Ultrasound staging in breast cancer: A decision-making oriented approach to axillary metastatic burden prediction

Nomogram based on multiparametric analysis of early-stage breast cancer: Prediction of high burden metastatic axillary lymph nodes

BACKGROUND

The Z0011 and AMAROS trials found that axillary lymph node dissection (ALND) was no longer mandatory for early-stage breast cancer patients who had one or two metastatic axillary lymph nodes (mALNs). The aim of our study was to establish a nomogram which could be used to quantitatively predict the individual likelihood of high burden mALN (≥3 mALN).

METHODS

We retrospectively analyzed 564 women with early breast cancer who had all undergone both ultrasound (US) and magnetic resonance imaging (MRI) to examine axillary lymph nodes before radical surgery. All the patients were divided into training (n = 452) and validation (n = 112) cohorts by computer-generated random numbers. Their clinicopathological features and preoperative imaging associated with high burden mALNs were evaluated by logistic regression analysis to develop a nomogram for predicting the probability of high burden mALNs.

RESULTS

Multivariate analysis showed that high burden mALNs were significantly associated with replaced hilum and the shortest diameter >10 mm on MRI, with cortex thickness >3 mm on US (p < 0.05 each). These imaging criteria plus higher grade (grades II and III) and quadrant of breast tumor were used to develop a nomogram calculating the probability of high burden mALNs. The AUC of the nomogram was 0.853 (95% CI: 0.790-0.908) for the training set and 0.783 (95% CI: 0.638-0.929) for the validation set. Both internal and external validation evaluated the accuracy of nomogram to be good.

CONCLUSION

A well-discriminated nomogram was developed to predict the high burden mALN in early-stage breast patients, which may assist the breast surgeon in choosing the appropriate surgical approach.

The role of pre-operative axillary ultrasound in assessment of axillary tumor burden in breast cancer patients: a systematic review and meta-analysis

BACKGROUND

Recent studies have suggested that a significant proportion of patients with axillary nodal metastases diagnosed by pre-operative axillary ultrasound (AUS)-guided needle biopsy were over-treated with axillary lymph node dissection (ALND). The role of routine AUS and needle biopsy in early breast cancer was questioned. This review aims to determine if pre-operative AUS could predict the extent of axillary tumor burden and need of ALND.

METHODS

PubMed and Embase literature databases were searched systematically for abnormal AUS characteristics and axillary nodal burden. Studies were eligible if they correlated the sonographic abnormalities in AUS with the resultant axillary nodal burden in ALND according to the ACOSOG Z0011 criteria.

RESULTS

Eleven retrospective studies and one prospective study with 1658 patients were included. Sixty-five percent of patients with one abnormal lymph node in AUS and 56% of those with two had low axillary nodal burden. Using one abnormal lymph node as the cut-off, the pooled sensitivity and specificity in prediction of axillary nodal burden were 66% (95%CI 63-69%) and 73% (95% CI 70-76%), respectively. Across the six studies that evaluated suspicious nodal characteristics, increased nodal cortical thickness may be associated with high axillary nodal burden.

CONCLUSION

More than half of the patients with pre-operative positive AUS and biopsy proven axillary nodal metastases were over-treated by ALND. Quantification of suspicious nodes and extent of cortical morphological changes in AUS may help identify suitable patients for sentinel lymph node biopsy.

Ultrasound Features to Differentiate COVID-19 Vaccine-Induced Benign Adenopathy from Breast Cancer Related Malignant Adenopathy

Rationale and Objective

To identify nodal features used to distinguish coronavirus disease 2019 (COVID-19) vaccine-Induced benign reactive adenopathy from malignant adenopathy.

Materials and Methods

This IRB-approved, single-institution, retrospective study compared features of 77 consecutive patients with benign adenopathy secondary to a messenger RNA COVID-19 vaccine with 76 patients with biopsy-proven malignant adenopathy from breast cancer. Patient demographics and nodal features were compared between the two groups using univariate and multivariate logistic regression models. A receiver operating characteristic analysis with the maximum value of Youden's index was performed for the cutoff value of cortical thickness for predicting nodal status.

Results

The mean cortical thickness was 5.1 mm ± 2.8 mm among benign nodes and 8.9 mm ± 4.5 mm among malignant nodes (p < 0.001). A cortical thickness ≥3.0 mm had a sensitivity of 100% and a specificity of 21% (area under the curve [AUC] = 0.60, 95% confidence interval [CI]: 0.52-0.68). When the cutoff for cortical thickness was increased to ≥5.4 mm, the sensitivity decreased to 74%, while the specificity increased to 69% (AUC = 0.77, 95% CI: 0.70-0.84).Cortical thickness correlated with nodal morphology type (r² = 0.57). An axillary node with generalized lobulated cortical thickening had a 7.5 odds ratio and a node with focal cortical lobulation had a 123.0 odds ratio compared to one with diffuse, uniform cortical thickening only (p < 0.001).

Conclusion

Cortical thickness and morphology are predictive of malignancy. Cortical thickness cutoff of ≥5.4 mm demonstrates higher specificity and improved accuracy for detecting malignant adenopathy than a cutoff of ≥3.0 mm.

Clinical Value of Preoperative Ultrasound Signs in Evaluating Axillary Lymph Node Status in Triple-Negative Breast Cancer

Purpose. To explore the clinical value of preoperative ultrasound signs in evaluating axillary lymph node status in triple-negative breast cancer (TNBC). Methods. A retrospective study was conducted on 162 patients with TNBC who were admitted to our hospital from January 2017 to June 2021. A total of 62 patients with axillary lymph node metastasis and 100 patients with normal axillary lymph nodes were included. Univariate and logistic regression was used to analyze the correlation between clinicopathological parameters, ultrasound features, and axillary lymph node metastasis between these two groups. The receiver operating characteristic (ROC) curve of each index was drawn to predict positive axillary lymph node. Results. The lymph node positive rate was higher in patients with tumor size ( $2\text{mm}<T\le 5\text{mm}$ ) and tumor stage III, and the difference between these two groups was statistically significant ( $P<0.05$ ). The patients with $\text{cortical}\text{thickness}\ge 3$ , blood flow grades II-III, $\text{aspect}\text{ratio}\left(\text{L}/\text{S}\right)\ge 2$ , and $\text{RI}\ge 0.7$ had higher lymph node positive rate, and the difference between these two groups was statistically significant ( $P<0.05$ ). Other index shows no correlation with ancillary lymph node positive rate, or the correlation was not statistically significant ( $P>0.05$ ). Further regression analysis indicated that the blood flow grade and L/S of axillary lymph nodes were independent influencing factors of axillary lymph node metastasis in TNBC patients ( $P<0.05$ ). Relevant receiver operating characteristic (ROC) curves were constructed, and the AUC of axillary lymph node blood flow grade and L/S for predicting axillary lymph node status was 0.6329 and 0.6498, respectively. The AUC for the joint prediction of the two indicators is 0.6898. Conclusion. Ultrasound sign combined with clinicopathological characteristics can predict the axillary lymph nodes metastasis in TNBC, which could guide clinical decision of axillary lymph node surgery.