Contrast-enhanced ultrasound -guided axillary lymph node core biopsy: Diagnostic accuracy in preoperative staging of invasive breast cancer

Predicting axillary metastasis in breast cancer using lymphatic contrast-enhanced ultrasound-guided fine-needle aspiration of one lymph node

OBJECTIVES

Fine-needle aspiration (FNA) is a microinvasive method to diagnose lymph nodes. This study aims to determine the capability of lymphatic contrast-enhanced ultrasound (LCEUS)-guided FNA in predicting the axillary metastasis with the target of one lymph node (LN) in patients with breast cancer.

METHODS

LCEUS was prospectively performed in 105 patients with breast cancer. The most suspicious LN was targeted based on the characters of LCEUS. FNA was performed in the LN, followed by localization using a guide wire. The detection of lymph cells and/or tumour cells was recognized as a puncture success. Cytologic diagnosis was compared with histologic diagnosis of wire-marked LN for diagnosing accuracy and compared with histologic diagnosis of axillary LNs for predicting accuracy.

RESULTS

LCEUS-guided FNA was performed in all 105 female patients who underwent axillary dissection. The puncture success rates were 74.3%, 91.4%, and 97.1% for three sequential groups (P = .010). In diagnosing LN metastasis, the sensitivity, specificity, and accuracy values of LCEUS-guided FNA were 89.7%, 100%, and 95.7%, respectively. In predicting axillary metastasis, the sensitivity, specificity, and accuracy values of LCEUS-guided FNA were 81.4%, 100%, and 91.3%, respectively.

CONCLUSIONS

The microinvasive LCEUS-guided FNA of one lymph node can be an accurate method and may help predict axillary metastasis in patients with breast cancer.

ADVANCES IN KNOWLEDGE

This study presented that LCEUS combined with FNA would be practical in clinic. The characters of LCEUS could indicate the suspicious LNs and promote the accuracy in predicting axillary metastasis.

Accuracy and Utility of Preoperative Ultrasound-Guided Axillary Lymph Node Biopsy for Invasive Breast Cancer: A Systematic Review and Meta-Analysis

Background

With the acceleration of the pace of life and work, the incidence rate of invasive breast cancer is getting higher and higher, and early diagnosis is very important. This study screened and analyzed the published literature on ultrasound-guided biopsy of invasive breast cancer and obtained the accuracy and practicality of preoperative biopsy.

Method

The four databases were screened for the literature. There was no requirement for the start date of retrieval, and the deadline was July 2, 2022. Two researchers screened the literature, respectively, and included the literature on preoperative ultrasound-guided biopsy and intraoperative and postoperative pathological diagnosis of invasive breast cancer. The diagnostic data included in the literature were extracted and meta-analyzed with RevMan 5.4 software, and the bias risk map, forest map, and summary receiver operating characteristic curves (SROC) were drawn.

Results

The included 19 studies involved about 18668 patients with invasive breast cancer. The degree of bias of the included literature is low. The distribution range of true positive, false positive, true negative, and false negative in the forest map is large, which may be related to the large difference in the number of patients in each study. Most studies in the SROC curve are at the upper left, indicating that the accuracy of ultrasound-guided axillary biopsy is very high.

Conclusion

For invasive breast cancer, preoperative ultrasound-guided biopsy can accurately predict staging and grading of breast cancer, which has important reference value for surgery and follow-up treatment.

Contrast-Enhanced Spectral Mammography-Based Prediction of Non-Sentinel Lymph Node Metastasis and Axillary Tumor Burden in Patients With Breast Cancer

Purpose

To establish and evaluate non-invasive models for estimating the risk of non-sentinel lymph node (NSLN) metastasis and axillary tumor burden among breast cancer patients with 1–2 positive sentinel lymph nodes (SLNs).

Materials and Methods

Breast cancer patients with 1–2 positive SLNs who underwent axillary lymph node dissection (ALND) and contrast-enhanced spectral mammography (CESM) examination were enrolled between 2018 and 2021. CESM-based radiomics and deep learning features of tumors were extracted. The correlation analysis, least absolute shrinkage and selection operator (LASSO), and analysis of variance (ANOVA) were used for further feature selection. Models based on the selected features and clinical risk factors were constructed with multivariate logistic regression. Finally, two radiomics nomograms were proposed for predicting NSLN metastasis and the probability of high axillary tumor burden.

