Preoperative ultrasound staging of the axilla make's peroperative examination of the sentinel node redundant in breast cancer: saving tissue, time and money

Assessing Whether Morphological Changes in Axillary Lymph Node Have Already Occurred Prior to Metastasis in Breast Cancer Patients by Ultrasound

Background and Objectives: Whether the morphological changes in axillary lymph node (ALN) have occurred prior to metastasis remains unclear in breast cancer (BC) patients. The aim of this study is to investigate the influence of BC for the morphology of non-metastasis ALN (N−) and, further, to improve the performance of ultrasound (US) examination for metastasis ALN (N+). Materials and Methods: In this retrospective study, 653 patients with breast mass were enrolled and divided into normal group of 202 patients with benign breast tumor, N− group of 233 BC patients with negative ALN and N+ group of 218 BC patients with positive ALN. US features of ALN were evaluated and analyzed according to long (L) and short (S) diameter, the (L/S) axis ratio, cortical thickness, lymph node edge, replaced hilum and color Doppler flow imaging (CDFI). Results: ALN US features of short diameter, replaced hilum, cortical thickness and CDFI have significant statistical differences in N− group comparing with normal group and N+ group, respectively (p < 0.05). Conclusions: Therefore, BC can affect ALN and lead to US morphological changes whether lymph node metastasis is present, which reduces the sensitivity of axillary US. The combination of US and other examination methods should be applied to improve the diagnostic performance of N+.

Diagnostic Accuracy of Fine-Needle Aspiration Cytology and Core-Needle Biopsy in the Assessment of the Axillary Lymph Nodes in Breast Cancer-A Meta-Analysis

Background: The present study aims to evaluate the diagnostic accuracy between ultrasonography-guided fine-needle aspiration cytology (US-FNAC) and core needle biopsy (CNB) of axillary lymph nodes (ALNs) in patients with breast cancer through a meta-analysis and a diagnostic test accuracy (DTA) review. Methods: The present meta-analysis and DTA review included 67 eligible studies. The diagnostic accuracy of various preoperative assessments, including US-FNAC and CNB, was evaluated for ALNs assessments in patients with breast cancer. In addition, a subgroup analysis based on methods of cytologic preparation was performed. In the DTA review, the sensitivity, specificity, diagnostic odds ratio (OR) and area under the curve (AUC) on the summary receiver operating characteristic (SROC) curve were calculated. Results: The diagnostic accuracy of the preoperative assessments of ALNs was 0.850 (95% confidence interval (CI) 0.833–0.866) for patients with breast cancer. The diagnostic accuracy of CNB was significantly higher than that of US-FNAC (0.896, 95% CI 0.844–0.932 vs. 0.844, 95% CI 0.825–0.862; p = 0.044 in a meta-regression test). In the subgroup analysis based on cytologic preparation, the diagnosis accuracies were 0.860, 0.861 and 0.859 for the methods of conventional smear, liquid-based preparation and cell block, respectively. In the DTA review, CNB showed higher sensitivity than US-FNAC (0.849 vs. 0.760). However, there was no difference in specificity between US-FNAC and CNB (0.997 vs. 1.000). US-FNAC with liquid-based preparation and CNB showed the highest diagnostic OR and AUC on the SROC, respectively. Conclusion: Both US-FNAC and CNB are useful in preoperative assessments of ALNs in patients with breast cancer. Although the most sensitive test was found to be CNB in this study, there was no difference in specificity between various preoperative evaluations and the application of US-FNAC or CNB may be impacted by various factors.

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

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

A Virtual Reality Environment to Visualize Three-Dimensional Patient-Specific Models by a Mobile Head-Mounted Display

INTRODUCTION

With the availability of low-cost head-mounted displays (HMDs), virtual reality environments (VREs) are increasingly being used in medicine for teaching and clinical purposes. Our aim was to develop an interactive, user-friendly VRE for tridimensional visualization of patient-specific organs, establishing a workflow to transfer 3-dimensional (3D) models from imaging datasets to our immersive VRE.

MATERIALS AND METHODS

This original VRE model was built using open-source software and a mobile HMD, Samsung Gear VR. For its validation, we enrolled 33 volunteers: morphologists (n = 11), trainee surgeons (n = 15), and expert surgeons (n = 7). They tried our VRE and then filled in an original 5-point Likert-type scale 6-item questionnaire, considering the following parameters: ease of use, anatomy comprehension compared with 2D radiological imaging, explanation of anatomical variations, explanation of surgical procedures, preoperative planning, and experience of gastrointestinal/neurological disorders. Results in the 3 groups were statistically compared using analysis of variance.

