The clinical utility of combining pre-operative axillary ultrasonography and fine needle aspiration cytology with radionuclide guided sentinel lymph node biopsy in breast cancer patients with palpable axillary lymph nodes

Predicting axillary nodal metastasis based on the side of asymmetrical cortical thickening in breast cancer: Evaluation with grayscale and microvascular imaging findings

PURPOSE

To investigate the relationship between sonographic findings and the axillary status, especially the side of thickening in the presence of cortical asymmetry.

METHODS

Patients with biopsy-proven axillary lymph node (ALN) metastasis were included in this study. The lymph nodes were divided into three groups depending on the type of cortical thickening as diffuse, closer (eccentric cortical thickening on the side near the tumor and/or breast) and distant (thickening on the further side) asymmetry. Longitudinal to transverse axis (L/T) ratio, the largest cortical thickness, cortex to hilum ratio (C/H), hilar status (normal/displaced/absent), orientation (parallel/vertical), capsular integrity (sharp/indistinct), vascularisation pattern (hilar/peripheral/penetrant/anarchic/avascular) on superb microvascular imaging (SMI) and presence of conglomeration were recorded for each lymph node. Axillary nodal status on ¹⁸F-FDG PET-CT/MRI scans was recorded, if available. Features of the breast lesions like size, laterality, nuclear grade, hormone receptor status and the level of Ki-67 expression have been added.

RESULTS

A total of 219 metastatic ALNs [diffuse (n = 122), closer asymmetry (n = 71), distant asymmetry (n = 26)] were evaluated. By the univariate analysis, ALN metastasis was significantly associated with the presence of closer asymmetrical cortical thickening (p < 0,0001), C/H ratio (p = 0.001), cortical thickness (p = 0.001), hilar status (p < 0.005) and vascular pattern (p < 0.005). L/T ratio was only a statistically significant parameter for lymph nodes with diffuse cortical enlargement in predicting metastasis, and conglomeration was also observed only in this group (p < 0.05). By multivariate analysis, nodal metastasis was significantly associated with asymmetrical cortical thickening (p = 0.001), C/H ratio (p = 0.005) and vascular pattern (p < 0.0001).

CONCLUSION

Asymmetrical cortical enlargement on the side closer to the breast, C/H ratio and abnormal microvascular pattern are the independent predictors of axillary nodal involvement. Closer asymmetry is an eligible, easy-to-detect grayscale US finding to decide sampling that highly predicts ALN metastasis.

Radiomic Signature Based on Dynamic Contrast-Enhanced MRI for Evaluation of Axillary Lymph Node Metastasis in Breast Cancer

Background. To construct and validate a radiomic-based model for estimating axillary lymph node (ALN) metastasis in patients with breast cancer by dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI). Methods. In this retrospective study, a radiomic-based model was established in a training cohort of 236 patients with breast cancer. Radiomic features were extracted from breast DCE-MRI scans. A method named the least absolute shrinkage and selection operator (LASSO) was applied to select radiomic features based on highly reproducible features. A radiomic signature was built by a support vector machine (SVM). Multivariate logistic regression analysis was adopted to establish a clinical characteristic-based model. The performance of models was analysed through discrimination ability and clinical benefits. Results. The radiomic signature comprised 6 features related to ALN metastasis and showed significant differences between the patients with ALN metastasis and without ALN metastasis ( $P<0.001$ ). The area under the curve (AUC) of the radiomic model was 0.990 and 0.858, respectively, in the training and validation sets. The clinical feature-based model, including MRI-reported status and palpability, performed slightly worse, with an AUC of 0.784 in the training cohort and 0.789 in the validation cohort. The radiomic signature was confirmed to provide more clinical benefits by decision curve analysis. Conclusions. The radiomic-based model developed in this study can successfully diagnose the status of lymph nodes in patients with breast cancer, which may reduce unnecessary invasive clinical operations.

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.

Breast sentinel lymph node biopsy with imaging towards minimally invasive surgery

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

Ultrasound combined with fine needle aspiration cytology for the assessment of axillary lymph nodes in patients with early stage breast cancer

This study aimed to explore the clinical usefulness of ultrasound-guided fine needle aspiration cytology (USG-FNAC) for the evaluation of axillary lymph nodes in patients with early stage breast cancer (BC) among the Chinese Han female population.Around 124 patients with early stage BC were included in this retrospective study. All patients underwent USG-FNAC (group A). Patients with proven metastasis also underwent axillary lymph node dissection (ALND) (group B). In addition, sentinel lymph node biopsy (SLNB) was performed 2 to 5 hours prior to the surgery.The sensitivity, specificity, accuracy, and positive predictive value (PPV) of axillary ultrasound were 75.0%, 75.0%, 75.0%, and 82.6%, respectively, while for USG-FNAC, they were 80.8%, 100.0%, 88.7%, and 100.0%, respectively. Significant differences were found in specificity, accuracy, and PPV between the 2 procedures (P < .05).The results of this study demonstrated that USG-FNAC was effective for selecting patients with early stage BC using ALND or SLNB among the Chinese Han female population.

The role of ultrasound and lymphoscintigraphy in the assessment of axillary lymph nodes in patients with breast cancer

Breast cancer is the most common malignancy and the leading cause of death due to cancer in European women. Mammography screening programs aimed to increase the detection of early cancer stages were implemented in numerous European countries. Recent data show a decrease in mortality due to breast cancer in many countries, particularly among young women. At the same time, the number of sentinel node biopsy procedures and breast-conserving surgeries has increased. Intraoperative sentinel lymph node biopsy preceded by lymphoscintigraphy is used in breast cancer patients with no clinical signs of lymph node metastasis. Due to the limited sensitivity and specificity of physical examination in detecting metastatic lesions, developing an appropriate diagnostic algorithm for the preoperative assessment of axillary lymph nodes seems to be a challenge. The importance of ultrasound in patient qualification for sentinel lymph-node biopsy has been discussed in a number of works. Furthermore, different lymphoscintigraphy protocols have been compared in the literature. The usefulness of novel radiopharmaceuticals as well as the methods of image acquisition in sentinel lymph node diagnostics have also been assessed. The aim of this article is to present, basing on current guidelines, literature data as well as our own experience, the diagnostic possibilities of axillary lymph node ultrasound in patient qualification for an appropriate treatment as well as the role of lymphoscintigraphy in sentinel lymph node biopsy.