Axillary lymph node dissection in breast cancer--current status and controversies, alternative strategies and future perspectives

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.

Different Imaging Modalities for the Diagnosis of Axillary Lymph Node Metastases in Breast Cancer: A Systematic Review and Network Meta-Analysis of Diagnostic Test Accuracy

BACKGROUND

Accurate diagnosis of axillary lymph node metastasis (ALNM) of breast cancer patients is important to guide local and systemic treatment.

PURPOSE

To evaluate the diagnostic performance of different imaging modalities for ALNM in patients with breast cancer.

STUDY TYPE

Systematic review and network meta-analysis (NMA).

SUBJECTS

Sixty-one original articles with 8011 participants.

FIELD STRENGTH

1.5 T and 3.0 T.

ASSESSMENT

We used the QUADAS-2 and QUADAS-C tools to assess the risk of bias in eligible studies. The identified articles assessed ultrasonography (US), MRI, mammography, ultrasound elastography (UE), PET, CT, PET/CT, scintimammography, and PET/MRI.

STATISTICAL ANALYSIS

We used random-effects conventional meta-analyses and Bayesian network meta-analyses for data analyses. We used sensitivity and specificity, relative sensitivity and specificity, superiority index, and summary receiver operating characteristic curve (SROC) analysis to compare the diagnostic value of different imaging modalities.

RESULTS

Sixty-one studies evaluated nine imaging modalities. At patient level, sensitivities of the nine imaging modalities ranged from 0.27 to 0.84 and specificities ranged from 0.84 to 0.95. Patient-based NMA showed that UE had the highest superiority index (5.95) with the highest relative sensitivity of 1.13 (95% confidence interval [CI]: 0.93-1.29) among all imaging methods when compared to US. At lymph node level, MRI had the highest superiority index (6.91) with highest relative sensitivity of 1.13 (95% CI: 1.01-1.23) and highest relative specificity of 1.11 (95% CI: 0.95-1.23) among all imaging methods when compared to US. SROCs also showed that UE and MRI had the largest area under the curve (AUC) at patient level and lymph node level of 0.92 and 0.94, respectively.

DATA CONCLUSION

UE and MRI may be superior to other imaging modalities in the diagnosis of ALNM in breast cancer patients at the patient level and the lymph node level, respectively. Further studies are needed to provide high-quality evidence to validate our findings.

EVIDENCE LEVEL

3 TECHNICAL EFFICACY: Stage 2.

Diagnostic Values of 8 Different Imaging Modalities for Preoperative Detection of Axillary Lymph Node Metastasis of Breast Cancer: A Bayesian Network Meta-analysis

OBJECTIVE

This study aimed to compare diagnostic performances of 8 different imaging modalities for preoperative detection of axillary lymph node (LN) metastasis in patients with breast cancer by performing a network meta-analysis (NMA) using direct comparison studies with 2 or more imaging techniques.

MATERIALS AND METHODS

PubMed, Cochrane, and Embase were searched for the studies evaluating the performances of 8 different imaging modalities for preoperative axillary LN staging in patients with breast cancer. The NMA was performed in patient-based analyses. The consistency was evaluated by examining the agreement between direct and indirect treatment effects, and publication bias was assessed by funnel plot asymmetry tests. The surface under the cumulative ranking curve (SUCRA) values were obtained to calculate the probability of each imaging modality being the most effective diagnostic method.

RESULTS

A total of 2197 patients from 22 direct comparison studies using 8 different imaging modalities for preoperative detection of axillary LN metastasis in patients with breast cancer were included. For preoperative detection of axillary LN metastasis of breast cancer, elastography showed the highest SUCRA values of sensitivity, specificity, positive predictive value, negative predictive value, accuracy, and diagnostic odds ratio. In addition, fluorine-18 fluorodeoxyglucose positron emission tomography (PET) or PET/computed tomography, fluorine-18 fluorodeoxyglucose PET/magnetic resonance, and contrast-enhanced computed tomography showed high SUCRA values.

CONCLUSION

Elastography showed the highest SUCRA values. Seven imaging modalities showed the complementary diagnostic roles for preoperative detection of axillary LN metastasis in patients with breast cancer, except mammography.

Rotter's Lymph Nodes-Do We Really Need to Remove During Axillary Clearance?