Results

A total of 182 patients [53.13 years ± 10.03 (standard deviation)] were included. For predicting the NSLN metastasis status, the radiomics nomogram built by 5 selected radiomics features and 3 clinical risk factors including the number of positive SLNs, ratio of positive SLNs, and lymphovascular invasion (LVI), achieved the area under the receiver operating characteristic curve (AUC) of 0.85 [95% confidence interval (CI): 0.71–0.99] in the testing set and 0.82 (95% CI: 0.67–0.97) in the temporal validation cohort. For predicting the high axillary tumor burden, the AUC values of the developed radiomics nomogram are 0.82 (95% CI: 0.66–0.97) in the testing set and 0.77 (95% CI: 0.62–0.93) in the temporal validation cohort.

Discussion

CESM images contain useful information for predicting NSLN metastasis and axillary tumor burden of breast cancer patients. Radiomics can inspire the potential of CESM images to identify lymph node metastasis and improve predictive performance.

Contrast-enhanced ultrasound: a new tool for imaging the superficial lymphatic vessels of the upper limb

Background

Despite the new lymphatic imaging methods, there is still a need for a straightforward method of detecting lymphatic abnormalities. Our goal was to investigate the feasibility of applying a contrast enhanced ultrasound (CEUS) procedure as a new approach for visualising the superficial lymphatic vessels of the upper limb.

Methods

Thirty healthy volunteers were examined with CEUS after bilateral intradermal injection of Sonazoid® contrast agent in distal antebrachium. We registered factors affecting intradermal injections, imaging of the superficial lymphatic vessels and the enhancement time of contrast agent reaching the levels of elbow and axilla.

Results

CEUS imaging of superficial lymphatic vessels was successful in 59 of 60 upper limbs (98.3%). Median [interquartile ranges] enhancement times of contrast agent to reach the elbow (right 18 s [11–25], left 15 s [12–25]) and axilla (right 77 s [33–118], left 66 s [42–115]) were equally fast. Successful intradermal injections were found to result in two types of contrast enhancement (strong or moderate), while the enhancement time depended on the type of the successful injection. No major differences in enhancement times were observed related to sex, body mass index, age, or side of the arm.

Conclusions

The superficial lymphatic pathways of the upper limb can be visualised with CEUS imaging. Since enhancement time is dependent on the success of intradermal injections, one must pay attention to the injection technique. Further studies are needed to evaluate the method in patients with lymphatic function disorders such as breast cancer therapy related lymphoedema.

Evaluation of whole axillary status with lymphatic contrast-enhanced ultrasound in patients with breast cancer

OBJECTIVES

This study aims to evaluate the whole axillary status of patients with breast cancer by lymphatic contrast-enhanced ultrasound (LCEUS).

METHODS

LCEUS was applied for 169 patients with suspected breast cancer. Abnormal patterns in lymphatic channels, sentinel lymph nodes (SLNs), and non-enhanced but abnormal lymph nodes were investigated. The signs of distorted, attenuated, netted, or interrupted lymphatic channels, defective-filling or no-filling SLNs, and the appearance of non-enhanced but abnormal lymph nodes were designated as features of axillary metastasis. A positive outcome was given when any of the abnormal patterns was found in the LCEUS. The diagnostic efficiencies were calculated to differentiate the axillary lymphatic status using LCEUS for the whole axilla, compared with conventional ultrasound (US) and LCEUS for SLNs.

RESULTS

The LCEUS procedure was successfully performed for 157 breast cancer patients with axillary dissection. Compared to normal axillae, abnormal patterns had a significantly higher frequency in metastatic axillae (p = 0.000). Using conventional US to evaluate the whole axillae, the diagnostic sensitivity, specificity, and accuracy were 69.1%, 71.9%, and 70.7%, respectively. When LCEUS was used for SLN evaluation to predict the whole axilla, the diagnostic sensitivity, specificity, and accuracy were 66.2%, 89.9%, and 79.6%, respectively. When LCEUS was used as the whole axillary evaluation method, the diagnostic sensitivity, specificity, and accuracy were 76.5%, 86.5%, and 82.2%, respectively.

