital, Providence, Rhode Island
| | | | - Ashley R Stuckey
- Women and Infants Hospital, Providence, Rhode Island; American Congress of Obstetricians and Gynecologists
| | | | - Nina S Vincoff
- Hofstra Northwell School of Medicine, Manhasset, New York
| | - Susan P Weinstein
- Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Mary S Newell
- Panel Chair, Emory University Hospital, Atlanta, Georgia
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Saidha NK, Aggarwal R, Sen A. Identification of Sentinel Lymph Nodes Using Contrast-Enhanced Ultrasound in Breast Cancer. Indian J Surg Oncol 2017; 9:355-361. [PMID: 30287998 DOI: 10.1007/s13193-017-0646-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Accepted: 03/20/2017] [Indexed: 12/12/2022] Open
Abstract
Sentinel lymph node (SLN) biopsy has become the standard of care in axillary staging of breast cancer patients who are clinically node negative as it reduces the morbidity of axillary nodal dissection. SLN biopsy using blue dye and radioisotopes have high identification rates but its limitations include anaphylaxis, disposal of radioactive waste, and potential second surgery in up to 35% of patients who show nodal metastases on SLN biopsy. Contrast-enhanced ultrasound (CEUS) has the potential for SLNs to be identified without the aforementioned risks. CEUS involves the administration of intravenous contrast agents containing microbubbles of perfluorocarbon or nitrogen gas. The bubbles greatly affect ultrasound backscatter and increase vascular contrast in a similar manner to intravenous contrast agents used in CT and MRI. It is safe and easily performed with no requirement for ionizing radiation and no risk of nephrotoxicity. Microbubbles are taken up by lymph nodes when injected directly into tissues, including sub-areolar injection in the breast cancer patient. This method may prove valuable in patients with ductal carcinoma in situ, where operative SLN biopsy remains controversial, and in women undergoing prophylactic mastectomies for high risk. This technique may also have a role after neoadjuvant chemotherapy where frequently there is fibrosis in the treated SLNs.
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Axillary Ultrasound Accurately Excludes Clinically Significant Lymph Node Disease in Patients With Early Stage Breast Cancer. Ann Surg 2017; 264:1098-1102. [PMID: 26779976 DOI: 10.1097/sla.0000000000001549] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Assess the performance characteristics of axillary ultrasound (AUS) for accurate exclusion of clinically significant axillary lymph node (ALN) disease. BACKGROUND Sentinel lymph node biopsy (SLNB) is currently the standard of care for staging the axilla in patients with clinical T1-T2, N0 breast cancer. AUS is a noninvasive alternative to SLNB for staging the axilla. METHODS Patients were identified using a prospectively maintained database. Sensitivity, specificity, and negative predictive value (NPV) were calculated by comparing AUS findings to pathology results. Multivariate analyses were performed to identify patient and/or tumor characteristics associated with false negative (FN) AUS. A blinded review of FN and matched true negative cases was performed by 2 independent medical oncologists to compare treatment recommendations and actual treatment received. Recurrence-free survival was described using Kaplan-Meier product limit methods. RESULTS A total of 647 patients with clinical T1-T2, N0 breast cancer underwent AUS between January 2008 and March 2013. AUS had a sensitivity of 70%, NPV of 84%, and PPV of 56% for the detection of ALN disease. For detection of clinically significant disease (>2.0 mm), AUS had a sensitivity of 76% and NPV of 89%. FN AUS did not significantly impact adjuvant medical decision making. Patients with FN AUS had recurrence-free survival equivalent to patients with pathologic N0 disease. CONCLUSIONS AUS accurately excludes clinically significant ALN disease in patients with clinical T1-T2, N0 breast cancer. AUS may be an alternative to SLNB in these patients, where axillary surgery is no longer considered therapeutic, and predictors of tumor biology are increasingly used to make adjuvant therapy decisions.
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Akıncı M, Bulut SP, Erözgen F, Gürbüzel M, Gülşen G, Kocakuşak A, Gülen M, Kaplan R. Predictive value of fine needle aspiration biopsy of axillary lymph nodes in preoperative breast cancer staging. ULUSAL CERRAHI DERGISI 2016; 32:191-6. [PMID: 27528822 DOI: 10.5152/ucd.2015.2913] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Accepted: 03/28/2015] [Indexed: 02/05/2023]
Abstract
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.