Surgical management of node positive breast cancer requires axillary dissection. Interpectoral nodes (IPNs) or Rotter's nodes removal is controversial as there is hardly any tissue in this region. IPNs involvement is rarely seen among breast cancer patients. Developing an effective protocol for surgical management of axilla is necessary for uniformity, to reduce the risk of regional recurrence and to avoid the morbidity of interpectoral lymphatic tissue clearance. This study aimed to evaluate the detection of lymph nodes in Rotter's region and positive metastasis rate of IPNs in patients with node positive breast cancer for analyzing the prognostic and therapeutic value of IPN excision during axillary clearance. Fifty-six patients undergoing axillary clearance, aged ≥ 18 years, were studied. Patients with recurrence or those who underwent neoadjuvant chemotherapy were excluded. Baseline investigations were done pre-operatively along with core needle biopsy, estrogen receptor (ER), progesterone receptor (PR), and Ki-67 status. Association between IPN status, age, and clinicopathological parameters were assessed by Kruskal Wallis and Chi-square test using R v 3.6.0. P value of ≤ 0.05 was considered statistically significant. Majority of patients had upper outer quadrant tumor location (22/56), and the most common histopathological type was invasive ductal carcinoma (46/56). IPNs were identified in 35.71% (20/56) of 56 patients, with metastasis prevalence of 27.27% (9/33 node positive patients). Patients having IPN metastasis had larger tumor size, later TNM classification, lower ER/PR, and higher Ki-67 positivity. Dissection of IPNs can be practiced routinely during axillary clearance and should be subjected to histopathological examination separately.

Preoperative Axillary Lymph Node Evaluation in Breast Cancer: Current Issues and Literature Review

Axillary lymph node (ALN) status is an important prognostic factor for overall breast cancer survival. In current clinical practice, ALN status is evaluated before surgery via multimodal imaging and physical examination. Mammography is typically suboptimal for complete ALN evaluation. Currently, ultrasonography is widely used to evaluate ALN status; nonetheless, results may vary according to operator. Ultrasonography is the primary imaging modality for evaluating ALN status. Other imaging modalities including contrast-enhanced magnetic resonance imaging, computed tomography, and positron emission tomography/computed tomography can play additional roles in axillary nodal staging.The purpose of this article is (1) to review the strengths and weaknesses of current imaging modalities for nodal staging in breast cancer patients and (2) to discuss updated guidelines for ALN management with regard to preoperative ALN imaging.

Ratio between positive lymph nodes and total excised axillary lymph nodes as an independent prognostic factor for overall survival in patients with nonmetastatic lymph node-positive breast cancer

BACKGROUND.: The status of the axillary lymph nodes in nonmetastatic lymph node-positive breast cancer (BC) patients remains the single most important determinant of overall survival (OS). Although the absolute number of nodes involved with cancer is important for prognosis, the role of the total number of excised nodes has received less emphasis. Thus, several studies have focused on the utility of the axillary lymph node ratio (ALNR) as an independent prognostic indicator of OS. However, most studies suffered from shortcomings, such as including patients who received neoadjuvant therapy or failing to consider the use of adjuvant therapy and tumor receptor status in their analysis. METHODS.: We conducted a single-center retrospective review of 669 patients with nonmetastatic lymph nodepositive BC. Data collected included patient demographics; breast cancer risk factors; tumor size, histopathological, receptor, and lymph node status; and treatment modalities used. Patients were subdivided into four groups according to ALNR value (<.25, .25-.49, .50-.74, .75-1.00). Study parameters were compared at the univariate and multivariate levels for their effect on OS. RESULTS.: On univariate analysis, both the absolute number of positive lymph nodes and the ALNR were significant predictors of OS. On multivariate analysis, only the ALNR remained an independent predictor of OS, with a 2.5-fold increased risk of dying at an ALNR of ≥.25. CONCLUSIONS.: Our study demonstrates that ALNR is a stronger factor in predicting OS than the absolute number of positive axillary lymph nodes.