CONCLUSION

LCEUS can be an accurate method to observe the whole axillae in breast cancer patients. Lymphatic channels, SLNs, and non-enhanced but abnormal lymph nodes constitute the LCEUS for whole axillary evaluation.

KEY POINTS

• LCEUS can be an accurate method to observe the whole axillae in breast cancer patients. • Three aspects in the LCEUS for whole axillary evaluation are the lymphatic channels, sentinel lymph nodes (SLNs), and non-enhanced but abnormal lymph nodes. • Signs of distorted, attenuated, netted, or interrupted lymphatic channels, defective-filling or no-filling SLNs, and the appearance of non-enhanced but abnormal lymph nodes were considered as features of axillary metastasis.

Does Contrast Enhanced Ultrasound (CEUS) of Normal/Benign Axillary Lymph Nodes in Patients with Breast Cancer Identify Significant Axillary Nodal Burden?

PURPOSE

Contrast enhanced ultrasound (CEUS) of the axilla allows preoperative identification and biopsy of the sentinel lymph node. Our aims were to evaluate the accuracy of the CEUS procedure for identifying axillary lymph node metastases preoperatively and compare the volume of axillary metastases in patients with malignant versus benign CEUS guided core biopsy at end of primary surgical treatment.

METHODS

Retrospective analysis of prospectively collected data on patients with breast cancer with normal axillary ultrasound or benign axillary FNAC undergoing preoperatively CEUS guided sentinel lymph node biopsy between 2013 and 2018.

RESULTS

SLN was successfully identified by CEUS in 186 (90.7%) of patients with definitive diagnosis obtained in 163 (87.6%). Overall sensitivity was 55.77%, but significantly higher for high volume disease (77.78%) than for low volume disease (32.00%, odds ratio = 7.44, 95% CI = 2.16 to 25.62, p = .001) Specificity was 100%. NPV was 82.84% overall, 86.72% for low volume disease and 94.87 % for high volume disease. 72.4% of patients with initial malignant CEUS guided SLN core biopsy had two or more macrometastases at end of surgical treatment compared to 4.47% of patients with initial benign CEUS guided core biopsy.

CONCLUSION

When disease was present, CEUS guided sentinel lymph node core biopsy identify nodal metastases in 55.77% of patients with normal axillary grey scale ultrasound. This study suggests that the likelihood of extensive axillary disease at end of surgical treatment is low with an initial benign CEUS guided SLN core biopsy.

[Capabilities of contrast-enhanced ultrasound for preoperative assessment of regional lymphatic basin in patients with early oral cavity squamous cell cancer]

This review paper describes the possibilities of visualization of regional lymph nodes using contrast-enhanced ultrasound. Discussed is the experience of contrast-enhanced ultrasound implication for differential diagnosis of regional metastases of squamous cell carcinoma of the oral mucosa. The basics of the technique of contrast-enhanced ultrasound examination of the neck lymphatic basin are described.

Contrast-Enhanced Ultrasound-Guided Fine-Needle Aspiration for Sentinel Lymph Node Biopsy in Early-Stage Breast Cancer

The purpose of this study was to assess whether translymphatic contrast-enhanced ultrasound (CEUS) combined with fine-needle aspiration (FNA) can be used pre-operatively to assess the status of axillary lymph nodes in early-stage breast cancer patients. Furthermore, we wanted to determine whether this less invasive method could potentially be a pre-operative surgical strategy. One hundred sixty-four sentinel lymph nodes (SLNs) were detected by CEUS after intradermal injection of microbubbles in 126 cases. One hundred twenty of 126 cases (95.24%) were accurately diagnosed with the SLN-FNA method. All 6 false-negative cases were due to micrometastasis or macrometastasis. There were no false-positive results after CEUS-guided FNA biopsy based on post-operative histopathological results. In conclusion, translymphatic CEUS combined with SLN-FNA is a less traumatic approach that has high accuracy in the pre-operative evaluation of axillary lymph node status. It might have the potential to be as reliable an indicator for axillary lymph node dissection as SLN biopsy.