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Affiliation(s)
- Muzaffer Akıncı
- Clinic of General Surgery, Haseki Training and Research Hospital, İstanbul, Turkey
| | - Serap Pamak Bulut
- Clinic of General Surgery, Haseki Training and Research Hospital, İstanbul, Turkey
| | - Fazilet Erözgen
- Clinic of General Surgery, Haseki Training and Research Hospital, İstanbul, Turkey
| | - Mihriban Gürbüzel
- Clinic of Pathology, Haseki Training and Research Hospital, İstanbul, Turkey
| | - Gökçe Gülşen
- Clinic of Radiology, Haseki Training and Research Hospital, İstanbul, Turkey
| | - Ahmet Kocakuşak
- Clinic of General Surgery, Haseki Training and Research Hospital, İstanbul, Turkey
| | - Mehmet Gülen
- Clinic of General Surgery, Haseki Training and Research Hospital, İstanbul, Turkey
| | - Rafet Kaplan
- Clinic of General Surgery, Haseki Training and Research Hospital, İstanbul, Turkey
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De Coninck C, Noël JC, Boutemy R, Simon P. Preoperative axillary lymph node staging by ultrasound-guided cytology using a four-level sonographic score. BMC Med Imaging 2016; 16:13. [PMID: 26847686 PMCID: PMC4743327 DOI: 10.1186/s12880-016-0116-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 01/22/2016] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
| | | | - Rachel Boutemy
- Erasme Hospital, 808 route de Lennik, 1070, Anderlecht, Belgium.
| | - Philippe Simon
- Erasme Hospital, 808 route de Lennik, 1070, Anderlecht, Belgium.
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Rocha RD, Girardi AR, Pinto RR, de Freitas VAR. Axillary ultrasound and fine-needle aspiration in preoperative staging of axillary lymph nodes in patients with invasive breast cancer. Radiol Bras 2016; 48:345-52. [PMID: 26811550 PMCID: PMC4725394 DOI: 10.1590/0100-3984.2014.0121] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
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.
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Affiliation(s)
- Rafael Dahmer Rocha
- MD, Radiologist, Trainee in Interventional Radiology at Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - André Ricardo Girardi
- MD, Radiologist, Trainee in General Radiology at Med Imagem - Real e Benemérita Sociedade Portuguesa de Beneficência, São Paulo, SP, Brazil
| | - Renata Reis Pinto
- MD, Breast Specialist, Hospital do Câncer III - Instituto Nacional de Câncer - Ministério da Saúde (INCA-MS), Rio de Janeiro, RJ, Brazil
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Moorman AM, Bourez RLJH, de Leeuw DM, Kouwenhoven EA. 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? ULTRASOUND IN MEDICINE & BIOLOGY 2015; 41:2842-2848. [PMID: 26259889 DOI: 10.1016/j.ultrasmedbio.2015.06.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Revised: 06/02/2015] [Accepted: 06/16/2015] [Indexed: 06/04/2023]
Abstract
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.
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Affiliation(s)
- A M Moorman
- Department of Surgery, Hospital Group Twente, Almelo, The Netherlands.
| | - R L J H Bourez
- Department of Radiology, Hospital Group Twente, Almelo, The Netherlands
| | - D M de Leeuw
- Department of Surgery, Hospital Group Twente, Almelo, The Netherlands
| | - E A Kouwenhoven
- Department of Surgery, Hospital Group Twente, Almelo, The Netherlands
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Y.L. JT, McGowan K, Cooley G, McLaughlin R, Sugrue M. The role of ultrasound guided core biopsy of axillary nodes in predicting macrometastases and avoiding overtreatment outside ACOSOG Z0011 parameters. Breast 2015; 24:57-61. [DOI: 10.1016/j.breast.2014.11.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Revised: 09/19/2014] [Accepted: 11/15/2014] [Indexed: 10/24/2022] Open
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17
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van Wely BJ, de Wilt JHW, Francissen C, Teerenstra S, Strobbe LJA. Meta-analysis of ultrasound-guided biopsy of suspicious axillary lymph nodes in the selection of patients with extensive axillary tumour burden in breast cancer. Br J Surg 2014; 102:159-68. [DOI: 10.1002/bjs.9663] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Revised: 04/15/2014] [Accepted: 09/01/2014] [Indexed: 11/07/2022]
Abstract
Abstract
Background
Recent studies show that not all patients with breast cancer and positive axillary lymph nodes need additional axillary surgery. A systematic review and meta-analysis of the literature was performed to test the hypothesis that ultrasound-guided biopsy of suspicious nodes can be a useful tool to identify patients with extensive axillary tumour burden.
Methods
PubMed and Embase were searched to identify articles reporting on ultrasound-guided techniques to stage the axilla of patients with breast cancer. The emphasis was to study the number of positive nodes found after axillary lymph node dissection (ALND) following a positive ultrasound-guided biopsy or a positive sentinel lymph node biopsy (SLNB). Information regarding the number of positive nodes thus had to be available. Results were tested for heterogeneity and a meta-analysis was performed.
Results
A total of 894 articles were identified, and 115 were selected based on title and abstract information by two independent reviewers. After extensive review, 18 articles were eligible for analysis. Eight studies reported sufficient data to perform a meta-analysis comparing 532 patients with a positive ultrasound-guided biopsy with 248 patients with a negative ultrasound-guided biopsy but a positive SLNB. The number of involved nodes was significantly higher in patients in whom axillary metastasis was detected by ultrasound-guided biopsy (P < 0·001). No heterogeneity in the observed effect was found (I2 = 22 per cent, P = 0·26).