Ratio between positive lymph nodes and total excised axillary lymph nodes as an independent prognostic factor for overall survival in patients with nonmetastatic lymph node-positive breast cancer

BACKGROUND

The status of the axillary lymph nodes in nonmetastatic lymph node-positive breast cancer (BC) patients remains the single most important determinant of overall survival (OS). Although the absolute number of nodes involved with cancer is important for prognosis, the role of the total number of excised nodes has received less emphasis. Thus, several studies have focused on the utility of the axillary lymph node ratio (ALNR) as an independent prognostic indicator of OS. However, most studies suffered from shortcomings, such as including patients who received neoadjuvant therapy or failing to consider the use of adjuvant therapy and tumor receptor status in their analysis.

METHODS

We conducted a single-center retrospective review of 669 patients with nonmetastatic lymph nodepositive BC. Data collected included patient demographics; breast cancer risk factors; tumor size, histopathological, receptor, and lymph node status; and treatment modalities used. Patients were subdivided into four groups according to ALNR value (<0.25, 0.25-0.49, 0.50-0.74, 0.75-1.00). Study parameters were compared at the univariate and multivariate levels for their effect on OS.

RESULTS

On univariate analysis, both the absolute number of positive lymph nodes and the ALNR were significant predictors of OS. On multivariate analysis, only the ALNR remained an independent predictor of OS, with a 2.5-fold increased risk of dying at an ALNR of ⩾0.25.

CONCLUSIONS

Our study demonstrates that ALNR is a stronger factor in predicting OS than the absolute number of positive axillary lymph nodes.

Lymph Node Ratio is More Valuable than Level III Involvement for Prediction of Outcome in Node-Positive Breast Carcinoma Patients

BACKGROUND

We examined the relationship between different expressions of positive axillary lymph nodes (PN) and the outcomes of node-positive breast carcinoma patients to determine the best predictor(s) among these expressions and to assess whether anatomic high level involvement is an independent prognostic factor.

STUDY DESIGN

In this retrospective study, the primary endpoints were distant recurrence (DR), locoregional recurrences (LRR), and disease-free survival (DFS). Univariate and multivariate prognostic factor analyses were carried out using survival and regression methods in the data of 704 patients with PN.

RESULTS

In multivariate analysis, the number of PN, ratio of PN, log odds of PN, and level III (L-III) involvement, separately, were significant factors for DR in addition to age, tumor size, and lymphovascular invasion (LVI). In the final model including all expressions of nodal involvement, age (continuous P = 0.001; hazard ratio [HR]: 0.98; 95% confidence Interval [95% CI]: 0.96-0.99), tumor size (continuous: P < 0.0001; HR: 1.3; 95% CI, 1.2-1.5), LVI (yes vs. no: P = 0.005; HR: 1.6; 95% CI, 1.2-2.2), and ratio of PN (continuous: P = 0.02; HR: 1.03; 95% CI, 1.01-1.06) were the independent prognostic factors for DR. For LRR, ratio of PN (continuous: P = 0.001; HR: 1.02; 95% CI, 1.01-1.03) was the most important factor in addition to age (continuous: P = 0.02; HR: 0.98; 95% CI, 0.97-0.99) and tumor size (continuous: P = 0.04; HR: 1.3; 95% CI, 1.1-1.6). When patients were stratified by number categories of PN (1-3 vs. 4-9 vs. >/= 10), there was no difference between DFSs of patients with and without L-III involvement. In contrast, when patients were stratified by L-III involvement, DFSs according to the number categories were statistically different.

CONCLUSIONS

Ratio of PN was more valuable than number of PN for predicting outcome in node-positive breast carcinoma patients. Level III involvement was not an independent prognostic indicator either for locoregional or for distant recurrences.

Potential of magnetic resonance spectroscopy to detect metastasis in axillary lymph nodes in breast cancer

