Ultrasound-Guided Fine-Needle Aspiration of Non-palpable and Suspicious Axillary Lymph Nodes with Subsequent Removal after Tattooing: False-Negative Results and Concordance with Sentinel Lymph Nodes

Ten-Year Oncologic Outcomes in T1-3N1 Breast Cancer After Targeted Axillary Sampling: A Retrospective Study

BACKGROUND

Targeted axillary sampling (TAS) is a new surgical concept for the assessment of axillary lymph node status in breast cancer that is hypothesized to be more effective at minimizing postoperative morbidities than axillary lymph node dissection (ALND), provided the metastatic axillary lymph node can be accurately detected without missing data; however, the oncologic outcomes over long-term follow-up have not been sufficiently investigated. This was a retrospective analysis to evaluate the 10-year oncologic outcomes in T1-3N1 breast cancer after TAS.

METHODS

Between 2008 and 2013, 230 female patients with cT1-3N1 breast cancer underwent breast and axillary surgery (ALND, n = 171; TAS, n = 59) at our institute. After TAS was applied, additional axillary radiotherapy was performed. Various postoperative complications, including postoperative seroma, lymphedema, and 10-year oncological outcomes, were evaluated and compared between the ALND and TAS groups.

RESULTS

Although overall survival during the 10-year follow-up period was better in the TAS group, there was no statistically significant difference in oncologic outcomes, including locoregional recurrence, distant metastasis, and overall survival (p = 0.395, 0.818, and 0.555, respectively). Furthermore, the incidence of lymphedema on the ipsilateral arm was significantly higher in the ALND group (p < 0.001).

CONCLUSIONS

The 10-year oncological outcomes of TAS were not inferior to those of conventional ALND in T1-3N1 breast cancers; however, the incidence of lymphedema was significantly higher in the ALND group.

Is image-guided core needle biopsy of borderline axillary lymph nodes in breast cancer patients clinically helpful?

BACKGROUND

When borderline axillary lymph nodes (bALN) are identified on ultrasound (US) for breast cancer (BC) patients, preoperative management is unclear. We aimed to evaluate if core needle biopsy (CNB) for bALN is clinically helpful or disruptive.

METHODS

Retrospective review of BC patients with bALN from 2014 to 2019 was performed. Clinicopathologic data were compared for those who did and did not have CNB.

RESULTS

CNB (n = 34) and no CNB (n = 31) were similar with respect to clinicopathologic factors. Surgical LN-positive rate was the same between cohorts (p = 0.26). CNB was disruptive in 58.8 %; all had CNB for pN0 disease. CNB was helpful in 34.2 %: 14.7 % proceeded directly to axillary dissection; 17.6 % had positive LN localized after neoadjuvant chemotherapy.

CONCLUSIONS

CNB for bALN is more likely clinically disruptive and did not impact surgical LN positive rate. BC patients with bALN should undergo CNB only if it will change clinical management.

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

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.

False-negative ultrasound-guided fine-needle aspiration of axillary lymph nodes in breast cancer patients

INTRODUCTION

The purpose of this study was to clarify the clinicopathological features of patients with false-negative fine needle aspiration cytology (FNAC) and to determine the factors associated with negative FNAC.

METHODS

Patients with negative FNAC from January 2010 to December 2019 were included. The patients with positive sentinel nodes (SN) were divided into two groups: micrometastasis (≤2 mm) group and macrometastasis (>2 mm) group. The clinicopathological characteristics were compared between the two groups using the χ² test.

RESULTS

A total of 165 patients with negative FNAC were included; 52 (31.5%) had positive SNs. Of the 52 patients, 13 (25%) had micrometastasis and the remaining 39 (75%) had macrometastasis. Of the 113 patients with negative SNs, none had metastases found in non-SNs. No significant differences were observed in age, cT stage or subtype, and preoperative ultrasound findings between the two groups.