Conclusion
Patients with breast cancer in whom axillary metastases are detected by ultrasound-guided biopsy have significantly more involved nodes than SLNB-positive patients. This finding enables further preoperative tailoring of axillary treatment in breast cancer.
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Affiliation(s)
- B J van Wely
- Department of Surgery, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - J H W de Wilt
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - C Francissen
- Department of Surgery, Geldersche Vallei Hospital, Ede, The Netherlands
| | - S Teerenstra
- Section of Biostatistics, Department of Health Evidence, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - L J A Strobbe
- Department of Surgery, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
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18
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Choy N, Lipson J, Porter C, Ozawa M, Kieryn A, Pal S, Kao J, Trinh L, Wheeler A, Ikeda D, Jensen K, Allison K, Wapnir I. Initial Results with Preoperative Tattooing of Biopsied Axillary Lymph Nodes and Correlation to Sentinel Lymph Nodes in Breast Cancer Patients. Ann Surg Oncol 2014; 22:377-82. [DOI: 10.1245/s10434-014-4034-6] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Indexed: 11/18/2022]
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Houssami N, Turner RM. Staging the axilla in women with breast cancer: the utility of preoperative ultrasound-guided needle biopsy. Cancer Biol Med 2014; 11:69-77. [PMID: 25009748 PMCID: PMC4069800 DOI: 10.7497/j.issn.2095-3941.2014.02.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Accepted: 03/26/2014] [Indexed: 02/05/2023] Open
Abstract
Preoperative staging of the axilla in women with invasive breast cancer using ultrasound-guided needle biopsy (UNB) identifies approximately 50% of patients with axillary nodal metastases prior to surgical intervention. Although moderately sensitive, it is a highly specific staging strategy that is rarely falsely-positive, hence a positive UNB allows patients to be triaged to axillary lymph-node dissection (ALND) avoiding potentially unnecessary sentinel node biopsy (SNB). In this review, we extend our previous work through an updated literature search, focusing on studies that report data on UNB utility. Based on data for 10,934 breast cancer patients, sourced from 35 studies, a positive UNB allowed triage of 1,745 cases (simple proportion 16%) to axillary surgical treatment: the utility of UNB was a median 19.8% [interquartile range (IQR) 11.6%-26.7%] across these studies. We also modelled data from a subgroup of studies, and estimated that amongst patients with metastases to axillary nodes, the odds ratio (OR) for high nodal disease burden for a positive UNB versus a negative UNB was 4.38 [95% confidence interval (95% CI): 3.13, 6.13], P<0.001. From this model, the estimated proportion with high nodal disease burden was 58.9% (95% CI: 50.2%, 67.0%) for a positive UNB, whereas the estimated proportion with high nodal disease burden was 24.6% (95% CI: 17.7%, 33.2%) if UNB was negative. Overall, axillary UNB has good clinical utility and a positive UNB can effectively triage to ALND. However, the evolving landscape of axillary surgical treatment means that UNB will have relatively less utility where surgeons have modified their practice to omission of ALND for minimal nodal metastatic disease.
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Affiliation(s)
- Nehmat Houssami
- Screening and Test Evaluation Program (STEP), School of Public Health, Sydney Medical School, University of Sydney, Sydney 2006, Australia
| | - Robin M Turner
- Screening and Test Evaluation Program (STEP), School of Public Health, Sydney Medical School, University of Sydney, Sydney 2006, Australia
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20
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Cyr AE, Margenthaler JA. Axillary ultrasound and sentinel lymph node biopsy: an evolving paradigm for management of the axilla. BREAST CANCER MANAGEMENT 2014. [DOI: 10.2217/bmt.14.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY Axillary lymph node dissection was used to treat and to provide staging information for women with invasive breast cancer. With the adoption of sentinel lymph node biopsy over the past two decades, evaluation and management of the axilla has become less invasive for many patients. However, as treatment decisions are more frequently based on tumor biology rather than anatomic staging information, the information obtained from even more minimal axillary surgery may be less clinically relevant, and any surgery may cause morbidity. Imaging technologies, such as axillary ultrasound, offer the capability of providing some staging information without the risks associated with surgery. In addition, the therapeutic need for axillary surgery is in question, and less invasive means of managing the axilla are under investigation.
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Affiliation(s)
- Amy E Cyr
- Department of Surgery, Washington University School of Medicine, 660 S Euclid Avenue, Campus box 8109, St Louis, MO 63110, USA
| | - Julie A Margenthaler
- Department of Surgery, Washington University School of Medicine, 660 S Euclid Avenue, Campus box 8109, St Louis, MO 63110, USA
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21
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Should Ultrasound be a Standard Preoperative Tool in Surgical Planning? CURRENT BREAST CANCER REPORTS 2014. [DOI: 10.1007/s12609-013-0133-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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22
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Fung AD, Collins JA, Campassi C, Ioffe OB, Staats PN. 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. Cancer Cytopathol 2013; 122:282-91. [PMID: 24353146 DOI: 10.1002/cncy.21384] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Revised: 10/31/2013] [Accepted: 11/04/2013] [Indexed: 01/27/2023]
Abstract
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.