RESULTS

Using cross-sectional medical imaging, the developed VRE allowed to visualize a 3D patient-specific abdominal scene in 1 hour. Overall, the 6 items were evaluated positively by all groups; only anatomy comprehension was statistically significant different among the 3 groups.

CONCLUSIONS

Our approach, based on open-source software and mobile hardware, proved to be a valid and well-appreciated system to visualize 3D patient-specific models, paving the way for a potential new tool for teaching and preoperative planning.

The predictive value of sentinel node biopsy in early breast cancer after neo-adjuvant chemotherapy: A prospective study

OBJECTIVE

A sentinel Node (SN) has replaced axillary lymph node dissection (ALND) in patients with clinically node negative axilla (cN0). SN after Neo-adjuvant chemotherapy (NACT) is feasible but not accurate in clinically node positive (cN1-3) patients. The goal of this study is to determine the negative predictive value (NPV) of SN in cN0 breast cancer after NACT. A secondary endpoint is to determine if ALND can be avoided after NACT regardless of the pre-treatment clinical staging of the axilla, in case of a normalization of the ¹⁸F-fluoro-2-deoxy-glucose positron emission tomography scan (PET-CT scan).

DESIGN

A single institution prospective study regarding the negative predictive value of the SN in breast cancer after NACT was conducted in the Multidisciplinary Breast Clinic of the Antwerp University Hospital from 29/03/2010 until 01/12/2015 (Study number: B30020108368). Inclusion criteria for study participation were: breast cancer, age above 18 years, female, tumor stages T2-T4 N0-3 or T1N1-N3. All patients were staged by a mammography, ultrasound of the axilla, MRI of the breast, PET-CT scan and bone scintigraphy. They received NACT consisting of 12 cycles of paclitaxel or 4 cycles of docetaxel followed by dose dense doxorubicin or epirubicin/cyclofosfamide or vice versa as a standard initial treatment. After 6 weeks, a PET-CT scan was performed for early tumour response evaluation. At the day of operation, a ⁹⁹mTC-labelled nanocolloid was used to identify the SN. During the surgery the SN were removed separately together with a complete ALND.

RESULTS

A total of 150 patients were enrolled in our study of which 129 were eligible for analysis. 53 patients had a positive SN of which 32 have a positive axillary lymph nodes (ALN), positive predictive value (PPV) was 60%; 76 patients had a negative SN of which 6 had a positive ALN (NPV 92%). The sensitivity is 84% and the specificity 76% with a false omission rate (FOR) of 8%. In total 45 patients ALN were clinical negative and no suspect lymph nodes were seen on ultrasound, MRI and PET-CT scan) and 45 patients had negative a SN, with no ALN and 2 patients had a positive SN of which 1 patients had axillary involvement (NPV 100%). The FOR of cN1: 5%, cN2: 37%, cN3 33%. A total of 22 patients out of 84 patients (26%) of which 15/49 cN1 (30%), 6/23 (26%) cN2, 1/12 (8%) have after 6 weeks of chemotherapy and normalization on PET-CT scan. A total of 17 patients had a negative SN and ALN. The FOR was in this group was 0%.

CONCLUSION

A SNB should become the standard after NACT if case of a cN0. If after NACT the PET CT has normalized, no ALND should be performed if the SN is negative.

Imaging and pathology features to predict axillary tumor load in breast cancer

AIM

We investigated if imaging and pathology features could help to identify a high axillary tumor burden (ATB) in breast cancer patients, in order to individualize decisions on axillary lymph node (ALN) dissection (ALND).

METHODS

We retrospectively analyzed patients primarily treated with surgery in our unit between 2011 and 2014. We divided the patients in two groups: low ATB (LATB) if ≤ 2 ALN were infiltrated and high ATB (HATB) if > 2 ALN were infiltrated.

RESULTS

Data of 105 patients was included in the study. Axillary ultrasound (AUS) features associated with HATB were any sign of ALN infiltration (76 vs 24%, P = 0.027) and > 2 suspicious ALNs (73% vs 27%, P = 0.018); however, when AUS revealed ≤ 2 suspicious ALNs, 39% of these patients had HATB. Any sign of ALN infiltration on magnetic resonance imaging was associated with HATB (48% vs 52%, P = 0.031). Positive preoperative ALN cytology or biopsy was associated with HATB (53% vs 47%, P = 0.008), while p53 positivity (80% vs 20%) and high histological grade (68% vs. 32%) correlated with LATB (P = 0.05 and P = 0.02, respectively). In multivariate analysis, only positive preoperative ALN cytology or biopsy was associated with HATB (P = 0.038).

CONCLUSIONS

AUS was useful for detecting HATB but was not as effective in patients with LATB. Proving axillary infiltration with AUS-directed cytology or biopsy is the most effective method to predict HATB.