A Novel Bimodal Imaging Agent Targeting HER2 Molecule of Breast Cancer

Nanobubble (NB), a newly developed nanoscaled ultrasound contrast agent (UCA) for molecular imaging, has been widely researched for these years. Targeting it with functional molecule, nanobubble can adhere selectively to cellular epitopes and receptors outside the vasculature via enhanced permeability and retention (EPR) effect of tumor blood vessel. To enhance the targeting rate of our previous prepared NBs-Affibody for HER2 (+) breast cancer imaging, we introduced a near-infrared fluorescent (NIRF) dye, IR783, in this study to enhance tumor-specific targeting rate and provide a promising modality for dual-mode imaging. The prepared IR783-NBs-Affibody presented a uniform nanoscale size around 482.7 ± 54.3 nm, good biosecurity, and stability over time. The encapsulation efficiency (EE) of IR-783 was 15.09% in the conjugates leading to a successful NIR fluorescence and ultrasound enhancement imaging ex vivo. IR783-NBs-Affibody was able to automatically accumulate on BT474 cells with a highly increased targeting rate of 85.4% compared with previous NBs-Affibody of 26.6%, while Affibody-guided HER2 binding was only found in HER2-positive cell lines (BT474 and T-47D). The newly developed IR783-NBs-Affibody is characterized with favorable HER2 targeting ability and bimodal imaging capability for breast cancer. Thus, IR783-NBs-Affibody holds great potential in molecular diagnosis for patients with breast cancer.

Enhanced pre-operative axillary staging using intradermal microbubbles and contrast-enhanced ultrasound to detect and biopsy sentinel lymph nodes in breast cancer: a potential replacement for axillary surgery

OBJECTIVE

To compare the experience of four UK Centres in the use of intradermal microbubbles and contrast enhanced ultrasound (CEUS) to pre-operatively identify and biopsy sentinel lymph nodes (SLN) in patients with breast cancer.

METHODS

In all centres, breast cancer patients had a microbubble/CEUS SLN core biopsy prior to axillary surgery and patients in Centres 1 and 2 had a normal greyscale axillary ultrasound. Data were collected between 2010 and 2016; 1361 from Centre 1 (prospective, sequential), 376 from Centre 2 (retrospective, sequential), 121 from Centre 3 (retrospective, selected) and 48 from Centre 4 (prospective, selected).

RESULTS

SLN were successfully core biopsied in 80% (Centre 1), 79.6% (Centre 2), 77.5% (Centre 3) and 88% (Centre 4). The sensitivities to identify all SLN metastases were 46.9% [95% confidence intervals (CI) (39.4-55.1)], 52.5% [95% CI (39.1-65.7)], 46.4% [95% CI (27.5-66.1)] and 45.5% [95% CI (16.7-76.6)], respectively. The specificities were 99.7% [95% CI (I98.9-100)], 98.1% [95% CI (94.5-99.6)], 100% [95% CI (93.2-100%)] and 96.3% [95% CI (81-99.9)], respectively.The negative predictive values were 87.0% [95% CI (84.3-89.3)], 84.5% [95% CI (78.4-89.5)], 86.9% [95% CI (82.4-90.3)] and 86.2% [95% CI (78.4-91.5)], respectively. At Centres 1 and 2, 12/730 (1.6%) and 7/181 (4%), respectively, of patients with a benign microbubble/CEUS SLN core biopsy had two or more lymph node (LN) macrometastases found at the end of primary surgical treatment.

CONCLUSION

The identification and biopsy of SLN using CEUS is a reproducible technique. Advances in knowledge: In the era of axillary conservation, microbubble/CEUS SLN core biopsy has the potential to succeed surgical staging of the axilla.

Is there a Role for Contrast-enhanced Ultrasound in the Detection and Biopsy of MRI Only Visible Breast Lesions?