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Affiliation(s)
- Adele D Fung
- Department of Pathology, University of Maryland School of Medicine and University of Maryland Medical Center, Baltimore, Maryland
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23
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Diepstraten SCE, Sever AR, Buckens CFM, Veldhuis WB, van Dalen T, van den Bosch MAAJ, Mali WPTM, Verkooijen HM. 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. Ann Surg Oncol 2013; 21:51-9. [PMID: 24008555 DOI: 10.1245/s10434-013-3229-6] [Citation(s) in RCA: 128] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Indexed: 01/01/2023]
Abstract
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.
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24
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Axillary ultrasound in patients with clinically node-negative breast cancer: which features are predictive of disease? J Surg Res 2013; 184:234-40. [DOI: 10.1016/j.jss.2013.03.068] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Revised: 03/17/2013] [Accepted: 03/20/2013] [Indexed: 02/05/2023]
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25
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Yoo EY, Shin JH, Ko EY, Han BK, Cho EY, Nam SJ, Hahn SY, Ko ES. Detectability and clinicohistological characteristics of small (≤1 cm) invasive breast cancer. Eur J Radiol 2013; 82:e556-61. [PMID: 23830035 DOI: 10.1016/j.ejrad.2013.05.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2012] [Revised: 05/03/2013] [Accepted: 05/29/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE To investigate the detectability and imaging characteristics of primary tumors according to imaging modalities and to identify clinical features and histological prognostic factors for axillary metastases in patients with small (≤1cm, T1a and T1b) invasive breast cancer. MATERIALS AND METHODS A total of 221 patients with histologically confirmed small invasive cancers were included for the statistical analysis. At mammography, ultrasonography and MRI, the detectability, and imaging characteristics of primary tumors were compared in patients with or without axillary metastases. Clinical features and histological prognostic factors for axillary metastases were investigated. RESULTS Of 221 patients examined, axillary metastasis was found in 42 (19%) at the time of surgery. There was no significant difference in detectability of small tumors using ultrasonography and MRI between patients with and without axillary metastasis. However, mammography had a higher positive rate of primary tumors in patients with axillary metastasis than without metastasis (92.9% vs. 77.1%, p=0.023). Patients with axillary metastasis in small cancers showed more common architectural distortion than negative (p=0.0147) or mass (p=0.0356) on mammography. Clinical features were not different in the two groups. Only lymphovascular invasion was independently associated with axillary metastasis (p=0.0051, 95% CI, 1.527-11.597). CONCLUSION The detectability of small invasive breast cancers among patients with and without axillary metastasis is different with mammography, but not with US and MRI. Lymphovascular invasion is only a predictor for axillary metastasis in small invasive cancers.
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Affiliation(s)
- Eun Young Yoo
- Deparment of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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26
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Mullen R, Purdie C, Jordan L, McLean D, Whelehan P, Vinnicombe S, Brown D, Evans A. Can additional histopathological examination of ultrasound-guided axillary lymph node core biopsies improve preoperative diagnosis of primary breast cancer nodal metastasis? Clin Radiol 2013; 68:704-7. [DOI: 10.1016/j.crad.2013.01.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2012] [Revised: 01/21/2013] [Accepted: 01/22/2013] [Indexed: 11/29/2022]
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Testori A, Meroni S, Moscovici OC, Magnoni P, Malerba P, Chiti A, Rahal D, Travaglini R, Cariboni U, Alloisio M, Orefice S. Surgical sentinel lymph node biopsy in early breast cancer. Could it be avoided by performing a preoperative staging procedure? A pilot study. Med Sci Monit 2013; 18:CR543-9. [PMID: 22936189 PMCID: PMC3560653 DOI: 10.12659/msm.883349] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Alberto Testori
- Department of Thoracic Surgery, Senology Unit, IRCCS Istituto Clinico Humanitas, Rozzano (Milano), Italy
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Hackney L, Williams S, Bajwa S, Morley-Davies AJ, Kirby RM, Britton I. Influence of Tumor Histology on Preoperative Staging Accuracy of Breast Metastases to the Axilla. Breast J 2012. [DOI: 10.1111/tbj.12042] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Lisa Hackney
- Department of Radiology; University Hospital of North Staffordshire, Breast Care Unit; Staffordshire England
| | - Susan Williams
- Department of Radiology; University Hospital of North Staffordshire, Breast Care Unit; Staffordshire England
| | - Saba Bajwa