Focused pathological evaluation of axillary lymph nodes in breast cancer is gaining importance. Nuclear magnetic resonance (NMR) spectroscopy that assesses the whole of the specimen has the potential in evaluating micrometastases. The biochemical changes associated with breast cancer metastases in axillary nodes by in vitro NMR and its use in the detection of axillary metastases in a clinical setting in comparison with conventional histopathology is presented in this study. Eighty-eight lymph nodes obtained from 30 patients with breast cancer were investigated. Histopathology revealed metastases in 20 nodes from 11 patients, while in vitro NMR spectroscopy revealed metastases in 22 nodes. Out of these 22 nodes, 16 were the same, which showed metastases on histopathology, while 6 nodes have shown metastases only on in vitro magnetic resonance spectroscopy (MRS). These 6 nodes with suspicion of metastases on MRS were subjected to reevaluation with serial sectioning and immunohistochemistry, but no additional metastases were revealed. Forty metabolites could be identified from the MR spectrum of lymph nodes. The levels of the glycerophosphocholine-phosphocholine (GPC-PC), choline, lactate, alanine and uridine diphosphoglucose were elevated significantly in nodes with metastases. In addition, the intensity ratio of GPC-PC/threonine (Thr) was higher in nodes with metastases, and using this as marker, MRS detected the axillary metastases with a sensitivity, specificity and accuracy of 80%, 91% and 88%, respectively. Neoadjuvant chemotherapy (NACT) lowered the concentrations of GPC-PC and GPC-PC/Thr ratio. The accuracy of MRS in detecting metastases was 75% in patients who received NACT (n=9) as compared to 96% in those who did not (n=21). Our results demonstrate the potential of in vitro MRS in characterizing the metabolite profile of the axillary nodes with breast cancer metastases. It detected axillary metastases with reasonable accuracy and can be complementary to histopathological evaluation and immunohistochemistry.

Factors Associated with Arm Swelling after Breast Cancer Surgery

PURPOSE

As life expectancy improves for women with breast cancer, more women will be living with symptoms of lymphedema. This study reports the incidence of arm or hand swelling and associated risk factors in women with invasive breast cancer following surgery.

METHODS

Data were obtained from baseline and follow-up interviews of women with invasive breast cancer (n = 145), and mammography and pathology records. The Kaplan-Meier method was used to estimate the probability of developing arm or hand swelling over time. Univariate and multivariate logistic regression analyses were conducted to identify risk factors for arm or hand swelling.

RESULTS

Of women in this study, 38% self-reported arm or hand swelling. There was a significantly increased risk of arm swelling if women were under 50 years of age, had axillary node dissection, received chemotherapy, worked outside the home, and had a high household income. There was no association of body weight with swelling. A significantly decreased risk of arm swelling was found in women who were on treatment for high blood pressure. After adjustment for nodal dissection, only age had a significant independent effect.

CONCLUSIONS

Our study highlights two important areas of future research that could reduce the incidence of lymphedema. There is a need to better understand the role that treatment for high blood pressure may play in protecting women from arm edema. Second, the potential effect of weight as a modifiable lymphedema risk factor needs to be studied in more detail in light of the conflicting results of different studies.

Time trends and regional differences in registration, stage distribution, surgical management and survival of breast cancer in Denmark

The aim of this study was to analyse time trends, stage at diagnosis, survival and registration of population-based cohorts of breast cancer patients in selected Danish counties (in total 2504) in 1986 and 1996-1997. In 1986, no differences in the extent of disease were observed between the counties. Patients from one county (Funen) had centralised surgery, significantly more lymph nodes removed and a better survival in the multivariate analysis. In 1996-1997, mammographical screening had been implemented in Funen, leading to a significantly better stage distribution, whereas stage remained unchanged in the other counties. In Funen, survival was significantly better than in the other counties in univariate, but not in multivariate analysis. Survival increased significantly with time only in Funen. Inclusion in clinical trials increased over time and the coverage of the database in the Danish Breast Cancer Cooperative Group (DBCG) was high. However, patients not notified in DBCG had, beside older age, also worse stage of disease distribution and less extensive surgery. A difference in survival was observed between the counties. In 1986, this may be explained by a centralised surgical system in one county, whereas in 1996-1997 improvements could be due to an early diagnosis and other as yet unknown factors. The DBCG database cannot be considered as representative of the Danish population of breast cancer patients.

Axilla surgery severely affects quality of life: results of a 5-year prospective study in breast cancer patients

No long-term prospective study has investigated arm morbidity and patient quality of life. It is unclear to what extent breast cancer patients suffer from arm problems, how long such problems affect their lives, and whether quality of life improves as arm problems abate. This prospective cohort study aims to provide data on the clinical factors associated with arm dysfunction, to estimate its prevalence and to relate arm morbidity to quality of life. The Munich Cancer Registry records clinical details of all cancer patients in and around Munich. Quality of life information was provided directly by breast cancer patients (n = 990) over 5 years. Arm morbidity, including movement limitations, swelling and lymph drainage, and quality of life (EORTC QLQ-C30) were assessed. Up to 5 years after diagnosis, 38% of patients were still experiencing arm problems (swelling and limited movement). Consistently over the 5 years, quality of life was significantly (p < 0.001) lower for patients with arm difficulties. For those whose arm problems dissipated, quality of life significantly improved (p < 0.01). A logistic regression analysis showed that extent of axilla surgery (p < 0.003), comorbidity (CVD and diabetes) (p < 0.003), employment (p < 0.01), younger age (p < 0.02), and operating clinic (p < 0.05) significantly contributed to arm problems. Axilla surgery should be re-evaluated since arm morbidity has such a profound effect on patient quality of life.