Background

This study aimed to evaluate the feasibility of contrast-enhanced ultrasound (CEUS) and CEUS-guided interventions in the diagnostics of MRI visible targeted US occult breast lesions.

Patients and methods

This retrospective study examined 10 females with 10 occult, MRI only detected breast lesions between July 2014 and April 2017. Targeted second look US followed by CEUS with 2.4 ml of SonoVue® were performed for all of the lesions. After positive CEUS localization the same dose was repeated for confirmation and CEUS-guided interventions were performed.

Results

MRI revealed 8 mass lesions with a mean size of 9 mm (range 5–16 mm) and 2 non-mass enhancing lesions of 10 and 20 mm in largest diameters. Targeted US revealed no morphological correlate for the lesions. Five out of 10 lesions (50%) were visible on CEUS. CEUS-guided core biopsy was performed on 4 lesions and 1 was marked with a clip for later surgical removal. Histopathological analysis confirmed 4 of them to be malignant. Three out of 5 nonvisible lesions on CEUS underwent MRI-guided interventions, 1 lesion was scheduled for follow-up as it was non-amenable for MRI biopsy, and 1 lesion was biopsied under US-guidance. Three of these nonvisible lesions on CEUS were confirmed to be malignant.

Conclusions

Based on our preliminary results, CEUS is a feasible tool for detecting many MRI only visible breast lesions, resulting in a more cost effective and less time-consuming practice. It is a more convenient alternative than MRI guided biopsy and has the potential to be included in the diagnostic algorithm which evaluates MRI only visible breast lesions.

[Imaging diagnostic methods for identification of sentinel lymph nodes in patients with early squamous cell carcinoma of the oral cavity mucosa: a literature review]

The paper describes properties of clinical visualization approaches which are applied for detection of sentinel lymph nodes in patients suffering from oral cavity squamous cell cancer. Diagnostic efficiency results and technological features of different imaging techniques are discussed.

Contrast-enhanced ultrasound mapping of sentinel lymph nodes in oral tongue cancer-a pilot study

OBJECTIVES

To assess the usefulness of contrast-enhanced ultrasound (CEUS) with peritumoral injection of microbubble contrast agent for detecting the sentinel lymph nodes for oral tongue carcinoma.

METHODS

The study was carried out on 12 patients with T1-2cN0 oral tongue cancer. A radical resection of the primary disease was planned; a modified radical supraomohyoid neck dissection was reserved for patients with larger lesions (T2, n = 8). The treatment plan and execution were not influenced by sentinel node mapping outcome. The Sonovue^™ contrast agent (Bracco Imaging, Milan, Italy) was utilized. After detection, the position and radiologic features of the sentinel nodes were recorded.

RESULTS

The identification rate of the sentinel nodes was 91.7%; one patient failed to demonstrate any enhanced areas. A total of 15 sentinel nodes were found in the rest of the 11 cases, with a mean of 1.4 nodes for each patient. The sentinel nodes were localized in: Level IA-1 (6.7%) node; Level IB-11 (73.3%) nodes; Level IIA-3 (20.0%) nodes. No contrast-related adverse effects were observed.

CONCLUSIONS

For oral tongue tumours, CEUS is a feasible and potentially widely available approach of sentinel node mapping. Further clinical research is required to establish the position of CEUS detection of the sentinel nodes in oral cavity cancers.

Recent technological advancements in breast ultrasound

Ultrasound is becoming increasingly common as an imaging tool for the detection and characterization of breast tumors. This paper provides an overview of recent technological advancements, especially those that may have an impact in clinical applications in the field of breast ultrasound in the near future. These advancements include close to 100% fractional bandwidth high frequency (5-18MHz) 2D and 3D arrays, automated breast imaging systems to minimize the operator dependence and advanced processing techniques, such as those used for detection of microcalcifications. In addition, elastography and contrast-enhanced ultrasound examinations that are expected to further enhance the clinical importance of ultrasound based breast tumor screening are briefly reviewed. These techniques have shown initial promise in clinical trials and may translate to more comprehensive clinical adoption in the future.