- Department of Radiology; University Hospital of North Staffordshire, Breast Care Unit; Staffordshire England
| | - Adrian J Morley-Davies
- Department of Cardiology; University Hospital of North Staffordshire; Staffordshire England
| | - Robert M. Kirby
- Department of Surgery; University Hospital of North Staffordshire, Breast Care Unit; Staffordshire England
| | - Ingrid Britton
- Department of Radiology; University Hospital of North Staffordshire, Breast Care Unit; Staffordshire England
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Al Ayyan M, Bu Ali O, Al Sharri S, Kassis A, Hussain S, Al-Bashir M. Negative axillary ultrasonography with biopsy may predict non-involvement of the non-sentinel lymph nodes in operable breast cancer patients. Asia Pac J Clin Oncol 2012; 10:e86-9. [DOI: 10.1111/ajco.12039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2012] [Indexed: 02/05/2023]
Affiliation(s)
- Muna Al Ayyan
- Department of Surgery; Tawam Hospital; Al-Ain United Arab Emirates
| | - Omaima Bu Ali
- Department of Surgery; Tawam Hospital; Al-Ain United Arab Emirates
| | | | - Adnan Kassis
- Department of Radiology; Tawam Hospital; Al-Ain United Arab Emirates
| | - Sabir Hussain
- Department of Oncology; Tawam Hospital; Al-Ain United Arab Emirates
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Choi JS, Kim MJ, Moon HJ, Kim EK, Yoon JH. False negative results of preoperative axillary ultrasound in patients with invasive breast cancer: correlations with clinicopathologic findings. ULTRASOUND IN MEDICINE & BIOLOGY 2012; 38:1881-1886. [PMID: 22975037 DOI: 10.1016/j.ultrasmedbio.2012.07.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Revised: 07/10/2012] [Accepted: 07/18/2012] [Indexed: 06/01/2023]
Abstract
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.
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Affiliation(s)
- Ji Soo Choi
- Department of Radiology, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Korea
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31
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Preoperative needle biopsy of sentinel lymph nodes using intradermal microbubbles and contrast-enhanced ultrasound in patients with breast cancer. AJR Am J Roentgenol 2012; 199:465-70. [PMID: 22826414 DOI: 10.2214/ajr.11.7702] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
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.
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Caretta-Weyer H, Sisney GA, Beckman C, Burnside ES, Salkowsi LR, Strigel RM, Wilke LG, Neuman HB. Impact of axillary ultrasound and core needle biopsy on the utility of intraoperative frozen section analysis and treatment decision making in women with invasive breast cancer. Am J Surg 2012; 204:308-14. [DOI: 10.1016/j.amjsurg.2011.10.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2011] [Revised: 10/12/2011] [Accepted: 10/12/2011] [Indexed: 02/05/2023]
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Rahbar H, Partridge SC, Javid SH, Lehman CD. Imaging Axillary Lymph Nodes in Patients with Newly Diagnosed Breast Cancer. Curr Probl Diagn Radiol 2012; 41:149-58. [DOI: 10.1067/j.cpradiol.2011.08.002] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Leenders MWH, Broeders M, Croese C, Richir MC, Go HLS, Langenhorst BLAM, Meijer S, Schreurs WH. Ultrasound and fine needle aspiration cytology of axillary lymph nodes in breast cancer. To do or not to do? Breast 2012; 21:578-83. [PMID: 22717665 DOI: 10.1016/j.breast.2012.05.008] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2012] [Revised: 05/12/2012] [Accepted: 05/17/2012] [Indexed: 02/05/2023] Open
Abstract
AIM The purpose of our study was to evaluate the accuracy of axillary ultrasound and ultrasound-guided fine needle aspiration cytology (FNAC) in the preoperative diagnosis of axillary metastases. METHODS Between 2004 and 2009, 1132 female patients were evaluated and treated in our clinic for histologically proven breast carcinoma. Preoperative axillary ultrasound with subsequent FNAC in case of suspicious lymph nodes was performed in 1150 axillae (18 bilateral breast carcinomas). We analyzed the results of axillary ultrasound and FNAC retrospectively. Pathological node status was used as the reference standard (based on axillary dissection or sentinel node biopsy). RESULTS Axillary ultrasound showed suspicious lymph nodes in 327 axillae (28.4%). FNAC showed axillary metastases in 107 of these 327 axillae. Final histological analysis confirmed 106 metastases (one false positive). Histological analysis showed metastatic disease in 429 of 1150 axillae (37.3%). Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of axillary ultrasound alone were 43.8% (188/429), 80.7% (582/721), 57.5% (188/327) and 70.7% (582/823), respectively. When combining axillary ultrasound with FNAC of suspicious lymph nodes, sensitivity was 24.7% (106/429), specificity was 99.9% (720/721), PPV was 99.1% (106/107) and NPV was 69.0% (720/1043). CONCLUSIONS 106/429 (24.7%) Node-positive axillae were identified by ultrasound-guided FNAC and spared unnecessary sentinel node biopsy. Unfortunately, the percentage of false negative results of ultrasound-guided FNAC (28.1%, 323/1150) was very high.