CONCLUSIONS

The false-negative rate of FNAC was high (31.5%). Micrometastatic disease was seen in patients with negative FNAC, and this might be the cause of false-negative FNAC results.

Axillary Nodal Evaluation in Breast Cancer: State of the Art

Axillary lymph node (LN) metastasis is the most important predictor of overall recurrence and survival in patients with breast cancer, and accurate assessment of axillary LN involvement is an essential component in staging breast cancer. Axillary management in patients with breast cancer has become much less invasive and individualized with the introduction of sentinel LN biopsy (SLNB). Emerging evidence indicates that axillary LN dissection may be avoided in selected patients with node-positive as well as node-negative cancer. Thus, assessment of nodal disease burden to guide multidisciplinary treatment decision making is now considered to be a critical role of axillary imaging and can be achieved with axillary US, MRI, and US-guided biopsy. For the node-positive patients treated with neoadjuvant chemotherapy, restaging of the axilla with US and MRI and targeted axillary dissection in addition to SLNB is highly recommended to minimize the false-negative rate of SLNB. Efforts continue to develop prediction models that incorporate imaging features to predict nodal disease burden and to select proper candidates for SLNB. As methods of axillary nodal evaluation evolve, breast radiologists and surgeons must work closely to maximize the potential role of imaging and to provide the most optimized treatment for patients.

Clinical risk analysis of non-visualized sentinel lymph node in breast cancer

OBJECTIVE

This study aimed to explore the positive rate of non-visualized sentinel lymph nodes (non-vSLN) [1] in breast cancer (BC) patients and the discrepancy of non-vSLN among different molecular subtypes, in order to further evaluate the clinical risk of non-vSLNs.

METHODS

A total of 627 patients were retrospectively analyzed. These patients were pathologically confirmed with invasive breast cancer and underwent sentinel lymph node biopsy (SLNB). Various factors were compared using chi-square test. The positive rate of SLNs between non-vSLNs and visible sentinel lymph nodes (vSLNs) were compared. Moreover, factors that influenced the prognosis, such as ER, PR, HER-2, histological grade and lymph node metastasis were compared between these two groups.

RESULTS

Among the 627 patients who underwent SLNB, 196 patients had non-vSLNs, accounting for 31.26% (196/627) and 113 patients had positive SLNs, accounting for 18.02% (113/627). Furthermore, 40.71% (46/113) of patients with positive SLNs had non-vSLN, and 17.39% (8/46) of patients with non-vSLN had HER-2+BC. In contrast, 35.82% (24/67) of patients with vSLNs had HER-2+BC. Moreover, 23.91% (11/46) of patients with non-vSLN and 5.97% (4/67) of patients with vSLNs had triple-negative breast cancer (TNBC). The metastasis rate was 41.30% (19/46) in the non-vSLN group and 43.28% (29/67) in the vSLN group. The difference in the rate of positive SLNs between the non-vSLN and the vSLN groups was statistically significant (P< 0.05), in which the positive rate of SLNs in the non-vSLN group was remarkably higher than that in the vSLN group. The differences in the proportion of HER-2+BC and TNBC between the non-vSLN and the vSLN groups were statistically significant (P< 0.05), in which HER-2+BCwas evidently higher in the vSLN group than in the non-vSLN group. Meanwhile, TNBC was markedly higher in non-vSLN group than in the vSLN group. Furthermore, differences in Luminal A subtype, Luminal B subtype and non-SLN metastasis between these two groups was not statistically significant. In addition, the difference in non-SLN metastasis rate was not statistically significant among breast cancers of different molecular subtypes and between the non-vSLN and the vSLN groups.

CONCLUSION

Breast cancer patients with positive non-vSLNs are more likely to have a TNBC subtype relative to patients with positive vSLN. Breast cancer patients with non-vSLN have higher positive rate of SLNs. The non-SLN metastasis rate in positive SLN patients was not correlated to the molecular subtype of breast cancer.