Age-related variations in the use of axillary dissection: a survival analysis of 8038 women with T1-ST2 breast cancer

PURPOSE

The use of axillary dissection (AD) in women with invasive breast cancer is increasingly questioned. This study analyzes the survival in women with T1-2 breast cancer according to age and AD use.

METHODS AND MATERIALS

Data from the Breast Cancer Outcomes Unit Database were analyzed for 8038 women aged 50-89 years referred to the British Columbia Cancer Agency between 1989 and 1998 with invasive T1-2,M0 breast cancer. Tumor and treatment characteristics were compared between women treated with and without AD (AD+ vs. AD-) according to three age groups: 50-64, 65-74 and 75+ years. Regional relapse and actuarial 5-year overall and breast cancer-specific survival were compared between AD+ and AD- women. Multivariate analysis of age, tumor and treatment factors, and adjusted hazard ratios with AD omission were performed.

RESULTS

AD was omitted more frequently with advancing age (4% vs. 8% vs. 22% in women aged 50-64, 65-74, and 75+ years, respectively, p <0.0001). Tumor characteristics were more favorable in AD- women, with fewer having Grade III disease, T2 tumors, or lymphovascular invasion (all p <0.0001). Women treated without AD were also less likely to undergo radiotherapy after lumpectomy or mastectomy (both p <0.0001). Systemic therapy use and regional relapse rates were comparable between AD- and AD+ women in each age-specific cohort. Multivariate analysis identified age, tumor size, grade, lymphovascular invasion, estrogen receptor status, clinical nodal palpability, type of surgery, and radiotherapy use as independent variables affecting survival. Hazard ratios adjusted for these variables showed AD omission to be associated with lower overall survival in the entire cohort (hazard ratio 1.52, p <0.0001) and lower breast cancer-specific survival in women aged 65-74 years (hazard ratio 1.99, p = 0.02).

CONCLUSION

AD was more frequently omitted with advancing age. The lack of differences in systemic therapy use, regional relapse, and breast cancer-specific survival among AD- compared with AD+ women aged 75+ years suggests that AD use may be selectively omitted in this elderly cohort. However, the lower survival associated with AD omission among women aged 65-74 years, and the lack of a survival advantage among AD- women aged 50-64 years despite more favorable tumor characteristics and comparable systemic therapy use support the hypothesis that definitive locoregional therapy has an impact on survival.

Application of a Multigene Reverse Transcription-PCR Assay for Detection of Mammaglobin and Complementary Transcribed Genes in Breast Cancer Lymph Nodes

Background: Mammaglobin mRNA expression is found in 70–80% of primary and metastatic breast tumor biopsies. The potential breast tumor markers B305D, B726P, and γ-aminobutyrate type A receptor π subunit (GABAπ) complement the expression of mammaglobin. Collectively the expression profile of these four genes could be used as a diagnostic and prognostic indicator for breast cancer.

Methods: A multigene reverse transcription-PCR (RT-PCR) assay was established to detect the expression of mammaglobin, GABAπ, B305D, and B726P simultaneously. Specific primers and TaqMan® probes were used to analyze combined mRNA expression profiles in primary breast tumors and metastatic lymph node specimens.

Results: The multigene RT-PCR assay detected substantial expression signals in 27 of 27 primary tumor and 50 of 50 metastatic breast lymph node samples. Specificity studies demonstrated no significant expression signal in 27 non-breast cancer lymph nodes, in 22 various healthy tissue samples, or in 14 colon tumor samples.

Conclusion: The novel RT-PCR-based assay described here provides a sensitive detection system for disseminated breast tumor cells in lymph nodes. In addition, this multigene assay could also be used to test peripheral blood and bone marrow samples.