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Affiliation(s)
- M W H Leenders
- Department of Surgery, Medical Centre Alkmaar, Wilhelminalaan 12, 1815 JD Alkmaar, The Netherlands.
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Houssami N, Ciatto S, Turner RM, Cody HS. Preoperative staging of the axilla in women with invasive breast cancer. BREAST CANCER MANAGEMENT 2012. [DOI: 10.2217/bmt.12.9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
SUMMARY Axillary node status is an important prognostic factor in invasive breast cancer. Axillary lymph node dissection (ALND) was previously the primary management approach; however, sentinel node biopsy (SNB) has largely replaced ALND, which is currently predominantly used to manage SNB-positive patients. Preoperative imaging-based staging of the axilla (with ultrasound, PET or MRI) for the detection of suspicious nodes has been applied to inform and potentially streamline axillary surgical management. Ultrasound with ultrasound-guided needle biopsy is the most accurate imaging-based strategy and has been shown to have clinical utility for preoperative axillary staging. A meta-analysis has reported a median sensitivity of 79.4% and a specificity of 100% for ultrasound-based staging, and estimated that ultrasound-guided needle biopsy triages 55.2% of women with metastatic axillary nodes (or a median of 17.7% of patients) directly to ALND, thereby avoiding unnecessary SNB. Although ultrasound-based staging has had a role in preoperative axillary assessment, it appears likely that this role will be shaped in the future by the ongoing evolution in surgical management of the axilla, particularly in light of recent evidence that challenges the need for ALND in some SNB-positive patients.
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Affiliation(s)
- Nehmat Houssami
- Screening & Test Evaluation Program (STEP), School of Public Health, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Stefano Ciatto
- UO Senologia Clinica e Screening Mammografico, Department of Diagnostics, Azienda Provinciale Servizi Sanitari (APSS), Trento, Italy
| | - Robin M Turner
- Screening & Test Evaluation Program (STEP), School of Public Health, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Hiram S Cody
- Breast Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center (MSKCC), NY, USA
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Preoperative ultrasound-guided needle biopsy of axillary nodes in invasive breast cancer: meta-analysis of its accuracy and utility in staging the axilla. Ann Surg 2011; 254:243-51. [PMID: 21597359 DOI: 10.1097/sla.0b013e31821f1564] [Citation(s) in RCA: 242] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Systematic evidence synthesis of ultrasound-guided needle biopsy (UNB) of axillary nodes in breast cancer. SUMMARY BACKGROUND DATA Women affected by invasive breast cancer undergo initial staging with sentinel node biopsy, generally progressing to axillary node dissection (AND) if metastases are found. Preoperative UNB can potentially identify and triage women with node metastases directly to AND. METHODS Review and meta-analysis of studies reporting UNB accuracy: we estimated sensitivity, specificity, and PPV, using bivariate random-effects models and examined the effect of covariates; we calculated UNB utility (effect on axillary surgery). RESULTS Thirty-one studies provided 2874 UNB data from 6166 subjects (median proportion with metastatic nodes 47.2%; IQR 39.5%, 61.2%). Modeled estimates for UNB were: sensitivity 79.6% (95% confidence intervals [CI] 74.1-84.2), specificity 98.3% (95%CI 97.2-99.0), PPV 97.1% (95%CI 95.2-98.3); median UNB insufficiency was 4.1% (IQR0%-10.9%). UNB sensitivity increased with increasing ultrasound sensitivity, and was higher in studies performing UNB for "suspicious" than for "visible" nodes. Specificity was higher in studies of consecutive (vs. selected) subjects, in studies reporting ultrasound data, and in more recent studies. Median proportion of women triaged directly to AND (attributed to UNB) was 19.8% (IQR11.6%-28.1%) or 17.7% (IQR11.6%-27.1%) if restricted to clinically node-negative series. Median proportion of women with metastatic axillary nodes potentially triaged to AND was 55.2% (IQR41.8%-68.2%) and was higher (65.6%; IQR48.9%-69.7%) in the subgroup of studies with median tumor size ≥21 mm. CONCLUSIONS Preoperative UNB of the axilla is accurate for initial staging of women with invasive breast cancer. Meta-analysis indicates that UNB provides better utility in women with average or higher underlying risk of node metastases.
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Park SH, Kim MJ, Park BW, Moon HJ, Kwak JY, Kim EK. Impact of preoperative ultrasonography and fine-needle aspiration of axillary lymph nodes on surgical management of primary breast cancer. Ann Surg Oncol 2010; 18:738-44. [PMID: 20890729 DOI: 10.1245/s10434-010-1347-y] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2010] [Indexed: 02/05/2023]
Abstract
PURPOSE To evaluate the accuracy of preoperative ultrasonography (US) and US-guided fine-needle aspiration (US-FNA) for detecting axillary lymph node (ALN) metastasis. PATIENTS AND METHODS We retrospectively reviewed 382 breast cancer patients with clinically negative ALN who underwent US and/or US-FNA for ALN. US-FNA of ALN was performed in 121 patients with suspicious findings on US. The diagnostic performance of US alone or with the addition of US-FNA for detecting ALN metastasis was calculated on the basis of final pathologic reports of ALN surgery. RESULTS Among a total of 382 patients, 129 had metastatic ALNs while 253 exhibited no signs of axillary metastasis on final pathology. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of axillary US alone were 56.6% (73/129), 81.0% (205/253), 60.3% (73/121), and 78.5% (205/261), respectively. Addition of US-FNA resulted in sensitivity, specificity, PPV, and NPV of 39.5% (51/129), 95.7% (242/253), 82.3% (51/62), and 75.6% (242/320), respectively. Excluding complete responders to neoadjuvant chemotherapy, specificity and PPV after adding US-FNA were increased to 99.6% (242/243) and 98.1% (51/52), respectively. The sensitivity and specificity of ALN metastasis were similar between the palpable and nonpalpable breast cancer groups; however, after adding US-FNA, NPV was increased in the nonpalpable breast cancer group compared with the palpable breast cancer group (p = 0.0398). By including preoperative axillary US and US-FNA, 16.2% (62/382) of all breast cancer patients were able to avoid unnecessary sentinel lymph node biopsy (SLNB). CONCLUSIONS The combination of axillary US and US-FNA is useful in preoperative work-up of breast cancer patients and provides valuable information for planning proper breast cancer management.
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Affiliation(s)
- So Hee Park
- Department of Radiology, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Korea
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Ogino I, Tayama Y, Arai M, Inoue T, Shimizu D, Ishikawa T. CT assessment of breast cancer for pathological involvement of four or more axillary nodes. Breast Cancer 2010; 19:125-30. [PMID: 20697857 DOI: 10.1007/s12282-010-0216-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2010] [Accepted: 07/02/2010] [Indexed: 02/06/2023]
Abstract
BACKGROUND To predict the likelihood of ≥4 pathologically positive axillary nodes in breast cancer patients by computed tomography (CT) before neoadjuvant chemotherapy (NAC). METHODS Inclusion criteria for the 97 patients reviewed were lymph nodes (LNs) pathologically proved positive with standard level I-II axillary dissection, contrast-enhanced CT was performed before surgery, contralateral breast cancer was not present, and NAC was not given before surgery. The size, number, and level of both ipsilateral and contralateral axillary LNs were studied by contrast-enhanced high-resolution CT for pathologically positive LNs in breast cancer patients. RESULTS Level III LN was only detected in ipsilateral axilla of patients with ≥4 pathologically involved nodes. The number of ipsilateral level I-II LNs is the only factor significantly related to the pathological involvement of ≥4 axillary nodes. Increasing numbers of contralateral level I-II LNs are significantly related to increasing numbers of ipsilateral level I-II LNs. For the criterion of maximal LN size ≥5 mm, if contralateral level I-II LNs were negative and the cutoff points for ipsilateral level I-II LNs were 0-2 and ≥3, the sensitivity and specificity for ≥4 pathologically involved nodes would be 84.6 and 73.3%. If contralateral I-II LNs were positive, the negative predictive value was 80.0%. CONCLUSION Level III LN detection in ipsilateral axilla and the number of level I-II LNs in bilateral axilla will be helpful to predict ≥4 pathologically positive axillary nodes.
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Affiliation(s)
- Ichiro Ogino
- Department of Radiation Oncology, Yokohama City University Medical Center, Minami-ku, Japan.
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Erpelding TN, Kim C, Pramanik M, Jankovic L, Maslov K, Guo Z, Margenthaler JA, Pashley MD, Wang LV. Sentinel lymph nodes in the rat: noninvasive photoacoustic and US imaging with a clinical US system. Radiology 2010; 256:102-10. [PMID: 20574088 DOI: 10.1148/radiol.10091772] [Citation(s) in RCA: 166] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE To evaluate in vivo sentinel lymph node (SLN) mapping by using photoacoustic and ultrasonographic (US) imaging with a modified clinical US imaging system. MATERIALS AND METHODS Animal protocols were approved by the Animal Studies Committee. Methylene blue dye accumulation in axillary lymph nodes of seven healthy Sprague-Dawley rats was imaged by using a photoacoustic imaging system adapted from a clinical US imaging system. To investigate clinical translation, the imaging depth was extended up to 2.5 cm by adding chicken or turkey breast on top of the rat skin surface. Three-dimensional photoacoustic images were acquired by mechanically scanning the US transducer and light delivery fiber bundle along the elevational direction. RESULTS Photoacoustic images of rat SLNs clearly help visualization of methylene blue accumulation, whereas coregistered photoacoustic/US images depict lymph node positions relative to surrounding anatomy. Twenty minutes following methylene blue injection, photoacoustic signals from SLN regions increased nearly 33-fold from baseline signals in preinjection images, and mean contrast between SLNs and background tissue was 76.0 +/- 23.7 (standard deviation). Methylene blue accumulation in SLNs was confirmed photoacoustically by using the optical absorption spectrum of the dye. Three-dimensional photoacoustic images demonstrate dynamic accumulation of methylene blue in SLNs after traveling through lymph vessels. CONCLUSION In vivo photoacoustic and US mapping of SLNs was successfully demonstrated with a modified clinical US scanner. These results raise confidence that photoacoustic and US imaging can be used clinically for accurate, noninvasive imaging of SLNs for axillary lymph node staging in breast cancer patients.
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Al Mushawah F, Tan MC, Margenthaler JA. Residual nodal disease in biopsy proven n1/n2 breast cancer following neoadjuvant systemic therapy. World J Surg 2010; 34:256-60. [PMID: 20012606 DOI: 10.1007/s00268-009-0328-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The purpose of this study was to determine the rate of complete pathologic response in axillary lymph nodes after neoadjuvant therapy and the clinicopathologic factors associated with a complete response. METHODS Clinical, demographic, and pathologic data from all patients with breast cancer treated at our institution are prospectively recorded in a database. We reviewed this database from 2000 to 2007 and identified 90 patients who were node-positive before neoadjuvant therapy based on image-guided fine needle aspiration biopsy; all 90 patients underwent axillary lymph node dissection (ALND) after neoadjuvant therapy. Data were compared using chi-square and Fisher's exact test. RESULTS Of 90 patients with breast cancer who were node-positive before neoadjuvant therapy, 71 (79%) had positive nodal disease on final ALND pathology and 19 (21%) had a complete nodal pathologic response. Age, race, tumor grade, clinical T and N stage, and estrogen/progesterone receptor and Her-2neu status were not predictive of a complete nodal response. The only factor predictive of a complete nodal response was the type of neoadjuvant therapy used; all 19 patients with a complete response received neoadjuvant chemotherapy and none received neoadjuvant endocrine therapy (P < 0.05). CONCLUSIONS Twenty-five percent of patients who underwent neoadjuvant chemotherapy had a complete pathologic response in the nodal basin, whereas no patient who underwent neoadjuvant endocrine therapy experienced a complete nodal response. Twenty-five percent of patients who underwent neoadjuvant chemotherapy had a complete pathological response in the nodal specimen, whereas no patient who underwent neoadjuvant endocrine therapy experienced a complete nodal response.
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Affiliation(s)
- Fatema Al Mushawah
- Department of Surgery, Washington University School of Medicine, 660 S. Euclid Avenue, Campus Box 8109, St. Louis, MO 63110, USA
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Somasundaram SK, Chicken DW, Waddington WA, Bomanji J, Ell PJ, Keshtgar MRS. Sentinel node imaging in breast cancer using superficial injections: technical details and observations. Eur J Surg Oncol 2009; 35:1250-6. [PMID: 19540710 DOI: 10.1016/j.ejso.2009.05.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2008] [Revised: 05/12/2009] [Accepted: 05/18/2009] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Sentinel lymph node (SLN) biopsy is the evolving standard of care for the management of early breast cancer. Accurate identification of the SLN is paramount for success of this procedure. Various techniques are described for SLN identification, but the superficial injection techniques, advocated by the UK National Training Programme (NEW START), are validated, reproducible and rapid. Pre-operative lymphoscintigraphy provides a road map for the surgeon and requires a reporting template. METHODS As one of the NEW START training institutions in the UK practising this technique, we reviewed a mature series of 100 unselected, consecutive SLN lymphoscintigraphy procedures. We correlated the imaging, operative and pathology findings and have provided technical details of the technique and a template for reporting SLN lymphoscintigrams. RESULTS The SLN localisation rate was 99% with one failed imaging. Seven patients required delayed imaging. The mean activity of the radiocolloid injected was 14.4MBq (range 8.3-23 MBq). The SLNs were visualised in the ipsilateral axilla in 98 images, intramammary in 3, and internal mammary in 1. A mean of 1.35 nodes were classified as 'True' SLNs on imaging criteria. Intra-operatively, a mean of 1.91 SLNs were excised. 32 of 116 hot and blue nodes, 7 of 15 only blue nodes, 13 of 47 only hot and 7 of 13 parasentinel nodes harboured metastases. CONCLUSION The NEW START recommended, combined superficial injection techniques, have high localisation rates. Pre-operative sentinel node imaging is recommended and a template for reporting is provided.
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Affiliation(s)
- S K Somasundaram
- University Department of Surgery, Royal Free and University College Medical School, Pond Street, London NW3 2QG, UK
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